Every finding on record at Medilodge of Farmington

Based on observation, interview, and record review, the facility failed to adequately monitor and assess residents for weight loss and implement interventions for two (R2 and R80) of three residents reviewed for nutrition, resulting in severe weight loss for R2 who lost 10.15 percent of their body weight within 60 days and R80 who lost 8.53 percent within 19 days. Findings include:R2 On 1/26/26 at 10:10 AM, R2 was observed lying in bed. R2 was receiving nutrition via a feeding tube and breathing assistance via mechanical ventilator. When addressed R2 did not open her eyes. A review of R2's clinical record revealed R2 was admitted into the facility on 2/29/24 and readmitted on [DATE] with diagnoses that included: acute and chronic respiratory failure with hypoxia, accidental poisoning by heroin, chronic obstructive pulmonary disease, type 2 diabetes, and dysphagia. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R2 had severely impaired cognition, was dependent on staff for all activities of daily living, bed mobility, and transfers, and received all nutrition via Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube surgically inserted into the stomach to deliver nutrition). A review of R2's Weight Summary revealed on 11/5/25, R2 weighed 182.2 pounds (lbs). On 1/3/26, R2 weighed 163.7 lbs which was a 10.15 percent weight loss. A review of R2's progress notes revealed no documentation that addressed R2's weight loss between 11/5/25 and 1/3/26. A review of a Nutrition Data Collection/Evaluation assessment dated [DATE] revealed the assessment was not completed and was blank. Further review of R2's documented Weight Summary revealed R2 weighed 182.2 lbs on 11/5/25 and 172.1 lbs on 12/3/25 which indicated a 5.54 percent weight loss within 30 days. A review of R2's progress notes revealed no documentation of R2's weight loss and how it was addressed. A review of a Nutrition Data Collection/Evaluation assessments revealed R2 was not evaluated by the dietician after the weight loss between 11/5/25 and 12/3/25. R2 was assessed on 11/13/25, however, R2 had not had significant weight loss identified at that time. On 1/27/26 at 12:36 PM, an interview was conducted with Registered Dietician (RD) 'C'. When queried about how she was alerted of residents with significant weight loss and when she assessed them, RD 'C' reported weight loss was discussed every morning with the interdisciplinary team (IDT). She typically assessed right away once weight loss was triggered and she was alerted of it. When queried about R2's weight loss of 10.15 percent on 1/3/26 and if she was aware and if she assessed the resident, RD 'C' reviewed R2's record and said there was an assessment started but it showed as incomplete. RD 'C' was unable to say what interventions were put in place as a result of the weight loss and was unsure if R2 was seen by a medical provider. When queried about the lack of assessment after R2 had a significant weight loss of 5.54 percent on 12/3/25, RD 'C' did not offer a response. When queried about how she would know if R2 had received the appropriate amount of tube feeding or if any changes needed to be made, RD 'C' reported R2 was classified as obese so her tube feeding was formulated based on her ideal body weight. When queried if R2 was on a physician prescribed weight loss plan that would have had an expected weight loss, RD 'C' said she was not. On 1/27/26 at 12:59 PM, an interview was conducted with the Director of Nursing (DON). When queried about who was responsible to ensure residents did not experience weight loss and that they received the appropriate amount of tube feeding, the DON reported dietary was mostly responsible to look for weight loss trends and if they had any would report to the DON and it would be addressed with the IDT (interdisciplinary team)to determine which dietary or medical interventions were needed. The DON reported the RD was responsible to notify the medical provider so that they would evaluate for an underlying medical cause for the weight loss. When queried about when the RD was supposed to assess the resident, the DON reported for any significant weight loss. R80 On 1/26/2026 at approximately 10:22 a.m., R80 was observed in their room, laying in their bed. R80 was observed to have enteral feeding infusing at 65ml (milliliter) per hour. R80 was observed with half-filled bottle of thin liquid soda on their bedside table. On 1/27/26 at approximately 8:53 a.m., R80 was observed in their room, up in bed. R80 was observed to still have the half drank bottle of soda on their bedside table. On 1/28/26 at approximately 12:57 p.m., R80 was observed in their room, up in their bed. R80w as observed to have a half-eaten lunch try. R80's meal ticket indicated R80 was to be provided 1:1 supervision with meals. R80 was queried if anyone helped them eat their meal and they indicated their wife did that day. R80 was queried if facility staff help them with their meals and they reported that he usually has to eat by himself. On 1/27/26 the medical record for R80 was reviewed and revealed the following: R80 was initially admitted to the facility on [DATE] and had diagnoses of Aphasia and Dysphagia. A review of R80's MDS (minimum data set) with an ARD (Assessment reference date) of 12/22/25 revealed R80 was dependent on facility staff with most of their activities of daily living. R80's BIMS score (brief interview of mental status) was 14 indicating intact cognition. A review of R80's Diet order revealed the following: Regular diet Pureed texture, Nectar/Mildly Thick consistency, Setup support. Upright for all intake. A Physician's order dated with a start date of 12/20/25 revealed the following: Weights weekly X 4 weeks then monthly every day shift every 7 day(s) weekly for 4 weeks. A review of R80's Documented Weights revealed the following: 12/19/25 (admission weight)-196 lbs. (pounds), 1/1/26-218.3 lbs., (11.38% gain) 1/6/26-180.6 lbs., 1/17/26-181.0 lbs. Further review of R80's weights did not reveal any documented weights for the period of 12/19/25 through 12/30/25. A review of R80's care plan revealed the following: Focus-Resident is at risk for altered nutritional status related to Tube feeding. Date Initiated: 12/19/2025 . A review of R80's dietary notes and evaluations did not reveal any progress notes or evaluations after the initial evaluation dated on 12/30/25 which revealed the following: CBW (current body weight) is 196# (BMI (body mass index): 23.9- underweight). Resident is added to weekly weightsx4 to establish trends. No edema noted.6 (-17.27%) A secondary review of the record did not reveal any medical provider evaluations or documentation that indicated R80 had been evaluated for their pathology of their severe weight gain noted on 1/1/26 or their severe weight loss on 1/6/26. On 1/27/26 at approximately 12:20 p.m., R80's medical record and weight fluctuations were reviewed with RD C. RD C was asked if they had been notified of the documented severe weigh gain on 1/1/26 (11.38%) and the subsequent weight loss on 1/6/26 of 180.6 (-17.26%). RD C indicated they were not made aware of the gain or loss and had not reassessed R80 since their initial evaluation on 12/20/25 using the admission weight of 196 lbs. RD C indicated that they do assess residents with severe weight loss and gain but had not for R80. RD C indicated that if the electronic medical record does not trigger for them to review a resident, then they rely on Nursing and Physician notification, and nobody had made them aware. On 1/27/26 at approximately 4:45 p.m., Physician QQ was asked if they had been made aware of the severe weight loss and gains that had been documented for R80 and they reported they had not. Physician QQ was asked they had assessed R80 for the reasons of the severe weight swings and they reported they had not but would check with their Nurse Practitioner. On 1/27/26 at approximately 5:12 pm., during a follow-up phone call from Physician QQ, Physician QQ reported they had spoken to Nurse Practitioner RR and that they believed Nurse Practitioner RR had been made aware of the concern, but no assessments or evaluations had been done. Physician QQ reported one of the medical providers would be in the evaluate R80 as the weight loss between the admission weight and the current weight was a concern. No documentation was provided by the end of the survey that documented R80 had been reassessed by the Registered Dietician or Medical Provider for their severe weight loss.

Based on observation, interview and record review the facility failed to maintain best practices in accordance with professional standards of food service safety. The deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: On 1/26/26 at approximately 8:39 a.m., during the initial tour of the kitchen, the following concerns were observed with Kitchen Manager LL (KM LL)Scattered pieces of food debris and trash were observed behind both of the ovens. A bowl of Chicken Salad was observed in the walk-in refrigerator with a used by date (UBD) of 1/24/26. A tray full of single serving portioned containers of yogurt was observed with a UBD of 1/24/26. Multiple single serving bowls of salad were observed in the walk-in refrigerator without any dating/labeling on them. An opened container of vegetable soup was observed in the walk-in refrigerator with a used by date of 1/24/26. A pan of uncooked bacon strips was observed unsealed and open to air in the walk-in refrigerator. A bag of opened frozen garlic bread was observed in the freezer unlabeled. A bag of frozen cooked chicken was observed with a UBD of 1/23/26 in the freezer. On 1/26/26 at approximately 9:45 a.m., the low temperature/sanitization dishwasher was observed to be not sanitizing at required levels of parts per million. KM LL was observed to be running multiple test strips which indicated PPM of 25-50. A review of the Dishwasher log revealed no log entry for the morning of 1/26/26. The Kitchen Manager indicated that kitchen staff had already ran the dishwasher that morning and they did not know why it was not logged but that it should have been. On 1/26/26 at approximately 9:50 a.m., during a follow-up conversation with KM LL, KM LL indicated they would throw away all the food that was past their documented used by dates or undated. They reported they would also contact the dishwashing company to come see what was wrong with the sanitization system and re-educate kitchen staff on logging the PPM tests on the daily log to ensure the dishwasher was sanitizing at appropriate levels. A review of the 2022 Food and Drug Administration (FDA) Food Code revealed the following: refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

Based on interview and record review, the facility failed to identify areas of deficiency and maintain an effective quality assurance and performance improvement program (QAPI) for a clean/comfortable/homelike environment and the facility's infection control program. This practice has the potential to affect all residents that reside in the facility. Findings include:On 1/28/26 at 3:34 PM, an interview was conducted with the facility's administrator regarding the facility's QAPI program. During the interview they were asked if the facility had identified any concerns with the physical environment or with the facility's infection control program through various methods utilized through their QAPI program and they reported they did not identify any environmental concerns or issues with the comprehensive infection control program. They did indicate the facility had four different infection control preventionists over the previous year and the most recent prior Infection Control Preventionist did not provide the QAPI members with any type of monthly report. Cross reference tags F584 and F880. A review of a facility document titled QAPI plan was reviewed and revealed the following: Purpose: It is the policy of this facility to systematically collect data as part of the QAPI program to ensure the care and services it delivers meet acceptable standards of quality in accordance with recognized standards of practice .

This citation pertains to intake 2628775. Based on observation, interview, and record review, the facility failed to identify and implement effective plans of action to correct identified quality deficiencies related to system failures including implementation of their abuse policy. This had the potential to affect all residents (including R88) who resided in the facility. Findings include:According to the facility's policy titled, Abuse, Neglect and Exploitation dated 1/10/2024: .An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur .Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations .Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and .Providing complete and thorough documentation of the investigation .The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation .Reporting/Response .Reporting of alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes as required by state and federal regulations: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury .Coordination with QAPI .Cases of physical or sexual abuse, for example by facility staff or other residents, will be reviewed for and receive corrective action and tracking by the QAA Committee. This coordinated effort results in the QAA Committee determining: a. If a thorough investigation is conducted. b. Whether the resident is protected. c. Whether an analysis was conducted as to why the situation occurred. d. Risk factors that contributed to the abuse .and e. Whether there is further need for systemic action . On 1/28/26 at 11:00 AM, an interview was conducted with the Administrator, Vent Administrator and two Regional Director of Operations staff.At that time, R88's facility reported incident (FRI) involving R88 and an alleged perpetrator (Certified Nursing Assistant/CNA 'H') was reviewed. Concerns were identified with the facility's documentation of investigation into this incident which included lack of timely notification to the State Agency, lack of police report filed, lack of suspension of the alleged perpetrator pending investigation, and lack of a complete, thorough investigation into the allegation.When asked if R88's investigation had been reviewed with the QAA (Quality Assessment and Assurance) Committee to review for areas of deficiencies or that needed corrective action, the Administrator reported their process was to review abuse allegations as part of QAA which included R88's allegation and they did not identify any concerns.

This citation pertains to intake #'s 2629174 and 2699963. Based on observation, interview, and record review, the facility failed to ensure an ongoing, comprehensive infection control program that: demonstrated ongoing facility surveillance for infections, identified infections and their origins, consistently utilized laboratory and diagnostic data, documented signs and symptoms of infections for monitoring for appropriate antibiotic usage, calculated facility infection rates, performed ongoing environmental surveillance, provided ongoing staff education, and adhered to accepted infection control principles such as hand hygiene and the use of proper transmission based precautions, resulting in the potential for the spread of infection, unidentified clusters or outbreaks of infection and inappropriate antibiotic usage. This deficient practice had the potential to affect all 83 residents who reside in the building. Findings include: On 1/28/26 at 11:04 AM, a review of the facility's comprehensive, ongoing infection control program was conducted. A review of the month of January 2026 revealed no ongoing data had been compiled to identify appropriate antibiotic usage, tracking for trends, clusters or outbreaks, ongoing surveillance, or staff education on infection control principles. Continued review of the monthly program data revealed the following: December 2025 There was no monthly summary that documented the prevalence of the different types of infection within the facility or a calculated infection rate. The facility's surveillance report documented 27 total infections. There were no documented signs and symptoms for any of the 27 infections to demonstrate they met the appropriate criteria for antibiotic usage. The report documented 17 infections (with no signs and symptoms) were treated with antibiotics, 3 infections were blank on whether they met criteria or did not meet criteria for antibiotic usage, and 7 infections were documented as meeting criteria for antibiotic usage despite no documented signs and symptoms. The report further documented 14 infections were healthcare-associated (developed in the facility), 4 developed prior to admission, and 9 were documented as developed, Other. It was also of note, December's data did not include any mapping for trends, clusters, or outbreaks. November 2025 There was no monthly summary that documented the prevalence of the different types of infection within the facility or a calculated infection rate. The surveillance report documented 28 total infections. There were no documented signs and symptoms to demonstrate whether any of the 28 met appropriate criteria for antibiotic usage. The report documented 9 infections were Acquired Prior, 3 were community acquired (outside of the facility), 10 were NA, and 6 were healthcare associated. It was unclear what the definition of Acquired Prior and NA meant. Further review of the report had No Response documented for all 28 infections in the Test Results and Test Type columns, and the Criteria Met column documented False for 21 infections and True for 7 infections despite no documented signs and symptoms. It was further noted No Response was documented in the Infection Type for 14 infections with the remaining 14 infections listing types such as: urinary tract infections, respiratory infections, blood stream infections, and skin infections. It was also noted the mapping for trends, clusters, and outbreaks only documented nine infections. It was unclear from the data what nine infections of the 28 total on the surveillance report were demonstrated on the mapping. October 2025 There was no monthly summary that documented the prevalence of the different types of infection within the facility or a calculated infection rate. The surveillance report documented 36 total infections. There were no documented signs and symptoms to demonstrate whether any of the 36 met appropriate criteria for antibiotic usage. The report documented 9 infections were Acquired Prior, 4 were community acquired (outside of the facility), 8 were NA, 1 was Null, and 14 were healthcare associated. Further review of the report had No Response documented for 35 infections in the Test Results and Test Type columns, with one having a test result and test type logged. The Criteria Met column documented False for 13 infections and True for 23 infections despite no documented signs and symptoms. It was further noted No Response was documented in the Infection Type for 11 infections with the remaining 25 infections listing types such as: urinary tract infections, respiratory infections, blood stream infections, and skin infections. It was also noted the mapping for trends, clusters, and outbreaks only documented nine infections. It was unclear from the data what nine infections of the 28 total on the surveillance report were demonstrated on the mapping. On 1/28/26 at 12:11 PM, an interview was conducted with the facility's Director of Nursing (DON) regarding the ongoing, comprehensive infection control program. The DON indicated the facility had four different infection control preventionists over the last year and didn't think they had the facility's best interests in mind. They indicated the data should list signs and symptoms of infections to demonstrate proper antibiotic usage and should accurately document whether residents admitted with infections or developed them in the facility. They further said the maps should be completed to demonstrate trends or outbreaks. They were asked about the terms Prior and NA documented in the Acquired columns and had no explanation saying infections can only be one of two ways, either a resident admits with an infection or develops it in the facility. The DON acknowledged the concerns with the program and indicated they had recently hired a new person for the position. On 1/28/26 at 3:32 PM, an interview was conducted with the facility's Administrator regarding the facility's Quality Assurance and Performance Improvement (QAPI) program. They were asked if they were aware of the status of the facility's infection control program and said they were not. They further volunteered the facility had been through several Infection Control Preventionists and the last person in the role did not report to the QAPI committee. A review of a facility policy titled, Infection Prevention and Control Program revised 12/27/23 was reviewed and read, Policy: This facility has established and maintains an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections as per accepted national standards and guidelines . Linen Storage: On 1/27/26 at 8:35 AM, Environmental/Housekeeping Manager (Staff 'AA') was requested to observe the facility's back-up linen supply and they reported they didn't have a key and would have to contact the Administrator who had those keys. On 1/27/26 at 8:55 AM, the Administrator provided the keys to Staff 'AA'. On 1/27/26 at 9:00 AM, upon entry to the basement storage room, just outside and across from the elevator, there were two large metal carts that had linens and resident care equipment (heel protectors) that were not covered and stored on the cart. There were several shelves of linens that were visibly soiled with debris particles. Staff 'AA' reported those should have been covered and would have to order covers for those carts. On 1/27/26 at 9:05 AM, upon entry into the locked storage room, there were several metal wire racks with many items stored, including the facility's emergency water supply, back-up linens, covid tests, face masks, and blankets. The entire flooring was heavily soiled with dark stains, debris and trash scattered throughout the area. The ceiling was observed to have visible water damage with pieces of the ceiling that were broken, bubbling up and discolored. The ceiling particles were also observed in piles on the flooring, on top of the shelves, including the emergency water supplies. There were three cardboard boxes which were later identified to contain blankets stored directly under the pipes that ran across the ceiling with the visible water damage. Each of these boxes were compromised from the water damage. On 1/27/26 at 9:12 AM, the Administrator joined in on the observation of the basement storage room and confirmed the same observations as identified above. They were then asked to identify the belongings that were stored throughout the storage room. The Administrator reported they had not previously been aware of the current conditions of the storage room. According to the policy titled, Collection, Sorting, Handling, and Transportation of Soiled Linens dated 2025: .The workflow of laundry processes should be designed in a way that prevents cross-contamination .Clean linens should be sorted, packaged, transported, and stored in a manner that prevents the risk of contamination by dust, debris, and other soiled items . According to the policy titled, Handling Clean Linen dated 10/30/2023: .It is the policy of this facility to handle, store, process, and transport clean linen in a safe and sanitary method to prevent contamination of the linen, which can lead to infection . On 1/26/26 at 9:35 AM, R64's room door was observed with signage for Enhanced Barrier Precautions (EBP) (an infection control intervention to reduce transmission of multidrug-resistant organisms) and gowns and gloves, the prescribed Personal Protective Equipment (PPE). Respiratory Therapist (RT) NN was observed providing tracheostomy tubing care and checking oxygen levels for R64 wearing only a pair of gloves. After care, RT NN was observed exiting the room removed their gloves and did not perform hand hygiene. On 1/26/26 at 10:53 AM, RT NN was observed at the respiratory treatment cart where they donned gloves, removed items from the cart, entered the room of R10 which was observed with EBP signage and PPE. RT NN provided respiratory care, wearing only gloves, and did not perform hand hygiene after providing care. On 1/27/26 at 9:22 AM, the Room of R46 was observed with EBP signage and PPE. RT Manager Q was observed wearing only gloves providing respiratory care to R46. On 1/27/26 at 9:22 AM, RT Manager Q verified anytime respiratory is providing care, touching the residents, they must wear the proper PPE and stated they must gown up. RT Manager Q was informed of the above observations and acknowledged this was not appropriate. Review of the facility policy titled Personal Protective Equipment dated 12/2023 documented. .All staff who have contact with residents and/or their environments must wear personal protective equipment as appropriate during resident care. Review of the facility policy titled Hand Hygiene dated 12/2023 documented. .All staff will perform proper hand hygiene procedures to prevent the spread of infection.

This citation pertains to Intake(s): #2629174, #2639760, #2658977, #2702355, and #2608297. Based on observation, interview, and record review, the facility failed to ensure there was sufficient nursing staff to meet the needs of the residents, resulting in a three hour delay in incontinence care for R16, R9, R43, R67, R71 and eight residents who wished to remain anonymous who attended the resident council interview and had the potential to affect all 83 residents who resided in the facility. Findings include: A review of a PBJ (Payroll Based Journal) Staffing Data Report for Fiscal Year (FY) Quarter 4 (7/1/25 – 9/30/25) revealed the facility triggered for excessively low weekend staffing based on the data they submitted. On 1/26/26 at 9:28 AM, R16 was observed sitting up in bed. R16 was able to understand questions asked and mouth answers but was unable to speak due to being dependent on a mechanical ventilator to breathe. R16's family member was at his bedside. An interview was conducted with R16 and his family member at that time. R16 reported he pushed the call light the night before at 4:00 AM and nobody helped him until 7:00 AM. R16 reported he needed his incontinence brief changed. When asked if anyone came into his room during that time, R16 said staff came in two times, but did not provide the care. R16's family member reported they did not think there was enough staff to care for the residents' needs during the weekends. On 1/26/26 at approximately 9:32 AM, R43 and R71 were observed lying in bed. Both residents were alert and able to answer questions asked. When asked about care at the facility, R71 reported that they are always low on staffing. Both R43 and R71 reported that on the midnight shift Sunday (1/25-1/26/26) there was only one CNA (certified nursing assistant) on the first floor from 2:00 AM to 7:00 AM. They stated it impeded on their roommate who requested to get out of bed by 6/6:30 AM as scheduled. R71 also reported that there were two residents that resided on the same hallway that kept screaming at one another and it appeared as if no staff could get them to calm down. On 1/26/26 at approximately 10:26 AM, CNA N was asked about staffing. They reported that there were only two CNA's working on the first floor today (1/26/26) as one CNA had called in. 33 residents resided on the first floor on 1/26/26. On 1/26/26 at approximately 10:30 AM, R9 was observed lying in bed. A hospice CNA was in the room with the resident. When asked about staffing care in the building, R9 reported that they did not believe there was enough staff to always care for her as she needed two people to assist. They noted that one of the reasons they chose Hospice services was that it ensured that they received more staffing for help with care as the facility was always short-staffed. On 1/27/26 at 1:30 PM, a confidential resident council meeting was held with 12 residents. When asked about whether they felt there was adequate staffing to meet their needs, eight residents expressed they felt there was not enough staff. Their responses were as follows: Over the weekend there were none here. On Sunday no one was here. A manager finally came in the afternoon. The weekends are the worst. A lot of staff recognizes the call light is on but will pass it up. Will keep on going down hall. End up waiting over an hour. It makes you feel insignificant. On 1/28/26 at approximately 9:11 AM, a nursing staff interview was conducted. The Nurse asked to remain anonymous. When asked about staffing they reported they did not feel like they could provide an honest answer as nursing staff are always yelled at when they report short staffing to State Surveyors. On 1/28/26 at approximately 10:15 AM, R67 was observed lying in bed. Their bedside table was out of reach from the resident. R67, who had difficulty verbally communicating, kept pointing to the table and tried to write on a piece of paper they needed assistance. R67 pressed their call light. CNA R entered the room and let R67 know that they know they moved the tray away from them as they were getting ready to give a shower but then had to leave to help other residents and left the tray table away from them. CNA R reported that they were assigned 17 residents and it was difficult to help residents timely. On 01/28/2026 at approximately 1:52 p.m., CNA I was queried regarding weekend staffing levels on Sunday evening (1/25/26) into the midnight shift. CNA I reported they were the only CNA for the ventilator unit on the second floor. CNA I indicated that if they were helping a resident and other call light buttons were going off with requests for assistance, they were unable to get to them on time. CNA I reported that over the last few months they worked by themselves about 19 times during their shifts. CNA I was asked how being short staffed affected the residents and they reported the residents had to wait longer for them to assist them. On 1/28/26 at approximately 2:25 p.m., Nurse SS was interviewed pertaining to staffing levels in the facility and they indicated that on Sunday midnight shift (1/25/26-1/26/26) the facility only had one (CNA) from 2:00AM-7:00AM on the first floor. Nurse SS indicated that many call lights were being pushed and there was not enough staff to answer all of them on time. On 1/28/26 at 12:07 PM, an interview was conducted with the Director of Nursing (DON) who was also in charge of the nursing staff scheduling in the absence of a Staffing Coordinator. When queried about how staffing was determined to meet the needs of the residents, the DON reported they followed the PPD (Nursing Hours per Patient Day) and operated within those numbers which were based on the census and time of day. When queried about how it was handled when staff called off of work, the DON reported they called people in to fill in the holes and if nobody was available, managers came in to work the floor. When queried about any staffing challenges on Sunday, 1/25/26-1/26/26, night shift, the DON reported she was unaware of any staffing problems that night. A review of the nursing staff schedule and assignment sheet and time punches from 1/25/26 night shift revealed CNA 'I' and CNA 'TT' punched out at 2:30 AM which left one CNA (CNA 'E') on the ventilator unit and one CNA (CNA 'G') on the First Floor. On 1/28/26 at 2:30 PM, a second interview was conducted with the DON and the above information regarding staffing on 1/25/26 night shift was discussed. The DON reported she was unaware that the facility was short staffed and said herself and the on call manager were not notified. *

This citation pertains to intake #s: 2608297, 2629174, 2639760, 2658977. Based on observation, interview and record review, the facility failed to maintain a clean, comfortable, safe, and homelike environment, affecting all 83 residents throughout the facility, including R8, R9, R30, R41, R43, R48, R56, R58, R59, R60, R64, R73, R78, R89, and five of 12 residents that attended the confidential resident council meeting. Findings include: On 1/26/26 at 10:25 AM, R56 was observed lying upon worn, ripped, stained, unclean fitted sheets. The bed frames were observed with dried substance matter along the perimeter of the mattress. The tube feeding pump, pole, and base was observed with dried splattered brown colored matter. Below the headboard revealed piles of small curly hair, and the flooring was dusty, stained, and appeared sticky. On 1/26/26 at 9:35 AM, Residents residing in room [ROOM NUMBER] (R64, R48, R59) were observed lying upon worn, ripped, stained, unclean fitted sheets. The bed frames were observed with dried substance matter along the perimeter of the mattresses. All three tube feeding pumps, poles, and bases were observed with dried splattered brown colored matter. The wall behind R59 was observed with a large opening exposing compromised dry wall. On 1/26/26 at 12:20 PM, the first-floor east shower room flooring was observed dirty, grimy, and small areas of dried white matter splattered on the floor in front of the sink. The toilet was observed having bowel movement and appeared to be sitting in the toilet bowl for some time. The shower bed mattress was unkempt and storing a soiled Hoyer lift tarp. The ceiling vent was observed with moderate dust coating the vents. The shower room on the first-floor west was observed with a grimy floor, and a pooled pile of water next to a black wheelchair which was observed covered in dirt, debris, and candy wrappers. A black seated cushion was observed lying next to the wheelchair with a large amount of brown colored dried substances. The room was cluttered with two Hoyer lifts (equipment to transfer and lift people), a ripped floor mat rolled up on the floor, two shower chairs with both seated areas ripped and exposing the foam padding. Oxygen tubing in a clear bag was observed on the floor underneath the shower chair along with a black comb. A Styrofoam cup with a lid was sitting on the sink counter and the toilet was covered in a clear plastic wrapping. The second-floor shower room west sink contained a moderate amount of pooled grey colored water revealing a ring around the perimeter of the basin indicating the water was sitting in basin for a while. The room was observed with a sewage type odor, and the shower bed padding was observed with tears exposing the foam and did not appear clean. The second-floor shower room east was observed storing two partial filled oxygen cylinders tagged with resident identifiers. The shower floor was observed with small piles of black hair on the right and back side. The floor drain under the shower bed revealed a caked-on substance and appeared dirty. The shower bed and shower chair were observed with hair and appeared not clean. On 1/26/26 at 4:00 PM, the Director of Nursing (DON), Housekeeping Manager AA, and Housekeeping Supervisor FF toured the shower rooms and indicated that housekeeping is responsible for maintaining the shower room floors and are cleaned daily between 7:00 AM and 3:00 PM. The DON confirmed shower equipment which included shower chairs, beds, and the paddings are cleaned in between resident use by nursing. During the tour of shower room east on the first floor, the DON and AA both indicated the bowel movement was in the toilet because there was a problem with the toilet not flushing. Both remarked that the bowel movement had been in the toilet for approximately one week, had submitted maintenance request to repair, and still was not done. The DON remarked the storage of Hoyer lifts, wheelchairs, and oxygen cylinders in shower rooms was not appropriate and should not be stored in the shower rooms. On 1/27/26 at 10:40 AM, an observation of the window blinds in rooms 219, 226, 221, 213, and 205 were observed damaged, bent, broken, and/or missing. On 1/27/26 at 8:20 AM, the round wall clock in room [ROOM NUMBER] displayed the time was 3:11 On 1/27/26 at 9:08 AM, the round wall clock in room [ROOM NUMBER] displayed the time was 3:17 On 1/27/26 at 9:11 AM, the round wall clock in room [ROOM NUMBER] displayed the time was 1:07 On 1/27/26 at 10:21 AM, the first-floor dining/activity room wall clock displayed the time was 3:43. R78 On 1/26/2026 at approximately 11:01 a.m., R78 was observed in their room, laying in their bed. R78 was queried if they had any concerns regarding their care and they reported they had concerns about their bed and leaning too far to the other side and they had multiple issues with facility linens being unavailable that included the facility running out of clean sheets/towels and wash cloths. R78 reported that their sheets are rarely changed due to the facility running out of clean sheets. On 1/27/26 at approximately 4:16 p.m., R78 was observed in their room, laying in their bed. R78 indicated that the facility was still having issues with linens and running out. R78 stated that Nurse aides are using towels and cutting them in half to use them to wipe up and then throwing them away which is causing the facility to run out. On 1/28/26 at approximately 9:42 a.m., R78 was observed in their room and up in their bed. R78 indicated that they had received a bed bath the previous evening (1/27/26) and that their sheets were wet as a result of the bath. R78 indicated they were left in wet sheets for hours, due to the staff not having any clean sheets available to change. On 1/27/26 the medical record for R78 was reviewed and revealed the following: R78 was initially admitted to the facility on [DATE]. A review of R78's MDS (minimum data set) with an ARD (assessment reference date) of 1/7/26 revealed R78 needed assistance from facility staff with their activities of daily living. R78's BIMS score (brief interview for mental status) was 15 indicating intact cognition. Review of the complaints reported to the State Agency included multiple concerns regarding the facility's environment, including safety, cleanliness, and availability of supplies, including linens. On 1/26/26 at 9:57 AM, the room occupied by R41 and R89 was observed with several environmental concerns, which included visible bowel movement matter left in the toilet bowel, and outside along the side of the toilet bowl, there was no toilet paper available in the room and several boxes of tissues were along the hand rails. There was a broken black trash can next to R41's bed with no liner, the wallpaper throughout the room was peeling. There were two large carts stored next to R89's bed along the wall near the bathroom that were heavily soiled with debris and dried splatters. The overbed light on the wall had the front covers pulled away which exposed sharp edges and not properly secured. The privacy curtains were heavily soiled. On 1/26/26 at 11:10 AM, R8 was observed lying in bed. The portion of the mechanical area under the bottom of the mattress and the overbed tray table were observed soiled with a dark brownish-red colored debris. On 1/26/2026 at 11:12 AM, R58 was observed lying in bed, asleep and not wake up. There was a tube feeding pole placed next to the bed that did not have any feeding hung. The pole and base of the tube feed holder was heavily soiled with tan colored debris (what appeared to be dried on tube feeding formula). The ceiling tiles directly above the bed and ceiling vent were also observed with the same tan colored debris (as if an object had splattered onto the ceiling). The privacy curtains around the bed were observed heavily soiled with dark stains and the netting that connected to the ceiling track contained several rips and holes. The wall under the window was observed to have water damage with the wallpaper peeling away. On 1/26/26 at 3:49 PM, the family of R56 approached the survey team and reported concerns that there were no linens available and because of this, their mother was unable to get their shower which had been scheduled for the day shift. On 1/26/26 at 3:52 PM, the room occupied by R41 and R89 was observed in the same manner as observed earlier this morning. Bowel movement matter was still present inside the toilet and dark stains along the entire outside of the toilet bowl. R89's bed linens were observed to have several small holes throughout the fitted sheet. R89 was not responsive to questions when approached. On 1/26/26 at 3:58 PM, there was a hard plastic cream-colored wall covering strip at approximately the ankle area that had missing end caps which exposed sharp edges to anyone walking by for rooms (223, 222, and the nursing office on the second floor center hall). On 1/26/26 at 4:00 PM, the doorframe for the soiled utility was observed with a sharp, plastic piece broken away near the bottom right side and potentially accessible to anyone walking by the area. On 1/26/26 at 4:04 PM, the linen room observed on the two east unit was observed to have no towels, no fitted sheets, no flat sheets, no gowns, no draw sheets, one bath blanket, five blankets. There was also an opened box of disposable gloves and two socks stored on the floor under the metal wire rack. Several of the washcloths were observed to be thin with strings hanging out and were dingy in appearance. On 1/26/26 at 4:05 PM, Interim Maintenance Director (Staff 'CC') was asked about the lack of linens and confirmed the lack of linens available in the linen room and would have someone arrange to get more linens available. When asked about the handrail located outside the soiled utility room (across from the linen room) on two east, Staff 'CC' confirmed the handrail was not secured properly and was pulled away from the wall. They reported they had not been aware of that before now. On 1/26/26 at 4:08 PM, the two west linen room was observed to have no towels, two fitted sheets, four gowns, nine flat sheets, no draw sheets, no bariatric gowns and several blankets. On 1/26/26 at 4:10 PM, Nurse 'A' was asked about the lack of linens and what their process was in the event they needed linens and reported they would visit other units and downstairs on first floor and go to laundry and see what's ready. On 1/26/26 at 4:12 PM, the first floor west clean linens room were very sparce and had no towels, one fitted sheet, no bibs, no bariatric gowns, only four flat sheets, one gown, one draw sheet, four bath blankets. Most of the linens were dingy in color with some that were yellowed and frayed. On 1/27/26 at 7:39 AM, the two west linen room was observed to have only one towel, no fitted sheets, five washcloths (thin/with strings and dingy in color), two flat sheets, no gowns, no draw sheets, no bariatric gowns. On 1/27/26 at 7:46 AM, the two east linen room was observed to have only one fitted sheet, no towels, one gown, several washcloths that were very thin, frayed and had stringy pieces hanging, no draw sheets, and no clothing protectors. On 1/27/26 at 8:12 AM, an interview was conducted with the Environmental/Housekeeping Manager (Staff 'AA) who reported they had been in their role at the facility since the end of November 2025. When asked to explain the facility's process for ensuring the facility had adequate linens available when needed, Staff 'AA' reported they usually had staff on three shifts (days, evenings and midnights) and were looking to hire several more housekeepers and laundry staff. When asked about who was responsible to ensure the linens that were being utilized were in good repair, Staff 'AA' reported if their staff saw anything like that (pointed to linens on two east that were frayed and worn), it should be reported to them and they would replace. When asked about the cleaning of the carts observed at bedside in the resident rooms, Staff 'AA' reported that was the responsibility of the nursing staff and their staff did not handle or touch the carts, including items like the tube feeding poles. Staff 'AA' further reported they sanitized bathroom door handles, bed frames, under the bed and mattress, and had a schedule to deep clean a different room everyday or if the resident moved or went to the hospital. When asked about the cleaning of the ceiling vents in the resident bathrooms, Staff 'AA' reported their staff were only responsible for cleaning the outer surface and did not remove the vent grids. When asked who would be responsible, they reported that would be the Maintenance staff or anyone that saw it visible soiled. When asked how it would be reported, Staff 'AA' reported the facility utilized an electronic reporting system. When asked about who maintained the resident's privacy curtains, Staff 'AA' reported their floor tech was responsible for changing the curtains if housekeeping or nursing staff identified any. At that time, Staff 'AA' confirmed the heavily soiled privacy curtains for rooms [ROOM NUMBER]. On 1/27/26 at 8:19 AM, Staff 'AA' was asked to observe several resident rooms and confirmed the same findings from 1/26/26 for R30's soiled bed frame, flooring, ceiling tiles, communication board, overbed tray table, privacy curtains, and debris throughout the floor. Staff 'AA' reported they would have to get R30 up to clean and wipe the table down but it would be up to nursing to clean the communication sheet and tube feeding poles. On 1/27/26 at 8:22 AM, Staff 'AA' was asked to observe the room shared by R41 and R89 and confirmed the same concerns as seen on 1/26/26 which included the debris scattered throughout the flooring, heavily soiled flooring, ceiling tiles with water damage, wall lights that were pulled away from the wall and exposed sharp edges, ceiling, tube feeding pole and privacy curtains remained soiled for R89. Additionally, the trash can for R41 had no liner and was filled with trash, the area under R41's bed remained soiled with multiple debris. The bathroom's flooring and walls remained soiled and the toilet bowl remained soiled with bowel movement matter. The ceiling fan also was heavily soiled with thick dust. The two carts next to R89's bed remained heavily soiled. Staff 'AA' reported their staff were not responsible for the carts in the room, and when asked about the other items, they reported they were and would have to follow up with their staff. On 1/27/26 at 8:33 AM, Staff 'AA' confirmed R58's room remained in the same soiled manner as observed on 1/26/26: dark brownish/reddish colored splatters on the mechanical underside of the bed, including onto the overbed tray table feet. Multiple debris scattered throughout the floors. The shared bathroom ceiling fan remained heavily soiled with thick dust and stringy debris. Staff 'AA' was unable to offer any further explanation as to the current state of the room and bathroom. On 1/27/26 at 8:35 AM, Staff 'AA' was requested to observe the facility's back-up linen supply and they reported they didn't have a key and would have to contact the Administrator who had those keys. On 1/27/26 at 8:55 AM, the Administrator provided the keys to Staff 'AA'. On 1/27/26 at 9:00 AM, upon entry to the basement storage room, just outside and across from the elevator, there were two large metal carts that had linens and resident care equipment (heel protectors) that were not covered and stored on the cart. There were several shelves of linens that were visibly soiled with debris particles. Staff 'AA' reported those should have been covered and would have to order covers for those carts. On 1/27/26 at 9:05 AM, upon entry into the locked storage room, there were several metal wire racks with many items stored, including the facility's emergency water supply, back-up linens, covid tests, face masks, and blankets. The entire flooring was heavily soiled with dark stains, debris and trash scattered throughout the area. The ceiling was observed to have visible water damage with pieces of the ceiling that were broken, bubbling up and discolored. The ceiling particles were also observed in piles on the flooring, on top of the shelves, including the emergency water supplies. There were three cardboard boxes which were later identified to contain blankets stored directly under the pipes that ran across the ceiling with the visible water damage. Each of these boxes were compromised from the water damage. Additionally, there was a wire that protruded from the ceiling that was wrapped around one of the metal shelving units and hung from the bottom shelf that had exposed wires. Staff 'AA' was asked about the current conditions of the room, including the items affected and they reported this was the first time they had been in the room and was not able to offer any further explanation. Staff 'AA' was requested to have the Administrator come to the storage room. On 1/27/26 at 9:12 AM, the Administrator arrived and confirmed the same observations as identified above. When asked about the exposed wiring, the Administrator proceeded to pull the wiring up and reported it was an old telephone jack. They were then asked to identify the belongings that were stored throughout the storage room. The Administrator reported they had not previously been aware of the current conditions of the storage room. On 1/27/26 at 11:05 AM, the Director of Nursing (DON) was asked to observe several resident rooms which included R30's room and confirmed the same observations of the heavily soiled communication board, overbed tray table, privacy curtains, tube feeding pole and bedframe, including the flooring which had a large amount of debris and trash under the bed. When asked who was responsible for cleaning the resident's equipment including the tube feeding pole and communication board, the DON reported they would expect that nursing picked up any items during care, but ultimately housekeeping was responsible. The DON was informed that Staff 'AA' had reported they were not responsible for those items. On 1/27/26 at approximately 3:00 PM, the Administrator, in the presence of Regional Director of Operations (RDO 'II' and RDO 'JJ'), they were notified the survey team identified substandard quality of care regarding the environment. They were asked if they had any questions and reported they did not. RDO 'II' reported the facility had identified concerns with environment about three weeks ago when their Maintenance Director left and was having a team of people try to tackle the environment. They were informed the concerns remained out of compliance during this standard survey and they expressed understanding. Resident Council: On 1/27/26 at 1:30 PM, during the confidential resident council meeting, residents were asked if they had any environmental concerns, including availability and appearance of linens such as bed sheets, towels, and washcloths. There were five of the 12 residents in attendance that expressed concerns. Responses included: The linens are ripped and have holes. Facility said they just got about 3,000 new linens, can't tell. Also, this morning my fitted sheet was soiled and the midnight shift said there were non available on the midnight shift so I had to stay in my chair for a few hours until the day shift aide got some new sheets. Think there is an issue of staff throwing out linens instead of washing them because they won't let us use wipes to clean people. We haven't been able to use for a while. Administration said wipes can no longer be used. I have a commode and there are no trash bags to replace or to empty the dirty linens in. Review of the electronic work order log from 11/27/25 - 1/27/26 revealed staff had not reported concerns with the multiple environmental concerns identified above. The policies provided regarding linens did not address the condition of the linens, or when they should be replaced. According to the policy titled, Handrails dated 1/1/2022: .All handrails will be firmly secured . According to the documentation provided by the facility which was not an official policy but included checklists for the housekeeping routines which included: .5 Step Procedure .Pull trash/Replace liner, Horizontal Surfaces, Vertical Surfaces, Dust Mop, Damp Mop .7 Step Procedure .Check/Refill Supplies, pull trash/Replace liner, Dust Mop/Sweep, Clean Sink Area/Tub, Clean Commode/Base, Clean Walls/partitions, Damp Mop . On 1/26/26 at 10:09 AM and 11:50 AM, the bedside table for room [ROOM NUMBER] bed 1 was observed to have dried spots appearing sticky with food debris and crumbs scattered across the table. At approximately 12:45 PM the resident assigned to 219 bed one was observed to have their lunch meal served on the soiled table. On 1/26/26 at 10:19 AM the bedside table for room [ROOM NUMBER] bed 1 was observed with a dried, yellow crusty substance running in the groove of the table. The table further revealed a large, dried, tan stain appearing sticky. The room itself was observed with copious amounts of food, crumb, and paper debris, discarded gloves on the floor and the floor was dirty and soiled in appearance. On 1/26/26 at 10:32 AM, 11:51 AM and 3:42 PM, an observation room [ROOM NUMBER] bed 1's area revealed a white, plastic respiratory cart containing an oxygen tank. The plastic cart had numerous brown stains dripped on it. Slightly behind the cart was oxygen tubing disconnected from the tank and lying on the floor. The bedside table belonging with 221 bed 1 was observed to be soiled with sticky substances and food and crumb debris. On 1/26/26 at 1:00 PM, the bedside table for room [ROOM NUMBER] bed 1 was still observed with a dried, yellow crusty substance running in the groove of the table and the large, sticky, dried, tan stain. At that time, it was further observed the resident assigned to 220 bed 1 had been served their lunch meal on the soiled table. The floor in the room remained littered with food and paper debris. On 1/26/26 at 1:10 PM and 3:43 PM, room [ROOM NUMBER] was observed to be empty and ready to receive admissions into the room. The fitted sheet on 202 bed 1 was observed to be very thin and had several diffuse holes in the center of the sheet. On 1/26/26 at 3:40 PM, the bedside table for 220 bed 1 remained soiled with the stains, food and crumb debris. The floor remained with food and paper debris and gave no indication the room had been swept or mopped since the first observation of the room at 10:09 AM. On 1/27/26 at 10:11 AM, room [ROOM NUMBER] remained empty, however; the thin fitted sheet with holes from 202 bed 1 observed on 1/26/26 was now observed to be on 202 bed 2. Further observations on 1/27/26 at 12:21 PM and 1/28/26 at 9:25 AM revealed the thin sheet with holes remained on 202 bed 2. On 1/27/26 at 10:13 AM and 2:25 PM, the bedside table for room [ROOM NUMBER] bed 1 was still observed with a dried, yellow crusty substance running in the groove of the table and the large, sticky, dried, tan stain. The floor in the room remained littered with food and paper debris. It was further observed a tracheostomy inner cannula was on the floor at the foot of 220 bed 2. A final observation on 1/28/226 at 9:28 AM continued to reveal the table for bed 220 bed 1 with the yellow, crusty, sticky stains, and the large sticky tan stain giving no indication the table had been cleaned or sanitized since the original observation on 1/26/26. On 1/27/2026 10:12 AM and 2:26 PM, and on 1/28/26 at 9:30 AM, a follow-up observation of room [ROOM NUMBER] bed 1's area revealed the soiled respiratory cart, the oxygen tubing on the floor, the dirty bedside table with sticky stains and food debris, and the floor appearing with paper and food and crumb debris scattered about, giving no indication the floor had been swept or mopped since the original observation on 1/26/26. During an initial tour of the facility on 1/26/26 between 9:17 AM and 10:40 AM the following was observed: R43 and R71: Upon entering their room a pile of dirty linen was lying on the floor. The floor was covered with trash and dirt. R43 and R71 were both alert and able to answer questions asked. They both reported that their room is rarely cleaned, the linen had been on the floor for days and noted that there were no housekeeping staff in the building on Saturday (1/24/26). Additionally, they pointed to their garbage cans and noted that there were no bags in the cans and additional noted that their sheets were torn and dirty. R9: R9 was observed lying in bed, was alert and able to answer all questions asked. A hospice CNA (certified nursing assistant) was also in the room assisting the resident. When asked about life in the facility, R9 had several concerns, with respect to the environment, they noted that there are never enough towels available and it impedes with their showers. Hospice CNA M noted they tried to give R9 a shower a few days ago but noted that there was no hot water in the building. Hospice CNA M stated that they did try to give R9 a shower/bath today but stated there were no bath towels available, only small face towels. R60: A half sharp piece of metal was observed on both the left and right side of the bed. There were no assist bars on top of the sharp metal poles. R60 was asked what the metal poles were for and they reported they were not certain but stated sometimes when they are rolled over by staff, they will grab them. On 1/26/26 at approximately 3:53 PM, metal bars were still attached to the bed. Physical Therapy Director (PTD) L was asked to observe the poles. PTD L reported that they appeared to be a part of what would have been an assist bar. However, they noted there was no order for assist bars for R9 and they should be removed from their bed.

This citation pertains to Intake(s): #2628775 and #2607040. Based on interview and record review, the facility failed to complete thorough investigations of allegations of staff to resident physical and sexual abuse and allegations of poisoning by R18 and a staff member and failed to implement interventions to protect the residents during the investigations for two (R86 and R88) of two resident reviewed for abuse. Findings include: On 1/26/26 at 2:00 PM, the Administrator was asked to provide R88's FRI report for review. Review of the FRI documentation submitted by the facility to the State Agency on 8/13/25 at 2:59 PM, with an investigation submitted on 8/20/25 at 9:28 PM. The documentation report read, .Perpetrator Name [Name redacted] .Certified Nursing Assistant (CNA 'H').Were There Any Witnesses? No .Date/Time Incident Discovered: 8/13/2025 12:30 PM .Date/Time Incident Occurred: 8/12/2025 12:30 PM .Facility Investigator: (Director of Social Services/DSS 'T') .Incident Summary: CNA (HH) reported that another resident stated that she witnessed the C.N.A in her room caring for a her [sic] roommate [R88] for an for an [sic] extended amount of time . The report did not identify the specific allegation of mistreatment. Further review of the facility's investigation summary included: .On 8\12\2025 Risk Management Coordinator (DSS 'T') was informed of an alleged incident from a C.N.A (HH) that was reported to her through (R86), (R88s) roommate. R86 alleged that CNA 'H' appeared to be caring for the roommate for an extended period of time. (R86) was not able to confirm any inappropriate behavior other than (CNA 'H') normally spending 15 minutes at most but this time he was in the room for approximately 45 minutes. Interviews: (R86) was interviewed regarding concerns and she stated that she did not see (CNA 'H') do anything inappropriately. She was concerned about the time that he spent caring for her as it was longer than normal. (R88) - Unable to interview residents as she has a BIMS (brief interview for mental status) of 2 and not able to verbally communicate. Skin and Pain assessment completed immediately. No skin or pain concerns noted. (CNA 'HH') was interviewed to what was reported to her by (R86). (R86) reported to (CNA 'HH') that (CNA 'H') was on (R88) side for an extended period of time. (R86) stated that she waited for about 15 minutes and then went to the bathroom and seen (CNA 'H') holding (R88) arm close to her wrist. (R86) at that time began to yell at (CNA 'H') asking What are you doing. (R86) stated that (CNA 'H') stated I am caring for her. (Administrator) interviewed (R86) the following morning. (R86) stated to writer that (CNA 'H') was caring for (R88) longer than normal and that made her uncomfortable. When writer asked her if she had witnessed or heard anything and resident stated no. She only heard (R88) making noise during care but nothing out the ordinary. Writer asked (R86) has she had any concerns with her care from (CNA 'H') and she said no. She was just concerned because he was in the room longer than normal. (CNA 'H') was interviewed regarding the allegation. (CNA 'H') stated when he entered the room he noticed that (R88) removed her brief and had been playing in BM (bowel movement). He exited to room to gather supplies to clean her up and also grabbed the nurse to come in and witness her condition. He had to give her a bed bath, change her gown, linen, and also clipped and cleaned her nails as her nails were longer than normal and also had BM underneath them. (CNA 'H') does admit to being in the room longer than normal due to (R88) requiring more assistance than normal. Interviewed all resident with BIMS of 11 and higher on (R86's) hallway to ensure they have had no concerns with staff during their stay. All residents interviewed has no concerns. Conclusion: The facility was unable to substantiate the allegations based on record review and interviews.(CNA 'H') has also been reassigned from the 1st floor to the 2nd floor. Center will continue to monitor resident per her plan of care. The facility respectfully requests a desk review. Action Plans: Notification of Physician Notification of Guardian Pain Assessment Completed: No Pain Noted Skin Assessment Completed: No Injury Noted Care Plans Reviewed. When (date and time) did the problem occur? 08/12/2025 12:30 PM Are law enforcement agencies involved? No Were There Any Witnesses? No Were Other Agencies Notified? No. There were no interviews included in the file initially provided by the facility. However, upon reviewing additional FRI's for R86 it was revealed the files were disorganized and additional documentation for this investigation was found filed within several other files, separate form this investigation. Further review of the additional documentation revealed, the incident was reported to facility staff and documented on a witness statement on 8/11/25 that the alleged incident occurred on 8/10/25. However the facility's documentation submitted to the State Agency documented the alleged incident had first been discovered on 8/13/25 at 12:30 PM and the incident occurred on 8/12/25 at 12:30 PM. The following witness statements revealed this incident was initially identified by facility staff on 8/11/25 at 2:45 PM to (Former Director of Social Services/DSS 'U') and also identified a different date of when the allegation occurred. This documentation included the following statements: STATEMENT OF WITNESS documents read: .Name and Position of Witness: (Social Service Staff/SS 'V') .Date and time of incident: 8/10/25 10:00 PM .Resident Name: (R86) .Name and title of person conducting interview: (Former DSS 'U') .Date and place of interview: 8/11/25 2:45 PM . .Statement of Witness .Resident reports during night shift yesterday, she observed the CNA assisting her roommate excessively long. Resident reports she observed the CNA bent over roommate & holding her wrists down. Resident reports her roommate looked upset. Resident reported when she asked what the CNA was doing, he reported he was clipping her nails. The allegation of holding her wrists down was not included in any of the documentation provided to the State Agency, or within the facility's investigation summary. Another STATEMENT OF WITNESS document read: .Name and Position of Witness: (SS 'V') .Date and time of incident: 8/10/25 10:00 PM .Resident Name: (R88) .Name and title of person conducting interview: (Former DSS 'U') .Date and place of interview: 8/11/25 2:45 PM . .Statement of Witness .Resident was rarely understood during interview, based on observation, resident seemed nervous & reluctant to speak. SW (Social Work) did not observe any physical symptoms/wounds. Residents nails were not clipped. Resident did smile at end of interview. This information was not identified by the facility's investigation, in which CNA 'H' reported they had clipped R88's fingernails. Another STATEMENT OF WITNESS document read: .Name and Position of Witness: (left blank) .Date and time of incident: (left blank) .Resident name: (R86) .Name and title of person conducting interview: (Business Office Manager/BOM 'GG') .Date and place of interview: 8/12/25 Admin Office . .Statement of Witness .When speaking to (R86) on the morning of 8-12-25 She stated that (CNA 'H') the CNA normally take 15 moments at the most to provide care to her or her roomate [sic]. So when (CNA 'H') was providing care to (another name for R88) it was alarming to her because of how long it was taking him to provide care to (R88) she also stated (R88) was making strange noises so she pulled the curtain back and seen (CNA 'H')'s shadow standing over (R88) and he did something with a towel and threw it on the floor. she then stated she got up and act as if she was going to the restroom so she can see what (CNA 'H') was doing so she observed him with his hands around (R88) wrist tight. she asked what was he doing so she observed him with his hands around (R88) wrist tight. She asked what was he doing to her and he said she has his arm and he was trying to get her to let go. After he got done providing care he went to (R86) to explain he would never hurt a resident. The section for signature and date for witness and interviewer was left blank. The information about CNA 'H's wrist around R88's wrist tight or that CNA 'H' had further discussion with R88 about what they alleged was not included in the documentation submitted to the State Agency, or within the facility's investigation. The facility's investigation documented that a skin assessment had been completed immediately, however this documentation which was found in another FRI investigation for R86 revealed the skin assessment for R88 had been completed on 8/9/25 (prior to the incident and the next documented skin assessment wasn't until 8/19/25). Further review of the time punch details for CNA 'H' revealed the employee continued to work the midnight shift on 8/12 and 8/14/25. The Administrator was requested to provide dates of CNA 'H's suspension and provided a handwritten note that stated 8/16/25 – 8/26/25. CNA 'H' had not been suspended pending investigation when the initial allegation was identified on 8/11/25. On 1/28/26 at 11:10 AM, an interview was conducted with the Administrator in the presence of Vent Administrator, the Regional Director of Operations (RDO 'II' and RDO 'JJ') and later joined by Corporate Clinical Support (Nurse 'KK'). When queried about the inaccurate, unorganized and misleading documentation included within the facility's investigation for R88, the Administrator was unable to offer any further explanation. When asked about the limited documentation provided and documentation found in other investigations and general lack of organized, accurate documents, the Administrator reported they could not offer any further explanation. When queried about why R88's allegation of being held down by CNA 'H' was not included in the report made to the State Agency, why the police were not notified, why the CNA wasn't suspended, and why the documentation was disorganized, and the investigation not reflective of the actual statements included in the witness statements, the Administrator reported the police should've been contacted and reported they went off what was told to them. When asked about the delay in reporting the allegation to the State Agency, the Administrator reported they were not able to offer any further explanation. Review of the clinical record revealed R88 was initially admitted into the facility on [DATE], and discharged on 11/11/25 with diagnoses that included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, altered mental status, aphasia, unspecified convulsions, metabolic encephalopathy, and aneurysm of unspecified site. According to the MDS assessment dated [DATE], R88 had severe cognitive impairment, had unclear speech and sometimes makes themselves understood, rarely/never understands others, and was dependent upon staff for most aspects of care. According to the facility's policy titled, Abuse, Neglect and Exploitation dated 1/10/2024: .An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur .Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations .Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and .Providing complete and thorough documentation of the investigation .Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation. B. Examing the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed. C. Increased supervision of the alleged victim and residents. D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. E. Protect from retaliation. R86 On 1/28/26 at 8:23 AM, the Administrator was asked to provide any incident reports and investigations for R86 for the month of August 2025. Multiple investigation files were provided and reviewed. Incident #1 (R86 and Certified Nursing Assistant – CNA 'H') A review of a FRI report submitted by the facility to the State Agency revealed on 8/18/25, R86 Reported an allegation of abuse against (CNA 'H') .Nurse Aide was suspended pending investigation. The report did not include what the abuse allegation was specifically. A review of the investigation file provided by the facility regarding that allegation on 8/18/25 revealed an incident report completed by Licensed Practical Nurse (LPN) 'D' on 8/18/25 that noted, .Pt (patient) reported alleged abuse to administrator.Pt states Nurse assistant raped her while doing patient care. It was documented the Director of Nursing (DON) was notified on 8/18/25 at 12:00 PM and the Administrator was notified on 8/19/25 at 4:29 PM. A review of the Investigation Summary completed by the Administrator revealed the following documentation, .On August 18th (R86) contacted the Abuse Coordinator to report that on August 11th, 2025, she felt that during her sleep she feels as if someone entered her room and did something to her. She stated that person is (CNA 'H') . It was documented CNA 'H' was suspended pending the investigation on 8/18/25. There was nothing documented in the investigation summary submitted to the State Agency that mentioned the allegation of rape made by R86 as documented on the incident report. Incident #2 (R86 and R18) A review of an investigation conducted by the facility revealed on 8/23/25, R86 texted the Abuse Coordinator (who was the Administrator) and alleged R18 poisoned her coffee. It was documented the incident occurred on 8/23/25 at 7:30 AM and it was discovered at 8:00 AM. It was documented on the Facility Reported Incident (FRI) report that the allegation was submitted to the State Agency on 8/23/25 at 8:00 PM, 12 hours after the allegation was made (discovered). Further review of the FRI report and the investigation folder provided by the facility revealed no investigation was submitted to the State Agency within the five-day required time frame. Incident #3 (R86 and LPN 'D') A review of an investigation conducted by the facility revealed on 8/19/26, R86 alleged LPN 'D' contacted the police and alleged LPN 'D' poisoned her coffee. A review of the facility's investigation summary revealed, .On August 19th at roughly 815pm, (R86) contacted the police and wanted to be transferred to the hospital. (R86) alleged to the local police that her nurse (LPN 'D') poisoned her coffee. The police arrived and escorted (R86) to the hospital at roughly 845pm.NHA (Nursing Home Administrator) requested lab work and urinalysis to be performed on her return from the hospital. Hospital paperwork, lab results and facility lab results pulled for review. Interviewed (LPN 'D'). (LPN 'D') stated that she did not have any involvement with preparing or delivering any coffee to (R86). Interviewed (R86's roommate) to see if she had any concerns with her food or if she felt ok. She did not witness anything. Also asked if she witnessed anyone put anything in (R86's) water when it was delivered. She stated no. (Unit Manager, Registered Nurse – RN 'K') reviewed the surveillance video to determine if any suspicious activities were noted during the water pass. Unit Manager did not see anything abnormal during the video.The facility was unable to substantiate the allegations based on record review and interviews. There was no evidence that R86 was interviewed regarding her allegation. Incident #4 (R86 and LPN 'D') A review of an investigation conducted by the facility revealed on 8/26/26, R86 alleged LPN 'D' poisoned her, and the resident contacted 911 to be transferred to the hospital. It was documented the incident occurred on 8/26/25 at 2:00 PM and it was discovered on 8/26/25 at 4:00 PM. A review of the facility's investigation summary revealed interviews with LPN 'D' and R86's roommate which were the same interview from the allegations made on 8/19/25 regarding LPN 'D' allegedly poisoning R86's coffee. The allegation made on 8/26/25 did not say R86's coffee was poisoned, only that she was poisoned. There was no evidence R86 was interviewed regarding the allegations and no evidence of any further investigation into how or what R86 believed she was poisoned with. On 1/28/26 at 11:00 AM, an interview was conducted with the Administrator (Abuse Coordinator). When asked why the allegation of rape was not included in the investigation summary the Administrator did not offer a response. When queried about why there was no investigation completed regarding R86's allegation of being poisoned by R18, the Administrator reported she did not know why and confirmed an investigation was not completed. When queried about why the investigation into R86's allegation of being poisoned by LPN 'D' on 8/26/25 was the same as the investigation into R86's allegation of LPN 'D poisoning her coffee on 8/19/25, the Administrator reported she submitted the wrong investigation. At that time, the correct investigation was requested. When queried about why R86 was not further interviewed to get additional information about her allegations, the Administrator reported she was. When queried about why the content of those interviews were not included in the investigations, the Administrator did not offer a response. No additional information was provided prior to the end of the survey. On 1/28/26 at 1:09 PM, a review of LPN 'D' personnel files was conducted. There was no evidence that LPN 'D' was suspended pending the investigations into the allegations on 8/18/25 and 8/26/25 that she poisoned R86. On 1/28/26 at approximately 2:00 PM, an interview was conducted with the Administrator. When queried about whether LPN 'D' was suspended pending the investigations after it was alleged on 8/18/25 and 8/26/25 that she poisoned R86, the Administrator reported she was not suspended and did not offer an explanation why. A review of R86's clinical record revealed R86 was admitted into the facility on 5/9/25 and discharged on 8/28/25 with diagnoses that included: schizoaffective disorder. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R86 had intact cognition.

Based on observation, interview and record review, the facility failed to lock medication/treatment cart and failed to store medications safely and securely on the second floor. Findings include:On 1/27/26 at 9:58 AM, an observation of medication cart #3 on the second floor was conducted with Nurse 'OO'. During the observation the third large drawer on the left side of the medication cart was observed to contain an opened can of energy drink. Nurse 'OO' said it did not belong to them, and the previous nurse must have left it in there. Continued review of the cart revealed a box of Dulcolax suppositories with an expiration date of 11/2025, and a bottle of redness relieving eye drops in an opened box that did not contain a label for whom they belonged. Nurse 'OO' said expired medications should be discarded and all medications in the cart should be labelled with a patient name. On 1/26/26 at 10:35 AM, the second-floor respiratory cart was observed unlocked and not under direct observation of authorized staff. A second respiratory cart was observed unlocked and not under direct observation of authorized staff and had a key with an orange-colored key ring in the lock. Access to all drawers was observed and medications identified. On 1/26/26 at 10:43 AM, Respiratory Therapist (RT) MM was observed exiting a resident room, not in view of the cart, walked to the cart then proceeded to remove the keys. On 1/26/26 at 10:51 AM, RT MM was interviewed and confirmed by opening the drawers and showing respiratory cart drawers contained breathing supplies, equipment, and medication. On 1/27/26 at 8:13 AM, a treatment cart located on the second floor outside of room [ROOM NUMBER] was observed unlocked and not under direct observation of authorized staff. While making note of the observation, Unit Manger Register Nurse Y inquired if I was done going through the cart and proceeded to reach around and lock the cart. On 1/27/26 at 9:18 AM, Licensed Practical Nurse (LPN) A was observed for medication administration and when retrieving medication from the narcotic box of the second-floor medication cart, two clear medicine cups with a cloudy gel-like substance was observed lying sideways in-between narcotic blister packs. LPN A indicated these were for one of their residents to be administered. When asked where it came from, LPN A indicated they retrieved the medication from the treatment cart down the hall, put the ointment in the cups, and stored it in the narcotic box. When asked what the medication was, LPN A said they weren't sure what the medication was called, mentioned it was something for the residents' legs, and observed looking into the Medication Administration Record (MAR) to find the name. On 1/28/26 at 12:08PM, The Director of Nursing (DON) was interviewed and acknowledged all respiratory, medication and treatment carts need to be locked and storing of medication cup was unsanitary, and medication without patient identifier or medication labeling is not acceptable. Review of the Medication Storage Policy dated 1/2024 documented. .It is the policy of this facility to ensure all medications housed on our premises will be stored.to ensure proper sanitation.and security.

This citation pertains to Intake #2628775. Based on interview and record review, the facility failed to report allegations of staff to resident physical and sexual abuse and resident to resident abuse (poisoning) to the State Agency within the required time frame that included accurate information regarding the allegations, report to law enforcement, and submit a five-day investigation to the State Agency for two (R86 and R88) of two residents reviewed for abuse, resulting in a delay in investigation into allegations of R86 being poisoned by R18 and raped by a staff member, and R88 being held down by her wrists by staff. Findings include: On 1/26/26 at 2:00 PM, the Administrator was asked to provide R88's Facility Reported Incident (FRI) report for review. Review of the FRI documentation submitted by the facility to the State Agency on 8/13/25 at 2:59 PM, with an investigation submitted on 8/20/25 at 9:28 PM. The documentation report read, .Perpetrator Name [Name redacted] .Certified Nursing Assistant (CNA 'H').Were There Any Witnesses? No .Date/Time Incident Discovered: 8/13/2025 12:30 PM .Date/Time Incident Occurred: 8/12/2025 12:30 PM .Facility Investigator: (Director of Social Services/DSS 'T') .Incident Summary: CNA (HH) reported that another resident stated that she witnessed the C.N.A in her room caring for a her [sic] roommate [R88] for an for an [sic] extended amount of time . The report did not identify the specific allegation of mistreatment. Further review of the facility's investigation summary included: .On 8\12\2025 Risk Management Coordinator (DSS 'T') was informed of an alleged incident from a C.N.A (HH) that was reported to her through (R86), (R88s) roommate. R86 alleged that CNA 'H' appeared to be caring for the roommate for an extended period of time. (R86) was not able to confirm any inappropriate behavior other than (CNA 'H') normally spending 15 minutes at most but this time he was in the room for approximately 45 minutes. Interviews: (R86) was interviewed regarding concerns and she stated that she did not see (CNA 'H') do anything inappropriately. She was concerned about the time that he spent caring for her as it was longer than normal. (R88) - Unable to interview residents as she has a BIMS of 2 and not able to verbally communicate. Skin and Pain assessment completed immediately. No skin or pain concerns noted. (CNA 'HH') was interviewed to what was reported to her by (R86). (R86) reported to (CNA 'HH') that (CNA 'H') was on (R88) side for an extended period of time. (R86) stated that she waited for about 15 minutes and then went to the bathroom and seen (CNA 'H') holding (R88) arm close to her wrist. (R86) at that time began to yell at (CNA 'H') asking What are you doing. (R86) stated that (CNA 'H') stated I am caring for her. (Administrator) interviewed (R86) the following morning. (R86) stated to writer that (CNA 'H') was caring for (R88) longer than normal and that made her uncomfortable. When writer asked her if she had witnessed or heard anything and resident stated no. She only heard (R88) making noise during care but nothing out the ordinary. Writer asked (R86) has she had any concerns with her care from (CNA 'H') and she said no. She was just concerned because he was in the room longer than normal. (CNA 'H') was interviewed regarding the allegation. (CNA 'H') stated when he entered the room he noticed that (R88) removed her brief and had been playing in BM (bowel movement). He exited to room to gather supplies to clean her up and also grabbed the nurse to come in and witness her condition. He had to give her a bed bath, change her gown, linen, and also clipped and cleaned her nails as her nails were longer than normal and also had BM underneath them. (CNA 'H') does admit to being in the room longer than normal due to (R88) requiring more assistance than normal. Interviewed all resident with BIMS of 11 and higher on (R86's) hallway to ensure they have had no concerns with staff during their stay. All residents interviewed has no concerns. Conclusion: The facility was unable to substantiate the allegations based on record review and interviews.(CNA 'H') has also been reassigned from the 1st floor to the 2nd floor. Center will continue to monitor resident per her plan of care. The facility respectfully requests a desk review. Action Plans: Notification of Physician Notification of Guardian Pain Assessment Completed: No Pain Noted Skin Assessment Completed: No Injury Noted Care Plans Reviewed. When (date and time) did the problem occur? 08/12/2025 12:30 PM Are law enforcement agencies involved? No Were There Any Witnesses? No Were Other Agencies Notified? No. There were no interviews included in the file initially provided by the facility. However, upon reviewing additional FRI's for R86 it was revealed the files were disorganized and additional documentation for this investigation was found filed within several other files, separate form this investigation. Further review of the additional documentation revealed, despite the FRI reporting the facility had first been discovered on 8/13/25 at 12:30 PM and the incident occurred on 8/12/25 at 12:30 PM, the following witness statements revealed this incident was initially identified by facility staff on 8/11/25 at 2:45 PM to (Former Director of Social Services/DSS 'U') and also identified a different date of when the allegation occurred. This documentation included the following statements: STATEMENT OF WITNESS documents read: .Name and Position of Witness: (Social Service Staff/SS 'V') .Date and time of incident: 8/10/25 10:00 PM .Resident Name: (R86) .Name and title of person conducting interview: (Former DSS 'U') .Date and place of interview: 8/11/25 2:45 PM . .Statement of Witness .Resident reports during night shift yesterday, she observed the CNA assisting her roommate excessively long. Resident reports she observed the CNA bent over roommate & holding her wrists down. Resident reports her roommate looked upset. Resident reported when she asked what the CNA was doing, he reported he was clipping her nails. It should be noted that the allegation of holding her wrists down was not included in any of the documentation provided to the State Agency, or within the facility's investigation summary. Another STATEMENT OF WITNESS document read: .Name and Position of Witness: (SS 'V') .Date and time of incident: 8/10/25 10:00 PM .Resident Name: (R88) .Name and title of person conducting interview: (Former DSS 'U') .Date and place of interview: 8/11/25 2:45 PM . .Statement of Witness .Resident was rarely understood during interview, based on observation, resident seemed nervous & reluctant to speak. SW (Social Work) did not observe any physical symptoms/wounds. Residents nails were not clipped. Resident did smile at end of interview. It should be noted that this information was not identified by the facility's investigation, in which CNA 'H' reported they had clipped R88's fingernails. Another STATEMENT OF WITNESS document read: .Name and Position of Witness: (left blank) .Date and time of incident: (left blank) .Resident name: (R86) .Name and title of person conducting interview: (Business Office Manager/BOM 'GG') .Date and place of interview: 8/12/25 Admin Office . .Statement of Witness .When speaking to (R86) on the morning of 8-12-25 She stated that (CNA 'H') the CNA normally take 15 moments at the most to provide care to her or her roomate [sic]. So when (CNA 'H') was providing care to (another name for R88) it was alarming to her because of how long it was taking him to provide care to (R88) she also stated (R88) was making strange noises so she pulled the curtain back and seen (CNA 'H') shadow standing over (R88) and he did something with a towel and threw it on the floor. she then stated she got up and act as if she was going to the restroom so she can see what (CNA 'H') was doing so she observed him with his hands around (R88) wrist tight. she asked what was he doing so she observed him with his hands around (R88) wrist tight. She asked what was he doing to her and he said she has his arm and he was trying to get her to let go. After he got done providing care he went to (R86) to explain he would never hurt a resident. The section for signature and date for witness and interviewer was left blank. It should be noted that this information about CNA 'H's hand around R88's wrist tight or that CNA 'H' had further discussion with R88 about what they alleged was not included in the documentation submitted to the State Agency, or within the facility's investigation. The facility's investigation documented that a skin assessment had been completed immediately, however this documentation which was found in another FRI investigation for R86 revealed the skin assessment for R88 had been completed on 8/9/25 (prior to the incident and the next documented skin assessment wasn't until 8/19/25). On 1/28/26 at 11:10 AM, an interview was conducted with the Administrator in the presence of Vent Administrator, the Regional Director of Operations (RDO 'II' and RDO 'JJ') and later joined by Corporate Clinical Support (Nurse 'KK'). When queried about the inaccurate, unorganized and misleading documentation included within the facility's investigation for R88, the Administrator was unable to offer any further explanation. When asked about the limited documentation provided and documentation found in other investigations and general lack of organized, accurate documents, the Administrator reported they could not offer any further explanation. When queried about why R88's allegation of being held down by CNA 'H' was not included in the report made to the State Agency, why the police were not notified, and why the documentation was disorganized, and the investigation not reflective of the actual statements included in the witness statements, the Administrator reported the police should've been contacted and reported they went off what was told to them. When asked about the delay in reporting the allegation to the State Agency, the Administrator reported they were not able to offer any further explanation. Review of the clinical record revealed R88 was initially admitted into the facility on [DATE], and discharged on 11/11/25 with diagnoses that included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, altered mental status, aphasia, unspecified convulsions, metabolic encephalopathy, and aneurysm of unspecified site. According to the MDS assessment dated [DATE], R88 had severe cognitive impairment, had unclear speech and sometimes makes themselves understood, rarely/never understands others, and was dependent upon staff for most aspects of care. According to the facility's policy titled, Abuse, Neglect and Exploitation dated 1/10/2024: .An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur .Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations .Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and .Providing complete and thorough documentation of the investigation .Reporting/Response .Reporting of alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes as required by state and federal regulations: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury . R86 On 1/28/26 at 8:23 AM, the Administrator was asked to provide any incident reports and investigations for R86 for the month of August 2025. Multiple investigation files were provided and reviewed. Incident #1 (R86 and Certified Nursing Assistant – CNA 'H') A review of a FRI (Facilty Reported Incident) report submitted by the facility to the State Agency revealed on 8/18/25, R86 Reported an allegation of abuse against (CNA 'H') .Nurse Aide was suspended pending investigation. The report did not include what the abuse allegation was specifically. A review of the investigation file provided by the facility regarding that allegation on 8/18/25 revealed an incident report completed by Licensed Practical Nurse (LPN) 'D' on 8/18/25 that noted, .Pt (patient) reported alleged abuse to administrator.Pt states Nurse assistant raped her while doing patient care. It was documented the Director of Nursing (DON) was notified on 8/18/25 at 12:00 PM and the Administrator was notified on 8/19/25 at 4:29 PM. A review of the Investigation Summary completed by the Administrator revealed the following documentation, .On August 18th (R86) contacted the Abuse Coordinator to report that on August 11th, 2025, she felt that during her sleep she feels as if someone entered her room and did something to her. She stated that person is (CNA 'H') . There was nothing documented in the investigation summary submitted to the State Agency that mentioned the allegation of rape made by R86 as documented on the incident report. There was no indication that law enforcement was contacted regarding the allegation of rape made by R86. Incident #2 (R86 and R18) A review of an investigation conducted by the facility revealed on 8/23/25, R86 texted the Abuse Coordinator (who was the Administrator) and alleged R18 poisoned her coffee. It was documented the incident occurred on 8/23/25 at 7:30 AM and it was discovered at 8:00 AM. It was documented on the Facility Reported Incident (FRI) report that the allegation was submitted to the State Agency on 8/23/25 at 8:00 PM, 12 hours after the allegation was made (discovered). Further review of the FRI report and the investigation folder provided by the facility revealed no investigation was submitted to the State Agency within the five-day required time frame. Incident #3 (R86 and LPN 'D') A review of an investigation conducted by the facility revealed on 8/26/26, R86 alleged LPN 'D' poisoned her and the resident contacted 911 to be transferred to the hospital. It was documented the incident occurred on 8/26/25 at 2:00 PM and it was discovered on 8/26/25 at 4:00 PM. According to the FRI report, the allegation was submitted to the State Agency on 8/27/25 at 2:15 PM, 22 hours after the allegation was made. On 1/28/26 at 10:48 AM, an interview was attempted with LPN 'D' via the telephone. LPN 'D' was not available for interview prior to the end of the survey. On 1/28/26 at 11:00 AM, an interview was conducted with the Administrator (Abuse Coordinator). When queried about the facility's protocol when a resident alleged abuse, the Administrator reported staff were to contact her immediately and that her phone number is accessible in the facility. Once she was contacted, she initiated an investigation into the allegation, and all allegations were reported to the State Agency within two hours. When queried about what would be reported to law enforcement, the Administrator reported any abuse was reported. When queried about why R86's allegation of rape by a staff member was not included in the report made to the State Agency, the Administrator reported R86 did not allege rape when she contacted her. When asked why the allegation of rape was not included in the investigation summary or why it was not reported once she was made aware, the Administrator did not offer a response. When queried about whether the sexual abuse allegation was reported to law enforcement, the Administrator reported it was not. When queried about why there was no investigation submitted within five days to the State Agency regarding R86's allegation of being poisoned by R18, the Administrator reported she did not know why and confirmed an investigation was not completed. When queried about why the allegation that R18 poisoned R86 was not reported to the State Agency until 12 hours after the allegation was made and the allegation that LPN 'D' poisoned R86 was not reported to the State Agency until 22 hours later, the Administrator did not offer a response. A review of R86's clinical record revealed R86 was admitted into the facility on 5/9/25 and discharged on 8/28/25 with diagnoses that included: schizoaffective disorder. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R86 had intact cognition.

