Every finding on record at Medilodge of Frankenmuth

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents who consume food from the kitchen. Findings include: On 05/04/2026 at 8:54am during the initial kitchen tour, observed yogurt with a best by date of April 22nd, 2026, in the walk-in cooler. On 05/04/2026 at 9:00am, milk with a use by date of 5/3/26 was observed in the three-door fridge. During this observation, when asked how long milk is kept for, Certified Dietary Manager (CDM) R stated it's good for seven days once opened. According to the 2022 Food Code, 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition, Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.On 05/04/2026 at 9:08am, the coffee machine was observed visibly soiled on the siding of the machine near the nozzles and mineralization build up was observed inside the nozzles. On 05/04/2026 at 9:12am, the mixer was observed visibly soiled on the interior ceiling of the mixer and reddish residue was observed inside the bowl. During this observation, when asked how often the mixer is cleaned, CDM R stated it's cleaned before and after it is used. On 05/04/2026 at 9:16am observed the ice machine filter dated 8/24/23 and cups laying on the floor behind the ice machine in the nourishment room. On 05/04/2026 at 9:20am, a brown splotch was observed on the interior wall of ice machine. During this observation, when asked how often the ice machine is cleaned, Maintenance Director (MD) S stated it's cleaned every month. When asked how often the ice machine filter is replaced, MD S stated it needs to be done now and that it's usually changed every year. According to the FDA 2022 Food Code, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, Equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations, nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. On 05/04/2026 at 9:26am cut watermelon was observed without datemarking in the fridge of the memory care unit. According to the 2022 Food Code, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, 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.According to the facility's policy on datemarking, All foods stored in the refrigerator or freezer will be covered, labeled and dated (opened on and ''use by date).On 05/04/2026 at 11:55am during lunch observation, boiled egg on salad was temped at 54 F and ranch at 53 F, sitting on a cart behind the steam table without ice. During this observation, CDM R was interviewed on what temperature food should be cold holding, and stated it should be at 40-41 F. On 05/04/2026 at 12:03pm observed [NAME] T go to fridge, then back to the prep area, and gloved one hand without washing hands. On 05/04/2026 at 12:11pm, cut tomato sitting in a container at the prep sink was temped at 65 F. On 05/04/2026 at 12:12pm cream of mushroom was temped at 75 F and was sitting out of its original container near the prep sink. During this observation CDM R stated the cream of mushroom should be refrigerated after opening. According to the FDA 2022 Food Code, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding, Except during preparation, cooking, or cooling, or when time is used as the public health control, time/temperature control for safety food shall be maintained: .at 5 C (41 F) or less.On 05/04/2026 at 12:24pm CDM R was interviewed on when hands should be washed when gloving hands, CDM R stated staff are supposed to wash their hands before gloving. According to the 2022 Food Code, 2-301.14 When to Wash, Food employees shall clean their hands and exposed portions of their arms.immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and.Before donning gloves to initiate a task that involves working with food.

Based on observation, interview, and record review, the facility 1) Failed to 1) follow enhanced barrier precautions (EBP) for residents identified with qualifying medical needs, for one resident #6 (R6) of one resident; 2) Ensure that respiratory treatment and suctioning equipment were properly stored and maintained, for one (R6) of one residents; 3) Ensure that infection control rounding data collection and surveillance was performed for all residents residing in the facility; and 4) Ensure that appropriate glucometer disinfection was followed for one of three residents reviewed (Resident #29) for infection prevention. Findings include: Observation and interview on 05/04/2026 at 10:36 AM surveyor knocked and walked into nurses providing high contact direct care to resident #8. Observed Resident #8 to be lying on his back with his brief down with foley catheter care with was cloth, abdominal peg tube site dressing being placed, and loose gray liquid stool noted on brief. The Unit manager Registered Nurse (RN) O, Licensed Practical Nurse (LPN) E and Licensed Practical Nurse (LPN) P were providing direct high contact care with no gowns, or mask worn. Observation of Resident #8's buttocks with LPN E and RN O revealed moisture associate skin damage with gray loose/liquid stool. RN O stated that staff are putting barrier cream on cracked skin areas, observed bleeding from multiple fissures/cracked in the skin, sloughing of the skin noted. On 05/04/2026 at 10:39 AM Licensed Practical Nurse P came into the room to assist with the cleaning of resident's bowel movement, loose, due to being on tube feeding. Resident was rolled to right side and did not wake up or have any change in cognition noted. Resident #8 remained Lethargic and non-responsive to his name. Not one of the staff members wore enhanced barrier precautions while attending to the resident with foley catheter, tube feeding, and multiple open areas on the buttocks noted. Infection Control Task: Observation and interview on 05/06/2026 at 11:50 AM Licensed Practical Nurse (LPN) Infection Preventionist (IP) N about facility wide round for surveillance Rounding, IP N stated that she began at the facility only 60 days prior to survey. Observation of the IP N office space revealed binders and desktop computer. Record review of the January 2026 rounding request data revealed a search of the infection control office area by IP N for rounding audits/data located a purple binder, Records review of the purple binder data from August 2025 through February 2026: August 2025-review of the surveillance binder noted there were no kitchen, medication rooms, dining rooms and therapy gym, resident rooms, or enhanced barrier precaution rooms rounding/audit of rounding surveillance documentation or analysis found. September 2025- review of the surveillance binder noted there were no kitchen/laundry rounding/audit, no medication room rounding/audit, no dining room rounding/audit or therapy room, resident rooms, or enhanced barrier precautions rounding/audit found. October 2025- Record review of the surveillance binder noted there were only: injection safety audit, Personal Protective Equipment (PPE) orientation audits, there were no rounding surveillance data collection forms/audits found. November 2025- Record review of the surveillance binder noted there were no rounding forms found in the binder. IP N continued to look in office and computer for more data/forms. December 2025 - Record review of the surveillance binder noted there were orientation Personal Protective Equipment (PPE) forms for new hires, IT equipment and wound audits. No rounding for kitchen, laundry, medication rooms, resident rooms, or enhanced barrier precautions rounding/audit found. 2026 binder- no rounding found for January, February, March 2026, and only a sanitation review 4/29/2026 by the Certified Dietary Manager (CDM) for the kitchen. Record review of the computer program used by the facility by IP N did not locate any additional documentation or data for rounding/surveillance/analysis of the facility for infection control program outcome and process surveillance to inhabit the likelihood for spread of microorganism to other residents. In an interview on 05/06/2026 at 11:50 AM during the infection control task the Infection Preventionist N stated that the housekeeping rounding is on the May 2026 audits to do but has not yet been done. In an interview on 5/6/2026 at 11:50AM The state surveyor gave the infection preventionist an example of an observation made during the survey of nurses providing high contact resident care to enhanced barrier precaution (EPB) resident with peg tube in the abdomen, and foley catheter, and moisture associated skin damage with loose liquid stool and the staff choice not to use gowns or mask while providing direct care. Infection Preventionist N stated that EBP should be used by staff. Staff are to have gown gloves, mask, if splash/liquids use goggles or a shield. IP N expects staff to protect themselves and the residents. Posting on the door, and a label maker with green name tags, and in the hallways are carts 3 drawer white plastic bins IP N stated that she fills the bins three times a week. There was no reason for staff not to have PPE (Personal Protective Equipment). Record review of the facility 'Infection Surveillance' policy dated 10/26/2023 revealed a system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections, monitor adherence to recommended infection prevention and control practices in order to reduce the infections and prevent the spread of infections. Definition: Infection Surveillance refers to an ongoing systemic collection, analysis, interpretation, and dissemination of infection-related data. Outcome Measures is a mechanism for evaluating outcomes or results, such as tracking specific infection events. Process Measures is a mechanism for evaluating specific steps in a process that lead, either positively or negatively, to a particular outcome metric. Also known as performance monitoring, a process measure is used to evaluate whether infection prevention and control practices are being followed. (5.) Surveillance activities will be monitored facility-wide, and may be broken down by department or unit, depending on the measure being observed . (6.) The facility will collect data to properly identify possible communicable diseases or infections before they spread . On 5/06/2026, at 11:49 AM, Nurse L entered Resident #29's room to obtain a blood glucose level. Once completed, Nurse L walked to the medication cart and wiped the front and back of the blood glucose meter with an alcohol swab before placing it in the top drawer of the medication cart. On 5/06/2026, at 2:53 PM, Nurse L was asked what they used to clean the glucose meter and Nurse L offered, an alcohol swab. Nurse L was asked if that's how they normally clean it and Nurse L stated, why, am I not supposed to?. Nurse L was asked if the facility instructed them on how to disinfect a glucose meter and Nurse L stated, yeah with a purple top. On 5/06/2026, at 12:32 PM, the Director of Nursing (DON) was asked how the facility disinfects blood glucose meters and the DON offered, they're supposed to use a purple top. R6A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated R6 was admitted to the facility on [DATE] with diagnoses: stroke, aphasia (cognitive communication deficient with speech and understanding), tracheostomy (artificial patent airway), percutaneous endoscopic gastrostomy tubes (PEG / delivers nutrition and medications directly into the stomach), epilepsy (seizure disorder), muscle weakness, right above the knee amputation (AKA). The MDS assessment dated [DATE] indicated the resident had severely impaired cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 0/15 and was dependent on assistance for care. On 05/04/2026 at 09:50AM, an observation of an EBP sign outside R6 door was made. An observation of R6 resting in bed with eyes closed, R6 had a dressed tracheostomy humidified with O2 set at 4L. A suction canister was sitting on the nightstand, canister had ~ (approximately) 200cc's of straw yellow drainage and was hooked up to tubing neither dated, the open end of the suction tubing was resting inside of a garbage can with visible trash and debris in the can. R6's call light was hung over the headboard of the bed and out of reach of the resident. There was a nebulizer mask hooked to the machine sitting in open air on the resident's bedside table. Hospice CNA A was present in the room and provided care to R6's roommate, she was asked to verify the location of the call light and condition of the suction canister, tubing and Nebulizer mask. Hospice CNA A confirmed that and said that it was not sanitary, she also verified that the resident call light was not with in his reach. According to a record review of the facilities procedure labelled Small volume nebulizer it was revealed: Purpose: small volume nebulizers convert liquid medications into a fine mist, allowing for delivery of the medication deep into the lungs. Appropriate cleaning and storage techniques of small volume nebulizers decrease the risk of introducing bacteria into the and reduces potential pulmonary infections. and Cleaning:1. Twist open the nebulizer cup and dump out any residual remaining from treatment. 2. Rinse nebulizer cup and components with water. 3. Allow the nebulizer cup and components to air dry on a clean absorbent towel. 4. Once dry store the nebulizer cup and mouthpiece in a bag and label. 5. Replace nebulizer hand tubing weekly per procedure. According to a record review of the facilities policy labelled Tracheostomy care it was revealed: Policy: facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice. and indicated that suctioning was a sterile technique, it did not include guidelines on equipment dating or storage. On 05/05/2026 at 08:50AM, an observation of R6 resting in bed with eyes closed, R6 had a dressed tracheostomy humidified with O2 set at 4L. A suction canister dated 5/4 was sitting on the nightstand, canister had ~ (approximately) 500cc's of straw yellow drainage and was hooked up the suction tubing was coiled on the nightstand with the open end of the suction hub was resting uncovered on the nightstand. There was a deconstructed nebulizer chamber with components and mask on the bedside table resting on a brown paper towel, no moisture was seen on equipment nor paper towel. On 05/05/2026 at 09:25AM, During an interview with Nurse B she was asked about suction and respiratory equipment storage and care for infection control, she said that nebulizers, masks and suction equipment not in use should be stored dry and clean in a container of bag and labeled/dated. When she was asked to return to R6's room to observe the equipment she said she was unable to at that time. On 05/05/2026 at 09:33AM, OT G was asked to observe R6's nebulizer and suction equipment, OT G observed R6 room and verified the nebulizer was dry and on the bedside table and the suction tubing was attached to the canister (with straw colored drainage accumulated) and open end of suction was coiled and, on the nightstand, uncovered. OT G said that does not seem correct and stated, I do not know for sure. On 05/05/2026 at 12:15PM, an observation of R6's deconstructed nebulizer chamber with components and mask remain in the same location as observation at 08:50Am and are dry and not stored. On 05/05/2026 at 12:45PM, during a follow up interview with Nurse B she said saw the condition of the equipment brought to her awareness earlier and that she had fixed it, she said she had changed R6's suction canister and tubing and stored it in a bag and labelled and dated it all. Nurse B was asked about the nebulizer being out and not stored she said it was ok if it was drying, when asked how long it takes to dry she did not have and answer why it had been dry and out since 08:50AM. Nurse placed then stored it in a plastic bag and placed in the plastic tub at the residents bedside. According to a record review of the facilities policy labelled Infection prevention and control program it was revealed: Policy: the facility has established and maintains an infraction control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of based transmission of communicable diseases and infection as per accepted national standards and guidelines. And 11. Supplies protocol: b. Sterile supplies are routinely checked for expiration dates and are replaced as necessary. d. Nonsterile supplies are stored and maintained as clean prior to use. On 05/06/2026 at 09:00AM, knocked on door and entered the room of R6, observation of R6 privacy curtain tucked behind the tube feed pole and open to roommate / door to hall side, the window on the other side of resident had the curtain open to the outside while CNA D completed a brief change for R6. CNA D was wearing gloves and no other PPE, she touched the linens, trash cans and removed her gloves with no hand hygiene and repositioned the resident in the bed. CNA D asked if the curtains should be closed for privacy with brief changing and care and she said yes, when she was asked if there were closed, she did not answer but gave a blank look. CNA D was asked if she needed to wear any PPE with personal care for R6 since he was in EBP and she stated, oh yes, I forgot. On 05/06/2026 at 11:31AM, during an interview with ICP Nurse she was queried about storage of suction and respiratory equipment, and she verified it should be stored clean when not in use. She was asked about EBP residents and high contact care, and she verified that regardless of why a resident is in EBP that dressing, toileting, bathing and brief changes were all considered high contact activities and required PPE to be used by staff. According to a record review of R6's care plan: Focus: (R6) requires enhanced barrier precautions related to trach, peg placement with Interventions: Use gown and gloves when providing direct care. Face protection may be needed if performing activity with risk of splash or spray; Utilize Enhanced Barrier Precautions when providing high contact resident care activities (dressing, bathing, transferring, personal hygiene, changing linens, changing briefs/assisting with toileting, device care: central lines, urinary catheters, feeding tubes, tracheostomy/ventilators, wound care, dialysis). And Focus: Resident has an impaired pulmonary/respiratory status related to tracheostomy with Interventions: Suction per orders and as needed; Treatments as ordered; Oxygen as ordered. According to a record review of the facilities policy labelled Enhanced barrier precautions it was revealed: Policy: it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multi drug resistant organisms. With Definition: enhanced barrier precautions refer to an infection control intervention designed to reduce transmission of multi resistant organisms that employ targeted gown and glove use during high contact resident care activities. and . Guidelines: 3. Implementation. b. PPE for EBP is only necessary when performing high contact activities. 4. High contact resident care activities. include: a. dressing; d. providing personal hygiene; f. changing briefs.

Based on observation, interview, and record review, the facility failed to maintain cleanliness and ensure that appropriate backflow prevention was installed at plumbing fixtures, resulting in the potential for the spread of pathogens and contamination to the water supply, affecting all residents. Findings include:On 05/04/2026 at 2:12pm the hand sink near the washers in the laundry room was observed without a sewer line. The wastewater was observed going directly into a trash bin below sink. The trash bin below the hand sink was approximately half full of wastewater. During this observation, when asked how long the sink has been broken, Housekeeping Manager U stated for about two months, and that they empty the trash can into the mop bucket sink. On 05/04/2026 at 2:18pm observed a utility sink without an atmospheric vacuum breaker (AVB), with an attached hose and a chemical feeder downstream, in the housekeeping closet on the east hall. On 05/04/2026 at 2:21pm observed a chemical feed downstream of an AVB on the utility sink in the housekeeping closet on main hall. On 05/04/2026 at 2:22pm observed a chemical feed downstream of an AVB in the housekeeping closet in central hallway. On 05/04/2026 at 2:27pm observed a chemical feed downstream of an AVB on the utility sink in the housekeeping closet on west hall. On 05/04/2026 at 2:28pm observed a soiled towel on the floor of the shower area in the shower room in west hall. According to the State of Michigan's 2008 Cross Connection Manual on atmospheric vacuum breakers, AVBs shall not be installed where they will be under continuous pressure for more than 12 hours (i.e. no downstream shutoff valve).According to the State of Michigan's 2008 Cross Connection Manual on chemical feeder backflow prevention, Another concern with a hose being run from a faucet to the dispenser is that many times a valve is installed on the hose downstream of an AVB, which is not allowed since AVBs cannot be subject to continuous pressure.