Based on interview and record review, the facility failed to submit for completion of an OBRA (Omnibus Budget Reconciliation Act) Level II Evaluation consideration for two (R58 and R59) of two residents reviewed for PASARRs (Preadmission Screen and Resident Review). Findings include:R58: Review of the clinical record revealed R58 was initially admitted into the facility on [DATE], discharged on [DATE], readmitted on [DATE] with diagnoses that included: schizophrenia. According to the Minimum Data Set (MDS) assessment dated [DATE], R58 had severe cognitive impairment. Further review of the clinical record revealed R58 had no available psych consultations completed for review. Additionally, the initial social service assessment did not identify any specific details of R58's mental health history. Review of the care plans included: Resident has behaviors related to SCHIZOPHRENIA as evidenced by refused showers. Date initiated: [DATE], Revision on: [DATE]. Resident has an impaired mood/psychiatric status related to Schizophrenia diagnosis. Date Initiated: [DATE], Revision on: [DATE]. Interventions included: Observe for and report to Physician .any signs and symptoms of mania or hypomania, racing thoughts or euphoria; increased irritability; frequent mood changes; pressured speech; flight of ideas; marked change in need for sleep; agitation or hyperactivity Date Initiated: [DATE] Further review of the admission PASARR dated [DATE] initiated by the previous facility identified all No's. However, the facility initiated a change in condition PASARR form (3877) on [DATE] which documented R58 had a diagnosis of schizophrenia, dementia and received no medications. There was no indication if this change in condition had been completed with OBRA as of this review. On [DATE] at 11:40 AM, an interview was conducted with Social Service Assistant (SS 'V'). When asked about whether R58 received a level II evaluation from OBRA since the change of condition form was completed on [DATE], or if there was an exemption completed, SS 'V' reported they would have to follow up with the Director of Social Services (DSS 'T'). On [DATE] at 12:10 PM, SS 'V' reported both DSS 'T' and the facility's MDS Nurse had access to the PASARR system and would follow-up to see if there was any additional information. On [DATE] at 12:20 PM, SS 'V' reported R58's PASARR documentation had been received and was now ready for view in the electronic medical record. Review of a letter from OBRA dated [DATE] documented, .Based on a review of the available information, the recipient does not require a Level II Evaluation under the PASARR provisions at this time due to: Pt (patient) discharged from facility . The facility had not notified OBRA that the resident returned to the facility, or submitted additional documentation to ensure R58 had been evaluated. On [DATE] at 12:32 PM, an interview was conducted with DSS 'T' who reported they had just taken over the role as DSS on Monday and had previously been in a risk management role. When asked who was responsible for managing the facility's PASARR's, DSS 'T' reported the facility's Regional Social Worker was but that person resigned so since then, it would be the Director of Nursing (DON). When asked why the facility had not notified R58 had returned to the facility or follow-up, DSS 'T' reported that should've been resubmitted once the resident returned to the facility and was unable to offer any further explanation. On [DATE] at 12:50 PM, DSS 'T' reported the OBRA letter was just updated (once identified as a concern during survey) by their new Regional Social Services staff that handled that documentation. They were requested to provide the contact information. On [DATE] at 1:02 PM, a phone interview was conducted with the facility's Regional Social Service Consultant (SS 'S'). When asked to explain what happened with R58's lack of level II evaluation with OBRA, SS 'S' acknowledged the concern and further reported they recently started doing that for this facility and the social service staff should've submitted that once the resident returned. According to the policy titled PASARR – Pre-admission Screen and Resident Review dated [DATE]: .A nursing facility must not admit, on or after [DATE] any new residents with: a. Mental illness as defined as an individual considered to have mental illness if the individual has a serious mental illness defined at 483.102(b)(1). 1. An individual is considered to have a serious mental illness (MI) if the individual meets the following requirements on diagnosis, level of impairment and duration of illness. 2. Diagnosis. The individual has a major mental disorder diagnosable under the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised in 1987. 6. A schizophrenic, mood, paranoid, panic or other severe anxiety disorder; somatoform disorder; personality disorder; other psychotic disorder; or another mental disorder that may lead to a chronic disability; but. 3. All residents are required to have a level I PASRR screen prior to or upon admission the facility. When indicated on the level I screen that a level II screen is required, the facility will complete notification to the State's PASRR program notice for the level II screen (in accordance with State specific laws. 4. If a resident is admitted with a level diagnosis as indicated above review is required upon change in the resident's condition. For example a. A review and determination under clause (i) or (ii) must be conducted promptly after a nursing facility has notified the State mental health authority or State mental retardation or developmental disability authority, as applicable, under subsection (b)(3)(E) with respect to a mentally ill or mentally retarded resident, that there has been a significant change in the resident's physical or mental condition. b. The facility is responsible for notifying the State agency which govern PASRR of a resident's change in condition. R59 Clinical record review revealed R59 was admitted to the facility in [DATE] and was ventilator dependent (inability to breath independently) because of Chronic Obstructive Pulmonary Disease (COPD) and respiratory failure. R59 had impaired neurological and cognitive function related to long term toxic encephalopathy (brain dysfunction caused by exposure to toxic substances). Due to cognitive impairment, a Brief Interview of Mental Status (BIMS) could not be assessed. R59 was a legally incapacitated individual and was appointed full guardianship. On [DATE] at 2:22 PM, a record review revealed R59 was outstanding for a PASSAR (Pre-admission Screening and Resident Review) Level II. The facility received notification from OBRA PASSAR Correspondence dated [DATE] that R59 could not be evaluated for a Level II evaluation due to: .proof of Guardianship.As of August, there was no proof of legal representative, cannot evaluate without it. Record review of the last recorded letter of guardianship confirmed R59's guardianship expired on [DATE]. On [DATE] at 11:47 AM, the Director of Social Services K was interviewed and when inquired if the facility had received documentation of R59s guardianship, K was observed reviewing the chart and indicated there was not an updated guardianship and R59 still had not been evaluated.

This citation pertains to intake #'s 2629174 and 2639760. Based on observation, interview, and record review, the facility failed to ensure ongoing assessment and accurate treatment orders for wound care for one resident (R22) of one resident reviewed for wound care, resulting in verbalized complaints with quality of care and the potential for wound complications. Findings include: On 1/27/26 at 11:02 AM, a phone call was placed to the complainant, and they expressed concerns over a new wound R22 developed to their left thigh/buttock area and did not think the facility was properly addressing the wound. On 1/27/26 at 12:16 PM, an observation of R22's wound was conducted with Nurse 'A'. Nurse 'A' peeled back the foam dressing, and the wound was observed to be a skin tear approximately 3 cm (centimeters) in length in the skin fold of their left gluteal sulcus (the spot where the thigh meets the buttock). At that time Nurse 'A' was asked about R22's treatment order and said the treatment was triple antibiotic ointment on the wound and cover with a foam dressing. On 1/27/26 at 12:28 PM, a review of R22's progress notes was conducted and revealed a note dated 1/4/26 at 3:03 PM that read, Was brought to writers [sic] attention that patient had a new area on her right leg under her buttock, in the crease . R22's weekly wound assessments were reviewed and the assessments performed on 1/7/26, 1/8/26, 1/15/26, and 1/22/26 did not document the presence of the wound on R22's right or left buttock/thigh area. It was noted the first documented assessment of the wound was dated 1/27/26. A review of R22's orders revealed an order dated 1/4/26 for a treatment to the right gluteal fold and an order to consult wound care with, No directions specified for order. On 1/27/25 at 12:40 PM, R22's record revealed a new wound care order entered by Wound Care Nurse 'PP' scheduled to start on 1/28/26 that read, Wound care: Rear Right Thigh; Cleanse area with normal saline, pat dry, apply triple antibiotics [sic] ointment, cover with border foam one time a day for wound care.On 1/27/26 at 1:39 PM, an interview was conducted with Wound Care Nurse 'PP'. They were asked why R22's wound was identified on 1/4/26 but no assessments of the wound were documented. Nurse 'PP' said the nursing staff had not made them aware of the new wound until earlier in the morning on 1/27/26. They were then asked to identify the gluteal side (right or left) the wound affected and they reported it was on their left gluteal. At that time, it was brought to their attention that all orders for the treatment since 1/4/26 indicated the wound was on the right gluteal cleft including their new order for the treatment starting on 1/28/26. Nurse 'PP' admitted the mistake and said they would change the order. A request for a policy for wound care was made, however; the policy provided only addressed wound care for pressure ulcers. The policy titled, Pressure Ulcer/Skin Breakdown-Clinical Protocol revised 3/2024 was reviewed and read, 5 .all PU/PI (pressure ulcers/pressure injury) or other skin related issues are measured and documented .7. continued assessment and management .

This citation pertains to Intake(s): #2610189 and #2658977 Based on observation, interview, and record review, the facility failed to administer tube feeding according to physician's orders for one (R79) of five residents reviewed for tube feeding. Findings include:On 1/26/26 at 10:22 AM, R79 was observed lying in bed, sleeping. R79 was receiving breathing assistance via a mechanical ventilator. R79 had a Percutaneous Endoscopic Gastrostomy (PEG) tube which delivered nutrition directly into R79's stomach. A tube feeding pump was observed in R79's room and was hooked up to the resident. A bottle of tube feeding formula was hung and dated 1/25/26. 850 milliliters (ml) of formula remained in the bottle. The tube feeding pump was not running at that time and an error message was present on the screen that read, Pump inactive. Pump has been idle for 10 minutes. On 1/26/26 at 11:45 AM, R79's tube feeding pump remained with the same error message that it was inactive. 850 ml remained in the bottle. On 1/26/26 at 2:10 PM, R79's tube feeding pump was alarming with a beeping sound. The screen read, Tube slip detected. Remove and reload cassette. 850 ml of formula remained in the bottle. On 1/26/26 at 3:49 PM, R79's tube feeding pump continued to alarm with a beeping sound and the same error remained on the screen, Tube slip detected. Remove and reload cassette. 850 ml of formula remained in the bottle. At that time Respiratory Therapist (RT) 'MM' entered the room to provide respiratory care and R79's husband was present in the room. After RT 'MM' exited the room, she was observed seated in the hallway. R79's tube feeding pump remained alarming. At that time, R79's husband said he was not sure why the pump was alarming and it had been doing that all day. R79's husband said he was not sure why a nurse has not addressed it. On 1/26/26 at approximately 3:52 PM, an interview was conducted with RT 'MM'. When queried about whether she reported the alarming tube feeding pump to the nurse. RT 'MM' said she did not notice it was alarming and reported she was new and did not alert anyone. On 1/26/26 at approximately 3:55 PM, an interview was conducted with Registered Nurse (RN) 'J'. RN 'J' reported he was not R79's assigned nurse that day, but her assigned nurse was on break. When queried about what should be done if a tube feeding pump has an error or was alarming, RN 'J' said a nurse was supposed to be alerted so it could be looked at and restarted. At that time RN 'J' observed R79's tube feeing pump and said a nurse should have been notified. On 1/26/26 at approximately 4:00 PM, an interview was conducted with the Director of Nursing (DON) who reported nursing should be made aware of any alarm or error message on a tube feeding pump so it could be reset. The DON reported anyone who noticed it was responsible to report to the nurse. A review of R79's physician's orders revealed no active orders to hold the tube feeding. R79 had an active order for Enteral Feed Order every shift every day and night shift Nepro with CARBSTEADY via peg @ 50ml/hr (milliliters per hour) x 20hrs (hours) to provide 1800kcals (kilocalories), 75g (grams) protein, 1000mls free water daily. A review of R79's clinical record revealed R79 was admitted into the facility on 9/15/25 and readmitted on [DATE] with diagnoses that included: chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, congestive heart failure, and dysphagia. R79 required a mechanical ventilator to assist with breathing and had a PEG tube to deliver all nutrition. R70 did not consume any food by mouth. A review of R79's Minimum Data Set (MDS) assessment dated [DATE] revealed R79 had moderately impaired cognition and was dependent on staff for all activities of daily living. A review of a facility policy titled, Feeding Tubes revised 10/15/24, revealed, in part, the following, .Feeding tubes will be utilized according to physician orders.

Based on observation, interview and record review, the facility failed to ensure a medical provider was notified and an assessment/evaluation was completed for two residents that sustained severe weight loss (R2 and R80) of three residents reviewed for nutrition, resulting in the potential for further unplanned weight loss to occur. Findings include:R2 On 1/26/26 at 10:10 AM, R2 was observed lying in bed. R2 was receiving nutrition via a feeding tube and breathing assistance via mechanical ventilator. When addressed, R2 did not open her eyes. A review of R2's clinical record revealed R2 was admitted into the facility on 2/29/24 and readmitted on [DATE] with diagnoses that included: acute and chronic respiratory failure with hypoxia, accidental poisoning by heroin, chronic obstructive pulmonary disease, type 2 diabetes, and dysphagia. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R2 had severely impaired cognition, was dependent on staff for all activities of daily living, bed mobility, and transfers, and received all nutrition via Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube surgically inserted into the stomach to deliver nutrition). A review of R2's Weight Summary revealed on 11/5/25, R2 weighed 182.2 pounds (lbs). On 1/3/26, R2 weighed 163.7 lbs which was a 10.15 percent weight loss. A review of R2's progress notes revealed no documentation that R2's severe weight loss that occurred between 11/5/25 and 1/3/26 had been evaluated by a medical provider. Further review of R2's documented Weight Summary revealed R2 weighed 182.2 lbs on 11/5/25 and 172.1 lbs on 12/3/25 which indicated a 5.54 percent weight loss within 30 days. A review of R2's progress notes revealed no documentation that R2's significant weight loss that occurred between 11/5/25 and 12/3/25 had been evaluated by a medical provider. A review of a Nutrition Data Collection/Evaluation assessments revealed R2 was not evaluated by the dietician after the weight loss between 11/5/25 and 12/3/25. R2 was assessed on 11/13/25, however, R2 had not had significant weight loss identified at that time. A review of a Nutrition Data Collection/Evaluation assessment dated [DATE] revealed the assessment was not completed and was blank. On 1/27/26 at 12:36 PM, an interview was conducted with Registered Dietician (RD) 'C'. When queried about how she was alerted of residents with significant weight loss and when she assessed them, RD 'C' reported weight loss was discussed every morning with the interdisciplinary team (IDT). She typically assessed right away once weight loss was triggered and she was alerted of it. RD 'C' explained she was typically responsible to notify the medical provider of residents who had significant weight loss. When queried about R2's severe weight loss of 10.15 percent on 1/3/26 and significant weight loss of 5.54 percent on 11/5/25 and whether the resident was evaluated by a medical provider, RD 'C' reported she was unsure. On 1/27/26 at 12:59 PM, an interview was conducted with the Director of Nursing (DON). When queried about who was responsible to ensure residents who experienced severe and/or significant weight loss were evaluated by a medical provider, the DON reported the RD was responsible. When queried about why it was important for the resident to be evaluated by a provider, the DON reported to determine if there was an underlying cause for the weight loss and to determine any additional interventions that were needed. At that time, the DON was asked if R2 had been evaluated by a medical provider for weight loss between 11/5/25 and 1/3/26 and she said she would look into it. On 1/28/26 at approximately 2:00 PM, the DON confirmed there was no evidence that R2 had been evaluated by a medical provider for severe and significant weight loss. R80 On 1/26/2026 at approximately 10:22 a.m., R80 was observed in their room, laying in their bed. R80 was observed to have enteral feeding infusing at 65ml (milliliter) per hour. R80 was observed with half-filled bottle of thin liquid soda on their bedside table. On 1/27/26 at approximately 8:53 a.m., R80 was observed in their room, up in bed. R80 was observed to still have the half drank bottle of soda on their bedside table. On 1/28/26 at approximately 12:57 p.m., R80 was observed in their room, up in their bed. R80 was observed to have a half-eaten lunch try. R80's meal ticket indicated R80 was to be provided 1:1 supervision with meals. R80 was queried if anyone helped them eat their meal and they indicated their wife did that day. R80 was queried if facility staff help them with their meals and they reported that he usually has to eat by himself. On 1/27/26 the medical record for R80 was reviewed and revealed the following: R80 was initially admitted to the facility on [DATE] and had diagnoses of Aphasia and Dysphagia. A review of R80's MDS (minimum data set) with an ARD (Assessment reference date) of 12/22/25 revealed R80 was dependent on facility staff with most of their activities of daily living. R80's BIMS score (brief interview of mental status) was 14 indicating intact cognition. A Physician's order dated with a start date of 12/20/25 revealed the following: Weights weekly X 4 weeks then monthly every day shift every 7 day(s) weekly for 4 weeks. A review of R80's Documented Weights revealed the following: 12/19/25 (admission weight)-196 lbs. (pounds), 1/1/26-218.3 lbs., (11.38% gain) 1/6/26-180.6 lbs., 1/17/26-181.0 lbs. Further review of R80's weights did not reveal any documented weights for the period of 12/19/25 through 12/30/25. A review of R80's care plan revealed the following: Focus-Resident is at risk for altered nutritional status related to Tube feeding. Date Initiated: 12/19/2025 . A review of R80's dietary notes and evaluations did not reveal any progress notes or evaluations after the initial evaluation dated on 12/30/25 which revealed the following: CBW (current body weight) is 196# (BMI (body mass index): 23.9- underweight). Resident is added to weekly weightsx4 to establish trends. No edema noted.6 (-17.27%) A secondary review of the record did not reveal any medical provider evaluations or documentation that indicated R80 had been evaluated for their pathology of their severe weight gain noted on 1/1/26 or their severe weight loss on 1/6/26. On 1/27/26 at approximately 12:20 p.m., R80's medical record and weight fluctuations were reviewed with RD C. RD C was asked if they had been notified of the documented severe weigh gain on 1/1/26 (11.38%) and the subsequent weight loss on 1/6/26 of 180.6 (-17.26%). RD C indicated they were not made aware of the gain or loss and had not reassessed R80 since their initial evaluation on 12/20/25 using the admission weight of 196 lbs. RD C indicated that they do assess residents with severe weight loss and gain but had not for R80. RD C indicated that if the electronic medical does not trigger for them to review a resident, then they rely on Nursing and Physician notification, and nobody had made them aware. On 1/27/26 at approximately 4:45 p.m., Physician QQ was asked if they had been made aware of the severe weight loss and gains that had been documented for R80 and they reported they had not. Physician QQ was asked they had assessed R80 for the reasons of the severe weight swings and they reported they had not but would check with their Nurse Practitioner. On 1/27/26 at approximately 5:12 pm., during a follow-up phone call from Physician QQ, Physician QQ reported they had spoken to Nurse Practitioner RR and that they believed Nurse Practitioner RR had been made aware of the concern, but no assessments or evaluations had been done. Physician QQ reported one of the medical providers would be in the evaluate R80 as the weight loss between the admission weight and the current weight was a concern. No documentation was provided by the end of the survey that documented R80 had been reassessed Medical Provider for their severe weight loss.

This citation pertains to intake 2610189.Based on observation, interview and record review, the facility failed to maintain a medication error rate of less than five percent. Three medication errors were observed (R72, R9) from a total of 32 opportunities resulting in an error rate of nine percent.Findings include:A complaint was received by the State Agency on 9/7/25 alleging a resident was given the wrong medication.On 1/27/26 at 8:08 AM, Licensed Practical Nurse (LPN) A was observed for medication administration. R72 was ordered Metoprolol (medication to treat high blood pressure) Extended Release (ER) 25 milligrams (mg) to be given by mouth and instructions to do not crush. LPN A was observed crushing the medication mixed with water and administered via a Percutaneous Endoscopic Gastrostomy (PEG) tube (tube surgically inserted into the stomach to deliver nutrition, medication).On 1/28/26 at 8:35 AM, LPN B was observed for medication administration. R9 was ordered Miralax (medication to treat irregular bowel movements and constipation)17 grams. LPN B was observed pouring the medication granules into the measuring cap and poured only half the medication. LPN B was asked how they knew that was measured at 17 grams. LPN B replied this was explained to them before by another nurse and to fill the granules up to the inside threading of the cap. LPN B further remarked the last time they filled the entire white inside of the cap, it was too much. When inquired why it was too much LPN B said another resident had a blowout.On 1/28/26 at approximately 9:00 AM, an interview with Unit Manager (UM) Registered Nurse (RN) K was asked if they could demonstrate how nurses measure Miralax. UM RN K was observed retrieving the same Miralax bottle from LPN B and pointed on the cap to the stamped measuring line that read 17 grams. This measurement was the entire white portion of the cup, up to the purple part of cap. When shown where LPN B measured the Miralax earlier, UM RN K acknowledged this was not the entire ordered 17-gram dose of the medication and confirmed LPN B did not administer the entire dose of Miralax.On 1/28/26 at 12:08 the Director of Nursing (DON) was interviewed and acknowledged the above observations were medication errors and provided an opportunity for re-education.Review of the policy titled Medication Administration revised 1/17/2023 documented: .Medications are administered.in accordance with professional standards of practice.Compare medication source with MAR (medication administration record) to verify medication name, form, dose, route.Do not crush medications with do not crush instructions.

Based on interview and record review, the facility failed to ensure Physician ordered laboratory diagnostics (labs) were completed in a timely manner for three residents (R2, R33 and R80) of three residents reviewed for diagnostics. Findings include:A review of R2's clinical record revealed R2 was admitted into the facility on 2/29/24 and most recently readmitted on [DATE] with diagnoses that included: acute and chronic respiratory failure with hypoxia, cardiac arrest, type 2 diabetes mellitus, and hypertension. R2 was dependent on a mechanical ventilator to assist with breathing and a feeding tube to deliver all nutrition directly into her stomach. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R2 had severely impaired cognition and was dependent on staff for all ADLs (activities of daily living), bed mobility, transfers. A review of R2's Physician's orders revealed the following orders:12/8/25 - UA C&S (Urinalysis Culture and Sensitivity) R/T (related to) elevated WBC (white blood count)12/18/26 – CXR (chest X-ray), UA, Urine C/S Dx (diagnosis): Leukocytosis (elevated WBC) A review of R2's progress notes revealed the following: On 12/8/25 it was documented in a Nurses' Note that R2 had an elevated white blood count. The physician was notified and a UA C&S was ordered. On 12/9/25, it was documented in a Physician Progress Note that R2 was evaluated for rising WBC and the UA culture was pending. On 12/11/25, it was documented in a Physician Progress Note that UA culture remains pending. On 12/17/25, it was documented by the Respiratory Provider that urine studies were previously ordered.results not documented in today's note. On 12/18/25, 10 days after a UA C&S was first ordered for R2, it was documented in a Physician Progress Note that R2 was .evaluated today for continued monitoring of leukocytosis following further rise in WBC .Prior urine specimen was contaminated and unable to yield results, repeat UA with culture ordered today. On 12/19/25, it was documented by the Respiratory provider that the UA was not completed due to unlabeled specimen. On 12/25/25, the following was documented in a Physician Progress Note, .Repeat urine specimen was ordered, lab notified nursing that specimen was rejected due to stability issue and will require recollection . On 1/1/26, 24 days since a UA C&S was first ordered for R2, it was documented in a Physician Progress Note, .UA remained pending after prior specimen rejection, recollection in progress . On 1/5/26 it was documented the UA results were still pending. Further review of R2's clinical record revealed no results from the UA C&S. On 1/27/26 at 11:48 AM, an interview was conducted with the Director of Nursing (DON) regarding R2's physician ordered UA C&S tests. The DON reported the first collection was not labeled properly by nursing and had to be redone. The DON further reported when the test was reordered the laboratory did not pick up the specimen in a timely manner which affected the stability. When queried about whether the UA C&S was ever completed for R2, the DON reported she would look into it On 1/27/26 at 12:20 PM, the DON reported the UA C&S was not completed for R2 and indicated nursing as well as the medical provider who ordered the laboratory test was responsible to follow up to ensure the order was complete. R80 On 1/27/26 the medical record for R80 was reviewed and revealed the following: R80 was initially admitted to the facility on [DATE] and had diagnoses of Aphasia and Dysphagia. A review of R80's MDS (minimum data set) with an ARD (Assessment reference date) of 12/22/25 revealed R80 was dependent on facility staff with most of their activities of daily living. R80's BIMS score (brief interview of mental status) was 14 indicating intact cognition. A Physician's order dated 1/22/26 revealed the following: cbc (complete blood count)/diff (differential) crp (C-reactive protein) esr (Erythrocyte Sedimentation Rate ) A Physicians progress note dated 1/22/26 revealed the following: Patient evaluated today for follow-up while continuing abx (antibiotic) therapy for stage IV sacral pressure ulcer and coordination of care with WC (wound care) physician Assessment and plan- #Stage IV sacral pressure ulcer with prior infection. Continue Augmentin per ID, tolerating well. WC physician evaluated today and notes exposed bone with concern for possible osteomyelitis. Order CBC (Complete Blood Count), BMP (Basic Metabolic Panel), ESR , and CRP for further evaluation. Obtain X-ray of sacrum to assess for underlying osteomyelitis. Further review of R80's medical record did not reveal any results from the labs that were ordered by the Physician on 1/22/26. R33 On 1/27/2026 The medical record was for R33 was reviewed and revealed the following: R33 was initially admitted to the facility on [DATE] and had diagnoses including Epigastric Pain and Major Depressive Disorder. A review of R33's MDS (minimum data set) with an ARD (Assessment reference date) of 10/25/25 revealed R33 needed assistance from facility staff with most of their activities of daily living. R33's BIMS score (brief interview for mental status) was 15 indicating intact cognition. A Physician progress note dated 1/20/26 revealed the following: Patient evaluated today following nursing report of an episode of emesis earlier today. Patient reports nausea and fatigue today and states emesis consisted of undigested food. No hematemesis or coffee-ground material reported. Denies ongoing vomiting at time of evaluation but continues to endorse mild nausea Assessment and plan: #Nausea and vomiting. Single reported episode of emesis with ongoing nausea and fatigue. Zofran 4 mg (milligram) PO (by mouth) q6h (every six hours) PRN (as needed) ordered. CBC, BMP (basic metabolic panel) .and abdominal X-ray ordered. Monitor intake, output, recurrence of emesis, abdominal pain, or distention . Further review of R33's medical record did not reveal any results of R33's CBC or BMP lab order on 1/20/26. On 1/27/26 at approximately 11:32 a.m., during a conversation with Unit Manger K (EM K) and the director of Nursing (DON), They were queried regarding the missing lab results for R80 and R33. Um K reported that the laboratory company comes every day but never came to draw R33's blood and the only lab that was done for R80 was a hemoglobin A1C level. The DON they have had issues with their lab company coming out and competing lab orders. The DON reported the facility would have to draw the blood for R80 and R33 and contact a new lab company to come get them to be analyzed. No results from R33's CBC/BMP or R80's CRP and ESR were provided for review by the end of the survey.

This citation pertains to Complaint #2658300.Based on interview and record review the facility failed to ensure adequate monitoring, thorough assessment including notification to a medical provider, and accurate and thorough documentation for a resident having a change in condition for one (R501) of one resident reviewed for changes in condition, resulting in a resident experiencing respiratory distress for 30 to 45 minutes before receiving emergency care and being transferred to the hospital. Findings include:A review of a complaint submitted to the State Agency (SA) revealed it was alleged the facility nurse did not call 911 in a timely manner when R501 wasn't breathing right and something was wrong on 10/28/25.On 11/7/25 at 12:46 PM, an interview was conducted with the complainant. The complainant said on the day in question (10/28/25), R501's breathing was different than normal. The complainant explained R501 experienced labored breathing (difficulty breathing, requiring more effort than usual) at times because he was on a mechanical ventilator (an automated machine that moves air in and out of the lungs to breathe for the individual). The complainant said when that happened, R501 usually just needed secretions to be suctioned and then his breathing would stabilize. On 10/28/25, however, the complainant said R501's breathing was different. Around 8:30 PM, R501's family member got Registered Nurse (RN) 'A' around 8:30 PM, she assessed the resident, took vitals, and went to get pain medications. She came back a couple minutes later, administered the medication, and said to let the medication work. About 30 minutes later, R501's lips were turning blue and his breathing did not get any better. R501's family member went to get a staff member and Respiratory Therapist (RT) 'B' came into R501's room, unhooked the resident from the ventilator, and provided manual ventilation. RT 'B' asked R501's family member to go get another staff member to assist, RN 'A' came back to the room to get vital signs and called 911. The complainant said her biggest concern was why RN 'A' did not send R501 to the hospital at 8:30 PM when it was concern about his breathing was first expressed by the family member. R501 was taken to the hospital around 9:20 PM. The complainant reported RT 'B' provided tracheostomy care earlier in the shift around 7:30 PM and gave R501 a breathing treatment because he was wheezing. There was no follow up until she asked RN 'A' to come in to assess R501 around 8:30 PM.On 11/12/25, an onsite investigation was conducted at the facility.A review of R501's clinical record revealed R501 was admitted into the facility on 9/24/25, readmitted on [DATE], and discharged to the hospital on [DATE] with diagnoses that included: acute and chronic respiratory failure with hypoxia, asthma, anoxic brain damage, and dysphagia (difficulty swallowing). A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R501 had severely impaired cognition, did not speak, was dependent on staff for all activities of daily living (ADLs) transfers, and bed mobility, had an indwelling urinary catheter, a feeding tube, and was on an invasive mechanical ventilator.A review of R501's progress notes revealed the following:On 10/28/25 at 7:15 PM (time stamped, but not created until later), RT 'B' wrote a Respiratory Note that documented, Pt [patient] eval [evaluation] complete. Trach [tracheostomy - an opening surgically placed in the windpipe where a tube is placed to assist with breathing] care done, [NAME] [no apparent respiratory distress]. RT to follow-up. Pt displayed agonal breathing [gasping for air) and thready heart rate [weak pulse]. Pt sent out to hospital with unstable saO2 [oxygen saturation]. It should be noted RT 'B' did not document R501's heart rate or oxygen level and in the same note documented R501 was not in respiratory distress.On 10/28/25 at 8:42 PM, it was documented in an Orders - Administration Note written by RN 'A' that R501 received tramadol for pain and Resident repositioned at this time.There were no other progress notes written by RN 'A' on the night shift of 10/28/25.A review of a SBAR [Situation Background Assessment Recommendation] Communication Form dated 10/28/25, completed by RN 'A', revealed R501 had a change in condition which was documented as Respiratory Distress. It was documented it started on 10/28/25 and got worse. In the section for Treatment for last episode, it was left blank. R501's Most Recent Pulse was documented as 132 (beats per minute - bpm, which was an elevated abnormal heart rate) on 10/28/25 at 8:41 PM, approximately one hour prior to the creation of the SBAR form. At that same time, R501's O2 Sats were 99 percent on mechanical ventilation. It was documented that R501 had labored breathing and agonal breathing. In the section for the RN to document What do you think is going on with the resident?, RN 'A' documented, n/a (not applicable). The Nursing Note section documented, Family called for Help in Resident's room, (RT 'B') went into room, Rt called for the nurse. Upon entering room Resident was observed Agonal breathing and RT bagging resident, unable to stabilize breathing and oxygen level. 911 called, [Physician 'C'] notified, Family at bedside notified, EMS arrived at [9:32 PM] Resident went out to hospital via EMS at [9:37 PM]. It was documented Physician 'C' was notified on 10/28/25 at 9:28 PM.A review of a Respiratory-Ventilator Resident Evaluation dated 10/28/25 at 7:15 PM revealed RT 'B' evaluated R501 at that time. The evaluation noted O2 Sats and a Pulse from 9:32 PM and did not document the vitals at the time of the assessment (7:15 PM). It was documented that R501 had Rhonchi (low-pitched wheezing) in the bilateral lungs and suction was attempted via the trach which produced a small amount of pale yellow, thick secretions. The following was documented, Pt eval complete. Trach care done, [NAME]. RT to follow-up. Pt displayed agonal breathing and thready heart rate. Pt send out to hospital with unstable saO2. It should be noted based on the time of the vitals and the time of the assessment, it is unclear which parts of the evaluation were at 7:15 PM and which were at the time R501 was sent to the hospital as multiple assessments appear to be combined into one.A review of a Nurse's Shift Note dated 10/28/25 at 7:00 PM did not document any issues with R501 at that time.A review of R501's Medication and Treatment Administration Records (MAR and TAR) for October 2025 revealed R501 had an order for Pulmicort Inhalation Suspension 0.5 MG (milligrams)/2ML (milliliter) .2 ml via vent (ventilator) every 12 hours . due at 9:00 PM and an order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 3MG/2ML .3 ml via vent four times a day . due at 8:00 PM. Neither order was signed out as administered. A review of a Transfer Form completed by RN 'A' revealed R501 was transferred to the hospital on 9/15/25 (wrong date as that date was more than a month prior) for Abnormal Hemoglobin or Hematocrit (low) (that was not the reason R501 was transferred to the hospital on [DATE]). The form then documented the reason for transfer as Respiratory Distress and included vital signs from 8:41 PM and not from the time R501 was transferred to the hospital. A review of R501's hospital records revealed the following:R501 was admitted to the Emergency Department (ED) on 10/28/25 at 9:57 PM. R501 was seen by the ED provider who documented, Patient arrived via EMS from [facility name] for tachypnea (rapid, shallow breathing) and hypoxia (low oxygen level). Patient's sisters are at bedside.They state that he has been having difficulty with breathing that started yesterday. They state that they noted his ventilator was alarming more frequently earlier today. Per EMS, on their arrival he was satting at 90 % on the ventilator and improved to 98% while being bagged.Pulse 10/28/25 [9:58PM] 155 [bpm].Respiratory distress present.Prior to being taken to CT (computed tomography) scan patient began having air hunger on the ventilator and was taken off and was bagged. Patient then lost pulses.The time of death was [11:12 PM].On 11/12/25 at 11:59 AM, an interview was conducted with RT 'B' via the telephone. RT 'B' confirmed he was familiar with R501 and worked the evening of 10/28/25. RT 'B' explained he did not typically start on R501's end of the unit (the ventilator unit), but R501's family member wanted him to look at R501. RT 'B' said when he walked into R501's room he noticed he had agonal breathing. RT 'B' reported his immediate response was to call for assistance. He wanted a nurse to see what I was seeing. RT 'B stated, I didn't think what I was seeing was respiratory and thought maybe it was neurological. When queried about any interventions or treatment he did after he noticed the agonal breathing, RT 'B reported he bagged the resident and took him off the ventilator. RT 'B' reported he started his shift at 6:30 PM and provided care at some point after that, but it was earlier.On 11/12/25 at 12:39 PM, an interview was conducted with RN 'A' via the telephone. When queried about R501 on the evening shift of 10/28/25, RN 'A' reported she came in around 7:00 PM and when she did her first rounds, R501 appeared calm, stable, in no distress. RN 'A' reported family was visiting R501. R501's family member came to get RN 'A' around 8:20-8:30 PM. RN 'A' stated, He appeared to be in some pain. RN 'A' explained she took R501's vital signs and his heart rate was high, but the RT said he gave a breathing treatment. RN 'A' did not know the time of the breathing treatment. RN 'A' said she administered tramadol for pain and told family she needed to give some time for the medication to work. When queried about how RN 'A' determined R501 was in pain, RN 'A' stated, He was huffing and puffing like he was hurting. RN 'A' said R501 was doing okay and his oxygen wasn't dropping so she repositioned him in bed, talked with the RT, and left the room and continued to provide care to another resident. When queried about what she talked to the RT about, RN 'A' did not offer a response (it should be noted, RT 'B' said he was not notified by the nurse of any respiratory concerns). RN 'A' further reported while in another resident's room, a CNA came to get her and said the RT was looking for her and they were already in R501's room. When RN 'A' entered R501's room, RN 'A' stated, Looked like he was having a hard time breathing real bad. RN 'A' explained she assessed R501's vitals and RT 'B' was already using the bag on him. When queried about any concerned expressed by R501's family member at the time RN 'A' determined he was in pain, RN 'A' said they were not concerned and just asked how his oxygen level was and it was up in the 90's. RN 'A' reported she did not contact a medical provider regarding the elevated heart rate because she gave the medication and did not go back to reassess R501 because it had not yet been an hour and that was how long it took the pain medication to work.On 11/12/25 at 1:55 PM, an interview was conducted with the Director of Nursing (DON). When queried about the nursing protocol if a resident on a mechanical ventilator had an elevated pulse of 132 and was huffing and puffing, the DON reported for ventilator residents she would expect the nurse to escalate the situation and contact the medical provider and the RT. Regarding R501, the DON said she thought the Nurse Practitioner (NP) was involved. At that time, R501's progress notes were reviewed and there was a progress note by the NP, however, it had to do with R501's catheter and not the respiratory change in condition. The DON reported she thought the Regional Clinical Specialist (RCP) looked into R501's change in condition and there was a soft file. At that time, any investigation was requested (It should be noted that the Administrator was asked to provide any investigations regarding R501 for the month of October 2025 on 10/28/25 at 1:20 PM and reported there were none).On 11/12/25 at 2:15 PM, an interview was conducted with RCP 'C'. When queried about what was done to look into R501's change in condition and subsequent hospital transfer and why it was investigated, RCP 'C' reported they looked at all transfers to the hospital. RCP 'C' reported she did not find anything unusual regarding R501. When queried about the combined assessments done by RT 'B' (starting at 7:15 PM but including information from the time R501 was sent to the hospital), RCP 'C' reported she did not notice that. When queried about the lack of initial assessment by RN 'A' and the statement of R501 huffing and puffing with a pulse of 132 and no medical provider contacted, RCP 'C' stated, You guys (SA) always have more information than we do.A review of a facility policy titled, Notification of Changes, revised 8/20/24, revealed, in part, the following, .The facility must inform the resident, consult with the resident's physician .when there is a change requiring such information .Circumstances requiring notification include .Life-threatening condition, or .clinical complications .Exacerbation of a chronic condition .Change in condition which should not delay activation of emergency personnel and transfer to acute care supersedes any of the above based on the clinician's assessment/evaluation and skill set .

Based on interview and record review, the facility failed to ensure physician oversight for wound care for two residents (R#'s 906 and 903) of three residents reviewed for physician services, resulting in incomplete, comprehensive care. Findings include: R906 On 9/3/25 at 8:00 AM, a review of R906's closed clinical record revealed they originally admitted to the facility on [DATE] with diagnoses that included: traumatic brain hemorrhage, skull fracture, and diffuse traumatic brain injury due to a pedestrian motor vehicle accident. R906 was non-verbal and displayed severely impaired cognition. A review of R906's weekly skin assessments revealed an assessment dated [DATE] that documented a scar to their neck and a blister to their toe. It was noted the next weekly skin assessment was conducted on 6/6/25 and documented an “other” skin impairment to their left lateral malleolus (ankle bone). A review of R906's “Skin and Wound” evaluations was conducted and revealed the following: An evaluation dated 6/5/24 that indicated R906 developed a facility acquired, unstageable pressure ulcer with, “slough and/or eschar” measuring 2.0 cm (centimeters) in length x 1.4 cm in width, no depth. An evaluation dated 6/13/25 that indicated the wound was worsening measuring 4.0 cm in length x 1.3 cm in width, no depth. An evaluation dated 7/18/25 that indicated the wound was again worsening measuring 7.6 cm in length x 1.6 cm in width, no depth. An evaluation dated 7/24/25 that indicated the wound had worsened measuring 8.0 cm in length x 2.8 cm in width with 0.1 cm of depth. Continued review of R906's clinical record was conducted and the following was revealed: Physician's notes on 6/19/25, 6/20/25, 6/25/25, and 7/7/25, 7/14/25, 7/18/25, 7/21/25, 7/22/25, 7/23/25, and 8/2/25 with no mention of the facility acquired pressure ulcer, no statement of whether it was avoidable or unavoidable, and no treatment plan for the wound. A Physician note dated 7/9/25 that read, “…Patient doesn't have any current wounds…” On 9/2/25 at 9:20 AM, R903 was observed in their room. Certified Nursing assistant (CNA) was observed assisting the resident with 1:1 eating. There were scrambled eggs and grits on the tray. The CNA stated that the resident was not eating much but they were about to get residents up and dressed to take him to the dining room. On 9/2/25 at 9:25 AM, the Director of Nursing (DON) was interviewed about R903's skin impairments and if there were any updates to the plan of care the DON replied that R903 was readmitted to the facility but would find out. On 9/2/25 at 9:40 AM, R903's skin was observed. A dark wound was present on the left heel and an open area that was a whiteish pink in color was observed located on the left buttocks. On 9/2/25 a record review was completed and showed that R903 was readmitted to the facility on [DATE] with a medical diagnosis of Alzheimer's disease and muscle weakness. A further review of the record revealed that R903 had a wound care assessment completed and a wound care consult order in. On 9/2/25 at 9:48AM, the wound care coordinator (WCC) was interviewed. WCC was asked who oversees the wounds at the facility, the WCC reported, they were recently hired into the role, but that primary care provider oversaw wound care until the facility hired a provider. The WCC was then asked who did the weekly wound rounds and provided further guidance if needed to the facility. The WCC reported that they completed weekly rounds with themselves and usually another staff member until the facility hired a provider, but it was no one over looking the wounds. The WCC was asked, had they personally rounded with the primary care providers at the facility for individuals with wounds, the WCC reported no. On 9/2/25 at 10:06 AM, an interview with the DON and Administrator were conducted, they were asked who oversaw the wounds at the facility. The DON reported that the primary care provider is supposed to oversee the care for wounds. The administrator and DON were asked when the last time they had a Wound Care provider, the DON reported that since late May or early June they had been without. The DON was then asked for the oversite, notes or any documentation from the medical provider for R903's wounds from the beginning of the admission to current. There was no additional documentation provided by the exit of the survey.

This citation pertains to intake #2579668Based on interview and record review, the facility failed to ensure enteral feeding orders were accurately transcribed upon admission and administered correctly for one resident (R905) of two residents reviewed for enteral feeding. Findings include:On 9/2/25 a complaint submitted to the State Agency was reviewed that alleged R905 was fed an incorrect amount of enteral formula. On 9/2/25 the medical record for R905 was reviewed and revealed the following: R905 was initially admitted to the facility on [DATE], discharged on 8/3/25 and had diagnoses including Dysphagia and Gastrostomy status. A review of R905's initial admission hospice Physician orders revealed the following: Evaluate need for supplemental tolerance of Glucerna 1.2 at 40ml/hr (milliliters per hour) for 16 hours.A review of R905's transcribed admission enteral orders revealed the following: Enteral Feed Order every morning and at bedtime every shift Glucerna @45ml/hr (milliliters per hour) x 16hrs via peg tube (percutaneous endoscopic gastrostomy tube) or until a total volume of 720ml. -Start Date- 07/30/2025 0700A progress note dated 7/31/2025 at 08:13 a.m., revealed the following: Received resident in bed with eyes open and resting with family at bedside. Resident feeding was currently running total volume infused when writer stop feeding was 1191 (milliliters), total volume to be infused was 720 ml. Resident abdominal area was hard and distended. Writer pulled 1000cc with residuals. Writer notified on call NP (Nurse Practitioner), who ordered to hold tube feeding and get STAT (immediately) x ray of abdomen. Writer notified DON (Director of Nursing) and on coming nurse of this change.On 9/3/25 at approximately 11:18 a.m., The Director of Nursing (DON) was queried regarding the enteral feeding order for R905 and the error of R905 being overfed on 7/31/25. The DON indicated they were aware of the error and that they had done an in-service with the Nursing staff on ensuring enteral orders are administered appropriately. On 9/3/25 at approximately 2:24 p.m., Nurse A was queried regarding R905 being over fed on 7/31/25. Nurse A reported that after they got shift report then went into R905's room to check their tube feeding (enteral) and observed R905 to have over what they were supposed to have. Nurse A indicated they had to stop the tube feeding pump and called the medical provider who ordered to hold the tube feeding. Nurse A reported that due to the overfeeding, R905's abdomen was distended. Nurse A indicated that the facility enteral pumps had to be set with a stop time otherwise the pump would keep running. Nurse A reported that they informed the Director of Nursing of the error. On 9/4/25 a facility document titled Feeding Tubes was reviewed and revealed the following: Policy: Feeding tubes will be used only as necessary to address malnutrition and dehydration, or when the resident's clinical condition deems this intervention medically necessary to maintain acceptable parameters of nutrition and hydration. Feeding tubes will be maintained in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible 7. Feeding tubes will be utilized according to physician orders .11. Direction for staff regarding nutritional products and meeting the resident's nutritional needs will be provided to include: e. Ensuring that the administration of enteral nutrition is consistent with and follows the practitioner's orders

This citation pertains to intake #2595964 and #2579668.Based on interview and record review, the facility failed to ensure wound treatments were provided for two residents (R905 and R906) of three residents reviewed for pressure uclers. Findings include: R906 On 9/3/25 at 8:00 AM, a review of R906's closed clinical record revealed they originally admitted to the facility on [DATE] with diagnoses that included: traumatic brain hemorrhage, skull fracture, and diffuse traumatic brain injury due to a pedestrian motor vehicle accident. R906 was non-verbal, and displayed severely impaired cognition. A review of R906's weekly skin assessments revealed an assessment dated [DATE] that documented a scar to their neck and a blister to their toe. It was noted the next weekly skin assessment was conducted on 6/6/25 and documented an “Other” skin impairment to their left lateral malleolus (ankle bone). The next skin assessment dated [DATE] only documented a right upper leg skin tear, and the assessment dated [DATE] indicated an “Other” skin impairment to the left ankle with a treatment in place. It was noted the next weekly skin assessment was conducted on 7/13/25, nearly a month later. A review of R906's “Skin and Wound” evaluations was conducted and revealed the following: An evaluation dated 6/5/24 that indicated R906 developed a facility acquired, unstageable pressure ulcer with, “slough and/or eschar” measuring 2.0 cm (centimeters) in length x 1.4 cm in width, no depth. An evaluation dated 6/13/25 that indicated the wound was worsening measuring 4.0 cm in length x 1.3 cm in width, no depth. An evaluation dated 7/18/25 that indicated the wound was again worsening measuring 7.6 cm in length x 1.6 cm in width, no depth. An evaluation dated 7/24/25 that indicated the wound had worsened measuring 8.0 cm in length x 2.8 cm in width with 0.1 cm of depth. A review of R906's treatment administration records was conducted and revealed five missing dressing changes in June 2025 and four missing dressing changes in July 2025. Continued review of R906's clinical record was conducted, and it was noted the physician documented progress notes numerous times through June 2025 and July 2025, however; none of the progress notes referenced R906 having a facility acquired, unstageable pressure ulcer, a statement of whether the wound was avoidable or unavoidable, or the plan of treatment for the wound. R906's care plans were reviewed and revealed their first care plan for the wound to their left ankle was implemented on 7/29/25, despite the wound being discovered on 6/6/25. On 9/3/25 at 1:38 PM, an interview was conducted with the facility's Director of Nursing, they acknowledged the concern with R906's facility acquired pressure ulcer. R905 On 9/2/25 the medical record for R905 was reviewed and revealed the following: R905 was initially admitted to the facility on [DATE], discharged on 8/3/25 and had diagnoses including Dysphagia and Gastrostomy status. A review of R905's Nursing admission Evaluation dated 7/29/25 revealed the following: Section V. Skin. A. 1. Does the resident have any identified skin conditions/wounds? b. [No] . A review of R905's progress notes revealed the following: 8/1/2025-Nurses' Notes Writer and DON (Director of Nursing) assessed resident. Resident had MSAD (moisture associated skin damage) to coccyx, heals balanceable 8/3/2025-Nurses' Notes Resident has MASD skin tear on coccyx triad applied. redness on bilateral heels . pictures of coccyx were taken before discharge . A Wound Evaluation dated 8/3/25 revealed the following: #1-Skin Tear-Category 1. Linear .Body Location: Right Gluteus .Acquired: Present on Admission. Dimensions: Area 0.63 cm (centimeters squared). Length 1.14 cm. Width 0.78 cm. Deepest point 0.1 cm Wound Bed epithelial [yes]. Periwound: Edges [non-attached]. Treatment: Dressing appearance [intact]. Cleansing solution [Generic wound cleanser]. Primary dressing [other]. Other, Specify: Triad. Further review of R905's wound picture on their 8/2/25 evaluation revealed the following: The picture showed an open area on the right gluteal fold that appeared to be in an area where friction and shear forces would be heightened. The picture also revealed cicatrix (scar of a healed wound) that mirrored the left gluteus. A review of R905's Physican orders did not reveal any treatment orders for the identified wound on their coccyx/right gluteus area. A review of R905's July and August 2025 TAR (treatment administration record) revealed no treatments to R905's coccyx/right gluteus wound were administered during their stay in the facility. On 9/3/25 at approximately 11:18 a.m., The DON was queried regarding the process for the identification of new skin impairments, and they indicated that when a skin impairment is identified, the Physican is notified, and new order tor treatment is put into the record for it and the careplan is updated. The DON was queired regarding R905's wound that was identified on 8/1/25 and the wound evaluation that was done on 8/3/25 that indicated the wound was present on admission and they reported that a Physician's order should have been implemented to treat it and that it should have been implemented upon admission to the facility.

This citation pertains to intake #MI00153092 and MI00153719 Based on interview and record review, the facility failed to protect the resident ' s right to be free from sexual abuse by a resident for one resident (R901) of four residents reviewed for abuse/neglect/mistreatment resulting in R901 shaking/trembling while their breast was being fondled without consent by R902. Findings include: On 6/24/25 multiple complaints submitted to the State Agency for review which alleged R902 had sexually abused R901. R901 On 6/24/25 the medical record for R901 was reviewed and revealed the following: R901 was initially admitted to the facility on [DATE] and had diagnoses including Dementia and Aphasia. A review of R901's MDS (minimum data set) with an ARD (assessment reference date) of 5/5/25 revealed R901 was dependent on facility staff for most of their activities of daily living. R901's BIMS score (brief interview for mental status) was six indicating severely impaired cognition. R901 was also noted to have a court appointed public legal guardian. On 6/24/25 at approximately 10:36 a.m., R901 was observed in their room, laying in their bed. R901 was queried regarding if they had felt uncomfortable by any male residents in the facility and they started talking with unintelligible speech. Further in-depth conversation was attempted regarding how they were feeling in the facility, and they were noted to be unable to follow the conversation and were incomprehensible. A review of R901's progress notes revealed the following: 4/27/2025 at 16:08-Nurses' Notes-Resident was observed in the dining area resting in Geri chair covered with sheets. Male resident was observed with right arm resting between female resident legs. Resident was moved near nurses station for close observation. Admin (Administrator) and DON notified. Will continue to closely monitor resident. 6/5/2025 at 23:33-Nurses' Notes-CNA (Certified Nursing Assistant) informed nurses that she had observed [R902] with his hand under the resident's shirt. Nurses removed resident from activity area and took her to her room .Nurses contacted Administrator, DON (Director of Nursing), Resident's doctor (MD), and Guardian. No new orders by MD at this time, but requested nurse to log in Dr's book. 15 minute checks in place for resident per DON 6/6/2025 at 15:33-Social Services Progress Notes-Writer met with resident today. Resident is alert and responsive. Her cognitive skills for daily decision making abilities are impaired R902 On 6/24/25 the medical record for R902 was reviewed and revealed the following: R902 was initially admitted to the facility on [DATE] and had diagnoses including Multiple Sclerosis. A review of R902's MDS (minimum data set) with an ARD (assessment reference date) of 6/11/25 revealed R902 was independent on facility staff for most of their activities of daily living. R902's BIMS score (brief interview for mental status) was 12, indicating moderately impaired cognition. A review of R902's progress notes revealed the following: 4/27/2025 at 15:01-Orders-General Note from eRecord-Resident observed resting right arm on female resident's wheelchair. Resident educated on resident safety. Resident informed of resident privacy and was compliant with nurse's request to remove his arm. 4/27/2025 at 16:02-Orders-General Note from eRecord-Resident observed for the second time with hand resting between female residents' legs. Resident had been informed that it was an invasion of privacy. resident stated, She likes it, she asked me to do it . Male resident was moved to different area of unit to separate him from female residents. DON notified administrator notified for further instructions . 6/5/2025 at 19:54-Nurses' Notes-CENA (Certified Nursing Assistant) came to writer to let writer know that resident was fondling another resident's chest under her shirt in dining room. CENA said she walked in dining room to see resident in wheel chair next to female resident and when she walked closer, she seen his hand in her shirt. CENA screamed for him to take his hand out of her shirt and separated him from the female resident by wheeling him outside the dining room Both residents immediately separated. Statement taken from witness. DON notified. Administrator notified. Guardian notified via voicemail. 15 minute visual checks implemented on resident to insure other residents safety. On 6/24/25 a form titled Statement of Witness pertaining to the sexual abuse allegation on 6/5/25 involving R901 and R902 was reviewed and revealed the following: Name and Position of Witness [CNA O] .Date and time of Incident: 6-5-25 Statement of Witness-I seen [R902] was behind [R901]. She was in Geri Chair. I seen [R902] hand in [R901] shirt. [R902] was behind her chair, her chair was lean back and his hand was in her shirt. She was shaken .What did you do? I call his name [R902] he jump and [R901] stop shaken. I told him to leave out of the day room. He rolled himself by the door of Nursing station and he sat there What did you do next? I went to the Nursing station keeping close observation of [R902] and reported to the Nurse . On 6/24/25 at approximately 12:40 p.m., the Administrator was queried regarding the incident between R901 and R902 on 6/5/25. The Administrator reported that CNA O had witnessed R902's hand inside R901's shirt on their breast and that the CNA had separated the residents and brought R901 to their room and notified the Nurse. The Administrator indicated the Nurse called them to inform them of the incident to speak to CNA O at that time on the phone. The Administrator indicated that after the incident they assigned the resident a 1:1 supervised staff member to supervise R902 and that R902 has had 1:1 supervision since then. On 6/25/25 at approximately 1:20 p.m., Nurse R was queried regarding the incident between R901 and R902 on 6/5/25 and they reported that CNA O had came and told them that R902 had been fondling R901's breast and had their hand down R901's shirt. Nurse R reported that they took R901 down to their room and R901 was visibly shaking/trembling. Nurse R reported that in the dining room where the incident occurred, water was observed to be around the residents and they did not know if R901 had been trying to fight off R902 which may have caused the water spillage. Nurse R reported that 15 minute visual checks were implemented for R902 for the rest of the shift and after that, they had a 1:1 sitter. On 6/25/25 at approximately 2:19 p.m., CNA O was queried regarding their witnessing of the incident between R901 and R902 on 6/5/25. CNA O indicated that they had snuck up behind R902 to see what was happening and observed R902 was behind and to the side of R901 and they were folding R901 breasts underneath R901's shirt. CNA O indicated that R901 was trembling and appeared to be frightened. CNA O said the shouted R902's name and they stopped and left the room. At that time, R901 stopped trembling. CNA O was queried if they had been made aware of any other issues between R901 and R902 and they reported they thought there was an earlier issue in which R902 had put their hand in between R901's legs and that had been why R902 was moved to the 2nd floor for awhile. CNA O did not know why R902 was moved back down to the first floor where R901 resided. On 6/5/24 a facility document titled Abuse, Neglect and Exploitation was reviewed and revealed the following: Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property Sexual Abuse is non-consensual sexual contact of any type with a resident

Deficient Practice Statement #1 This citation pertains to Intake # MI00149906. Based on interview and record review, the facility failed to timely assess and intervene for a resident who had a new tracheostomy (an artificial opening in the windpipe to assist with breathing), and who alerted staff that they were in distress by using non-verbal gestures, resulting in the death for one (R313) of three residents reviewed for a change in condition. Findings include: The IJ began on [DATE] when R313 had encountered a change in condition and notified CNA B. The Administrator was notified of the IJ on [DATE] at 2:05 PM. A plan of removal was requested at that time to remove the immediacy. The IJ was removed and verified on [DATE] based on the facility's implementation of an acceptable plan of removal. Although the immediacy was removed, the deficient practice was not corrected and remained isolated with potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency (SA). On [DATE] at 10:07 AM, Family Member (FM) R was interviewed via telephone. FM R was asked about the death of R313. FM R reported that before the incident, the facility could not get R313's food texture right. FM R further reported that often themselves or a sibling would be present at the facility at mealtimes because they did not trust the facility to provide the correct diet texture. R313 was on tube feeding in addition to getting food by mouth. FM R stated on the day R313 expired in the facility, a staff member called their sibling and stated R313 aspirated (choked). FM R stated their sibling received a call from a female nurse who was crying and stated that R313 had passed away because they aspirated. FM R stated when they arrived at the facility with their sibling the food tray for R313 was still in the room, and the food was observed to be the incorrect texture. FM R reported family members were usually present at the facility for R313's meals due to previous incidents of the kitchen staff providing the incorrect texture. FM R stated the one dinner they were not present for is the day R313 died . FM R went on to say they provided R313 a board and paper to communicate due to difficulties communicating with a tracheostomy. FM R reported that R313 utilized the board often to communicate their needs. FM R reported, when they went to the facility on the evening of R313's death their communication board was observed to have RT (Respiratory Therapist) written on there by R313. FM R reported, the paper observed in R313's room also had noted that RT was needed. FM R reported, R313 had a fear of choking, so for R313 to die from choking was heart breaking. FM R reported the facility RT manager said that R313 should have been on aspiration precautions and signage was supposed to be placed over R313's bed to ensure all staff knew what to monitor R313 for when eating, drinking and ensuring the bed was in the correct position. FM R reported, R313 was supposed to have assistance with meals and family came daily to assist. A record review revealed that R313 was admitted to the facility on [DATE] with the diagnosis of Hemiplegia and hemiparesis following a cerebral infraction affecting the left side, acute and chronic respiratory failure with hypoxia, dysphagia-oropharyngeal phase (difficulty with swallowing), Gastrostomy status(a tube surgically inserted in the abdomen for eating) and tracheostomy status. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status Score (BIMs) of 9, which indicated moderate cognitive impairment. A further review of the record revealed a nursing progress note dated [DATE] at 9:18AM that documented, Writer entered into residents' room at 19:45 (7:45 PM) on [DATE]. Upon entering room writer noticed resident skin was discolored, immediately checked carotid pulse absent. Called residents name-no response. Code blue called and immediately began compressions. Staff in room with defibrillator. 911 called. CPR (cardiopulmonary resuscitation) continued. 20:09 (8:09PM) resident pronounced dead by EMS (emergency medical services)/MD (medical doctor). On [DATE] at 2:00 PM, Nurse A was interviewed via telephone. Nurse A was asked about the day of R313's death. Nurse A reported, they were short on nurses for the afternoon shift, and they were the only nurse on the unit until about 7:00 PM. Certified Nursing Assistant (CNA) B was assigned to R313. Nurse A reported around 5:30 or 6:00 PM, CNA B who was at the end of the hallway stated Uhh they want you. Nurse A reported that they asked CNA B who wanted them, and CNA B just walked away and went on break. Nurse A reported, they had worked with CNA B before and they were always zoned out, did not communicate well and took nothing serious. Nurse A reported that they continued to prepare medications and start medication pass. Nurse A reported, they completed the first cart of medications, around 6:30 or 7:00 PM when CNA B asked them, Did you ever see what they wanted? Nurse B reported, they asked CNA B which resident and what room. CNA B indicated R313's room. Nurse A reported that CNA B did not specify the nature of the situation. Nurse A reported after they prepped medications for the back cart, they entered R313's room. Nurse A noticed R313's head of bed was not elevated, which was abnormal for that resident who preferred their bed at a 90-degree angle. When Nurse A went to adjust the bed for R313 they noticed R313 face was a different color. Nurse A explained they checked R313's pulse and quickly started CPR and 911 was called. Nurse A reported EMS (emergency medical services) told them R313 aspirated on fruit punch. Nurse A reported they informed the family of R313's death. Nurse A reported they followed up with CNA B after R313's death, and asked CNA B was R313 the resident who needed help earlier. CNA B stated, They (R313) were choking and grabbing my arm [NAME]. It was weird they (R313) wouldn't let me go. On [DATE] at 3:00 PM, CNA B was interviewed. CNA B was asked what they remembered about R313's death. CNA B reported, when they came on shift R313 was squirming around on the bed sideways. CNA B reported that R313 was acting up and they were trying to get R313 to calm down. CNA B reported R313 was tripping. CNA B reported, that R313 wrote on their communication board and papers RT (referencing the respiratory therapist). CNA B further reported they went to notify two RTs (RT AA and RT BB) for their help with R313. RT AA and RT BB told CNA B they don't go on that side (to the unit where R313 resided), and the nurse can suction a resident. CNA B was asked if they reported the concern with R313 to Nurse A. CNA B responded, No one was listening man. CNA B was then asked why they went on break, leaving R313 alone and in distress. CNA B did not respond. On [DATE] at 8:42 AM and 4:04PM, RT AA , was called with no response. On [DATE] at 8:56 AM and 4:34 PM, RT BB was called with no response. On [DATE] at approximately 1:00 PM, a request was made to review the two east camera footage for [DATE]. Regional Corporate Personnel CC reported that the cameras only went back for ten days and the footage was not available. On [DATE] at 3:23 PM, the facility was asked to provide the investigation documents pertaining to R313's death. A review of CNA B's personnel file revealed a document titled Performance Improvement Form dated [DATE] that read, . On [DATE] (CNA B) was the assigned CNA for resident (R313 room number) the resident aspirated resulting in her expiring. (CNA B) alerted the assigned nurse of a resident possibly needing assistance. However, he did not state which resident or what the need was at that time. (CNA B) later reported to the assigned nurse that the resident was choking as she was grabbing his arm also stating that it was weird. (CNA B) left the resident and went on break without ensuring that she was properly cared for and safe . It is expected that if a resident is choking that the CNA will provide the Heimlich maneuver technique used for a conscious choking victim . is also expected to stay with a resident and call out for help maintain the resident's safety to the best of his ability until help arrives . The form indicated that CNA B was suspended. On [DATE] at 4:09 PM, The Director of Nursing (DON) was interviewed about the death of R313. The DON reported, they were in the facility when a code blue was called for R313. The DON was asked what was expected from CNA B when they observed R313 in distress. The DON reported that CNA B should have reported clearly to Nurse A and the RTs on who and what the concern was. The DON reported, Nurse A and the RTs should have obtained more information from CNA B and assessed the resident timely. On [DATE] at 4:15 PM, RT Manager C was interviewed. RT Manager C was asked what the RT responsibilities were when notified of the change in condition for R313. RT Manager C reported the RTs should have assessed and treated the Resident timely. A further review of the record showed that R313 had no care plan in for aspiration precautions, that they were a one person assist with mealtimes. The care plan also showed that R313 had interventions to observe for physical/non-verbal indicators of discomfort or distress and follow up as needed. A review of the case report from local police department dated [DATE] at 8:01 PM, revealed, . Subject Sudden Death . information . (R313) alive at approximately 1800hrs (6:00PM). (Nurse A) found (R313) unresponsive at approximately 1958hrs (7:58 PM) and started CPR (Local Fire department) medical personnel also stated that (R313) was full of fluid and (facility name) staff stated, (R313) might have had aspirated from red fruit punch (shown in photos taken). The Immediate Jeopardy that began on [DATE] was removed and the deficient practice corrected on [DATE] when the facility took the following action to remove the immediacy: Identification of Residents Affected or Likely to be affected: The facility took the following actions to address the citation and prevent any residents from an adverse outcome. (Completion Date: [DATE]). Current residents residing in the facility were assessed by licensed nurses to ensure that residents with changes in condition needs were met and that physicians, RP/guardians were notified on [DATE]. Actions to Prevent Occurrence/Recurrence: Education: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: [DATE]). On this date [DATE] we educated nurses, CNAs, and RT on the following: Head to toe observation for changes in condition for CNAs posted at nurses' station and handout given. Head to toe observation, clinical pathways for changes in condition and respiratory for Nurses posted at medication carts and handout given. Hierarchy Notification Steps handout given to nurses, CNAs, and RT. Notification of Hierarchy (Steps of Notification of Changes) Notify floor nurse assigned to resident of changes in condition. If nurse does not respond notify the RT. If the RT doesn't respond notify the on call manager. If the on call manager doesn't respond notify the DON. Verbal and non-verbal signs of distress Signs of distress, both verbal and nonverbal, can include: changes in voice tone (e.g., shaky, high-pitched), crying, sighing, complaining, withdrawn behavior, avoiding eye contact, clenched fists, pacing, fidgeting, facial expressions like frowning or grimacing, rapid breathing, sweating, changes in appetite, and disrupted sleep patterns. Verbal signs of distress: Changes in voice tone: Speaking in a higher pitch, trembling voice, or a quieter than usual tone. Complaints: Expressing physical discomfort, pain, or emotional distress through verbal complaints. Negative self-talk: Putting oneself down or making pessimistic statements. Crying or sobbing: Tears as a visible expression of emotional distress. Swearing or using strong language: May indicate heightened frustration or anger. Asking for help: Directly stating a need for support. Nonverbal signs of distress: Facial expressions: Frowning, furrowed brows, narrowed eyes, pursed lips, grimacing Body language: Crossed arms, hunched posture, avoiding eye contact, tense muscles, fidgeting Physical changes: Sweating, rapid breathing, increased heart rate, flushed face Changes in movement: Pacing, rocking, restless behavior, sudden withdrawal Vocalizations: Sighing, moaning, groaning, muttering Changes in appetite: Loss of interest in food or overeating Sleep disturbances: Difficulty falling asleep, frequent waking, insomnia Self-harm behaviors: Picking at skin, pulling hair, substance abuse Important considerations: Context matters: What might be considered a sign of distress in one situation may be normal behavior in another. Individual differences: People express distress differently, so it's important to be sensitive to individual cues. Observe patterns: Look for recurring behaviors or changes in behavior to better assess distress. There was no additional information provided at the exit of survey. 32568 Deficient Practice #2 This citation pertains to Intake Number(s): MI00149629. Based on observation, interview, and record review, the facility failed to prevent, identify and accurately assess new skin breakdown and administer treatment to vascular wounds according to physician's orders for two (R300 and R301) of three residents reviewed for skin integrity, resulting in R300 developing an open lesion to the back of the knee with exposed tendon and the potential worsening wounds to R301's toes. Findings include: R300 A review of a complaint submitted to the State Survey Agency (SSA) revealed an allegation that R300 had wounds and was not being positioned frequently. It was also alleged that the facility was short of staff with only one nurse handling wound care. On [DATE] at 10:26 AM, R300 was observed lying in bed in a fetal position with his legs bent and tucked up toward his abdomen. R300 was positioned to the right side. No pillows were observed to offload pressure from R300. A sign hung by R300's family member noted a specific patterned pillow was to be used to position R300. The patterned pillow was observed at the foot of the bed. R300 was receiving nutrition via a Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube surgically inserted into the stomach to deliver nutrition. R300 had a tracheostomy (a tube surgically inserted into the windpipe to assist with breathing). When spoken to R300 did not respond or make eye contact. On [DATE] at approximately 12:30 PM, R300 was observed in bed. A family member was visiting. When queried about any concerns, the family member explained R300 had a wound between his right shin and the knee on the back side of his leg. According to R300's family member, she discovered the wound when she noticed blood on R300's bedding a few months ago and when they looked behind R300's knee there was an open area with exposed tendon which has not yet healed. On [DATE] at 8:20 AM, 10:00 AM, and 11:32 AM, R300 was observed lying in bed in the same position. There were no pillows or devices being used to extend R300's right leg. On [DATE] at approximately 4:00 PM, an interview was conducted with the facility's wound care coordinator, Licensed Practical Nurse (LPN) 'D'. When queried about the skin impairment to the back of R300's right knee, LPN 'D' reported R300 had an open lesion to the back of the right knee caused by moisture. LPN 'D' reported that when she first assessed the skin impairment the tendon was exposed. LPN 'D' reported the open lesion has not healed. When queried about any preventative measures that were in place to prevent breakdown to that area and to prevent worsening and promote healing, LPN 'D' reported she would look into it. A review of R300's clinical record revealed R300 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: acute respiratory failure with hypoxia, contractures, metabolic encephalopathy, nontraumatic chronic subdural hemorrhage, and hydrocephalus. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R300 had no speech, highly impaired hearing, severely impaired cognition, had upper and lower bilateral range of motion impairment, was dependent on staff for bed mobility, transfers, and all activities of daily living (ADLs), and had two unhealed pressure ulcers, an open lesion, and moisture associated skin damage (MASD). A review of a Skin Assessment completed on [DATE] revealed R300 did not have any new or existing abnormal skin areas. It should be noted that at that time R300 did have two existing pressure ulcers. A review of a Wound Assessment completed by LPN 'D' and a Surgical Note completed by the consultant wound provider on [DATE] revealed R300 had a new, in-house acquired open lesion to the right popliteal fossa (the diamond shaped space located in the back of the knee joint) that measured 0.6 cm (centimeters) in length x (by) 1.8 cm in width x 0.5 cm in depth. It was documented that tendon exposed. A review of a Skin and Wound Evaluation dated [DATE] revealed R300 had an open lesion to the right popliteal fossa that measured 0.7 cm x 1.1 cm x 1.0 cm. It was documented the wound was healable. In the notes section it was documented that wound has increased in size. Wound not likely to heal d/t (due to contractures) .offload at tolerated . A review of the Wound Evaluation which included a photo of the wound revealed R300's tendon was exposed. A review of the previous wound consult notes documented by the wound provider on [DATE] revealed the wound decreased in size and was improving. A review of R300's Physician's orders revealed orders beginning on [DATE] that recommended offloading wound with positioning leg in as much extension as possible. On [DATE] at 1:35 PM, an interview with the Director of Nursing (DON) was conducted. When queried about what interventions were put into place to prevent skin breakdown for residents with contractures, the DON reported they would have restorative care and we can't predict something that would pop up. At that time, R300's skin assessment on [DATE] and wound assessment on [DATE] were reviewed with the DON. The DON reported the weekly skin assessments should be accurate to what is going on with the resident. When queried about what was in place to prevent skin breakdown behind R300's knee prior to the development of a open lesion with exposed tendon and what additional precautions were added after the skin impairment was identified, the DON reported she would look into it. On [DATE] at approximately 2:00 PM, LPN 'D' followed up regarding the information requested from the DON. When queried about any preventative measures that were implemented prior to R300's skin breakdown on the back of the right knee and what additional measures were put into place after the development of the open area, LPN 'D reported she would look into it. On [DATE] at 2:22 PM, LPN 'D' followed up and reported she found old orders for passive ROM, but nothing in place to keep that area free of moisture or to help extend the leg before or after the development of the open lesion. R301 On [DATE] at 10:30 AM, R301 was observed in bed sleeping. R301's right foot was wrapped with dressing which was soiled in the area of his toes which were sticking out of the end of the blanket. On [DATE] at 11:00 AM, R301 was observed in bed. The blanket was no longer covering R301's right foot. The dressing applied to R301's right foot was soiled in the area of his toes. The dressing was dated [DATE] with initials (discovered to be Licensed Practical Nurse - LPN 'Q') written with thick black marker which was written over thinner writing that was labeled [DATE]. On [DATE] at 11:09 AM, an observation of the dressing on R301's right foot was conducted with Unit Manager, Registered Nurse (RN) 'U'. When queried about the date of [DATE] written on top of the date of [DATE], RN 'U' did not offer a response. On [DATE] at 11:19 AM, an observation of the dressing on R301's right foot was conducted with the DON who replied They just changed it! When queried about who and when, the DON pointed to the dressing which was dated for the day prior, [DATE]. The DON reported she looked at the dressing and saw the date from yesterday but did not notice the date underneath. On [DATE] at approximately 11:25 AM, R301's right foot and toes were observed with RN 'U'. RN 'U' unwrapped the dressing from R301's foot. The dressing was soiled and stuck to R301's toes which required RN 'U' to moisten the dressing in order to remove it. The top of R301's right great toe was observed to have an open area described by RN 'U' as Red and beefy, draining, with white patches on the inside of the toe. The top of R301's second toe was observed with an open area described by RN 'U' as a little red and a little white, but not draining as much as the other toe. There is white on the side of the toe. R301's right great and second toe were dark in color in comparison to his other toes and the rest of the right foot. On [DATE] at 10:06 AM, an interview was conducted with LPN 'Q' via the telephone. When queried about the date of [DATE] written on R301's dressing to his right foot with writing underneath labeled [DATE], LPN 'Q' confirmed that he wrote the date on the dressing without actually performing wound care. LPN 'Q' reported he did it because he was assigned to too many residents and could not complete all of his nursing tasks. A review of R301's Physician's Orders and Treatment Administration Record for February 2025 revealed an order to Cleanse right great toe and second toe with wound cleanser and pat dry. Apply calcium alginate AG with honey-based gel and wrap with dry dressing every day shift . It was signed off on the TAR that the treatment was administered on [DATE] and [DATE], despite the dressing indicating the last treatment was done on [DATE]. On [DATE], there was no nurse's signature to indicate a treatment was administered to R301's right toes. A review of R301's clinical record revealed R301 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: acute respiratory failure with hypoxia. A review of a Progress Note from a podiatry consult dated [DATE] revealed R301 was diagnosed with peripheral vascular disease and had multiple wounds to the right foot. It was recommended that an arterial Doppler be completed. A review of a Radiology Results Report dated [DATE] revealed R301 had a right lower extremity arterial Doppler ultrasound completed which revealed monophasic waveforms (slow, blunted systolic blood flow) in the anterior tibial artery (a major blood vessel that supplies blood to the lower leg and foot) with increased velocity, likely related to peripheral vascular disease and monophasic waveforms in the proximal, mid superficial femoral and popliteal arteries (an artery that runs deep in the mid-thigh and through to the knee) in favor of peripheral vascular disease. A review of a Skin and Wound Evaluation dated [DATE] revealed R301 had an Open lesion to the right dorsum first digit (top of great toe) that was in-house acquired that measured 1.4 cm x 2.0 cm x 0.2 cm with evidence of infection (warmth). It was documented that the wound increased in size and R301 was receiving ABX (antibiotics) r/t (related to) soft tissue cellulitis to the right foot. A review of a second Skin and Wound Evaluation dated [DATE] revealed R301 had an open lesion to the top of the right second digit (toe) that measured 1.2 cm x 1.0 cm x 0.2 cm. On [DATE] at 2:15 PM, an interview was conducted with LPN 'D' who said the nurses were required to do weekly head to toe skin assessments and to alert LPN 'D' of any changes (new or worsening) to skin and the floor nurses were required to complete the daily wound treatments. LPN 'D' reported she rounded with the wound provider one time per week. LPN 'D' reported she had been following the progression of R301's toes since she started in her position and indicated although they did not worsen after treatment was not done for three days, he currently was being treated for an infection and it was important to complete the wound care as ordered. A review of a facility policy titled, Wound Treatment Management, revised on [DATE], revealed, in part, the following, .Wound treatments will be provided in accordance with physicians orders . A review of a facility policy titled, Pressure Injury Prevention and Management, revised [DATE], revealed, in part, the following, .Licensed nurses will conduct a full body skin assessment .weekly .