Based on observation, interview and record review, the facility failed to ensure that residents were treated in a respectful and dignified manner to ensure timely assistance with care, that call lights were in reach, privacy and a homelike environment for a Confidential Group of Residents and Residents #6, #17, #67, and #83 from a sample of 41 residents reviewed. Findings Include: Confidential Group of Residents On 5/05/2026 at 11:01 AM, during an interview with a Confidential Group of Residents they verbalized their frustration with staff entering their rooms to answer call lights and then the staff say they will be back, shut off the call lights and leave and don't come back. The Confidential residents said, Why don't they take care of our needs while they are there; sometimes they will not be back at all if you complain about it. During the interview on 5/5/2026 at 11:12 AM, the Confidential Group of Residents said, Sometimes the (meal) trays are late. The food is cold, including grilled cheese. One Confidential Resident said they received 2 hamburgers ice cold and when they told the staff about it they were laughed at. During the same interview, another Confidential Resident said they were awakened at 4:30 AM in the morning by a doctor working on their toenails. The Confidential Group of Residents said they had heard a few staff say some words that Weren't very nice. Several of the Confidential Residents said they heard what sounded like parties at the nurses desk in the evenings, at night and on the weekends when the management staff were not in the building. The Residents said, Staff go out for food and then more staff go out and bring in more at the nurses desk. The Confidential Group was frustrated because they were having issues with staff laughing about their cold food and waiting for care, while they brought in food for themselves. On 5/06/2026 at 1:13 PM, during an interview with the Director of Nursing/DON, the Confidential Group of residents' issues related to dignity, how they were spoken to and treated by some staff including staff saying not very nice words and not answering their call lights was reviewed. The DON said that was not Ok. Reviewed with the DON the residents' issues with staff congregating at the nurses desk and being very loud on 2nd and 3rd shifts and she said they would be addressing that. Reviewed the food concerns had been reviewed with the Registered Dietitian/RD, but the staff laughing at the residents was very upsetting to them. The DON said the staff should not be acting like that. A resident being awakened in the night for the Podiatry care was reviewed with the DON and she said she would check on what time the Podiatrist came in. A review of the facility policy titled Promoting/Maintaining Resident Dignity, date implemented 10/30/2020 and reviewed/revised 10/26/2023 provided, Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. When interacting with a resident, pay attention to the resident as an individual. Respond to requests for assistance in a timely manner. Staff members do not talk to each other while performing a task for the resident as if the resident is not there. Speak respectfully to residents. Respect the residents living space. R6 A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated R6 was admitted to the facility on [DATE] with diagnoses: stroke, aphasia (cognitive communication deficient with speech and understanding), tracheostomy (artificial patent airway), percutaneous endoscopic gastrostomy tubes (PEG / delivers nutrition and medications directly into the stomach), epilepsy (seizure disorder), muscle weakness, right above the knee amputation (AKA). The MDS assessment dated [DATE] indicated the resident had severely impaired cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 0/15 and was dependent on assistance for care. On 05/04/2026 at 09:50AM, an observation was made of R6's call light hung over the headboard of the bed and out of reach of the resident. Hospice CNA A was present, she was asked to verify the location of the call light and Hospice CNA A verified that the resident call light was not within R6's reach. Hospice CNA A verified R6 was not verbal and relied on the call light to get help. There was a putty knife with sticky debris on the blade on R6's beside table, Hospice CNA A said she believed it was left by maintenance and said they had been scrapping the floor in the room earlier. A record review of R6's care plan revealed: Focus: (R6) is at risk for falls/injury related to other nontraumatic intracerebral hemorrhage, epilepsy, seizures, osteogenesis imperfecta with Interventions: Encourage resident to keep needed items within reach; Encourage resident to use call light. Focus: (R6) has an impaired musculoskeletal status related to osteogenesis imperfecta, acquired absence of right leg above knee with Interventions: Encourage resident to ask for assistance when needed. Focus: (R6) has an ADL self-care performance deficit related to cva (stoke), peg placement with Interventions: bed mobility: 2 person assist; toileting: 2 person assist; Encourage resident to use call light when assistance is needed. On 05/06/2026 at 09:00AM, knocked on the door and entered the room of R6, an observation of R6 privacy curtain tucked behind the tube feed pole and open to roommate / door to hall side, the window on the other side of resident had the curtain open to the outside while CNA D completed a brief change for R6. CNA D was asked if the curtains should be closed for privacy with brief changing and care and she said yes, when she was asked if there were closed, she did not answer but gave a blank look. According to a record review of the facility policy labelled promoting and maintaining resident dignity the Policy: it is the practice of this facility to protect and promote residents rights and treat each resident with respect and dignity. with Guidelines: 1. All staff members involved in providing care to residents (are) to promote and maintain resident dignity and respect residents rights; 12. Maintain resident privacy. R83 A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated R83 was admitted to the facility on [DATE] with diagnoses: progressive multiple sclerosis (effects the central nervous system), quadriplegia (numbness / paralysis of 4 limbs), encephalopathy and depression. The MDS assessment dated [DATE] indicated the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15/15 and required assistance with care. On 05/04/2026 at 09:45AM, During an interview with R83 she said she is dependent on care from staff because she was unable to walk. R83 said she had long call wait times of 30 minutes or more, explained it was especially long waits on 2nd and 3rd shifts. R83 said that last week she requested assistance from a CNA because she needed her brief changed due to having had a bowel movement and that the CNA turned off her light left her room and no one came to change her for several hours when she again requested assistance from 3rd shift. R83 expressed that she felt embarrassment from sitting in a dirty and malodourous brief that long. On 05/05/2026 at 09:20AM, during an interview with Nurse E she was asked about the call light system operations, she said that there was no centralized area that notified when a call light was triggered, that the call light are a light outside the residents room that lights up when triggered and a faint tone when from the bed side. Nurse E said that the light is red and a louder tone if it is triggered from a restroom. Nurse E acknowledged that the nurse's station was not located with clear site down each resident's hall and that if staff were not on the unit there was no central location to check for call lights. When asked about R83 complaint Nurse E said she could not account for response times on other shifts when asked. A record review of R83's care plan revealed: Focus: (R6) has an ADL self-care performance deficit related to multiple sclerosis, quadriplegia. with Interventions: ambulation: non ambulatory; bed mobility: 2 person assist with b/l (bilateral) assist bars for increased mobility; toileting: 2 person assist; transfers: (R86) will need 2 person assist and use of full mechanical lift.; Encourage resident to use call light when assistance is needed. According to a record review of the facility policy labelled promoting and maintaining resident dignity the Policy: it is the practice of this facility to protect and promote residents rights and treat each resident with respect and dignity. with Guidelines: 1. All staff members involved in providing care to residents (are) to promote and maintain resident dignity and respect residents rights; 6. Respond to request for assistance with in a timely manner. Resident #17 On 5/04/2026, at 11:17 AM, During a foot skin observation, Resident #17 was noted to pull at their chin whiskers throughout the assessment. Resident #17 was asked if they were ok with their facial whiskers and the resident quickly responded, no, I have a razor somewhere. A review of the Task list for Bathing: Monday and Thursday Evening Shift Look Back . revealed the following showers were provided: 4/6/2026 4/9/2026 4/13/2026 4/20/2026 4/23/2026 4/30/2026 5/4/2026 The column Patient Refused was not checked marked for the missed showers on 4/16/2026 and 4/27/2026. A review of the progress notes revealed no explanation as to why the resident wasn't provided their showers. On 5/05/2026, at 1:30 PM, a record review of Resident #17's electronic medical record revealed an admission on [DATE] with diagnoses that included Hypertension, Heart attack and congestive heart failure. Resident #17 required assistance with activities of daily living and had intact cognition. Resident #67 On 5/06/2026, at 9:18 AM, During medication administration for Resident #67, Nurse J administered Resident #67's morphine after great encouragement to the resident. Nurse J stated to the resident, thank you (Resident #67) Jesus Christ with a smile on their face. Upon exit of Resident #67's room, Nurse J was asked if they normally say that to residents and Nurse J stated, yeah.

Based on interview and record review, the facility failed to ensure that HS (evening/nighttime) snacks were provided on a regular basis for a Confidential Group of Residents, resulting in residents verbalizing feelings of anger, and frustration. Findings Include: On 5/05/2026 at 11:01 AM, during a meeting with a Confidential Group of Residents, they said they were upset about the process for receiving a snack in the evening at bedtime. They said you had to fill out a blue form, that came on their meal tray, but you had to have the form returned to the kitchen by 2:00 PM or you didn't get a snack. The residents said they did not like this process, because you could change your mind about what you wanted or they might not have what you chose if someone else took it, also some of the resident's could not ask for or fill out the form. Some of the residents said they did not receive a snack. They said if you didn't fill out the form, you did not receive one. Some of the residents said they were upset that they observed staff taking snacks for themselves and then they didn't receive one. On 5/5/2026 at 2:30 PM, during an interview with the Registered Dietitian/RD Q she was asked if the residents received an evening/HS (nighttime) snack. She said if the residents wanted a specific snack, they could fill out a blue form that came on their meal tray titled, Please Select a Snack for Tonight. There were a variety of options on the form and the form stated, Please circle 1 or 2 items only. This slip must be turned into the kitchen by 2pm to be able to honor your request. The RD said there was a snack cart that was filled by the kitchen staff and then the clinical staff, usually a nurse aide would distribute the snacks from the cart to the residents. The RD was asked about the blue form; what if the resident couldn't fill it out, or if they couldn't say what they wanted? The RD said the staff could offer the resident a snack. The RD was asked if residents could change their mind about which snack they wanted and she said they could, but the snack might not be available. Discussed with the RD Q that some residents said staff were observed taking snacks from the carts for themselves and then the residents had less options, less to choose from. She said the facility would look at their process to try to ensure the residents received a snack if they wanted one. On 5/06/2026 at 1:13 PM, the Director of Nursing/DON was asked about the process for Residents to receive an HS snack. She said she was newer to the facility and not familiar with their process. The blue form was shown to the DON, and she said she had a problem with having to fill out a blue sheet by 2pm to receive a snack. She said they would work on that.