Based on interviews and record reviews the facility failed to ensure residents that required Ventilator care were provided ongoing medical supervision and oversight by a Physician for their respiratory care, ventilator and/or tracheostomy care, including the weaning process for ventilator residents, respiratory examinations, assessments and respiratory/ventilator changes in status throughout their inpatient stay, for nine (R's 40, 30, 55, 57, 35, 41, 10, 19 & 42) of 15 residents reviewed for ventilator care resulting in an identified systemic failure of interdisciplinary approach and Physician oversight for residents that required Ventilator and respiratory care, including adequate implementation of policies and procedures to monitor and supervise the weaning process for mechanical ventilation, and responding to mechanical ventilation alarms and respiratory needs, which resulted in the increased likelihood of serious harm, serious injury and/or death to occur. Findings include: The Immediate Jeopardy (IJ) was identified on [DATE] at 11:51 AM. The IJ began on [DATE]. The Administrator and Ventilator Unit Administrator A was notified of the IJ on [DATE] at 1:34 PM. A plan of removal was requested at that time to remove the immediacy. The IJ was removed and verified on [DATE] based on the facility's implementation of an acceptable plan of removal. Although the immediacy was removed, the deficient practice was not corrected and remained patterned with potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency (SA). R40 Review of a closed record death at the facility for R40 revealed the following: R40 was admitted to the facility on [DATE] and expired in the facility less than a month later on [DATE]. Admitting diagnoses included: acute and chronic respiratory failure, epilepsy and epileptic syndromes, history of sudden cardiac arrest, acute systolic congestive heart failure, atrial fibrillation, hemiplegia/hemiparesis affecting right dominant side, tracheostomy status, gastrostomy status and ventilator dependent. Review of the progress notes revealed the following for the date of [DATE]: A Respiratory Note (RT) at 9:00 AM, documented in part . Per protocol, placed pt (patient) on CPAP (continuous positive airway pressure) /PSV (pressure support ventilation) vent mode; appeared to be tolerating wean . [NAME] (no apparent respiratory distress) noted. Will con't (continue) to monitor resp (respiratory) status. A RT note at 7:06 PM, documented in part . patient received from previous shift, non-verbal, non-focused response, moderately diminished gag/cough reflex, oral, nasal and tracheal secretions suctioned in moderate to large amounts, patient not tolerating PSV vent settings and change to AC (assist control) due to persistent low minute volume alarms, low RR (respiratory rate), grayish facial skin, slightly diaphoretic, will continue to monitor. A Nursing note at 10:44 PM, documented in part . At 2244 (10:44 PM), found to have no pulse. Chest compressions started and also bagged with full support. Patient already traced and vented. 911 in and used thumper machine. Seven does <sic> of epinephrine used. Patient underlying rhythm asystole. Patient pronounc <sic> 2326 (11:26 PM). Patient's daughter notified and came up to the facility. Patient medical service and DON (Director of Nursing) called about event . Review of a policy titled Ventilator Unit- Weaning protocols for the mechanically ventilated patient revised on [DATE], documented in part . Purpose - To facilitate the liberation of patients from mechanical ventilation and provide a consistent approach to the ventilator weaning process. This pathway is a collaborative plan mean to guide the care of ventilator patients. It may be modified based on clinical indication, if appropriate and documented, or in emergency situations . Weaning from mechanical ventilation will be initiated with a physician's order only. Nurses and Respiratory Therapists will be responsible for the care of eligible residents . The ventilator weaning protocol will be implemented following the order of a physician. Eligibility for ventilator liberation will be assessed daily through a collaborative evaluation between respiratory therapy and nursing . Mechanical ventilator weaning will be initiated if: 1. The physician concurs that the patient's condition is consistent with weaning and is clinically stable. 2. The physician may write weaning parameter orders. 3. A pulse oximeter will be utilized on all patients to follow specifically ordered weaning parameters. 4. If at any time the patient develops respiratory distress, or does not tolerate the weaning procedure, returning the patient to safe acceptable ventilator settings and notify the physician. Review of R40's medical record revealed no assessments/evaluations documented by a physician to determine if R40's condition was clinically stable and was eligible for weaning, no weaning parameter orders/protocol, no ongoing pulse oximeter readings documented during the weaning process and no documentation of notification to the physician once R40 was identified to have a change of condition. There was also no identified ongoing nursing assessments documented in the residents record after the identified change of condition. The record revealed no physician order implemented for Pressure Support Ventilation to start the weaning process for R40. Further review of the medical record revealed no examinations/evaluations completed by the facility's Pulmonologist or Physician regarding their ventilator and respiratory care. On [DATE] at 3:39 PM, a telephone interview was attempted with Registered Nurse (RN) G (the nurses assigned to R40 the evening they expired in the facility) and a message was left for RN G to return the call. On [DATE] at 3:31 PM, a telephone interview was attempted with Respiratory Therapist (RT) H (the evening RT who provided care to R40 on [DATE]) and a message was left for RT H to return the call. On [DATE] at 8:32 AM, a second attempt for a telephone interview with RT H was unsuccessful. On [DATE] at 10:20 AM, an interview was conducted with the Respiratory Therapy Director (RTD) I. RTD I was asked if they were aware of R40's change of condition on [DATE] and the physician to not have been notified. RTD I stated they talked to RT H because they had worked the night shift and they questioned RT H about the incident on [DATE]. RTD I stated RT H found that R40 was not tolerating the weaning process and that R40 was not breathing well. RTD I stated RT H then stated they put R40 back on full ventilator support. RTD I stated that RT H verbalized R40's nurse being in the room at the time, so they did not feel the need to chart any more or contact the physician. RTD I stated they educated RT H at . length about documentation and the importance of making sure it's in the medical record. RTD I was asked the facility's protocol on weaning, due to the review of R40's medical record revealed no documentation of the weaning protocol they utilized on [DATE]. RTD I stated . It's a little vague on the weaning . but stated they will find the sheet that they use. On [DATE] at 12:27 PM, the primary Physician for R40, (Physician J ) was interviewed via telephone and asked if they had been notified of R40's change of condition after the unsuccessful weaning process on [DATE] and Physician J stated they were not notified. On [DATE] at 2:36 PM, RN G returned the call and was interviewed. RN G was asked about [DATE] and the events leading up to R40 being found unresponsive. RN G stated R40 was not tolerating the weaning because the alarm (on the ventilator) was going off consistently. RN G stated they informed RT H that R40 was not tolerating the weaning process and needed to go back on full support. RN G stated they did not have any other issues with R40 until they were found unresponsive. RN G was asked the facility's monitoring process for a resident who was identified with a change of condition after an unsuccessful weaning attempt and RN G stated they never seen a protocol in place to wean a person. RN G stated that R40 was in pretty bad shape and prognosis was poor prior to the attempted wean. RN G was then asked who decided that R40 was an eligible candidate to wean if they were in such bad shape and RN G stated they were not sure. RN G denied being informed of R40 to have been grayish in color and diaphoretic as noted by RT H. On [DATE] at 4:07 PM, RT H returned the call and was interviewed regarding R40 on the date of [DATE]. RT H stated at the start of their shift they had received report from the off going RT who stated R40 was being weaned and was tolerating the wean. RT H stated the off going RT instructed RT H to leave R40 on their current weaning settings throughout the night since they were tolerating the wean. RT H stated R40 was comatose and didn't move. RT H was asked who decided R40 was an eligible candidate to wean and RT H stated they were not sure. RT H stated RN G informed them of R40's vent alarms continuously going off and that they were not tolerating the wean. RT H stated the ventilator alarms were going off and the resident was not looking good and was diaphoretic and they had never seen the resident like that before. RT H stated they put R40 back on full ventilator support. RT H stated that RN G was aware of R40's change of condition. RT H stated in part . he was only breathing 8 (respiration rate) per minute and this patient usually is in the 20's and 30's and he was 8 because the air is not getting through to him . RT H stated they work night shift in the facility and would usually not wean the residents at night due to the fact that they weaned during the day and needed to rest and recuperate throughout the night. RT H stated they did not have any other interactions with R40 until they were notified of the code called for R40 due to being unresponsive. RT H was asked where the weaning protocol or order could be found for R40 and RT H stated . I already pointed it out numerous times that it should be a doctor's order to do it . RT H went on to say that they verbally communicate the orders and . there is no order so I have to do what I see fit and he (R40) was not tolerating it (wean) so I changed him (back to full ventilator support) . RT H stated they responded to the code, R40 was identified with a lot of vomit and they suctioned them. RT H stated R40 did not have a gag reflex and vitals were absent. RT H stated that's when the nurses came in to do CPR (Cardiopulmonary Resuscitation). RT H stated the facility initiates standard orders to wean residents when they are admitted , however felt it was . a big thing . that an ordered weaning protocol was not in place. RT H stated at one point of time the facility did have a weaning protocol in place. RT H stated usually a person being weaned would be done under observation and monitoring with the right equipment. RT H stated they are not getting a true picture of the residents oxygenation levels because of the lack of monitoring implemented for the residents they are weaning. RT H stated . when you are weaning someone they are able to breathe on their own but the machine ventilator was giving him (R40) his breaths. I didn't see orders so I'm basically on my own . this was an emergency . As far as I'm concerned we didn't have to call our primary or pulmonary (physician) and there was no order and we really don't call them unless the resident is being sent out (to the hospital) . They should really do trial runs on people (for weaning eligibility) but whoever is being told to do the weaning protocols they supposedly chart on it and let them run for a whole 12 hours . RT H denied informing the Physician or Pulmonologist of R40's change of condition. On [DATE] at 4:48 PM, the RTD I was recalled for a second interview and asked how often the facility's Pulmonologist completes their evaluations/assessments on ventilator residents. RTD I stated Not frequent. That's why I've been trying to get it changed . Everyday we do a weaning protocol with our residents. We still try them no matter what. If they are tolerating the wean we would wean by protocol . RTD I was asked a second time for the weaning protocol due to none being found in the medical record for R40. RTD I stated they were doing a slow wean because his (R40) acuity . RTD I was asked how they decided that R40 was eligible to wean since their acuity and prognosis was poor as stated by their staff. RTD I stated every vent resident has an as needed order implemented to wean. When asked for the examinations/evaluation from the physician that determined the residents to be an eligible candidate to wean, RTD I replied the Pulmonologist for the facility does not come often enough. RTD I stated . the vagueness with this policy is what bothers me . in reference to the weaning protocol. RTD I stated the Pulmonologist has never charted their examinations or assessments. RTD I stated they will sometimes reach out to the Pulmonologist for concerns with no response. RTD I stated they completed an audit of all the ventilator residents to ensure the trach supplies, ambu bag and ventilator settings matched the orders and found that most of the settings did not match the physician orders. RTD I stated the Pulmonologist will not address anything regarding the care of residents with a tracheostomy. On [DATE] at 5:21 PM, a second interview was conducted with R40's primary Physician J and Physician J was asked if they assess or examined R40's respiratory care, ventilator care/settings and eligibility for weaning and Physician J stated No, that's the pulmonologist, they come weekly. Physician J stated the Pulmonologist handles that, not them. Review of the Pulmonologist contract with the facility revealed the following: On [DATE] Pulmonologist K signed a contract that documented in part, . the facility desires to avail itself of the services of the physician as the Pulmonologist of the facility . The Pulmonologist is licensed to practice medicine in the State where the facility is located . and agreement set forth herein, the Parties agree as follows . The Pulmonologist shall provide oversight for the Facility's Respiratory Unit as follows . Conduct weekly visits and review individual respiratory residents' care plans with the Unit Manager and Respiratory Staff . Review and approve policies specific to the Respiratory Unit . Provide care for tracheostomy and vent patients, and consult on equipment needs . Provide education, as needed, to facility staff, upon request of the Administrator of the Facility . Consult with Facility Staff on changes in status and other resident needs . Due to the identified concern with R40's care the survey team expanded the sample and reviewed additional medical records of ventilator residents. The team identified no documentation in any of the ventilator resident records from Pulmonologist K. Review of a typed Ventilator Weaning Protocol . Ventilator Discontinuance/Trach Weaning/Capping Trials (undated) that was provided by RTD I revealed no documentation of it to have been reviewed by a Physician or Pulmonologist K. The typed protocol was not found to be implemented in any of the medical records of the residents dependent on the Ventilators. On [DATE] at 8:54 AM, Pulmonologist K was interviewed and asked if they were the contracted Pulmonologist for the facility and Pulmonologist K explained they were not contracted with the facility and operated independently. Pulmonologist K was asked how often they come to the facility to assess/examine the residents and Pulmonologist K' stated every two to three weeks. Pulmonologist K was asked where they documented their assessments and examinations and Pulmonologist K stated they document their notes in the medical record. Pulmonologist K was informed that the survey team was unable to identify any consultations, exams or assessments in any of the ventilator dependent residents for the last year and Pulmonologist K stated they had access to the facility's electronic medical system and input their notes in the system. Pulmonologist K was asked their involvement in identifying eligible candidates to wean off ventilators and stated the facility had a protocol for weaning and if they have difficulty they would discuss it. Pulmonologist K was asked if the residents being weaned should be monitored and documented continuously during the weaning process and Pulmonologist K stated Yes. Pulmonologist K stated in part . It's not safe to wean residents sometimes . Pulmonologist K was asked if they were informed of R40's unsuccessful wean and change of condition on [DATE] and Pulmonologist K stated they were not familiar with R40 and denied being notified on [DATE]. Pulmonologist K stated usually the residents are weaned during the day and put back on full support at night which is the safest way. When asked how the vent settings are determined for each ventilator resident, Pulmonologist K stated the facility follows the vent settings from their admission. Pulmonologist K was asked the expectations of the staff if a ventilator resident condition changed and needed modifications to their ventilator settings and Pulmonologist K stated the facility has a protocol for modifications for the resident ventilators. On [DATE] at 9:20 AM, the Administrator and Ventilator Unit Administrator A was asked to provide the policies for Ventilator care/management, Tracheostomy care/management, pulmonologist visits, ventilator settings protocol & ventilator weaning protocol. A policy was not provided regarding ventilator settings and the ventilator weaning protocol is documented in full as noted above, which does not contain parameters or a protocol for the weaning process. On [DATE] at 9:21 AM, the facility's Medical Director (MD) L was interviewed via telephone and asked their involvement in the respiratory care for the facility's ventilator residents. MD L stated they had nothing to do with the respiratory care for the ventilator residents. MD L stated the facility has a Pulmonologist to take care of the respiratory care, however, knew the facility was having a lot of problems with the current Pulmonologist. MD L denied ensuring collaboration of respiratory care was being provided to the mechanical ventilator residents and stated in part . I don't do anything with them, my role is not to run different parties . On [DATE] at 11:45 AM, the Administrator and Vent Unit Administrator A were interviewed and informed of the concern regarding the lack of Physician oversight, monitoring and supervision of respiratory care for residents that required mechanical ventilators. The Administrator and Vent Unit Administrator A was asked to provide all Physician documentation regarding the respiratory care, assessments and evaluations for all of the residents that required mechanically ventilation. At 1:34 PM, the Administrator and Vent Unit Administrator returned and stated they were unable to provide any documentation completed by the Pulmonologist K or provide documentation of Physician oversight regarding the respiratory care for the ventilator dependent residents. The Administrator stated Pulmonologist K would be in the facility later in the evening to provide the facility with their documentation. On [DATE] at approximately 2:50 PM, the exit conference was conducted with the facility's Administration team and Corporate staff. Corporate Personnel (CP) F stated the facility had identified the concerns with the Physician services and had plans on fixing it, however they failed to address it in time and now are forced to look into it and change their system. On [DATE] at approximately 3:00 PM, Pulmonologist K approached the survey team in the parking lot of the facility and asked what documentation the State Agency was looking for. Pulmonologist K was informed that all assessments, evaluations, collaboration with care, weaning protocols should be identified in each residents record. Pulmonologist K asked if it was too late to provide the documentation and Pulmonologist K was referred to consult with the facility's Administration team. No further information or documentation was provided by the end of the survey. 38271 R10 On [DATE] the medical record for R10 was reviewed and revealed the following: R10 was initially admitted to the facility on [DATE] and had diagnoses including Chronic respiratory failure with hypoxia and Dependence on respirator ventilator status. Further review of R10's medical record revealed Physician's orders that indicated the following: Vent settings: PCV (pressure controlled ventilation) Targeted Vt (volume targeted), PIP 30 (Peak inspiratory pressure) (Vt 450ml), RR (respiratory rate) 14, PEEP 5 (Positive end-expiratory pressure) A second Physician's order dated [DATE] revealed the following: [Name of pulmonologist] to consult and participate in care. R41 On [DATE] the medical record for R41 was reviewed and revealed the following: R41 was initially admitted to the facility on [DATE] and had diagnoses including Chronic respiratory failure with hypoxia and Dependence on respirator ventilator status. Further review of R41's medical record revealed Physician's orders that indicated the following: Settings: Mode: AC (assistive control) RR:16 PEEP:5 Vt 450 A second Physician's order dated [DATE] revealed the following: Evaluation/Assessment of resident on ventilator . R55 On [DATE] the medical record for R55 was reviewed and revealed the following: R55 was initially admitted to the facility on [DATE] and had diagnoses including Chronic respiratory failure with hypoxia. Further review of R55's medical record revealed Physician's orders that indicated the following: Settings: AC 18, 450, Peep+5 every 12 hours A second Physician's order dated [DATE] revealed the following: Evaluation/Assessment of resident on (Ventilator) as needed . R57 On [DATE] the medical record for R57 was reviewed and revealed the following: R57 was initially admitted to the facility on [DATE] and had diagnoses including Chronic respiratory failure with hypoxia. Further review of R57's medical record revealed Physician's orders that indicated the following: Settings: Mode: A/C RR: 14 PEEP: 5 VT 450ml On [DATE] at approximately 1:37 p.m., the facility Administrator and Ventilator Unit Administrator, were queired if they were able to provide any documentation from the facility contracted pulmonologist that indicated R10, R41, R55 and R57 had been assessed/evaluated by them for ongoing respiratory/ventilator care at all during their stay in the facility and they reported they could not. 47283 R30 Record review revealed R30 was a long-term resident admitted to the facility on [DATE]. R30's admitting diagnoses included acute and chronic respiratory failure, anoxic (lack of oxygen) brain damage, and quadriplegia (paralysis of both upper and lower extremities). Review of R30's clinical record revealed that they were on ventilator, under pressure-controlled ventilation (a mechanical ventilation technique that uses a set pressure to inflate a patient's lungs). Further review of the medical record revealed no examinations/evaluations completed by the facility's Pulmonologist or Physician regarding their ventilator and respiratory care since [DATE]. R19 Record review revealed R19 was a long-term resident of the facility, admitted on [DATE]. R19's admitting diagnoses included dependence on a ventilator/respirator due to respiratory failure, chronic obstructive pulmonary disease (COPD), cirrhosis of liver, and malnutrition. Review of R19's clinical record revealed that they were on ventilator, under assist control (AC) ventilation setting (the ventilator setting that delivers a set volume of air to the patient's lungs at a set rate, either when the patient breathes or at fixed intervals). Further review of the medical record revealed no examinations/evaluations completed by the facility's Pulmonologist or Physician regarding their ventilator and respiratory care since [DATE]. R42 Record review revealed R42 was a long-term, ventilator dependent resident of the facility. They were admitted to the facility on [DATE]. R42's admitting diagnoses included chronic respiratory failure, cardiac arrest, anoxic brain damage, and dependence on ventilator. Review of R42's clinical record revealed that they were on ventilator, under pressure-controlled ventilation (PCV - a mechanical ventilation technique that uses a set pressure to inflate a patient's lungs). Further review of the medical record revealed no examinations/evaluations completed by the facility's Pulmonologist or Physician regarding their ventilator and respiratory care since [DATE]. R35 Record review revealed R35 was a long-term, ventilator dependent resident of the facility. They were admitted to the facility on [DATE]. R35's admitting diagnoses included bone marrow failure syndrome, respiratory failure, diabetes, and COPD. Review of R35's clinical record revealed that they were on ventilator, under pressure-controlled ventilation (PCV - a mechanical ventilation technique that uses a set pressure to inflate a patient's lungs). Further review of the medical record revealed no examinations/evaluations completed by the facility's Pulmonologist or Physician regarding their ventilator and respiratory care since [DATE]. An interview with Nurse Practitioner (NP) T was completed on [DATE]. During the interview they were queried if they were overseeing the care for ventilator dependent residents and they reported that they were only overseeing residents who were assigned to the medical director. They were queried about the ventilator settings and coordination of care with the pulmonologist for ventilator dependent residents. NP T reported that they did not handle that and they were only coordinating the care with the attending physician who was also the Medical Dierctor. The Administrator (NHA) submitted the following accepted removal plan on [DATE] at 5:53 PM: Identification of Residents Affected or Likely to be affected: All residents with ventilator assistance. The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: [DATE]) The NHA notified the Medical Director of the incident. The Pulmonologist will complete physical assessments on all like residents to identify any changes in condition and confirm current ventilator settings on [DATE] The Pulmonologist has received education outlining responsibility for oversight for respiratory care for all Ventilator residents including but not limited to o Completing physical assessments o Monitoring ongoing care o Documenting consultations/evaluations o Providing orders for weaning for ventilator residents The pulmonologist has agreed to round for the residents on the ventilator unit at least 2 times per week. She is available to take call 24 hours in coordination with Primary Care Provider. Ventilator orders sets are entered on admission. o Oxygen: RUN @ []L/MIN VIA []N/C []MASK []TRACH[] HOURS PER DAY [] PRN [] CONTINUOUS o Assess stoma site and under trach collar o Trach Change. Trach brand: Trach size: o Change trach collar/strap every 3 days and prn o Visual check of ventilator dependent residents per care plan and prn. o Weaning prn, per physician order, or respiratory protocol o Enter time in minutes to complete airway equipment management task o Evaluation/Assessment of resident on (Vent/Tracheostomy) o Oxygen saturation q shift and prn o Oxygen tubing/filter change every week. Enter time in minutes to complete task o Suction tracheostomy as needed o Resident/Resident Representative Education o Trach Care PRN (as needed) o Trach tie change with baths and as needed o Settings: Mode: RR: PEEP: PS: o Change circuits monthly and PRN. Enter time in minutes to complete circuit change task. o Trach care every shift and as needed

This citation pertains to intake(s): MI00138580, MI00138907 & MI00139261. Based on observation, interview, and record reviews the facility failed to timely implement adequate preventive wound interventions and consistently assessed, monitored and notified the physician for the worsening of wounds for two (R's 802 & 804) of three residents reviewed for pressure ulcers, resulting in R804 to have developed multiple pressure ulcers including a Stage 4 wound to the sacrum within a little over a month after admission into the facility and for R802 to have developed a stage II pressure ulcer to the coccyx. Findings include: R804 On 9/28/23 at 2:33 PM, R804 was observed lying on their back in bed, the resident was connected to a mechanical ventilator and was observed to have a tracheostomy in place. R804 was able to shake their head yes or no to interview questions. A brief interview was held with the resident at that time. Review of the preadmission paperwork provided to the facility by the transferring facility on 7/13/23, documented the resident to have been at the prior facility from 6/2/23 until 7/13/23 with no documentation of the resident to have developed any wounds. Review of the medical record revealed R804 was admitted to the facility on [DATE] with a readmitted [DATE] and diagnoses that included: acute respiratory failure with hypercapnia, chronic obstructive pulmonary disease, type 2 diabetes mellitus, tracheostomy status, gastrostomy status, and a history of transient ischemic attack. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 10 (which indicated moderately impaired cognition) and required staff assistance for all Activities of Daily Living (ADLs). Review of an admission braden assessment dated [DATE] at 1:31 PM, documented a score of 17.0 . AT RISK . Review of an admission skin assessment dated [DATE] at 1:40 PM, documented in part . Right buttock- bruising/ mole . Left buttock- Bruising . Sacrum- Redden . Review of the care plan titled . resident has potential for skin impairment . initiated 7/13/23, documented the following interventions . Avoid scratching and keep hands and body parts from excessive moisture, Keep fingernails short, Educate resident/family/caregivers of causative factors and measures to prevent skin injury, Keep skin clean and dry. Use lotion on dry skin. Do not apply on skin impairment area(s) . These interventions were not adequate in preventing worsening and/or the development of a pressure ulcer to the sacrum and buttock areas. Review of a facility policy titled Pressure Injury Prevention and Management dated 1/1/22, documented in part . This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries . Licensed nurses will conduct a pressure injury risk assessment, using . Braden tool . After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions . Review of the July 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed on 7/13/23, the following order was implemented . Miconazole Nitrate External Cream 2% . Apple to buttocks, Groin and folds topically two times a day for skin care until 7/20/23 . The cream was not applied on 7/20/23, however stopped as directed after. Review of the medical record revealed no documentation of treatment or physician notification for the redden sacrum area and no physician follow up to ensure the prescribed cream was effective for the buttock area. Review of a Nursing note dated 7/23/23 at 11:55 AM, documented in part . A new skin problem was observed. Coccyx unstageable DTI (Deep Tissue Injury). Notification place in DON (Director of Nursing) box . This indicated the sacrum wound had worsened. Review of the July 2023 MAR and TAR revealed the following in part . Cleanse with wound cleanser. Pat dry. Apply Bordered Foam as directed to Coccyx. Skin barrier wipe to peri wound at bedtime for DTI . Start Date- 07/23/2023 . D/C (discontinued) Date- 07/28/2023 . Review of a wound consultation note dated 7/27/23, documented in part . Consultation and evaluation of a wound found at the sacrum . LOCATION: Sacrum . Wound Stage: Deep Tissue Pressure Injury . DRESSING USED: Triad, Bordered Foam . EXUDATE: Scant, Serous . PERIWOUND: Unhealthy . Length (cm- centimeters) 4.0, Width 4.0, Depth Utd (unable to determine), Wound area (cm2- centimeters squared) 16.00 . WOUND PROGRESS: Undetermined: first visit . The wound is stable and requires continued topical wound dressing therapy as noted above . Review of a wound consultation note dated 8/3/23, documented in part . evaluate a wound found at the sacrum . Wound Stage: Unstageable Pressure Injury . DRESSING USED: Calcium Alginate with Honey, Bordered Foam . Underlying dti starting to open up to unstageable . 40% Slough . 10% Necrotic Tissue . 3.8 Length, 2.2 Width, Utd Depth, 8.36 Wound area . Review of the care plan titled The resident has a DTI to Sacrum . Initiated 8/8/23, documented the following intervention . Monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size (length x width x depth), stage . Review of the medical record revealed no documentation of the staff to have identified or reported to the physician the worsening of the sacrum wound from 7/27/23 to 8/3/23 (the day the wound physician identified worsening of the sacrum wound.) Review of a Nursing note dated 8/16/23 at 7:17 PM, documented in part . Writer observed wounds on BL (bilateral) heels during ADL care. Reported to husband on site, bl heel boots applied, heels floated, wounds assessed, and treatment initiated . Review of the care plans revealed the lack of adequate interventions implemented to protect the resident heels prior to the identification of the right wound heel. Review of a wound consultation note dated 8/17/23, documented in part . evaluate wounds found at the sacrum and right heel . Sacrum . Wound Stage: 4 - Pressure Injury . Necrotic tissue . Subcutaneous tissue debridement performed by surgical excision of devitalized subcutaneous tissue. A total area of 19.2 sq (square) cm of devitalized tissue was debrided with no loss of blood. The pre-op wound area was found to be 6.5 cm x 5.9 cm x Utd cm (38.4 sq cm). The post-op wound area was 6.5 cm x 5.9 cm x Utd cm (38.4 sq cm) . DRESSING USED: Calcium Alginate with Silver, Honey-based Gel . UNDERMINING: 1.5 CM AT 2 o'clock, ODOR: Mild, EXUDATE: Moderate, Serous . 40% Slough, 20% Granulation, 40% Necrotic Tissue . Right Heel . Wound Stage: Deep Tissue Pressure Injury . DRESSING USED: Skin Prep . 3.2 Length, 2.7 Width, Utd Depth, 8.64 Wound area . Review of the medical record revealed no documentation of the staff to have identified or reported to the physician the worsening of the sacrum wound from 8/3/23 to 8/17/23. On 9/28/23 at 3:53 PM, the Director of Nursing (DON) was interviewed and asked the facility's protocol on the identification of a skin impairment or worsening of a wound, the DON replied the nurse would notify the physician and ensure the appropriate treatment is in place. The DON was asked the facility's protocol on the implementation of preventive interventions to prevent skin impairments and the accuracy of braden assessments completed and the DON replied the braden assessments are conducted when the resident admits to the facility and the nurses are responsible for implementing interventions. The DON was then asked why timely interventions was not implemented for R804 and the consistent lack of monitoring and identification of the worsening of the sacrum wound to report to the physician. The DON stated the wound nurse was not working during the duration of the survey, however they would look into it and follow back up. No further explanation or documentation was provided by the end of the survey. R802 Review of the medical record revealed R802 was admitted to the facility on [DATE] with diagnoses that included: respiratory failure, injured in motor-vehicle accident, traumatic cerebral edema with loss of consciousness, tracheostomy status, gastrostomy status, and dependence on respirator ventilator status. A MDS assessment dated [DATE], documented Severely impaired cognitive skills for daily decision making and required staff assistance for all ADLs. Review of an admission skin assessment dated [DATE] at 3:52 PM, documented no identification of a pressure wound. Review of the July 2023 MAR and TAR documented the following orders: . border foam dressing to coccyx daily for prophylaxis every night shift for prophylaxis . Start Date- 7/7/23. . Cleanse with wound on Sacrum with wound cleanser and apply Dermaseptin and covered with bordered form <sic> daily. One time a day . Start Date- 7/29/23. Review of the progress notes revealed no documentation of the wound or the wound characteristics. Review of the care plans revealed inadequate interventions to prevent the development of a pressure wound to the coccyx area. Review of the first Skin & Wound Evaluation completed (dated 8/4/23) documented in part . Pressure . Stage 2: Partial-thickness skin loss with exposed dermis . Location Coccyx . In-House Acquired . New . 0.9 cm2 (centimeters square) Area, 2.2 cm (centimeters) Length, 0.6 cm Width . On 9/29/23 at 10:56 AM, an observation of R802 buttock area was conducted with Unit Manager (UM) F and Certified Nursing Assistant (CNA) G. UM F and CNA G removed the brief of R802 and turned the resident on their side. Initial evaluation revealed no protective treatment applied to the resident's coccyx area. When UM F was questioned about the treatment, UM F replied the resident does not have prescribed treatment to the coccyx area. R802's coccyx area was intact, observed was a healed pressure ulcer that revealed a light tan/brown discoloration to the coccyx area. Review of the physician orders documented in part, . Cleanse with wound cleanser. Pat dry. Apply Bordered Foam as directed to coccyx. Skin barrier wipe to peri wound every day shift . This order was not applied to the coccyx as ordered by the physician. Review of a care plan titled resident has history of skin integrity of the following location coccyx . implemented on 8/4/23, documented the following intervention . Keep skin clean and dry and apply foam dressing . On 9/29/23 at 1:22 PM, an interview was conducted with the DON, the DON was asked why preventive interventions was not implemented timely to prevent pressure wounds for R802 and why the ordered foam dressing was not applied as ordered by the physician for R802's coccyx area on 9/29/23 observation. The DON replied they would look into it. The DON returned shortly after, and stated staff was recently educated on pressure wounds. No further explanation or documentation was provided by the end of the survey.

This citation pertains to intake: MI00138158. Based on interview and record review the facility failed to prevent and identify the root cause of a second degree burn for one (R809) of two residents reviewed for accidents, resulting in R809 being transferred and admitted to the hospital for treatment to a Second degree burn of left upper arm. Findings include: Review of a complaint submitted to the State Agency (SA) documented in part, . On 7/02/2023, (R809 name) was transported to the hospital for a second degree burn on (R809) left arm. It is unknown how (R809) got the burn . Review of the medical record revealed R809 was admitted to the facility on [DATE] with diagnoses that included: nontraumatic subarachnoid hemorrhage, cerebral infarction, acute respiratory failure, hypertension, and gastrostomy status. A Minimum Data Set (MDS) assessment dated [DATE], documented Severely impaired cognitive skills for daily decision making and was dependent on staff assistance for all Activities of Daily Living (ADLs). Review of the progress notes revealed the following: A Nursing note dated 7/1/23 at 8:18 PM, documented in part . rash appeared on resident's upper left arm. Red skin, with blisters, warm to the touch. Notified (doctor's name). hydrocortisone cream was ordered as well as Medrol pack. Called pharmacy and requested drop ship so meds (medications) will start on time. This note was documented by Registered Nurse (RN) C. A Nursing note dated 7/1/2023 at 8:37 PM, documented in part . one area of redness seems smaller. There are more blisters now, and they are larger. A Nursing note dated 7/2/23 at 9:07 AM, documented in part . reddened area is smaller, blisters are large. Notified DON (Director of Nursing) and MD (Medical Doctor). MD said to send her to the hospital . Review of the hospital medical record revealed the following: An ED (Emergency Department) Provider Note dated 7/2/23 at 9:58 AM, documented in part . evaluation of blisters and erythema to left upper arm . was taken for shower when she (R809) came back there is an area of erythema and blistering on the left lateral shoulder . symptoms concerning for partial-thickness burns to left upper extremity . clinical exam is consistent with partial-thickness burn to left upper arm; likely from shower as patient was visualized by family without having lesion before and it was present after the shower occurred. Concern for incidental burn from water during shower. Family members requesting patient not be send back to her facility . Patient admitted to hospital for further care and evaluation of the partial-thickness burn to left upper arm . Diagnosis . Second degree burn of left upper arm . Partial thickness burn of left upper arm . I spoke at length with mother and sister who are acting as independent historians and state that mother saw pt (patient) the day before and when she was lotioning her after shower the pt had what appeared to be a burn on her left upper arm . She was admitted for wound care and antibiotics treatment . Review of the hospital picture of R809's upper left arm was reviewed and clearly revealed a second-degree burn, with redden skin and blisters noted to the whole upper left arm and extending down towards the elbow area. Review of R809's Task documentation for July 2023, revealed a shower was provided to R809 on 7/1/23 by Certified Nursing Assistant (CNA) B. On 7/25/23 at 2:16 PM, a telephone interview was conducted with RN C when asked, RN C stated they were first notified of the R809's redden area by R809's mother. RN C stated R809's family regularly visited R809 and was present the day of R809's shower. RN C confirmed that R809 did have a shower on the evening of 7/1/23. When asked RN C stated that CNA B had not informed them of anything abnormal regarding R809's shower or skin. RN C stated R809 did not go out to the hospital the evening of the shower but the next day. When asked if the facility's Administration team followed up with them regarding the incident RN C replied the facility's Administrator and Director of Nursing (DON) completed a telephone interview with them. On 7/25/23 at 2:27 PM, a telephone interview was conducted with CNA B. CNA B was asked about R809 and the shower they provided on 7/1/23. CNA B stated it was a normal shower and the only thing different was that R809's family provided a different shower gel to use on the resident. When asked how they test the water temperature before they started R809's shower, CNA B replied they test the water with their hand or the resident's feet before washing them. When asked CNA B denied that the water temperature was hot when they provided R809's shower. CNA B stated in part . From what I understand the water doesn't get that hot to burn anybody, because they (facility staff) tested it . When asked CNA B stated R809 is nonverbal and confirmed that R809 is dependent on staff for all ADLs. CNA B stated they did not notice anything abnormal with R809 after the shower and was told later that a blister had formed. CNA B stated the facility's Administration staff followed up with them regarding the incident and took a statement from CNA B at that time. On 7/25/23 at 2:39 PM, the facility's maintenance staff (later identified as Maintenance Director- MTD D) was requested to meet the surveyor by the shower room with a thermometer to test the water in the shower room used to shower R809. At 2:57 PM, the facility's Administrator for the Ventilator unit, identified as NHA Vent A met with the surveyor and stated MTD D was currently not in the facility and NHA Vent A would complete the water temperatures of the shower room. Upon entering the shower room two shower heads were identified on opposite sides of the shower room. Shower #1 water temperature was tested by NHA Vent A and was observed to reach the highest at 98.3. Shower #2 was tested and observed to reach the highest at 97.4. When asked what the water temperature levels should be, NHA Vent A stated between 105-120 for a safe and comfortable level. When asked, NHA Vent A was unsure on why the temperature was not maintaining a comfortable level. At this time the facility's water temperature testing logs was requested from June 1, 2023, to July 1, 2023. On 7/26/23 at 8:31 AM, a second request was made to the Administrator for the facility's water temperature testing logs. Shortly after the Administrator and MTD D arrived in the conference room and provided the water temperature logs. Review of the water temperature logs in the presence of the Administrator and MTD D was completed. The water temperature logs provided were for the weeks of 6/8/23, 6/19/23, 6/28/23 and 7/13/23. The Administrator and MTD D was asked about the testing logs for the weeks between 6/28/23 and 7/13/23, when the incident occurred and MTD D replied they had no logs for that week. The Administrator asked MTD D if another maintenance personnel could have possibly tested the water that week and MTD D replied they were the main personnel that would test the water temperature and they did not have logs for the period between 6/28/23 and 7/13/23. When asked how the facility ensured the water temperature was at a safe and comfortable temperature between the weeks of 6/28/23 and 7/13/23, there was no reply. Further review of the facility waterlog documents revealed the last water temperature check completed prior to 7/1/23 (the date of the incident) was 6/28/23. The prior logs dated 6/19/23 and 6/28/23, documented numbers in the 70's (6/19/23) and 20's (6/28/23) which the MTD D could not explain what the temperatures were or what the numbers meant, when asked. This confirmed the facility water temperatures were not accurate for the weeks prior to the date of the alleged incident. On 7/26/23 at 9:05 AM, the Administrator was asked if they were made aware of the facility's water temperature not maintaining a comfortable level and stated they were informed by NHA Vent A, and the facility is currently in the process of putting in a service call. The Administrator was asked to provide any documentation of the scheduled date for the third party to assess and address the facility's water temperature issue. The Administrator stated they would follow back up. No further documentation was provided by the end of survey. Review of the facility's investigation into the incident with R809 revealed the following typed Administrative Statement Investigation Analysis completed by the former Administrator who no longer was employed at the facility, later identified as Former Administrator (FM) E. The report documented the following in part . Date of Occurrence: 7-1-2023 . Time of Occurrence: Approximately 6:45 PM . Allegation: Resident had an injury of unknown origin to her left upper arm . Resident had received shower by caregiver which took approximately 10 minutes. Responsible party reported noted irritation to arm 2.5 hours after shower was provided. The minor injury was examined by a nurse and reported to MD who initiated orders for hydrocortisone cream and Medrol pack . Upon being informed of this allegation the Administrator (LNHA) immediately began an investigation . Nurse aide went to resident's room at approximately 3:45 PM to provide resident her shower . CNA stated she showered resident for approximately 8 to 10 minutes . After caregiver returned resident to her room, her responsible party applied lotion to resident and assisted with brief change . It was then reported by responsible party at 6:45 PM that resident had small bumps and a rash on her left arm. The nurse reported the next morning at 9 AM that the afflicted area became smaller but there were more blisters, and the MD (Medical Doctor) requested the resident be transferred to the hospital . resident was transferred to the hospital earlier that day and diagnosis from ER (emergency room ) was unspecified burn . on the picture the area is rectangle and flatten (referring to picture of R809's upper left arm) . The alleged injury is much localized. The upper left arm only was involved, while the resident's entire body was showered. Also, where resident was showered the shower holder is broken, which would rule out water being applied to a particular area for any extended prior of time . The water temperature was not high enough to cause a second-degree burn. The temperature of the water in the hot water tank was measured and found to be 115 F . The shower room is located a long distance from the hot water tank since it is located on the second floor . This injury of unknown origin could not be classified as water being origin of injury . New product was applied to skin, which could contribute to chemical vs (verses) thermal skin injury in addition to history of family applying heating device per staff . The resident family member brings a tote bag each visit . Responsible party declined having or using a heating device despite numerous nursing staff stating they have seen them previously . During interview facility staff noted that they have observed responsible party using a heating pad / blanket on resident. Staff states the responsible party was advised to prohibit bringing the heating pad/ blanket into the facility. The facility concludes that the injury of unknown origin is unable to be determined. The injury may be the result of cellulitis or possibly a chemical burn caused by the use of a new personally hygiene product or some type of heating device due to the uniformity of the affected area. It's highly unlikely that resident would be burned by water in only one area of her upper extremity . We cannot substantiate an injury of unknown origin was cause by facility . On 7/27/23 at 3:55 PM, a telephone interview was attempted with FM E. A message was left for FM E to return the call. A return phone call was not received by the end of the survey. Further review of the facility's investigation into the injury of unknown origin with R809 revealed no accurate documentation of water temperatures obtained for the time frame prior to the incident with R809. Review of the facility staff statements revealed no staff member identified that witnessed R809's family member to have ever bring a heated pad or blanket into the facility. There was no documentation of the facility to have ever identified R809's family bringing in a heating device nor was their documentation of the facility to have ever educated R809's family on bringing heating devices into the facility as noted in the investigation above. The description of the wound and diagnosis documented in the above investigation completed by the facility was also found to be incorrect. The injury was not minor as documented in the facility's investigation. On 7/26/23 at 9:05 AM, the Administrator was interviewed and asked to identify the staff the facility documented in their investigation who witnessed R809's family to have brought into the facility a heating pad, blanket or device and the Administrator stated they could not identify a staff member that actually seen the family bring in the device. The Administrator was then asked to provide statements from the staff that witnessed R809's family to have brought and used a heating device on R809 and to provide the education documentation that was provided to R809's family as stated in the facility's investigation and the Administrator confirmed the facility had no eye witness staff statements of staff witnessing R809's family using a heating device in the facility nor did the facility have documentation to provide that R809's family was ever educated on this matter as documented in the facility's investigation. The Administrator was asked what the facility concluded the cause of the second degree burn for R809 and again the Administrator stated they believed it was from a heating device placed by R809's family. The Administrator was asked to provide all documentation the facility had to support the claims documented by the facility in their investigation. No further documentation was provided by the end of survey.

Based on observation, interview and record reviews the facility failed to consistently complete a root cause analysis of falls, complete a fall risk assessment upon admission per the facility policy and implement adequate and effective interventions in an attempt to prevent future falls for one (R55) resident with a history of falls and assessed as a high fall risk, and failed to ensure proper positioning while in bed, unattended for one (R28) of three residents reviewed for falls. Findings include: R55: On 10/17/22 at 10:06 AM, R55 was observed sitting on the side of their bed. At this time an interview was attempted. Some questions were answered appropriately but most questions were not. Review of the medical record revealed R55 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: abnormalities of gait and mobility, bilateral [CONDITION(S)] of knee and muscle weakness. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11 indicating moderately impaired cognition and required staff assistance for ambulation, transfer and bed mobility. Review of the preadmission documents provided to the facility documented the following: A diagnosis of Repeated Falls on the face sheet. . Fall risk . Confusion . on a Physical Therapy Treatment Encounter Note. . brought into the hospital after a fall . states she sprained her ankle with the fall . Extremity Weakness . This is a chronic problem .Documented in a Physician Progress Note dated 6/1/22 at 3:25 PM. Review of the medical record revealed a Fall Risk Evaluation was not completed on the resident upon admission into the facility. Review of a care plan titled The resident is at risk for falls related to: muscle weakness, [CONDITION(S)] medication use, abnormality of gait and mobility revised on 6/29/22 documented one intervention . Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed . initiated 6/17/22. Review of a facility policy titled Fall Prevention Program revised 1/1/22, documented in part . Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls . Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk . The nurse will indicate the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk . The facility failed to complete an admission fall assessment and implement effective and adequate interventions to prevent falls. Review of the progress notes documented the following: . 7/5/22 11:00 . post fall skin assessment . no skin abnormalities at site of pain . 7/5/22 12:27 . legal guardian, notified of fall and transfer to hospital . Review of facility incident report dated 7/5/22 at 11 AM, documented in part . Physically Impaired . Decision making impaired . Unobserved Fall . Resident was found on floor next to bed by RT (Respiratory Therapist). Resident stated she was trying to get into the bed . pain on left side of forehead no bruise/redness . Review of a facility Fall RCA (root cause analysis) Investigation Tool dated 7/5/22, documented in part . face up next to bed - partly sitting up, trying to stand . MATTRESS WAS NOT COMPLETELY ON BED FRAME . confused at baseline . confused after fall . She was on the floor the opposide <sic> of the bed her walker is on. The mattress was partially off the bed. It doesn't seem likely that she was trying to get into the bed . ROOT CAUSE OF THIS FALL- (Blank) . Describe initial interventions to prevent future falls . asked resident to use call light when getting out of bed . Falls Team Meeting Notes . Summary of Meeting: Systemic or operational conditions that may contribute to falls? Any patterns or trends to the resident falls? (Blank) . Conclusion (Blank) . Additional Care Plan / Nurse Aide Assignment Updates (Blank) . Signatures (Blank) . Review of a facility Quality Assessment & Assurance Investigation Report attached to the incident report was not completed. Review of a facility incident report dated 7/5/22 at 12:00 PM, documented in part . Memory impaired . Physically impaired . Decision making impaired . Fall . Resident observed in room on floor next bed <sic>, laceration noted on mid (middle) Lt (left) forehead approximately I inch in length, superficial steristrips applied. Resident assessed, assisted back to bed . Resident transferred to hospital for CT scan . Call 911 . Sent to Hospital . Review of a facility Quality Assessment & Assurance Investigation Report dated 7/5/22 at 12:00 PM, documented in part . Resident stated she was trying <sic> get into the bed. Resident was observed on floor in room on the left side of bed . Review of a Fall RCA Investigation Tool dated 7/5/22 at 1200 PM, documented in part . Resident lost their balance . Found on the floor (unwitnessed) . Attempting to self-transfer . A & O x1 (Alerted and Oriented times one- to person) . Root Cause Of This Fall- Amount of assistance in effect . Medical status/Physical condition/Diagnoses . Mood or mental status . What appears to be the initial root cause(s) of the fall? Transferring without assistance or walker . Describe initial interventions to prevent future falls: To be assessed upon return form hospital . Falls Team Meeting Notes . Summary of meeting: Systemic or operational conditions that may contribute to falls? Any patterns or trends to the residents' falls? Conclusion, Additional Care Plan/ Nurse Aide Assignment Updates, Signatures (all blank) . The facility then completed an Admission Fall Risk Evaluation and added two additional interventions to the resident's care plan. Review of a Fall Risk Evaluation dated 7/5/22 at 1:55 PM, documented a score of 15.0 indicating interventions Required. Review of the care plan titled The resident is at risk for falls related to: muscle weakness, [CONDITION(S)] medication use, abnormality of gait and mobility documented two additional interventions, . Bed at the following height when not providing care. At knee height to facilitate safe transfer . [NAME] locked at bedside when resident is in the bed. Both interventions were added on 7/5/22. Review of a hospital Internal Medicine H&P (History and Physical) dated 7/5/22, documented in part . Chief Complaint Patient presents with Fall . on 07/05/22 via EMS (Emergency Medical Services) from an ECF (Extended Care Facility) after 2 falls. Per the records, pt (patient) fell while getting out of bed and then fell a second time in her room. She did hit her head. During the examination, pt is A&O x3 but is confused and answers most other questions incorrectly . only follows some commands . does not remember the second fall but when reminded of it thinks that she fell because she saw blood . The resident was admitted to the hospital and discharged back to the facility on [DATE]. Review of a Nursing note dated 7/11/22 at 5:00 PM, documented in part, . Resident received via stretcher accompanied by EMS (Emergency Medical Services) . A&O x1-2 able to make some needs known . Stitches and discoloration noted to forehead . Review of the fall care plan noted no documentation of additional interventions added or modifications upon the resident readmission to the facility. Review of a facility incident report dated 9/19/22, documented in part . writer in hall, heard a loud noise, ran to room, found resident on the floor next to bed . Resident Unable to give Description . No injuries observed at time of incident . Review of the medical record revealed no documentation of the Interdisciplinary (IDT) team to have met to perform a root cause analysis of the 9/19/22 fall and no modification to the care plan. On 10/19/22 at 3:15 PM, the Director of Nursing (DON) was interviewed and asked about the inadequate fall care plan interventions implemented for a confused, high fall risk resident with a history of falls. The DON was also asked about the fall risk assessment to not have been completed upon admission as directed by the facility policy and the Interdisciplinary meetings not to have been consistently conducted to find the root cause and to modify the care plan if needed. The DON stated they would look into it and follow back up. No additional explanation or documentation was provided before the end of the survey. R28: On 10/17/22 at 9:54 AM, Certified Nursing Assistant (CNA 'I') was observed to bring a mechanical lift into R28's room and closed the door. At 9:56 AM, CNA 'I' exited the room, closed the door and proceeded to go down the hallway out of sight. On 10/17/22 at 9:59 AM, CNA 'I' walked past Nurse 'Y' and was about to re-enter R28's room when Nurse 'Y' asked the CNA if they were going to transfer the resident and CNA 'I' stated they were, but they were looking for someone to help. Nurse 'Y' asked CNA 'I' if they wanted help and the CNA did not respond immediately, then responded OK. Upon entering R28's room, R28 was observed to be in bed laying on top of a hoyer lift sling while in bed, with the bed positioned in a high manner. When asked about the positioning of the resident, CNA 'I' did not indicate there was any concern and reported they had placed the resident on the hoyer sling themselves just before they went to look for help with the hoyer lift. When asked about the positioning of the resident, CNA 'I' did not indicate there was any concern. Review of the clinical record revealed R28 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses which included: cerebral infarction, [CONDITION(S)] following cerebral infarction, cerebral [CONDITION(S)], and unspecified convulsions. According to the MDS assessment dated [DATE], R28 had unclear speech, was usually understood and usually able to understand orders, cognition was Not assessed/no information, required limited assistance of one person for bed mobility and was totally dependent upon one person physical assistance for transfers (which conflicted with the current plan of care). Review of the activities of daily living (ADL) care plan initiated on 8/3/17, revised 11/22/21 read: (R28) has an ADL self-care performance deficit r/t (related to) [CONDITION(S)] ([CONDITION(S)]/Stroke). S/P (Status Post) craniotomy. Hearing is adequate, with unclear speech, able to make self usually understood and usually understands others (with pictures to describe her needs, pen and paper at bedside), with impaired vision (sees only large print) and incontinent of bowel and bladder. Interventions included: TRANSFER: The resident requires Mechanical Lift (Hoyer) with 2 or more staff assist for transfers. This had been initiated on 8/3/17 and remained a current intervention. Review of the safety care plan initiated 8/3/17, revised 3/27/18 read: Safety: (Name of R28) is at risk for falls r/t loss of body control due to [CONDITION(S)]. Hx (History) of falls prior to admission Interventions included: Low bed when not providing care. This had been initiated on 8/3/17 and remained a current intervention. According to the most recent completed fall risk evaluation dated 11/4/2020, R28 scored an 18.0 and indicated Interventions Required. On 10/17/22 at 10:42 AM, an interview was conducted with the Director of Nursing (DON) in the presence of the Regional Director of Clinical (Nurse 'S') and Corporate Clinical (Nurse 'O') to review the concerns observed with R28 being left positioned high in bed while unattended. The DON reported they would follow-up and acknowledged the resident should not have been left like that while unattended. On 10/19/22 at 9:54 AM, the facility was requested to provide a facility policy for a resident's positioning while in bed. Review of the policies provided did not address this concern.

This citation pertains to intake #'s MI 173 and MI 226 Based on observation, interview, and record review, the facility failed to ensure weekly skin assessments were completed, perform physician ordered wound care treatments, and implement interventions to prevent the development of pressure ulcers, or the worsening of existing pressure ulcers for four residents (R#'s 402 and 403), of four residents reviewed for pressure ulcers. Findings include: A review of a facility provided policy titled, Pressure Injury Prevention and Management with a revision date of 1/1/2022 was conducted and read, .2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate .3. Assessment of Pressure Injury Risk .b. Licensed nurses will conduct a full body skin assessment on all residents .weekly, and after any newly identified pressure injury .c. Assessments of pressure injuries will be performed by a licensed nurse and documented in the medical record .4. Interventions for Prevention and to Promote Healing .c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present . R402 On 5/10/22 at 11:35 AM, a review of R402's closed clinical record was conducted and revealed they admitted to the facility on [DATE] and discharged to the emergency roiagnom on [DATE]. R402's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R402's Minimum Data Set (MDS) assessment dated [DATE] indicated R402 had moderately impaired cognition, did not exhibit any behaviors, was not ambulatory, and required total assistance from two staff members for transferring and bed mobility. A review of section M. Skin Conditions was reviewed and indicated R402 did not have any pressure ulcers upon admission to the facility. A review of R402's admission skin assessment was conducted and revealed they admitted to the facility with moisture associated skin damage (MASD) to their bilateral breasts, bilateral abdominal folds, groin, thighs, and skin folds on their back. A review of R402's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of R402's clinical record was conducted and revealed R402's first weekly skin assessment (almost three weeks after their admission 3/16/22) was documented on 4/3/22 and indicated R402 had MASD on their left posterior thigh and their left back skin folds. The assessment also documented R402 had a stage III (full thickness skin loss in which fat may be visible and granulation tissue and rolled edges are often present; slough or eschar may be visible) pressure ulcer to their left heel. It was noted there were no measurements or additional description of the wound. R402' next skin assessment dated [DATE] was blank with a status of Incomplete. The next two skin assessments dated 4/20/22 and 4/27/22 did not list any wound sites or descriptions but read, Comments: Anterior Neck, Bilateral breasts, bilateral abdominal folds, bilateral back folds, bilateral posterior thighs, groin, left heel). It was noted the 4/27/22 assessment had the addition of coccyx added to the comments. A review of R402's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply Calcium Alginate as directed to Left Heel Pressure Ulcer. Skin barrier wipe to peri-wound. Cover with bordered Foam. every night shift for Wound Care. The corresponding Treatment Administration Record (TAR) was reviewed and was left blank for the wound care treatment on 4/7/22, 4/8/22, 4/12/22, 4/13/22, 4/15/22, 4/19/22, and 4/28/22. A review of R402's progress notes revealed a note from Wound Care Nurse Practitioner 'B' dated 4/27/22 (three and a half weeks after the documentation of the discovery of a stage III pressure ulcer on R402's heel) that read, .1. Left heel unstageable pressure injury: Measures 3.4 x 1.5 cm (centimeters), Unable to determine depth. Wound bed dark eschar. No drainage .2. Right chest / breast moisture associated skin damage .Wound is limited to skin breakdown, scattered open areas. Skin is denuded and inflamed with [CONDITION(S)] . On 5/11/22 at approximately 9:00 AM, a review of R402's hospital records was conducted and revealed they admitted to the emergency department on 4/29/22 with .Numerous wounds present throughout the skin fold regions . Continued Review of R402's hospital records revealed a wound care consult that read, .Patient is very large and has many folds on back, abdomen, breasts, buttocks, and thighs causing pressure injuries. Breasts are large and pendulous with wounds from pressure. Pt (patient) has multiple open areas all over the above areas. Some of these wounds are shallow pink, some with slough. Several areas noted to be dark, purplish DTIs (deep tissue injuries) .Most of right breast has pressure areas from shallow pink to white underneath breast to dark DTI to mid breast .Inner and posterior thighs and buttocks have multiple open wounds, mostly with white slough .Coccyx has unstageable approx 3cm x 1cm, yellow .Back folds, mostly to left side, has shallow pink and white wounds, also darker area of DTI to left mid back .DTI to right heel 5cm x 3cm .Unstageable to left heel 3cm x 3cm eschar . On 5/11/22 at 1:43 PM, an interview was conducted with the facility's Director of Nursing (DON) and Corporate Nurse Consultant 'A'. They were asked about skin assessments and performing treatments, and they said nursing staff were supposed to document skin assessments weekly and accurately and perform the physician ordered wound care treatments and sign them off on the TAR. They were then asked specifically about the 'as needed' order for R402's [MEDICATION(S)] and why it had never been applied despite the documentation that R402 had several areas of MASD on their body. They had no response for why the order did not get put in as a scheduled order. They were then asked about consulting the wound care Nurse practitioner for R402's stage III pressure ulcer discovered on 4/3/22 and said wound care should have been consulted prior to 4/27/22. On 5/11/22 at 12:25 PM, a request was made for R402's Certified Nursing Aide (CNA) tasks for turning and repositioning, however; it was not received by the end of the survey. R403 On 5/10/22 at 10:30 AM, R403 was observed in their bed on their back. They were observed with their heels pressed into the mattress leaving indentations on the mattress surface. R403 was not observed to have their heels floated or any type of heel protection such as soft boots on their feet at that time. A closer observation of R402's heels revealed the following: The left heel had an area of dark purple tissue that was harder to the touch than the surrounding skin. The center of the darkened area had a smaller area of lighter pink tissue. The darkened area on the heel measured approximately 3cm x 3cm and appeared to be a deep tissue injury. The right lateral ankle over the bony prominence had a darkened purplish discoloration that measured approximately 1.5cm x 1.5cm and appeared to be a deep tissue injury. The medial aspect of the right heel was observed to have a dark purple discoloration that measured approximately 2cm x 2cm and had the appearance of being scabbed over. On 5/10/22 at 11:50 AM, 12:50 PM, 2:29 PM, and 4:11 PM R403 was observed in their bed. R403's heels were not observed to be floated and no soft heel boots were observed to be on their feet. R403's heels were observed to be pressed into mattress creating indentations into the mattress surface. At 4:11 PM, R402's closets and drawers were observed for the presence of soft heel boots, but none were discovered in the room. On 5/1122 at 8:15 AM and 10:30 AM, R403 was observed in their bed. R403 had pillows under their thighs in an attempt to elevate their heels off the mattress surface, however; due to the pillows positioning under the thighs this caused R403's knees to be flexed and their heels were still observed in direct contact with the mattress surface. A review of R403's clinical record was conducted and revealed an admitted [DATE] and a re-admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R403's MDS assessment dated [DATE] indicated R403 had severe cognitive impairment, was non-ambulatory, and required total assistance from one staff member for all activities of daily living. A review of R403's weekly skin assessments was conducted and revealed a skin assessment dated [DATE], with the next assessment performed on 4/28/22. There were no weekly skin assessments for the month of May. A review of R403's TAR was conducted, and it was discovered that despite no observations of R403 having heel boots on 5/10/22, the treatment that read, Check heel boots placement. Ensure heels is <sic> being floated-not touching mattress or anything. every shift for DTPI (deep tissue pressure injury). Continued review of R402's record included a review of a 30-day look-back of 402's Certified Nursing Aide day, afternoon, and midnight shift tasks for repositioning and revealed the following: 4/1/22-Task signed off only for midnight and day shift. 4/15/22-Task signed off for only the afternoon shift 4/17/22-Task signed off for only the day and afternoon shift 4/18/22-Task signed off for only the day and afternoon shift 4/21/22-Task signed off for only the day shift 4/23/22-Task signed off for only the midnight and day shift. 4/24/22-Task signed off for only the day shift 4/28/22-Task signed off for only the day shift 5/1/22-Task only signed off for day and afternoon shift 5/4/22 and 5/5/22-Task only signed off for the day shift 5/9/22-Task only signed off for the day shift On 5/11/22 at 1:43 PM, an interview was conducted with the facility's Director of Nursing (DON) and Corporate Nurse Consultant 'A'. They were asked about R403's heel boots. Consultant 'A' confirmed R403 did not have them on their feet on 5/10/22 and they also could not find them in their room. They were then asked if the CNA's should document their tasks on each shift and indicated they should. They were then asked about the facility's wound care program and indicated they had been without a consistent wound care nurse for quite some time, and they were aware of some issues with wounds in the facility.

Based on observation, interview, and record review, the facility failed to ensure tube feeding formula and water flushes for hydration were administered per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R9 On 6/29/21 at 11:40 AM, 12:19 PM, 3:30 PM, and 4:05 PM, R9 was observed in their bed and was not responsive to attempts at verbal communication. At each of the observations, it was observed R9 had a full, 1000 milliliter (mL) bottle of tube feeding formula hanging from a pole connected to a pump for tube feeding delivery, as well as a bag of water for flushing and hydration. It was observed the tubing that delivered the water and tube feeding formula from the bottle to the resident was wrapped around the pole, disconnected from the resident's feeding tube, and the pump used for delivery was powered off. It was noted the tube feeding bottle's label indicated the tube feeding had been placed on the pole for delivery to the resident via the pump on 6/28/21 at 9:30 PM. On 6/30/21 at 8:10 AM, R9 was observed in bed. At that time, it was observed the tube feeding pump was delivering water for flushing and hydration at 60 mL/hour and the tube feeding formula for nutrition at 75 ml/hr. An observation of the label on the bottle of tube feeding formula indicated the bottle had been placed on the pole on 6/28/21 at 9:30 PM, the same time and date of the bottle observed on 6/29/21. On 6/30/21 a record review for R9 was conducted and revealed an admitted [DATE] and a re-admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's most recent Minimum Data Set (MDS) assessment dated [DATE] was reviewed and revealed R9 had moderately impaired cognition (per a staff assessment), was non-ambulatory, and required total assistance from one to two staff members for all activities of daily living. A record review of R9's orders was also conducted on 6/30/21 and revealed an active order dated 3/23/21 that indicated R9 was to receive their tube feeding formula at 75 mL/hr and water flushes at 60 mL/hr for 20 hours for a total of 1500 mL of tube feeding formula. On 7/1/21 at 11:00 AM, an interview was conducted with the facility's Director of Nursing (DON) regarding R9's tube feeding not observed as being given on 6/29/21 and the bottle dated 6/28/21 at 9:30 PM, being observed as given on 6/30/21 and they had no explanation but would be looking into it. R213 On 6/29/21 at 10:20 AM, R213 was observed in their bed. At that time, it was observed R213 had tube feeding formula and water for flushing and hydration hanging on a pole with a tube feeding pump at their bedside. The pump was not observed to be on at the time of the observation. On 6/29/21 at 12:50 PM, R60 was observed in bed. An observation of the bottle of tube feeding formula and water bag revealed they were still on the pole, but the pump was not on delivering tube feeding formula to the resident. A record review for R213 was conducted and revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R213's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R213's orders did not include any orders for weight monitoring. A review of R213's weights was conducted and revealed they had not had a weight obtained at the facility. A review of R213's nutritional assessments was conducted and also revealed they had not been assessed by the facility's Registered Dietician. R215 On 6/29/21 at 10:30 AM, R215 was observed in their room in their Geri-chair at the foot of their bed. It was observed a tube feeding pump and pole was at the head of the bed. A bottle of tube feeding formula was hanging on the pole and was empty. The long line that ran from the tube feeding formula bottle to the pump and then connected to the resident's feeding tube was observed hanging from the bottle and was on the floor. The label on the tube feeding formula bottle revealed the bottle had been hung at 12:15 AM on 6/28/21. On 6/29/21 at 12:55 PM, R215 was observed in their Geri-chair at the nurses station. It was not observed R215 had any tube feeding being delivered. An observation of R215's room was then conducted and still revealed the empty tube feeding bottle on the pole with the line hanging from the bottle on the floor. On 6/30/21 at approximately 11:30 AM and 3:15 PM, R215 was observed seated in their Geri-chair at the nurses station. R215 was not observed to be receiving tube feeding. A record review for R215 was conducted and revealed an admitted [DATE] with a discharge to the hospital on 6/8/21 and a re-admitted [DATE]. R215's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R215's MDS assessment dated [DATE] revealed R215 had severe cognitive impairment, was non-ambulatory and required total to extensive assistance for activities of daily living. A review of R215's orders was conducted and revealed the following an order dated 6/3/21 (discontinued 6/30/21) that indicated R215 was to receive tube feeding formula scheduled at 9 PM at a rate of 55 mL/hour. It was noted the order did not include for how many hours the feeding was scheduled to run or the total amount of feeding to be delivered. Continued review of R215's orders revealed they were also to receive a regular mechanical soft diet. A review of a nutritional assessment titled, Nutrition Data Collection/Evaluation-V (version) 2 dated 6/21/21 for R215 was reviewed and indicated R215 was to receive 55 mL/hr of tube feeding formula around the clock for a total volume of 1320 mL. On 7/1/21 at 9:22 AM, R215 was observed in their bed asleep, a breakfast tray was present on the resident's bedside table. An observation of the room revealed no tube feeding pole or pump was present in the room. On 7/1/21 at 9:30 AM, a second review of R215's orders was reviewed and revealed that on 6/30/21, R215's tube feeding order for 55 mL/hr. (no indication for how many hours) had been discontinued and a new order was written for R215 to receive tube feeding at 88 mL/hr for 15 hours starting at 8:00 PM in the evening and ending at 11:00 AM the next day. On 7/1/21 at 9:35 AM, an interview with Registered Nurse (RN) 'J' was conducted regarding whether R215 was receiving their tube feeding. RN 'J' indicated they were not and when they came on their shift there was no tube feeding pump or pole in the room. At that time, R215's orders were reviewed with RN 'J', and they said the resident hadn't received their tube feeding dose the previous night and they would call the physician. On 7/1/21 at approximately 9:45 AM, another review of R215's clinical record was conducted and revealed they had only been weighed on their first admission on 6/3/21 (224 lbs.), and upon their re-admission on 6/16/21 (175.5 lbs.). During this review, R215's medication administration records for the administration of the tube feeding formula ordered 6/3/21 revealed nurses had only been hanging one bottle of tube feeding at 9 PM and based upon the calculation of 55 mL/hour for 24 hours, a second bottle of formula would have to be documented as given to make up the total volume of 1320 mL. On 7/1/21 at 10:20 AM, an interview with the facility's Registered Dietician (RD) 'H' was conducted regarding weights and formal assessments for resident's nutritional status. RD 'H' indicated resident weights were to be obtained upon admission and once a week for four weeks to establish a resident's baseline. RD 'H' also indicated that a formal nutritional assessment should be conducted on residents within 48 hours of admission. On 7/1/21 at 1:00 PM, an interview was conducted with the facility's Regional Dietician, RD 'I' regarding R215. RD 'I' acknowledged R215's original tube feeding order dated 6/3/21 was not clear as it did not include for how long the feeding was to run or how many milliliters of tube feeding formula were to be delivered. RD 'I' said, I believe it was running 24 hours a day. When queried about how the MAR's indicated nursing staff were only hanging one bottle of tube feeding formula per 24 hour period day, RD 'I' said they assumed the nursing staff were running it around the clock and indicated they could not speak about nursing and nursing documentation or how to prove a second bottle had been hung in the 24 hour period to make up the total volume delivery recommended by the previous Dietician who had placed the unclear order. A review of a facility provided policy titled, Nutritional Management reviewed/revised 7/31/20 was conducted and read, Policy: The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status .2 .a. Nursing staff shall obtain the resident's height and weight upon admission, and subsequently in accordance with facility policy .c. A comprehensive nutritional assessment will be completed by a dietician on admission . A review of a second facility policy titled, Weight Monitoring reviewed/revised 10/30/20 was conducted and read, .5 .Newly admitted residents-monitor weight weekly for 4 weeks . R52 On 6/29/21 at approximately12:35 PM, R52 was observed in the dining room. A full lunch tray was in front of the resident who was not making any attempts to eat their food. Activities Assistant Y who was feeding another resident, attempt to assist R52 who took a small bite of their lunch. Activities Assistant returned back to assist the other resident. On 6/30/21 at approximately 12:40 PM, R52 was observed in the dining room with a full tray in front of her. The resident was observed eating a small amount of food. On 7/1/21 at approximately 8:47AM a breakfast tray was brought into R52's room and placed on a tray table. At 9:15 AM a CNA was observed taking the full uneaten breakfast tray out of the resident's room and reported the resident did not want to eat. A review of R52's clinical record documented the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS indicated the resident had a BIMS score of 5/15 (cognitively impaired) and required extensive one person assistance for feeding. A Nutritional Data Collection/Evaluation (6/2/21) documented, in part, the following: .Nutritional Summary .resident assessed by RD for admission, nutritional assessment .CBW(current body weight): 124#, BMI: 21.3- underweight by BMI. Potential for weight variances .Weekly weight x4, then monthly ordered to ensure stability .Considered at risk for malnutrition r/t low BMI, co-morbidities . Continued review of R52's clinical record documented only one weight (124 lbs.) completed on 5/25/21. There were no further weekly weights noted in the resident's record. R52's care plan was reviewed and documented, in part, the following Focus: The resident is at risk for nutritional deficits and malnutrition r/t (related to) low BMI (body mass index) and comorbidities . Continued review of the R52's clinical record revealed only on(5/27/21) .Interventions: .Monitor/document/report to nurse any signs of .refusing to eat (5/27/21) . During an interview on 7/1/21 at approximately 10:30 AM, RD H reported that they were new to the facility and had not met or reviewed the records for R52. RD H indicated that she was trying to catch up with all the residents. When queried as to the general policy/protocol regarding weights, RD H reported that residents that are newly admitted should be weighed upon admission and once a week thereafter for four weeks. If the resident's weight is stable, then they are to be weighed once per month. An attempt was made to get the weight of R52; however the resident was sleeping. No new weights were logged into the resident's record by the end of the survey. R6 On 6/29/21 at 11:31 AM, R6 was observed lying in bed. R6 was observed to have a [CONDITION(S)] tube that was connected to a ventilator. R6's eyes were closed, and they did not respond to any questions asked. R6 was connected to an enteral tube feeding pump was on a pole next to the bed. The pump was running and set to deliver 60 ml/hr of the formula and 80 ml/hr of water auto flush. Review of the clinical record revealed R6 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS assessment dated [DATE], R6 had severely impaired cognition. The MDS assessment also indicated R6 received all nutrition through a feeding tube. Review of R6's enteral nutrition care plan revealed an intervention revised 3/18/21 that read, The resident is dependent with tube feeding and water flushes. See MD (medical doctor) orders for current feeding orders. [MEDICATION(S)] 1.5 @ 60mL/hr formula infuses with 85mL/hr H2O via autoflush. This provides: 1800 kcalories, 77g protein, 2612ml total H2O. On 6/30/21 at 8:31 AM, 6/30/21 at 12:58 PM and 7/1/21 at 9:25 AM, R6's enteral tube feeding pump was set to deliver 80 ml/hr of water on auto flush. It is noted the order was for 85 ml/hr water auto flush. On 7/1/21 at 9:29 AM, RN G was interviewed and asked to verify R6's rate on the enteral tube feeding pump. RN G checked the computer, wrote the order on a piece of paper, and checked the settings on the pump. RN G changed the auto flush function to 85 ml/hr. When asked who entered the rate on the pump, RN G explained the nurse should check the order when hanging a new bottle of formula, and ensure the pump was set correctly, and when starting a shift, the nurse should verify the rate was correct. On 7/1/21 at 9:47 AM, the DON was interviewed and asked when should enteral feeding pump rates be verified. The DON explained the nurse that hangs a bottle of formula should check, then every nurse should verify the rate when they were giving medications to the resident. When informed the auto flush rate had been wrong for R6, the DON had no answer.