Based on interview and record review, the facility failed to follow the antibiotic stewardship program and standards of practice for 4 residents (#4, #18, #40, #59) of 4 residents reviewed, for antibiotic usage, resulting in four residents receiving antibiotics without appropriate clinical rationale. Findings include: Record review of the facility 'Antibiotic Stewardship Program' policy dated 12/13/2023 revealed the purpose of the program was to optimize the treatment of infections while reducing the adverse events associated with antibiotic use . Laboratory testing shall be in accordance with current standards of practice . The facility uses the McGreer criteria to define infections .Whenever possible, narrow-spectrum antibiotics that are appropriate for the condition being treated shall be utilized. Antibiotic orders obtained upon admission, whether new admission or readmission, to the facility shall be reviewed for appropriateness. Monitor response to antibiotics, and laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made . Records review and interview on 05/06/2026 at 11:50 AM Licensed Practical Nurse (LPN) Infection Preventionist N of the antibiotic stewardship ship program: Record review of monthly Infection Tracking forms for January 2026 through April 2026 were reviewed with Infection Preventionist N:January 2026 line listing revealed that Resident #18 1/27/2026 through 2/3/2026 was started on Macrobid antibiotic for a facility acquired urinary tract infection (UTI) that did not meet the McGeer's criteria. The Infection Preventionist (IP) N could not locate a culture or organism that was to be treated. The IP N stated that there was no culture or Urine Analysis (UA) done and may have been a dip sticked urine test and decided to treat off that. The IP N could not produce a policy for urine dip stick testing or documentation of dip stick results. Record review of Resident #4 January line listing noted on 1/27/2026 through 2/5/2026, the resident #4 received Cipro antibiotic for urinary tract infection (UTI) that did not meet the McGeer's criteria. The IP N stated that the resident was re-admitted with antibiotic and no culture or UA was found, and when admitted the former IP should have gotten the cultures/lab results for documentation. Record review of the February 2026 Infection Tracking Form Revealed:Record review of Resident #59's February line listing noted facility acquired urinary tract infection (UTI) and received levofloxacin from 2/26/2026 through 3/5/2026 that did not meet the McGeer's criteria. The IP N looked for data and stated that no culture or Urine analysis for organisms was found. Record review of Resident #40's February line listing noted facility acquired urinary tract infection (UTI) and received Bactrim DS antibiotic from 2/6/26 through 2/8/26, that did not meet McGeer's criteria. Again, the IP N looked for data and stated that no culture or Urine analysis for organism was found. During the antibiotic stewardship task, the state surveyor Requested urine dip stick policy and procedure. The Infection Preventionist (IP) N stated that there is no policy or procedure that she could locate. The state surveyor requested the McGeer's policy or procedure that the facility would follow regarding infection criteria and the IP N stated that the McGeer's infection criteria is done by the infection control computer program automatically tells us if the symptoms meet or do not meet the McGeer's criteria, we don't stop the antibiotics we tell the nurse practitioner and she decides if we stop the antibiotics.

Based on observation, interview and record review, the facility to follow standards of practice during medication administration for three of three residents reviewed (Resident #3, Resident #28, Resident #43) along with a confidential group of residents, resulting in resident complaints of not getting their medications correctly. Findings include: On 5/05/2026, at 8:29 AM, Nurse K was standing at the medication cart outside room five. There were two medication cups filled with medications. Nurse K picked up both medication cups; 1 in their left hand and the other in their right hand. Nurse K entered room five and handed the cup from their right hand of medications to Resident #28 (Bed 1). As Resident #28 took the medications one fell and Nurse K picked up the pill and placed it into the used medication cup. Nurse K then walked to Resident #43 (bed 2) who was struggling to get their oxygen tubing adjusted into their nose. Nurse placed Bed 2's full medication cup into the used medication cup from Bed 1 (that housed the dirty pill), donned gloves and assisted Resident #43 (Bed 2) with their oxygen. Nurse K then pulled the full medication cup out of the dirty medication and handed them to Resident #43 who consumed them. Nurse K then left out of the room, threw the dropped pill into the drug buster bottle and got a new blood pressure pill for Resident #28. Resident #3: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #3 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Amyotrophic Lateral Sclerosis/ALS, dysphagia (difficulty swallowing), need for a feeding tube, COPD, diabetes, sleep apnea, heart disease, GERD and PTSD. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and the resident needed some assistance with all care. A review of an Acute Care Note dated 4/26/2026 at 12:38 PM identified, .recurrent PEG tube clogging was managed without tube replacement. he continued active medications for ALS, COPD, diabetes, and other chronic conditions. On 5/04/2026 at 9:39 AM, Resident #3 was observed lying in his bed, awake and talkative. He said sometimes he did not receive all of his medications. He said sometimes during his medication administration via a peg tube/feeding tube into his stomach, medication squirted out and he didn't receive all of it. He said he really worried about that because he needed his medication and when that happened they didn't replace the medication. A review of the Care Plans for Resident #3 indicated Care Plans for Heart disease, decreased fluid intake, diabetes, gastric reflux disease/GERD, bowel and bladder incontinence, impaired mood, pain, COPD, sleep apnea, and risk for impaired skin integrity. Each Care Plan contained an intervention to Administer medications as ordered. A Confidential Group of Residents: On 5/5/2026 at 11:20 AM, during a meeting with a Confidential Group of Residents, several residents said the nurses left the residents' medications in a cup at the bedside and then the nurse exited the room before the resident took them. One resident said there were times medications were left in a cup in the room while they were in the bathroom; the nurse was not present when the resident took the medications. One Confidential Resident said there were a few times the nurse forgot to give them their medication and the resident stated, So I went and said something about it.

Based on observation, interview and record review, the facility failed to follow standards of practice for insulin administration and needle safety for one resident (Resident #29) of three residents reviewed for insulin administration, resulting in the likelihood of decreased dosage administered and infection. Findings include. On 5/06/2026, at 11:49 AM, Nurse L gathered Resident #29's insulin pen for administration. Nurse L pulled out a needle and attached it to the insulin pen without cleaning the insulin pen with an alcohol swab. Once Nurse L applied the needle to the pen, they turned the administration dial to 8 units and entered Resident #29's room. Nurse L administered the insulin pen without priming the needle with the required 2 units. On 5/06/2026, at 12:32 PM, the Director of Nursing (DON) was alerted that Nurse L did not clean the insulin pen with an alcohol swab prior to the needle attachment nor prime the required 2 units prior to administration.

Based on observation, interview and record review, the facility failed to date dressings and give consistent dressing changes for 2 residents (Resident #1, Resident #17) of 3 residents reviewed for wound care, resulting in prolonged healing. Findings include: Resident #1: In an interview on 05/04/2026 at 9:28 AM with Resident #1 was lying in bed with a sheet covering him. Resident #1 was not sure if he came with the coccyx wounds or got them at facility, he believes at hospital. Observed air mattress in place. The resident stated that the treatments/dressings are not always done every day, and he does not know why, the wounds seem to be getting bigger to him. He declined to have surveyor look at his wounds. Surveyor will request wound care nurse dressing change. Record review of Resident #1's medical record revealed he is his own responsible party, Brief Interview of Mental status (BIM's) score of 13 out of 15, some cognitive impairment, will check the MAR TAR records for consistency of dressing change/treatments. Record review of treatment administration record for January through May 2026 revealed missing documentation of treats provided or performed and signed out by the nursing staff. January 2026- 3 missed treatments to the coccyx, 3 missed treatments to left gluteal. February 2026- 3 missed treatments to the coccyx, 3 missed treatments to left gluteal. March 2026- 6 missed treatments to the coccyx, 6 missed treatments to left gluteal. April 2026- 3 missed treatments to the sacrum, 3 missed treatments to left gluteal. Observation and interview on 05/06/2026 at 10:59 AM licensed Practical Nurse (LPN) wound care C of Resident #1's room and dressings. Observation on 05/06/2026 at 11:03 AM Observed pressure wearing boots when in bed, Resident stated that the boots get hot and sweaty he did not want them on, declined a pillow to elevate the feet also. LPN C stated that the resident's Coccyx wound he does not like to be off his bottom, we had a conversation that I educated again to get off his coccyx to offload, Resident #1 at present declined to offload or shift position. Residents left lateral leg abrasion, he declined soft boots and pillow he stated no. Left gluteal- facility acquired, we have an unavoidable form for him. The Resident signed on to hospice recently and has human immunodeficiency virus. LPN C stated that she did not understand the skin and wound tab, in the computer program. LPN C started in December at the facility. Resident #1 is his own person, and he is non-compliant with his care/positioning, after his last hospital admission he came back with worsening of wounds. In an interview and records review on 05/06/2026 at 1:14 PM with the Director of nursing (DON) about the skin/wound treatments on the Treatment Administration Records (TAR). Record review of Resident #1's Medication Administration Record (MAR) and Treatment Administration Records (TAR) the DON stated that she was aware there are blanks on the MARs and TARs with blank spots. The DON did not know why they are blank, and there should have been a progress note if left blank. The State surveyor inquired of the chart codes/follow-up codes located at the bottom of the MAR/TARs, the DON stated that the codes chart at the bottom of the MAR/TAR forms has a documentation key for staff when resident at Hospital, refuses, Leave of Absence, the nurses are not using the key. The DON stated that the facility was trying to monitor the MAR TARs. Nurses are on 12-hour shifts, and the MAR TARs are set up for 8-hour shifts so there is a shift not accounted for. The facility is Liberal treatments and med pass but still have blank spots. Plan was to get the PCC switched to 12 shifts. But it has not happened, The DON stated that she is new to the building started March 2nd, 2026, and has a lot of work to do. On 5/04/2026, at 10:56 AM, Unit Manager (UM) , entered Resident #17's room for a skin observation of their feet. UM M removed a bandage that was covering the right great toe wound. There was no date on the bandage. The bandage appeared to be old. The inside pad of the bandage was completed saturated with dark red and black drainage that appeared old and was odorous. UM M was asked if they saw a date on the bandage and UM M stated, there's no date on it. Resident #17 stated, they had put the bandage on two days ago. On 5/05/2026, at 1:30 PM, a record review of Resident #17's electronic medical record revealed an admission on [DATE] with diagnoses that included Hypertension, Heart attack and congestive heart failure. Resident #17 required assistance with activities of daily living and had intact cognition. A review of the Treatment Administration Record 5/1/2026 – 5/31/2026 revealed a treatment order Right great toe: Cleanse with NS or wound cleanser, pat dry, apply collagen Ag and cover with foam dressing. Every day shift -Start Date- 04/29/2026 0700 – D/C Date- 05/05/2026 . On 5/06/2026, at 10:09 AM, Wound Nurse C was alerted of the observation of the undated dressing to Resident #17's right great toe wound and that the dressing appeared old.

Based on observation, interview and record review, the facility failed to ensure that an Enteral nutrition (tube feeding/nutrition through a feeding tube into the stomach or intestines) formula was administered as ordered for one resident (Resident #3) and the enteral feeding equipment was properly maintained for one resident (Resident #4) of 4 residents reviewed for enteral nutrition/feeding tubes. Findings Include: Tube Feeding: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #3 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Amyotrophic Lateral Sclerosis/ALS, dysphagia (difficulty swallowing), need for a feeding tube, COPD, diabetes, sleep apnea, heart disease, GERD and PTSD. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and the resident needed some assistance with all care. On 5/04/2026 at 9:24 AM, Resident #3 was observed lying in bed awake and alert. He answered and asked questions. He said he had a feeding tube, and a gauze dressing undated was observed on his abdomen at the feeding tube insertion site. The feeding tube had a darkened substance on the outside or inside of the tube near the port. Th resident said the dressing was not changed daily and was supposed to be. During the interview with Resident #3 on 5/4/2026 at 9:24 AM, when asked about the tube feeding/enteral nutrition, the resident said the staff sometimes took the tube feeding down early. He said it was supposed to run at nighttime and finish in the morning. He said sometimes the nurses did not start the tube feeding until 12:00 AM and he would not receive all of the tube feeding. Resident #3 said sometimes the bottle was not empty when they took it down. Resident #3 also said the nurses didn't always flush the tube with water properly, and sometimes it would spray him in the face. A review of the physician orders for Resident #3 provided: Nutren 2.0 @100 ml/hr (per hour) x 10 hours, Provides: 2000 kcal (calories), 80g protein, 700 ml free water, 1000 ml Total Volume, Up at 2000 (8:00 PM)- ensure volume starts at zero. Down at 0600 (6:00 AM)- Document pump volume and clear, start date 3/24/2026. On 5/05/2026 at 2:40 PM, Registered Dietitian/RD Q was interviewed about Resident #3's enteral nutrition. She said he was supposed to receive 1000 ml a day, which was one entire container of Nutrin 2.0 that contained 2000 calories of nutrition. She said the resident should receive the 1000 ml of the Nutrin and if it was not finished, the nurse should let it continue to run until it was finished. RD Q said the orders were written to clarify this to ensure the resident received the appropriate amount. The RD said she had spoken to the resident about his calorie/nutrition needs. During the interview on 5/5/2026 at 2:40 PM with the RD Q, nursing documentation of the administration of the Nutrin 2.0 tube feeding was reviewed in the electronic medical record Medication Administration Record/Treatment Administration Records (MAR/TAR) for April and May 2026. The RD said the amount administered should be documented on the MAR. On the May 2026 MAR, there were various amounts of tube feedings documented as administered: several were much less than 1000 ml daily as ordered. The RD Q said the nurses had said in the past that they had trouble with the administration pumps for the tube feeding and they did not always work appropriately. A review of the March, April, and May 2026 MAR's with RD Q on 5/5/2026 at 2:45 PM identified the following: March 2026 MAR: 12 days were below 1000 ml; 2 days were 729 ml, 2 days were 750 and 759 ml; 9 days were over 1000 ml with one day 1529 ml and one day 1562 ml. (The order on the MAR said Up at 2000 (8:00 PM) and down at 0600 (6:00 AM) (for a total of 10 hours at 100 ml an hour = 1000 ml). April 2026 MAR: 2 days had no documentation that the resident received the tube feeding and there was no explanation why; 22 days were below 1000 ml; 4 of the 22 days was 800-900 ml; 7 days were below 800 ml with 2 days in a row exactly 746 ml. The lowest amount was 730 ml. May 2026 MAR: May 1st – 700 ml, May 2nd - 997 ml, May 3rd – 997 ml, May 4th – 2000 ml. A review of the Care Plans for Resident #3 provided: (Resident #3) has an impaired gastrointestinal status related to GERD, recent feeding tube placement, date initiated 12/17/2024 and revised 5/7/2025 with Interventions including: Diet as ordered, date initiated 12/17/2024. (Resident #3) is at risk for altered nutritional status related to ALS. date initiated 12/22/2024 and revised 4/30/2026 with Interventions including: Administer enteral nutrition per orders, date initiated 5/8/2025. On 5/5/2026 at 4:45 PM, Resident #3 and Confidential Person W were interviewed and said on 4/29/2026 the resident did not receive his tube feeding and his stomach became upset the next morning when he received his medications, she said they were worried about it because they were taking a day trip to the casino. Resident #3 confirmed there was at least one day he did not receive his tube feeding. The resident said he had spoken with the Dietitian and hoped it would be better in the future. A review of the facility policy titled, Feeding Tubes, date implemented 1/1/2021 and reviewed/revised 10/15/2024 provided, 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. A resident who is fed by enteral means receives the appropriate treatment and services. The facility will utilize the Registered Dietician in estimating and calculating a resident's daily nutritional and hydration needs. Ensuring that the administration of enteral nutrition is consistent with and follows the practitioner's orders. Resident #4: On 5/04/2026, at 10:35 AM, Resident #4 was resting in their bed with their enteral feeding hooked to their abdomen and running. The enteral bag was dated 5/3 0200 (2:00 AM) with the initials K E written on the bag. On 5/04/2026, at 10:45 AM, Nurse C entered Resident #4's room and was asked what date was written on the enteral feed bag and Nurse C stated, 5/3 2AM. Nurse C offered, maybe it was a mistake as the water flush bag had the date of 5/4. Nures C was unsure if the initials K E was the nurse initials that hung the bag or possibly the residents' initials. On 5/04/2026, at 3:45 PM, Resident #4 remained in their bed with the enteral feed bag attached to their abdomen with the date of 5/3 0200. On 5/05/2026, at 3:00 PM, a record review of Resident #4's electronic medical record revealed a readmission on [DATE] with diagnoses that included Traumatic brain injury, Dysphagia with Percutaneous gastrostomy tube placement. Resident #4 required extensive assistance with all activities of daily living and had severely impaired cognition. A review of the Focus (the resident) is at risk for altered nutritional status related to NPO (nothing by mouth) with PEG tube placement . Inerventions . Provide nutritional supplements as ordered Date Initiated: 02/10/2025 . On 5/06/2026, at 12:57 PM, The Director of Nursing (DON) was alerted of Resident #4 's enteral nutrition bag observation. According to Indiana University Health, Guidelines for tube feeding expiration dates, feeding bags: replace every 24 hours to prevent bacterial buildup.