This citation pertains to intake #MI 676 and #MI 445. Based on interview and record review, the facility failed to ensure treatment and services including: turning/repositioning, ongoing assessment, and wound care treatment to prevent the development of an unstageable pressure ulcer (Full-thickness skin and tissue loss in which the extent of the tissue damage within the ulcer cannot be confirmed because it is obscured by slouch or eschar) for one resident (R902) of three residents reviewed for pressure ulcers. Findings include: On 4/28/21 a review of discharged resident R902 closed clinical record was conducted. It was revealed R902 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R902's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R902 had severe cognitive impairment, was non-ambulatory, and required total assistance from one or more staff members for all activities of daily living. Continued review of R902's MDS assessment included a review of Section M.-Skin Conditions and it was documented R902 did not admit with any pressure ulcers or pressure injuries and was at risk for the development of pressure ulcers/injuries. Continued Review of R902's clinical record included a review of a Nursing Admission Evaluation dated 1/9/21. Section A. Skin on the Evaluation was reviewed and revealed R902 admitted with blisters to their left shoulder and groin, an abrasion to their right foot, and [CONDITION(S)] to the back of their right hand. A review of R902's admission Braden Score (a score calculated to determine a person's risk for the development of pressure ulcers/injuries) revealed R902 scored 12.0, with any score between 10-12 indicating a High Risk. A review of R902's weekly skin assessments was conducted and revealed that though they admitted [DATE], their next skin assessment was dated 1/28/21 and revealed there was a new skin abnormality. The skin assessment documented the site as Sacrum and under the description it read sacrum. Per an interview on 4/29/21 at 2:45 PM, with Wound Care Nurse 'C', .the staff nurses were responsible for the weekly skin assessments . and with the Director of Nursing on 4/28/21 at approximately 3:50 PM, .the nurses should have been doing their weekly skin assessments . A review of a document dated 1/28/21 titled, Skin & Wound Evaluation by Registered Nurse (RN)/Wound Care Nurse 'C' documented R902 had a Blister on their Sacrum that measured 2.2 cm (centimeters) x 8.7 cm. The assessment further documented a, Ruptured serum filled blister with light exudate (drainage). It was documented RN 'C' ordered a treatment and applied it upon the discovery of the wound. The wound care treatment was to be done every night shift and a review of the January Treatment Administration Record (TAR) revealed the dressing was not changed on 1/29/21. Continued review of R902's Skin and Wound Evaluation was conducted and revealed the next evaluation dated 2/3/21 documented R902 had a Pressure type wound, stage II (Partial-thickness loss of skin with exposed dermis. Wound bed is viable, pink, or red, moist and may also present as an intact or ruptured serum-filled blister) on their sacrum that measured 2.7 cm x 3.7 cm. The Skin and Wound Evaluation dated 2/9/21 was reviewed and documented R902 had a Pressure type wound, stage III (Full-thickness loss of skin in which fat tissue is visible in the ulcer and granulation and rolled wound edges are often present, slough and/or eschar may be present) on their sacrum that measured 2.3 cm x 3.8 cm. The documentation indicated 80% of wound was filled with granulation and 20% of the wound was covered in slough, the wound was Deteriorating, and a note contained in the assessment read, Burgandy <sic> discoloration on wound bed-ischemic changes . The Skin and Wound Evaluation dated 2/15/21 was reviewed and documented R902 had had a Pressure type wound, stage III on their sacrum that measured 2.7 cm x 4.7 cm. The documentation indicated 80% of wound was filled with granulation and 20% of the wound was covered in slough. A review of the February TAR was conducted and revealed R902's treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Skin and Wound Evaluation dated 2/22/21 was noted to still have an In Progress status, but documented R902 had a Pressure type wound, unstageable (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar) Due To: Slough and/or eschar on their sacrum that measured 3.7 cm x 4.8 cm. The assessment did not include a description of the wound bed. A review of a progress note dated 2/23/21 note from the facility's Wound Care Nurse Practitioner/Consultant was reviewed and read, .Presenting Problem: .Sacrum wound appears to have began as a blister and evolved into a unstageable pressure injury .Skin: .Sacrum unstageable pressure injury: Measuring 4.2 x 8.5 cm. Depth is undetermined. Wound bed is 30% granular tissue and 70% slough. Wound edges are attached. Periwound with blanchable [CONDITION(S)] and moisture associated skin damage. Satellite [CONDITION(S)] present. Skin is red and irritated .Continue to reposition patient to offload pressure and reduce risk of further skin breakdown . It was not noted in the Wound Care Nurse Practitioner's note that R902's pressure ulcer was avoidable or unavoidable. A review of R902's weekly skin assessments was conducted and revealed only one additional skin assessment for February 2021. The skin assessment was dated 2/18/21, 21 days after the 1/28/21 skin assessment that identified the sacral wound. It was noted the 2/18/21 skin assessment did not identify any wounds on R902's sacrum. A review of R902's care plans was conducted and revealed interventions for R902's pressure ulcers that read: Avoid positioning the resident on back. Turn to sides only initiated 2/18/21, and The resident needs to turn/reposition at least every 2 hours, more often as needed or requested initiated 1/15/21. A review of R902's CNA (Certified Nursing Assistant) tasks for January 2021 thru March 2021 was conducted and revealed that R902 had a task that read, MONITOR-Turn and Reposition per Care Plan and PRN (as needed), however; it was noted the task was only active on the task list for two days, 1/11/21 and 1/12/21, and after 1/12/21 it did not appear as a task for the CNA's to perform and document, so no documentation after 1/12/21 was present that R902 had been turned and re-positioned. An additional care plan intervention read, Daily skin evaluations by licensed nurse if current pressure ulcer (See TAR) initiated 1/15/21. A review of R902's TAR's did not indicate the intervention of the daily skin evaluation by the licensed nurse had ever been implemented. Continued review of R902's CNA tasks included a review of the task MONITOR-Skin Observation to be signed off three times a day, once on each eight hour shift. Review of the documentation for February 2021 revealed that of the 84 shift documentation's, 48 had been left blank and 11 had been documented that R902 did not have any skin impairments, despite the documentation that R902 had an identified blister on 1/28/21 that deteriorated to an unstageable pressure ulcer. On 4/28/21 at approximately 3:50 PM, an interview with the facility's Director of Nursing (DON) was conducted regarding R902's pressure ulcer. The DON was unaware and did not know why R902's turning/repositioning CNA task had been removed from the task list but would look into it. At that time, the DON indicated that the CNA's should have been accurately documenting their skin observations on the task list and the nurses should have been doing their weekly skin assessments. They further indicated they believed Wound Care Nurse 'C' also did a full body weekly skin assessment on their wound care rounds, but would look into it, as there was no documentation from Wound Care Nurse 'C' that indicated they performed a whole body skin assessment during their wound care rounds. On 4/29/21 at 2:45 PM, an interview was conducted with Wound Care Nurse 'C' regarding whether they do a full body skin assessment on residents during their wound care rounds. Nurse 'C' indicated they did not, and the staff nurses were responsible for the weekly skin assessments. Wound Care Nurse 'C' indicated they assessed resident wounds when they were informed by the staff nurses of new wounds, or if it was identified in a clinical alert. A review of a facility provided policy titled, Pressure Ulcer/Skin Breakdown-Clinical Protocol with an implementation date of 1/1/21 and a reviewed/revised date of 10/30/20 was conducted and read. Policy: Based on the comprehensive assessment of a resident, a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing .

This citation pertains to intake MI 724. Based on observation, interview and record review, the facility failed to implement an effective restorative nursing program for two (R902 and R905) of two residents reviewed for range of motion services, resulting in lack of restorative services, lack of assessment, documentation, and implementation of treatment and services that resulted in decreased range of motion and/or development of/worsening of contractures and potential for increased pain and physical limitations. Findings include: Resident 905: Review of the clinical record revealed R905 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) assessment dated [DATE], R905 has severely impaired cognition and requires extensive assistance of two or more people for dressing, transfers, and bed mobility, and had functional limitation in range of motion impairment to one side for upper and lower extremities (no changes identified since the initial MDS assessment on 12/17/18) and had not received restorative therapy services (none identified as provided since admission). On 2/2/21 at 2:45 PM, 4:38 PM, and 2/3/21 at 8:50 AM and 9:10 AM, R905 was observed lying in bed while tube feeding was running via a mechanical pump and was receiving mechanical ventilation. R905 did not open eyes or respond upon approach. Both of the resident's arms were bent upward at the elbows (so that the forearms were touching the upper arms) and both hands were closed into a fist. There were no hand/arm devices in place such as splints or a washcloth. The nails on both hands were also observed to be very long in length (approximately 1/4 inch in length beyond the fingertips). The resident's legs were not visible as they were covered by blankets. On 2/3/21 at 8:50 AM, an observation of R905 was conducted with the Director of Nursing (DON) who reported she had been the acting DON since end of December 2020. When asked who was responsible for the facility's restorative nursing program, the DON reported it was the DON. During the observation of R905, the DON confirmed the long nails and lack of any splint devices for the resident's hands/arms. When queried about whether R905 had any splints or other devices to prevent decline in range of motion, the DON acknowledged the lack of any applications during this observation and left the room to find the assigned nursing assistant. On 2/3/21 at 8:53 AM, an interview was conducted with R905's assigned nurse (Registered Nurse/RN 'D'). When asked about whether R905 had any interventions in place such as hand/arm splints, rolled washcloth, palm protectors, or received restorative nursing services, RN 'D' reported not being aware of any of those interventions for R905. RN 'D' was unable to offer any further explanation as to whether R905 had any contractures or changes in range of motion. On 2/3/21 at 9:10 AM, an interview was conducted with Certified Nursing Assistant (CNA 'E') who reported was frequently assigned to care for R905. When queried about the R905's positioning of the arm/hands and whether there were any preventative measures in place such as hand/arm splints, rolled washcloth, palm protectors, or restorative nursing services, CNA 'E' acknowledged the lack of any preventative devices and reported, Restorative therapy is responsible for placing a washcloth in the palm. When asked about how often R905 received restorative nursing services, CNA 'E' reported, (R905) used to be on restorative but I have not seen any restorative services done lately. CNA 'E' further reported that although there was restorative nursing staff, they frequently get pulled to work as an assigned CNA due to staffing shortages. On 2/3/21 at 10:45 AM, an interview was conducted with Therapy Manager (Staff 'B') and Occupational Therapy/OT (Staff 'C'). When asked about the facility's process for recommendations for restorative nursing services and/or need for adaptive devices such as splints/orthotics, Staff 'B' reported the therapy department conducted quarterly Screenings. When asked to explain what a screening included, Staff 'B' reported, It's a visual assessment only and talking to staff. When asked when an actual hands-on evaluation would occur, Staff 'B' reported, If alerted to change in condition would prompt an evaluation. When queried about whether R905 had ever had any screenings or evaluations for the use of any splinting/orthotic devices to address the resident's range of motion limitations and/or referral for restorative nursing services, Staff 'B' reported he would attempt to review the available documentation and provide for review. Review of R905's therapy documentation provided by Staff 'B' revealed the following: An occupational therapy EVALUATION ONLY dated 6/13/19 which documented, in part: .Reason for Referral: Patient referred to OT due to exacerbation of decrease in range of motion and increased need for assistance from others indicating the need for OT to decrease painful condition of UE (Upper Extremity) .RUE ROM (Right Upper Extremity Range of Motion) = WFL (Within Functional Limits); LUE (Left Upper Extremity) ROM = Impaired (splint required at elbow wrist following splinting for elbow) .Clinical Impressions: OT to order and assess the need for splinting Spoke with .Services for a L (left) elbow splint . A physical therapy EVALUATION ONLY dated 7/9/19 which documented, in part: .Reason for Referral: Pt (patient) needs PRAFO's (Pressure Relief Ankle Foot Orthosis - a device which can be used to resist the development of contractures) for his right ankle due to contracture .Clinical Impressions: Pt has right ankle PF (plantarflexion) contracture of (greater than) 10 degrees. He will benefit with right PRAFO to prevent further worsening, keep the patients affected joint in corrected position. He is non ambulatory and has developed muscle weakness secondary due <sic> his medical condition and immobility . There was no documentation provided by the facility that indicated R905 had received any further skilled or restorative therapy services since the above evaluations. There was no documented evidence that R905 had received any splinting as identified in the therapy evaluations. On 2/3/21 at 12:05 PM, the DON was requested to provide any documentation that R905 had received restorative therapy since admission as there was no documentation available for review. The DON reported she would attempt to locate, however there was no further documentation provided by the end of the survey. On 2/3/21 at 12:55 PM, an observation of R905 was conducted with OT Staff 'C' to evaluate the resident's current range of motion limitations. OT Staff 'C' assessed both the upper and lower extremities and during this time, upon stretching the resident's left arm and left wrist/hand, R905 began to visibly wince and attempt to grab at the arm of the therapist using the right arm. At that time, OT Staff 'C' reported, He is tight on this side. Bicep is really tight. OT Staff 'C' proceeded to open the left fist and acknowledged the long fingernails as well and stated It's (degree of ability to open fingers from palm of hand) where I can put a small cone in there. OT Staff 'C' confirmed there was no preventative measures in place, including any splints or washcloth. At that time, OT Staff 'C' proceeded to attempt to bend the resident's left leg and R905 again began to wince and attempt to move the right arm to the left knee area during this assessment. OT Staff 'C' reported, Knee is tight, hip is too. Better range of motion on the right but limited right upper shoulder. On 2/3/21 at approximately 2:20 PM, Staff 'B' provided additional documentation that indicated skilled therapy screenings for R905 on 8/14 and 10/7 (no year identified but Staff 'B' verbally indicated 2020). Review of these screenings revealed for the screening on 8/14, R905 was assessed as impaired under a majority of the functional areas with a line drawn under IMP (impaired). There were portions of this assessment that had blank entries. The section that assessed the resident's upper extremity range of motion was marked impaired, and the section for assessment of the resident's joint contracture was marked with an X for WFL (within functional limits). The form prompted the assessor for Evaluation Indicated? which was circled No. The screening for 10/7 prompted the assessor if there was a change which documentation had a circle by NO and a line under the same functional areas as the screening on 8/14, with the exception of the assessment for joint contracture which had an X for Change Yes. The form prompted the assessor for Evaluation Indicated? which was circled No. There was no further details of the level of impairment, or recommendations to prevent further decline or impairment for either of these screenings. Review of the resident's care plans revealed a current care plan that was initiated on 7/5/19 and last reviewed on 12/28/20 which documented: SPLINT/BRACE: Resident would benefit from splint/brace program for contracture prevention/contraction management) r/t (related to) neuromuscular compromise / immobility. Interventions included: Application, removal, skin/circulation under the device and of affected joint to be provided RESTORATIVE: Lt (left) hand splint daily, goal of 2 hours as tolerated / allowed by resident. R (right) ankle daily goal 1-2 hours as tolerated/allowed by resident. Date initiated: 07/05/2019. Observe for changes in joint mobility which may indicate need for splint/brace. Refer to therapy as indicated. Date initiated: 07/05/2019. Report to nurse if splint/brace does not fit as normal, resident complains or indicates pain, or there is difficulty applying or taking off. Date initiated: 07/05/2019. Reposition affected joint in correct alignment when applying/removing device. Date Initiated: 07/05/2019. With application and removal of the splint/brace, observe for skin problems and adequate circulation under the device. Report to nurse if impaired skin or signs of impaired circulation observed. Date Initiated: 07/05/2019. Review of the current POC (Plan of Care) documentation which identified the resident's specific care needs and where direct care staff document care provided to the residents did not identify any of the above care planned interventions. Additional review of R905's current and discontinued physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/3/21 at 2:25 PM, an interview was conducted with Restorative Aide (Staff 'F'). Staff 'F' reported working at the facility for about six years and currently was the only restorative aide. Staff 'F' further reported concerns with lack of communication with skilled therapy staff to effectively provide restorative therapy services due to changes made by administration and further reported a concern with maintaining restorative therapy documentation. When queried about whether R905 had been receiving any restorative therapy services, Staff 'F' indicated being familiar with R905 and further reported, I don't recall (R905) being on restorative. (R905) never was a stiff person. Review of the facility's Restorative Nursing Program policy dated Reviewed/Revised: 10/30/2020 documented, in part: .The Restorative Nursing Program is led by the Director of Nursing (DON) or designee .Once determined that the resident would benefit from a restorative nursing program, implement the following .Re-visit at least quarterly to determine if resident would still benefit .Determine resident and/or family goals for restorative services .Review during care plan review meeting .Restorative documentation requirements include .Incorporated into the plan of care which is part of the clinical record .Monthly review by a licensed nurse .Documentation of implementation should be completed on the Restorative Service Delivery Record or EMR (electronic medical record) as applicable . R902 On 2/21/21 at 1:00 PM, R902 was observed in their room in bed. R902 had a [CONDITION(S)], a feeding tube, a suprapubic catheter, and was receiving mechanical ventilation. R902 was alert and tracked with their eyes, however; they were non-verbal and offered no purposeful response with attempts at communication. R902 was observed to have knee, elbow, and hand contractures. R902 was not observed to have any devices (splints, orthotics, hand rolls, etc.) in use at that time. R902 was also observed on 2/2/21 at 4:05 PM, and 2/3/21 at 8:25 AM, and 11:55 AM in their bed. It was observed no splints, orthotics, or hand rolls were in use at those times. A review of R902's clinical record was conducted and revealed an original admitted [DATE]. It was noted R902 had multiple hospitalization s and re-admissions with their most recent return date being 1/18/20. R902's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R902's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed R902 had severe cognitive impairment per a staff assessment, was non-ambulatory, required total assistance of one or two staff members for wheelchair mobility, activities of daily living (including personal hygiene and bathing), and had bilateral upper and lower extremity range of motion impairments. It was noted in R902's admission and discharge history they had been out of the facility and admitted to a long-term acute care (LTAC) facility from 10/22/21 to 12/4/21. On 2/2/21 at 4:30 PM, the facility's Director of Nursing (DON) was asked where restorative therapy, range of motion (ROM), or splinting would be documented, and the DON indicated it would be in the CNA task list and documented by the CNA's in the task documentation. A review of R902's clinical record prior to their stay at the LTAC was conducted and revealed a that on 4/4/19 R902 had been discharged from skilled therapy services to the facility's Restorative Therapy Program. The recommendation read, .Elbow splint .Current Schedule: 3 hours each time to prevent contractures .ROM/Exercises .Ankle/Foot .Passive .B/L (bilateral) ankle 10 times with 10 sec (second) hold to prevent contractures before splinting . A review of R902's most recent quarterly therapy screening dated 8/13/20 was conducted and read, .Comments: Have B/L ankle PRAFO's (a brand of foot orthotics). No change in status. Not appropriate . A review of the facility's Certified Nursing Assistant (CNA) task list that included cancelled tasks was reviewed and did not reveal any tasks for restorative therapy, range of motion or splinting to be provided to R902. R902's care plans were reviewed and included a focus dated 4/12/19 last revised on 1/4/21 that read, .Focus: SPLINT/BRACE: Lt (left) resting hand splint, Right Hand cone, Rt. Knee splint. Resident was benefit from splint/brace program for (Impaired physical mobility/contracture prevention/contraction management. WEAR a minimum 2 HOURS EACH TIME TO PREVENT CONTRACTURES . It was noted the neither the Restorative Referral from 4/4/2019 or the most recent Therapy Screening from 8/13/2020 mentioned any recommendations for the hand splints or cones mentioned in R902's care plans. A review of R902's clinical record for the time-period of 12/4/20-2/2/21 (after their stay at the LTAC) was conducted and revealed R902 was back on skilled therapy case load. A review of R902's current CNA task list included a task dated 1/4/21 that read, .Level 1 Restorative: Splint-Left resting Hand splint, RT (right) HAND CONE-Rt (right) Knee splint for at least 2 hours/day . A review of a 30-day look- behind period for completion of the task was conducted and the following was documented: 1/5/21 and 1/6/21 Did not occur 1/8/21 Did not occur, No documentation was present for 1/8/21 thru 2/1/21, and on 2/2/21 Did not occur. On 2/3/21 at approximately 8:45 AM, a review of R902's therapy orders were conducted and revealed the following: An order dated 12/4/20 for Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (SLP) to evaluate, An order dated 12/11/20 and discontinued 12/22/20 that indicated they were to have OT treatment three times a week, .addressing BUE (bilateral upper extremity) contractures, splinting as needed . An order An order dated 12/24/20 and discontinued 1/18/21 that indicated they were to have OT treatment five times a week, .addressing BUE contractures, splinting management . A current order dated 1/19/21 that indicated they were to have OT treatment five times a week, .addressing BUE contractures and provide splinting as needed . On 2/3/21 at approximately 12:00 PM, an interview with the facility's DON was conducted regarding the CNA task that indicated R902 was to have a hand splint, a hand cone, and a knee splint. The DON said those tasks had recently been added. When asked if they could provide a restorative referral form from the therapy department that indicated nursing staff should be performing the splinting in the task list the DON indicated they would look for it. A referral form from the therapy department was not received by the end of the survey. On 2/3/21 at approximately 11:30 AM, an interview was conducted with the facility's Therapy Director and Occupational Therapist (OT) 'C', R902's OT. They were queried about the process of a resident transitioning from skilled therapy to restorative therapy. They indicated that after a resident finished their skilled therapy, a restorative therapy referral with recommendations was made. If needed, they would educate restorative/nursing staff on splints, braces, or exercises and then restorative/nursing would be performing the care. During the interview it was confirmed that R902 was receiving skilled therapy services and OT 'C' had been working on passive exercises on R902's hands so they would be more appropriate for splinting. OT 'C' indicated R902's hands had contractures and they were making progress with loosening the contractures, but at the current tightness of the contractures they were not ready for splints and splints could actually cause more harm such as pressure ulcers. OT 'C' was asked if they had made any recommendations for any type of splinting or restorative therapy for the nursing department to perform for R902 and indicated they had not. On 2/3/21 at 2:30 PM, an interview with the facility's Restorative Nursing Aide/CNA 'F' was conducted regarding R902's history with restorative nursing in the facility. CNA 'F' indicated that prior to the COVID19 pandemic, R902's family was in the facility around the clock and worked with him with exercises; and she also worked with him on his restorative program. When asked where it was documented CNA 'F' said they used to have an area in the therapy room where they kept their paper record of restorative therapy. CNA 'F' continued to explain that the prior Administrator told her she could no longer use the therapy room and since then, all the records she kept had been lost. CNA 'F' was asked about the process of referral from skilled therapy services to restorative and indicated that when they received recommendations from therapy, a restorative program performed by nursing staff was initiated. CNA 'F' indicated they were to wait until they had been informed and educated from therapy on what a resident might need as far as their restorative therapy services. CNA 'F' was asked if R902 was currently receiving any restorative therapy services and indicated they were not sure and since they had been removed from the therapy room, they did not know what was going on with the restorative program. A review of a facility provided document titled, Restorative Nursing Programs with a review date of 10/30/20 was conducted and read, Policy: The goal(s) of Restorative Nursing includes improving and/or maintaining independence in activities of daily living and mobility .Restorative documentation requirements include: .Documentation of implementation should be completed on the Restorative Service Delivery Record or EMR (Electronic Medical Record) as applicable .

Based on observation, interview, and record review, the facility failed to identify complications and skin breakdown to the indwelling urinary catheter site for one (R#502) of one resident reviewed for indwelling urinary catheters, resulting in a medical device related full thickness pressure injury to the penis, penile bifurcation (splitting of the penis) and erosion of the underside of the penile shaft. Findings include: On 3/25/21 at 4:45 PM, R#502 was observed lying in bed. R#502 was observed blinking their eyes but was unable to respond verbally when spoken to. R#502 received mechanical ventilation for breathing through a [CONDITION(S)] and received nutrition through a feeding tube. On 3/26/21 at 8:20 AM, Licensed Practical Nurse (LPN) A and Registered Nurse (RN) B were observed providing wound care to R#502's penis. An indwelling Foley catheter was observed anchored to the resident's leg. A drainage bag was observed to the left side of resident's bed. When R#502's penis was lifted by LPN A, the underside of the penis shaft was split and separated. The catheter tubing was observed exiting from underneath the penis rather than the urethral opening at the tip of the penis where a Foley catheter was typically inserted. A review of R#502's clinical record was conducted and revealed the following: R#502 was originally admitted into the facility on [DATE] and most recently readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) assessment dated [DATE] documented R#502 had severely impaired cognition, no speech, was totally dependent on staff for bed mobility, transfers, and all activities of daily living (ADLs), was always incontinent, had a feeding tube, a [CONDITION(S)], and required mechanical ventilation for breathing. A Physicians Order dated 3/17/21 documented, Groin/Penile Bifurcation: Cleanse area with normal saline. Pat dry. Apply skin prep to shaft, allow to dry. Apply Dermaseptin, wrap penis with non border foam, secure with tape- ensure tape is not adhering to skin every 12 hours as needed for PI (pressure injury) AND every night shift. An active Physicians Order with a start date of 3/17/21 documented, Maintain indwelling catheter 16F/30mL (milliliter). A Nurses' Note dated 2/16/2021 at 4:24 PM documented, Resident Foley catheter came out. physician notified and waiting on return text for order to put back Foley. An Encounter note dated 2/16/21 completed by Nurse Practitioner (NP) D documented, .Date of Service: 02/17/2021. Visit Type: Acute .Chief Complaint / Nature of Presenting Problem: Penis extorited <sic> .Patient being evaluated for Foley dislodgment. Per nursing, patient Foley was dislodged. Upon assessment by nursing staff, wound was appreciated .Skin: penis wound .Diagnosis, Assessment and Plan .Wound, open, penis New issue Wound team consulted condom catheter in place Monitor . An Encounter note written by Physician Assistant (PA) F (the facility's contracted wound practitioner) dated 2/23/2021 documented, .Date of Service: 02/24/2021 .Visit Type: Wound .Chief Complaint / Nature of Presenting Problem: Wound care evaluation .He has a penile wound that was brought to our attention by nursing this week .Penis bifurcation mucosal membrane (glans) wound: medical device catheter related pressure injury. Wound is at underside of penile shaft. Full-thickness wound. Measures 5.3 x 1.3 x 1.5 cm (centimeters). Red granular moist base of wound. No slough. Marked deformity at shaft of penis with erosion. No sign of infection. Catheter is in place. Light serous drainage. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .Pressure ulcer of unspecified site, unspecified stage .Penis: Apply Dermaseptin cream and NBF (non border foam) to anchor penis. Keep area clean and dry . Weekly Skin Assessments dated 2/10/21 and 2/17/21 completed by RN C did not indicate any new skin issues and did not document any wounds to R#502's penis. Further review of R#502's skin assessments from December 2020 through 2/17/21 did not document any skin issues to the penis. A Skin and Wound Evaluation dated 2/17/21 documented R#502 had a Pressure - Medical Device Related Pressure Injury to the groin. The stage documented, Mucosal Membrane: found on mucous membrane. The evaluation documented the wound was in-house acquired and the wound had been present since 2/17/21 (the day of the evaluation). The measurements of the wound were noted to be 4.8 (length) x 2.4 (width) x 1.5 (depth) cm with light serous exudate. The following was documented in the Notes section: Requested to see resident re: penile bifurcation. Foley catheter is currently not in place. Underside of the penis is non existent. Dermaseptin and non border foam used. Non border foam was wrapped over the penis and secured with tape. On 3/25/21 at 3:46 PM, the Director of Nursing (DON) was interviewed. When queried about how R#502 acquired penile bifurcation as documented on 2/17/21, the DON reported the Wound Care Coordinator (RN E) would have information. On 3/25/21 at 3:50 PM, RN E was interviewed about R#502 and the penile bifurcation and medical device catheter related pressure injury acquired in the facility and documented on 2/17/21. RN E explained she was first contacted to evaluate R#502's penis on 2/17/21 and that was the first time she evaluated that area. RN E reported at the time of the first evaluation of R#502's penis, it was split, and the underside of the penis was not there. When queried about what would cause penile bifurcation, RN E stated, It happens when there is no catheter anchor. When queried about the facility's wound protocol, RN E reported if a skin change is identified, the nurse would let her know or she received a clinical alert that would generate when a change in skin was documented on the weekly skin assessment. RN E reported she did not receive any notification or alert about R#502's penis prior to 2/17/21. At that time, RN E was asked what interventions were in place to prevent injury or complications to the catheter site prior to the development of the bifurcation and pressure injury. RN E reported she would look into it. On 3/26/21 at 9:55 AM, RN C (the nurse who completed R#502's weekly skin assessments on 2/10/21 and 2/17/21) was interviewed. When queried about why the skin assessment on 2/17/21 did not document any new wounds or the penile bifurcation, RN C stated, I usually just look at the pressure points. I might not have looked as well as I should have. RN C reported he rounded with wound care as well. When queried about how long R#502 had the penis wound and bifurcation, RN C stated, Probably for the last couple months. On 3/26/21 at 10:00 AM, the DON and RN E reported R#502's penile bifurcation and pressure injury looked old and they did not think it was acquired in the facility. At that time, any documentation for when the penis bifurcation and pressure injury were first identified was requested. On 3/26/21 at 10:30 AM, RN B was interviewed. RN B reported he was familiar with R#502 and that the resident came to his unit back in February. When queried about when R#503's penis complications were first identified, RN B reported that when the resident was first assigned to him R#502's penis was split and excoriated and the Foley (catheter) fell out. RN B further reported R#502 began retaining urine and had to be sent to the hospital and returned with the Foley inserted through the urethra. On 3/26/21 at 10:53 AM, the DON reported she did not find any documented issues with R#502's penis prior to 2/17/21. On 3/26/21 at 10:56 AM, NP D was interviewed via the telephone. NP D explained they began seeing residents in the facility in February. NP D reported they were notified to see R#502 when his catheter came out and physically evaluated the resident. NP D reported that was the first time she saw R#502. When queried about what the outcome of the catheter evaluation was, NP D stated, The tip (of the penis) was split, but when you actually looked underneath the skin was eroded all the way to the testicles. NP D reported they did not think the Foley catheter should have been reinserted, but a week later R#502 was having urine retention and was sent to the hospital. When queried about how the split and the eroded skin occurred, NP D stated, A split in the meatus comes from not having a leg strap and when they turn the patient it pulls. At the time, (R#502) did not have a leg strap. NP D further reported the eroded skin underneath could have been from excess moisture but would have occurred over time. NP D reported she was unsure of when the erosion to the penis was first identified. On 3/26/21 at 11:15 AM, the DON provided additional information. The DON provided a care plan for R#502 that documented the bifurcation to R#502's penis. The care plan documented, .Penile Bifurcation-Genital Region . with a revision date of 2/23/21. The DON reported 2/23/21 was the date when the care plan was updated to address the penis wound. When queried about how R#502 obtained the penile wound and what was in place prior to him acquiring it, the DON stated, We talked about making sure residents had leg straps (anchors) in QA (Quality Assurance) and then made sure everyone had a leg strap. A review of the Medication and Treatment Administration Records for February 2021 revealed nurses signatures indicating R#502's catheter was anchored. No explanation was provided of how R#502's penis split, and the skin eroded prior to the end of the survey. Further review of R#503's care plans revealed a care plan that documented, (R#502) has a indwelling catheter r/t (related to) OBSTRUCTIVE AND REFLUX [CONDITION(S)] initiated on 10/11/17 and revised on 2/15/19. Interventions initiated on 10/11/17 and 12/14/18 documented, Position catheter bag and tubing below the level of the bladder and away from entrance room door and Provide for gravity drainage. There were no care planned interventions to anchor the catheter. Further review of R#502's clinical record revealed the following: A Physicians Order with a start date of 12/8/20 documented, Maintain indwelling catheter 16F/30mL (milliliters). The order was discontinued on 2/17/21. A Physicians Order with a start date of 2/17/21 documented, Condom Catheter to drainage bag every shift. The end date for the order was 2/18/21. There was no physicians order for an indwelling catheter between 2/17/21 and 3/17/21. Physicians orders for Catheter - Anchor Secured in Place every day and night shift were in place 5/1/20 through 2/17/21. The current active order started 3/17/21. There was no order between 2/17/21 and 3/17/21. A Nurses' Note dated 3/13/2021 at 6:48 AM documented, .Oncall notified of resident's status of showing s/s of pain, including spasms. Resident urinary status monitored throughout night with no output noted, unable to cath due to trauma to penis. Writer advised to transfer resident out to [hospital name redacted] for Foley insertion. DON (Director of Nursing) notified of transfer . A NP/PA Progress Note dated 3/13/2021 at 6:54 AM documented, Notified by nursing of client with abdominal and bladder distension, no void throughout shift. Unable to cath d/t anomalous anatomy, client with hx of obstructive [CONDITION(S)]. Order given to send for Foley insertion . A Nurses' Note dated 3/16/21 documented, Resident was readmitted from the hospital, 16F Foley placed through the urethra for urine drainage. Resident on ABT (antibiotic) [MEDICATION(S)] for bladder infection x 7days .Penis is excoriated, and Foley inserted through urethra . A review of documentation made by Certified Nursing Assistants (CNA) on the Documentation Survey Report for February 2021 documented daily skin observations from 2/1/21 through 2/17/21. No new skin conditions were documented. The report documented catheter care was provided daily from 2/1/21 through 2/17/21. On 2/19/21, 2/21/21, 2/22/21, 2/26/21, 2/27/21, and 2/28/21 it was documented catheter care was provided. However, there was no physicians order at that time for an indwelling urinary catheter. Based on the physicians orders, CNA documentation, and progress notes that documented unable to cath, it was unclear how R#502 was eliminating urine or if the resident had a catheter. A facility policy titled, .Catheters should be secured to prevent pulling and damage to the urethral meatus .

This citation pertains to intake #s: MI 837 and MI 840. Based on interview and record review, the facility failed to provide consistent assessment, identification, monitoring and provision of pressure ulcer treatments and interventions per plan of care and physician orders [REDACTED]. Findings include: Review of multiple complaints reported to the State Agency identified concerns with residents which included R803, of developing pressure ulcers while at the facility and that the wound care treatments were not being completed as ordered. Review of the closed clinical record revealed R803 was initially admitted into the facility on [DATE], readmitted on [DATE], hosptalized on [DATE], and remained out of the facility during the onsite investigation. [DIAGNOSES REDACTED]. According to the most recent completed Minimum Data Set (MDS) assessment dated [DATE] documented R803 did not have any pressure ulcers but was identified as at risk for developing pressure ulcers and had interventions which included a pressure relieving mattress. Review of R803's physician orders [REDACTED]. Further review of the physician progress notes [REDACTED]. Review of the nursing weekly skin assessments available for review as of 8/24/20 through 9/7/20 each documented there were no new skin areas identified. The section of the assessment which prompted if there were any existing abnormal skin areas was marked No for these assessments as well. The weekly skin assessment dated [DATE] documented yes to two new areas. One was on R803's right trochanter (hip) open pressure ulcer which measured 7.5 (centimeters) x 6.5 (centimeters) x 1.0 (centimeters) and had undermining noted on top of wound bed with eschar with slough, red open peri wound with slough was noted and the second area was on the coccyx which was noted as excoriated and discolored red and beefy. The weekly skin assessment dated [DATE] documented yes to new areas for R803's Left trochanter and indicated this was a deep tissue injury (a type of pressure ulcer in the underlying tissue below the skin's surface that results from prolonged pressure in an area of the body causing restricted blood flow and tissue death) which measured 4.0 x 2.0 x 0.0 dark purple area noted. The second new skin alteration was documented as the right trochanter which measured 7.5 x 6.5 x UTD (unable to determine) unstageable wound. The next weekly skin assessment dated [DATE] documented there were no new areas but now indicated the left trochanter had a deep tissue pressure injury with no measurements, an unstageable pressure ulcer to the sacrum and an unstageable pressure ulcer to the right buttocks. None of these wounds had any description of these wounds identified. The weekly skin assessment dated [DATE] documented there were no new areas but now identified the left hip was a stage 4, the left buttock was a stage 2, and the right hip was a stage 2. There were no descriptions of any of these wounds and the section which prompted any existing areas was left blank. The weekly skin assessment dated [DATE] documented yes to new areas and indicated there was a deep tissue injury to the right heel which measured 3 cm x 3 cm. The section which prompted any existing areas identified a pressure ulcer to the right trochanter, deep tissue injury to the left trochanter and deep tissue injury to the sacrum. There were no descriptions of any of these wounds included in this documentation. The weekly skin assessment dated [DATE] documented there were no new areas but indicated the existing areas as a deep tissue injury to the left trochanter, stage 2 to the sacrum, and unstageable to the right buttock. There were no descriptions of any of these wounds included in this documentation. The weekly skin assessment dated [DATE] documented there were no new areas but identified the existing areas as a coccyx wound, right trochanter wound, right heel wound, and left heel red area. There were no other descriptions of any of these wounds included in this documentation. The most recent available wound care documentation for details/measurements of R803's pressure ulcers was on 10/16/20. Review of R803's wound care documentation which included the consulting wound care physician revealed the most recent documentation was from 10/16/20. This consultation identified R803 had five pressure ulcers which were identified as: Coccyx - unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) 0.5 x 0.4 x UTD (unable to determine) with scant serous drainage and 100% slough. (Eschar is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color and may appear scab-like; Slough is non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture.) Left trochanter (hip) unstageable 3.0 x 1.1 x UTD scant serous drainage 100% slough. Right sacrum unstageable 1.0 x 1.7 x UTD scant serous drainage 100% slough. Right ischium stage 4 (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer.) 7.5 x 6.2 x 2.0 moderate sero sang. Drainage 90% granular 10% slough. Undermining 2.9cm at 10-3 o'clock. Right heel unstageable 3.1 x 2.5 x UTD no drainage 100% eschar. Review of R803's physician orders [REDACTED]. Ordered 8/17/20, discontinued 9/12/20, Cleanse with wound cleanser. Pat dry. Apply Triple Antibiotic Ointment to R (right) hip wound. Skin barrier wipe to peri wound. Apply Bordered Foam to Right Hip. Every night shift . There were six blank entries on: 8/21, 8/26, 8/27, 8/28, 9/4, and 9/7. Ordered 9/18/20, discontinued 10/2/20, Right Sacrum: Cleanse with wound cleanser. Pat dry. Apply skin prep to R Sacrum wound and periwound. Cover with Boarder <sic> Foam. Every evening shift for PI (Pressure Injury). There were six blank entries on: 9/23, 9/24, 9/25, 9/28, 9/29, and 10/1. The above order was changed on 10/2/20 until R803's hospitalization on [DATE] to Right Sacrum: Cleanse with wound cleanser. Pat dry. Apply Honey Gel to necrosis, skin prep to R sacrum periwound. Cover with Boarder <sic> Foam. Every evening shift for PI. There were six blank entries on: 10/2, 10/9, 10/10, 10/11, 10/12, and 10/15. Ordered 9/19/20, discontinued 9/30/20, Right Trochanter/R Buttock; Cleanse with wound cleanser. Pat dry. Apply [MEDICATION NAME] Gel to Necrotic areas and apply Calcium Alginate to right hip wound. Skin barrier wipe to peri wound. Cover with border foam dressing. every day shift for Pressure Ulcer. There was one blank entry on 9/28. Ordered 9/15/20, discontinued 10/14/20, Cleanse with wound cleanser. Pat dry. Apply skin prep q (every) shift and prn (as needed). Left Hip area, cover with border foam. Every 8 hours for wound care. There were 22 blank entries on: 9/19 at 6:00 AM, 9/20 at 6:00 AM, 9/22 at 6:00 AM, 9/23 at 10:00 PM, 9/24 at 10:00 PM, 9/25 at 6:00 AM and 10:00 PM, 9/27 at 6:00 AM, 9/28 at 2:00 PM and 10:00 PM, 9/29 at 10:00 PM, 10/1 at 10:00 PM, 10/2 at 6:00 AM and 10:00 PM, 10/8 at 6:00 AM, 10/9 at 6:00 AM and 10:00 PM, 10/10 at 10:00 PM, 10/11 at 6:00 AM and 10:00 PM, 10/12 at 6:00 AM and 10:00 PM. Ordered 10/5/20, held 10/22/20, Cleanse area with soap & H20 (water), rinse, pat dry. Apply split 4x4. Change gaily 7p-7a and prn. Every evening shift. There were five blank entries on: 10/9, 10/10, 10/11, 10/12 and 10/15. Ordered 10/14/20, held 10/22/20, Left Trochanter; Cleanse with wound cleaner. Pat dry. Apply skin prep to periwound area, allow to dry. Apply honey gel to necrotic tissue, cover with border foam. Every night shift for PI. There were three blank entries on: 10/15, 10/20 and 10/21. Ordered 10/14/20, held 10/22/20, Bilateral Buttocks, Sacral: Cleanse area with normal saline. Pat dry. Apply Dermseptin every shift and prn every day and night shift for PI. There were two blank entries on: 10/15 night shift and 10/20 night shift. Ordered 10/14/20, held 10/22/20, Left lateral ankle: Cleanse with wound cleanser. Pat dry. Apply skin prep q shift and prn. every day and night shift for Stage 1 PI. There were two blank entries on: 10/15 night shift and 10/20 night shift. Ordered 10/14/20, held 10/22/20, Right Elbow: Cleanse with wound cleanser. Pat dry. Apply skin prep q shift and prn. every day and night shift for PI. There were two blank entries on: 10/15 night shift and 10/20 night shift. There were no prn wound care orders documented as provided to R803 from August to October 2020 for the above orders that indicated scheduled and prn. None of the aforementioned blank/missing TAR wound care treatments for R803 had any available corresponding documentation to indicate the reason for the blank entries/missed treatments, or if the physician had been notified of the missed treatment to provide additional direction. There was no documentation available for review or provided by the facility that the physician had documented R803's clinical rationale of an unavoidable wound development On 10/28/20 at 10:50 AM, an interview was conducted with the Director of Nursing (DON) and Wound Care Nurse (Nurse E) in the presence of a corporate staff. When queried about R803's pressure ulcers, the DON reported she had a soft file from September for R803. The DON was asked to provide any documentation for R803 that pertained to the pressure ulcers, interventions and when these wounds were first identified as the documentation available for review in the progress notes, skin assessments and wound consultations was inconsistent. Nurse E and the DON both reported R803 had heel boots initiated but R803 still developed heel ulcers, the facility had ran multiple labs tests and also reported (R803's) skin was constantly moist, had lots of fungal issues, was incontinent of stool and had loose stools and was always on turn and reposition like every two hours and as needed. When asked about whether the facility had considered or identified a concern with the possibility of missed wound care treatments as a possible factor in the development and worsening of R803's pressure ulcers, the DON referred to the soft file and indicated that documentation would be provided. On 10/28/20 at 1:05 PM, the DON provided additional documentation for R803 which was reported as the same as what was in the soft file. Review of this documentation revealed the same documentation that was available for review in the resident's clinical record. When queried about the inconsistent documentation and discrepancies of when the pressure ulcers were first identified, the DON reported the first areas had started on the hip which had then progressed to the other hip and so on. The DON further reported that the facility had run multiple labs, tests to rule out other medical issues [MEDICAL CONDITION]. When queried if the facility had anyone who was responsible for monitoring the TARs to oversee and/or identify issues such as the multiple missed/blank treatments, the DON reported the facility had been focused on addressing the previous survey related concerns but that Wound Care Nurse (Nurse F) was responsible for monitoring. When asked about the discrepancies with the wound descriptions in the skin assessments, the DON reported Nurse F was not as detail oriented and information varied from different staff assessing the resident. The DON reported Nurse F had recently resigned and Nurse E had only been working in the facility for about six weeks. The DON further reported the plan was to focus on the facility's process regarding pressure ulcers. When asked about whether there had been any further documentation or clarification as to the missing/blank wound care entries or if there was any further documentation to show these entries may have been provided but not documented, the DON reported she was unable to offer any further explanation for the missing/blank entries and had no additional documentation to provide. The DON was asked about the lack of any prn pressure ulcer treatments documented as provided to R803 given the DON and Nurse Es earlier report of constantly moist skin, and loose stools and reported she was unable to offer any further explanation. Review of the facility's Pressure Ulcers/Skin Breakdown - Clinical Protocol policy dated 01/2020 documented, in part: .a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatments and services, consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing .The IDT (Interdisciplinary Team) will characterize the likelihood of wound healing, based on a review of pertinent factors; for example .Healing or Prevention Likely .Healing or Prevention Possible .Healing or Prevention Unlikely .

This citation pertains to intake #MI 808. Based on observation, interview and record review, the facility failed to ensure appropriate supervision during care per assessed need for one (R801) of three residents reviewed for falls, resulting in a fall onto the floor from an elevated height in which R801 sustained multiple lacerations, and a nondisplaced intertrochanteric [MEDICAL CONDITION] femur which required hospitalization and surgical intervention. Findings include: Review of a complaint filed with the State Agency on 9/25/20 included concerns that R801 had sustained a fall with injury when the facility did not provide two people during care of the resident as required. On 10/27/20 at 11:00 AM, R801 was observed from the hallway lying in bed wearing a hospital gown up to the abdomen which exposed the brief and both legs. Upon entry into the room, (R801 was on droplet isolation precautions) the resident's right leg was observed to have been amputated, and the left leg near the hip and upper thigh had healing surgical incision sites. At that time, although the resident was unable to speak, responses to simple questions asked were appropriate and R801 responded with nodding head and/or blinking eyes. When asked about the fall, R801's eyes closed for a while. Review of R801's progress notes included an entry on 9/17/20 at 11:00 PM by Nurse Practitioner (NP K) which documented, in part .rolled out of bed during am (morning) care. Bed was approximately 3 feet. He has a large gash 2cm (centimeters) long in right eyebrow and right forehead and left toe laceration small 1-2 cm long. He is on anticoagulation (blood thinner) and he is non-verbal he is able to answer yes and no questions however is acting erratic. We will send to the hospital for CT (Computed tomography - a series of x-ray images taken from different angles) given that he is on AC (anticoagulant) .Patient rolled out of bed from a height of around 3 feet onto his face. He has a large gash above his left eyebrow .His behavior is strange but he is non-verbal so difficult to assess. Will send to hospital . Review of R801's care plans and Kardex (resident specific directives on care needs for direct care staff) identified R801 was to have two people during care for bed mobility, toilet use and transfers. The fall care plan initiated 11/5/19 was last revised on 9/17/20 with no new interventions identified. The two interventions that were documented read Anticipate and meet the resident's needs based on nursing assessments. Date Initiated: 11/05/2019 and Bed in lowest position when not providing care. Date Initiated: 11/05/2019. Further review of the resident's clinical record revealed R801 was initially admitted into the facility on [DATE], hosptalized on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment dated [DATE], R801 required total care of two plus people for bed mobility, transfers, dressing, toilet use and bathing, and had no falls. Review of R801's incident/accident report dated 9/18/20 at 9:55 AM documented, in part .Resident was receiving care by CNA (Certified Nursing Assistant/CNA G) he went too far off bed and rolled off. Sent to ER (emergency room ) for evaluation. Education provided to CNA for 2 person assist and check Kardex .CNA provided care with one person assist resulting in fall . On 10/28/20 at approximately 11:15 AM, an interview and record review was conducted with the Director of Nursing (DON). Upon review of R801's fall on 9/18/20, the DON acknowledged R801 had fallen and reported the facility was unaware of the fracture until the resident was due to return to the facility. The DON acknowledged CNA G had provided care to R801 without ensuring another staff assisted per plan of care. On 10/28/20 at 11:30 AM, an interview was conducted with CNA G. When queried about R801's fall, CNA G reported, I was doing patient care. (R801) was in center (of bed) but rolled over. When asked if the bed was in an elevated position since care was being provided, CNA G reported it was. When asked if CNA G was aware R801 required two people for care, CNA G reported, I was aware two person, the nurse was busy. The other CNA was doing patient care. I know I can ask for help now. Review of the facility's Falls - Clinical Protocol policy dated 6/2018 documented, in part: .Interventions should be developed and implemented per the assessed needs .In addition, interventions for direct care givers should be placed on the KARDEX or similar format .The care plan and KARDEX should be updated as interventions change .

This citation pertains to intakes MI 996 and MI 047. Based on observation, interview, and record review, the facility failed to ensure accurate skin assessments, wound care treatments, coordination of care with outside consultants, and interventions to prevent pressure ulcers were performed as ordered for four residents (R#'s 601, 606, 613, and 615) of four residents reviewed for pressure ulcers, resulting in formal complaints to the State Agency, the development of a stage 3 pressure ulcer (full thickness loss of skin where fat tissue is visible and slough or eschar may be present), and the potential for worsening of existing pressure ulcers and the development of new pressure ulcers. Findings include: R#601 On [DATE] a review of R601's closed clinical record was conducted and revealed R601 was a long-term care patient and discharged home from the facility on [DATE]. R601's [DIAGNOSES REDACTED]. Continued review of R601's clinical record revealed the following: A wound care note from the facility's Wound Care Consultant dated [DATE] that read, Wound Assessment(s) .Cicatrix (a scar resulting from new connective tissue over a healing sore or wound) to R (right) hip . A wound care note from the facility's Wound Care Consultant dated [DATE] that did not address any assessments of R601's right hip. A wound care note dated [DATE] from the facility's Wound Care Consultant that did not address any assessments of R601's right hip. A weekly skin assessment dated [DATE] that documented No checked for the question, Are there any new abnormal skin areas? It was further noted the assessment did not address any concerns regarding R601's right hip. A review of a document dated [DATE] from an outside Wound Care Consultant (Nurse Practitioner 'D') associated with a nearby hospital system was reviewed and read, Appointment Details .Patient presents with Wound Check .It is unknown what wound treatment they are currently using at the facility .PHYSICAL EXAM .Wound/Skin: .Pressure Injury .right ischium (hip) .Site Assessment: Red; Yellow .Pressure Injury Stage 3 . A review of a document titled, AFTER VISIT SUMMARY From Nurse Practitioner 'D', dated [DATE] and scanned into R601's clinical record was conducted. The AFTER VISIT SUMMARY read, .You Saw (Nurse Practitioner 'D') .for: Wound Check. The following issues were addressed: Pressure Injury of right ischium (hip), stage 3; .Wound Care Instructions .Right Ischium: 1. pack/fill with moistened [MEDICATION NAME] (a wound care product that absorbs drainage and contains a low level of silver that aids in killing bacteria) daily. If [MEDICATION NAME] is still present at time of change, leave in place, moisten, and fill. 2. Cover with (name of foam dressing) or other bordered foam. Use a new foam after ,[DATE] days . Continued review of R601's clinical record revealed a wound care note dated [DATE] from the facility's Wound Care Consultant that read, .Wound Assessment(s) .Cicatrix to R Flank, R Hip .TREATMENT RECOMMENDATIONS .FOAM DRESSING Q3D (every three days) AND PRN (as needed)-R Flank, R Hip x 7 days . It was noted the consult did not address the presence of a pressure ulcer of any stage, despite R601 having been seen on [DATE] for a stage 3 ulcer to their right hip. A weekly skin assessment dated [DATE] that had No checked for the question, Are there any new abnormal skin areas?. It was noted the weekly skin assessment did not have any sites listed for any skin issues for R601. A wound care note dated [DATE] from the facility's Wound Care Consultant that did not address any assessments of R601's right hip. A wound care note dated [DATE] from the facility's Wound Care Consultant that did not address any assessments of R601's right hip. A review of the next documented weekly skin assessment dated [DATE] (13 days after the previous scheduled weekly skin assessment) also had No checked for the question Are there any new abnormal skin areas? It was noted this assessment did not identify any concerns with R601's right hip. A review of R601's physician's orders [REDACTED]. Pat dry. Apply Bordered Foam as directed to Right hip. Skin barrier wipe to periwound at bedtime every 3 day(s) for [MEDICATION NAME] for 7 days . No further orders that addressed the treatment and packing of R601's wound were present in the orders, and no orders for any treatments to R601's right hip/ischium were present after the order expired on [DATE]. On [DATE] at 2:20 PM, a telephone interview with the facility's Director of Nursing (DON) was conducted regarding the wound on R601's right hip/ischium. The DON was queried if they were aware R601 had been to see a Wound Care Consultant outside of the facility. At that time, The DON reviewed the chart and confirmed the presence of the AFTER VISIT SUMMARY dated [DATE]. The DON was asked about the discrepancies between the facility's Wound Care Consultant documentation, (no mention of a stage 3 hip/ischium wound) the outside Wound Care Consultant (Nurse Practitioner 'D') documentation that indicated there was a stage 3 pressure ulcer that required a treatment, and the weekly skin assessments that did not address any concerns with the right hip/ischium. The DON had no explanation and indicated they would look into it. R#606 A review of R606's closed clinical record was conducted on [DATE] and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of R606's Wound Care Consultant Progress notes was conducted and revealed that on [DATE] The Wound Care Consultant Progress note read, .Plan .Additional Orders: .Pressure Relief/Offloading: FREQUENTLY REPOSITION. ELEVATE BLE (bilateral lower extremities). FLOAT HEELS. SOFT HEEL LIFT BOOTS . Continued review of additional Wound Care Consultant notes dated [DATE], [DATE], [DATE], [DATE] and [DATE] also indicated R606 was to be frequently repositioned, have lower extremities elevated, have heels floated, and be wearing soft heel lift boots. A review of a Wound Care progress note dated [DATE] was conducted and read, .Wound Assessment(s) .Right heel is a Deep Tissue Injury .TREATMENT RECOMMENDATIONS: DRY DRESSING Q2D AND PRN-R Heel . It was noted the Consultant's note did not indicate whether the deep tissue injury was avoidable or unavoidable. A review of R606's physician's orders [REDACTED]. A review of the physician's orders [REDACTED].Cleanse with wound cleanser. Pat dry. Apply Bordered Foam as directed to Right heel. Skin barrier wipe to peri wound. every day shift every 2 day(s) related to PRESSURE-INDUCED DEEP TISSUE DAMAGE OF RIGHT HEEL . It was noted on the TAR the dressing was scheduled to start on [DATE] but was not signed out as having been done. It was further noted the TAR was blank for the scheduled dressing change on [DATE]. A review of R606's CNA tasks for February 2020 and [DATE] was conducted and revealed the following question, .Were resident's heels floated while in bed? The following was noted in response to the question: [DATE] Documented responses for two of three shifts. [DATE] Documented response for one of three shifts. [DATE] Documented response for one of three shifts. [DATE] No documented responses for the day [DATE] Documented response for one of three shifts [DATE] Documented responses for two of three shifts [DATE] Documented responses for two of three shifts [DATE] Documented response for one of three shifts [DATE] No documented responses for the day [DATE] Documented responses for two of three shifts [DATE] Documented response for one of three shifts [DATE] Documented response for one of three shifts [DATE] and [DATE] Documented responses for two of three shifts [DATE] Documented response for one of three shifts [DATE]-[DATE] Documented responses for two of three shifts [DATE] and [DATE] Documented response for one of three shifts A review of a second CNA task for R606 was conducted for February 2020 and [DATE] and asked the following question, .Was Resident turned and repositioned per the plan of care? The following was noted in response to the question: [DATE] and [DATE] Documented responses for two of three shifts [DATE] Documented response for one of three shifts [DATE] Documented responses for two of three shifts [DATE] Documented response for one of three shifts [DATE] No documented responses for the day [DATE] Documented responses for two of three shifts [DATE] Documented response for one of three shifts [DATE] Documented responses for two of three shifts [DATE] and [DATE] Documented responses for two of three shifts [DATE] Documented response for one of three shifts [DATE] No documented responses for the day [DATE] Documented response for one of three shifts [DATE] and [DATE] Documented responses for two of three shifts [DATE] Documented response for one of three shifts [DATE]-[DATE] Documented responses for two of three shifts [DATE] and [DATE] Documented response for one of three shifts On [DATE] at approximately 1:35 PM, an interview with the facility's DON was conducted regarding the CNA task documentation. During the interview, the DON indicated the CNA's worked three 8 hour shifts and further indicated the CNA's should be documenting for turning and repositioning and floating heels every shift. On [DATE] at 2:20 PM, a follow-up interview via the telephone was conducted with the DON. At that time, the DON was asked why there was no evidence (physician's orders [REDACTED]. The DON indicated it was a standard of care to use the heel boots if residents were at risk and they don't do orders for them. The DON further explained the order and the added care plan intervention for the boots could have been picked up on a quarterly care plan review. R#613 On [DATE] at 11:05 AM, R613 was observed in bed. R613 was alert, did not respond to verbal communication, and minimally tracked movement with their eyes. R613 was observed to require mechanical ventilation, have a [MEDICAL CONDITION], feeding tube, indwelling urinary catheter, and had contracted joints in bilateral upper and lower extremities. A review of R613's clinical record was conducted and revealed a re-admission date of [DATE] with [DIAGNOSES REDACTED]. Continued review of R613's clinical record was conducted and revealed a note from the Wound Care Consultant dated [DATE] that read, .PHYSICAL EXAM .Skin; Stage III pressure ulcer to right heel has recently re-opened .Plan .Wound treatment will be performed daily and PRN to right heel stage III pressure ulcer cleansed with wound cleanser pat dry. Apply meta honey (wound care treatment) topically cover with gauze . It was noted the Consultant's progress note did not indicate whether the wound was avoidable or unavoidable. A review of the weekly skin assessment dated [DATE] was conducted and did not indicate R613 had any skin impairments on their right heel, despite having a Wound Consult three days prior that indicated they had a stage 3 pressure ulcer. A review of a 30-day look-back for the CNA tasks was conducted and revealed the question, Was Resident turned and re-positioned per the plan of care?, the following was noted in response to the question: [DATE] and [DATE] Documented responses for two of three shifts [DATE] and [DATE] Documented response for one of three shifts [DATE], [DATE], and [DATE] No documented responses for those days [DATE] Documented responses for two of three shifts [DATE] Documented response for one of three shifts [DATE] Documented response for one of three shifts [DATE] and [DATE] Documented response for one of three shifts [DATE] Documented responses for two of three shifts R#615 On [DATE] at 11:28 AM, R615 was observed lying in bed with a [MEDICAL CONDITION] connected to oxygen, a feeding tube, and an indwelling urinary catheter. R615 was alert, but did not respond to verbal communication A review of R615's clinical record revealed an admission date of [DATE], and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Continued review of R615's clinical record revealed physician's orders [REDACTED]. One order dated [DATE] read, Cleanse with wound cleanser. Pat dry. Apply Hydrogel Impregnated Gauze as directed to left hip. Skin barrier wipe to peri wound. Cover with border foam, every day and night shift for wound care related to PRESSURE ULCER OF LEFT HIP . A review of R615's TAR's revealed missed documentation of treatments, including the treatments for the pressure ulcer of R615's left hip. The missed treatments were the following dates: [DATE]: night shift - [DATE], [DATE], [DATE], [DATE] and [DATE]. [DATE]: night shift - [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]; day shift - [DATE]. [DATE]: night shift - [DATE], [DATE], [DATE] and [DATE]. A review of a 30-day look-back for the CNA tasks for R615 was conducted and revealed the question, Was Resident turned and re-positioned per the plan of care?, the following was noted in response to the question: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] Documented response for one of three shifts. [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] No documented response for these days. [DATE], [DATE], [DATE] and [DATE] Documented response for two of three shifts. On [DATE] at 2:20 PM, a telephone interview was conducted with the DON, who was queried about the missed treatments for R615's pressure ulcers. The DON explained the nurses were responsible for completing all treatments as ordered. When asked if nurses were staffed differently for day and night shifts, the DON explained both shifts were staffed the same and stated, midnights are almost better than day shift for number of nurses. On [DATE] a review of a facility provided document titled, Pressure Ulcers/Pressure Injury Prevention and Treatment-Clinical Protocol with a Reviewed/Revised Date of [DATE] was conducted and read, Purpose: Based on the comprehensive assessment of a resident, a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing . The facility was asked if they had any additional documentation to provide regarding the concern; none was provided by the end of the survey.