Based on observation, interview and record review the facility failed to ensure sanitary storage of respiratory equipment for 1 resident (Resident #3) of 3 residents reviewed for respiratory care. Findings Include:Resident #3: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #3 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Amyotrophic Lateral Sclerosis/ALS, dysphagia (difficulty swallowing), need for a feeding tube, COPD, diabetes, sleep apnea, heart disease, GERD and PTSD. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and the resident needed some assistance with all care. On 5/04/2026 at 9:39 AM, Resident #3 was observed lying in his bed, awake and talkative. He had a variety of oxygen equipment at the bedside including: an AVAPS (Average volume-Assured Pressure Support) machine providing oxygen used to assist in airway management/oxygenation; a cough assist machine, used to promote a cough and clear the airway and a suction machine to clear mucous secretions. Resident #3 pointed at the AVAPS machine and said he used that when sleeping. When asked about the cough assist machine, he said he used it sometimes when the staff helped him. The cough assist machine was sitting on the bedside nightstand, and the hose was observed bent at an angle and pinched in the drawer to the nightstand. The mask for the AVAPS machine was lying uncovered in a basket on the upright cart holding the AVAPS machine. It was buried beneath other items. Also observed in Resident #3's room on 5/4/2026 at 9:40 AM, were 3 one gallon jugs of distilled water. One jug sat on a shelf and was approximately 2/3 full and was not dated when opened. Two more gallon jugs were sitting on the floor, and both were empty. One had another residents name written in permanent marker on the jug. The other resident's room was across the hall from Resident #3. Neither bottle had been dated when opened. A review of the physician orders and May 2026 Medication Administration Orders/Treatment Administration Orders- MAR/TAR's for Resident #3 identified the following: Cough Assist- Ensure device is working correctly. Assist resident to use cough assist q (every) night and as needed, at bedtime, start date 3/3/2026. Cough Assist- Clean mouthpiece after use and as needed with soap and water q (every) day. Dry well, ensuring no visible moisture or water droplets remain on the equipment prior to storing Cover with a Plastic bag or completely enclosed in storage when not in use, every day shift, start date 3/3/2026. AVAPS- Clean mask cushion after use with soap and water q (every) day. Dry well, ensuring no visible moisture or water droplets remain on the equipment prior to storing. Cover with a Plastic Bag or Completely enclosed in storage when not in use, every day shift, start date 3/3/2026. On 5/04/2026 at 9:34 AM, during an interview with Nurse V, she observed the empty 1 gallon distilled water bottle with another resident's name written on it. The Nurse said it was a resident across the hall, and she did not know why it was in Resident #3's room; she said it shouldn't have been in the room and she disposed of it. On 5/06/2026 at 10:40 AM observed residents room with Nurse O, observed Resident #3's oxygen mask for the AVAP machine lying on top of the basket attached to the machine. The resident said it did not get cleaned; observed the mask was uncovered and appeared soiled. The Nurse said she would take care of the mask. Observed the cough machine and the tubing was kinked and partially shut in the bedside dresser top drawer; it was observed in the same location for 3 days. The distilled water gallon jug 2/3rds full was undated when opened, reviewed the water could grow bacteria over time; Nurse O said she would take care of it. A review of the Care Plans for Resident #3 identified the following: (Resident #3) has an impaired pulmonary/respiratory status related to COPD (chronic obstructive pulmonary disease)/Emphysema, sleep apnea and ALS, date initiated: 12/17/2024 and revised 2/6/2025. The Care Plan referenced CPAP (continuous positive airway pressure) but did not refer to the AVAP machine. There was no mention of caring for or cleaning the equipment for the AVAP machine or mask. There was no mention of the Cough Assist machine. A review of the facility policy titled, Oxygen Administration, date implemented 06/23/2025 provided, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. The Resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: a. The type of oxygen delivery system. Keep delivery devices in a plastic bag when not in use. Cleaning and care of equipment shall be in accordance with facility policies for such equipment.

This citation pertains to Intake Number 2993831.Based on observation, interview, and record review, the facility failed to ensure that nursing staff were reviewed for competency prior to caring for residents, for one of five staff reviewed for staffing education and competency.Findings include: On 05/05/2026 at 11:41Am, an e-mail request was sent requesting performance evaluations, competencies, education, license and certificates for 5 selected staff that included Nurse J. On 05/05/2026 at 10:45 AM, An observation of Nurse J was made independently working on the dementia unit and requested her assistance with resident identification in the dining/activities room. When asked Nurse J she said she had been a nurse about 1 year and was newer to the facility. On 05/05/2026 at 1:20PM, During an interview with Human Resources (HR) J she was asked to provide education, competencies, certificates and licensure requested for the 5 selected staff that included Nurse J. On 05/06/2026 a record review of Nurse J revealed that she was hired at the facility on or around on March 11th, 2026, and was assigned skilled nursing facility (SNF) competencies, in-services and trainings on March 11th, 2026, with completion due dates of March 31st and April 10th, 2026. The record revealed Nurse J had completed 2 of the 30 competencies, in-services and trainings on March 26th, 2026, and none of the others. The 2 completed competencies were PPE donning and doffing and hand hygiene. The record revealed that 4 additional competencies, in-services and trainings were assigned to Nurse J on April 10th, 2026 with completion due date of April 30th; and on May 1st, 2026, with completion due date of May 31st, 2026. None of the additional 4 assignments were marked as completed. According to a record review of the 6AM to 6PM nurse shift assignments for May 4th 2026 that Nurse J worked independently and was not indicated as orientation; 6AM to 6PM nurse shift assignments for May 5th, 2026 that Nurse J worked independently and was not indicated as orientation; 6AM to 6PM nurse shift assignments for May 6th, 2026, that Nurse J worked independently and was not indicated as orientation. On 05/06/2026 at 10:01AM, During and interview with the DON she was asked how she ensured her staff, including nurses were competent and completed the required competencies, in-services and trainings. The DON said that from what she understood that was all done upon hire and that HR tracked that. The DON said she is new to the facility and that she had not taken part in that yet, the DON said that HR I was not at work for bereavement that day. The DON was asked if staff are allowed to be on the floor independently if they have not completed the initial competencies, in-services and training, and she said, 'they are not supposed to be'. The DON said that her staff also get assignments monthly in the SNF (computerized) training program and they have a due date to complete the competencies, in-services and trainings or they will be removed from the schedule until they complete it. The DON was asked to review the competencies, in-services and trainings that were provided by HR on 05/06/2026, After review of the documentation the DON said she was surprised by this and now, I want to check everybody's competencies, in-services and training. The DON agreed that Nurse J had worked at the facility since March of 2026 and verified she was no longer on orientation and had worked independently as a nurse. On 05/06/2026 at ~(approximately) 9AM to ~3PM, Nurse ' was observed working independently on the dementia unit. On 5/06/2026, at 9:24 AM, the Administrator was asked to provide competency, eligibility for hire, dementia and abuse training for Nurse J . The Administrator and DON was alerted of the observation of Nurse J with Resident #67. On 5/06/2026, at 9:49 AM, the Administrator entered the conference room to clarify the request for Nurse J's dementia/abuse training needs and stated the facility had already provided the document. On 5/06/2026, at 9:50 AM, a record review along with the Administrator of Nurse J's education document revealed that Nurse J only had completed sections for Personal Protection Equipment (PPE) and Hand Hygiene. A further review revealed General Orientation-Abuse, Neglect . Behavioral health . Dementia . Resident rights . Medication Pass . Assigned [DATE] Due [DATE] . were all not completed. The Administrator was asked to provide proof Nurse J was eligible for hire and the Administrator offered that Human Resources (HR) was out of the office and would provide it as soon as they could. On 5/07/2026, at 10:00 AM, the facility provided an updated education document for Nurse J. The document was updated to revealed Nurse J had completed the above training on 5/5/2026 which was the day prior to the record review with the administrator of the incomplete education document.

Based on interview and record review, the facility failed to ensure that the daily staff posting was accurate for all staff that provided care for all residents at the facility.Findings include: A record review of the facility daily staff postings revealed that it displayed CNA's, LPN/LVN and Med tech and No RN hours. It was requested for the last 2 weeks (April 21st through May 6th) be uploaded to the (computer document storage program).On 05/05/2026 at 1:20PM, during an interview with scheduler H was asked about the daily staffing posted that displayed CNA's, LPN/LVN and Med tech and No RN hours. She said she was new and that it was completed by HR. During the interview HR I entered the room and was asked about the posting and RN coverage, she said it was pulled from the (scheduling system) and maybe it was not pulling that information, She agreed that the format they posted did not show RN hours and that it was inaccurate.05/05/2026 at 3:20PM, requested copy of the posted staffing and that it be placed into (computer document storage program), 2nd request. Received paper copy of the postings. HR I said that she was still working on getting the system updated and will upload the updated version, she was aware they are non-compliant with the regulation of posting RN hours as part of the schedule.