Based on observation, interview, and record review, the facility failed to: perform employee /visitor screening assessments for the COVID-19 virus prior to entry into the facility, ensure the appropriate use of personal protective equipment (PPE) for residents in droplet isolation including residents in isolation for COVID-19, ensure appropriate isolation of residents in droplet isolation for COVID-19, ensure appropriate signage was in place to indicate a droplet isolation room, and ensure increased clinical assessments were completed for residents with a positive or suspected case of COVID-19 for 25 residents, (R#s 701, 702, 703, 704, 705, 706, 707, 708, 709, 710, 711, 712, 713, 714, 715, 716, 717, 718, 719, 720, 721, 722, 723, 724, and 725) of 25 residents reviewed for infection control practices, resulting in an immediate jeopardy to the safety and health of all residents in the facility when the facility's infection control practices put all residents at risk of serious harm and/or death due to the actual and potential spread of the COVID-19 virus. Findings include: The Immediate Jeopardy (IJ) started on [DATE]. The IJ was identified on [DATE] at approximately 10:30 AM. The Administrator was notified of the IJ via telephone and electronically on [DATE] at 4:50 PM. The immediacy was removed on [DATE] at 7:00 PM, based on the facility's implementation of an acceptable plan of removal as verified both off-site and on-site by the survey team. Although the immediacy was removed, the facility remained out of compliance at the scope of widespread and a severity of potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency. On [DATE]-[DATE] a COVID-19 Focused Survey was conducted. On [DATE] at 8:45 AM, an interview with the facility's Administrator and Director of Nursing (DON - who was identified as the facility's Infection Control Preventionist - ICP) was conducted. During the interview, they reported they considered both hallways (1 West and 1 East) on the first floor as well as the 2 East [MEDICAL CONDITION] (trach) unit on the second floor as designated units for COVID-19 residents. When queried about how they designated the units and how residents were assigned to rooms, they indicated the first floor had confirmed positive cases of COVID-19 as well as multiple other residents they were treating as positive but had not received a swab for the test, due to not being able to obtain the testing swabs. They also indicated that on [MEDICAL CONDITION] there was one resident with a positive COVID-19 diagnosis, and one resident being treated as positive, but was asymptomatic and a swab had not been ordered. When queried about the residents they referred to that had not been swabbed, it was explained that those residents had been exposed to someone who had tested positive for COVID-19 at some point, but remained asymptomatic, so swab tests were not ordered for those residents but they were 'presumed positive' related to exposure to other residents who had tested positive. The DON reported all residents on the first floor and [MEDICAL CONDITION] on the second floor were on droplet precautions (isolation precautions to prevent transmission of pathogens transmitted by respiratory droplets). The DON reported staff were to wear a gown, gloves, an N95 respirator mask, and goggles or a face shield when entering the droplet precaution rooms. When queried about PPE availability, the DON reported the facility was doing good as far as access to PPE and the supplies were counted daily, passed on to the corporate office, and the corporate office would get the facility what they needed. The DON reported that the facility had access to COVID-19 tests and that results were received much quicker now (within ,[DATE] hours). The DON reported the facility's protocol for screening visitors and staff for COVID-19 was to take their temperature and ask screening questions at the door. If a staff member had a fever, they were sent home and could not return until they went 72 hours without a fever and no fever reducing medications. The DON also reported that anyone with a sore throat, cough, or body aches was not permitted to enter the facility and were sent home. On [DATE] at approximately 10:15 AM, during an observation of the first-floor units, no staff were observed to be positioned at the rear entrance. No signage was observed to direct those who entered to check in for screening. A clipboard with a screening log and a temporal artery thermometer was observed to be placed on the ledge of the nurse's station. At approximately 10:20 AM, Physician L entered the facility through the rear entrance. There was no staff present at the door to screen Physician L. Physician L proceeded to go behind the desk at the nursing station where two staff members were seated, including Nurse E. Physician L asked the staff members if there were any new rules to which Nurse E replied there was not. Physician L proceeded to enter the elevator and go upstairs to the second floor. No screening of Physician L was observed. On [DATE] at 10:35 AM, Physician L reentered the first-floor unit. When queried about why they did not get screened prior to going upstairs to see residents, Physician L reported that they asked, and nobody instructed them to be screened. At that time, Ward Clerk F was observed to screen Physician L prior to them leaving the facility. When queried about the process for screening employees and visitors who entered the facility through the rear entrance, Ward Clerk F reported that staff could fill out their own screening and there was usually a manager present to screen people when Ward Clerk F was not present. On [DATE] at 10:55 AM, Maintenance Staff G was observed entering the facility through the rear entrance and punched in at the time clock. There was nobody at the door to screen for COVID-19. Maintenance Staff G entered through the double doors and proceeded to step all the way into the elevator. When queried about screening, prior to closing the door on the elevator, Maintenance Staff G identified they were maintenance staff and just arrived for their shift. On [DATE] at 11:00 AM, the Administrator was interviewed about the facility's protocol for screening staff and visitors for COVID-19. The Administrator reported that physicians were educated on the need to be temped (temperature taken) and asked the screening questions. The Administrator reported that Medical Records Staff H was assigned to screen all staff leaving and entering the facility through the rear entrance from 6:30 AM until 7:45 AM and then the log and thermometer was taken to the nurse's station. The Administrator reported a charge nurse would be responsible for ensuring staff were being screened and if the charge nurse was not present, Staff should do it on their own. The Facility provided a Plan of Removal via email on [DATE] that detailed how the Facility would ensure the immediacy would be removed. On [DATE] at 9:15 AM, upon entrance to the facility through the rear entrance, Medical Records Staff H proceeded to take the State Surveyors temperatures. No screening questions were asked by Medical Records Staff H and the State Surveyors were permitted to enter the facility. On [DATE] at 9:30 AM, during an interview with Medical Records Staff H, the Staff Vitals/Screening Log for [DATE] was reviewed. Next to the State Surveyors' names the Temp. on entrance was filled in, as well as the following: New onset Cough yes/no: No New onset Sore throat yes/no: No New/Unusual SOB (Shortness of Breath): No Travel outside of the US within last 14 days: No Contact with any suspected or confirmed [DIAGNOSES REDACTED].>The Screener Signature was signed by Medical Records Staff H. When queried about why the answers were filled in for the State Surveyors when they were not asked the screening questions upon entrance, Medical Records Staff H reported they were notified that the State Surveyors were in the facility the previous day and the questions did not need to be asked again. When queried about how Medical Records Staff H would have known in the Surveyors had any new onset symptoms such as cough, sore throat, or shortness of breath, Medical Records Staff H stated, That's what I was told to do. When queried about the process for screening staff who were also in the building the previous day, Medical Record Staff H did not offer a response. On [DATE] at approximately 9:35 AM, the Administrator was interviewed regarding the screening process. The Administrator reported that all screening questions should be asked for every staff member or visitor that enters the building. R#'s 707 and 708 On [DATE] at approximately 9:30 AM, an observation of the second floor 2 [MEDICAL CONDITION] was conducted. During the observation, it was observed R707 and R708 shared a room. A sign outside of the door indicated the room was on droplet isolation precautions, requiring the use of a gown, gloves, face mask, and facial shield. At approximately 9:40 AM, the DON was queried about the second floor and they indicated all residents on [MEDICAL CONDITION] were on droplet isolation precautions and that one of the residents (R707) had tested positive for COVID-19. When queried about the other resident in the room (R708) the DON explained they were not positive, but because they had been exposed to their roommate prior to testing positive, they were treated as being positive as well, so the two continued to room together. On [DATE] A review of R707's clinical record was conducted and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A social service progress note dated [DATE] in R707's record read, .family has put discharge on hold since resident has tested positive for COVID 19. Review of R707's physicians orders indicated that droplet isolation was ordered on [DATE]. A review of R708's clinical record was conducted and revealed a re-admission date of [DATE] with [DIAGNOSES REDACTED]. Continued review of R708's clinical record indicated they received COVID-19 swabs on [DATE] and [DATE] and both tests had been negative. A review of R708's physician's orders was conducted and revealed two active orders dated [DATE] and [DATE] that indicated R708 was placed on droplet precautions. It was noted R708 had two negative COVID-19 swabs, had been placed on droplet precautions, and remained roommates with R707, who had tested positive for [MEDICAL CONDITION]. On [DATE] at approximately 9:55 AM, Certified Nursing Assistant (CNA) K was observed working on the 2 East unit. CNA K was wearing a blue plastic gown, goggles that they verbalized were too big and falling off their face, and an N95 respirator mask with a surgical mask underneath the N95. CNA K reported they were instructed to stay gowned up and when they go on break, they remove the gown and reapply the same gown when going back to work. CNA K reported they did not know of any residents in the facility who were positive for COVID-19. R#'s 701, 702, 703, and 715 On [DATE] at approximately 10:05 AM, a tour of the first floor 1 East unit was conducted. During the tour, R#'s 701, 702 and 703 were observed in their beds, sharing the same room. A sign was observed on the door that indicated the room was a droplet isolation room. On [DATE] a review of R701's clinical record was conducted and revealed an admission date of [DATE] and a re-admission date of [DATE] with [DIAGNOSES REDACTED]. A nursing note dated [DATE] read, .Notified .NP (Nurse Practitioner) regarding resident running 101 degree fever, resident complains of dry cough .Orders received for chest x-ray .influenza (flu) test, and covid-19 swab. It was noted there were no nursing notes prior to [DATE] that addressed R701's fever beginning on [DATE], or any increased monitoring of vital signs when the COVID-19 swab had been ordered. Continued review of R701's record revealed a consult note from Infectious Disease NP 'M' dated [DATE] that read, .Following for Acute [MEDICAL CONDITION] syndrome likely due to COVID-19 . A review of R701's physician's orders was conducted and an order dated [DATE] read, Droplet precautions-for suspected Covid-19. Please isolate patient to private room to prevent further spread . A review of R701's laboratory result for COVID-19 dated [DATE] indicated they had tested positive for [MEDICAL CONDITION]. On [DATE] a review of R702's clinical record was conducted and revealed an admission date of [DATE] and re-admission date of [DATE] with [DIAGNOSES REDACTED]. A review of R702's physician's orders did not indicate R702 had orders for droplet isolation precautions. On [DATE] a review of R703's clinical record was conducted and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Continued review of R703's record did not include an order that indicated R703 was on droplet isolation precautions, and a Nurse Practitioner's note dated [DATE] read, .No evidence of COVID-19 infection at this time, patient doesn't exhibit any symptoms of fever/cough/sob/malaise or fatigue . R#715 On [DATE] a review of R715's clinical record was conducted and revealed a re- admission into the facility on [DATE] that included: COVID-19, [MEDICAL CONDITION], shortness of breath, diabetes, and end stage [MEDICAL CONDITION] requiring [MEDICAL TREATMENT]. It was noted R715 readmitted to a two-bed room they did not share with a roommate. Further review of R715's record included a review of their physician's orders, it was noted the first order in the record to place R715 on droplet precautions was dated [DATE], six days after their re-admission from the hospital with a COVID-19 diagnosis. On [DATE] at approximately 3:30 PM, an interview was conducted with the Facility's Administrator and Director of Nursing. They were queried why R701, 702, and 703 remained roommates when R701 tested positive for COVID-19, but neither 702 or 703 had been tested or exhibited any signs and symptoms. They indicated that because R702 and R703 had been exposed to R701 they had been presumed positive. When further queried why R701 (COVID-19 [DIAGNOSES REDACTED]. At that time, they were also asked that if a resident was placed in droplet isolation precautions, should there be a physician's order for the isolation, and it was indicated there should be an order. R#'s 709, R710, 724, and R715 On [DATE] at approximately 10:05 AM, R709 and R710 were observed sharing a room on the 1 East Unit. There was signage on their door that alerted to the residents being placed on droplet precautions. An isolation caddy was located on the door of the residents' room and did not contain any gowns. CNA N who was wearing a yellow isolation gown in the hallway was interviewed and reported R710 tested positive for COVID-19, but their roommate (R709) did not. CNA N reported they wore the same gown for all residents on the unit, including R710 and R709 because everyone was in droplet precautions. A review of R710's clinical record on [DATE] revealed the following: R710 was admitted into the facility on [DATE] and readmitted on [DATE]. R710 resided in the same room since their admission in 2014 on the 1 East Unit. R710 had [DIAGNOSES REDACTED]. A review of progress notes revealed R710 had a fever and congestion on [DATE] and was assessed by the NP. An Infectious Disease Progress Note dated [DATE] documented, .Acute [MEDICAL CONDITION] Syndrome likely due to COVID-19 . A progress note written on [DATE] documented R710 was placed on droplet precautions related to COVID-19. Physicians Orders for R710 revealed the following: [DATE] Check temperature every shift [DATE] Droplet precautions related to fever [DATE] COVID-19 nasal swab [DATE] Place peripheral IV (intravenous) for hydration [DATE] Droplet precautions [DATE], a new order for oxygen to maintain SPO2 (oxygen saturation) of 92% or greater. A review of R709's clinical record was conducted and revealed R709 was admitted into the facility on [DATE] and readmitted on [DATE]. A progress note dated [DATE] by the Physician Assistant (PA) documented R709 had congestion. On [DATE], R709 was evaluated by the Infectious Disease physician who documented, .likely COVID-19 . R709 had a negative chest X-ray and a negative influenza test on [DATE]. Results of R709's COVID-19 test were received on [DATE] and was negative. It was noted R709 and R710 remained roommates after R710 had tested positive for the COVID-19 virus. A review of the Midnight Census Reports from [DATE] and [DATE] revealed a third resident (R724) resided in the same room as R710 and R709 until [DATE] when they were discharged to the hospital. On [DATE], R724 was tested for COVID-19 and positive results were received on [DATE]. R724 was transferred to the hospital on [DATE], after a change in condition and expired in the hospital. The DON was interviewed via the telephone on [DATE] at 11:15 AM. When queried about why R709 and R710 resided in the same room, when R710 tested positive for COVID-19 and R709 tested negative, the DON reported it was due to bed availability and, (R709) tested negative before, but could still become positive. On [DATE], a review of the Midnight Census Report For [DATE]-[DATE] was conducted, and it was discovered R710 (positive COVID-19 [DATE]) could have been placed in the same room as R715 (also positive COVID-19), as a bed was available in that room. R#714 On [DATE] at approximately 10:45 AM, a sign outside R714's room indicated the room was a droplet isolation room. The sign indicated staff entering the room should be wearing a gown, gloves, face mask, and eye protection. R714 could be observed from the hallway and was in their bed. At that time, Activity Staff 'B' was observed at R714's bedside providing a one-on-one activity. Activity Staff 'B' was observed to be wearing a gown, face mask, and eye protection. Activity Staff 'B' was not observed to be wearing gloves in the droplet isolation room. On [DATE] at 11:05 AM, Activity Staff 'B' exited the room and an interview was conducted. Activity Staff 'B' was asked what type of PPE was required for a droplet isolation room, and Activity Staff 'B' reported they needed a gown, mask, and eye protection. When queried about the use of gloves, Activity Staff 'B' stated, If I am coming in contact with residents, I put on gloves. A review of R714's clinical record was conducted and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of R714's physician's orders was conducted and revealed an order dated [DATE] that indicated R714 was placed on droplet precautions related to possible exposure to COVID-19. On [DATE] at 11:45 AM, an interview with the facility's DON was conducted regarding appropriate PPE for droplet isolation rooms. The DON indicated that staff entering droplet isolation rooms should wear a gown, gloves, face mask, and eye protection. At that time, the DON was made aware of the observation of Activity Staff 'B' not wearing gloves in R714's droplet isolation room. R#'s 711, 712, and 713 On [DATE] a review of the second-floor census report was conducted and indicated R711, 712, and 713 shared a three-bed room on the second floor. On [DATE] a review of R711's clinical record was conducted and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of R711's physician's orders was conducted and revealed an order dated [DATE] for a COVID-19 nasal swab. It was noted there was no increased monitoring of vital signs ordered upon the suspicion of COVID-19, and the first order for droplet isolation precautions was placed on [DATE], five days after the COVID-19 swab was ordered. On [DATE] a review of R712's clinical record was conducted and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of Infectious Disease NP 'M's note dated [DATE] was reviewed and read, .No evidence of COVID-19 infection at this time . On [DATE] a review of R713's clinical record was conducted and revealed a re-admission date of [DATE] with [DIAGNOSES REDACTED]. A review Infectious Disease NP 'M's note dated [DATE] was conducted and did not mention any concern for COVID-19. A review of a facility provided Census report dated [DATE] was conducted and indicated that [MEDICAL CONDITION] had two empty rooms available on [DATE], but R712 and R713 both remained in the same room as R711, who was suspected as having the COVID-19 virus. R#'s 716, R717, and R725 On [DATE], R716, R717 and R725's clinical records were reviewed. According to a list of residents who were confirmed positive for COVID-19, pending tests, or transferred to the hospital provided by the DON, R717 had a test ordered, but it was not yet obtained and R716 tested positive for COVID-19 and was in the hospital. R725 was not included on the list. R716's clinical record was reviewed and revealed R716 was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Physician Orders for R716 revealed the following: [DATE] Check temperature every four hours [DATE] Droplet precautions related to fever [DATE] Please complete respiratory assessment and document in a nurse's note. Assess for cough, SOB, rhinitis, lung sounds every 4 hours. [DATE] Oxygen at 2L per minute for 24 hours per day as needed, maintain SPO2 greater than 90% A review of R716's progress notes revealed the following: On [DATE] a Nurse's Note documented, .Denies cough, sore throat, SOB. Covid screen pending. On [DATE] a Nurse's Note documented, .Resident cxr (chest x-ray) positive for slight right upper lobe pna (pneumonia) . On [DATE] a Nurse's Note documented, Resident currently in bed eyes closed. earlier in shift PT (patient) reported body aches and headache .slight cough, no resp. (respiratory) distress noted .B/P (blood pressure) ,[DATE] temp 101.1 HR (heart rate) 22 resp. (respiratory rate) 19 pain 3 . On [DATE], a Nurse's Note documented, Resident is febrile with temperature of 101.6 and show signs of respiratory distress. Vitals taken BP ,[DATE], P 98, RR 19, SPO2 81%. RT (Respiratory Therapist) assessed resident. P.A on site and assessed patient. New order given for 2L (Liters) O2 to maintain saturation above 90% and new ABX (antibiotics) ordered. Resident saturation is now 92%. Will continue to monitor resident . On [DATE], an SOC-Infection note documented, .Resident positive for COVID 19- nasal swab obtained on [DATE] and resulted <sic> [DATE]. Remains febrile at this time. Denies cough or sore throat. C/o (complains of) headache. CXR completed and positive for PNA- remains on ABX at this time .Precaution type: Droplet . On [DATE], an Infectious Disease progress note documented, .Following for [MEDICAL CONDITION] Pneumonia due to COVID-19 XXX,[DATE]: COVID-19 positive XXX,[DATE]: Slight Right Upper lobe pneumonia .1. Acute [MEDICAL CONDITION] Pneumonia due to COVID-19 . On [DATE] at 5:10 PM, a PA progress note documented, .Seen for . tachypnea (increased respiratory rate), BP, [MEDICAL CONDITION] .and for multiple medical conditions requiring monitoring to prevent decline .RR (respiratory rate) 30, O2 83% on 6L+ SOB .Pulmonary: few scattered rhonchi with exp (expiratory) wheezes .[MEDICAL CONDITION] with tachypnea. Will transfer the patient to the hospital for further eval and treatment . R716 resided in the same room with R717 and R725 until [DATE] when they (R716) were transferred to the hospital despite a pending COVID-19 test performed on [DATE] and a confirmed positive result on [DATE]. A review of R725's clinical record revealed R725 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Physician Orders for R725 documented the following orders: [DATE]-[DATE] Check temperatures every four hours [DATE]-[DATE] Droplet Precautions [DATE]-[DATE] Please complete respiratory assessment and document in a nurse's note. Assess for cough, SOB, rhinitis, lung sounds every 4 hours. [DATE] Please consult ID (Infectious Disease) for recent COVID-19 infection and treatment with continued fevers. [DATE]-[DATE] [MEDICATION NAME] .for COVID-19 positive . A review of R725's MAR (Medication Administration Record) and TAR (Treatment Administration Record) for [DATE] revealed R725 was on droplet precautions until [DATE] when they were transferred to the hospital. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]= 100.8, [DATE] at 1:00 PM = 100.0 and 5:00 PM = 100.1, [DATE] at 5:00 AM = 101.1, [DATE] at 9:00 AM and 5:00 PM = 100.1 and 100.2 at 9:00 PM = 100.2, and [DATE] at 1:00 AM = 100.0. Respiratory Assessments were documented as completed on the MAR indicated [REDACTED]. R725's progress notes were reviewed for the physician ordered respiratory assessments beginning [DATE] (the order was to document the assessments in a nurses note every four hours) and revealed that on [DATE] at 11:47 PM, a blank respiratory note was entered, and two blank respiratory notes were entered on [DATE] at 12:55 PM and 4:40 PM. The next progress in the record was written on [DATE] at 6:55 AM, and documented, Res (resident) temp (temperature) elevated @ 101.1 . It was noted R725's clinical record did not include any progress notes or assessments from [DATE]-[DATE]. On [DATE], two days after the last progress note, a dietary note documented R725 had refused two meals which was rare for that resident. The next progress note was entered on [DATE] and documented, 2pm social worker checking residents when resident c/o DOB <sic>, writer checked patient stated, 'I can't breath, <sic> SPO2 is 88%-90%. 2L is given, still SpO2 is ,[DATE]%. Called NP .ordered to send to hospital . A nurse's note dated [DATE] documented R725 returned from the hospital on 5L of oxygen. Hospital records for R725 were reviewed and revealed the following: A Discharge Summary for R725's hospital stay from [DATE] through [DATE] documented the Discharge [DIAGNOSES REDACTED]. Hospital Course .lives at an ECF (extended care facility) with COVID-19 positive roommates presents to the emergency department with [MEDICAL CONDITION] in the mid 80's prior to arrival .Patient has a cough. No fever. Patient has been breathing at 30 times a minute but this improved with increased oxygen .Initial triage temperature was 100 Fahrenheit .Per discussion with patient's nurse at (facility name redacted) patient was notably short of breath with O2 saturation ,[DATE] % on 6L (of oxygen) .Pt does not wear oxygen at home per facility .Per discussion, patient has 2 roommates at her facility with recent exposure to COVID-19. She denied any complaints besides shortness of breath .Given [MEDICAL CONDITION] markers despite negative COVID testing patient was treated with current COVID protocol . A COVID-19 test was completed in the hospital on [DATE] and results were negative. An Infectious Disease progress note dated [DATE] documented, COVID-19 [MEDICAL CONDITION] markers are consistent. This coupled with high O2 needs with abnormal CT (computed tomography) of chest, and apparent known exposure highly suspect COVID infection with a false negative test. Maintain COVID isolation . Continued review of the record revealed R725 was readmitted into a room with R717 on [DATE] and both residents were moved to a different room which they also shared, and where they remained until [DATE] when R717 expired and later tested positive for COVID-19. R717's clinical record was reviewed and revealed the following: R717 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. R717 resided in the same room from [DATE] until [DATE], at which time she was moved to the same room with R725. Physician Orders were reviewed and included the following orders: [DATE] Check temperature every four hours [DATE] and [DATE] Droplet precautions Progress notes for R717 documented the following: On [DATE], a physician progress notes [REDACTED]. Upon examination in her room, she admits of having a poor appetite all these days. she does not exhibit any other symptoms for covid- 19 .will monitor for any s/s (signs/symptoms) of covid-19 . There were no other progress notes that documented clinical monitoring of R717. The next progress note in the record was written on [DATE], eight days after the physician's note, and documented, Code Blue called over head. CPR (cardiopulmonary resuscitation) in progress. EMS arrived. A second progress note dated [DATE] documented, Resident seen at around 8:40 AM. Resident was alert and responded to writer. Med administered. Resident found unresponsive at 12:42 PM. EMS called at 12:42 PM. CPR started at 12:42. EMS arrived at 12:56PM. iv placed on left leg .CPR stopped at 1:33 PM. A progress note written on [DATE] documented, Resident COVID results obtained- positive. Health department notified of results and death. Skilled Daily - Cardiopulmonary Assessment forms were completed on [DATE], [DATE] [DATE], [DATE], and [DATE], However; all the above assessments were completed (locked and signed) on [DATE]. The vital signs on all the above assessments were dated [DATE]. An O2 Sats (saturation) Summary for R717 documented on [DATE] at 5:43 PM, O2 Sats were 89 percent on room air. The summary documented all future O2 Sats were assessed with [REDACTED]. It was noted documentation did not address R717's decreased oxygen saturations on [DATE], and also noted there was not a physician's order for oxygen. On [DATE] at 11:22 AM, an interview was conducted with the DON via the telephone. The Midnight Census Reports from [DATE] through [DATE] were reviewed and showed R717 in a different room than where she was on [DATE]. The DON confirmed that R717 resided in the same room as R725 on [DATE] and was moved to a different room with R725 until their (R717) death on [DATE] and that R717, R725, and R716 resided in the same room until [DATE] when R716 was transferred to the hospital. The DON explained the facility conducted a lot of room changes and R717's did not get chang(TRUNCATED)

This citation pertains to intake #MI 3: Based on interview and record review, the facility failed to perform thorough fall investigations using root cause analysis, ensure appropriate supervision to prevent fall re-occurrence, promptly implement resident specific fall interventions and update care plans for two residents (R#'s 503 and 504) of three residents reviewed for falls, resulting in repeated falls, a fall that resulted in a [MEDICAL CONDITION], pain and transfers to the emergency room . Findings include: On 11/5/19 a review of R#503's closed record was conducted. The record revealed R#503 admitted to the facility on [DATE], re-admitted on [DATE], and was discharged on [DATE]. R#503's [DIAGNOSES REDACTED].#503 had been transferred out of the facility for a fall on 7/25/19. A review of R#503's Minimum Data Set (MDS) assessment dated [DATE] indicated R#503 had a Brief Interview for Mental Status (BIMS) Score of 13/15 that indicated intact cognition, did not experience any hallucinations, delusions, rejection of care or wandering, but did exhibit other behavioral symptoms one to three days during the assessment period. The MDS further indicated R#503 was non-ambulatory, required total assistance of one staff member for wheelchair mobility, required extensive to total assistance of one to two staff members for all other activities of daily living, and had range of motion deficits on one lower extremity. It was noted there was no MDS data prior to the resident's readmission on 8/12/19. A review of R#503's medication orders included an order for [REDACTED].#503's Fall Risk Evaluation dated 7/21/19 indicated R#503 scored a 16 and read, Interventions Required. A review of facility provided Incident/Accident (I&A) report/investigation packets was conducted and revealed the following: Fall #1 7/23/19 at 3:35 PM, R#503 had an unwitnessed fall in their room. The I&A packet documented, .Brief Description: Pt. (patient) states she stood up to pull off brief and instead of sitting in the chair she sat on the floor .Immediate interventions implemented: Resident education. Pt. placed in bed with call light in reach .QUALITY ASSESSMENT & ASSURANCE INVESTIGATION REPORT .14. Results of investigation: Resident attempting to transfer from bed to upright and remove her brief. Resident states she sat on the floor .Resident placed back into bed. Interview with daughter .reveals resident often sits on the floor from a standing position. Care Plan interventions added . Fall #2 7/23/19 at 10:57 PM, R#503 had an unwitnessed fall in their room. The I&A packet documented, .Brief Description: Resident observed lying on right side on floor .in doorway of room .QUALITY ASSESSMENT & ASSURANCE INVESTIGATION REPORT .14. Results of Investigation: Resident stood up, took off brief, and sat down on floor instead of wheelchair .Fall Investigation Report .Fall Description Details: Observed lying on right side on floor .IN doorway .Describe initial interventions to prevent future falls: Keep resident up during daytime hours. Keep active during daytime .conclusion: Educate resident to use call light . It was noted the nurses Brief description of the incident and the Results of the Investigation were conflicting in this report. A review of activity documentation provided by the facility was conducted to determine how the facility and staff were implementing the intervention of keeping the resident active in an attempt to prevent future falls. The documentation provided revealed that on 7/21/19 at 2:59 PM, R#503 had a Room visit, on 7/23/19 at 2:59 PM R#503 had a Manicure/Salon, Music/Entertainment, Reminiscing, and Pet visits, on 7/24/19 at 2:03 PM, R#503 had a Room visit and at 2:59 PM, had a Special Event. All other documentation provided for activities for R#503 were documented as Watching TV, or Daily Routine. Fall #3 7/25/19 at 2:45 PM, R#503 had a fall in their room. The report indicated the fall was unwitnessed, however the I&A packet documented, .Brief Description: Pt was found on the floor next to bed in sitting position. Housekeeper was cleaning floor and advised pt to <sic>floor would be wet. Pt. attempted to self transfer from bed to wheelchair and slid off bed . It was unclear from the investigation packet if the Housekeeper was present at the time of the fall, as no statement was obtained from the housekeeper, but they had advised the resident the floor was wet. The report packet further documented, .QUALITY ASSESSMENT & ASSURANCE INVESTIGATION REPORT .List Care Planned Interventions Prior to Fall/Accident: educated to use call light before transfers, lock bed at all times with bed in lowest position, encourage resident to participate in activities in evening, educate resident/family about safety .14. Results of Investigation: Resident self transferred from wheelchair to bed and slid onto floor. Unwitnessed fall .Fall Investigation Report .Additional Care Plan/Nurse Aide Assignment Updates: Regular mattress put on bed, grip socks given . A review of a nursing progress note dated 7/25/19 at 2:53 PM, pertaining to this fall read, Note Text: Resident observed laying on the floor with her head just past the end of the bed. When asked what happened she stated that she sat herself up on the edge of the bed and was reaching for her wheelchair and the bed slid out from under her. Upon inspection it appears that there is only one lock on the bed. She also stated that the air mattress shifts air around and it makes her slide off the bed. Order placed to replace the air mattress with a standard bed . Fall #4 7/25/19 at 7:30 PM, R#503 had an unwitnessed fall in their room. The I&A Packet documented, .Brief Description: Resident was observed on the floor next to bed. Resident stated, I was trying to reach for my w/c (wheelchair) to get out of bed and fell on my right side .pain scale 0-10 10 .QUALITY ASSESSMENT & ASSURANCE INVESTIGATION REPORT .List Care planned Interventions prior to Fall/Accident: Bed in lowest position, floor matts <sic> in place .14. Results of Investigation: Resident fell on to floor due to self transfer. Resident sent out to Hospital due to increased pain .Fall Investigation Report .Describe initial interventions to prevent future falls: bed in lowest position, grip socks, use call lights, change mattress .Conclusion: Resident transferred to hospital due to increased pain r/t (related to) fall . It was noted this investigation referenced the use of fall mats, however; a review of the previous fall investigation, physician's orders [REDACTED].#503 did not indicate fall mats were ever implemented or put in place. It was further noted that all Initial interventions to prevent future falls had already been listed as interventions in falls prior to this one. Review of a nursing evaluation summary note dated 8/12/19 (date of the resident's readmission to the facility) documented, .Resident admitted via ambulance on a strecher <sic> alone. Resident Dx (diagnosis) with right [MEDICAL CONDITION] with surgical incision . Fall #5 8/14/19 at 4:00 AM, R#503 had a witnessed fall in their room. The I&A packet documented, .Brief Description: Resident rolled out of bed on to the floor .QUALITY ASSESSMENT & ASSURANCE INVESTIGATION REPORT .List Care Planned Interventions Prior to Fall/Accident: Low bed, Floor mats .Resident's explanation of incident: I'm going to fall out of bed .Results of Investigation: Resident rolled herself out of bed .Fall Investigation Report .Describe initial interventions to prevent future falls: Scoop mattress to be given to resident .Conclusion: Resident is known to have numerous falls per family . It was noted the portion of the packet that could have included witness statements did not contain any statements from the staff member who observed the fall. It was further noted this investigation referenced the use of fall mats, however; a review of the physician's orders [REDACTED].#503 did not indicate fall mats were ever implemented or in place. Fall #6 8/23/19 at 3:10 PM, R#503 had an unwitnessed fall in their room. The I&A packet documented: .Brief Description: Resident found on floor next to bed sitting up right <sic> .QUALITY ASSESSMENT & ASSURANCE INVESTIGATION REPORT .List Care Planned Interventions Prior to Fall/Accident: bed in lowest positions, call light within reach .Fall Investigation Report .Describe initial interventions to prevent future falls: Bed in lowest position, visual checks q1 (every hour) .Conclusion: Resident had unwitnessed fall . It was noted this investigation did not reference the use of the fall mats as an intervention that the fall on 8/14/19 referenced, nor did this investigation reference the use of the scoop mattress that had been listed as a new intervention after the fall on 8/14/19. A review of R#503's physician's orders [REDACTED].#503. Fall #7 9/1/19 at 6:33 AM, R#503 had a fall in their room. The I&A packet did not indicate whether the fall was witnessed or unwitnessed. The I&A packet documented: .Brief Description: Resident observed laying on right side of bed on the floor, Resident stated I am going for a walk .QUALITY ASSESSMENT & ASSURANCE INVESTIGATION REPORT .List Care Planned Interventions Prior to Fall/Accident: Floor matts <sic>, bed in lowest position .14. Results of Investigation: Resident was observed lying on the right side of her bed between the bed & wall. Resident stated she was going for a walk. Physician notified and family notified. Daughter insisted resident be sent to the hospital . It was noted this investigation did not reference the use of the scoop mattress that had been provided as a new intervention after the fall on 8/14/19. On 11/5/19 at 3:45 PM, an interview with the facility's Director of Nursing (DON), Administrator, and Corporate Nurse Consultant was conducted regarding R#503's falls. They were first queried why the results of their investigation for fall #2 were the same as the results for fall #1, when the I&A report for fall #2 indicated they had been found in the doorway, not next to the bed in the sitting position; no explanation was provided. Next, they were queried regarding fall #3 and whether the housekeeper had been present since it was documented they (housekeeper) informed R#503 that the floor had been wet. They did not know if the housekeeper was present and indicated they should have taken a statement from them. They were then asked about the note regarding fall #3 and the bed sliding out from underneath R#503 as R#503 described. This question was deferred to the Assistant Director of Nursing (ADON) as it was indicated she handled the investigation on that fall. The Administrator, DON, and Corporate Nurse Consultant were then queried about fall #4 that required R#503 to be transferred to the emergency room where she was diagnosed with [REDACTED]. [REDACTED]. for certain whether she had floor mats in place or not. They were next asked about fall #5 that was documented as having been witnessed. They were queried as to who the witness was and what the witness had observed. They indicated that the nurse who filled out the form, Nurse 'E' was the witness to the incident; however; they indicated Nurse 'E' did not write a statement and they did not know exactly what happened when R#503 rolled out of bed. They were then asked if R#503 ever received the scoop mattress as indicated as a new initial intervention as no order, care plan, or reference to it being present was included in the I&A's for fall #6 or fall #7. It was explained that R#503 had some room changes and they were not sure if she ever had the mattress or if it got moved with her when she changed rooms. Next, they were asked about fall #6 and #7 with the references to the floor mats and no references to the scoop mattress having been in place and they indicated they were not sure whether they were there and explained that they needed to do a better job with the investigating and care planning for the falls. On 11/6/19 at 9:25 AM, an interview with the facility's ADON was conducted regarding fall #5 where the bed had slid out from under R#503. The ADON explained that when R#503 admitted to the facility she was admitted to a room with a bariatric, low air loss air mattress. The ADON explained that the bed was rented from a contract company. The ADON continued to explain that the bed would move or slide when force was applied to it, and she stated, I pushed on it and it moved a little, also it could have been the air mattress that she slid on. After that incident I had the whole bed replaced with a standard bed. She didn't need that bed anyway, she didn't have any wounds. When queried if any of the wheel locks were broken that may have caused the bed to slide, the ADON indicated she only noticed the bed having one wheel lock, but wasn't sure if that's the way it came from the contract company. R#504: The clinical record for R#504 was reviewed and revealed the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Per review of the resident's significant change MDS assessment dated [DATE], it was documented the resident scored 6 out of 15 on a BIMS exam, which indicated the resident was severely cognitively impaired. Review of previous MDS assessments for R#504 revealed the resident scored 6 out of 15 on a BIMS assessment dated [DATE], and scored 5 out of 15 on a BIMS assessment dated [DATE]. Both assessments also indicated the resident was severely cognitively impaired. Review of an I/A report for R#504 dated 8/11/19 at 12:15AM revealed the resident had sustained an unobserved fall in the resident's room, and it was documented the resident had been alert prior to the incident. Per the Brief Description section of the form it was documented, Cena (Certified Nursing Assistant) found resident sitting on the floor Next to bed. Resident stated I was reaching for a letter and fell out the bed. Per the I/A it was noted that the resident did not sustain injury from the fall. Review of an investigation report attached to the I/A documented toileting before and after meals, bed in lowest position, using the call light for assistance, and a gait belt as the care planned interventions prior to the resident's fall. Review of an unsigned witness statement dated 8/11/19 at 12:30 for R#504 documented, I capture (R#504) on the floor facing upright position while doing my hourly rounds. I <sic> immediately asked How she <sic> failed and she told me that she wouldn't hardly remember but, she know that she hit her head and she both sides of her leg was hurting. So, I <sic> immediately call the nurse in to <sic> lifeted her up from the floor. R#504 was noted to have a fall risk evaluation completed for the date of 8/11/19. Review of a nurses' note for 8/11/19 at 7:56AM documented, in part, the following: .resident stated that she hit her head on bed mattress . Review of an I/A report for R#504 dated 8/14/19 at 5:45PM documented the resident sustained [REDACTED]. The Brief Description section of the form documented, Resident observed <sic> 0 sitting on floor. Resident slid out of chair .attempting to reach for something. Per the form, it was documented the resident had not sustained injury. Review of an investigation report pertaining to the resident's fall documented the place of of occurrence as the resident's room (not the hallway as per the I/A), and documented, Resident was observed sitting on floor by wheelchair. Interventions prior to the resident's fall were documented as encouraging rest periods, utilizing a gait belt for transfers, and offering toileting before and after meals. Per the Environmental factors section of the form it was documented, Reaching .for something far away. It was documented the resident had last been seen 1 minute ago and the resident's explanation had been .states she was trying to go home. The following was documented per the result of the investigation: Resident was observed sitting on floor next to wheelchair. Fall was unwitnessed. Resident state that she slid out of her wheelchair .The initial root cause of the resident's fall was documented as Resident is confused. It was documented that an anti-slip device was to be added to the resident's wheelchair. R#504 was not noted to have a fall risk evaluation completed for the resident's fall on 8/14/19. Per an I/A report for R#504 dated 9/4/19 at 2:30AM it was documented the resident sustained [REDACTED]. The Brief Description documented, Cena observed resident on Floor near bed during walking rounds. CENA immediately called for Nurse. Resident was assessed. Vitals were taken and resident was put back in bed. Bed was in lowest position. Injuries pertaining to the fall indicated the resident had a head injury and hematoma/bruise. Care planned interventions prior to the resident's fall documented , Bed in lowest position. The resident's explanation of the event documented, At first resident didn't remember how she fell later resident stated I was trying to get up. Immediate interventions implemented documented, Assessed Resident Neuro checks done, vitals measured, Ice pack on hematoma. The investigation documented the resident sustained [REDACTED]. Review of the results of the investigation documented, Resident states she was trying to get up out of bed but did not know where she was going. Resident was last seen for 115 (1:15)am by the CNA (Name Redacted) and she was sleeping in her bed. At 0230 (2:30AM) resident was observed on the floor next to her bed. She had struck her forehead (L side) on the floor and sustained a hematoma. Resident was ordered to transfer to ER (emergency room ) for evaluation r/t (related to) head trauma. It was also documented, Call light was not in use. Careplan-fall mat to left side of bed. R#504 was not noted to have a fall risk evaluation completed for the fall on 9/4/19. Review of a NP/PA (Nurse Practitioner/Physician Assistant) Progress Note dated 9/5/19 at 12:35PM documented, in part, Reason for visit: [NAME] & M s/p (status [REDACTED]. Review of an Orders-Administration Note dated 9/7/19 at 2:51AM documented, sent out to Hospital due to fall. Per a Orders-General Note from eRecord note dated 9/7/19 at 7:01AM it was documented, Resident fell during HS (evening) care during shift. The CNA (Certified Nursing Assistant) assigned to her reported to writer that during <sic> car resident attempting to self transfer from wheel chair while her back was turned. Resident appeared to hit head during fall as evident by a hematoma at the base of her head. Resident was sent to (Hospital Name Redacted) and returned before the end of shift @ approximately 7am. No Orders noted at this time. An I/A/Investigation was not received by the facility pertaining to the resident's fall that was documented on 9/7/19. Also, assessments were not observed in the resident's clinical record to provide further description of the resident's fall documented on 9/7/19, to assess/update the resident's fall risk, to indicate who was notified of the resident's fall and what time notifications had been completed, or to indicate additional interventions for R#504's plan of care. Review of an I/A report for R#504 dated 9/15/19 at 1:00AM documented the resident sustained [REDACTED]. The Brief Description section of the I/A form had been left blank. Per the investigation report it was documented, Resident found on floor next to bed laying on mat.The resident's description of the event documented, too much to even try to explain. The section of the form to document care planned interventions prior to the resident's fall was observed to have been left blank. Also per the form it was documented, Resident stated she rolled out of bed while adjusting her blankets-new intervention <sic> enuse blankets are not tucked into mattress while in bed. Review of the Results of Investigation section of the form documented, Resident interviewed by writer and (Name Redacted) on 9/16/19 R/t (related to) fall. Resident stated she was too warm while sleeping and was attempting to remove the covers when she became tangled and fell out of bed. No injury was sustained. Floor mat at bedside Review of R#504's fall risk evaluation scores revealed the resident was given the same numerical fall risk score on 8/11/19 and 9/16/19, although the resident's clinical record documented the resident had fallen on 8/11/19, 8/14/19, 9/4/19, 9/7/19, and 9/15/19. Review of a plan of care for R#504 dated 6/15/18 and revised on 10/3/19 documented, (R#504) is at risk for falls related to: Acute Process, Balance deficits, Pain, left AKA (above-the-knee amputation). The following interventions were included in R#504's plan of care: -anti slip cover to residents wheelchair (date initiated 8/20/19) -Anticipate and meet the residents needs (date initiated 6/18/19, revised 3/25/19) -Bed in lowest position when not providing care (date initiated 6/19/18) -Encourage rest periods as needed to avoid overtiring (date initiated 6/19/18) -Ensure blankets are not tucked into the bed while resident is in the bed (date initiated 9/16/19) -Offer toileting before and after meals and at bedtime (date initiated 11/30/18) -Provide activities of interest (date initiated 6/19/18) -Resident has a grabber (8/12/19) -Use gait belt for transfers/walking (6/19/18) -Floor mat applied to left side of bed to reduce risk of serious injury (date initiated/revised 9/18/19) On 11/6/19 at approximately 3:45PM, the facility's Director of Nursing (DON) and Corporate Nurse Consultant were queried in regard to the process to follow after a resident had a fall. It was explained, in part, that the nurse in charge or a witness would do an I/A, statements could be taken, and the interdisciplinary (IDT) team/Unit Manager would do an investigation that day or the next morning. It was explained that the DON/Administrator would typically have the I/A report the next day, and it was acknowledged that every fall was to have an I/A completed. The IDT team would decide on new interventions that would be added to the resident's plan of care. It was also explained that the fall risk evaluation would be completed by the nurse right after the resident's fall, and that all falls were investigated. A review of a facility provided policy titled, Falls-Clinical Protocol reviewed/revised 6/2018 was conducted and read, .4. Interventions should be developed and implemented per the assessed needs. 5. In addition, interventions for direct care givers should be placed on the KARDEX (resident care guide) or similar format. 6. The care plan and KARDEX should be updated as interventions change .c. Once a fall occurs it is important to gather as much information as possible: .V. Staff present and responders, what did they see/hear .3. Update the plan of care with the new or revised interventions .2. Residents will be reviewed through Standards of Care at a determined time frame after new interventions are implemented to determine if effective or revision is necessary .If the individual continues to fall, the interdisciplinary team should re-evaluate the situation and consider other possible reasons for the resident's falling and will re-evaluate the continued relevance of current interventions. The facility was asked if they had any additional information to provide regarding the concern; none was received by the end of the survey.

This citation pertains to MI 2045 and MI 3223: Based on observation, interview, and record review the facility failed to promptly identify, assess, and implement treatment to areas of altered skin integrity, treat identified pressure ulcers per physician order, and prevent avoidable pressure ulcers for six (R#28, R#33, R#34, R#50, R#59, and R#78) of ten residents reviewed for pressure ulcers, resulting in the development of multiple stage three pressure ulcers (full thickness loss of skin in which subcutaneous fat may be visible .Slough (non-viable tissue) and/or eschar (dead/devitalized tissue) may be visible but does not obscure the depth of tissue loss). Findings include: Resident #34 A complaint was submitted to the State Agency which included concerns of a preventable worsening of a coccyx/sacrum pressure wound for R#34. On 6/10/19 at 8:52 AM, 3:09 PM, and 4:47 PM R#34 was observed in bed laying on his back with his eyes closed. On 6/11/19 at 8:17 AM, 10:37 AM, 1:30 PM and 2:33 PM R#34 was observed laying on his back with his eyes closed. R#34's clinical record was reviewed and revealed R#34 was admitted into the facility on [DATE] with a readmission date of [DATE]. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented R#34 to have total dependence on staff for all activities of daily living. A physician order [REDACTED]. A Skin assessment dated [DATE] revealed, Coccyx- small skin opening. A physician order [REDACTED]. On 3/21/19 at 12:13 PM a Dietary noted revealed .Resident is to be followed in S[NAME]-nutrition secondary to stage 3 pressure ulcer to the coccyx measuring 1.2cm x 0.9cm x 0.2cm (centimeter). On 3/28/2019 at 10:26 an S[NAME]-Skin progress note revealed, .Resident has a pressure Ulcer on his coccyx and has received a status of Not Healed. Subsequent wound encounter measurements are 1.6cm length x 0.8cm width x 0.01cm depth, with an area of 1.28 sq cm and a volume of 0.013 cubic cm. There is a small amount of sero-sanguineous (blood and fluid) drainage noted which has no odor. Wound bed has Pink Base [MEDICATION NAME], Minimal Yellow Slough slough . A 4/4/2019 S[NAME]-Skin progress note revealed, .Coccyx is Stage 3 Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 1.2 cm length x 0.7 cm width x 0.01 cm depth, with an area of 0.84 sq cm and volume of 0.008 cubic cm. There is a small amount of sero-sanguinous drainage with no odor. Wound bed has Pink Base [MEDICATION NAME] (new growth of tissue), Minimal Yellow Slough . On 6/11/19 at 2:01 PM Nurse Practitioner (NP) J was interviewed on the above findings and stated, If the nurses notice that a wound is worsening they can call me at any time. I am available 24 hrs a day and they can call me or a physician. On 6/12/19 at 2:56 PM the Director of Nursing (DON) was interviewed about expectations for staff if a wound was worsening and stated, They are expected to call us and the physician when a wound is worsening. A care plan for R#34 with a title of . at risk of additional impaired skin integrity r/t (related to) increase need with ADL's (activities of daily living), VDRF (ventilator dependent [MEDICAL CONDITION]), [MEDICAL CONDITION] and incontinence initiated 12/11/18 documented, . Follow facility policies/protocols for the prevention/treatment of [REDACTED].Report changes to licensed nurse immediately . Resident #59 On 6/11/19 at 10:31 AM R#59 was observed laying on his back in bed, with his bed positioned low to the floor. A flat gray mat was positioned next to the bed. R#59's [MEDICAL CONDITION] was observed, and gauze was in place at the resident's [MEDICAL CONDITION] site. On 6/12/19 at 1:48 PM observations were made of NP J's assessment. R#59's tracheosotomy wound was assessed and treatment was applied. R#59's clinical record was reviewed and revealed: A Nursing Admission Evaluation dated 4/26/19 documented, .patient has skin tear [MEDICAL CONDITION] about the size of a quarter . A note by the Respiratory Therapist on 4/26/19 documented, .Trach care completed, observed a quarter-sized round wound under lower left edge [MEDICAL CONDITION] (secures the tube in place), Nurse aware. Review of the R#59's (MONTH) 2019 physician orders [REDACTED]. A physician's orders [REDACTED]. wound cleanser apply calcium alginate daily and PRN (as needed) every 1 hours as needed for loose or soiled. A physician's orders [REDACTED]. wound cleanser apply calcium alginate daily and PRN one time a day for wound care. A review of R#59's clinical record, treatment administration record and progress notes revealed no treatment to R#59's [MEDICAL CONDITION] wound from admission on 4/26/19 to 5/9/19. On 5/23/19 at 11:32 AM a S[NAME]-Skin note from R#59's clinical record documented, (Resident name redacted) was admitted with a wound., Wound #1 Peri-Trach is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 2cm length x 1.5cm width x 0.2cm depth, with an area of 3 sq cm and a volume of 0.6 cubic cm. There is a small amount of sero-sanguineous drainage noted which has no odor. Wound bed has Pink Base [MEDICATION NAME], Minimal Yellow Slough slough . R#59's clinical record was reviewed and revealed R#59 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS assessment dated [DATE] documented R#59 to have total dependence on staff for all activities of daily living. On 6/11/19 at 2:01 PM the NP J was asked if a resident was admitted into the facility and had not yet been seen by the physician and staff found a wound on their assessment, what should staff do? NP J stated, If a new resident is admitted into the facility with skin issues they can contact me or the primary physician for orders and then we will see the resident when we come. On 6/12/19 at 2:52 PM the DON was informed of the above findings and was asked if a resident was admitted into the facility and had not yet been seen by the physician and staff found a wound on their assessment, what should staff do? The DON stated, Staff should call the physician to initiate an order. A care plan titled . has skin impairment to the peritrach area Stage 3 pressure ulcer r/t immobility [MEDICAL CONDITION]. initiated on 4/26/19, documented . Monitor/document location, size and treatment of [REDACTED].Treatments as ordered . The DON was asked to provide any further documentation that the facility may have regarding the above and none was provided by the exit of survey. R#78 On 6/10/19 at 8:25 A.M. and 10:45 A.M., R#78 was observed lying on his back. R#78's legs appeared contracted and were bent over to the left side and knees were bent making direct contact with the mattress. R#78 was receiving nutrition via a Percutaneous Endoscopic Gastrostomy tube (PEG - a tube surgically placed into the stomach to provide nutrition) and had a [MEDICAL CONDITION] R#78's eyes were closed and he did not respond when spoken to. On 6/10/19 at 12:29 P.M., R#78 was observed positioned on his left side facing the door of the room. On 6/10/19 at 3:52 PM the resident remained positioned on his left side. On 6/11/19 at 8:23 A.M., R#78 was positioned on his left side. A review of R#78's clinical record revealed the following: R#78 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS assessment dated [DATE] revealed R#78 had severely impaired cognition, was totally dependent on staff for transfers and bed mobility, and had a stage 3 pressure ulcer present on admission and a stage 4 pressure ulcer not present on admission. An admission MDS assessment dated [DATE] revealed R#78 had one unstageable (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer upon admission on 11/2/18. On 6/12/19 at approximately 10:30 A.M., R#78 was observed lying on his left side. R#78's legs and feet were making direct contact with the mattress and each other. An undressed open area was observed on the bony prominence of R#78's right outer ankle. Nurse P, with the assistance of the DON rolled R#78 to the right side to reposition into the mechanical lift sling. An adhesive dressing dated 6/11/19 was observed on R#78's left outer ankle. Nurse P placed three pillows underneath the bony prominence of R#78's feet and legs elevating them off of the mattress and each other. Nurse P reported that R#78 should have pillows placed for positioning at all times. On 6/12/19 at approximately 1:00 P.M., the DON was queried about the open area observed on R#78's right outer ankle during the above observation. The DON later provided a wound consult and documentation that revealed the open area to R#78's right outer ankle was present upon admission to the facility on [DATE]. The DON reported there was a physician ordered treatment for [REDACTED].>Further review of R#78's clinical record (physician's orders [REDACTED]. Pat dry. Apply Honey Gel (an antibacterial wound treatment) as directed to left lateral ankle. Skin barrier wipe to peri wound. Cover with foam dressing. A second physician's orders [REDACTED]. Apply Hydrogel as directed to R lateral ankle. Skin barrier wipe to peri wound. Cover with foam dressing. In the afternoon. R#78's TAR for (MONTH) 2019 was reviewed and the treatment to the right ankle was signed off as administered on 6/11/19. However, no dressing was observed to R#78's right ankle as of 6/12/19 at 10:30AM. On 6/12/19 at 5:25 P.M., the DON was interviewed. When queried about the dressing observed on R#78's left outer ankle, the DON reviewed R#78's clinical record and reported that it was a new wound to R#78's left ankle that was identified on 6/11/19. The DON provided a wound consult completed by the contracted wound care NP dated 6/11/19 that documented the following: .Patient has decreased activity levels .The patient demonstrates contractures to right lower extremity. The patient demonstrated contractures to left lower extremity .Left, Lateral Ankle is a Stage 3 Pressure Injury Pressure Ulcer .measurements are 1.5cm length x 1cm width x 0.01cm depth .There is a small amount of sero-sanguineous drainage noted .Wound bed has Yellow Necrotic Base [MEDICATION NAME] .Right, Lateral Ankle is a Stage 3 Pressure Injury Pressure Ulcer .0.7cm length x 0.6cm width x 0.01cm depth . There was no documentation in R#78's clinical record to indicate the pressure ulcer on R#78's left ankle was identified by the facility prior to the wound consult on 6/11/19. A Skin assessment dated [DATE] did not document any skin abnormalities to R#78's left ankle. Resident #50: On 6/11/19 at 1:10 PM R#50 was observed in bed, and NP 'J' was observed to assess R#50's wounds, including a wound to the resident's [MEDICAL CONDITION] area. Review of the clinical record for R#50 revealed the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Per review of the resident's quarterly MDS assessment dated [DATE], it was documented the resident scored 13 out of 15 on a brief interview for mental status (BIMS) exam, which indicated the resident was cognitively intact. Also per this assessment it was documented R#50 was at risk for developing pressure ulcers, and had two stage three pressure ulcers not present on the resident's admission, entry, or re-entry to the facility. Review of skin assessments, progress notes, and the resident's Medication Administration Record [REDACTED] Per R#50's MAR for (MONTH) 2019 it was documented R#50's stoma site and area under the resident's [MEDICAL CONDITION] collar was being assessed every shift for every day of the month (April 1-30, 2019). Review of the resident's TAR revealed the following was started on 4/10/19: Cleanse wound [MEDICAL CONDITION] apply (Brand Name Dressing) and cover with gauze one time a day for wound care. Per the resident's TAR, the first date the treatment had been administered was 4/12/19. Skin assessments dated 4/11/19 and 4/18/19 documented the following: 4/11/19 (Lock date of assessment 4/12/19): 1. Are there any new abnormal skin areas? A response of Yes was selected. New abnormal skin areas documented the following: Left buttock open area 1.8 x 0.6. Existing abnormal skin areas documented left arm bruising. 4/18/19 (Lock date of assessment 4/19/19): 1. Are there any new abnormal skin areas? A response of No was selected. Existing abnormal skin areas documented the following: Generalized bruising, Right buttock pressure, Coccyx excoriation, Under trach-open area. Review of an S[NAME] Skin Note dated 4/18/19 at 2:05PM was not noted to document the presence of an open area under R#50's [MEDICAL CONDITION], nor address treatment to the area. Review of a progress note for R#50 dated 4/21/19 at 7:10AM documented the following: .Resident's wnd <sic> [MEDICAL CONDITION] appears to be getting larger in size. Noticeable dark areaon <sic> the wnd <sic> with some beige and beefy red areas. Wound consult ordered Review of a respiratory note dated 4/21/19 at 8:03PM documented the following: Stoma care done and Resident has a small reddish black ulceration on right side of stoma under [MEDICAL CONDITION] . Review of a respiratory note dated 4/24/19 at 8:13PM documented, Resident has a small ulceraation <sic> on stoma located under trac <sic. phange on the rigt <sic> side . Skin Assessment: 4/25/19 (Lock date of assessment 5/1/19): 1. Are there any new abnormal skin areas? A response of No was selected. Existing abnormal skin areas documented the following: Under trach-open area, generalized bruising, Right buttock pressure, coccyx excoriation. Review of a Nutrition/Hydration S[NAME] note dated 4/25/19 at 11:33AM documented, .stage 3 pressure ulcer to the peri-trach measuring 1.5cmx2.1cmx0.01cm (centimeter) . Review of an S[NAME] Skin Note dated 4/25/19 at 11:37AM did not reveal measurements of the resident's peri-trach wound, however did address treatment to the wound. Review of a respiratory note dated 4/26/19 at 7:35PM documented, .Wound near stoma. Nurse notified . Review of a respiratory note dated 4/29/19 at 9:20PM documented, Stoma care done and revealed a med size ulceraiation <sic> on the right side of stoma [MEDICAL CONDITION]. Ulceration oozing with pale yellow exudate and was cleansed . Review of a visit report note by the facility's wound care provider dated 6/11/19 documented, in part, the following: Wound #3 Peri-Trach is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 0.5 cm length x 1cm width x 0.2cm depth, with an area of 0.5 sq cm and a volume of 0.1 cubic cm. There is a small amount of sero-sanguineous drainage noted which has no odor. Wound bed has Pink Base [MEDICATION NAME]. The wound is improving . Per a plan of care for R#50 initiated on 5/16/19 the following was documented: (R#50) has stage . pressure ulcer on coccyx (stage 3) and his Peri-trach (stage 3) r/t disease process and decreased mobility. Interventions (dated 4/18/19) included, in part, the following: Daily skin evaluations by licensed nurse if current pressure ulcer (see TAR) .Monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size (length x width x depth), stage . R#33 On 6/10/19 at 8:42 AM, R#33 was observed lying in bed, positioned on their back. R#33 appeared to be awake and alert, but did not respond to questions asked. On 6/10/19 at approximately 1:30 PM, R#33 was observed lying in bed, positioned on their back. On 6/11/19 at approximately 10:00 AM, R#33 was observed lying in bed, positioned on their back. On 6/12/19 at 9:45 AM and at 1:46 PM, R#33 was observed lying in bed, positioned on their back. Review of R#33's clinical record revealed R#33 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the most recent comprehensive MDS assessment dated [DATE], R#33 had severely impaired cognition. The MDS assessment also indicated R#33 was totally dependent on staff for all ADLs, including bed mobility. The Admission MDS dated [DATE] indicated R#33 did not have any pressure ulcers. Review of a skin assessment for R#33 dated 4/16/19 indicated Yes for new abnormal skin areas. The site was listed as Right heel. The description read, Wound (pressure) treatment in place. Review of R#33's care plan revised 4/25/19 read in part, The resident has an acquired, Stage 3, pressure ulcer/injury to his right heel. The care plan was revised 5/16/19 to read in part, (R#33) has a Stage 3 pressure ulcer/injury to his right heel. Review of progress notes for R#33 revealed a S[NAME]-Skin note dated 4/25/19 that read in part, (R#33) has a Right Heel wound. It is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 1.6cm length x 1.4cm width x 0.2cm depth . Contributing deficits: decreased mobility, muscle weakness . A S[NAME]-Skin progress note dated 5/16/19 read in part, Right Heel is a Stage 3 Pressre Injury Pressure Ulcer and has reeived a status of Not Healed. Subsequent wound encounter measurements are 0.2cm length x 0.2cm width x 0.01cm depth . A S[NAME]-Skin progress note dated 5/23/19 read in part, (R#33) has a stage 3 pressure ulcer to the right heel measureing 1.2cm x 1.6cm x 0.2cm . A S[NAME]-Skin progress note dated 5/30/19 read in part, (R#33) has a stage 3 presssure ulcer to the right heel measuring 1.6cm x 1.9cm x 0.2cm . On 6/11/19 at 3:10 PM, wound care was observed to R#33's right heel. R#33 was observed lying in bed, positioned on their back. NP 'J' measured the wound as 1.2 cm x 1.4 cm x 0.3 cm. NP 'J' was asked if the wound to R#33's right heel was facility acquired. NP 'J' stated, Yes, it is facility acquired. On 6/12/19 at approximately 11:00 AM, the DON was interviewed and queried about how new wounds should be reported by nurses. The DON indicated that the nurse should inform the doctor and the DON of any new wound so treatment could be started. Resident #28: On 6/11/19 at approximately 2:58 PM, R#28 was observed in bed. NP 'J' was observed to assess R#28's wound. Licensed Practical Nurse (LPN) 'I' was observed to be present at this time. Review of a physician ordered treatment for [REDACTED]. Pat dry. Apply (Brand Name Ointment) to 4x4 and apply to wound bed. Skin barrier wipe to peri wound. Cover with border foam. AND Apply to Sacrum/left buttocks topically as needed for wound care. On 6/11/19 at approximately 3:09PM, a wound care observation was conducted with LPN 'I'. LPN 'I' was observed to apply cleanser to gauze, and was observed to cleanse around the outer edges of the resident's wound. LPN 'I' was then observed to apply ointment to the outer edges of the resident's wound using cotton tipped applicators. LPN 'I' was not observed to clean or apply treatment to the bed of the resident's wound. At approximately 3:20PM, LPN 'I' applied a new dressing dated 6/11 to the area. Review of the clinical record for R#28 revealed the resident was admitted on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Per review of the resident's quarterly MDS assessment dated [DATE] it was revealed R#28 had an unhealed pressure ulcer, documented as a stage 3 wound not present on admission, entry, or re-entry to the facility. Review of a Visit Report from the facility's wound care provider dated 6/11/19 for R#28 documented, in part, the following: Wound #1 Sacrococcyx/ L (left) buttock is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 4cm length x 2.8 cm width x 0.7cm depth, with an area of 11.2 sq cm (square centimeters) and a Pink Base [MEDICATION NAME], Minimal Yellow Slough slough . Per the [DIAGNOSES REDACTED]. Treatment recommendations documented the following: (Brand Name Moisture Barrier Ointment) QD (daily) and PRN (as needed)-Periwound (Brand Name Debridement Ointment) DAILY AND PRN-To wound base. Review of the resident's plan of care dated 5/10/18 and revised on 5/23/18 documented the following: (R#28) is at risk for unavoidable pressure ulcer development (Sacrococcyx/ L buttock Stage 3 Pressure Ulcer) despite aggressive wound management and preventative measures r/t (related to) immobility and nutritional deficits s/t (secondary to) disease progression, Multiple comorbidities and multiple medications, Receiving TF (tube feeding) requiring HOB (head of bed) elevated which increases sacral pressure. (R#28) is incontinent of bowel. Per an intervention dated 6/11/18 the following was documented: Treatment as ordered by physician. On 6/11/19 at approximately 11:00AM the facility's DON was queried about the facility's wound care nurse, and explained that the staff member who had been the wound care nurse no longer worked at the facility. On 6/11/19 at 3:38 PM the facility's DON was queried in regard to the facility's wound program. The DON explained that he would receive wound notes from the nurse practitioner, would review the notes, and would make S[NAME] notes and input the information to the facility's electronic medical record system. The DON was queried as to when a resident would be referred by the wound nurse practitioner, and explained a consult would be requested if changes in skin were observed or could be requested on admission for evaluation and treatment. The DON was queried as to what staff were to do if they were to notice a new area on a resident's skin. The DON explained that a CNA could document in the facility's electronic medical record and could notify the nurse when they did a shower. The nurse could ask for a consult, and would notify the DON/unit manager so they could assess the wound. The DON was queried in regard to the reason for development of peri-trach wounds at the facility, and the DON did not provide a reason as to why residents had developed peri-trach wounds. On 6/12/19 at 3:06 PM Respiratory Therapy Director (RTD) 'K' was queried about the presence of [MEDICAL CONDITION] wounds. RTD 'K' explained that [MEDICAL CONDITION] wounds would be followed by nursing for wound care, and respiratory therapy (RT) would follow the residents for [MEDICAL CONDITION] care. RTD 'K' explained that [MEDICAL CONDITION] care would be provided twice in a twenty-four hour period and as needed for every resident with a [MEDICAL CONDITION]. RTD 'K' explained, in part, that if RT were to notice a wound, RT may measure and put it in a note. Per RTD'K', staff should make a note that there was a wound present, and once they saw a wound they would notify the nurse, and make RTD 'K' aware as well. RTD'K' explained that she would follow up with the nurse as well. Review of a facility policy titled, Pressure Ulcers/Pressure Injury Prevention and Treatment-Clinical Protocol with a revision date of 11/28/17 revealed the following: Based on the comprehensive assessment of a resident, a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develp pressure ulcers unless the resident's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection, and precent new ulcers from developing. Also per the policy was the following: 9. Change of condition/New skin alteration: a. complete head to toe skin assessment, document in the medical record; b. Notify physician; c. Obtain new orders as needed; d. Notify the Resident and Resident's Representative of all new and/or non-healing/worsening PU/PIs (pressure ulcer/pressure injuries) e. Complete new (Redacted) scale; f. Refer to Registered Dietician as needed; g. Update plan of care to reflect any new risks, goals, and interventions; h. Initiate significant change MDS as indicated. Per the Treatment/Management section of the policy the following was documented: With each dressing change, or at least weekly (and more often when indicated by wound complications or changes in wound characteristics), an evaluation of the PU/PI(s) be documented. At a minimum, documentation should include the date observed, location, staging, size (perpindicular measurements of the greatest extent of length and width of the PU/PI), depth; and the presence, location and extent of any undermining or tunneling/sinus tract; exudate, if present; type (such as purulent/serous), color, odor, and approximate amount; Pain, if present; nature and frequency (e.g., whether episodic or continuous); Wound bed: Color and type of tissue/character including evidence of healing (e.g., granulation tissue), or necrosis (slough or escar); and description of the wound edges and surrounding tissue (e.g., rolled edges, redness, hardness/induration, maceration) as appropriate.

This citation pertains to intake #MI 1 Based on observation, interview, and record review, the facility failed to attach a head board and foot board to the bed intended for resident safety from falls for one resident (R#701), who was at risk for, and had a history of [REDACTED]. Findings include: On 2/7/19 at 11:47 AM, R#701 was observed in bed in their room. R#701 was not responsive to attempts at verbal communication. At that time Certified Nursing Assistant (CNA) 'D' was observed providing care to R#701. R#701's back was observed at that time with CNA 'D' and three adhesive foam dressings were observed on R#701's right back, scapula, and shoulder. A review of R#701's progress notes was conducted and revealed the following notes: 1/31/2019-S[NAME] (standards of care) - Late Entry: Explain area(s) .: Wound #1 Left [MEDICATION NAME] spine measures 7cm (centimeter) X4cmX 0.01 there is a moderate amount of sero-sanguineous drainage noted. Wound bed has pink base [MEDICATION NAME], minimal yellow slough. Periwound is intact. Wound #2 is a fluid filled blister on the [MEDICATION NAME] spine, 4cmX 2.2cm the periwound is intact. Wound #3 is two fluid filled blisters on the Right [MEDICATION NAME] spine. Measuring 2cmX 0.6cm the periwound is in tact. 2/5/2019- S[NAME]-Fall New Fall/Follow-Up: Follow up to fall on 1/27/19 Situation .Resident was observed on floor by staff between HOB (head of bed) and wall. Injury/No injury: yes-a burn to the upper left side of back, a blister on mid back with redness on left and right side of back. (3 blister) .Analysis of interventions to implement: Head board was missing from bed, head board replaced. Radiator was missing a cover, cover replaced . A review of a facility provided investigation file for a fall R#701 sustained on 1/27/19 was conducted. The file contained an untitled facility form dated 1/27/19 at 11:15 PM, completed by Licensed Practical Nurse (LPN) 'C' that documented .Brief Description: Writer was made aware by CNA that Pt (patient) was found laying between head of bed and was against vent .Injury type: Burn . A review of a form titled Quality Assessment and Assurance Investigation in the file, also completed by LPN 'C' documented, .6. Provide a brief objective of the alleged incident: Pt observed side lying on the floor between the head of the bed and the wall .Environmental Factors: No headboard on bed, no cover on vent . Continued review of the Quality Assessment and Assurance Investigation document indicated R#701 had sustained burn injuries and a blister to their back. Section 14 of the form read, .Results of Investigation: Resident wiggled off head of bed landing on floor, leaning against heater knocking off heater cover. 2 areas on upper back burned .head board foot board replaced . The file was also noted to contain a form titled Fall Investigation Report which included a sketch of the resident's room set-up. The sketch demonstrated that R#701's left side of the bed was against the left wall and the head of the bed was perpendicular to the intersecting wall that contained the vent style heating unit. The sketch further demonstrated that R#701 had been found having rolled off the perpendicular head area of the bed and was found lying parallel to wall that contained the heating vent. In the section of the Fall Investigation Report that identified Factors observed at time of fall, LPN 'C' documented, Pt moved up to top of bed and fall <sic> between hob (head of bed) and wall no headboard in place . A review of the ROOT CAUSE OF THIS FALL section of the report contained a box with a check mark that read, Environmental factors/items out of reach. The response documented by LPN 'C' for the section reading What appears to be the initial root cause(s) of the fall? read, No headboard. A review of R#701's clinical record was conducted and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. R#701's most recent completed Minimum Data Set (MDS) assessment dated [DATE] indicated R#701 was severely cognitively impaired and required extensive to total assistance of one to two staff members for all activities of daily living. Continued review of R#701's record indicated R#701 had a history of [REDACTED].#701) is at high risk for falls r/t (related to) impaired mobility, intracranial injury, [MEDICAL CONDITIONS] disorder, poor trunk strength . On 2/17/19 at 1:10 PM, a review of the room where R#701 had rolled out of bed was conducted. The room revealed that a vent style heating unit ran along the wall approximately 8 inches above the floor. The metal vents that covered the heating parts of the unit were attached to the wall and the vent cover section that ran to the corner of the intersecting wall was not observed to be attached to the wall, but had fallen to the floor. The vents were observed to be radiating heat and when touched felt very warm. On 2/7/19 at 1:25 PM, an interview with the facility's Director of Nursing (DON) was conducted regarding R#701's fall out of bed resulting in burns. The DON was asked to summarize the incident and stated, She somehow wiggled to the head of the bed and rolled off between the head of the bed and the vent. When she fell , it knocked the vent cover off and she was burned by the hot pipes, she didn't have a headboard on the bed at that time. The DON was queried about the missing headboard on R#701's bed at the time of the fall and stated, In (MONTH) someone switched out her mattress for a concave mattress and it was to long for the bed so they removed the headboard and the footboard to fit the mattress. When queried if R#701's bed was changed out after the fall, The DON stated, The headboard was replaced the next morning when maintenance got here. When further queried how it was possible R#701 rolled off the top of the bed that was perpendicular to the heater vent and was found parallel against the hot heater vent that ran along the wall, the DON stated, It's a mystery, she does have a history of convulsions and movements. On 2/7/19 at 2:02 PM, a phone call was placed to LPN 'C' for an attempt at an interview, a voicemail was left, however; the phone call was not returned. On 2/7/19 at 2:04 PM, a phone call was placed to CNA 'D' for an attempt at an interview, a voicemail was left, however; the phone call was not returned. On 2/7/19 at 3:20 PM, an observation of [MEDICAL CONDITION] R#701's back was conducted with LPN 'I'. It was noted that R#701 had darkly pigmented skin and the burn on R#701's right upper back/shoulder area was observed to be round with irregular edges measuring approximately 7.5 cm x 5 cm. The irregular round wound appeared shiny and was bright pink/reddish at the edges turning white toward the center of the wound . The second wound toward R#701's right middle back was observed to be round with irregular edges measuring approximately 3.0 cm x 3 cm. The irregular round wound appeared shiny and was bright pink/reddish at the edges turning white toward the center of the wound. On 2/7/19 at 3:40 PM, an observation of the room where the fall occurred was conducted with the facility's DON and Corporate Nurse Consultant 'A'. They were queried about the corner section of the vent that was observed on the floor. Corporate Nurse Consultant 'A' indicated that maintenance would be contacted immediately to fix it. A review of an undated, facility provided policy titled, FEDERAL RIGHTS OF NURSING CENTER RESIDENTS was reviewed and read, The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility including those specified in this section .(i) Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment .including but not limited to receiving treatment and supports for daily living . The facility was asked if they had any additional information to provide regarding the concern; none was received by the end of the survey.

This citation pertains to intake #MI 949. Based on observation, interview and record review, the facility failed to ensure adequate supervision was implemented during a transfer for R#701 resulting in R#701 falling and sustaining multiple lacerations, a subdural hematoma (a collection of blood outside the brain) and subdural hemorrhaging which required surgical intervention (craniotomy -a surgical removal of part of the bone from the skull to expose the brain). Findings included: Resident #701 On [DATE] at 7:30 AM, review of a complaint filed with the State Agency included a concern that R#701 was with staff on [DATE] when he fell hitting his head on objects, was taken to the hospital where it was found he had bleeding on his brain, and after multiple surgeries was placed on hospice and passed away on [DATE]. On [DATE] at 11:30 AM, an interview was conducted with the Director of Nursing (DON). At that time, the DON reported, If I was family, I'd be concerned too. He had to go out a second time to get drained again (remove blood pooling in the brain) and then died . Review of R#701's fall incident investigation provided by the facility included, .Pt (patient) was to be transferred from bed to wheelchair. Pt sitting at the edge of bed. CNA (Certified Nursing Assistant) C advised that she told pt 'to lean one way and pt leaned the opposite way and slid off of bed .laceration on forehead and left eye .When was resident last seen 10:05 am, What were they doing Getting dressed by Aide .Pt states he fell and hit head on tray table stand next to bed . A hand-written note signed by CNA C and D read, [DATE] As we were sitting (R#701) up in the bed he began to rock and fall off of the bed. He hit his head on the bedside table. Review of R#701's second CT (Computed tomography is a diagnostic test that produces multiple images or pictures inside of the body) of the head performed at the local hospital dated [DATE] included: .Findings: Extra-axial spaces: Redemonstration of a hyperdense subdural collection along the right cerebral convexity overlying the frontal, parietal, and temporal lobes, with extension into the right sylvan fissure and small component along the anterior falx .There is interval decrease in size of the subdural collection which now measures 11 mm (millimeters) in greatest dimension .Midline shift: Interval improvement of leftward midline shift now measuring 5 mm (previously 18 mm) .Subdural hematoma status [REDACTED]. Postsurgical changes consistent with interval right craniotomy and subdural drain placement with interval decrease in size of right subdural hematoma .2. Pneumocephalus (presence of air or gas within the cranial cavity), predominately along the frontal convexity bilaterally, likely secondary to #1 . Review of R#701's care plans included: Safety: (R#701) is at risk for falls r/t (related to) Confusion, Gait/balance problems and unawareness of safty <sic> needs Date initiated: [DATE], Revision on: [DATE]. Interventions added [DATE] and revised [DATE] included: Provide 2 staff extensive assistance for Transfers and Provide 2 staff total assistance for bed mobility. Review of the Kardex (guide to nursing staff on the specific care needs of the resident) documented the same approaches as mentioned above on the care plan regarding two staff for transfers and bed mobility. Review of the Transfer Safety Evaluation assessment dated [DATE] included, .Ability to sit on edge of bed .Can the resident maintain sitting with little or no help? No (was marked with a dot) .Interventions: Transfer the Resident requires Mechanical Lift (Hoyer) with 2 or more staff assist for transfers . There was no further transfer safety evaluation assessment completed until [DATE] (following the fall with serious injuries). Further review of the clinical record revealed R#701 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the annual Minimum Data Set (MDS) assessment dated [DATE], R#701 scored an ,[DATE] on brief interview for mental status (BIMS) exam which indicated moderately impaired cognition, required extensive assistance with bed mobility and transfers, and had a fall since prior assessment with an injury. On [DATE] at 12:00 PM, an interview was completed with Licensed Practical Nurse (LPN B) who confirmed she was the nurse who completed the fall report for R#701 on [DATE] and was the nurse who responded and treated R#701 following the fall. When asked to recall the events, LPN B reported, That day I was at my cart passing meds. Two aides (CNA C and CNA D) were working together at the time. I believe CNA D said (R#701) was on the ground. He was lying still on his right side. There was a lot of blood. Had about four or five lacerations on face. Was able to get in bed and was responding well .According to the aides, CNA C said she was trying to put (R#701) in chair. He went the opposite way. Didn't have gait belt on or anything. He was like dead weight. Not sure if both aides were helping. I think she (CNA D) was making the bed. When asked if the resident required the use of a mechanical lift, LPN B stated, I seen him up by hoyer before. Not sure if that particular time he was one person or two person assist. He was able to tell me he hit his head on tray table next to him and his head was on the rolling part of that table. Afterwards they said he had brain bleeds . On [DATE] at 12:17 PM, a phone interview was conducted with CNA D. When asked to recall the events from R#701's fall on [DATE], CNA D reported, We were getting everyone ready. CNA C was right in front of him. He was seated on the edge of the bed and was rocking forward right and fell . She (CNA C was in front and I went to grab his shoes at the end of the bed and he went down. When asked if she could recall if he required one or two person assist with transfers and bed mobility, CNA D stated, That was my first time with him but someone told us he was a two person. When asked if anyone from Administration had provided any education or follow up following the fall with serious injury and CNA D reported, No. On [DATE] at 1:05 PM, a phone interview was conducted with CNA C. When asked to recall the events from R#701's fall on [DATE], CNA C reported, I was in the room helping (CNA D). (R#701) was seated on side of the bed and he layed forward and his his head on not sure tube feeding pole or oxygen. He was moving too fast and rocking. I was standing close to the front of him but he went to the opposite side. CNA D was not too far away from me. When asked if she could recall if he required one or two person assistance, CNA C stated, Usually I believe he was a two person. We had just started at the facility for about three weeks and tried to work together with every resident. On [DATE] at 1:35 PM, the DON was informed of the concerns regarding the lack of adequate supervision during transfer when CNA D left the resident with CNA C to grab shoes and the resident slipped forward falling and hitting his head on the tray table. The DON was unable to offer any further explanation in regards to the details of R#701's fall with serious injury. Review of the facility's Falls-Clinical Protocol policy dated (MONTH) (YEAR) documented: .Interventions should be developed and implemented per the assessed needs .The care plan and CNA Kardex in the electronic Health Record should be updated as interventions change .Update the plan of care with new or revised interventions .

This citation refers to Intake #MI 581 Based on observation, interview and record review the Facility failed to ensure an oversized television placed on a bedside dresser drawer was properly secured for one (#701) Resident out of two Residents reviewed for accidents/injuries out of a total sample of three, resulting in a television falling onto the Resident causing a fracture to the right ulna (arm), a hospital visit, pain and a reduction in the use of the right arm and hand. Findings include: On 5/21/18 the Facility reported to the State Agency that a television resting on the night stand next to Resident #701's bed fell on the Resident resulting in a hospital visit, fractured ulna and pain. On 7/9/18 at 3:30 PM Resident #701 was observed sitting in the dining room in a wheelchair. The Residents right arm was resting in a sling and wrapped in gauze from the fingers to above the right elbow. When queried as to what happened to the arm, Resident #701 reported that a television fell on him. Resident #701 stated, It really hurt. When queried as to how the incident occurred, Resident #701 stated, It just fell on me, I think someone knocked it over. Resident #701 was not able to recall how the television was knocked over, by whom or when the incident occurred. A review of Resident #701's clinical record was conducted on 7/10/18 at approximately 8:00 AM and documented that the Resident was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Resident's MDS (minimum data set) dated 4/13/18 indicated that the Resident had a BIMS (brief interview for mental status) score of 3/15 (cognitively impaired) and required two person assist for transfers and bed mobility. Continued review of Resident #701's clinical record revealed a progress note dated (5/15/18 ) and authored by Nurse D that documented, Note Text: Cena (certified nursing assistant) explained to writer that while answering a call light in (room number redacted) she accidentally bumped her hip into the tv set that was behind (room number redacted) curtain. The tv set landed on (number redacted) -Resident #701's rt (right) arm and hand .writer came to room and observed resident holding his rt. lower arm. Writer assessed the area .some slight swelling noted. Resident stated that pain 10/10 physician stated send Resident to Hospital .hand elevevated upon pillow while being transferred. A physician note dated 5/16/18 documented, in part, the following: .up after hospital visit s/p incident in the facility .awake and alert .pt c/o (complains of ) pain when area touch or when moved. cast in place .rt arm with cast and ace bandage . A Hospital (name redacted) discharge summary dated 5/16/18 documented, in part, This information is about your .injury ULNA shaft fracture .the ULNA is one of two bones in your forearm . A progress note dated 5/16/18 documented, Resident's television set repositioned away from the resident. Safely maintained. A review of an Incident and Accident Report (I & A) dated 5/16/18 documented, in part, the following: Date of Incident: 5/15/18 time: 11:04 PM .Location: Resident's room .Incident Type: Equipment . Brief description: CENA (certified nursing assistant) stated while in (room # redacted) answering the call light, her hip bumped (room # redacted) tv set and fell on his arm and hand (rt). On 7/09/18 at approximately 3:45 PM an interview was conducted with the Maintenance Director Staff E regarding the incident involving Resident #701. The interview took place in Resident #701's room. The television that fell on Resident #701 was observed sitting on the Resident's bedside dresser. Staff E reported that the TV was approximately 28 inch's and probably weighed 40-50 lbs. Staff E stated, One of our staff was able to obtain a number of televisions for residents from (name redacted). The televisions are older, not the current thin or flat screen type. Staff E reported that after the incident all the TV's similar to Resident #701's were glued down to the bedside dresser to ensure that they will not fall off the dresser. On 7/10/18 at approximately 11:06 AM a phone interview was conducted with CENA C. CENA C was queried as to the incident that led to Resident #701 sustaining a fractured ulna. CENA C reported that she had worked in the Facility for only a few weeks prior to the incident. CENA C stated, I worked the evening shift and was assigned to Resident #701 and his roommates. I had just changed Resident #701. I went to turn the light off for his roommate. Resident #701's curtain was pulled around his bed. When I went to turn the light off, I must have hit the television with my hip. I am a larger person. I picked up the television and saw that his arm was swollen and let the nurse know. When queried as to the placement of the television, CENA C stated, I'm really not sure where it was located, I assume on top the bedside dresser, I do know now that all the TVs are glued down. On 7/10/18 at approximately 9:00 AM an interview and record review was conducted with the Administrator. The Administrator reported that the incident was immediately reported and an investigation was started. The Administrator stated, It was just an accident. We worked with the maintenance department and secured our televisions. We in-serviced CENA C on safety concerns. On 7/11/18 at approximately 9:50 AM the Facility was asked to provide any Facility Policy(s) related to accidents and incidents. On 7/11/18 at 10:00 AM a review of the Facility Policy titled, Accidents and Incidents- Investigating and Reporting (revised 12/1/17) was conducted and documented, in part, the following:All accidents or incidents involving residents, employees occurring on our premises must be investigated and reported to the Administrator

This citation pertains to MI 471: Based on observation, interview, and record review the facility knowingly failed to provide wound care services as ordered by the physician to prevent the development and worsening of pressure ulcers for one resident (#903) of two residents reviewed for pressure ulcers from a total sample of three, resulting in a pressure ulcer worsening from a stage two pressure ulcer to an unstageable pressure ulcer, the potential for wound infection, and decline of health status. Findings include: On 11/2/17 at approximately 9:30am the clinical record for Resident #903 was reviewed and revealed the resident had been admitted into the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Per review of the resident's quarterly MDS assessment dated [DATE] the resident had severely impaired cognition, had two stage two pressure ulcers present on admission, two stage three pressure ulcers present on admission, one stage four pressure ulcer not present on admission, and one unstageable pressure ulcer not present on admission. On 11/2/17 at 10:48am Nurse 'B', who was the facility's wound care nurse, was observed to perform wound care to the pressure ulcer to Resident #903's left posterior lower leg. At this time Resident #903 was observed laying in his bed, and a dressing dated 10/30/17 was observed to the resident's left posterior lower leg. Post removal of the dressing, Nurse 'B' was queried in regards to the appearance of the resident's wound to the left posterior lower leg. Nurse 'B' responded and said that the wound was unstagable (full thickness where depth of the wound bed not able to be visualized related to slough/eschar). Upon observing the wound bed, Nurse 'B' responded, that is eschar (necrotic tissue). Nurse 'B' stated that the wound had been unstageable with slough, and now it had turned to eschar. Nurse 'B' was observed to redress the resident's wound, and the resident was observed to make moaning sounds. Nurse 'B' applied a new dressing to the resident's wound and applied a soft blue boot to the resident's left foot/lower leg. On 11/2/17 review of documentation pertaining to a facility reported incident for Resident #903 was reviewed and revealed, in part, that Resident #903 had a physician order [REDACTED]. Cleanse left posterior lower leg with wound cleanser. Pat dry. Apply (brand name dressing) to wound bed. Cover with Bordered foam. every day shift. Additional review of the facility reported incident documentation revealed the following: Per a performance improvement form dated 10/11/17 pertaining to Licensed Practical Nurse (LPN) 'C', the following was documented as the Reason for Counseling/Corrective Action: On 10/5 you documented that you administered a dressing to (Resident #903, name redacted) on his Left posterior lower leg. On 10/11 it was noted that the dressing on the left posterior lower leg was dated 10/4 with another nurse's initials. These treatments were falsely documented as administered. Per review of a performance improvement form dated 10/12/17 pertaining to LPN 'D', the following was documented as the Reason for Counseling/Corrective Action: On 10/6, 10/7, and 10/8 you documented that you administered a dressing to (Resident #903, name redacted) on his left posterior leg. On 10/11 it was noted that the dressing on the left posterior leg was dated 10/4 with another nurse's initials. These treatments were falsely documented as administered. Per review of a performance improvement form dated 10/16/17 pertaining to LPN 'E', the following, in part, was documented as the Reason for Counseling/Corrective Action: On 10/9 and 10/10 you documented that you administered a dressing to (Resident #903, name redacted) on his Left medial knee, Left buttock, Right medial knee, Left posterior lower leg, and Right greater trochanter. On 10/11 it was noted that the dressing present on the left medial knee and right greater trochanter was dated 10/8/17 with another nurse's initials. There were no dressings on the left buttock or right medal knee. The dressing on the left posterior lower leg was dated 10/4 with another nurse's initials. Also per the performance improvement form was the following: These treatments were falsely documented as administered. On 11/2/17 at 2:30pm further review of the resident's clinical record revealed, in part, the following: Review of a S(NAME) Skin note dated 10/2/17 documented that Resident #903 had a stage two pressure ulcer to the left posterior leg which measured 2.0cm (centimeter) x1.0cm x0.1cm. Per a S(NAME)-Nutrition/Hydration Note dated 10/5/17 the following was documented: .Wounds are left leg is declining. Review of a S(NAME) Skin note dated 10/9/17 authored by Nurse 'B' revealed, in part, that Resident #903 had a stage two pressure ulcer to the Left posterior leg which measured 4.7 x 1.8x 0.1cm. Additional review of the resident's clinical record revealed a Wound Consultation form dated 10/19/17 which documented, in part, that the resident had an unstageable pressure ulcer to the left posterior leg. Review of a S(NAME) Skin note dated 10/23/17 revealed the resident had an unstagable pressure ulcer to the left posterior lower leg which measured 3.3cm x0.8cm x UTD (unable to determine). At this time, slough was also noted to the wound base. On 11/2/17 at approximately 2:40pm review of Resident #903's pressure ulcer scale evaluations for 9/25/17, 10/2/17, and 10/9/17 revealed that Resident #903 had been identified as being at high risk for pressure ulcer development on all three assessments. On 11/2/17 at 2:50pm review of a careplan for Resident #903 dated 6/2/17 and revised on 9/1/17 revealed, in part, that Resident #903 had pressure ulcer development to the sacrum and left sacrum related to dehydration, immobility, and nutritional deficits. This careplan also identified Resident #903 as being at risk for further skin breakdown. Per a careplan intervention dated 6/2/17, the following was documented: Administer treatments as ordered and evaluate for effectiveness. On 11/2/17 at 4:48pm Nurse 'B' was queried regarding who was responsible for completion of woundcare at the facility. Nurse 'B' stated that she completed rounds weekly with the facility's wound doctor, and said that the remainder of treatments were completed by the floor nurses. When queried as to whether she was aware of concerns related to wound treatments for Resident #903, she stated that she was aware of the facility reported incident. On 11/3/17 at approximately 10:16am an interview was conducted with the facility's Director of Nursing (DON). At this time, the DON stated that treatments that had been charted as completed for the resident that had not been done. The DON said that education had been done as staff had not followed facility policy and procedure. On 11/3/17 at 11:20am a facility policy titled Wound Care dated 3/23/11 was reviewed and revealed, in part, the following: Documentation: The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing wound care. 5. Any change in the resident's condition. 6. All assessment data (i.e., wound bed color, size, drainage, etc) obtained hen inspecting the wound. 7. How the resident tolerated the procedure. 8. Any problems or complaints made by the resident related to the procedure. 9. If the resident refused the treatment and the reason(s) why. 10. The signature and title of the person recording the data.

This citation refers to Intake # MI 232. Based on interview and record review, the facility failed to prevent the worsening of a pressure wound for one sampled resident (#607) out of 2 residents reviewed for wound care resulting in infection of the wound with hospitalization . Findings include: Resident #607 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident #607 had a Brief Interview for Mental Status (BIMS) score of 3 of 15 points which indicated severe cognitive impairment. At the time of the survey, Resident #607 was no living at the facility. On 10/3/17 at 2:00 PM, a record review of the progress notes indicated the following information: 8/1/17 - Small open area on sacrum on admission. 8/2/17 - Stage 2 wound to coccyx. Measurement - 4.1 x 1.0 x 0.1 cm (centimeter) 8/3/17 - Wounds are new with admission per wound care nurse. 8/10/17 - Stage 2 to coccyx. Measurement 2.1 0.4 x 0.1 cm. 8/17/17 - Stage 3 to coccyx. Measurement 4.0 x 2.1 x 0.1 cm. Granulated base. 8/25/17 - Stage 3 to coccyx. Measurement 3.2 x 1.7 x 0.1 cm. Granulated base. 9/12/17 - Director of Nursing (DON) charted: resident had a decline in coccyx wound, treatment for [REDACTED]. 9/22/17 - Sacral (coccyx) wound infection. To be debrided on 10/2/17. 9/24/17 - Antibiotics started. Drainage present with mild odor. 9/25/17 - Sacral (coccyx) wound stage 4. 9/26/17 - Unstageable wound to coccyx. Measurement 3.2 x 2.0 x 0.6 cm. Undermining (deep tissue damage involving subcutaneous fat and muscle around the wound margin.) from 7 to 9 o'clock measuring 5.3 cm, thick slough (yellow devitalized tissue) with copious amount of brown drainage. On 10/3/17 at 2:15 PM, a record review of the wound care plan for Resident #607 revealed the following interventions: encourage frequent position changes, follow facility protocols for skin breakdown, monitor labs, prompt incontinence care, turn and position every 2 hours, Supplements - protein, amino acids, vitamins, minerals to assist healing. On 10/3/17 at 2:20 PM, a record review of the facility's Prevention of Pressure Ulcers policy and procedure, undated, stated under the topic General Guidelines, 1. Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue. On 10/4/17, according to the DON, the pressure ulcer for Resident #607 occurred over a pressure ulcer in the coccyx that had not properly healed.

This citation refers to Intake #MI 2811 Based on observation, interview and record review the Facility failed to administer an antipsychotic medication ([MEDICATION NAME]) as ordered by the treating physician for one Resident (#701) out of two residents reviewed for antipsychotic medication administration out of total sample of three, resulting in Resident #701 having a significant change in condition including refusal of care, refusal of medication administration, behavioral outburst and episodes of unresolved crying. On 10/24/16 at 9:00 a.m., Resident #701 was observed lying in her bed. The Resident was alert, calm and able to answer basic questions asked. Resident #701 was not able to provide any information pertaining to the medication administered to her at the Facility. A review of the Resident clinical record was conducted on 10/24/16 at 9:30 a.m. and revealed that the Resident was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) indicated that the Resident had a Brief Interview for Mental Status (BIMS) score of three (cognitively impaired) and required one person assist for transfers and ambulation. A review of the Resident's Care Plan (revised 3/29/16) documented the following: Focus: Problematic manner in which characterized by ineffective coping: rejection/refusing of care medications, crying . Interventions: Change meds as needed (4/20/16) A medication administration order by Physician E dated 5/18/16 documented the following: [MEDICATION NAME][MEDICATION NAME] Reconstituted 25 MG (milligrams) 1x per day every 14 days. Route of Administration: intramuscularly. A Facility Investigation Report/ RE: Resident #701 (dated 10/11/16) was reviewed and documented the following: On 10/5/16 it was notified by the facility MDS coordinator that Resident #701 had an order for [REDACTED]. During a chart audit by the MDS Nurse related to behaviors the resident was exhibiting (i.e. refusing care, refusing medication) she decided to look for the medication in the medication refrigerator to see if it was present and was being given. When looking at the label on the medication box for the [MEDICATION NAME] she noted that the delivery date was 5/29/16.The MAR (Medication Administration Record) for the previous 5 months did indicate that the resident did receive the medication from the nurse(s) assigned to care for Resident #701. Pharmacy was contacted to request documentation of delivery of the medication. The Pharmacy reported that the medication was last sent for the resident on 5/29/16. On 10/24/16 at 12:10 p.m., an interview was conducted with MDS Nurse D regarding Resident #701 and the failure to administer the Resident [MEDICATION NAME] every 14 days as ordered. MDS Nurse D stated, I was in the process of doing a quarterly evaluation for Resident #701. I went to talk to Resident she was having trouble focusing and having for behavior concerns. I went to double check her medication. I found in the refrigerator an order of the [MEDICATION NAME] dated 5/29/16. The box contained a one time dose of the medication. There was a note on the box that stated, Nurse must re-order. I spoke with the pharmacy and we knew that was the last order that was sent to the Facility was the 5/29/16 dose. I knew that that meant that she never got any more of the medication since May. It is a very expensive medication and we only receive one dose at a time. We checked the MAR and it appeared as if the medication was given to her as it was checked off by our Nurses May through October. I went to the Director of Nursing (DON) and told her what I found. On 10/24/16 at 12:25 p.m., an interview was conducted with Nurse Practitioner (NP) F regarding the error in medication administration for Resident #701. NP F indicated that she works directly with Physician E, who had originally prescribed the order for [MEDICATION NAME] 25 mg to be administered intra muscularly. With respect to Resident #701 not receiving the ordered medication, NP F stated, I remember a few weeks ago, the Unit Manager Nurse called me about the error made in the MAR. Resident #701 had not been receiving her medication as ordered. I was informed by the Nurse that the Resident was restless, agitated, having episodes of tearfulness and was combative at times. We went ahead and re-ordered the medication to be administered every 14 days as previously ordered back in May. The Resident received that dose, I believe on 10/6/16 and we added an oral dose of [MEDICATION NAME] as well. I just saw the Resident today and she was very pleasant and seemed much more stable than she was a week ago. On 10/24/16 at 1:20 p.m., an interview was conducted with the DON. The DON was queried as to the medication administration of the [MEDICATION NAME] for Resident #701. The DON stated, We knew we had a problem because we contacted the Pharmacy to obtain the last date the medication was sent to the Facility. It was on 5/29/16. We figured out the Nurses who indicated they gave the medication by looking at the MAR. We attempted to interview them and figure out what happened. We narrowed it down to three nurses (Nurse A, Nurse B and Nurse C). All three made statements. Nurse A indicated that she forgot to check that the Resident refused the medication. Nurse B indicated that she got the Medication from the nursing cart. Nurse C indicated that she gave the medication orally and not through injection as ordered. We new that the medication was never on the medication cart as Nurse B had indicated. None of nurses are still working with us. They were either terminated and/or resigned and we could not do any further investigation. We started to re-educated our nurses after this incident. Nurse A, B and C were not able to be reached for interview during the Survey. On 10/24/16 at 4:00 p.m., the Facility Policy titled Medication Orders (revised 12/21/10) was reviewed and documented the following: Purpose: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. A Facility Policy titled, Administering Medication (revised 12/21/10) was reviewed and documented: Policy Statement: Medications shall be administered in a safe and timely manner and as prescribed. Policy Interpretation and Implementation 2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. 3. Medications must be administered in accordance with the orders, including any required time frames. 12. The individual administering the medications must initial the resident's MAR on the appropriate line after giving each medication and before administering the next one. ( )

This Citation Pertains To MI 397 Based on observation, interview and record review, the facility failed to implement interventions in order to prevent pressure ulcers from developing and worsening for 2 Residents (#501 and 504) of 4 residents that were reviewed for pressure ulcers from a total sample of 4. Resulting in a stage 4 pressure ulcer on his coccyx that required surgical debridement for Resident #501. Findings include: On 8-18-2016 at 9:15 a.m. during a review of Resident #501 electronic medical record (emr), it was revealed that Resident #501 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] reflected Resident #501 required total care for all activity of daily living skills, was unable to ambulate and required the assistance of 2 staff members to transfer and had 1 stage 2 pressure ulcer. According to the facility skin assessments dated 6-28-2016 and 7-05-2016 Resident #501 had no pressure ulcers. The facility skin assessment dated [DATE] reflected 1. Are there any abnormal skin areas? Yes. 3. Describe all abnormal skin areas. Include length,width, and depth of each area and stage of each pressure area. coccyx. There was no description of the wound that included length, width, depth or stage. There was no treatment for [REDACTED]. According to the treatment administration record (TAR) cleanse sacral pressure area with normal saline, pat dry and apply large sacral heart silicone dressing everyday and pm every day shift The TAR reflected there was no dressing change done on 7-20-2016. The nurses note dated 7-12-2016 resident noted to have new skin issues. 7/12/2016 utd to sacrum 8.2 x 10 cm, right 2.2 cm x 5 cm DTI left heel 4.5 cm x 4.5 cm DTI, left foot 3rd toe joint 0.5 cm x 0.2 cm DTI, TX put in place family and Dr. aware. The nurses note dated 7-20-2016 reflected wound care Dr. wrote every 3 day wrap for bilat DTI to heels. Order not initiated due to this order not part of facility policy for this type of wound. Wound care Dr. notified. The skin care plan dated 6-22-2016 with a revision date of 7-13-2016 reflected The resident had actual skin impairment to skin integrity r/t (related to) fragile skin, immobility, VDRF (ventdependent [MEDICAL CONDITION]), DM (diabetes) sacrum utd (undetermined) left heel DTI (deep tissue injury) right heel DTI, left foot 3rd toe joint 0.5 cm x 0.2 cm. The TAR reflected bilateral offloading and boots skin prep every 8 hours were not initiated until 7-13-2016. The nurses notes dated 7-27-2016 reflected Resident #501 was transferred to the hospital for low hemoglobin. Hospital records dated 8-02-2016 revealed Resident #501 had a surgical procedure to debride the sacral wound that measured 12 centimeters by 10 centimeters. On 8-18-2016 at 2:08 p.m., during an interview with the Director of Nursing (DON), the electronic and paper medical record for resident #501 was reviewed. The DON was unable to find a [DIAGNOSES REDACTED].#501 as stated in the care plan, The DON was unable to find any evidence that preventive measures were in place to prevent the sacral wounds. When queried how it was determine the bilateral heel ulcers were deep tissue injuries opposed to pressure ulcers she reported that she had not been the DON very long and was unable to speak on how or where that determination came from, further stating the facility's wound care nurse had recently resigned. A request for the wound care physician consult from 7-20-2016 was requested but not received, when the DON was asked to clarify where in the facility policy was every 3 day wrap for bilat DTI to heels ordered by the wound physician was not part of the facility policy, she was not able to. When queried about the coccyx treatment not being completed on 7-20-2016, the DON was not sure why it was not done, further stating The system for wounds is broken here. ( ) Resident #504 On 8-18-2016 at 10:15 a.m. during a review of Resident #504 electronic medical record (emr), it was revealed that Resident #504 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] refected Resident #504 was in a persistent vegetative state, required total care for all adls and had no pressure ulcers. A review of the weekly skin assessments from 5-30-2016 thru 8-15-2016 all reflected 1. Are there any skin abnormalities? No 2. By acknowledging this box, I confirm that I conducted a full skin assessment and no abnormal areas were observed. (checked box next to #2.) According to the TAR a treatment was started on 8-05-2016 for Apply [MEDICATION NAME] day shift for wound care. A review of the TAR reflected no wound care was done 8-08-2016, 8-09-2016, 08-13-2016, 08-15-2016 and 08-16-2016. There was no documentation as to length, width, depth or stage of the wound. According to the timeline of the wound, provided by the DON, Resident #504 had .a newly identified facility acquired pressure ulcer (peri-Trach-stage II). Which was identified on 8-07-2016. On 8-18-2016 at 2:08 p.m., during an interview with the Director of Nursing (DON), the electronic and paper medical record for resident #504 was reviewed. When queried how Resident #504 developed the pressure ulcer, she reported it was from the [MEDICAL CONDITION] stabilizer. When queried why treatments were not completed on the above listed dates, she reported she could not speak to that. When queried if resident #504 was receiving treatment for [REDACTED].? DON reported the nurses need education on wounds and skin assessments. The system for wounds is broken here. On 8-18-2016 at 2:25 p.m., the wound was observed to be approximately 1 inch to the right of Resident #504 [MEDICAL CONDITION] site and the pressure ulcer was observed to be pink. The [MEDICAL CONDITION] stabilizer covered the wound prior to treatment. According to the undated facility policy titled Strategies for Prevention and Healing of Ulcers Under the heading for prevention : Relieve heel pressure in bed. For stages 2 thru 4 read : Identify/relieve underlying cause and contributing factors. Monitor status daily Measure/assess wound weekly and chart healing process. The facility provided a past non-compliance for wound care with a compliance date of 8-19-2016. ( )

This Citation Pertains To Intake Number: MI 030 and MI 049. Based on observation, interview and record review the facility failed to immediately report and protect one resident (#901) from verbal, physical and mental abuse, out of 3 sampled residents reviewed for abuse from a total of 3 sampled residents, resulting in prolonged mental anguish, seclusion, physical abuse and crying out. Findings include: On 6/23/16 at 8:20 a.m., Resident #901's clinical record was reviewed and revealed the following: Resident #901 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 5/19/2016, documented that Resident #901 had severely impaired cognition and required extensive physical assistance from one to two staff members for locomotion on unit, bed mobility, transfers and dressing. An observation of Resident #901 on 6/23/2016 at 8:30 a.m., was conducted. Resident #901 was in bed, awake with bed in lowest position and bilateral fall mattresses on floor. Resident #901 appeared confused when spoken too and continued to eat breakfast. On 6/23/2016 at 8:45 a.m., a review of the nurse's note dated 6/7/2016 for Resident #901 was conducted. The nurse's note indicated that Resident #901 had returned to the facility from the hospital via wheelchair and was escorted by his son. Resident #901 was alert with confusion. Resident #901 had a cardiac catheterization procedure performed at the hospital, which is a medical procedure used to diagnose and treat some heart conditions. The procedure consisted of a long thin, flexible tube called a catheter that was placed into a blood vessel and threaded to the heart. Safety measures and monitoring were to be maintained. A nurse's note documented later, that Resident #901 was combative and agitated. A review of the facility's incident and accident report dated 6/8/2016 was conducted on 6/23/2016 at 9:00 a.m. The incident and accident report indicated that CENA 'E' had witnessed and reported to Unit Manager 'D' that Resident #901 had been mistreated the previous night. CENA 'E' indicated that a nurse forced Resident #901 to take his medications while a CENA held his arms down. The nurse pushed Resident #901 via wheelchair into a dark dining room and shut the door. Unit manager 'D' reported the incident to the administrator and a video tape of what had occurred was reviewed. An interview with Resident #901 was conducted on 6/23/2016 at 11:15 a.m. Resident #901 appeared confused. After introductions and explanation as to the purpose of the visit, Resident #901 was queried regarding general care at the facility. Resident #901 indicated that he had concerns with care at the facility. However, Resident #901 could not remember what those concerns were. Resident #901 commented about a facility in the past where he had received care several times and was redirected to care concerns at current facility. Resident #901 stated: I don't remember. On 6/23/2016 at 3:45 p.m., a phone interview was conducted with CENA 'E'. CENA 'E' was queried regarding Resident #901 being wheeled into a dark dining room and administered medication. CENA 'E' indicated that Resident #901 was observed being pushed via wheelchair by a nurse and CENA into a dark dining room and left alone with the door shut closed. CENA 'E' indicated that after Resident #901 was placed in the dark dining room, the nurse turned around and stated: no body bet not open that door and then walked away. CENA 'E' indicated that Resident #901 could be heard hollering in the dining room where the door had been closed. An interview with unit Manager 'D' was conducted on 6/23/2016 at 4:00 p.m. Unit Manager 'D' was queried regarding alleged abuse of Resident #901. The unit Manager stated: We immediately viewed the video, the Administrator, Assistant Administrator, Director of Nursing and myself. The unit Manager explained that the video showed Resident #901 had been administered medication against his wishes and placed in the dark dining room alone with doors shut closed by a nurse and a CENA. The unit Manager indicated that there were several staff that witnessed the incident because it occurred during afternoon and midnight shift change. The unit Manager indicated that Resident #901 was interviewed and started crying. Resident #901 stated: they do this to me and others but could not tell the unit Manager who the others were. Resident #901 informed the unit manager that the nurse was told no'' when the resident's arms were held down and medication was administered. The unit Manager further explained that the CENA who witnessed it, has been disciplined. The unit Manager stated: She (referring to the CENA that witnessed the incident) had let the resident out of the dining room about 40 minutes later. The nurse and 2 other CENAs (the CENA who held the resident's arms while the medication was administered by the nurse and the CENA that was located approximately four feet away from the incident and continued to document notes) were terminated. The Director of Nursing (DON) was interviewed on 6/23/2016 at 5:00 p.m. The DON was queried regarding alleged abuse of Resident #901 and facility's abuse protocol. The DON indicated that she was informed of Resident #901 being administered medication against his will and wheeled into a dark dining room at approximately 8:30 p.m. on 6/8/2016. The DON indicated that the Administrator and Assistant Administrator were in the building when notified of the incident on 6/8/2016. The DON explained that the Administrator immediately had begun the investigation protocol. Staff were given abuse training and abuse policy was reviewed. A review of the facility's Abuse Prevention Program Policy Statement revised October 2012 was conducted on 6/23/2016 at 5:15 p.m. The Policy Statement stated: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Our abuse prevention program provides policies and procedures that govern, as a minimum: b. Mandated staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse. ( )

This citation has four deficient practices. Deficient practice #1 Based on observation, interview and record review, the facility failed to accurately assess and provide interventions for a resident in pain for one (#709) of three residents reviewed for pain, from a total sample of 18, resulting in repeated facial grimacing, moaning, and verbalization of pain during wound care and repositioning. Findings include: During a tour of the facility on 3/7/16 at 8:35 A.M., Resident #709 was observed lying in bed on his back with an elastic netting and dressing covering a large lump protruding from the top of his head. Resident #709's hands and legs appeared to be contracted. When asked how he was doing, Resident #709 stated, I hurt. Can you help pull me up in bed and put me on my side? Certified Nurse Assistant (CNA) R entered Resident #709's room on 3/7/16 at 8:45 A.M. CNA R explained that it was difficult for her to reposition Resident #709 on her own and stated, If I do it myself it is too hard and takes a really long time. CNA R returned to Resident #709's room with Restorative CNA Q. When CNA Q lowered the head of the bed, Resident #709 grimaced and grunted. CNA R and CNA Q proceeded to move Resident #709 up toward the head of the bed using a draw sheet. Resident #709 moaned and grimaced while being moved. CNA R and CNA Q apologized to Resident #709 and continued to reposition him into a seated position by raising the head of the bed. Resident #709 continued to grimace and moan with each movement. CNA R was asked why Resident #709 was making grimacing facial expressions and moaning. CNA R stated, He always does that. He's always uncomfortable and it hurts him when we reposition him. He doesn't like to sit like that, but he has to sit up for breakfast. On 3/8/16 at 8:35 A.M., Resident #709 was observed lying on his left side in a fetal position. A dressing was observed peeling off from the top of his head, exposing a large pink protruding lump and red drainage on the bandage. Resident #709 appeared to be sleeping, but was observed grimacing with his eyes closed. On 3/8/16 at 9:00 A.M., CNA P entered Resident #709's room and stated, Let's get you repositioned. Resident #709 was observed lying on his left side with his eyes closed. When CNA P lowered the head of the bed, Resident #709 grimaced and groaned. CNA P apologized to Resident #709 and continued to reposition him into a seated position. Resident #709 grimaced and moaned with movement throughout repositioning. On 3/8/16 at 12:30 P.M., the Wound Care Coordinator (Nurse G) and Nurse M were observed providing wound treatment to Resident #709. Nurse G removed foam boots from both of Resident #709's feet. Resident #709 groaned and said Ahh. Resident #709 continued to moan in pain as Nurse G touched his feet. Nurse G and Nurse M positioned Resident #709 onto his left side. Resident #709 grimaced, grunted and moaned when moved. Nurse G continued to provide treatment to what she described as a deep tissue injury (DTI- a pressure related injury under intact skin) to Resident #709's right ischium (lower back part of the hip). Resident #709 yelled out ah! when Nurse G removed a dressing from his sacral area (triangular bone at the base of the spine) revealing what was described by Nurse G as two suspected DTIs. Nurse G continued to provide treatment to Resident #709's sacral area without assessing his level of pain or offering any pain relief interventions. When Nurse G and Nurse M asked Resident #709 if he was ready to turn to his other side, he said No. Resident #709 was turned onto his right side by Nurse G and Nurse M and he moaned and grimaced with movement. Further observation of Resident #709's head wound treatment was made at this time with Nurse G and Nurse R. As Nurse G was removing a bordered adhesive gauze from the top of Resident #709's head, the dressing was observed to be stuck to his hair and multiple hairs were observed on the sticky part of the dressing after it was removed. During removal of the dressing, Resident #709 moaned and grimaced. Under the dressing, Resident #709 was observed to have a large (8.0 centimeter (cm) in length by 7.5 cm in width by 1.6 cm in height) tumor, as measured and described by Nurse G. Nurse G described the head tumor as having hypergranulation with slough and necrotic tissue scattered inside of the tumor. While cleaning the head tumor and providing treatment, Resident #709 continued to grimace and moan and stated, You're hurting me! Resident #709 reached his hand up to push Nurse G's hand away. Nurse G asked if it hurt and Resident #709 responded that it did. Nurse G stated, We are going to get you a pain pill after this. Nurse G continued to with the treatment. On 3/8/16 at 3:40 P.M., Nurse L (the nurse assigned to Resident #709 that day) was interviewed about Resident #709's level of pain. Nurse L stated, He's on hospice and gets [MEDICATION NAME]. He doesn't even complain of pain. Nurse L was asked how Resident #709 was assessed for pain and stated, It's mostly all non-verbal and the only time he really has pain is when we are doing treatments. Nurse L was queried about the non-verbal signs used to assess pain for Resident #709 and stated, He gets agitated. We know when he's in pain. Sometimes he might tell you, but it's really, really seldom that he complains of pain. When asked if Resident #709 typically received pain medication prior to receiving wound treatment, Nurse L reported that Resident #709 often experienced pain during wound care, but when they ask him if he wanted pain medication he would refuse it. Nurse L was queried about what CNAs should do if Resident #709 exhibited signs of pain during care or repositioning. Nurse L stated, They should tell the nurse. Really he (Resident #709) just wants to be left alone. Resident #709's clinical record was reviewed on 3/8/16 at 2:15 P.M. and revealed that Resident #709 was originally admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment, dated 2/9/16, documented that Resident #709 had severely impaired cognition and required extensive to total physical assistance with bed mobility, transfers and all activities of daily living. Current physician's orders [REDACTED]. [MEDICATION NAME] Suppository 650 mg (milligram) rectally every 8 hours as needed for pain . [MEDICATION NAME] (concentrate) solution 20 mg/ml (milliliter) give 5 mg by mouth every 1 hour as needed for pain . (Brand name [MEDICATION NAME]) extra strength tablet give 2 tablets by mouth every 12 hours as needed for pain . Pain assessment every shift .if resident has pain, verbal or nonverbal, please complete pain assessment form. The Medication Administration Record [REDACTED] On 3/7/16 (day shift) and 3/8/16 (day shift), Resident #709 had a pain level of 0 (indicating that the resident did not experience any pain). No pain medications were administered to Resident #709 in March 2016, except on 3/3/16, when Resident #709's pain level was assessed as a 6. Nursing progress notes for Resident #709 were reviewed for March 2016 and did not document anything about the pain experienced by Resident #709 on 3/7/16 during repositioning or on 3/8/16 during wound care. There was no documentation that Resident #709 was offered pain medication or other pain relief interventions and refused it. There was no pain assessment form completed, per the above physician's orders [REDACTED].>A plan of care for pain initiated on 3/13/14 and revised on 11/16/15, documented, The resident has chronic pain r/t (related to) Arthritis. admitted to hospice services. Interventions were revised on 2/9/16 and documented, Anticipate the resident's need for pain relief and respond immediately to any complaint of pain .Monitor/document for probable cause of each pain episode. Remove/limit causes where possible .Monitor/record/report to Nurse any s/sx (signs/symptoms) of non-verbal pain: .Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy); Eyes (wide open/narrow slits/shut .); Face ( .grimacing); Body ( .curled up) .Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment . The Director of Nursing (DON) was interviewed on 3/9/16 at 11:15 A.M. regarding pain assessment of residents. The DON was asked what non-verbal signs of pain staff should look for and stated, Grimacing, restlessness, agitation, moaning. When queried about what the process was when CNAs observe a resident exhibiting signs of pain, the DON reported that they should always report it to the nurse. The above observations and reports of pain by staff were discussed with the DON. The DON was asked how this resident should have been assessed. The DON reported that the pain level should be assessed and documented based on the resident's verbal and non-verbal symptoms of pain. The DON explained that if a resident refused pain medications after complaining of pain or exhibiting non-verbal signs of pain, then the appropriate pain level would be documented and it would be documented that the resident refused the medication. During a Quality Assurance and Assessment (QA&A) interview on 3/9/16 at 12:00 P.M., the Administrator reported that pain assessment had previously been identified as a problem. The facility's policy, titled, Pain - Clinical Protocol, was reviewed on 3/9/16 at 3:00 P.M. and it documented the following: .Staff should use a standardized pain assessment instrument appropriate to the resident's cognitive level . .The staff .will evaluate nonverbal individuals for nonspecific signs and symptoms that could reflect pain; for example, grimacing while being repositioned or having a wound dressing changed . .The staff will evaluate and report how much and how often the individual asks for PRN pain medication . .Staff will provide the elements of a comforting environment and appropriate physical complementary interventions . .The staff will reassess the individual's pain and consequences of pain at regular intervals . .The staff will discuss significant changes in levels of comfort with the attending physician who will adjust interventions accordingly . ( , ) Deficient Practice #2 Based on interview and record review, the facility failed to ensure documentation of post [MEDICAL TREATMENT] treatment was completed for one of one (#713) out of a total of 18 sampled residents, resulting in the potential for the lack of relaying pertinent and critical information, and the potential for the resident not receiving the necessary medical care. Finding Include: On 3/8/16 at 5:10 p.m., a review of the clinical record revealed Resident #713 was originally admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Further review of the clinical record revealed incomplete post documentation by the nurse upon the resident's return to the facility for the following dates: 1/2/16, 1/7/16, 1/9/16, 1/12/16, 1/14/16, 1/16/16, 1/21/16, 1/26/16, 1/30/16, 2/2/16, 2/4/16, 2/20/16, 2/23/16, 2/27/16, 3/3/16, 3/5/16, and 3/8/16. A review of the facility's care plan revealed Resident #713 received [MEDICAL TREATMENT] three times a week related to end stage [MEDICAL CONDITION] with [MEDICAL TREATMENT] three time week, (Tuesday, Thursday and Saturday). History of non-compliance despite multiple ongoing education/counseling from stuff, both to receiving treatments and dietary regimen. Monitor dry weight from [MEDICAL TREATMENT] for review. Fluid Restrictions 1500 cc (cubic centimeter) . On 3/9/16 at 2:40 p.m., during an interview, when queried about completed post [MEDICAL TREATMENT] documentation for Resident #713, Charge Nurse, Licensed Practical Nurse (LPN) U stated, When the resident returns to the facility, the nurse on duty should take the resident's blood pressure, vital signs and weight, and document in the nurses notes or PCC (Point Click Care). At that time a copy of the nurses' notes were requested. On 3/9/16 at 3:05 p.m., LPN U return with a printed document titled Weights and Vitals Summary. The Weights and Vitals Summary only revealed blood pressure readings from 1/2/16 through 2/4/16, and 2/20/16 through 3/8/16. There was no documentation of any other vital signs or weights. LPN U stated, she was unable to provide documentation from 2/6/16 thru 2/19/16, because the facility was going through a change. A review of the facility's policy titled [MEDICAL TREATMENT] dated 3/23/11 documented the following: Rationale To assist resident in maintaining homeostasis and to assess and maintain patency of the [MEDICAL TREATMENT] access . Post-[MEDICAL TREATMENT] Log completed upon resident return from [MEDICAL TREATMENT] 1. Vital Signs 2. Weight 3. All assessment of shunt 4. Check shunt site for: bleeding, pain, redness, swelling. ( ) Deficient Practice #3 Based on observation, interview, and record review the facility failed to follow a physician's orders [REDACTED].#715) out of one resident receiving a diuretic medication, out of six residents observed during the medication pass resulting in the potential for complications from [MEDICAL CONDITION] (low blood pressure). Findings include: On 3/7/16 at 9:05 am, Resident #715 was observed during the medication pass. Resident #715 received multiple medications including [MEDICATION NAME] (a powerful diuretic medication with side effects including low blood pressure that can cause dizziness, weakness, [MEDICAL CONDITION], and headaches) 80 milligrams daily. On 3/8/16 at 3:05 pm, a review of Resident #715's medication orders was conducted. During the review it was discovered that the physician's orders [REDACTED]. pressure and hold the medication if the resident's systolic blood pressure was less than 110. At this time, a review of Resident #715's blood pressures documented in the electronic medical record (EMR) indicated the last blood pressure obtained was on 3/3/16. A review of Resident #715's Medication Administration Record [REDACTED]. On 3/8/16 at 5:00 pm, an interview with the facility's Director of Nursing (DON) was conducted regarding Resident #715. The DON had no explanation as to why staff were not following the physician's orders [REDACTED]. On 3/9/16 at 3:00 pm, a policy titled, 'Physician's Medication Orders' with a revision date of 12/21/2010 was provided by Regional Nurse Consultant 'T' but did not address staff's responsibility to follow physician's orders [REDACTED]. did not have a specific policy regarding following physician's orders [REDACTED]. Deficient Practice #4 Based on observation, interview, and record review the facility failed to consistently perform skin assessments and perform physician ordered wound care treatments for three sampled Residents (Resident #702 and #708 #709) out of six residents reviewed for skin care, out of a total sample of eighteen residents, resulting in the potential for the development of new wounds to go un-detected, the worsening of existing wounds, and the increased risk of infection. Findings include: Resident #702 On 3/7/16 at 8:40 am, Resident #702 was observed in bed during the initial tour of the second floor. Resident #702 was alert, but not responsive to verbal stimuli. Resident #702 observed to be on a ventilator with a [MEDICAL CONDITION] and a gastrostomy. On 3/7/16 at 10:00 am, the facility identified Resident #702 as having a wound on his buttocks, and the wound had been acquired during his stay at the facility. On 3/7/16 at 3:25 pm, a review of Resident #702's clinical record was conducted. Resident #702 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] indicated that Resident #702 was severely cognitively impaired, and required total assistance of one or two staff members for all activities of daily living. Continued review of the electronic and paper medical record at that time was conducted to determine the date of the development of the wound, however assessments and progress notes reviewed did not indicate a date of when Resident #702 developed the wound on his buttocks or any ongoing skin assessments. On 3/8/16 at 4:30 pm, an interview with the facility's Wound Care Coordinator (WCC) was conducted. During the interview, the WCC was asked if she knew the date that Resident #402 developed the wound. She indicated that she had recently taken over the position in January of 2016 and was unsure of the date that the wound developed. The WCC was next asked about the expectation of the staff to perform ongoing skin assessments and where they would be documented. The WCC explained that the nurses were responsible for twice weekly skin assessments and they should be documenting them in the electronic medical record (EMR) under progress notes since there wasn't an assessment tool or form for them to use. The WCC was asked if she was following the progress notes to ensure the nursing staff were performing the skin assessments and admitted that she was not, 'ensuring nurses are doing them.' She also indicated that the nursing staff was not letting her know if there were concerns with resident's skin assessments. The WCC was asked to provide the progress notes or any other documentation for twice weekly skin assessments for Resident #702 and was not able to provide any documentation by the end of the survey that Resident #702's skin was being assessed. ( ) Resident #708: On 3/7/16 at 9:00am during the initial tour of the facility, Resident #708 was observed lying on his back in bed. A dressing dated 3/5/16 was observed to be present on the resident's left foot. On 3/7/16 at 10:00am, the face sheet for Resident #708 was reviewed and revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's admission minimum data set (MDS) assessment dated [DATE] revealed the resident scored 15/15 on a brief interview for mental status assessment, which indicated the resident was cognitively intact. Review of physician orders [REDACTED]. Review of Resident #708's treatment administration records for February revealed this order had not been transferred onto the electronic treatment administration record (TAR), and was only visible when reviewing physcian orders for Resident #708. The treatment order was also not visible on the March 2016 TAR, until a new order for wound treatment was intiated on 3/7/16. On 3/8/16 at 3:20pm, wound care coordinator G was queried in regards to the lack of documentation of the resident's left foot dressing change from 2/19/16 through 3/6/16. WCC G responded that the treatment wasn't showing up for documentation, and stated that whoever put the order in for the treatment must have clicked no documentation required. WCC G replied, I know people were doing it jut nobody was writing it down. When queried if the nurse performing the treatment was to document wound care treatment provided in a progress note, WCC G responded that she had inserviced staff about documenting a progress note for wound treatments. Progress notes during this time period were reviewed with WCC G, and no progress notes were observed which referred to a dressing change being performed to the left foot wound for Resident #708. On 3/9/16 at 11:10am, the Director of Nursing (DON) was queried regarding documentation and frequency of wound care for Resident #708. The DON responded that the order for wound care should have been on the TAR. The DON replied that progress notes should be present in regards to wound care treatments, and stated, If its a daily dressing change it's supposed to be done daily. On 3/9/16 at 3:00pm, review of the treatment order to the resident's left foot incision was reviewed and revealed that no documentation reqiured was selected when this order was input into the facility's electronic charting system. On 3/9/16 at 4:00pm, review of facility policy titled Wound Care revised on 3/23/11 revealed, in part, the following: Per the documentation section of the policy, The following information should be recorded in the residents medical record: 1. The type of wound care given 2. The date and time the wound care was given 4. The name and title of the individual performing wound care .6. All assessment data (i.e, wound bed color, size, drainage, etc) obained when inspecting the wound This policy did not specifically adress following the specified frequency of wound treatment orders. ( ) Resident #709 During a tour of the facility on 3/7/16 at 8:35 A.M., Resident #709 was observed lying in bed on his back with an elastic netting and dressing covering a large lump protruding from the top of his head. On 3/7/16 at 3:50 P.M., Resident #709 was observed lying in bed. A gauze like dressing with a large amount of pinkish-red drainage was observed on top of a large pink lump on the top of Resident #709's head. On 3/8/16 at 7:55 A.M., Resident #709 was observed with a bordered dressing (different than the dressing observed on 3/7/16) on the top of his head, dated 3/8/16. On 3/8/16 at 8:35 A.M., the dressing on Resident #709's head was observed to be peeling from one side, exposing a large protruding lump and red colored drainage to the dressing. On 3/8/16 at 12:30 P.M. during a treatment observation with Nurse G and Nurse M, Nurse G was asked about the ordered treatment for [REDACTED]. Nurse G reported that Resident #709 had [MEDICAL CONDITION]/tumor on the top of his head and the treatment was to cleanse it with wound cleanser, pat dry, apply crushed [MEDICATION NAME] (an antibiotic) on an oil [MEDICATION NAME] dressing ([MEDICATION NAME]), then a foam dressing cut to fit over top the head tumor. Nurse G explained that the tumor would then be wrapped with kerlix and a tubular elastic bandage would be applied to hold the dressing in place. When asked if that was the dressing that was currently on Resident #709's head, Nurse G stated, No. That's not what on him. That is a waterproof border gauze. Nurse G proceeded to remove the waterproof border gauze which was stuck to Resident #709's hair. When removed, Resident #709's hair was pulled out and stuck on the sticky part of the dressing. When asked if Resident #709's hair should be pulled out with the dressing, Nurse G stated, It only happens if you this (the waterproof border gauze dressing) on it. Nurse G described Resident #709's head tumor as having a slight odor from [MEDICAL CONDITION] with serosanguious drainage (fluid mixed with small amounts of blood), measured at 8.0 centimeters (cm) by 7.5 cm and 1.6 centimeters in height with slough and necrotic tissue scattered throughout the tumor. On 3/9/16 at 9:30 A.M., Resident #709 was observed to have a waterproof bordered gauze dressing on his head. An interview was attempted with Nurse G on 3/9/16 at 9:45 A.M., however she was unavailable for interview. The DON was interviewed on 3/9/16 at 11:15 A.M. regarding the above observation on 3/8/16 and reported that she was informed by Nurse G that Resident #709 had the incorrect dressing on his head tumor. When queried about the same type of dressing being observed on Resident #709's head at 9:30 A.M., the DON reported that the dressing should be applied according to the physician's orders [REDACTED]. Resident #709's clinical record was reviewed on 3/8/16 at 2:15 P.M. and revealed that Resident #709 was originally admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment, dated 2/9/16, documented that Resident #709 had severely impaired cognition and required extensive to total physical assistance with bed mobility, transfers and all activities of daily living. Current physician's orders [REDACTED]. An active order dated 2/19/16 for Scalp wound - cleanse with wound cleanser, pat dry, apply crushed [MEDICATION NAME] to wound bed, cover with [MEDICATION NAME], wrap with kerlix, and secure with surgilast netting to hold in place every day shift [MEDICAL CONDITION] wound to head .and as needed A care plan initiated on 3/13/14 and revised on 3/7/16 documented, (Resident #709) is at rick for increased skin break down r/t squamous cell [MEDICAL CONDITION] lesion (cancer) to scalp .Interventions documented, .Treatment as ordered . The Administrator was asked on 3/9/16 at 3:30 P.M. if there was any additional information the facility would like to provide before the end of the survey and reported there was not. ( )

Based on interview and record review the facility failed to prevent a significant medication error when they did not administer medications per the physician order for [REDACTED]. During review of Resident #201's clinical record on 5/12/15 at 10:30 a.m., the Nursing progress notes dated 4/27/15 revealed Resident #201, who was diagnosed with [REDACTED]. The note describing the [MEDICAL CONDITION] activity was as follows: 4/27/15 at 16:27: Received resident resting in bed.at 8:00 AM CNA, (certified nurse aide) reported to nurse, resident was observed shaking. Writer went to assess resident and observed resident having convulsions (suspected [MEDICAL CONDITION]). Writer timed [MEDICAL CONDITION], after 15 minutes nurse got order from (Nurse Practitioner (NP)) to administer 2 mg/ml ([MEDICATION NAME]) inject one time now.after administration resident continued to have [MEDICAL CONDITION] activity. At 8:45 AM, NP ordered 10 mg [MEDICATION NAME] IM (intramuscularly) now. Writer administered medication. At 9:20 AM, (ambulance company) was called and arranged for transfer to hospital. (ambulance company) arrived at 9:45 am, started IV.Blood Sugar (BS) 107. Writer administered another 10 mg [MEDICATION NAME] IM at 10:10 AM. Resident was transferred to the hospital at 10:30 AM. Further review of the clinical record on 5/12/15 at 11:00 a.m. revealed that Resident #201 was admitted to the facility 10/16/06 with [DIAGNOSES REDACTED]. According to the Minimum Data Set ((MDS) dated [DATE], Resident #201 was described with cognitive/decision-making ability that was severely impaired. Resident #201 required extensive to total physical assistance for all activity of daily living. A plan of care addressing [MEDICAL CONDITION] Disorder, dated 3/15, was as follows: Goal will remain free from [MEDICAL CONDITION] related activity. Interventions: Give [MEDICAL CONDITION] medication as ordered by doctor. Monitor/document side effects and effectiveness, monitor labs and report any sub-therapeutic or toxic results to the doctor. According to the Nursing Progress note, dated 4/23/15 at 9:11 a.m., Resident #201 was noted to be lethargic at approximately 7:00 a.m. The note described that Resident #201 was cold to touch, with altered mental status but was verbally responsive to vigorous touch. The physician was contacted and ordered tranfer of the resident to a local community hospital. According to the facility's readmission assessment progress note dated 4/24/15 at 23:12 (11:12 PM), Resident #201 was admitted from hospital with Diagnoses: [REDACTED]. We will continue to care. Vital signs checked, vent and labs ordered, no pain or distress noted. Skin check done, no opening in skin observed. MD notified, medication entered, called pharmacy to verify admission, will continue with per care plans. According to a nursing note dated 4/26/15 at 2:06 PM, On call PA (Physician Assistant) phoned regarding medications (that were) discontinued upon arrival (4/24/15). Per the PA, [MEDICATION NAME] (for hypertension) 12.5 and mirtazepine (for depression) 15 mg was restarted. Writer also advised to restart [MEDICATION NAME] (for [MEDICAL CONDITION] disorder) at 500 mg po (by mouth) and [MEDICATION NAME] (for pain) 5 mg po every 8 hours prn (as needed). Writer logged in physician log to review other discontinued medications to possibly restart. HR (heart rate) noted at 135, [MEDICATION NAME] given (and) HR rechecked and decreased to 74. Orders transcribed and noted to E-MAR (electronic medical administration record). Resident continues on ABT (antibiotic) therapy due to pneumonia. No adverse reactions noted.Will continue to monitor resident. A review of the hospital Discharge Summary dated 5/4/15, Discharge Diagnoses: [REDACTED]. They were unable to break the [MEDICAL CONDITION]. She did receive benzodiazepines (psychoactive drugs) in the emergency department and [MEDICAL CONDITION] broke. She was noted to have not been receiving her [MEDICATION NAME] therapy at the facility.This was reinstituted at 1500 mg twice daily. On 5/12/15 at 11:00 AM, the Director of Nursing (DON) was interviewed about Resident #201's [MEDICAL CONDITION] activity and stated, The resident was being followed by the nurse practitioner. [MEDICATION NAME] (for [MEDICAL CONDITION]) was not on the discharge summary instructions (4/24/15) from the hospital, however it had been on our transfer sheet. We assumed that it was reviewed and discontinued. On 5/12/15 at 3:00 PM, the Unit Manager, employee 'A' was interviewed. She stated, The resident (#201) went to the hospital for mental status changes on 4/23/15 (prior to [MEDICAL CONDITION]) with [MEDICAL CONDITION] medications ([MEDICATION NAME]) on the physician order sheet. She returned on 4/24/15 without the order. On 4/26/15 the PA reviewed the orders and noted that the resident was sensitive to [MEDICAL CONDITION] activity and should be on [MEDICATION NAME] for [MEDICAL CONDITION] The MAR (Medication Administration Record) for April 2015 was reviewed with employee 'A'. A review noted orders dated 4/26/15 at 2:00 PM, for [MEDICATION NAME]. However, a [MEDICATION NAME] dose for 6:00 PM had not been administered, and a [MEDICATION NAME] dose for 4/27/15 at 6:00 AM had not been administered. The Unit Manger was questioned if the nurse had failed to administer medications as ordered by the physician and she stated, I had not caught that the [MEDICAL CONDITION] medications had not been ordered. On 4/27/15, at 10:30 AM, the resident was transferred to the hospital after experiencing multiple episodes of [MEDICAL CONDITION]. Further review of the MAR indicated [REDACTED]. However, it was discontinued upon hospitalization [DATE], and on readmit 4/24/15 the medication was not reordered, resulting in seven missed doses between 4/25/15 - 4/27/15. Also, [MEDICATION NAME] 0.5 mg tablet by mouth every eight hours for anxiety/[MEDICAL CONDITION] disorder had not been reordered resulting in seven missed doses between 4/25/15 - 4/27/15. On 5/12/15 at 4:30 PM, the Administrator and DON were interviewed. The DON was questioned about the missed doses of [MEDICAL CONDITION] medications and effects it would have on the resident. She stated, I am not sure about the half life of the medication ([MEDICATION NAME]), but most likely significant. Per the Administrator, It is the facility's protocol to review medications upon readmit from the hospital. The nurse noticed a concern (4/26/15) and contacted the physician. The physician ordered to restart the medication However, review noted that the medications were never reordered and administered to the resident. On 5/13/15 at 10:30 AM, a NP (nurse practitioner) was interviewed. She stated, When the resident returned, the doctor on call covered. It was not me. I saw the resident on 4/23/15 and sent her to the hospital. She had mental status changes was difficult to arouse with history of [MEDICAL CONDITION] on and off. Approximately, two years ago we got resident #201 to therapeutic range on [MEDICAL CONDITION] medications. She has a very low threshold for [MEDICAL CONDITION] sent out on 4/24/15, thinking that if hospital made medication changes they would monitor. Her medications [MEDICATION NAME], clonopin and [MEDICATION NAME] were discontinued in the hospital. The nurse called (on 4/26/15)and spoke with PA who ordered (on 4/26/15 at 2:06 PM) to restart [MEDICATION NAME] 500 mg, but at a new lower dose. On Monday (4/27/15) morning I saw (resident #201) she would have only had one dose of [MEDICATION NAME]. The withdrawal of [MEDICATION NAME] and [MEDICATION NAME], she was completely off all medications for [MEDICAL CONDITION]. [MEDICATION NAME] level prior to leaving for the hospital was high (laboratory finding dated 4/23/15, [MEDICATION NAME] 108.2, therapeutic range 3.0 - 60.0) and remained high on readmit (5/7/15, 100.4). I was here when EMS (emergency medical services arrived). She was seizing. We gave IM [MEDICATION NAME] and [MEDICATION NAME] to stop the [MEDICAL CONDITION] but the resident did not respond. On readmit (4/24/15) I assess, but she had been admitted on a Friday. I was not in facility until Monday (4/27/15) and she was sent out to the hospital. A review of the facility policy on Admissions dated 2/2014, noted that The attending physician shall assess a newly admitted resident resident within forty-eight hours of the resident's admission to the facility.Procedure 1. If the attending physician is not present at the time of the resident's admission, the attending physician may give admission orders [REDACTED]

This citation pertains to intake number MI 684 Based on observation, interview and record review, the facility failed to provide proper repositioning and care to prevent the development of pressure sores for one (#502) of two residents reviewed for pressure sores, from a total of four sampled residents, resulting in the development of a Stage III pressure sore. Findings include: On 10/13/14 at 11:10 a.m., during a wound care observation, Resident #502 was observed in his room laying in bed in supine position (on his back). Resident #502 required the use of a ventilator for breathing and was receiving nutrition via a percutaneous gastrostomy tube and had an indwelling urinary catheter. Licensed Practical Nurse (LPN) "B" who was present during the observation, was queried. When asked if Resident #502 had pressure sores, LPN "B" reported, "Yes. He has a pressure sore to his coccyx. I just changed his dressing. The area has a pink base with moderate serosanguinous drainage. The wound has irregular edges and we're dressing it with Medi-Honey (Wound treatment) and a dry dressing. He's currently on antibiotics for his sputum. His tube feeding is infusing at 65 cc's (cubic centimeters) per hour and he has a Foley. LPN "B" further reported, "His (Resident #502) wound is facility acquired." A review of the clinical record revealed that Resident #502 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive Minimum Data Set ((MDS) dated [DATE] revealed that Resident #502 had severely impaired cognitive skills for decision making and required total physical assistance of staff with all activities of daily living (ADL's) including bed mobility, dressing, eating, hygiene, bathing and toileting. The MDS indicated that Resident #502 had no pressure sores at the time of admission. A review of Resident #502's "Admission Assessment" dated 3/28/14 revealed that Resident #502's skin was intact upon admission into the facility. A "Wound Evaluation Record" dated 5/16/14 revealed: "Date wound developed, 5/15/14. Place pressure ulcer developed: Facility. Left buttock pressure sore 1.0 x 4.0 State II. Skin assessment on 5/15/14 by wound care nurse (LPN "A") revealed Stage II pressure ulcer to left buttock. Pink base." A Wound Care Specialist progress note dated 5/16/14 documented, "Pressure Ulcer Stage II left buttock. Left buttock: 1.0 x 4.0 cm (centimeters). 2 wounds with a bridge, pink bases, minimal serosanguinous drainage, irregular edges. Opti-foam everyday and as needed to Left buttock. Frequently reposition." A Wound Care Specialist progress note dated 10/10/14 documented, "Pressure Ulcer Stage III Coccyx. Coccyx: 3.0 x 1.4 x .04 cm pink base, minimal slough, minimal serous drainage, irregular edges. [MEDICATION NAME] Gel every day and as needed to coccyx. Frequently reposition." A review of Resident #502's "Alteration in skin Integrity" care plan dated 3/31/14 revealed, "Resident #502 has an alteration in skin integrity as evidenced by: Stage III pressure ulcer to left buttock. Interventions: Reposition every 2 hours and as needed." On 10/13/14 at 1:50 p.m., during an interview, LPN "A" (wound care nurse) reported, "Resident #502 was admitted on [DATE]. I identified th wound on 5/15/14. It started on his left buttock and now it's on his coccyx. We had issues with turning and repositioning on this unit. I didn't have a good support system. Nurses weren't doing weekly skin assessments. The CNAs (Certified Nursing Assistant) weren't turning or repositioning and the CNA's weren't reporting skin issues to the nurse once they identified them during showers. On 5/15/14 the wound initially started on his left buttock; It's now on his coccyx and it's at a Stage III." On 10/13/14 at 2:43 p.m., The director of Nursing (DON) was interviewed. When asked how Resident #502 acquired pressure ulcers, the Don reported, "I can't give you a reason. It's facility acquired. that's what I can tell you. The CNA's are scared to reposition them (Residents) because of the equipment (Ventilators/Respiratory tubing). I walked around today after you and I saw the same thing you did. The residents weren't repositioned correctly." During an observation of Resident #502 with the DON present, Resident #502 was observed to be in the same position as previously observed. On 10/13/14 at 3:00 p.m., during an interview, CNA "C" was interviewed and reported, "I've only worked on a Vent (Ventilatory) unit for about a month and a half. It's hard. It's scary repositioning them (Residents). I need help repositioning them" A review of the facility's "Prevention of Pressure Ulcers: General guidelines" policy revised 11/5/08 documented: "Policy: Prevention and treatments are based upon consistently providing routing and individualized interventions." "for a person in a bed: Change position at least every two hours or more frequently if needed." "Immediately report any signs of a developing pressure ulcer to the supervisor and physician." The facility's "Prevention of Pressure Ulcers: Providing Preventative Skin Care" policy dated 11/5/08 documented: "Preventative skin care will be provided routinely, as needed, facilitating in the assessment and prevention of pressure ulcers."

This citation pertains to intake number MI 251 Based on observation, interview and record review, the facility failed to assess a PEG (Percutaneous endoscopic gastrostomy/Feeding Tube) site for one (#501) of two residents reviewed for PEG tube site care, from a total of three sampled residents, resulting in an elevated temperature (fever) and the development of an infection at the insertion site. Findings include. On 6/3/14 at 9:05 a.m., during an initial tour of the facility with the Director of Nursing (DON), Resident #501 was observed in her room lying in bed with a white cloth to her forehead. The resident was dependent on a ventilator (to breathe). The Director of Nursing was asked why Resident #501 had a white cloth to her forehead, Nurse "A", who was present in the resident's room stated, "The midnight nurse said she was running a fever." Resident #501 had a formula infusing through the PEG tube. Observation of the PEG tube insertion site revealed an area that was slightly reddened with areas of dried blood, and with and purulent (pus) drainage coming from the opening. The DON donned a pair of gloves and used wound cleanser to clean the site and applied a dry dressing to the area. The Unit Manager, Nurse "B", who was present in the room during the observation, reported, "The physician came in and saw it and said it was resolved." When queried about Resident #501's PEG site, The Unit Manager (Nurse "B") reported, "I'll have to look and see if the physician wrote any orders". A review of the facility's "Admission Record" on 6/03/14 at 9:30 a.m. revealed that Resident #501 was initially admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] revealed that Resident #501 had severely impaired cognitive skills for decision making and was was totally physically dependent on staff for activities of daily living including bed mobility, transfers, dressing, eating, hygiene, bathing and toileting. On 6/3/14 at 10:00 a.m., during an interview, the facility's Administrator was queried about the resident's PEG tube site and stated, "I spoke with the family about a week ago about these concerns. I told the afternoon supervisor to look at her (Resident #501) PEG site and document the findings. It raised concern with me." When asked if she instructed the staff to notify the physician, The Administrator reported, "I didn't instruct staff to notify the doctor." When asked if she was aware that Resident #501 had an elevated temperature, The Administrator reported, "I wasn't aware that she was running a fever". On 6/3/14 at 10:39 a.m. during an interview, Nurse "A" was queried and reported the following, "I didn't do an assessment on Resident #501 yet. The compress was on her forehead because the night nurse said she had a low grade fever so I left it on her. I rechecked her temperature (temp) at 10:00 a.m. and it was 99.3 (Farenheit). I gave Resident #501 some Tylenol and I put another cool towel on her forehead. I don't know if the midnight shift nurse called the doctor. On 6/3/14 at 10:54, review of the clinical record revealed there was no documented evidence that the physician had been notified of the resident's elevated body temperature (fever). Review of physician orders [REDACTED]." The physician progress notes [REDACTED]. Checked the PEG site and it looks like infection. Culture and sensitivity obtained." The next physician order, dated 5/27/14 documented: "PEG site redness and drainage resolved." There were no evidence the results of the culture and sensitivity report was received and whether or not the PEG tube insertion site was infected. The surveyor was unsuccessful at reaching the physician by telephone at the number provided. On 6/3/14 at 11:26 a.m., during an interview, the Physician's Assistant (PA), reported, "She (Resident #501) had a dressing on so I couldn't get a good look at the site at first. When I removed the dressing, it looked nice and clean". The DON joined the interviewed and reported that "the area had been cleaned but prior to being observed by the PA and there ws purulent drainage and dried blood from the site." The PA further clarified that the documentation from the physician's progress note which referenced the culture and sensitivity test to determine the causative organism was conducted on Resident #501's eyes and not her PEG tube site as ordered. On 6/3/14 at 1:05 p.m., during a subsequent interview, The PA reported, "I just wanted you to know that I did a work-up on her (Resident #501) because of her elevated fever and I see the drainage..." On 6/3/14 at 2:30 p.m. during a review of the facility's "Gastrotomy/Jejunotomy site care" policy, revised 10/24/08 revealed, "The nurse will assess the stoma site for redness, swelling and/or drainage, report any signs of infection or pain to the physician and complete a comprehensive evaluation for any change in condition." There was no documented evidence in the clinical record that staff thoroughly monitored and addressed the clinical findings presented at Resident #501's PEG insertion site which resulted in infection.

This citation has two deficient practice statements Deficient Practice #1: This citation pertains to intake MI 588: Based on interview and record review, the facility failed to ensure that only medication to treat known medical conditions was administered to one (#703) of 5 sampled residents reviewed for medication administration out a total of 7 sampled residents, resulting in a resident with no diagnoses of diabetes mellitus receiving injections of [MEDICATION NAME], (a long-acting insulin). This significant medication error resulted in the resident being found unresponsive, having a hypoglycemic reaction, and being sent to the hospital for treatment. Findings include: On 4/22/14 at 10:48 AM, an interview was conducted with the guardian of resident #703 at the facility. The guardian stated, "Back on March 7th, (name) Resident #703 was started on [MEDICATION NAME]. I was not even aware of it until we went to an Endocrinologist appointment on April 7th. The Endocrinologists asked if I was aware that Resident #703 was on insulin. I told him no. The Endocrinologist said she was on a lot of of it--too. The next day she had a crisis." On 4/22/14 at 11:30 AM, a review of the paper and electronic medical record (EMR) revealed that resident #703 was originally admitted into the facility on [DATE] and readmitted into the facility on [DATE] with diagnoses of convulsions, [MEDICAL CONDITION], diabetes insipidus (Diabetes insipidus (DI) is an uncommon condition that occurs when the kidneys are unable to conserve water as they perform their function of filtering blood. Source: http://www.nlm.nih.gov/medlineplus/ency/article/ 7.htm. This disease has nothing to do with regulating blood sugar with the use of medication), and metabolic [MEDICAL CONDITION]. There was no diagnoses of diabetes mellitus (Diabetes mellitus refers to a group of diseases that affect how your body uses blood glucose, commonly called blood sugar...If you have diabetes, no matter what type, it means you have too much glucose in your blood, although the reasons may differ." Source: http://www.mayoclinic.org/diseases-conditions/diabetes/basics /definition/con- 091) noted in either clinical record. The Minimum Data Set (MDS), dated [DATE], indicated that resident #703 had severely impaired cognition and required extensive assistance with activities of daily living. On 4/22/14 at 11:30 AM, A review of the monthly physician order for [REDACTED]." received a telephone order from Physician "E" that stated, "(3) D/C (discontinue [MEDICATION NAME] 100 unit/ml (3 ml)), (4) New order: [MEDICATION NAME] 100 units/ml inject 36 units sq (subcutaneous) at bedtime." The April 2014 Medication Administration Record [REDACTED]. The "Nursing Home to Hospital Transfer Form", dated 4/8/14, stated: "Transfer to hospital non-responsive... BS (blood sugar) 32. Resident #703's April MAR indicated [REDACTED]. A review of the physician orders from 2/5/14 to 3/7/14 revealed that resident #703 had no previous order for [MEDICATION NAME]. On 4/23/14 at 9:12 AM, the Director of Nursing (DON) was asked about the insulin orders for Resident #703 and reported the nurse received "a phone order" on 3/07/14 at 4:35 am and wrote it on the MAR. The DON stated, "I met with Physician "E" on 4/11/14 after the incident. He said there's no way he would have given the order." The DON's investigation, dated 4/11/14, stated, "Physician "E" informed DON that there is no way he would have given the order for the resident to receive 36 units of [MEDICATION NAME] and she does not have any issues with her blood sugar nor is she a diabetic and the order must have been written as an error." The investigation documented that Nurse "D" stated, she "could have only got the order from physician "E", otherwise she would not have written it." The March 2014 MARs were requested but the facility was unable to locate them by the end of the survey on 4/25/14. On 4/23/14 at 10:46 AM, during a telephone interview, Nurse "D" was asked about the [MEDICATION NAME] order. Nurse "D" stated, "I got a slip from the pharmacy and they changed all the insulin orders and her name was on it. They changed brands or companies." Nurse "D" was asked if she had actually gotten the [MEDICATION NAME] order from Physician "E". Nurse "D" stated, "No. It was on the slip I got from pharmacy." When Nurse "D" was informed that Resident #703 had not been on [MEDICATION NAME] prior to the new order she wrote on 3/7/14 and did not have diabetes mellitus, Nurse "D" stated, "I didn't know that at the time. I followed pharmacy. I didn't know she wasn't taking any diabetic medicine." The nurse had no explanation why she had not question the pharmacy since there was no [MEDICATION NAME] order to discontinue. At 11:10 AM, during a telephone interview, Physician "E" was asked if resident #703 was diabetic. Physician "E" stated, "Nope. She is not diabetic. She has diabetes insipidus, but not diabetes mellitus. I believe the order was written on the wrong chart..." On 4/25/14 at 9:00 AM, a review of the facility policy titled "Transcription of Physician Orders", revised 10/28/08, stated, "Accurate and timely transcription of a physician's order is to be completed by the licensed nurse receiving the order...the message "d/c" (discontinued) and the effective date are entered on the MAR/TAR (treatment administration record after the last administered doses/treatment to prevent further administration." ( ) This citation pertains to intake MI 588: Based on interview and record review, the facility failed to ensure that one (#703) of 5 sampled residents reviewed for medication administration out of a total of 7 sampled residents were free from significant medication errors, resulting in the resident not receiving prescribed medications to treat diabetes insipidus and orthostatic hypertension. Findings include: On 4/22/14 at 11:30 AM, a review of the paper and electronic medical record (EMR) revealed that resident #703 was originally admitted into the facility on [DATE] and readmitted into the facility on [DATE] with diagnoses of orthostatic hypertension, [MEDICAL CONDITION], diabetes insipidus, and metabolic [MEDICAL CONDITION]. There was no diagnoses of diabetes mellitus noted in either clinical record. The minimum data set (MDS), dated [DATE], indicated that resident #703 had severely impaired cognition and required extensive assistance with activities of daily living. On 4/22/14 at 11:30 AM, a review of the physician order for [REDACTED]. There was no order to discontinue the medication noted in the clinical record. On 4/23/14 at 4:05 PM, A review of the MAR for April 2014 revealed the medication [MEDICATION NAME] had been circled as not given on 4/22/14, 4/23/14, and 4/24/14. Unit Manager "Q" was asked why the [MEDICATION NAME] had not been administered. Unit Manager "Q" stated, "I don't know why-- the medication is in the cart". Unit Manager "Q" went to the cart and pulled the cartridge of Fludrocortisone 0.1 mg and stated, "The medication is here. Maybe they don't know it is the same as [MEDICATION NAME]." ([MEDICATION NAME] and Fludorocortisone are different medications). Further comparison of the MAR indicated [REDACTED]. Multiple pills were missing from two of the Fludrocortisone cartridges. Review of the MAR indicated [REDACTED]. [MEDICATION NAME] was not in the medication cart, but [MEDICATION NAME] 0.1 mg had been signed out "as given". The medication cartridge was not able to be located in the medication cart. Unit manager "Q" was asked if the nurses could have administered Fludrocortisone and signed it out as [MEDICATION NAME]. Unit manager "Q" had no explanation. The DON was asked about the discrepancy in the medication. The DON revealed that staff was supposed to let their unit manager know if they don't have a medication. Unit manager "Q" revealed the nurses had not let her know the medication ([MEDICATION NAME]) was not available. On 4/25/14 at 9:00 AM, a review of the facility policy titled "Transcription of Physician Orders", revised 10/28/08, stated, "Accurate and timely transcription of a physician's order is to be completed by the licensed nurse receiving the order." The facility policy titled "Medication shortages/unavailable medications", dated 12/01/07, stated, "If facility nurse is unable to obtain a response from the attending physician/prescriber in a timely manner, Facility nurse should notify the nursing supervisor..." ( )

This citation pertains to intake #MI 793 Based on interview and record review, the facility failed to provide insulin therapy and breathing treatments as prescribed by the physician for one (#31) of three sampled residents receiving diabetic and respiratory care and services from a total sample of five, resulting in a compromise/decline in health status. Findings include: On [DATE] at 1:25 PM, the daughter of resident #31 was interviewed by phone. The daughter stated she found out that nurse 'A' failed to properly obtain and monitor the resident's blood glucose levels when she questioned the nurse about them and that the facility failed to provide appropriate care and treatment. The daughter stated that the resident had a [MEDICAL CONDITION] (artificial opening in the airway to facilitate breathing), was diabetic, had just been weaned from a ventilator at a hospital and transferred to the facility (on [DATE]) where resident #31 died approximately 13 hours after arrival (on [DATE] at 1 AM). Resident #31's daughter stated that the resident should have been monitored more closely by staff. She stated that the resident was placed in the farthest room from the nurses station at the end of the hallway. She stated that staff did not respond promptly to the call light signal forcing her to go to the desk twice to tell nurse 'A' that the resident needed to be suctioned, "only to find (nurse 'A') sitting at the desk talking on her cell phone." On [DATE] at 9:45 AM, the Respiratory Therapy (R.T.) director was interviewed. The director stated that residents on ventilators (vents) were placed on the 2 West unit and residents with tracheostomies (trachs) that were not on vents (such as resident #31), were placed on the skilled care (2 East) unit. When asked if there were exceptions where a resident with a trach, but not on a vent would be placed on the 2 West unit where the vents were located, the director gave the following examples: "Depends on how much secretions they have and the frequency of suctioning (required)," and "If they are unstable." A policy regarding these exceptions was requested, but not provided by the time of exit. At 10:30 AM, resident #31's clinical record and hospital records dated [DATE] thru [DATE] were reviewed that revealed the following: Per a hospital infectious disease progress note dated [DATE], resident #31 had been weaned off of the vent for 48-hours, the resident had hospital acquired pneumonia, and had diarrhea associated with [MEDICAL CONDITION] bacteria. Per a hospital wound progress note dated [DATE], the resident had four pressure sores that were "getting worse." Per a hospital physician's progress note dated [DATE], the resident had a white blood count of 16.8 (normal range is below 12), indicating infection, and a hemoglobin of 9.9 (normal range is 12), indicating a reduced ability to oxygenate the body. Per the hospital discharge summary and orders dated [DATE]: Resident #31's [DIAGNOSES REDACTED]. Transfer orders included, 1. Blood glucose monitoring every 6 hours with administration of [MEDICATION NAME]for blood sugars at 100 or greater based on a sliding scale. 2. [MEDICATION NAME] nebulizer treatments, used to increase lung airflow, three times a day and as needed for shortness of breath (SOB), scheduled at 9 AM-1 PM-5 PM. 3. Atrovent inhalation solution, used to increase lung airflow, three times a day and as needed for shortness of breath (SOB), scheduled at 9 AM-5 PM-9 PM. 4. [MEDICATION NAME] inhaler, a steroid used to increase lung airflow, every 12-hours, scheduled for 9 AM-9 PM. Per review of the EMS (emergency medical services) run sheet, Resident #31 was transferred from the hospital to the care of the facility on [DATE] at 11:39 AM. The resident was receiving oxygen through [MEDICAL CONDITION] was placed in the farthest room on the 2 East unit from the nurses station. On [DATE] at 3:15 PM, nurse 'B', who was assigned to the resident from time of arrival until 7 PM was queried regarding the resident's blood sugar levels that were to be obtained every six hours. Nurse 'B' stated initially that she obtained a level of 188 at approximately 12:30 PM. When asked to verify the time, the nurse looked in the computer. The level of 188 was repeatedly listed three times on [DATE] and one time on [DATE] followed by these entries: 4 hours 51 minutes, 12 hours 20 minutes, 18 hours 21 minutes, and 12 hours 18 minutes). The nurse said, "I don't know why it (the computer) did that" and indicated that she was unable to figure out what the entries meant. Nurse 'B' then stated that she obtained the blood sugar level at 3 PM, but no insulin was given for the level of 188. Per the physician's orders [REDACTED]. There was no documentation that the blood sugar level scheduled for 6 PM was monitored. When queried about obtaining resident #31's oxygen levels, nurse 'B' reviewed her nurses notes dated [DATE] at 6:09 PM and 6:34 PM. The nurse stated that there were no documented nurses notes at an earlier time. Nurse 'B' documented the resident's vital signs in her notes, but there were no documented oxygen levels. The nurse said, "I did the pulse ox (oxygen level)" then said, "I don't see it. I thought I did it." When asked about the resident receiving the three [MEDICATION NAME] and Atrovent treatments due at 1 PM and 5 PM, nurse 'B' stated that they were not given because, "It is really busy and people (residents) come and go constantly." On [DATE] at 3:35 AM, nurse 'A', who was resident #31's evening/night nurse on [DATE] from 7 PM-7 AM the next day, was queried about the family member's complaint that nurse 'A' improperly conducted blood sugar testing scheduled for 12 midnight on [DATE]. The nurse said, "When I did the accucheck (blood sugar testing) around 12 (midnight), I saw blood dripping down her finger so I lifted the dressing (a dressing that was covering a skin tear sustained to the hand during hospitalization )....and got a drop of blood. I didn't stick her (finger) because she was already anxious." Nurse 'A' said, "I suctioned her when I first came on (duty) around 7:15 (PM). I hadn't even gotten the keys (to secured areas and items from the day shift nurse) yet. It was very thick, foul smelling, a large amount each time....the daughter came to get me around 10 (PM) for suctioning and around 10:30 (PM), I suctioned her when me and the (nurse aide) was turning her. I suctioned her again around 12 (Midnight) when I did her accucheck....I suctioned her around four times. She was very anxious throughout the shift and was thrashing her hands....She probably should have been on the vent unit to be closer to respiratory (staff) so they could check on her more frequently because she needed suctioning and was anxious, but that was not my decision." When asked if a manager was notified about her concerns regarding resident #31's placement on the non-vent unit or the resident's anxiousness and need for frequent suctioning, nurse 'A' said, "We don't usually do that" then said, "My supervisor wasn't here. I guess I could have talked to someone about it." There was no indication that nurse 'A' gave the resident the 9 PM doses of Atrovent and [MEDICATION NAME]. When asked why, nurse 'A' did not respond. Per review of nurses notes dated [DATE] at 12:20 AM by nurse 'A', nurse aide 'E' called the nurse to the room to assess the resident because the resident was not breathing, EMS was called, an attempt was made to resuscitate the resident without success, and the resident expired. (When interviewed on [DATE] at 3:30 PM, aide 'E' stated that she went to the resident's room to turn her but saw that the resident "was pale and looked dead. I called the nurse." The aide stated that throughout the evening of [DATE], the resident "was restless and constantly reaching out for me. She may have been afraid.") On [DATE] at 12:15 PM, the Assistant Director of Nursing (ADON), who was the interim DON at the time of resident #31's admission and death, was interviewed about the respiratory treatments, blood sugar testing, and monitoring of the resident's status on [DATE]. The ADON stated that she was informed by the resident's daughter, after the resident expired, about the accucheck being improperly obtained. The ADON did not respond why the timing of the first accucheck by nurse 'B' could not verify by computer, why the resident did not receive insulin as prescribed when the level was 188, and why the 6 PM accucheck was not done. When asked about respiratory treatments not being given as prescribed, the ADON stated that nursing staff was responsible for giving them on the non-vent 2 East unit, not respiratory staff. When queried about the large amount of mucous, frequent suctioning, and the resident's anxiousness throughout the evening, the ADON said, "She (nurse 'A') could have notified someone. The DON is always on call or she could have called the physician, but she didn't do that." On [DATE] at 3:30 PM, the Administrator did not respond regarding the allegations. The following facility policies were reviewed on [DATE] at 5 PM: "Notification of Physicians Regarding Changes in Resident Status" dated ,[DATE]: Purpose of policy-"to provide adequate and timely communication, ensuring the earliest medical intervention, the primary on call physician....will be notified promptly regarding any/all changes in resident status....Abnormal drainage, foul-smell discharge....any other sign about which you are concerned or uncertain should prompt physician notification." "Concurrent Review" dated ,[DATE] and "Blood Glucose Monitoring Technique" (with an unknown date): "The licensed nurse will assess the resident daily to determine any change in status. This process or assessment can be carried out throughout the shift. Observation and appraisal shall include, but not limited to....communication between licensed nurses....with other facility personnel...."; "Prepare the finger to be lanced....Prick the patient's finger lateral to the fingertip...." ( )