Based on observation, interview, and record review, the facility failed to 1) Ensure that corrective action was taken when out-of-range temperatures were identified on medication refrigerator temperature logs for one of one medication refrigerator and 2) Discard discontinued or expired topical medications for two of two treatment carts reviewed for medication storage, creating the potential for compromised integrity of temperature-sensitive and topical medications. Findings include: Medication Storage and Labeling: Observed on [DATE] at 8:52 AM with Registered Nurse (RN) [NAME] unit manager of the west resident care unit treatment cart revealed multiple-dose opened ointments and creams used for wound/skin care. Observation noted resident prescription treatments included: Resident #7 -Clotrimazole-Betamethasone .05% external cream. There was no date on the box ad when observed there was no date on the opened tube of medication. Record review of Resident #7's physician order recap noted that Clotrimazole-Betamethasone .05% external cream was ordered [DATE] for 21 days, discontinued [DATE] was still in the treatment cart. Resident #3 - Anaipram HC external cream 2.5oz – box with no date and used tube with no date when medication was opened. Record review of Resident #3's physician order recap noted that 1% Hydrocortisone acetate with pramoxine ordered [DATE] and discontinued [DATE] was still within the treatment cart. Resident #40- Clotrimazole-Betamethasone .05% external cream. There was no date on the box and when observed there was no date on the opened tube of medication. Nystatin 100,000 powder container was opened and used. Record review of Resident #3's physician order recap noted that Clotrimazole-Betamethasone .05% external cream was ordered [DATE] for 21 days, discontinued [DATE] was still in the treatment cart. Nystatin External Powder 100,000 unit/GM started on [DATE] and discontinued on [DATE], was still in the treatment cart. Resident #39- Nystatin 100,000 cream tube was opened and used. There was no date on the box and when observed there was no date on the opened tube of medication. Record review of Resident #39's physician order recap noted that Nystatin External cream 100,000 unit/GM started on [DATE] and discontinued on [DATE], was still in the treatment cart. Resident #96- Nystatin 100,000 powder containers were opened and used. Record review of Resident #96's progress notes revealed that the resident discharged from the facility [DATE] and the resident's medication was still in the treatment cart. Observation and interview on [DATE] at 9:01 AM with Licensed Practical Nurse B of the East unit treatment cart- Resident #5- Nystatin 100,000 powder containers opened and used. There was no date on the container. Resident #68- Mupirocin 2% ointment opened with no date on tube or box. When opening the box, a second tube fell out of triamcinolone 1% with no resident name or date on the tube of cream in the box. Record review of Resident #68's Medication Administration record and Treatment Administration record did not have either ointment/treatment listed. record review on [DATE] at 3:03 PM per team lead and per facility there are no treatment cart policy and no discontinued medication policy. On [DATE] at 1:32PM, an observation of the medication storage refrigerator in the medication storage room that contained biologics, insulin and other temperature sensitive medications, including back up and stock medications. A record review of the refrigerator temperature logs from February 2026 revealed: On [DATE] at 0730AM temperature recorded 34 degrees F. with no evidence of corrective action documented; [DATE] at 0300AM temperature recorded 32 degrees F. with no evidence of corrective action documented; [DATE] at 0800AM temperature recorded 32 degrees F. with no evidence of corrective action documented; and [DATE] at 0730AM temperature recorded 32 degrees F. with no evidence of corrective action documented. On the log was a column labelled Corrective action taken when outside of 36-46 F with no entries made in the column. On [DATE] at 1:45PM, During an interview with the DON, she observed, reviewed and validated that staff acknowledged the temperature deviation on the February log but did not document or initiate corrective steps. The DON was asked what should be done if the temperature is found outside of range and she said they should document it and contact maintenance. The DON was requested to provide policies and procedures medication storage, corrective action plans for refrigerated medications/products and other supporting documents. A record review revealed: No evidence of corrective action. No documents of recalibration, maintenance, replacement or staff re-education. According to a record review of the facilities policy titled Medication storage revealed: it is the policy of this facility to ensure all medications housed on our premises will be stored according to the manufacturer's recommended and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.; And 5. Refrigerated products: b. Temperatures are maintained within 36 to 46 degrees F. Charts are kept on each refrigerator and temperature levels are recorded daily by the charge nurse or other designee. c. In the event that a refrigerator is malfunctioning, the person discovering the malfunction must promptly report such findings to the maintenance department for emergency repair. d. In the event that that emergency repairs cannot be made timely, temporary or emergency space is available in the pharmacy refrigerator or the refrigerators located in each medication room.

This Citation Pertains to Intake Number 2992230. Based on observation, interview and record review, the facility failed to provide timely assistance with activities of daily living (ADL) including grooming and shaving for 2 residents (#9 and #12), of 2 residents reviewed for ADLs. Findings Include: Resident #9: Observation and interview on 05/04/2026 at 9:42 AM of Resident #9 was observed outside in the courtyard noted with chin whiskers of gray and black in color visible. Resident #9 stated that staff only shave her on shower days and would like it more often. Observation on 05/05/2026 at 11:52 AM of Resident #9 with whiskers today. seated in dining room. Observation on 05/05/2026 at 12:59 PM of Resident #9 and a visitor to go into the courtyard to sit in the sun outside. Resident chin Whiskers were visible again. Observation on 05/06/2026 at 9:57 AM of Resident #9 was observed up in wheelchair in the hallway with chin whiskers visible. Resident #12: A review of the medical record indicated Resident #12 was admitted to the facility on [DATE] with diagnoses: Dementia, PTSD, back pain, diabetes, and depression. The Minimum Data Set/MDS assessment dated [DATE] revealed the resident had severe cognitive loss with a Brief Interview for Mental Status/BIMS score of 3/15. Section E: Behavior of the MDS assessment indicated the resident had no behaviors during the assessment look back period. Section GG of the MDS indicated the resident needed supervision or touch assistance with hygiene tasks including shaving. On 5/04/2026 at 11:09 AM, during a tour of the Dementia unit, Resident #12 was observed unshaven with whiskers approximately 1/2 to 1 inch long and sleeping at an activities table in the day room. On 5/5/26 at 10:00 AM, Resident #12 was observed in the day room in the Dementia unit, unshaven. On 5/06/2026 at 10:35 AM, Resident #12 was observed in the day room, sitting at one of the tables; his was breakfast finished. The activities staff were present, and the resident continued to be unshaven. On 5/06/2026 at 10:45 AM, the day room on the Dementia Unit was observed with Unit Manager M. Observed all male residents, approximately 6 residents but one, were unshaven: this included Resident #12. The Unit Manager/UM M was asked about this and said she did not know why they were not shaved. She said if they refused to be shaved the Nurse Aides would chart their refusal when they charted their showers. A review of the Care Plans for Resident #12 revealed: (Resident #12) has an ADL (activities of daily living) self-care performance deficit related to generalized weakness and deconditioning, date initiated 12/17/2024 and revised 3/20/2025 with Interventions including: (Resident #12) showers Monday and Thursday evening, date initiated 1/25/2025 and revised 11/11/2025; Bathing: 1 person assist, date initiated 12/19/2024 and revised 3/20/2025. There was no mention of assisting the resident with shaving or that the resident refused shaving. A review of the Tasks: Behavior Symptoms charting from April 7, 2026, to May 6, 2026 revealed the resident had a few behaviors of repetitive movements and wandering. The remainder of the charting said, None of the above observed. There was no aggressive behaviors or rejection of care. A review of the Tasks: Bathing Monday and Thursday Evening shift documentation from 4/9/2026 to 5/4/2026 revealed the resident missed one bath/shower on 4/13/2026. There was no indication that the resident refused to be shaved. A review of the facility policy titled, Activities of Daily Living (ADL's), date implemented 10/30/2020 and revised 12/28/2023 provided, The facility takes measures to minimize the loss of resident's functional abilities, including activities of daily living (ADLs). Activities of Daily Living include the ability to: 1. Bathe, dress, and groom. A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