This citation pertains to MI 032, MI 351 and MI 056 and MI 358, and MI 176. Based on observation, interview and record review , the facility failed to evaluate change in the resident's condition and a "baseball size lump on the right upper arm/shoulder" from the time it was first noticed (10/09/13 during the day shift through 10/10/13 at approximately 8:00 a.m.) for one (#501) of three residents reviewed for assessment and change in condition, from a total sample of three, resulting in the delay in treatment and delay in hospitalization . In the subsequent hospitalization of resident #501 it was determined that the resident had multiple rib fractures, a right upper arm fracture, a right hemothorax and right pneumothorax. Findings Include: An unannounced on-site abbreviated survey was conducted at the facility on 10/15 and 10/16/13 regarding complainant allegations that Resident #501 sustained multiple fractures and injuries of unknown origin. Resident #501's clinical record was reviewed on 10/15/13 at approximately 3:00 p.m. and throughout the day on 10/16/13. Facility staff members were interviewed during this time period. The investigation revealed a delay in assessment for change of condition that lead to a delay in hospitalization and the findings of the investigation of the incident leading to hospitalization of injury was placed in chronological order: CNA (J), who was interviewed on 10/16/13 at 9:30 a.m. about the incident involving Resident #501 reported. "...while assisting CNA (L) to put the hoyer lift sling under the resident (resident #501)...on 10/09/13 in the morning... sometime before lunch, "...resident (# 501) was "screaming" when we were putting the sling under her (resident # 501)...I did tell unit manager (C)..." Unit manager (C) stated during an interview on 10/15/13 at 3:00 p.m., on 10/09/13 was she was told about resident #501 screaming and said she (unit manager (c) did not do a comprehensive assessment or evaluation on resident #501 (no time given), and stated, "...when it was reported to me ( by CNA K and L) that the resident # 501was screaming out, it was not unusual for the resident to yell out". There was no evidence that resident #501 was assessed by unit manager (C) to determine the cause of resident #501's screaming and yelling out. Unit manager (C) was unable to explain why a comprehensive evaluation was not conducted at that time (10/09/13--day shift--7:00 am to 3:00 p.m.) when resident #501 was "screaming out". According to a written statement made by CNA (L) on 10/09/13 and interview on 10/16/13 at 9:30 a.m., revealed that when she was assisting CNA (K) to get resident # 501 dressed for bed at dinner time (estimated to be between 5:00 p.m., and 6:00 p.m.) "...a large lump about the size of a baseball was observed on the resident's (#501's) right upper arm..." CNA (L) stated she did not report this "lump" to the nurse on duty at the time; however, did discuss it with CNA (K)--the person who was assigned to provide care for resident # 501 on 10/09/13, p.m. shift. (3:00 p.m. to 11:00 p.m.) and stated, " ...I think she (CNA K) forgot to tell the nurse, (nurse F) on duty at that time..." According to a written statement by CNA (K) and telephone interview conducted on 10/16/13 at 8:30 p.m., CNA (K) reported that on 10/09/2013, there was a large lump observed on resident #501's right upper arm, and stated, "...but I forgot to report it to the nurse (nurse F) ... there was another emergency going on with another resident...resident (# 501) was moaning and saying ouch..." On 10/16/2013 at 9: 45 a.m.., during an interview with CNA (L) it was reported on 10/09/2013 in the morning, resident #501 was "screaming out" when CNA (L) was getting the resident dressed for the day, stating, "... the unit manager (unit manager (C) and (CNA L) were right there... I never heard her (resident # 501) scream like that..." CNA (G) was interviewed and reported, "I... worked the midnight shift on 10/09/13, I did last rounds on her (resident#501) around 6:00 a.m., I changed her brief and repositioned her (resident #501). CNA (G) acknowledged resident #501 was repositioned by one person. However, the CNA care guide required that resident #501 be turned and repositioned with the assistance of two staff. The Nurse Practitioner (NP) reported, regarding resident #501's emergency situation on 10/10/13 in the morning resident (#501) was in obvious respiratory distress with abnormal vitals signs. The resident's "...oxygen saturation (oxygen in the blood) was 85-86 % on room air... I ordered [MEDICATION NAME] to help slow down the resident's breathing and [MEDICATION NAME] for the resident's anxiety...I did not do a full examination...range of motion... or assessment...the respiratory distress was more that likely caused by the fractured ribs, hemothorax and pneumothorax..." The NP was interviewed on 10/16/2013 at 9:00 a.m. Further review of resident #501's clinical record revealed a skin assessment was last conducted on 9/30/2013. The skin assessment did not identify a based ball sized lump on resident #501's right arm. According to a nursing note, dated 10/10/13 at 6:30 am written by Nurse (F), resident # 501 was found by CNA (certified nurse assistant) (G) at 6:30 a.m., as described in the following nursing note: "...CENA (competency evaluated nurse assistant) in to do last round care on resident, changed her brief, turned and repositioned her. Resident noted to experience some deep breathing, which was normal for resident when agitated, will continue to monitor.." There was no evidence documented in the clinical record that indicated resident #501 was assessed by the nurse on duty (Nurse F) to determine the source or cause of resident #501's "agitation" and "deep breathing" at the time of the nurses observation. Nurse (F) was interviewed on 10/16/13 at 3:00 p.m. and was unable to explain why an evaluation or assessment was not conducted for resident # 501 when it was reported by (D) that resident #501 was "agitated". Nurse (F) was interviewed on 10/16/2013 at 3:00 p.m. The next nursing note 10/10/13 at 7:00 a.m. that was signed by nurse (E) revealed resident # 501 was administered a scheduled dose of [MEDICATION NAME] (antianxiety medication) 1 mg (milligram) and the resident's condition was described as follows: " ...Respiration noted to be back to heavy and distressed ... " The next nursing entry, titled, "addendum" (no time provided) and signed by nurse (E) stated, " ... Day shift nurse in, NP (Nurse Practitioner) notified of resident's change in condition ... " The next nursing progress note (signed by day shift nurse (E) at 7:10 stated), "...received resident in bed, restless, tube feeding [MEDICATION NAME] 1.2 infusing at 70 cc/hr per peg (percutaneous endoscosopy gastrostomy tube...V/S (vital signs) taken B/P (blood pressure 111/86 P (pulse) 125, O 2 (oxygen blood saturation 86.1 %) (Target range 90-100%) Clinical Nursing Skills and techniques, Perry and Potter 6 th edition )... , R (Respirations)-48 ( normal range between 12 and 20 RPM), Clinical Nursing Skills and techniques, Perry and Potter 6 th edition )...pyrexia (Temperature 100.2 AX (axilla-under arm) ...At 7:20 (a.m.), reported to NP about resident's respiratory distress ... NP requested to give breathing treatment and [MEDICATION NAME] (pain medication) at 7:20 ...7:30 (am)... NP requested to transfer resident to the hospital..." The Nurse Practitioner progress notes for resident # 501 dated 10/10/13 at 7:45 a.m. was as follows: "..resident (resident # 501) was in ...respiratory distress ...respirations at 48 BPM (breaths per minute)... pulse rate 125 BPM (beats per minute) ... T (temperature) 100.1 ... diaphoretic (sweating) ...pale ... positive distress ... BS (breath sounds) diminished ...moaning ...in bed on(l) (left) side [MEDICATION NAME] given at 7 am [MEDICATION NAME] given at 7 am ...oxygen nebulizer treatment given at 7:40 a.m. ...no improvement ...send to (name of hospital) ...Respiratory distress, [MEDICAL CONDITION](rapid heart rate greater than 100, (Clinical Nursing Skills and techniques, Perry and Potter 6 th edition )...pyrexia (fever)...debility... affect flat (sad), moaning, respiration distress.. irregular... " The next entry "Addendum" (no time provided) was as follows: "...Spoke with ED (Emergency Department) physician at: 10:00 AM. Enquiring (inquiring) if pt (patient) had a fall. No falls were noted. Per Emergency Department (ED) physician pt had a broken arm, multiple rib fractures, & a pneumothorax. I transferred the call to DON for investigation..." On 10/15/13 at 2:00 p.m., resident #501 was observed in bed, in the intensive care unit at a local hospital. Resident # 501 was intubated (endotracheal-tube inserted through the mouth into the trachea to assist in mechanical breathing and oxygen delivery) and on a respirator/ventilator/life support. A chest tube (a catheter inserted through the thorax (chest) to drain fluid and/or air from the space between the lung/pleural cavity to allow/promote lung reexpansion) was inserted into resident # 501's right lateral (side) chest wall. There was approximately 1,000 cubic centimeters (approximately 33 ounces) of serosanguinous fluid (blood tinged) observed in a collection chamber that drained from the chest tube catheter. A fiber glass cast was on resident #501's right arm that extended from the shoulder to the wrist. The cast had been wrapped with an ace bandage. Resident #501's right hand and fingers were [MEDICAL CONDITION] (swollen) as well as the resident's feet and toes. Resident # 501 was not alert and was observed making facial grimaces when the hospital care giver touched or positioned her. Shortly afterwards, On 10/15/13 at 2:00 p.m., hospital records for resident # 501 were reviewed. The emergency medical service (EMS) progress notes revealed resident #501 was transported from the facility (priority one, emergency) at 8:00 a.m. on 10/16/2013, and arrived at a local hospital emergency department/room at 8:25 a.m.. The ER records and progress notes revealed the following: A hospital consultation request note at 9:20 a.m. stated, "...the patient was admitted on ,[DATE] after being brought in secondary to respiratory distress and was emergently (urgent) intubated (tube placed through the into the trachea (wind pipe) ER, post intubation on CXR (chest x-ray) revealed mult (multiple) rib FX (fractures--breaks) and hemothorax ( bloody fluid in the pleural cavity) and PTX (pneumothorax)( air or gas in the pleural cavity, around the lung) requiring CT (chest tube)...she (resident #501) was found to have (R) right humerus FX (fracture)..." At 9:24 a.m., a CT (computerized tomography) of the thorax and abdomen were performed and showed: Clinical indication: Trauma " ...Impression: 1. Small right pneumothorax (air or gas in around the lung) 2. Small right upper lobe [MEDICAL CONDITION] contusion (bruise) 3. [MEDICAL CONDITION] 3rd through 11 th ribs inclusively with the fourth through 10 th ribs fractured in 2 locations ...the fourth through tenth ribs are fractured posteriorly and laterally ... " A hospital x-ray report dated, 10/10/13 at 10:00 a.m., of resident # 501 " right arm was performed and revealed: " ...Clinical Indication: Pain: The right humerus was examined in two positions. [MEDICATION NAME] fracture through the proximal diaphyseal portion of the right humerus was identified. There is a lateral displacement of the distal fragment ...Summary: Fracture proximal diaphysis right humerus ... " An emergency physician progress notes [REDACTED].#501 stated the following: " ...Pt. (patient) ...sent from her nursing home for difficulty in breathing at 8:25 a.m., per ED staff, pt was [MEDICAL CONDITION] (rapid heart rate), tachypnea (rapid breathing) and unresponsive, so pt was intubated (VDRF) (...hemo ( thorax pneumothorax multiple rib (FX) fractures (4-11)and right pneumothorax ... ER placed thoracotomy (chest tube) ... ER placed (R) [MEDICATION NAME] (CVC) (central venous catheter)...(R) UE (upper extremity) likely contusion FX (fracture) place in ICU (intensive care unit) for management. On eval (evaluation) pt sedated, withdrawing to pain in all extremities..." The facility's policy " ...COMPREHENSIVE EVALUATION OF CHANGE OF CONDITION...", revised 8/13, stated licensed nursing staff will conduct concurrent review of all residents daily. Concurrent review is defined as daily rounds, which include observation and appraisal of each resident by a licensed nurse to determine any change in the resident's condition. The nurse will conduct a comprehensive evaluation of each resident with a change in physical and or mental status. ON 10/16/13 at 2:00 p.m., an interview was conducted with the administrator and the DON regarding resident #501 being identified at the facility with pain , restlessness, a large lump on the right arm and in respiratory distress the previous days, before being transported to a local hospital and lack of skin assessments and a comprehensive evaluation when a change in the residents condition was identified. Neither the administrator or DON were able to explain why interventions for resident # 501's change in condition had not been fully assessed and addressed. According to the face sheet record Resident #501 was originally admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent minimum (MDS) data set [DATE] revealed resident # 501 was totally dependent on staff for all activities of day living, non-ambulatory, and was severely impaired in cognitive skills for daily decision making. Resident #501 was immobile and totally dependent on staff for bed mobility, transfers ) and repositioning. Resident #501 received nutrition via gastrostomy tube (catheter tube inserted directly in the stomach to deliver formula). The initial nursing admission assessment (dated 2/8/12) for resident #501 reveled on admission into the facility, resident #501's skin was intact, range or motion was within normal limits with no contractures, a 2 person hoyer lift for transfer, breath sounds were even, regular and unlabored. The falls risk assessment revealed resident #501 was at high risk for falls. The facility's 24 hour incident report for resident #501 was reviewed. A typed report signed by the DON, dated 10/14/2013, (no time provided), stated, " ...on 10/10/2013 resident (#501) was sent to (name of hospital) ER (emergency room for respiratory distress at Approximately 745 (7:45 a.m.) Approx(approximately) 2-3 hours later a doctor from (name of hospital) ER stating that resident had multiple rib fractures, a pneumothorax on the right side and a right humerus fracture..." ( )3:00 p.m. and throughout the day on 10/16/13.

There are two deficient practice statements. Deficient Practice #1 (This citation pertains to intake MI 982) Based on interview and record review the facility failed to ensure all residents were free from abuse in 1 (Resident #108) of 11 residents reviewed for abuse out of a total sample of 11 residents when a Competency Evaluated Nurse Aide (CENA) yelled at Resident #108 making her feel belittled and afraid. Findings: Review of an "Admission Record" dated 10/8/13, indicated Resident #108 was a [AGE] year old woman originally admitted to the facility on [DATE]. Review of "Nurse's Notes" dated 10/01/13, indicated Resident #108 had [DIAGNOSES REDACTED]. Resident #108 was ventilator dependent and alert and oriented to person, place and situation and communicated by "mouthing" words and a writing board. Review of a "Facility Reported Incident 24 Hour Report" dated 10/5/13 indicated "At approximately 3:30 PM (10/5/13), (CENA "M") was becoming 'frustrated' with (Resident #108) as the resident was asking for numerous items, but due to ventilator was not able to be understood. CENA "M" then began yelling loudly at the resident and stating such things as..."I don't have time for this I need to make rounds" and stormed out of the room. Resident was physically upset and crying..." An "Investigation Statement" dated 10/5/13 by Respiratory Therapist "N" detailed witnessing a "...heated conversation between (Resident #108) and CENA "M"...CENA "M" was using an aggressive tone with (Resident #108) and (Resident #108) was very upset. CENA "M" left the room mumbling...(Resident #108) called me into the room and was crying and very upset..(Resident #108) said that CENA "M" was mean to her all the time...asked for another CENA to take care of her and wanted to report CENA "M". During an interview on 10/10/13 at 10:15 AM, Resident #108 stated, "...CENA"M" had an excuse about everything, she yelled 'I have other clients'...it made me feel like a child and even if I was a kid nobody needs to be treated like that...I don't feel safe..if I had it my way I'd be out of here believe me, this is terrible the way you're treated around here--it really is. They don't give you the time to say or do anything...fast, fast, fast, fast...I'm afraid to ask for help because I'm afraid they're not going to have time." Review of the facility policy for "Abuse and Neglect" last revised 2012, included definitions of mental and verbal abuse and neglect. "Mental Abuse-The infliction of mental/emotional suffering. It includes, but is not limited to, humiliation, harassment, making demeaning statements, intimidation, threats of punishment or deprivation. Verbal Abuse-The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident; such as telling a resident that he/she will never be able to see his/her family again. Neglect-The failure to provide goods and services necessary to avoid physical harm or mental anguish. Neglect is the failure to provide the necessary treatment, rehabilitation, care, attention, food, shelter, supervision, or medical services by a caregiver. Neglect is also creating situations in which esteem is not fostered. This could include instances where competent resident's wishes are not honored, restricting contact with family, ignoring the resident's need for verbal and emotional contact." Multiple attempts were made to contact and interview CENA "M" and were unsuccessful. Deficient Practice #1 (This citation pertains to intake MI 982) Based on record review and interview, the facility failed to ensure two person's assisted the positioning of one (Resident #102) of 11 residents reviewed for abuse, from a total sample of 11, during the performance of an X-Ray, resulting in the potential for mistreatment and the resident treated in a "rough manner". Findings include: The document "Resident Admission Record" (undated) reflected that Resident #102 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The document "Facility Incident Report - 24 Hours" (dated 7/3/13) reflected "Resident claims that this event took place on 6/27/13 but did not report to staff at facility until 7/02/13: He alleges that the x-ray technician while performing a chest x-ray "threw him around", pulled the pillow from under his head, and states that he "hurt his back" He said that it "hurt for a couple of days" but that he's fine now, as of today, 7/02/13". (PA "J" - Physician assistant) spoke with supervisor at (X-ray company's name), and they said they were investigating. The x-ray tech's (technician's) name is (x-ray tech "H")...." This report was signed by Former Administrator "C". The document "Facility Investigation Report - 5 Working Days" (dated 7/11/13) reflected "Investigation within the facility included an interview of 3 staff members working with the resident on the day and time of the occurrence. All 3 staff members stated they were not in the room during the x-ray on 6/27/13, and each staff member stated the resident did not complain of mistreatment after the x-ray on that day or after until he complained to the NP (Nurse Practitioner) on 7/02/13 (seven days later). The x-ray technician's supervisor with (X-ray company's name) was contacted and an investigation interview with (x-ray tech "H"s name)he stated that he "followed the protocols for the single AP CXR exam (anterior and posterior chest x-ray)". He did communicate with the patient indicating each step he was taking during the course of obtaining the radiograph. He also indicated, that due to the patient's condition (unable to communicate except via eye-activated computer and he was turned on his side) he had no way of knowing if the patient was uncomfortable during the exam..." This report was signed by Former Administrator "C". An e-mail response from the Director of the x-ray company "E"(dated 7/8/13), to the facility reflected "I apologize for the delay in responding to patient complaint -claim # 889, that our Xray tech was "rough" with him. My chief Tech (Chief Tech "K") did investigate and obtained in writing the visit by tech (x-ray tech "H"). Unfortunately, she has been on vacation, and I cannot access her file. I did speak with (x-ray tech "H") and he indicates that he followed the protocols for the single view AP CXR exam. He did communicate with the patient indicating each step he was taking during the course of obtaining the radiograph. He also indicated, that due to the patient's condition, he had no way of knowing if the patient was uncomfortable during the exam. I cannot substantiate any abuse of the patient at this time..." A written statement by X-ray tech "H" (dated 7/2/13) "On 6/28/13 I did an x-ray on (Resident #102). I obtained a 1 view AP CXR while following all proper procedures. at (sic) no time during the exam did I cause any harm to the pt. (patient). The only possible discomfort would have been from the imaging plate behind the pt back which is needed when establishing any CXR". Resident #102's Minimum Data Set (MDS) assessment (Dated 4/20/13) reflected that Resident #102 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which reflected he had no cognitive impairment. The same MDS assessment reflected that Resident #102 was totally dependent by "Two person physical assist" for "Bed mobility" and "Transfers". Resident #102's "Resident/Caregiver's Information Sheet" (dated 10/18/12) reflected a check next to "Assist 2" in the "Turn Position" box. Resident #102 was interviewed in his room on 10/9/13, beginning at 8:20 am. Resident #102 used his eye activated computer to type answers to questions. Resident #102 revealed that he had had an x-ray where the x-ray tech was "rough" with him. Resident #102 also revealed that the x-ray tech was alone when doing the x-ray and did not have a CNA help him when turning for the x-ray. Resident #102 then verified that there were rules in the facility about having 2 people work with him when turning and moving him in bed. The Director of Nursing (DON) was interviewed in her office on 10/9/13 at 1:20 pm. The DON was asked if there have been interventions put in place to prevent an x-ray tech from attempting to move Resident #102 for an x-ray without the help of an aid. The DON revealed that there were no facility practices in place to ensure x-ray techs would follow a residents plan of care. CNA "I" was interviewed on 10/9/13 at 1:40 pm, and indicated she was working with Resident #102 that day. CNA "I" stated that she had not been educated by the facility regarding being required to assist an x-ray tech in helping turn or transfer Resident #102. Multiple attempts were made by this surveyor to speak to X-ray tech "H" throughout the survey, but contact information could not be obtained by the facility, and had not been provided by the X-ray company. The Director of the x-ray company "E" was interviewed via phone on 10/10/13 at approximately 11:00 am. and stated that X-ray tech "H" was unavailable to speak at that time but did verify that X-ray tech "H" stated he was alone during the x-ray he performed with Resident #102 on 6/27/13. She went on to say X-ray tech "H" said he rolled Resident #102 over in bed and placed an x-ray plate underneath him, rolled him back over, took the x-ray, rolled him over again to remove the plaque, and rolled him back onto his back, all without the assist of one of the facility's staff. Director of the x-ray company "E" then added "I myself have done x-rays on vent (ventilator) patient's there and I have been alone. X-ray techs would ask for help if they feel they need it." The Facility's contract with the x-ray company (dated 4/12/02) reflected "... 21. Rules and Regulations: Notwithstanding any other provision in this contact, the Facility remains responsible for ensuring that any service provided pursuant to this Agreement complies with all pertinent provisions of federal, state and local laws, rules and regulations." ( )

This citation pertains to intakes MI 782, MI 983 Based on observation, interview and record review the facility failed to ensure all residents were free from accidents for one (#109) of 11 sampled residents reviewed for accidents from a total of 11 sampled residents resulting in residents when Resident #102 was moved in bed by an x-ray technician without appropriate staff assistance resulting in Resident #102 feeling that he was handled roughly and when a Competency Evaluated Nurse Aide (CENA) transferred Resident #109 in a mechanical lift without a second staff person and Resident #109 fell to the floor, dislodging her ventilator, resulting in Resident #109 feeling terrified. Findings include: Review of a "Resident Admission Record" undated, revealed Resident #109 was a [AGE] year old woman last admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a "Minimum Data Set" dated 5/27/13 indicated Resident #109 was cognitively intact and required total assistance of two people for bed mobility and transfers. Review of a "Resident/Caregiver's Information Form" found inside Resident #109's closet for quick reference by CENA's or nurses indicated Resident #102 was a "Full Lift with 2 Assist" for transfers using an extra-large sling. Review of a "Facility Report-24 hours" dated 10/7/13, indicated " ...CENA " M " was providing care to (Resident #109) and transferred Resident #109 without staff member. (Resident #109) asked CENA to get help and she did not. Hoyer (mechanical lift) began to lean and resident fell to the floor. CENA "M" did not report incident to nurse or supervisor ... ". Review of an "Accident/Incident Report" dated 10/7/13, indicated that on 10/4/13 around dinner time " ...CENA "M" was putting her back to bed alone with the Hoyer lift after dinner-the Geri-chair tipped back, the Hoyer tipped over and she fell to the floor. (Resident #109) alert and oriented ... " Review of a statement signed by Respiratory Therapist (RT) "L" indicated he responded to a 'low pressure alarm' for Resident #109 and upon arrival found Resident #109 connected to the Hoyer lift, suspended by the straps off of the ground between the vent table and her bed ...(RT "L" ) reconnected Resident #109 to the ventilator ...CENA "M" was trying to free Resident #109 from the Hoyer lift and the entangled straps ... ". Review of a facility investigation statement dated 10/7/13 at 4:45 PM, Resident #108, Resident #109 ' s roommate stated she overheard " ...( Resident #109 ) tell CENA "M" to get help (before the transfer), the aide said she didn't need no help... 'It scared the s*** out of me, it was sad, it was three people who helped get her off the floor, it was loud I thought the building was coming down ... " During an interview on 10/10/12 at 10:30 AM, Resident #109 said CENA "M" transferred her without help from another aide. " ...I went backwards, the vent almost fell off the table, the tubing came off ...I was so scared, I was terrified, I can't breathe or talk without my tubing ...it was terrible!". ( )

THIS CITATION PERTAINS TO INTAKE: MI 834. BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE STAFF SUPERVISION TO PREVENT FALLS 1 OF 5 RESIDENTS (#103) REVIEWED FOR FALLS, FROM A TOTAL SAMPLE OF 5, RESULTING IN RESIDENT #103 ROLLING OUT OF BED DURING CARE AND LACERATING HER FOREHEAD AND SUSTAINING A TYPE 2 DENS FRACTURE, (FRACTURE OF THE TOOTH-LIKE PROTRUSION FROM THE 2ND CERVICAL VERTEBRAE IN WHICH THE ATLAS AND CRANIUM ROTATES AROUND.) FINDINGS INCLUDE: ACCORDING TO THE FACILITY'S INCIDENT REPORT DATED 8/6/12, AT APPROXIMATELY 4:50 P.M., RESIDENT #103 WAS RECEIVING INCONTINENCE CARE FROM CERTIFIED NURSING ASSISTANT (CNA #6) WHEN THE RESIDENT ROLLED OFF THE BED ONTO THE FLOOR, LACERATING HER RIGHT EYEBROW AND FOREHEAD AREA. RESIDENT #103 WAS SENT TO THE HOSPITAL FOR treatment of [REDACTED]. ACCORDING TO THE HOSPITAL RECORD DATED 8/6/12, RESIDENT #103 WAS NONVERBAL, UNABLE TO FOLLOW ANY COMMANDS, AND UNRESPONSIVE TO TACTILE STIMULATION. A CT SCAN OF THE HEAD REVEALED A NON DISPLACED (TYPE 2) DENS FRACTURE. NO SURGICAL INTERVENTION WAS RECOMMENDED AND CERVICAL COLLAR WAS ORDERED. A REVIEW OF THE MEDICAL RECORD REVEALED THAT RESIDENT #103 WAS A [AGE] year OLD FEMALE WHO admitted to the facility on [DATE] WITH MULTIPLE [DIAGNOSES REDACTED]. RESIDENT #103 WAS IDENTIFIED TO HAVE NO VERBAL OR PHYSICAL RESPONSES TO STIMULI, DOES NOT FOLLOW ANY COMMANDS, AND IS TOTALLY DEPENDENT ON STAFF FOR ALL ACTIVITIES OF DAILY LIVING. ACCORDING TO THE MINIMUM DATA SET, RESIDENT #103 REQUIRES TOTAL ASSISTANCE OF 2 STAFF MEMBERS FOR BED MOBILITY, AND TRANSFERS. DURING OBSERVATIONS OF RESIDENT #103 ON 9/11/12 AT 11:15 A.M., AND AGAIN ON 9/12/12 AT 12:25 P.M., SHE DISPLAYED NO RESPONSES TO PHYSICAL OR VERBAL STIMULI. RESIDENT #103 DID NOT DISPLAY ANY TYPE OF VOLUNTARY MOVEMENT FROM UPPER OR LOWER EXTREMITIES. RESIDENT #103 WAS POSITIONED IN A BARIATRIC BED (LARGE SIZE) WITH A CERVICAL COLLAR IN PLACE, AND FLOOR MATS NEXT TO THE BED. DURING AN INTERVIEW ON 9/19/12 AT 10:00 A.M., CNA #6 SAID THAT SHE PULLED RESIDENT #103 TOWARDS HER AND THEN ROLLED HER ON HER SIDE, FACING AWAY FROM THE CNA. CNA #6 SAID THAT AFTER CLEANING RESIDENT #103 AND PLACING NEW LINEN AND PADS UNDER HER, SHE (CNA #6) ROLLED RESIDENT #103 ONTO HER BACK AND THE RESIDENTS LEGS SLID OFF THE BED. CNA #6 SAID WHEN SHE ATTEMPTED TO PUSH RESIDENT #103'S LEGS BACK ONTO THE BED, RESIDENT #103'S HEAD AND BODY fell OFF THE BED. RESIDENT #103 HIT HER FOREHEAD ON A PIECE OF MOLDING FROM THE NIGHTSTAND AND CUT HER RIGHT EYEBROW AREA. CNA #6 SAID RESIDENT #103 IS ONLY LISTED AS A 1 PERSON ASSIST WITH BED MOBILITY ON THE CARE CARD, EVEN THOUGH HER LEGS HAVE SLID OFF THE BED DURING INCONTINENCE CARE ON SEVERAL PAST OCCASIONS. DURING AN INTERVIEW ON 9/12/12 AT 2:00 P.M., THE ADMINISTRATOR SAID RESIDENT #103 IS NOW ON A LARGER BED (BARIATRIC) WITH FLOOR MATS ON THE FLOOR TO PREVENT ANY FURTHER FALLS. THE ADMINISTRATOR SAID CNA #6 WAS TERMINATED FROM THE FACILITY DUE TO NOT FOLLOWING THE POLICY REGARDING CARE FOR RESIDENT #103. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ASSESS, MONITOR AND PROVIDE PAIN CONTROL AFTER MULTIPLE TOOTH EXTRACTIONS (ORAL SURGERY) FOR ONE (#810) OF NINE SAMPLED RESIDENTS WHO WERE IDENTIFIED DEPENDENT ON STAFF TO ANTICIPATE THEIR NEEDS, FROM A TOTAL OF SEVENTEEN SAMPLED RESIDENTS, RESULTING IN A RESIDENT CRYING DUE TO THE FACILITY'S FAILURE TO DEVELOP A MEANS FOR THE RESIDENT TO COMMUNICATE PAIN, ANTICIPATE THE RESIDENT'S PAIN AND NEED FOR PAIN CONTROL, AND ADMINISTER PAIN MEDICATION. FINDINGS INCLUDE: ON 6/19/12, AT 9:15 A.M., AN INITIAL TOUR OF THE SECOND FLOOR NURSING UNIT WAS CONDUCTED WITH UNIT MANAGER (B). RESIDENT #810 WAS OBSERVED LYING IN BED AND BOTH OF RESIDENT #810 EYES WERE OPENED WIDE AND TEAR DROPS WERE FALLING ON THE RESIDENT'S CHEEKS. NO OTHER FACIAL EXPRESSIONS WERE OBSERVED. RESIDENT #810'S AFFECT WAS FLAT. IT WAS ALSO OBSERVED THAT THE RESIDENT'S TONGUE WAS PROTRUDING FROM HER MOUTH. DRIED BLOOD WAS OBSERVED ON THE RESIDENT'S TONGUE AND LIPS. A SUCTION CANISTER OVER THE HEAD OF THE BED AND ATTACHED TO THE WALL WAS FILLED WITH A BLOOD TINGED FLUID. UNIT MANAGER (B) EXPLAINED THE BLOOD TINGED FLUID WAS A RESULT OF RESIDENT #810 HAVING SEVERAL TEETH EXTRACTED ON 6/14/12 AT A LOCAL HOSPITAL. AT THAT TIME, UNIT MANAGER (B) WAS INTERVIEWED REGARDING RESIDENT #810'S TEARING EYES AND IF THIS MIGHT BE AN INDICATION THAT RESIDENT #810 COULD BE EXPERIENCING MOUTH PAIN. UNIT MANAGER (B) REPLIED, RESIDENT # 810 HAD NOT INDICATED PAIN WITH A FACIAL GRIMACE. RESIDENT #810'S TEAR FILLED EYES FOLLOWED THE UNIT MANAGER AROUND THE ROOM. TEARS CONTINUED TO FLOW DOWN RESIDENT #810'S CHEEKS, WITH STILL, NO OTHER FACIAL EXPRESSION. UNIT MANAGER (B) ASKED RESIDENT # 810 IF THERE WAS MOUTH PAIN PRESENT. IN REPLY, RESIDENT #810 CONTINUED TO STARE DIRECTLY AT UNIT MANAGER (B) WITH WIDE OPENED TEAR-FILLED EYES AND MADE NO OTHER ATTEMPT OR MEANS TO COMMUNICATE. UNIT MANAGER (B) FURTHER STATED, RESIDENT #810 WAS UNABLE TO COMMUNICATE. AT THAT POINT, RESIDENT # 810'S ROOMMATE (RESIDENT #811) INTERJECTED AND INFORMED UNIT MANAGER (B) TO INSTRUCT RESIDENT #810 TO BLINK HER EYES " ...ONCE FOR YES AND TWO TIMES FOR NO ... " UNIT MANAGER (B) INSTRUCTED RESIDENT #810 TO BLINK ONCE FOR "YES" IF THERE WAS MOUTH PAIN PRESENT AND TO BLINK TWO TIMES FOR "NO" IF THERE WAS NO MOUTH PAIN PRESENT. RESIDENT #810 BLINKED ONCE TO INDICATE, "YES" THERE WAS MOUTH PAIN PRESENT. AT 10:00 A.M., (6/19/12) UNIT MANAGER (B) INFORMED MEDICATION NURSE (A) THAT RESIDENT #810 WAS EXPERIENCING MOUTH PAIN. UNIT MANAGER (B) INSTRUCTED NURSE (A) TO COMMUNICATE WITH RESIDENT #810 BY INSTRUCTING THE RESIDENT TO BLINK ONCE FOR "YES--MOUTH PAIN PRESENT" AND TWICE FOR "NO-MOUTH PAIN NOT PRESENT". MEDICATION NURSE (A) ASKED RESIDENT #810 IF SHE WAS EXPERIENCING PAIN BY BLINKING ONE TIME FOR "YES" AND TWO TIMES FOR "NO". AGAIN, RESIDENT #810 INDICATED WITH ONE BLINK THERE WAS MOUTH PAIN PRESENT. RESIDENT #810 WAS UNABLE TO OPEN HER MOUTH FOR AN ORAL ASSESSMENT OF THE GUMS AND ORAL CAVITY. AT 10:30 A.M., NURSE (A) WAS INTERVIEWED AS TO WHETHER RESIDENT #810 HAD BEEN ASSESSED FOR PAIN AND OFFERED PAIN MEDICATION DURING THE 9:00 A.M., MEDICATION PASS. NURSE (A) STATED, "I DIDN'T KNOW SHE (RESIDENT #810) WAS IN PAIN..." RECORD REVIEW FOR RESIDENT #810, ON 6/19/12 AT 11:00 A.M., (REGARDING TEETH EXTRACTIONS) REVEALED THE FOLLOWING: 1. THERE WERE NO NURSING NOTES FROM 6/11/12 THROUGH 6/19/12 THAT REVEALED THE RESIDENT HAD ORAL SURGERY, THE NUMBER/EXTENT OF TEETH EXTRACTED, OR HOW RESIDENT #810'S WAS RESPONDING AFTER THE ORAL SURGERY 2. HOSPITAL PROGRESS NOTES AND DISCHARGE INSTRUCTIONS- THERE WERE NO HOSPITAL PROGRESS NOTES OR DISCHARGE INSTRUCTIONS IN RESIDENT #810'S CLINICAL RECORD OR IN THE FACILITY. 3. PHYSICIAN ORDERS- A physician's orders [REDACTED]. 4. THE Medication Administration Record, [REDACTED].M. THERE WAS NO EVIDENCE THAT RESIDENT #810 HAD BEEN ASSESSED FOR PAIN AND EVALUATED FOR PAIN RELIEF FROM 6/15/12 THROUGH 6/19/12. 5. PAIN ASSESSMENT- " RESIDENT PAIN REVIEW TOOL" DATED 6/04/12 STATED "...RESIDENT (#810) IS NOT VERBAL AND IS UNABLE TO ANSWER..." THERE WAS NO EVIDENCE THAT ANY OTHER ATTEMPTS WERE MADE TO ASSIST RESIDENT #810 TO COMMUNICATE PAIN. 6. PAIN PLAN OF CARE- "POTENTIAL FOR ALTERATION IN COMFORT/RELATED TO: HX OF MOUTH PAIN." THE CARE PLAN WAS LAST UPDATED/REVISED ON 6/04/12, BEFORE THE TEETH EXTRACTIONS ON 6/14/12. THE PLAN OF CARE HAD NOT BEEN UPDATED TO ADDRESS COMPLICATIONS RELATED TO TEETH EXTRACTIONS OR ORAL SURGERY. ON 6/19/12, AT 11:45 P.M., AN INTERVIEW WAS CONDUCTED WITH UNIT MANAGER (B) REGARDING RESIDENT #810'S TEETH EXTRACTIONS AND PAIN CONTROL. UNIT MANAGER (B) WAS UNABLE TO REPORT THE NUMBER OF TEETH RESIDENT #810 HAD EXTRACTED ON 6/14/12 OR LOCATE INFORMATION FROM THE SERVICING HOSPITAL RELATED TO RESIDENT #810'S TEETH EXTRACTION AND DISCHARGE INSTRUCTIONS. UNIT MANAGER (B) CONFIRMED THAT THE FACILITY FAILED TO DEVELOP A MEANS FOR RESIDENT #810 TO COMMUNICATE PAIN AND PAIN RELIEF, AND CONFIRMED THAT A PLAN OF CARE TO MONITOR FOR COMPLICATION RELATED TO TEETH EXTRACTIONS OR ORAL SURGERY SUCH AS SWELLING, BLEEDING, AND PAIN CONTROL WAS NOT DONE. WHEN UNIT MANAGER (B) WAS UNABLE TO LOCATE THE HOSPITAL PROGRESS NOTES AND DISCHARGE INSTRUCTIONS, UNIT MANGER (B) CONTACTED THE SERVICING HOSPITAL AND REQUESTED ADDITIONAL COPIES OF THE HOSPITAL PROGRESS NOTES AND DISCHARGE INSTRUCTIONS FOR RESIDENT #810. ON 6/20/12 AT 1:16 P.M., HOSPITAL DISCHARGE INSTRUCTIONS AND PROGRESS NOTES RELATED TO RESIDENT #810'S TEETH EXTRACTIONS AND ORAL SURGERY WERE FAXED TO THE FACILITY. THE DISCHARGE INSTRUCTIONS REVEALED RESIDENT #810 HAD ORAL SURGERY AND A TOTAL OF EIGHT TEETH EXTRACTED ON 6/14/12. THE HOSPITAL DISCHARGE INSTRUCTIONS INCLUDED MONITORING FOR THE FOLLOWING: "THE FOUR THINGS YOU SHOULD EXPECT TO EXPERIENCE AFTER YOUR SURGERY: 1. MINOR BLEEDING AND OOZING FOR 1-2 DAYS 2. PAIN AND DISCOMFORT SLOWLY IMPROVING IN 1-5 DAYS 3. SWELLING FOR 1 WEEK BECOMING WORSE ON THE 2ND OR 3RD AFTER SURGERY 4. TIGHTNESS AND STIFFNESS TO THE JAW AND JOINT AREAS THE FACILITY'S PAIN RISK REVIEW AND MANAGEMENT PROGRAM, LAST UPDATED 5/05/09 REVEALED THE FACILITY FAILED TO DO THE FOLLOWING: "...PROVIDE A CONSISTENT METHOD FOR THE REVIEW, PLANNING, DEVELOPMENT AND EVALUATION OF A PAIN MANAGEMENT PLAN OF CARE. THE TREATMENT PLAN IS GUIDED BY THE NEEDS OF THE RESIDENT AND MAY INCLUDE MEDICATION, PHYSICAL OR OCCUPATIONAL THERAPY, PAIN PSYCHOLOGY, INTERVENTIONS PROCEDURES, REFERRALS TO OTHER MEDICAL SPECIALIST OR NON-MEDICAL INTERVENTIONS... RESIDENTS WHO HAVE DEMENTIA AND CANNOT VERBALIZE THEY ARE FEELING PAIN SHOULD BE REVIEWED FOR SYMPTOMS OF PAIN. SYMPTOMS CAN BE MANIFESTED BY PARTICULAR BEHAVIORS SUCH AS: ? CALLING FOR HELP ? PAINED FACIAL EXPRESSIONS ? REFUSING TO EAT ? STICKING OUT AT ANYONE WHO TRIES TO MOVE THEM OR TOUCH A BODY PART ? RUBBING AREA ? PULLING AT CLOTHES ? ROCKING MOTION ON 6/22/12 AT 10:00 A.M., AN INTERVIEW WAS CONDUCTED WITH RESIDENT #810'S LEGAL GUARDIAN WHO WAS A FAMILY MEMBER. THE FAMILY STATED ON DURING A CARE CONFERENCE ON 5/29/12, WITH UNIT MANAGER (B), THE SOCIAL WORKER, AND THE RESPIRATORY THERAPIST PRESENT, THE FAMILY MEMBER PROVIDED INSTRUCTIONS ON HOW TO COMMUNICATE WITH RESIDENT #810. THE FAMILY STATED THE STAFF MEMBERS WERE INFORMED THAT RESIDENT #810 HAD ONLY ONE MEANS TO COMMUNICATE AND THAT WAS BY BLINKING, "...ONE FOR YES AND TWO FOR NO..." THE ADMISSION RECORD, DATED 2/09/12, INDICATED RESIDENT #810 WAS ORIGINALLY admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE INITIAL Minimum Data Set, dated dated [DATE], INDICATED RESIDENT #810 WAS SEVERELY IMPAIRED IN COGNITIVELY SKILLS FOR DAILY DECISION MAKING, NON AMBULATORY, TOTALLY DEPENDENT ON STAFF FOR ALL ACTIVITIES OF DAILY LIVING. RESIDENT #810 RECEIVED HER NUTRITION VIA GASTROSTOMY TUBE (TUBE INSERTED DIRECTLY INTO THE STOMACH TO DELIVER ENTERAL FORMULA). THE MINIMUM DATA SET REVEALED THE PAIN ASSESSMENT (SECTION J) WAS NOT COMPLETED AND LEFT BLANK AND INCOMPLETE. THE MOST RECENT ADMISSION NURSING ASSESSMENT, DATED 2/08/12, INDICATED RESIDENT #810 WAS ALERT WITH ADEQUATE VISION AND HAD UNCLEAR VERBAL EXPRESSIONS AND SLOW TO COMPREHEND. THE CARE AREA ASSESSMENTS, DATED 12/06/11, REVEALED THE FOLLOWING: COGNITIVE LOSS/ DEMENTIA - " ...RESIDENT HAS DX (DIAGNOSIS) OF DEMENTIA AND IMPAIRED ABILITY TO COMMUNICATE DUE TO AFFECTS [MEDICAL CONDITION]. SHE IS UNABLE TO COMMUNICATE THOUGHTS OR FOLLOW INSTRUCTION. STAFF ANTICIPATE HER NEEDS AND PROVIDE ALL CARE ACCORDING TO TREATMENT DECISIONS MADE BY LEGAL GUARDIAN ... " VISUAL FUNCTION- " ...RESIDENT NAME HAS IMPAIRED VISION. NO CHANGES. VISION CANNOT BE ASSESSED DUE TO NON-VERBAL STATUS. HER NEEDS ARE ANTICIPATED AND MET BY STAFF DAILY ... " COMMUNICATION- " ...(RESIDENT'S NAME) IS UNABLE TO COMMUNICATE HER NEEDS. SHE IS CHRONIC [MEDICAL CONDITION] ...HER NEEDS ARE ANTICIPATED AND MET BY STAFF. RESIDENT HAS HX (HISTORY) OF DEMENTIA [MEDICAL CONDITION] FURTHER COMPROMISES ABILITY TO COMMUNICATE ... " ON 6/22/12 AT 11:30 A.M., AN INTERVIEW WAS CONDUCTED WITH THE ACTING DIRECTOR OF NURSING (DON) (THE ASSISTANT DIRECTOR OF NURSING). THE ACTING DON CONFIRMED THE FACILITY FAILED TO ASSESS, MONITOR AND PROVIDE CONTROL FOR RESIDENT #810 status [REDACTED]. THE ACTING DON ALSO CONFIRMED THE FACILITY FAILED TO DEVELOP AND IMPLEMENT A PLAN OF CARE FOR RESIDENT #810 AFTER ORAL SURGERY TO MONITOR AND HELP PREVENT COMPLICATIONS RELATED TO ORAL SURGERY. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO DEVELOP A COMPREHENSIVE CARE PLAN AND IMPLEMENT INTERVENTIONS FOR ONE OF 17 SAMPLED RESIDENTS (#810) DEPENDENT ON STAFF TO ANTICIPATE THE RESIDENTS NEEDS AND status [REDACTED]. FINDINGS INCLUDE: ON 6/19/12, AT 9:15 A.M., AN INITIAL TOUR OF THE SECOND FLOOR NURSING UNIT WAS CONDUCTED WITH UNIT MANAGER (B). RESIDENT #810 WAS OBSERVED LYING IN BED. IT WAS OBSERVED THAT RESIDENT #810 EYES WERE OPENED WIDE AND TEAR DROPS WERE FALLING ON THE RESIDENT'S CHEEKS. NO OTHER FACIAL EXPRESSION WEE OBSERVED. RESIDENT #810 AFFECT WAS FLAT. IT WAS ALSO OBSERVED THAT THE RESIDENTS TONGUE WAS PROTRUDING FROM HER MOUTH. THE RESIDENTS TONGUE AND LIPS HAD DRIED ON BLOOD. A SUCTION CANISTER OVER THE HEAD OF THE BED AND ATTACHED TO THE WALL WAS FILLED WITH A BLOOD TINGED FLUID. UNIT MANAGER (B) EXPLAINED RESIDENT #810 HAD SEVERAL TEETH EXTRACTED ON 6/14/12, THUS, EXPLAINING THE BLOOD TINGED FLUID IN THE SUCTION CANISTER. AT THAT TIME, UNIT MANAGER (B) WAS INTERVIEWED REGARDING RESIDENT #810 TEARING EYES AND IF THIS MIGHT BE AN INDICATION THAT RESIDENT #810 COULD BE EXPERIENCING MOUTH PAIN. UNIT MANAGER (B) REPLIED, RESIDENT # 810 HAD NOT INDICATED PAIN WITH A FACIAL GRIMACE. RESIDENT #810 ' S TEAR FILLED EYES FOLLOWED THE UNIT MANAGER AROUND THE ROOM. TEARS CONTINUED TO FLOW DOWN RESIDENT #810'S CHEEKS, WITH STILL, NO OTHER FACIAL EXPRESSION AND A FLAT AFFECT. UNIT MANAGER (B) THEN ASKED RESIDENT # 810 IF THERE WAS MOUTH PAIN PRESENT. IN REPLY, RESIDENT #810 CONTINUED TO STARE DIRECTLY AT UNIT MANAGER (B) WITH WIDE OPENED, TEAR FILLED EYES AND MADE NO OTHER ATTEMPT OR MEANS TO COMMUNICATE. UNIT MANAGER (B) FURTHER STATED, RESIDENT #810 WAS UNABLE TO COMMUNICATE. AT THAT TIME, RESIDENT # 810'S ROOMMATE (RESIDENT #811) INTERJECTED AND INFORMED UNIT MANAGER (B) TO INSTRUCT RESIDENT #810 TO BLINK HER EYES, " ...ONCE FOR YES AND TWO NO ... " UNIT MANAGER (B) INSTRUCTED RESIDENT #810 TO BLINK ONCE FOR YES IF THERE WAS MOUTH PAIN PRESENT AND TO BLINK TWO FOR NO IF THERE WAS NO MOUTH PAIN PRESENT. RESIDENT #810 BLINKED ONCE TO INDICATE YES THERE WAS MOUTH PAIN PRESENT. AT 10:00 A.M., ( 6/19/12) UNIT MANAGER (B) INFORMED MEDICATION NURSE (A) THAT RESIDENT #810 WAS EXPERIENCING MOUTH PAIN. UNIT MANAGER (B) INSTRUCTED NURSE (A) TO INSTRUCT RESIDENT #810 TO BLINK ONCE FOR YES AND TWO FOR NO IF THERE WAS MOUTH PAIN PRESENT. AGAIN, RESIDENT #810 INDICATED WITH ONE BLINK TO INDICATE YES, THERE WAS MOUTH PAIN PRESENT. RESIDENT #810 WAS UNABLE TO FOLLOW INSTRUCTIONS TO OPEN HER MOUTH FOR AN ORAL ASSESSMENT OF THE GUMS. AT 10:30 A.M., NURSE (A) WAS INTERVIEWED AS TO WHY RESIDENT #810 HAD BEEN ASSESSED FOR PAIN AND OFFERED PAIN MEDICATION DURING THE 9:00 A.M., MEDICATION PASS. NURSE (A) STATED, "I DIDN'T KNOW SHE (RESIDENT #810) WAS IN PAIN. RECORD REVIEW FOR RESIDENT #810, ON 6/19/12 AT 11:00 A.M., (REGARDING TEETH EXTRACTIONS) REVEALED THE FOLLOWING: NURSING NOTES 6/11/12 THROUGH 6/19/12- NO MENTION OF TEETH EXTRACTIONS, PRE AND POST EXTRACTION, AND NO MENTION RESIDENT #810'S STATUS, CONDITION, OR MONITORING RELATED TO THE TEETH EXTRACTIONS/ORAL SURGERY. PAIN PLAN OF CARE- "POTENTIAL FOR ALTERATION IN COMFORT/RELATED TO: HX OF MOUTH PAIN", WAS LAST UPDATED/REVISED ON 6/04/12, BEFORE THE TEETH EXTRACTIONS ON 6/14/12. THE PLAN OF CARE HAD NOT BEEN UPDATED TO ADDRESS COMPLICATIONS RELATED TO TEETH EXTRACTIONS OR ORAL SURGERY SUCH AS BLEEDING, SWELLING AND PAIN. ON 6/19/12, AT 11:45 P.M., AN INTERVIEW WAS CONDUCTED WITH UNIT MANAGER (B) REGARDING RESIDENT #810 TEETH EXTRACTIONS, PAIN CONTROL AND MONITORING FOR COMPLICATIONS RELATED TO ORAL SURGERY AND TEETH EXTRACTIONS. UNIT MANAGER (B) WAS UNABLE TO EXPLAIN WHY A COMPREHENSIVE PLAN OF CARE HAD NOT BEEN DEVELOPED AND INTERVENTIONS IMPLEMENTED FOR RESIDENT #810 TO HELP PREVENT COMPLICATIONS RELATED TO ORAL SURGERY/TEETH EXTRACTIONS. ON 6/20/12 AT 1:16 P.M., HOSPITAL DISCHARGE INSTRUCTIONS AND PROGRESS NOTES RELATED TO RESIDENT #810'S TEETH EXTRACTIONS WERE REVIEWED. THE DISCHARGE INSTRUCTIONS REVEALED RESIDENT #810 HAD A TOTAL NUMBER OF EIGHT TEETH EXTRACTED ON 6/14/12. THE HOSPITAL DISCHARGE INSTRUCTIONS INCLUDED MONITORING FOR THE FOLLOWING: "THE FOUR THINGS YOU SHOULD EXPECT TO EXPERIENCE AFTER YOUR SURGERY: 1. MINOR BLEEDING AND OOZING FOR 1-2 DAYS 2. PAIN AND DISCOMFORT SLOWLY IMPROVING IN 1-5 DAYS 3. SWELLING FOR 1 WEEK BECOMING WORSE ON THE 2ND OR 3RD AFTER SURGERY 4. TIGHTNESS AND STIFFNESS TO THE JAW AND JOINT AREAS . THE FACILITY'S "PROCESS FOR CARE PLAN DEVELOPMENT AND COMMUNICATION" POLICY AND PROCEDURE DATED, 1/10/08, STATED THE FOLLOWING: THE RESIDENTS' PLAN OF CARE IS AN INTERDISCIPLINARY DOCUMENT TO BE USED AS A COMMUNICATION TOOL FOR ALL STAFF PROVIDING CARE. THE RESIDENTS CARE PLAN SHALL IDENTIFY THE RESIDENTS' NEEDS, PROBLEMS, STRENGTHS, RISKS FACTORS AND MEASURABLE GOALS...THE DIRECT CARE STAFF WILL UPDATE THE RESIDENT'S CARE PLAN AS THE RESIDENT'S NEEDS CHANGE. ( )

REFER TO INTAKE #MI 428 BASED ON OBSERVATIONS, INTERVIEWS AND CLINICAL RECORD REVIEW THE FACILITY FAILED TO MONITOR AND ASSESS AND PROVIDE APPROPRIATE WOUND/SKIN CARE AS ORDERED TO 2 (#101 AND #103) OF 5 SAMPLED RESIDENTS REVIEWED FOR SKIN AND WOUND CARE FROM A TOTAL SAMPLED OF 12, RESULTING IN THE DEVELOPMENT OF NEW SKIN BREAKDOWN. FINDINGS INCLUDE: RESIDENT #103 RESIDENT #103 WAS admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. THE NURSE AIDE (CNA) CARE CARD, UPDATED 4/26/12, NOTED THAT RESIDENT #103 WAS TO BE TURNED EVERY 2 HOURS, WAS IMMOBILE AND WAS INCONTINENT. RESIDENT #103'S CARE PLAN FOR ALTERATION IN URINARY ELIMINATION PATTERN DATED 2/16/12, WAS FOR INCONTINENCE CARE EVERY 2 HOURS AND PRN (AS NEEDED) AND TO MONITOR SKIN STATUS. HER BRADEN SCORE DATED 3/4/12, WAS 16, WHICH MEANS AT RISK FOR SKIN BREAKDOWN. THE MDS (MINIMUM DATA SET) ASSESSMENT, DATED 4/22/12, DOCUMENTED THAT RESIDENT #103'S FUNCTIONAL STATUS WAS TOTAL DEPENDENCE FOR ALL ADLS (ACTIVITIES OF DAILY LIVING), REQUIRING 2 PERSONS FOR BED MOBILITY AND TRANSFER. RESIDENT #103 WAS INCONTINENT OF BOTH BOWEL AND BLADDER. OBSERVATION OF RESIDENT #103 ON 4/30/12 AT 8:00 PM, REVEALED THAT RESIDENT #103 WAS WEARING TWO (2) INCONTINENCE PADS, BOTH SOAKED WITH URINE. NURSE AIDE #8 WAS INTERVIEWED ON 4/30/12 AT 8:00 PM. NURSE AIDE #8 STATED SHE WAS AWARE THAT RESIDENT #103 WAS ASSIGNED TO HER (#8) FOR CARE, BUT SHE (#8) DID NOT "GET AROUND TO HER (#103)" UNTIL NOW (8:00 PM) BECAUSE "WE WERE SHORT (STAFFED)." NURSE AIDE #8 STATED THAT SHE (#8) HAD NOT PROVIDED INCONTINENCE CARE TO RESIDENT #103 SINCE THE START OF THE SHIFT (AT 3:00 PM). NURSE AIDE #8 STATED SHE WAS ASSIGNED TO 10 RESIDENTS ON THE 2 WEST (VENT UNIT) AND RESIDENT #103 WAS THE ONLY RESIDENT ASSIGNED TO HER ON 2 EAST UNIT. NURSE AIDE #8 STATED FURTHER: "REALISTICALLY, IT IS IMPOSSIBLE TO PROVIDE INCONTINENCE EVERY 2 HOURS FOR EACH 11 RESIDENTS." FURTHER OBSERVATION REVEALED THAT THERE WAS REDNESS AND EXCORIATION AT THE RESIDENT'S PERIAREA AND BUTTOCKS. TWO (2) OPEN AREAS WERE FOUND ON RESIDENT #103'S LEFT BUTTOCKS AREA. ACCORDING TO THE DON, THESE TWO AREAS OF SKIN BREAKDOWN WERE PREVIOUSLY UNRECOGNIZED, NOT ASSESSED AND NOT ADDRESSED. DURING INCONTINENCE CARE, THE DON (DIRECTOR OF NURSING) ON 4/30/12 AT 8:15 PM, WITH THE 2 EAST CHARGE NURSE OBSERVED 2 OPEN AREA ON THE LEFT BUTTOCKS AREA. OBSERVATION REVEALED THAT THESE TWO AREAS WERE DIME-SIZED, WITHOUT DEPTH AND WITH ONE OF THE AREAS ONE ON THE FOLD OF THE BUTTOCK. AT 9:30 PM, ON 4/30/12, THE DON STATED THAT SHE COULD NOT FIND ANY DOCUMENTATION RELATED TO SKIN ALTERATION AND OPEN AREA IN RESIDENT #103'S TARS (TREATMENT ADMINISTRATION RECORD) AND NURSES NOTES OR SKIN ALTERATION/INITIAL WOUND EVALUATION. THERE WAS NO WRITTEN EVIDENCE OF ANY SKIN PROBLEM AT THE TIME OF THE OBSERVATION. SHE ALSO STATED THAT SHE REEDUCATED THE NURSING STAFF NOT TO PUT 2 INCONTINENCE PAD ON A RESIDENT. THE DON DID NOT EXPLAIN THE DEVELOPMENT OF THE TWO NEW OPEN AREAS ON RESIDENT #103'S BUTTOCK. ALTHOUGH NO TREATMENT ORDERS FOR THE OPEN AREA ON THE BUTTOCKS WERE FOUND, THE CLINICAL RECORD SHOWED A TREATMENT ORDER (#1) DATED 4/19/12 FOR [MEDICATION NAME] 1% CREAM TO BACK AND BUTTOCKS RASH BID (TWICE A DAY) X 5 DAYS. THE TAR DATED APRIL 2012, SHOWED THAT THIS TREATMENT WAS DONE ON 4/21 AT BREAKFAST AND ON 4/22/12 AT BREAKFAST TIME. NO ASSESSMENT OF THIS RASH WAS DONE FROM 4/19/12 THROUGH 4/23/12. NO FOLLOW UP WAS NOTED. A SECOND TREATMENT ORDER (#2) WAS WRITTEN ON 4/20/12, TO MIX EQUAL PART OF [MEDICATION NAME] CREAM, [MEDICATION NAME] CREAM, [MEDICATION NAME] CREAM AND [MEDICATION NAME] CREAM AND APPLY TO BACK Q (EVERY) DAILY UNTIL (RASH) DRIED UP. AN INITIAL "M" WAS NOTED ON 4/22/12 ON THE TAR. NO OTHER TREATMENT WAS RECORDED. RESIDENT #103 RECEIVED ONLY 1 treatment for [REDACTED]. THERE WAS NO ORDER TO DISCONTINUE THESE TREATMENT ORDERS (#1 AND #2). THE DON WAS ASKED BY THE SURVEYOR ON 4/30/12 AT 9:30 PM, TO RETRIEVE THE PRESCRIBED TREATMENT TUBES OR CREAM AND TO SHOW EVIDENCE TO THE SURVEYOR IF PHARMACY DELIVERED THE TREATMENT AS ORDERED. THE DON DID NOT SHOW ANY PROOF OR EVIDENCE THAT THESE ORDERED TREATMENTS HAD BEEN PROVIDED. RESIDENT #101: RESIDENT #101 WAS admitted to the facility on [DATE], WITH HISTORY OF T-BAR RESPIRATORY INSUFFICIENCY, SPINAL CORD INJURY, [MEDICAL CONDITION] IN ADDITION TO OTHER DIAGNOSIS. MDS dated [DATE], REVEALED THAT RESIDENT WAS TOTALLY DEPENDENT TO NURSING STAFF WITH ADLS (SUCH AS EATING, TOILET USE, AND BED MOBILITY). RESIDENT #101 REQUIRED 2 PERSON TO SAFELY AND APPROPRIATELY TRANSFER. RESIDENT #101 HAD SUPRAPUBIC CATHETER. RESIDENT #101 WAS OBSERVED DURING INCONTINENCE CARE ON 4/30/12 AT 8:45 PM, WAS OBSERVED WITH A PREVIOUSLY UNRECOGNIZED AND NOT ASSESSED OPEN AREA THE SIZE OF A QUARTER WITH NO DEPTH ON THE SKIN AT THE BUTTOCKS AREA. EVEN THOUGH RESIDENT #101 HAD A SUPRAPUBIC CATHETER IN PLACE THE INCONTINENCE PAD WAS SOAKED WITH URINE, AS URINE WAS LEAKING OUT FROM THE RESIDENT ' S PENIS, AS WAS OBSERVED BY THE SURVEYOR IN THE PRESENCE OF THE DON. PER DON ON 4/30/12 AT 9:00 PM, THERE WAS NO DOCUMENTATION REGARDING SKIN ALTERATION IN RESIDENT #101'S CLINICAL RECORD, TREATMENT RECORD OR SKIN/ WOUND EVALUATION FOR RESIDENT #101. NOTHING WAS FOUND ON THE NURSES' NOTES OR THE MAR. THE DON DID NOT EXPLAIN THE DEVELOPMENT OF THE NEW OPEN AREA ON RESIDENT #101'S BUTTOCK. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE APPROPRIATE TREATMENT, PRESSURE RELIEF DEVICES, REPOSITIONING, ASSESSMENT, MONITORING, DEVELOPMENT AND IMPLEMENTATION OF PLANS OF CARE TO PREVENT THE DEVELOPMENT OF NEW PRESSURE SORES FOR EIGHT (#'S 702, 704,705, 706, 707, 711, 712 AND 723) OF 11 RESIDENTS REVIEWED FOR PRESSURE ULCERS AND WHO ENTERED THE FACILITY WITHOUT PRESSURE ULCERS/SORES, RESULTING IN AN IMMEDIATE JEOPARDY AND THE POTENTIAL FOR THE DEVELOPMENT OF FURTHER FACILITY ACQUIRED PRESSURE ULCERS. THE IMMEDIATE JEOPARDY (IJ) WAS IDENTIFIED ON 8/19/11 AT 3:00 P.M. THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 8/19/11 AT 5:19 P.M. THE IJ WAS REMOVED ON 8/20/11 BASED ON THE PROVIDER'S IMPLEMENTATION OF CORRECTIVE ACTIONS ON 8/20/11, AS VERIFIED ONSITE ON 8/24/11, DURING THE COMPLETION OF THE EXTENDED SURVEY. ALTHOUGH THE IJ WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE WAS NOT CORRECTED AND REMAINED AS PATTERN. ACTUAL HARM THAT IS NOT IMMEDIATE JEOPARDY. THE FACILITY ALSO FAILED TO PROMOTE HEALING OF AN EXISTING PRESSURE ULCER FOR ONE (#710) RESIDENT FROM A TOTAL SAMPLE OF 23, RESULTING IN THE POTENTIAL FOR SERIOUS INFECTIONS TO RESIDENT # 710. FINDINGS INCLUDE: RESIDENT #706 WAS OBSERVED LYING ON HER BACK ON 8/16/11 AT 10:30 A.M., 12:05 P.M., 2:00 P.M. AND 3:05 P.M.; ON 8/17/11 AT 9:00 A.M., 11:30 P.M. AND 1:30 P.M.; ON 8/18/11 AT 9:00 A.M., 12:00 P.M., 2:00 P.M., 2:27 P.M. AND 3:15 P.M. AND ON 8/19/11 AT 8:53 A.M., 9:50 A.M. AND 12:30 P.M. RECORD REVIEW REVEALED THAT RESIDENT # 706 DEVELOPED A FACILITY ACQUIRED STAGE 4 SACRAL (BUTTOCK) DECUBITUS ULCER THAT MEASURED APPROXIMATELY 3.9 CENTIMETERS (CM) X 3.1 CM X 0.7 CM WITH PINK BASE, MODERATE SEROSANGUINOUS DRAINAGE AND IRREGULAR EDGES. A BRADEN SCALE, DATED 6/1/11 HAD A TOTAL SCORE OF 16. (A SCORE OF 15-18 = INDICATED THE INDIVIDUAL WAS "AT RISK" FOR PRESSURE SORE DEVELOPMENT). ON 8/17/11 AT 10:15 A.M., RESIDENT #706 WAS ALERT AND ORIENTED, LYING IN BED ON HER BACK. THE RESIDENT WAS INTERVIEWED AND STATED, "I'M JUST LYING HERE... I CAN ' T REMEMBER THE LAST TIME I WAS UP IN MY CHAIR IT'S BEEN SO LONG AGO. IT WOULD BE SO NICE TO GET UP ... " ON 8/18/11 AT 4:45 P.M., RECORD REVIEW REVEALED THAT RESIDENT # 706 WAS admitted INto the facility on [DATE] AND RE-admitted on [DATE] WITH [DIAGNOSES REDACTED]. THERE WAS NO DOCUMENTED EVIDENCE THAT THE RESIDENT HAD A PRESSURE SORE. REVIEW OF RESIDENT #706' S MINIMUM DATA SET (MDS) ASSESSMENTS REVEALED THE FOLLOWING: 1. MDS dated [DATE], NO DECUBITUS ULCER. 2. MDS dated [DATE], RIGHT SACRAL STAGE 2 DECUBITUS ULCER THAT WAS BROWN WITH ESCHAR AND NORMAL WOUND EDGES. 3. MDS dated [DATE], RIGHT SACRAL STAGE 4 DECUBITUS ULCER MEASURING 8.0 CM X 8.0 X 0 CM. 4. MDS dated [DATE], RIGHT SACRAL STAGE 4 DECUBITUS ULCER MEASURING 10.2 CM X 10.0 CM X 3.5 CM WITH NECROTIC ESCHAR (BLACK HARD TISSUE). RESIDENT #706 WAS TOTALLY DEPENDENT ON STAFF FOR ALL HER ACTIVITIES OF DAILY LIVING. THE RESIDENT HAD A FOLEY (URINARY) CATHETER AND WAS INCONTINENT OF STOOL. REVIEW OF THE CERTIFIED NURSING ASSISTANT (CNA) CARE CARD UPDATED 6/30/11 REVEALED THE FOLLOWING: 1. TURN EVERY 2 HOURS, DECUBITUS CARE AND PREVENTATIVE DEVICES. 2. SPECIAL CHAIR, 2 PERSON ASSIST. 3. ACTIVITIES: UP TO GERI-CHAIR AS TOLERATED MONDAY, WEDNESDAY AND FRIDAY. REVIEW OF RESIDENT # 706 CARE PLAN ENTITLED, "ALTERATION IN SKIN INTEGRITY RELATED TO ACTUAL PRESSURE (DECUBITUS) ULCER," DATED 7/1/11 REVEALED THE FOLLOWING INTERVENTIONS: 1. ASSESS NEED FOR ALTERNATIVE PRESSURE REDUCING MATTRESS - AIR MATTRESS DATED 7/1/11. 2. ASSESS NEED FOR LIMITED OOB (OUT OF BED) SCHEDULE - NOT TO EXCEED 2 HOURS PER INTERNAL DATED 7/1/11. 3. SPECIAL POSITIONING DEVICES UTILIZED - FUTON IN GERI-CHAIR DATED 7/1/11. RECOMMENDATIONS FROM WOUND CARE TEAM DATED 6/8/11 THROUGH 8/17/11 INCLUDED " FREQUENTLY REPOSITION. " RESIDENT # 707 WAS OBSERVED LYING IN HER BED ON HER BACK ON 8/16/11 AT 9:20 A.M., 12:00 P.M., 2:00 P.M. AND 3:40 P.M. ON 8/17/11 AT 9:00 A.M., 10:10 A.M., 11:30 A.M. AND 1:25 P.M. ON 8/18/11 AT 9:00 A.M., 12:00 P.M., 2:00 P.M., 2:27 P.M. AND 3:15 P.M. RECORD REVIEW REVEALED THAT RESIDENT # 707 WAS ALERT, ORIENTED TO SELF AND HAD A FACILITY ACQUIRED STAGE 4 SACRAL DECUBITUS ULCER THAT MEASURED APPROXIMATELY 4.0 CM X 5.0 CM X 4.0 CM. THE BASE OF THE WOUND HAD PINK TISSUE WITH SHINY MOIST GRANULAR APPEARANCE. ON 8/18/11 AT 1:30 P.M., RECORD REVIEW REVEALED THAT RESIDENT # 707 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. ACCORDING TO THE MDS ASSESSMENT, DATED 3/7/11, RESIDENT #707 DID NOT HAVE A DECUBITUS ULCER AT THE TIME OF HER ADMISSION. SHE WAS ALERT AND ORIENTED TO SELF, AT RISK FOR THE DEVELOPMENT OF A PRESSURE ULCER AND SHE WAS TOTALLY DEPENDENT ON STAFF FOR ALL ACTIVITIES OF DAILY LIVING. SHE HAD A FOLEY (URINARY) CATHETER AND WAS INCONTINENT OF STOOL. THE MDS assessment dated [DATE] REVEALED RESIDENT #707 HAD A STAGE 4 DECUBITUS ULCER ... REVIEW OF RESIDENT #707'S CARE PLAN ENTITLED, "ALTERATION IN SKIN INTEGRITY RELATED TO ACTUAL PRESSURE (DECUBITUS) ULCER," DATED 3/13/11 REVEALED RESIDENT #707 DEVELOPED A STAGE 2 COCCYX DECUBITUS ULCER OF THE LEFT AND RIGHT BUTTOCKS DATED 3/13/11. HOWEVER, ON 4/20/11, SHE HAD A STAGE 4 DECUBITUS ULCER THE CARE PLAN INCLUDED THE FOLLOWING INTERVENTIONS: 1. ASSESS NEED FOR ALTERNATIVE PRESSURE REDUCING MATTRESS (LOW AIR LOSS) DATED 4/20/11. 2. SPECIAL POSITIONING DEVICES UTILIZED - WEDGES DATED 5/18/11. 3. ONGOING ASSESSMENT FOR CHANGES TO CURRENT TURNING SCHEDULE PER CARE PLAN. 4. AVOID PRESSURE OVER BONY PROMINENCES. ACCORDING TO THE CERTIFIED NURSE ASSISTANT (CNA) CARE CARD DATED 6/7/11 THE FOLLOWING INTERVENTIONS WERE INCLUDED: 1. TURN EVERY 2 HOURS SIDE TO SIDE. 2. DECUBITUS CARE AND PREVENTATIVE DEVICES. THE WEDGE WAS NOT ORDERED UNTIL 5/18/11, THE WEDGE WAS ALSO NOT INCLUDED ON RESIDENT #707'S CARE PLAN AND WAS NOT OBSERVED IN PLACE DURING OBSERVATIONS 8/16/11 THRU 8/19/11. 3. RECOMMENDATIONS FROM WOUND CARE TEAM DATED 6/8/11 THROUGH 8/17/11 INCLUDED " FREQUENTLY REPOSITION. " ( ) REVIEW OF THE UNDATED ADMISSION RECORD INDICATED THAT RESIDENT #702 WAS ORIGINALLY admitted INto the facility on [DATE] AND RE-admitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MOST RECENT MINIMUM DATA SET (MDS), dated [DATE], INDICATED RESIDENT #702 HAD INDEPENDENT IN COGNITIVE SKILLS FOR DECISION MAKING, WAS NON-AMBULATORY AND TOTALLY DEPENDENT ON STAFF FOR BED MOBILITY, TRANSFERS, PERSONAL HYGIENE AND BATHING. THE ADMISSION NURSING ASSESSMENT, DATED 1/28/11, INDICATED RESIDENT #702'S SKIN WAS INTACT, WITH NO WOUNDS PRESENT. THE MINIMUM DATA SET (MDS), dated [DATE], INDICATED RESIDENT #702 HAD INDEPENDENT COGNITIVE SKILLS FOR DECISION MAKING, WAS NON-AMBULATORY AND TOTALLY DEPENDENT ON STAFF FOR BED MOBILITY, TRANSFERS, AND PERSONAL HYGIENE. RESIDENT #702 WAS INCONTINENT OF STOOL AND HAD AN INDWELLING CATHETER DUE TO [MEDICAL CONDITION]. THE MDS INDICATED RESIDENT #702 HAD NO UNHEALED PRESSURE SORES. THE CARE AREA ASSESSMENT (CAA), INDICATED RESIDENT #702 HAD NO PRESSURE ULCERS AND REMAINED AT RISK FOR THE DEVELOPMENT OF PRESSURE ULCERS DUE TO DECREASED MOBILITY STATUS. A CARE PLAN WAS INDICATED AND WOULD BE DEVELOPED. THE CARE AREA ASSESSMENT INDICATED, "... PROCEED WITH A CARE PLAN... " . THE "WEEKLY WOUND PROGRESS NOTE", DATED 4/4/11, INDICATED RESIDENT #702 HAD ACQUIRED A STAGE TWO (II) PRESSURE ULCER THAT MEASURED 6.5 X 1.5 CM. (STAGE II-PARTIAL THICKNESS LOSS OF DERMIS, PRESENTING AS A SHALLOW OPEN ULCER) THE WOUND physician progress notes [REDACTED]. THE WOUND physician progress notes [REDACTED]. (STAGE III- FULL THICKNESS TISSUE LOSS, SUBCUTANEOUS FAT MAY BE VISIBLE). ON 8/17/11 AT 11:40 A.M., A DRESSING CHANGE AND WOUND CARE OBSERVATION WAS CONDUCTED FOR RESIDENT #702 WITH THE WOUND CARE PHYSICIAN AND THE FACILITY'S WOUND CARE/TREATMENT NURSE (D). IT WAS OBSERVED THAT RESIDENT #702 HAD A STAGE III PRESSURE ULCER ON THE COCCYX THAT MEASURED 1.5 X 0.8 X 0.4, WITH A PINK BASE, THICK IRREGULAR BASES, AND MODERATE SEROUS DRAINAGE. DURING AN INTERVIEW ON 8/17/AT 12: 30 P.M., WOUND NURSE (D) WAS INTERVIEWED REGARDING ANY EVIDENCE OF INDIVIDUALIZED AND PREVENTATIVES INTERVENTIONS THAT WERE IN PLACE FOR RESIDENT #702 TO HELP PREVENT THE DEVELOPMENT OF NEW PRESSURE ULCERS. WOUND NURSE (D) WAS UNABLE AN PROVIDE ANY EVIDENCE THAT PREVENTATIVES MEASURES WERE IN PLACE FOR RESIDENT #702 PRIOR TO THE DEVELOPMENT OF THE PRESSURE ULCER THE COCCYX. REVIEW OF THE CLINICAL RECORD FOR RESIDENT #702 REVEALED THAT INDIVIDUALIZED PRESSURE ULCER PREVENTION INTERVENTION HAD NOT BEEN PUT IN PLACE UNTIL 5/04/11 AND AFTER THE ULCER ON RESIDENT #702's COCCYX HAD ALREADY DEVELOPED. ( ) ACCORDING TO THE ADMISSION RECORD (UNDATED) RESIDENT #712 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE ADMISSION MINIMUM DATA SET (MDS) INDICTED RESIDENT #712 WAS COGNITIVE INTACT FOR DAILY DECISION MAKING, NON-AMBULATORY, AND REQUIRED EXTENSIVE TO TOTAL ASSISTANCE WITH BED MOBILITY, TRANSFERS AND ACTIVITIES OF DAILY LIVING. THE NURSING ADMISSION SKIN CONDITION ASSESSMENT, DATED 8/08/11, INDICATED RESIDENT #712 WAS admitted TO THE FACILITY WITH NO WOUNDS PRESENT AND RESIDENT #712'S SKIN WAS INTACT WITH "...BOTTOM RED..." ON 8/16/11 AT 12:30 P.M., RESIDENT #712 WAS OBSERVED IN THE "DRAKE DINING ROOM" SEATED IN A WHEEL CHAIR. IT WAS OBSERVED RESIDENT #712 WAS SEATED ON A REGULAR WHEELCHAIR CUSHION AND NOT A ROHO CUSHION. LATER THAT SAME AFTERNOON AT 2:30 P.M., RESIDENT #712 WAS OBSERVED LYING IN BED. IT WAS OBSERVED THAT RESIDENT #712 WAS LYING IN BED ON A REGULAR PRESSURE RELIEF MATTRESS AND NOT AN AIR MATTRESS. ON 8/18/11 AT 9:00 A.M., RESIDENT #712 WAS OBSERVED IN THE "DRAKE" DINING ROOM SEATED IN A WHEEL CHAIR. IT WAS AGAIN NOTED THAT RESIDENT #712 WAS SEATED ON A REGULAR WHEELCHAIR CUSHION AND NOT THE ROHO CUSHION AS RECOMMENDED BY THE WOUND CARE PHYSICIAN. IN ADDITION, IT WAS OBSERVED THAT THERE WAS NO AIR MATTRESS ON THE BED FOR RESIDENT #712. ON 8/19/11 AT 12: 00 P.M., A WOUND CARE OBSERVATION WAS CONDUCTED FOR RESIDENT #712 WITH WOUND/TREATMENT NURSE (D). IT WAS OBSERVED THAT RESIDENT #712 HAD A PIN POINT OPENING ON THE SACRUM THAT MEASURED APPROXIMATELY 0.1 X 0.1 CM WITH AND PINK SURROUNDING TISSUE. IMMEDIATELY AFTER THE WOUND CARE AND DRESSING CHANGE HAD BEEN COMPLETED, WOUND NURSE (D) WAS INTERVIEWED REGARDING THE LACK OF PRESSURE RELIEF DEVICES FOR RESIDENT #712 AS RECOMMENDED BY THE WOUND CARE PHYSICIAN AND AS STATED IN THE PLANS OF CARE HAD NOT BEEN IMPLEMENTED. WOUND NURSE (D) HAD NO EXPLANATION. THE ADMISSION Minimum Data Set, dated dated [DATE], INDICATED RESIDENT #712 HAD NO PRESSURE ULCERS PRESENT AT THAT TIME, BUT WAS "AT RISK" FOR THE DEVELOPMENT OF PRESSURES ULCERS AND SKIN BREAKDOWN. THE CARE AREA ASSESSMENT (CAA) INDICATED INTERVENTIONS WOULD BE PUT IN PLACE FOR PREVENTION OF PRESSURE SORES/SORES. AN INITIAL WOUND EVALUATION, DATED 5/13/11, FOR RESIDENT #712 INDICATED RESIDENT #712 HAD ACQUIRED A STAGE II PRESSURE ULCER ON THE RIGHT (1.0 X 1.0 CM) AND LEFT BUTTOCK (0.1 X 0.1 CM) WITH MODERATE DRAINAGE/EXUDATE. A WEEKLY WOUND PROGRESS NOTE, DATED 5/25/11, INDICATED THERE HAD BEEN A CHANGE IN THE PRESSURE ULCER AND RESIDENT #712 HAD A STAGE II PRESSURE ULCER ON THE COCCYX THAT MEASURED 2.0 X 1.0 CM WITH MODERATE DRAINAGE /EXUDATE. THE PHYSICIAN'S WOUND CARE AND PROGRESS NOTE, DATED 6/01/11, INDICATED RESIDENT #712 HAD A STAGE III PRESSURE ULCER (FACILITY ACQUIRED) ON THE SACRUM THAT MEASURED 1.6 X 1.0 CM WITH A YELLOW NECROTIC BASE AND MODERATE SEROUS DRAINAGE . THE PERI-WOUND WAS ERYTHREMIC (RED IN COLOR). RECOMMENDATION INCLUDED ROHO CUSHION TO WHEELCHAIR AND AIR MATTRESS TO THE BED (SPECIAL AND INDIVIDUALIZED PRESSURE RELIEF DEVICES TO HELP RELIEVE PRESSURE ON BONY PROMINENCES AND HELPS TO PREVENT THE DEVELOPMENT OF PRESSURE ULCERS. A REVIEW OF THE NURSING PLAN OF CARE FOR RESIDENT #712, DATED, 5/13/11, 6/01/11 AND 7/30/11 FOR ACTUAL PRESSURE ULCERS AND PREVENTION INCLUDED IMPLEMENT AIR MATTRESS TO BED AND ROHO CUSHION TO WHEELCHAIR. THE WOUND PHYSICIAN'S WOUND CARE AND PROGRESS NOTE, DATED 7/06/11, INDICATED THE STAGE III SACRAL PRESSURE ULCER MEASURED 0.4 X 0.3 CM WITH MINIMAL SEROSANGUINOUS DRAINAGE. A BRADEN SCALE (TOOL USE TO DETERMINE PRESSURE SORE RISK), DATED 7/30/11, INDICATED RESIDENT #712 REMAINED AT RISK FOR THE DEVELOPMENT OF NEW PRESSURE ULCERS. THE WOUND PHYSICIAN'S WOUND CARE AND PROGRESS NOTE, DATED 8/03/11, INDICATED THE STAGE III PRESSURE ULCER ON RESIDENT #712'S SACRUM MEASURED 0.9 X 0.6 CM WITH A NECROTIC BASE AND THE PERI-WOUND WAS FRAGILE. THERE WAS NO CHANGE IN INDIVIDUALIZED PRESSURE RELIEF DEVICES AND INTERVENTIONS. THE WOUND PHYSICIAN'S WOUND CARE AND PROGRESS NOTE, DATED 8/17/11, INDICATED THE STAGE III PRESSURE ULCER ON RESIDENT #712 COCCYX WAS RESOLVED. ON 8/19/11 AT 10:30 AM., A DRESSING CHANGE AND WOUND CARE OBSERVATION WAS CONDUCTED ON RESIDENT #712 WITH THE FACILITY'S WOUND CARE NURSE (D). IT WAS OBSERVED THAT RESIDENT #712 HAD A PIN SIZE OPENING ON THE SACRUM THAT MEASURED 0.1 X 0.1 CM. THE FACILITY'S "SKIN AND WOUND MANAGEMENT PROGRAM OVERVIEW" POLICY AND PROCEDURE, DATED 6/01/07, STATED THE FOLLOWING" 1. ''...RESIDENTS IDENTIFIED AT RISK FOR DEVELOPMENT OF PRESSURE ULCERS WILL HAVE A CARE PLAN DEVELOPED AND DOCUMENTED TO MINIMIZE THE RISK OF DEVELOPING A PRESSURE ULCER... 2. "...RESIDENTS WITH NEWLY IDENTIFIED OR KNOWN PRESSURE ULCERS/ /WOUNDS WILL BE ASSESSED BY THE INTERDISCIPLINARY TEAM UPON NOTIFICATION AND WEEKLY THEREAFTER, AND A CARE PLAN WILL BE DEVELOPED, IMPLEMENTED, EVALUATED AND RE-EVALUATED TO TREAT ACTUAL PRESSURE ULCERS/WOUNDS AND MINIMIZE RISKS OF FURTHER OCCURRENCES..." ( ) RESIDENT #711 WAS OBSERVED LYING IN HER BED ON HER BACK ON 8/16/11 AT 11:35 A.M., 12:15 P.M., 2:10 P.M. AND 3:15 P.M., ON 8/17/11 AT 9:15 A.M., 11:35 P.M. AND 1:40 P.M.; ON 8/18/11 AT 9:05 A.M., 12:25 P.M., 2:05 P.M., 2:29 P.M. AND 3:25 P.M. AND ON 8/19/11 AT 8:50 A.M., 9: 55 A.M. AND 10:30 A.M. RECORD REVIEW REVEALED THAT RESIDENT # 711 HAD A FACILITY ACQUIRED STAGE THREE PRESSURE SORE ON THE RIGHT GLUTEAL THAT MEASURED APPROXIMATELY 0.9 CENTIMETERS (CM) X 0.7 CM X 0.3 CM WITH PINK BASE, MODERATE SEROSANGUINOUS DRAINAGE AND IRREGULAR EDGES. A VASCULAR ULCER'S ON THE RIGHT HEEL MEASURING 3.2 CM X 3.3 CM PINK BASE, MODERATE SEROSANGUINOUS DRAINAGE, IRREGULAR EDGES. A RIGHT MEDIAL LEG 2.0 CM X 1.0 CM PINK BASE MODERATE SEROSANGUINOUS DRAINAGE. A LEFT LATERAL ANKLE WITH MULTIPLE SUPERFICIAL WOUNDS WITH PINK BASES AND SCANTY SEROSANGUINOUS DRAINAGE. A BRADEN SCALE DATED 6/01/11 DOCUMENTED A TOTAL SCORE OF 16. (ADULT RESIDENTS < 18 = AT RISK). A TREATMENT OBSERVATION WAS MADE ON 8/19/11, AT 11:30 A.M., RESIDENT #711 WAS OBSERVED POORLY POSITIONED LYING IN BED ON HER BACK WITH HER HEAD IN BETWEEN THE RAISED LEFT SIDE RAILS AND PILLOW. AT THE TIME OF THE DRESSING CHANGE, THE TREATMENT NURSE, WAS OBSERVED AS SHE WASHED THE RIGHT GLUTEAL AND LEFT LATERAL ANKLE WITH THE WOUND CLEANSER SOLUTION. THE TREATMENT NURSE FAILED TO SPRAY SUFFICIENT AMOUNTS OF THE SOLUTION AND WHEN PULLING OFF THE OLD GAUZE ON THE LEFT LATERAL ANKLE WOUND, PART OF THE RESIDENTS SKIN CAME OFF AND WAS ATTACHED TO THE GAUZE. RESIDENT #711 WAS MOANING. ON 8/19/11 AT 3:45 P.M., RECORD REVIEW REVEALED THAT RESIDENT # 711 WAS admitted INto the facility on [DATE] AND RE-admitted on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF RESIDENT #711' S MINIMUM DATA SET (MDS) ASSESSMENTS REVEALED THE FOLLOWING: 1. MDS dated [DATE], 2 STAGE III DECUBITUS PRESSURE ULCERS--ONE OF THE ULCERS WAS PRESENT UPON ADMISSION. (MEASURED 1.4 CM X 2.5 CM X 0.0 CM.) 2. MDS dated [DATE], ONE STAGE 3 DECUBITUS ULCER RESIDENT #711 WAS TOTALLY DEPENDENT ON STAFF FOR ALL HER ACTIVITIES OF DAILY LIVING. SHE HAD A FOLEY (URINARY) CATHETER AND WAS INCONTINENT OF STOOL. REVIEW OF THE CERTIFIED NURSING ASSISTANT (CNA) CARE CARD UPDATED 6/16/11 REVEALED THE FOLLOWING: 1. TURN EVERY 2 HOURS, DECUBITUS CARE AND PREVENTATIVE DEVICES. 2. SPECIAL CHAIR, 2 PERSON ASSIST. 3. ACTIVITIES: UP TO GERI-CHAIR AS TOLERATED MONDAY, WEDNESDAY AND FRIDAY. THE CARE PLAN FOR RESIDENT #711 INDICATED "AT RISK FOR IMPAIRED SKIN INTEGRITY RELATED TO ACTUAL PRESSURE (DECUBITUS) ULCER " DATED 6/16/11 REVEALED THE FOLLOWING: 1. ASSESS NEED FOR ALTERNATIVE PRESSURE REDUCING MATTRESS - AIR MATTRESS DATED 6/16/11. 2. SPECIAL POSITIONING DEVICES UTILIZED - PILLOW OR CUSHION BETWEEN BONY PROMINENCES. 3. MONITOR IMPACT OF PAIN ON QOL ISSUES (SLEEP, APPETITE, SOCIALIZATION, ENERGY LEVEL) AND ADDRESS ACCORDINGLY. MONITOR FOR NON- VERBAL INDICATORS OF PAIN, (FACIAL GRIMACING, GUARDING, MOANING, ETC.). MONITOR RESIDENT FOR CHANGES IN SIGNS AND SYMPTOMS OF PAIN, MEDICATE PER PHYSICIAN ORDER, MONITOR EFFECTIVENESS OF PAIN MEDICATION AND PAIN MODALITIES AND ADJUST AS INDICATED, IDENTIFY ACTIVITIES THAT CAN EXACERBATE PAIN AND MEDICATE PRIOR TO ACTIVITY AS INDICATED. ( ) ON 8/16/11 AT 9:15 A.M., STAFF "E "WAS QUERIED ABOUT THE FREQUENCY IN WHICH RESIDENTS ARE TURNED. STAFF E STATED, "RESIDENTS ARE TURNED EVERY TWO HOURS." ON 8/17/11 AT 11:15 A.M., WOUND CARE TREATMENT WAS OBSERVED FOR RESIDENT #705, WHO HAD A STAGE 4 PRESSURE ULCER (FULL THICKNESS, TISSUE LOSS WITH EXPOSED BONE, TENDON OR MUSCLE) ON THE POSTERIOR THORAX, MEASURING 7.0 CM IN LENGTH X 3.0 CM IN WIDTH. THE WOUND WAS DRAINING MODERATE AMOUNTS OF SEROSANGUINOUS (CLEAR FLUID MIXED WITH BLOODY) FLUID. THE WOUND WAS FOUL SMELLING. ON 8/17/11 , RESIDENT #705 WAS OBSERVED LYING IN BED AWAKE RESTING ON HER BACK. THE RESIDENT HAD BEADS OF MOISTURE ON HER FOREHEAD AND HER FAN WAS BLOWING ON HER. A RESIDENT INTERVIEW WAS CONDUCTED AT 2 P.M. WHEN THE RESIDENT WAS ASKED THE LAST TIME SHE WAS REPOSITIONED, SHE STATED, "THEY DON'T... THEY ONLY COME IN TO TURN ME WHEN I ASK THEM (FACILITY STAFF). I ONLY ASK THEM (FACILITY STAFF) TO REPOSITION ME WHEN I START FEELING PAIN. I NORMALLY ASK FOR A TURN ABOUT EVERY FOUR TO SIX HOURS BUT BY THEN, I'M USUALLY IN A LOT OF PAIN." ADDITIONALLY, RESIDENT #705'S BILATERAL HEELS WERE RESTING ON THE MATTRESS. THEY WERE NOT ELEVATED, AND WERE OBSERVED TO BE "CRUSTY", DRY, AND PEELING WITH MULTIPLE SMALL RED AREAS DEVELOPING ON LEFT HEEL. RESIDENT #705 REQUESTED TO BE TURNED BY THE FACILITY STAFF AT 2:10 P.M. AT 3:30 P.M., 4:30 P.M., 5:30 P.M., AND 6:30 P.M., RESIDENT #705 WAS OBSERVED LYING IN BED ON HER BACK IN THE SAME POSITION SHE WAS IN AT 2:10 P.M. RESIDENT #705 WAS NOT REPOSITIONED OR OFFERED TO CHANGE HER POSITION BY FACILITY STAFF FOR A TOTAL OF FOUR HOURS AND TWENTY MINUTES. ON 8/17/11 AT 3:30 P.M., A REVIEW OF THE FACE SHEET REVEALED THAT RESIDENT #705 WAS admitted INto the facility on [DATE]. THE HISTORY AND PHYSICAL, DATED 11/17/08, INDICATED THAT RESIDENT #705 WAS diagnosed with [REDACTED]. THE QUARTERLY MINIMUM DATA SET (MDS), dated [DATE], INDICATED THAT RESIDENT #705 NEEDED TOTAL ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING. THE RESIDENT WAS BEDFAST (DID NOT GET OUT OF BED). THE RESIDENT SCORED 15 OUT OF 15 ON THE BRIEF INTERVIEW FOR MENTAL STATUS (BIMS) AND WAS ABLE TO COMMUNICATE HER NEEDS. THE FACILITY'S CORPORATE VARIATION OF THE "BRADEN SCALE" (AN ASSESSMENT TOOL TO IDENTIFY PRESSURE ULCER RISK) WAS COMPLETED ON 5/25/11 AND THE RESIDENT WAS IDENTIFIED AS A "14", WHICH INDICATED THE RESIDENT WAS "AT RISK" FOR PRESSURE ULCER DEVELOPMENT. THE WOUND WAS FIRST DESCRIBED IN A WEEKLY WOUND PROGRESS NOTE DATED, 9/15/10. THE RIGHT POSTERIOR THORAX WOUND DEVELOPED 9/15/10 AND MEASURED 5.5 CM IN LENGTH X 3.0 CM IN WIDTH. THE WOUND BASE WAS DESCRIBED AS "BEEFY RED" WITH "IRREGULAR EDGES", AND MINIMAL HEMORRHAGIC (BLOODY) DRAINAGE. THE SURROUNDING TISSUE WAS "RASHY AND ROUGH". RECENT WOUND CARE PROGRESS NOTES DESCRIBE INCREASE IN SIZE OF THE [MEDICATION NAME] WOUND AS FOLLOWS: 7/06/11: 6.0 CM IN LENGTH X 4.5 CM IN WIDTH--BEEFY RED BASE. MODERATE SEROSANGUINOUS DRAINAGE. RECOMMEND FREQUENT REPOSITIONING. 7/13/11: 6.5 CM IN LENGTH X 4.0 CM IN WIDTH--PINK BASE WITH IRREGULAR EDGES. HEAVY SEROSANGUINOUS DRAINAGE. RECOMMEND FREQUENT REPOSITIONING AND FLOAT HEELS. THE PHYSICIAN ALSO NOTED AN OPEN AREA ON THE RIGHT HEEL MEASURING 0.3 CM IN LENGTH X 0.2 CM IN WIDTH. THE WOUND BASE WAS PINK WITH SCANT SEROUS DRAINAGE. 7/27/11: 6.0 CM IN LENGTH X 3.0 IN WIDTH--RED BEEFY BASE. MODERATE SEROSANGUINOUS DRAINAGE WITH IRREGULAR EDGES. RIGHT HEEL 0.4 CM IN LENGTH X 0.4 CM IN WIDTH. SUPERFICIAL PINK BASE WITH SCANT SEROUS DRAINAGE. RECOMMEND FREQUENT REPOSITIONING AND FLOAT HEELS. [MEDICATION NAME] (ANTI-FUNGAL) POWDER EACH DAY TO THE RIGHT HEEL FOR 14 DAYS. 8/03/11: 6.5 CM IN LENGTH X 3.4 CM IN WIDTH--PINK BASE WITH HEAVY SANGUINEOUS DRAINAGE. RECURRENT CANDIDAL (FUNGUS) [MEDICAL CONDITION] RIGHT HEEL RESOLVED, HOWEVER, [MEDICATION NAME] POWDER TO RIGHT HEEL FOR SEVEN DAYS. RECOMMEND FREQUENT REPOSITIONING AND FLOAT HEELS. 8/10/11: 6.5 CM IN LENGTH X 4.5 CM IN WIDTH--RED BEEFY BASE WITH MODERATE SANGUINEOUS DRAINAGE AND IRREGULARE EDGES. RECURRENT CANDIDAL (FUNGUS) [MEDICAL CONDITION] RIGHT HEEL RESOLVED, HOWEVER, [MEDICATION NAME] POWDER TO RIGHT HEEL FOR SEVEN DAYS. RECOMMEND FREQUENT REPOSITIONING. DURING AN INTERVIEW WITH THE WOUND CARE PHYSICIAN ON 8/17/11 AT 11:15 AM AND REVIEW OF HIS PROGRESS NOTE, DATED 8/17/11, RESIDENT #705 CURRENTLY HAD A STAGE FOUR (IV) PRESSURE ULCER THAT MEASURED 7.0 CM IN LENGTH X 3.0 CM IN WIDTH. THE PRESSURE SORE WAS DESCRIBED AS "BEEFY RED" WITH A HEMORRHAGIC BASE AND MODERATE SEROSANGUINEOUS DRAINAGE. THE PHYSICIAN RECOMMENDED FREQUENT REPOSITIONING AND FLOATING HEELS (ELEVATE HEELS OFF THE MATTRESS). A REVIEW OF THE "NURSING ALTERATION IN SKIN" CARE PLAN, DATED 3/16/11, REVEALED THAT RESIDENT #705'S HEELS WERE TO BE ELEVATED WHILE IN BED. THE RESIDENT CARE PLAN, DATED 5/04/11 AND UPDATED 6/01/11, FAILED TO IDENTIFY A TURNING SCHEDULE, ASSISTIVE DEVICES USED TO AID IN POSITION CHANGES, OR EDUCATION TO THE RESIDENT REGARDING THE CONSEQUENCES FOR REMAINING IN BED. ON 8/18/11 AT 11:00 AM, 12:00 P.M., 1:00 P.M., 2:10 P.M., AND 3:45 P.M., RESIDENT #704 WAS OBSERVED LYING IN BED RESTING ON HER RIGHT SIDE FACING THE DOOR IN THE SAME POSITION. RESIDENT #704 WAS NOT REPOSITIONED BY THE FACILITY STAFF FOR A TOTAL OF FOUR HOURS AND FORTY-FIVE MINUTES. MULTIPLE REQUESTS FOR OBSERVATION OF RESIDENT #704'S WOUND CARE WERE MADE; HOWEVER, THE ONLY TREATMENT NURSE IN THE FACILITY WAS UNABLE TO FACILITATE AN OBSERVATION DURING THE SURVEY. ON 8/18/11 AT 3:45 P.M., A REVIEW OF THE FACE SHEET REVEALED THAT RESIDENT #704 WAS admitted INto the facility on [DATE]. THE HISTORY AND PHYSICAL, DATED 6/10/10, INDICATED THAT RESIDENT #704 WAS diagnosed with [REDACTED]. THE QUARTERLY MDS, dated [DATE], INDICATED THAT RESIDENT #704 WAS HIGHLY VISUALLY IMPAIRED AND NEEDED TOTAL ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING. THE FIVE STAR "BRADEN SCALE" TOOL FORM DATED 8/19/11, REVEALED RESIDENT #704'S BRADEN SCORE WAS 12 (HIGH RISK FOR SKIN BREAKDOWN). NURSING PROGRESS NOTES FIRST IDENTIFIED THE WOUND ON 1/14/11 AND DESCRIBED IT AS 1.6 CM IN LENGTH X 0.8 CM IN WIDTH X 0.5 CM DEEP. THE WEEKLY WOUND PROGRESS NOTE, DATED 1/19/11 IDENTIFIED THE COCCYX WOUND, IDENTIFIED AS A STAGE III (full layer of skin is destroyed. A stage 3 bed sore pressure sore or decubitus ulcer extends into the underlying subcutaneous tissue layer, but not all the way to the bone), A stage 3 bed sore pressure sore or decubitus ulcer extends into the underlying subcutaneous tissue layer, but not all the way to the bone), THAT MEASURED 1.6 CM IN LENGTH X 0.8 CM IN WIDTH X 0.5 CM IN DEPTH. WOUND BASE IS PINK AND RED WITH WELL-DEFINED WOUND EDGES. DRAINAGE IS MODERATE WITH INTACT PERI-WOUND TISSUE. PLACE IN-DWELLING CATHETER FOR WOUND MANAGEMENT. A DEBRIDEMENT AGENT WAS INITIATED. THERE WAS NO EVIDENCE THIS RESIDENT'S WOUNDS WERE EVALUATED BY A WOUND CARE SPECIALIST UNTIL 6/01/11. THE WOUND CARE PROGRESS NOTES DESCRIBED THE COCCYX STAGE III PRESSURE SORE AS FOLLOWS: SACRAL STAGE III PRESSURE ULCER MEASURING 0.8 CM IN LENGTH X 0.5 CM IN WIDTH X 0.4 CM DEPTH. PINK BASE, IRREGULAR THICK EDGES, PERI-WOUND MINIMAL SEROUS DRAINAGE. RECOMMEND: PRESSURE REDUCTION MATTRESS, FREQUENT REPOSITIONING, AND FLOAT HEELS. NO OTHER WOUND CARE SPECIALIST EVALUATIONS WERE PROVIDED. THE QUARTERLY MDS, dated [DATE], INDICATED THAT RESIDENT # 704 HAD ONE STAGE III COCCYX PRESSURE ULCER, MEASURED AT 2.1 CM IN LENGTH, 0.7 CM IN WIDTH AND 0.3 CM IN DEPTH. A REVIEW OF RESIDENT #704'S, MDS dated [DATE], REVEALED THE WOUND INCREASED IN SIZE AND WAS DESCRIBED AS A STAGE III COCCYX PRESSURE ULCER, MEASURED AT 2.1 CM IN LENGTH X 0.7 CM IN WIDTH X 0.3 CM IN DEPTH. THE "C.E.N.A CARE CARD" FORM, DATED, 5/22/11, DIRECTED THE NURSING STAFF THAT RESIDENT #704 WAS TO BE TURNED EVERY TWO HOURS. REVIEW OF THE INTERDISPLINARY CARE PLAN, DATED 6/01/11 FAILED TO ADDRESS THE NEED FOR RESIDENT #704 TO BE TURNED WITH ANY FREQUENCY. ( / ) ACCORDING TO THE CLINICAL RECORD FACE SHEET, RESIDENT #723 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. ON 8/26/11 AT 10:00 AM, REVIEW OF THE ADMISSION NURSING ASSESSMENT FOR RESIDENT #723, DATED 8/22/11 REFLECTED THAT RESIDENT #723 WAS INCONTINENT, TOTALLY DEPENDANT ON STAFF FOR BED MOBILITY AND TRANSFER. THE "INITIAL WOUND EVALUATION FOR RESIDENT #723, DATED 8/22/11, DOCUMENTED THAT RESIDENT #723 HAD A REDDENED AREA ON THE SACRUM/COCCYX, "... NO OPEN AREAS." THERE WAS NO EVIDENCE OF TREATMENT ORDERS TO ADDRESS THE SKIN CONDITION FOR RESIDENT #723. THE BRADEN SCALE FOR RESIDENT #723, DATED 8/22/11 DOCUMENTED A SCORE OF 15 WHICH INDICATED RESIDENT #723 WAS AT HIGH RISK FOR PRESSURE ULCERS. THERE WAS NO DOCUMENTED EVIDENCE OF ANY NURSING INTERVENTIONS TO HELP PREVENT PRESSURE ULCERS AND FURTHER SKIN BREAKDOWN FOR RESIDENT #723. ON 8/26/11 AT 2:25 PM, A SKIN ASSESSMENT FOR RESIDENT #723 WAS CONDUCTED WITH WOUND NURSE "D". IT WAS OBSERVED RESIDENT #723, HAD ACQUIRED A STAGE 2 PRESSURE ULCER ON THE COCCYX THAT MEASURED 1.0 CM X 0.5 CM WITH A REDDENED PERIO-WOUND (SURROUNDING THE ULCER AREA). (STAGE 2- PARTIAL THICKNESS LOSS OF DERMIS PRESENTING AS A SHALLOW OPEN ULCER). THE 8/2011 PHYSICIAN ORDERS [REDACTED]. DURING AN INTERVIEW, UNIT MANAGER "E" COULD NOT EXPLAIN WHY INTERVENTIONS FOR RESIDENT 723'S SKIN HAD NOT BEEN PUT IN PLACE. FURTHER, UNIT MANAGER "E" COULD NOT EXPLAIN WHY THERE WERE NO TREATMENT ORDERS FOR RESIDENT #723'S REDDENED SACRAL/COCCYX AREA UPON ADMISSION to the facility on [DATE]. ( , ) THE FACILITY SUBMITTED THE FOLLOWING PLAN OF ACTION TO REMOVE THE IMMEDIATE JEOPARDY: " A SKIN SWEEP WAS COMPLETED ON 8/19/11 TO ASCERTAIN ANY POTENTIAL UNIDENTIFIED SKIN ISSUES. RESIDENT #702'S BRADEN SCORE IS 12. HE/SHE WAS REASSESSED ON 8/19/11 AND IS CURRENTLY UTILIZING AN ACCUMAX STAGE III/IV MATTRESS AND ROHO WHEELCHAIR CUSHION. HIS/HER HEELS ARE FLOATED ON PILLOWS. HE/SHE IS TURNED IN ACCORDANCE WITH HIS/HER PLAN OF CARE (POC) BY NURSING STAFF. THE POC HAS BEEN UPDATED TO BE REFLECTIVE OF THE SAME. RESIDENT #704'S BRADEN SCORE IS 14. HE/SHE WAS REASSESSED ON 8/19/11 AND IS CURRENTLY UTILIZING AN ACCUMAX STAGE III/IV MATTRESS AND IS ON BEDREST. HIS/HER HEELS ARE FLOATED ON PILLOWS. HE/SHE IS TURNED IN ACCORDANCE WITH HIS/HER PLAN OF CARE (POC) BY NURSING STAFF. THE POC HAS BEEN UPDATED TO BE REFLECTIVE OF THE SAME. RESIDENT #705'S BRADEN SCORE IS 13. HE/SHE WAS REASSESSED ON 8/19/11 AND IS CURRENTLY UTILIZING AN ACCUMAX STAGE III/IV MATTRESS AND IS ON BEDREST. HE/SHE IS UTILIZING A "HEELZUP" DEVICE TO FLOAT THE HEELS. HE/SHE IS TURNED IN ACCORDANCE WITH HIS/HER PLAN OF CARE (POC) BY NURSING STAFF. THE POC HAS BEEN UPDATED TO BE REFLECTIVE OF THE SAME. RESIDENT #706'S BRADEN SCORE IS 14. HE/SHE WAS REASSESSED ON 8/19/11 AND IS CURRENTLY UTILIZING A LOW AIR-LOSS MATTRESS AND A ROHO WHEELCHAIR CUSHION. HIS/HER HEELS ARE FLOATED ON PILLOWS. HE/SHE IS TURNED IN ACCORDANCE WITH HIS/HER PLAN OF CARE (POC) BY NURSING STAFF. THE POC HAS BEEN UPDATED TO BE REFLECTIVE OF THE SAME. RESIDENT #707'S BRADEN SCORE IS 12. HE/SHE WAS REASSESSED ON 8/19/11 AND IS CURRENTLY UTILIZING A LOW AIR-LOSS MATTRESS IS ON BEDREST. HIS/HER HEELS ARE FLOATED ON PILLOWS. HE/SHE IS TURNED IN ACCORDANCE WITH HIS/HER PLAN OF CARE (POC) BY NURSING STAFF. THE POC HAS BEEN UPDATED TO BE REFLECTIVE OF THE SAME. RESIDENT #710'S BRADEN SCORE IS 12. HE/SHE IS A HOSPICE RESIDENT AND WAS REASSESSED ON 8/19/11 AND IS CURRENTLY UTILIZING AN ACCUMAX STAGE III/IV MATTRESS AND IS ON BEDREST. HIS/HER HEELS ARE FLOATED ON PILLOWS. HE/SHE IS TURNED IN ACCORDANCE WITH HIS/HER PLAN OF CARE (POC) BY NURSING STAFF. THE POC HAS BEEN UPDATED TO BE REFLECTIVE OF THE SAME. RESIDENT #711'S BRADEN SCORE IS 11. HE/SHE IS A HOSPICE RESIDENT AND WAS REASSESSED ON 8/19/11 AND IS CURRENTLY UTILIZING AN PLEXIUS MATTRESS AND A STAGE III/IV WHEELCHAIR CUSHION. HIS/HER HEELS ARE FLOATED ON PILLOWS. HE/SHE IS TURNED IN ACCORDANCE WITH HIS/HER PLAN OF CARE (POC) BY NURSING STAFF. THE POC HAS BEEN UPDATED TO BE REFLECTIVE OF THE SAME. RESIDENT #712'S BRADEN SCORE IS 12. HE/SHE WAS REASSESSED ON 8/18/11 AND IS CURRENTLY UTILIZING AN ACCUMAX STAGE III/IV MATTRESS AND IS ON BEDREST. HE/SHE HAS A ROHO WHEELCHAIR CUSHION. HIS/HER HEELS ARE FLOATED ON PILLOWS. HE/SHE IS TURNED IN ACCORDANCE WITH HIS/HER PLAN OF CARE (POC) BY NURSING STAFF. THE POC HAS BEEN UPDATED TO BE REFLECTIVE OF THE SAME. TREATMENTS ARE COMPLETED BY THE WOUND CARE NURSE OR DESIGNEE IN ACCORDANCE WITH THE MD ORDERS FOR ALL RESIDENTS. ALL OTHER RESIDENTS WERE REASSESSED FOR BRADEN SCORES AND EQUIPMENT NEEDED ON 8/20/11 WITH EQUIPMENT CHANGES COMMENSURATE WITH THAT INFORMATION. ANY IN NEED OF UPDATED PLANS OF CARE HAVE BEEN COMPLETED. RESIDENTS ARE ASSESSED FOR PREVENTION MEASURES UPON ADMISSION, WEEKLY FOR THE FIRST FOUR WEEKS, QUARTERLY AND WITH SIGNIFICANT CHANG BE OF CONDITION BY USING THE BRADEN RISK ASSESSMENT. THE FACILITY WOUND CARE PHYSICIAN HAS SEEN RESIDENTS WITH PRESSURE WOUNDS WEEKLY SINCE JUNE. HE MADE ROUNDS ON 8/17/11 AND SAW RESIDENTS WITH PRESSURE WOUNDS AND COMPLETED NEW RECOMMENDATIONS AS NEEDED, AND WILL CONTINUE ON THIS ROTATION WEEKLY. ALL ORDERS FOR TREATMENTS FOR CURRENT RESIDENTS WITH PRESSURE ULCERS HAVE BEEN REVIEWED AND ANY CHANGES REQUIRED WERE COMPLETED. SKIN SWEEPS WILL BE COMPLETED WEEKLY DURING THE CORRECTIVE PERIOD, WITH ALL INFORMATION BEING FORWARDED TO THE QA COMMITTEE FOR FURTHER ANALYSIS AND ACTION. NURSES WERE RE-EDUCATED IN COMPL

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROTECT ONE (#714) OF 23 SAMPLED RESIDENTS FROM MISTREATMENT AS RESIDENT #714 WAS FORCEFULLY HELD DOWN BY TWO STAFF MEMBERS WHILE A NURSE GAVE THE RESIDENT AN INTRAMUSCULAR (IM) [MEDICATION NAME] INJECTION AGAINST HER WILL, RESULTING IN AN IMMEDIATE JEOPARDY TO THE RESIDENT'S HEALTH AND SAFETY AS EVIDENCED BY EMOTIONAL DISTRESS AND MISTREATMENT. THE IMMEDIATE JEOPARDY (IJ) WAS IDENTIFIED ON 8/17/11 AT 9:25 A.M. THE FACILITY'S ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 8/18/11 AT 5:55 P.M. THE IJ WAS REMOVED ON 8/19/11 BASED ON THE PROVIDER'S IMPLEMENTATION OF CORRECTIVE ACTIONS ON 8/19/11, AS VERIFIED ONSITE ON 8/19/11. ALTHOUGH THE IJ WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE WAS NOT CORRECTED AND REMAINED AS ISOLATED. ACTUAL HARM THAT IS NOT IMMEDIATE JEOPARDY. FINDINGS INCLUDE: ON 8/17/11 AT 9:25 A.M., DURING THE MEDICATION PASS OBSERVATION, MEDICATION NURSE (A), UNIT MANAGER (B), AND CERTIFIED NURSE ASSISTANT (CNA) (C), WERE OBSERVED AS THEY ENTERED RESIDENT #714'S ROOM. RESIDENT #714 WAS SEATED IN HER RECLINER CHAIR. SHE HAD A CALM DEMEANOR AND DISPLAYED NO AGGRESSIVE BEHAVIORS. NURSE (A), UNIT MANAGER (B) AND CNA (C) APPROACHED THE RESIDENT. NURSE (A) STATED, "I AM GOING TO GIVE YOU YOUR MEDICINE." RESIDENT #714 RESPONDED, "I DON'T WANT YOUR MEDICINE... I DON'T WANT YOUR INJECTION... LEAVE ME ALONE AND GO AWAY." UNIT MANAGER (B) AND CNA (C) USED BOTH OF THEIR HANDS TO FORCEFULLY HOLD (PHYSICALLY RESTRAIN) RESIDENT #714'S ARMS TO HER SIDE. UNIT NURSE MANAGER (B) USED HER LEGS TO HOLD RESIDENT #714'S LEGS DOWN. NURSE (A) FORCED THE [MEDICATION NAME] INJECTION INTO RESIDENT #714'S LEFT UPPER ARM. THE THREE INCH NEEDLE BECAME DISCONNECTED FROM THE SYRINGE CONTAINING MEDICATION AND WAS MOMENTARILY STUCK IN THE RESIDENT'S ARM. THE SYRINGE SEPARATED FROM THE NEEDLE AND THE MEDICATION SPLASHED ALL OVER. RESIDENT #714 CONTINUED TO PLEAD AND YELL THAT SHE DID NOT WANT ANY INJECTION AND STAFF SHOULD LEAVE HER ALONE. ALL THREE STAFF MEMBERS DISREGARDED THE RESIDENT'S WISHES TO BE LEFT ALONE . RECORD REVIEW ON 8/17/11 AT 2:35 P.M., REVEALED THAT RESIDENT #714 WAS admitted INto the facility on [DATE], WITH [DIAGNOSES REDACTED]. REVIEW OF THE MOST CURRENT QUARTERLY MINIMUM DATA SET (MDS), dated [DATE], INDICATED THE RESIDENT HAD "CLARITY OF SPEECH", USUALLY UNDERSTOOD AND COMPREHENDED MOST CONVERSATION, HAD VISION IMPAIRMENTS, THOUGH SHE WAS ABLE TO SEE LARGE PRINT. RESIDENT #714 HAD SEVERELY IMPAIRED LONG AND SHORT TERM MEMORY PROBLEMS AND THERE WAS NO INDICATION OF POSSIBILITY FOR THIS RESIDENT TO HARM HERSELF. BEHAVIORAL SYMPTOMS WERE IDENTIFIED AS PHYSICAL AND VERBAL ABUSE DIRECTED TOWARDS OTHERS. RESIDENT #714 WAS TOTALLY DEPENDENT ON STAFF FOR ACTIVITIES OF DAILY LIVING. THE RESIDENT WAS PRESCRIBED A CHAIR THAT PREVENTED HER FROM RISING WHICH WAS DOCUMENTED AS A FORM OF PHYSICAL RESTRAINTS. REVIEW OF THE MEDICATION ADMINISTRATION RECORDS (MAR) REVEALED an order written [REDACTED]. THIS DOSAGE WAS GIVEN TO THE RESIDENT FOR ALL OF AUGUST 2011. REVIEW OF THE BEHAVIOR LOG SHEETS FOR AUGUST 2011 REVEALED THE RESIDENT HAD NOT EXHIBITED ANY VERBALLY ABUSIVE OR PHYSICALLY ABUSIVE BEHAVIORS. DURING A BRIEF INTERVIEW ON 8/17/11, AT 9:45 A.M., AFTER INCIDENT, UNIT NURSE MANAGER (B) ON 1-EAST, INDICATED THAT THE [MEDICATION NAME] IM INJECTION WAS THE "ONLY WAY TO GET RESIDENT #714 TO GET HER TREATMENT SINCE SHE IS RESISTIVE TO CARE." NURSE (A) AND CNA (C) WERE NOT AVAILABLE FOR INTERVIEW. DURING AN INTERVIEW ON 8/17/11, AT 10:08 A.M., THE EYE DOCTOR VOICED CONCERNS THAT [MEDICATION NAME] 3 MILLIGRAMS (MG) INJECTION WAS NOT NECESSARY OR NEEDED FOR RESIDENT #714. THE DOCTOR STATED RESIDENT #714 HAD "DENSE [MEDICAL CONDITION]". THE DOCTOR ADDED THE RESIDENT WAS ABLE TO SEE AND ABLE TO FEED HERSELF. IN AN INTERVIEW ON 8/17/11, AT 12:59 A.M., WITH THE DIRECTOR OF NURSING (DON), SHE REPORTED RESIDENT #714 SHOULD NOT HAVE BEEN PHYSICALLY AND CHEMICALLY RESTRAINED IN ORDER TO RECEIVE AN INJECTION "AGAINST HER WILL." THE DON INDICATED THAT THE NURSING STAFF SHOULD NOT HAVE RESTRAINED THE RESIDENT AND SHOULD HAVE RESPECTED THE RESIDENT'S RIGHTS TO REFUSE TREATMENT. THE ADMINISTRATOR WAS ASKED ABOUT THE FACILITY'S POLICY THAT ADDRESSED INDIVIDUAL RESIDENT'S RIGHTS TO REFUSE MEDICATION. THE ADMINISTRATOR REPORTED THERE WAS NO FACILITY POLICY--STAFF WERE FAMILIAR WITH "RESIDENT'S RIGHTS". REVIEW OF THE FACILITY'S ABUSE PROHIBITION AND PREVENTION PROGRAM POLICY, DATED 10/20/08, DID NOT DEFINE "MISTREATMENT" AND DID NOT ADDRESS HOW STAFF WOULD PROCEED WITH CARE WHEN A RESIDENT OBJECTED TO CARE, TREATMENT OR SERVICES. ON 8/19/11 THE FACILITY SUBMITTED THE FOLLOWING PLAN OF ACTION TO REMOVE THE IMMEDIATE JEOPARDY: "(AT) 1:15 P.M., SURVEYORS INFORMED THE NURSING HOME ADMINISTRATOR AND DIRECTOR OF NURSING THAT THEY HAD OBSERVED AN INCIDENT OF MISTREATMENT BETWEEN 9:15 AND 9:30 A.M. INVOLVING RESIDENT #714. IMMEDIATELY FOLLOWING THE INFORMATION BEING RECEIVED, THE THREE STAFF MEMBERS INVOLVED WERE REMOVED FROM RESIDENT CARE AND INTERVIEWED SEPARATELY. AT THE CONCLUSION OF THOSE INTERVIEWS, ALL THREE STAFF MEMBERS WERE SUSPENDED PENDING INVESTIGATION AND REMOVED FROM THE FACILITY. A BODY CHECK WAS ATTEMPTED BY THE WOUND CARE NURSE AND RESTORATIVE SUPERVISOR BUT REFUSED BY RESIDENT #714. RESIDENT #714 WAS RE-APPROACHED TIMES ONE AND CONTINUED TO REFUSE, SO OBSERVATIONS WERE MADE OF HER HAND AND WRIST ON THE LEFT ARM AND HER HAND, WRIST AND FOREARM ON THE RIGHT SIDE WHICH SHOWED NO SIGNS OF BRUISING OR REDNESS. THE IM INJECTION WAS A ONE TIME DOSE RELATED TO THE NEED OF AN EYE EXAM AND ORDERED BY THE PHYSICIAN WHO WAS PRESENT IN THE FACILITY AT THE TIME OF THE ALLEGED EVENT. PHYSICIAN WAS NOTIFIED AND ORDER WAS DISCONTINUED. GUARDIAN WAS NOTIFIED. RESIDENT #714 WAS INTERVIEWED BY THE SOCIAL WORKER (SW) AND RESIDENT #714 RESPONDED WITH NONSENSICAL REMARKS. ALL OTHER NON-INTERVIEWABLE RESIDENTS RECEIVED A BODY CHECK TO ASCERTAIN IF THEY HAD ANY INDICATIONS OF ABUSE THAT MAY HAVE NOT BEEN REPORTED. ANY IRREGULARITIES WILL BE BROUGHT FORWARD FOR INVESTIGATIONS AS INDICATED TO THE QA COMMITTEE. ALL INTERVIEWABLE RESIDENTS HAVE QUERIED ON CARE RELATED ISSUES BY MANAGEMENT STAFF ON 8/19/11. ALL NON-INTERVIEWABLE RESIDENT HAVE HAD SKIN ASSESSMENT TO ASSESS FOR ANY SIGNS OF INJURY THAT WOULD RELATE TO MISTREATMENT OR ABUSE BY 8/19/11. AT 3:30 P.M. INFORMATION WAS GATHERED ON RESIDENT RIGHTS AND ABUSE. IN-SERVICING WAS STARTED BY THE SW ON 8/17/11 AND HAS CONTINUED ON EVERY SHIFT TO DATE. 101 OF 176 STAFF MEMBERS HAVE BEEN IN-SERVICED AT THIS TIME. IN-SERVICING WILL BE CONDUCTED DURING EACH SHIFT UNTIL ALL STAFF HAVE BEEN RE-EDUCATED. THE FACILITY HAS DEVELOPED A PROTOCOL TO ADDRESS REFUSAL OF CAR ISSUES FOR STAFF TO REFERENCE. RESIDENT RIGHTS AND ABUSE TRAINING IS CONDUCTED DURING THE GENERAL ORIENTATION PROCESS AND THEN AT LEAST ANNUALLY THEREAFTER. MED PASS AND CARE OBSERVATIONS WILL BE CONDUCTED BY NURSING MANAGEMENT ON A DAILY BASIS TO ASSESS FOR UNUSUAL REACTIONS OR BEHAVIORS RELATED TO THIS TASK DURING THE CORRECTIVE PERIOD. RESIDENT INTERVIEW WILL BE CONDUCTED DAILY BY MANAGEMENT STAFF (ADMINISTRATOR, MANAGER ON DUTY, SOCIAL WORKER) TO QUERY CARE RELATED ISSUES DURING THE CORRECTIVE PERIOD. MED PASS/CARE OBSERVATIONS AND RESIDENT INTERVIEWS WILL BE BROUGHT FORWARD ON A DAILY BASIS MONDAY THROUGH FRIDAY, TO THE NHA, FOR REVIEW. ANY IRREGULARITIES NOTED WILL BE BROUGHT FORWARD TO THE QA COMMITTEE FOR FURTHER ANALYSIS AND ACTION PLANNING. A RESIDENT COUNCIL MEETING WILL BE CONDUCTED ON 8/19/11 FOR THE PURPOSES OF EDUCATING THE RESIDENTS OF THEIR RIGHTS; INCLUDING BUT NOT LIMITED TO THE RIGHT TO REFUSE TREATMENT. THESE SAME ISSUES WILL BE DISCUSSED AT ALL RESIDENT COUNCIL MEETINGS GOING FORWARD TO ENHANCE THE EDUCATION PROCESS. THE FARMINGTON POLICE DEPARTMENT WAS NOTIFIED OF THE ALLEGED ABUSE FOR THEIR PURPOSES. THIS PLAN OF CORRECTION AND ALL IRREGULARITIES WILL BE FORWARDED TO THE QA COMMITTEE FOR FURTHER ANALYSIS AND ACTION. THE ADMINISTRATOR WILL BE RESPONSIBLE FOR THE COMPLIANCE OF THIS POC." ( , , , , )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT 3 (#'s 703, 708, AND 714) OF 3 SAMPLED RESIDENTS WITH RESTRAINTS OUT OF A TOTAL SAMPLE OF 23 RESIDENT'S WERE KEPT FREE FROM PHYSICAL RESTRAINTS APPLIED WITHOUT APPROPRIATE ASSESSMENTS, PHYSICIAN'S ORDERS, AND FOR THE CONVENIENCE OF STAFF, RESULTING IN SEVERE EMOTIONAL DISTRESS FOR RESIDENT #714 AND THE POTENTIAL FOR PHYSICAL AND MENTAL DECLINE FOR RESIDENT #703 AND 708. FINDINGS INCLUDE: ON 8/17/11 AT 9:25 A.M., DURING THE MEDICATION PASS OBSERVATION, MEDICATION NURSE (A), UNIT MANAGER (B), AND CERTIFIED NURSE ASSISTANT (CNA) (C), WERE OBSERVED AS THEY ENTERED RESIDENT #714 ' S ROOM. RESIDENT #714 WAS SEATED IN HER RECLINER CHAIR. SHE HAD A CALM DEMEANOR AND DISPLAYED NO AGGRESSIVE BEHAVIORS. NURSE (A), UNIT MANAGER (B) AND CNA (C) APPROACHED THE RESIDENT. NURSE (A) STATED, "I AM GOING TO GIVE YOU YOUR MEDICINE." RESIDENT #714 RESPONDED, "I DON'T WANT YOUR MEDICINE... I DON'T WANT YOUR INJECTION... LEAVE ME ALONE AND GO AWAY." UNIT MANAGER (B) AND CNA (C) USED BOTH OF THEIR HANDS TO FORCEFULLY HOLD (PHYSICALLY RESTRAIN) RESIDENT #714'S ARMS TO HER SIDE. UNIT NURSE MANAGER (B) USED HER LEGS TO HOLD RESIDENT #714'S LEGS DOWN. NURSE (A) FORCED THE [MEDICATION NAME] INJECTION INTO RESIDENT #714'S LEFT UPPER ARM. RESIDENT #714 CONTINUED TO PLEAD AND YELL THAT SHE DID NOT WANT ANY INJECTION AND STAFF SHOULD LEAVE HER ALONE. ALL THREE STAFF MEMBERS DISREGARDED THE RESIDENT'S WISHES TO BE LEFT ALONE AND CONTINUED TO HOLD HER DOWN. THE RESIDENT DID NOT STRIKE OUT OR KICK. RECORD REVIEW ON 8/17/11 AT 2:35 P.M., REVEALED THAT RESIDENT #714 WAS admitted INto the facility on [DATE], WITH [DIAGNOSES REDACTED]. REVIEW OF THE MOST CURRENT QUARTERLY MINIMUM DATA SET (MDS), dated [DATE], INDICATED THE RESIDENT HAD "CLARITY OF SPEECH", WAS USUALLY UNDERSTOOD AND COMPREHENDED MOST CONVERSATION AND HAD VISION IMPAIRMENTS, THOUGH SHE WAS ABLE TO SEE LARGE PRINT. RESIDENT #714 HAD SEVERELY IMPAIRED LONG AND SHORT TERM MEMORY PROBLEMS AND THERE WAS NO INDICATION OF POSSIBILITY FOR THIS RESIDENT TO HARM HERSELF. BEHAVIORAL SYMPTOMS WERE IDENTIFIED AS PHYSICAL AND VERBAL ABUSE DIRECTED TOWARDS OTHERS. RESIDENT #714 WAS TOTALLY DEPENDENT ON STAFF FOR ACTIVITIES OF DAILY LIVING. THE RESIDENT WAS PRESCRIBED A CHAIR THAT PREVENTED HER FROM RISING WHICH WAS DOCUMENTED AS A FORM OF PHYSICAL RESTRAINT. ON 8/18/11, AT 9:05 A.M., RECORD REVIEW OF THE RESIDENT #714'S CLINICAL RECORD, REVEALED THAT THERE WAS NO PHYSICIAN'S ORDER FOR RESIDENT #714 TO BE PHYSICALLY HELD BY STAFF. THERE WAS NO NURSING CARE PLAN OR INTERDISCIPLINARY CARE PLAN INSTRUCTING STAFF TO PUT THEIR HANDS ON THE RESIDENT AND "HOLD HER DOWN". THERE WAS NO EVIDENCE THAT "EMERGENCY USE" OF PHYSICAL RESTRAINT WAS WARRANTED FOR RESIDENT #714. THERE WAS NO EVIDENCE THE RESIDENT'S PHYSICAL SAFETY WAS IN IMMEDIATE DANGER, AND THERE WAS NO EVIDENCE THAT RESIDENT #714 WAS EXPERIENCING A LIFE THREATENING CRISIS OR WAS A DANGER TO HERSELF OR OTHERS. THERE WAS NO EVIDENCE STAFF WERE INSTRUCTED OR TRAINED TO "PHYSICALLY RESTRAIN" AND PLACE THEIR HANDS ON THE RESIDENT IN A MANNER TO CONTROL BEHAVIOR. IN AN INTERVIEW ON 8/17/11, AT 12:59 A.M., WITH THE DIRECTOR OF NURSING, SHE INDICATED THAT THE NURSING STAFF SHOULD NOT HAVE RESTRAINED THE RESIDENT AND SHOULD HAVE RESPECTED THE RESIDENTS RIGHTS TO REFUSE TREATMENT. REVIEW OF THE RESTRAINT POLICY, DATED 11/06/01, STATED, "ONLY STAFF MEMBERS EDUCATED IN THE PROPER APPLICATION/REMOVAL OF RESTRAINTS SHALL APPLY AND MONITOR RESTRAINTS. THE EMERGENCY USE OF PHYSICAL RESTRAINT MAY BE INDICATED IN PHYSICAL SAFETY OF THE RESIDENT IN IMMEDIATE DANGER, AND IN MEDICAL OR LIFE THREATENING CONDITIONS." RESIDENT #708 WAS OBSERVED ON 8/16/11 AT 9:58 A.M., DURING THE TOUR OF THE FACILITY IN THE DINING ROOM SITTING IN HER WHEELCHAIR WITH A SEAT BELT RESTRAINT SECURED ACROSS HER ABDOMEN. THE RESTRAINT WAS TIED TO THE BACK OF THE RESIDENT'S HIGH-BACK WHEELCHAIR. WHEN THE RESIDENT WAS ASKED TO RELEASE HER SEATBELT, RESIDENT #708 WAS UNABLE TO FOLLOW THE COMMAND AND COULD NOT RELEASE HER SEATBELT. ON 8/16/11 AT 11:35 A.M., 1:25 P.M., 1:45 P.M., AND 2:39 P.M., RESIDENT #708 WAS OBSERVED IN THE DAY ROOM WEARING HER RESTRAINT. STAFF PRESENT IN THE DAY ROOM FAILED TO RELEASE THE SEATBELT OR REPOSITION THE RESIDENT. ON 8/17/11, AT 10:56 A.M., AND 1:45 P.M., RESIDENT #708 WAS OBSERVED WITH HER SEATBELT TIED BEHIND THE BACK OF THE WHEELCHAIR. STAFF FAILED TO RELEASE THE SEATBELT AND REPOSITION THE RESIDENT. AT 5:37 P.M., DURING DINNER MEAL, RESIDENT # 708 WAS OBSERVED IN HER WHEELCHAIR WITH HER SEATBELT RESTRAINTS IN PLACE WHILE BEING FED HER DINNER MEAL. REVIEW OF RESIDENT #708'S Minimum Data Set, dated dated [DATE], REVEALED A [AGE] year OLD FEMALE WITH SEVERELY IMPAIRED COGNITIVE SKILLS. RESIDENT #708 NEVER OR RARELY MADE DECISIONS. SHE HAD MEDICAL [DIAGNOSES REDACTED]. THE CLINICAL NURSE COORDINATOR WAS INTERVIEWED ON 8/18/11, AT 2:59 P.M., REGARDING RESTRAINT ASSESSMENT AND THE USE OF THE "LEAST RESTRICTIVE" DEVICE PRIOR TO THE USE OF THE SEATBELT. THE NURSE WAS UNABLE TO PROVIDE ASSESSMENT DOCUMENTATION REGARDING RESTRAINT USE. THE NURSE WAS UNABLE TO EXPLAIN AND PROVIDE EVIDENCE OF CARE PLANNING IN RELATIONSHIP TO CONCERNS ASSOCIATED WITH RESTRAINT USE, SUCH AS ACTIVITIES, RESTRAINT RELEASE (TIME-OFF PLAN), REPOSITIONING AND CIRCULATION, RANGE OF MOTION, AND TOILETING PROVIDED TO RESIDENT #708. IN AN INTERVIEW WITH THE PHYSICAL THERAPIST ON 8/18/11, AT 3:00 P.M., SHE REPORTED THAT SHE WAS NOT INFORMED BY NURSING TO ASSESS RESIDENT #708'S USE OF SEATBELT RESTRAINT AS PART OF THE INTERDISCIPLINARY TEAM. THE THERAPIST STATED SHE DID NOT MAKE RECOMMENDATIONS. ON 8/16/11, AT 3:05 P.M., REVIEW OF THE RESIDENT #708'S INFORMED CONSENT FOR "RESTRAINT USE", DATED 2/22/11, REVEALED THAT THE RESIDENT AND/OR THE RESIDENTS RESPONSIBLE PARTY DID NOT SIGN FOR THE USE OF THE RESTRAINT. THERE WAS NO PHYSICIAN'S VERBAL OR WRITTEN ORDER OBTAINED, AND THERE WAS NO JUSTIFICATION FOR THE CONTINUATION OF RESTRAINTS. THE RESTRAINTS WERE NOT ASSESSED EVERY 24 HOURS AS INSTRUCTED BY THE PHYSICIAN'S WRITTEN ORDER. THE PHYSICAL RESTRAINT/SAFETY RISK REVIEW, DATED 2/22/11, INDICATED THE RESTRAINT WAS REQUIRED DUE TO THE USE OF ANTIPSYCHOTIC MEDICATIONS, A FALL, LETHARGIC, ANXIOUS, INCREASED WHEELCHAIR INCREASED AND WANDER GUARD. RESTRAINT RECOMMENDATIONS INCLUDED THE USE OF A "SELF RELEASE RESTRAINTS. RESIDENT #703 WAS A [AGE] years OLD FEMALE WITH [DIAGNOSES REDACTED]. REVIEW OF RESIDENT #703'S MINIMUM (MDS) data set [DATE], REVEALED RESIDENT #703 WITH SEVERELY IMPAIRED COGNITIVE SKILLS, AND NEVER OR RARELY MADE DECISIONS. OBSERVED RESIDENT #703 FOR PROLONGED PERIODS OF TIME WITH A SEATBELT RESTRAINT IN PLACE ON 8/16/11 AT 9:30 A.M., 12:05 P.M., 2:30 P.M. AND 3:45 P.M. ON 8/17/11 AT 9:10 A.M., 11:30 A.M. AND 1:30 P.M. ON 8/18/11 AT 9:05 A.M., 12:10 P.M., 2:10 P.M., 2:37 P.M. AND 3:17 P.M. ON 8/19/11 AT 8:53 A.M., 9:50 A.M. AND 1:30 P.M. IN AN INTERVIEW WITH THE PHYSICAL THERAPIST (PT) ON 8/18/11, AT 2:30 P.M., SHE INDICATED THAT SHE RECEIVED A REHABILITATION REFERRAL FORM FROM NURSING ON 9/27/10, TO ASSESS RESIDENT #703 FOR SELF RELEASE BELT. THE (PT) INDICATED THAT SHE OBSERVED RESIDENT #703 AND RECOMMENDED THAT RESIDENT DOES NOT FIT THE CRITERIA FOR THE USE OF A SEAT BELT RESTRAINTS SINCE THE RESIDENT DOES NOT ATTEMPT TO GET UP FROM HER WHEELCHAIR, DOES NOT SLID OFF HER WHEELCHAIR, NOT AT RISK FOR FALLS, AND DOES NOT LEAN FORWARD. IN AN INTERVIEW WITH THE CLINICAL NURSE COORDINATOR ON 8/18/11, AT 2:59 P.M.,RELATING TO LEAST RESTRICTIVE INTERVENTIONS ATTEMPTED PRIOR TO SELF RELEASE RESTRAINTS. SHE AGREED THAT THE PROBLEM WAS THE FACILITY'S RECOMMENDATION OF SELF RELEASE RESTRAINTS FOR RESIDENT'S UNABLE TO SELF RELEASE THEIR SEAT BELT'S. REVIEW OF THE RESTRAINT POLICY, DATED 11/06/01, INDICATED THAT PRIOR TO UTILIZING PHYSICAL RESTRAINTS, THERE MUST BE A PHYSICIAN'S ORDER FOR EACH TYPE OF RESTRAINT. AN ASSESSMENT WOULD BE CONDUCTED BY AN INTERDISCIPLINARY TEAM ON ADMISSION, QUARTERLY, IN CONJUNCTION WITH THE RESIDENT AND OR FAMILY TO ASCERTAIN THE FEASIBILITY OF LESS RESTRICTIVE DEVICES. ONLY STAFF MEMBERS EDUCATED IN THE PROPER APPLICATION/REMOVAL OF RESTRAINTS SHALL APPLY AND MONITOR RESTRAINTS. "THE EMERGENCY USE OF PHYSICAL RESTRAINT MAY BE INDICATED IN PHYSICAL SAFETY OF THE RESIDENT IN IMMEDIATE DANGER, AND IN MEDICAL OR LIFE THREATENING CONDITIONS." ( )

This citation pertains to intake MI 721 It was alleged facility staff failed to secure the [MEDICATION NAME] that accompanies the prosthesis resulting in the closure of the resident's voice prosthesis opening. Based on interview and record review, the facility failed to secure a [MEDICATION NAME] that accompanies a voice prosthesis in one (Resident #101) of eight sampled residents resulting in the closure of the resident's voice prosthesis opening. Findings include: An unannounced on-site investigation was conducted beginning on 10/05/10 Record review of the "Minimum Data Set (MDS)", dated 7/23/10, Resident #101 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #101 was totally dependent on staff for bed mobility, transfers, dressing, eating, toileting, personal hygiene, and was incontinent of bowel and bladder. Record review of "Physician's Admission History and Physical", dated 7/02/10, revealed the resident was transferred from a specialty care hospital after a right [MEDICAL CONDITION] (stroke) with left sided [MEDICAL CONDITION] (the resident is left hand dominant), [MEDICAL CONDITION] secondary to laryngectomy from [AGE] years ago, increased secretions, [MEDICAL CONDITION], depression, [MEDICAL CONDITION] (CAD), coronary artery bypass graft (CABG) of four vessels, diabetes, gastro-[MEDICAL CONDITION] reflux disease (GERD), high blood pressure, low [MEDICAL CONDITIONS] ([MEDICAL CONDITION]), a history of [MEDICAL CONDITIONS] with [MEDICAL CONDITION] embolism (PE), [MEDICAL CONDITIONS], multiple infections, and deconditioning. No mention is made of a speaking valve. Record review of "Nurses Notes", dated 7/3/10, "...able to verbalize needs..." Record review of "Nurses Notes", dated 7/04/10, "...able to express needs with no problems..." Record review of a "physician progress notes [REDACTED].#101) because respiratory therapy is concerned that her speaking valve has disappeared, it is normally taped to the neck stoma where she has O2 (oxygen) without using a mask over the trachea, without a [MEDICAL CONDITION], as she has had a laryngectomy, The concern is when the tape became moistened from perspiration, the tape loosened and the speaking device disappeared into the stoma, and the concern is I do not know where it is in the trachea and if it occludes at the [MEDICATION NAME] bifurcation, then that will be a problem..." Record review of a hospital "Consultation" report, dated 7/06/10, dictated by a psychiatrist revealed the resident was admitted to the hospital due to a dislodged voice prosthesis and presented for "...psychiatric consultation due to symptoms of depression and suicidal ideation...", and is diagnosed by the psychiatrist with,"(1) Depression, Not otherwise specified (NOS), (2) Mood disorder due to general medical condition. The plan was to continue taking [MEDICATION NAME] (anti-psychotic) and [MEDICATION NAME] (antidepressant)". Record Review of a hospital "Special Procedures Report", dated 7/06/10, revealed "...fiberoptic tracheoscope and red rubber insertion in the [MEDICAL CONDITION] fistula, which was secured at the skin...a 12-French red rubber catheter was then inserted through the stoma into the esophagus. Once in place...a nylon suture was then thrown in two areas, which secured the red rubber catheter to the patient's left side of the neck keeping it in place through the [MEDICAL CONDITION] fistula..." Record review of a "History and Physical Readmission Note", dated 7/14/10, revealed resident #101 "...was out to the hospital from 7/06/10 to 7/13/10 because she had a complete laryngectomy and has a speaking device and the speaking device was misplaced or lost, and thought to have been dislodged into either airway...she had two laryngocoscopies, and no speaking valve was reportedly found...she also has a history of suicidal ideation reported in the emergency department, that she wanted to take a gun a shoot herself...parotid glands reveals a stoma that is closed over, and then she has a [MEDICAL CONDITION] stoma with no [MEDICAL CONDITION]." Record review of a hospital "History and Physical", dated 7/14/10, revealed "...communication is somewhat difficult...the patient has a [MEDICAL CONDITION] and 'mouths' the words. She is sent in with a box containing the voice box [MEDICAL CONDITION] present with Foley catheter like device also in the stoma...". Record review of a "physician progress notes [REDACTED]. Record review of a hospital "Consultation" record, dated 8/05/10, indicated, "...patient was recently seen within the past six weeks. We became aquatinted with the patient after she presented from her extended care facility (ECF) with [MEDICAL CONDITION] prothesis dislodgement. We were asked to evaluate the trachea for the presence of prosthesis. Unfortunately, the prostheses was out for over 24 hours, and the stoma began to close. A catheter was placed...while at the ECF the red rubber catheter that was in place maintaining the stoma was dislodged and the stoma closed...it is noted that there is no longer a [MEDICAL CONDITION] fistula...Impression: (1) status [REDACTED]. Record Review of a "History and Physical Readmission Note", dated 8/11/10, "...history of tracheal [MEDICAL CONDITION] prothesis dislodgement, and being out for more than 24 hours, the stoma has closed, and unsuccessful dilation for reinsertion of same...she is able to whisper her words..." Record review of a "physician progress notes [REDACTED]. She has had a laryngectomy for laryngeal [MEDICAL CONDITION] [AGE] years ago." Record review of a "physician progress notes [REDACTED]. Record review of a "Care Plan", dated 7/14/10, initiated on 7/14/10 after the prosthesis was dislodged, indicated Resident #101 "had a voice prosthesis placed and has been taking care of it at home for the last [AGE] years. No description of the device or instructions for care or monitoring are indicated in the care plan. No reference to the red rubber catheter inserted at the site and sutured to the skin while the resident was in the hospital is mentioned. An interview, on 10/05/10 at 3:45 p.m., with respiratory therapist (RT) #6 revealed that he heard resident #101 had a special voice prosthesis but denied ever seeing it or any other device outside her open [MEDICAL CONDITION] stoma. An interview on 10/05/10 at 4:30 p.m. with Resident #101's attending physician at the facility confirmed the information dictated in the physician's progress notes and readmission history and physical reports. The physician explained that Resident #101 was admitted to the facility after having a [MEDICAL CONDITION] and subsequent stroke which left her with left sided weakness. He indicated the resident was left hand dominant and that she came into the facility with rapid decline, the resident had functioned quite well for [AGE] years after her laryngectomy and was now facing significant decline in functional status. An interview, on 10/05/10 at 5:00 p.m., with respiratory therapist #17 revealed that Resident #101 could only 'mouth' words without much sound. RT #17 indicated the resident seemed frustrated and sad and seemed like she would give up. RT#17 denied ever seeing the the voice prosthesis or the catheter sutured to the resident's skin to keep the [MEDICAL CONDITION] fistula for the prosthetic device open. An interview, on 10/06/10 at 1:10 p.m., with RT #18 and RT #19 revealed that neither had seen the voice prosthesis device or the red catheter that was inserted to maintain patency of the stoma opening for the voice prothesis. An interview, on 10/06/10 at 1:30 p.m., with Administrator #1 revealed that the facility did not know on admission that the resident had a voice prosthesis and heard that it was healing from the inside out because it was so small. When asked, the administrator did not have any idea how or why the prosthesis or the catheter fell out. She was first informed of the dislodged prosthesis by the director of respiratory therapy during a stand-up meeting and a 24-hour daily report. The surveyor requested the 24 hour report for the days in question at 1:30 p.m. on 10/06/10, and at the close of investigation on 11/01/10, no report was produced. An interview, on 10/08/10 at 2:00 p.m., with the director of respiratory therapy revealed that the facility did not know about the voice prosthesis until late in the day on the day of admission. She recalled it being secured in place with tape on the neck. She had never heard about the red rubber [MEDICATION NAME]. The director of respiratory therapy indicated that the respiratory staff were educated on the voice speaking prosthesis a week after the resident was admitted to the facility. A record review of nurses notes and respiratory assessments in Resident #101's clinical record did not reveal a description of the voice prosthesis or of the red rubber [MEDICATION NAME] that was inserted after the voice prosthesis was lost. ( )