This citation pertains to Intake Number 2726226. Based on observation, interview and record review the facility failed to implement individualized interventions to address the dementia care needs of one resident (Resident #606) of six residents reviewed for dementia. Findings Include:Resident #606:On 4/6/2026 at 11:00 AM, a tour was completed of the locked memory care unit. We entered through the common room area where residents were observed at tables with two facility staff members. Once in the hallway there was no nursing staff observed. Upon entering room [ROOM NUMBER], a gentleman was observed sleeping in bed b and Supervisor A stated that was not Resident #603 but Resident #606. He stated he resides next door as their rooms connect via the bathroom and it's possible, he entered through the bathroom. Supervisor A left the room to locate a staff member to assist in redirecting Resident #606 back to his room. He returned a few moments later with a staff members observed earlier in the common area and as she was assisting the resident another aide came up the hallway and stopped to assist as well.It can be noted as the tour with Supervisor A was occurring on the memory unit Resident #606 wandered into room [ROOM NUMBER] and there was no nursing staff visible in the hallway at that time.On 4/6/26 at approximately 11:20 AM, CNA (Certified Nursing Assistant) B stated Resident #606 does wander in/out of resident rooms and they have to keep an eye on him and redirect as needed. CNA B continued they do have stop signs they put on resident doors as well as a deterrent. The CNA was asked if there was stop sign inside the bathroom that may possibly deter the resident and he stated there was none. On 12/6/26 at 11:45 AM, an interview was conducted with Social Worker C regarding Resident #606's persistent wandering into other residents' rooms (specifically Resident #603). Social Worker C stated Resident #606 likes to wander in/out of resident's bedrooms and within this year this behavior has been more prominent. They initially thought he had a preference of a one room (Resident #603' room) and completed a room change but found after room change that it did not make a difference.Social Worker C was asked did they account for two residents sharing bathrooms once the room change was completed and she stated they did not. She was further asked what other interventions are in place to deter Resident #606 from wandering and subsequently getting into other residents' beds. She reported the residents did not have an issue with Resident #606 wandering into their rooms and getting into their beds. Social Worker C was questioned regarding how that would be an accurate statement, given the residents on the memory care unit cognitive status and inability to be interviewed. It was unknown how she came to this deduction and was queried if communication was sent to their responsible parties to verify their acceptance of bed sharing. She stated notification was not sent out to responsible parties.Social Worker C continued Resident #606 wandering and sleeping in other residents' bed is a part of his dementia diagnosis. It can be noted she was not able to provide any other interventions implemented and/or trialed by the facility. She further stated during Resident #603's care conference they asked his wife had it improved and she stated it had not. She expressed her frustration but stated she would just have to accept it, as nothing was changing. Social Worker C shared they asked his wife what she would like the facility to do to mitigate her concerns and she stated she did not know.It appeared the facility placed responsibility on Resident #606's wife to provide solutions for Resident #606's wandering/bed hopping. On 4/6/2026 at 12:50 PM, an interview was conducted with Infection Preventionist H regarding Resident #606's wandering. She reported in the month that she has been in their role she has observed him in 3-4 different rooms/beds, but he has been easily redirectable. Preventionist H stated it would be the expectation that staff would change the linen and send any personal bedding to laundry if Resident #606 was found sleeping in a room not his own.On 4/6/2026 at 1:20 PM, Resident #603's wife explained when she voiced her concerns to floor staff and they informed her they could not consistently monitor him (Resident #606) when he gets out the bed and walks the hallways. She reported that she visits about twice a week and she observed Resident #606 in her husband's bed at least once during her visits. She stated it was frustrating as the issue persisted and it was unsanitary as they were not stripping the bed every time they would find the other resident in his bed.On 4/6/2026 at 3:00 PM, Nurse M shared Resident #603's bed was Resident #606's old bed and he does frequent his room/bed. They will redirect him and offer a snack which is usually effective. At times Resident #606 can be incontinent and they were educated today to change linens on the bed when he (Resident #606) is found in someone else's bed. From her recollection these behaviors began around December 2025.On 4/6/2026 at 3:15 PM, CNA L, shared Resident #606 does wander into other residents' rooms and sleeps/rests in their beds, but that is a behavior of his due to his dementia. They can redirect him and attempt to catch him prior to him laying down in another resident's bed.Resident #606:On 4/6/2026 at approximately 1:00 PM, a review was conducted of Resident #606's medical records and it revealed he admitted to the facility on [DATE] with diagnoses that included, Alzheimer's, Hyperlipidemia, Vascular Dementia, Insomnia and Anxiety. Further review of the records yielded the following:Review was completed of past 30 days of documented instances of Resident #606 being found in other residents' bed. It was documented 31 times that Resident #606 was found sleeping/resting in another resident's bed. Care Plan:Focus: .Like to sleep in other residents' beds at times.Interventions: .If found in another resident's bed, and the other resident is upset, gently redirect (Resident #606) to his own bed.It can be noted it is unclear if staff allow Resident #606 to continue sleeping in other residents beds and there is no mention of cleaning practices when he is found in another room.Practitioner Notes:3/6/26 at 20:16: .Staff reports patient often wanders on memory unit and goes into other peoples rooms. He was seen in another person's room had been laying down in their bed and staff report lets him thus what he does. He was not taken out of the room at this point as there was no agitation or irritability on his part nor did staff wish to promote that at this moment.3/20/2026 at 21:27: .There are persistent intrusive behaviors, poor boundaries, and repeated episodes of grabbing, antagonizing, and violating personal space of staff and residents. There is persistent wandering, frequent entry into other residents' rooms.Progress Notes:2/20/26 at 12:25: .tends to wander unit and has been found sleeping in 28b bed; Resident redirected to his own room.3/4/26 at 23:07: Care on going Resident is pleasant / found in different beds at time redirected to his own room.4/2/26 at 12:01: pt (patient) is going in and out of residents bedrooms urinating in their closets. Resident #603:On 4/6/2026 at approximately 1:10 PM, a review was conducted of Resident #603's medical records and it revealed he admitted to the facility on [DATE] with diagnoses that included, Dementia, Anxiety, Hypertension, Dysphagia and Hyperlipidemia. Further review yielded the following:Concern Forms:1/23/26: .She is tired of (Resident #606) sleeping in (Resident #603)'s bed.Progress Notes:3/13/2026 at 11:08: Spoke to resident and wife about a room move for (Resident #603) as there is another resident that likes to sleep in that room/bed. Let them know will be moving (Resident #603) to room [ROOM NUMBER]. There were no questions or concerns at this time.On 4/6/2026 at 4:20 PM, the DON (Director of Nursing) and Administrator were informed of the observations made and subsequent concerns. They both expressed understanding of the concern.Review was conducted of the facility policy entitled, Comprehensive Care Plans, revised 6/30/2022. The policy stated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with their resident rights.

Based on observations, interview and record review, the facility failed to ensure dignity and privacy for five residents (#9, #24, #27, #35, #37) of 18 residents reviewed for dignity and privacy, resulting in feelings of being dismissed, forgotten and embarrassment. Findings include: Dining: On 4/02/25, at 12:05 PM, an observation of main dining room lunch meal service was conducted. There were two residents sitting at a table together. At 12:10 PM, there was a tray offered to the one resident from the east hall tray cart. Resident #9 was sitting at the table and was overheard saying where's my food. In response, CNA K was overheard stating to Resident #9, one moment (Resident #9). At another table, a resident was served their lunch meal at 12:11 PM. Resident #37 was sitting across and was not served their meal. On 4/02/25, at 12:21 PM, Resident #9 and Resident #37 still had not been served their meals while the two residents sitting at their tables finished their meals and was assisted out of the dining room via their wheelchair and walker by CNA K. On 4/02/25, at 12:27 PM, the remaining residents still had not been served their meals. On 4/02/25, at 12:28 PM, a medal tray cart was pushed out of the kitchen into the dining room. The nursing staff passed the lunch meals to the remaining residents in an orderly manner. On 4/02/25, at 12:30 PM, a record review of the mealtimes that was posted on the dining room wall revealed East Hall Trays 11:45 AM . Dining room served 12:15 PM . On 4/02/25, at 12:50 PM, an interview with Registered Dietician (RD) B was conducted. RD B was asked why two residents were served their lunch meal, finished their lunch meals before all the other residents were served and RD B offered, they will chose to eat either in the dining room or their rooms. That is why their trays were on the East Hall tray cart. RD B was asked if that was a normal process for the tray pass and RD B offered, the aides should have let the kitchen know and they didn't as RD B was in the kitchen for the meal service. On 4/02/25, at 2:00 PM, a record review of Resident #9's electronic medical record revealed an admission on 11/26/2024 with diagnoses that included Diabetes, Legal Blindness and Anxiety disorder. A review of the Self-care performance deficit . care plan revealed . Interventions . EATING: (Resident #9) needs assistance with set-up all meals r/t blindness . A review of the most recent quarterly Cognitive Patterns assessment revealed Resident #9 had severely impaired cognition. On 4/02/25, at 2:15 PM, a record review of Resident #37's electronic medical record revealed an admission on 03/23/2023 with diagnoses that included bipolar disorder, schizoaffective disorder and other symptoms and signs involving cognitive impairment. A review of the most recent Annual Cognitive Patterns assessment revealed Resident #37 was moderately impaired cognition. On 4/03/25, at 8:29 AM, The Director of Nursing (DON) was alerted of the lunch meal pass observation the day prior. Resident #27: On 4/02/25, at 10:42 AM, surveyor knocked on Resident #27's door and entered. Resident #27 was lying in their bed with no clothes on. Surveyor quickly closed the door. Moments later, the door opened, and Resident #27 was again exposed with no clothes on. Once CNA I noticed surveyor, they quickly pulled the privacy curtain closed. Resident #27's door opened into their room. Their bed was closest to the hallway with an angle that could have exposed Resident #27 to the residents that were in the dining room across the hallway. On 4/03/25, at 10:45 AM, Unit Manager (UM) Q was alerted that Resident #27's privacy curtain was not closed while staff were performing cares. On 4/02/25, at 2:30 PM, a record review of Resident #27's electronic medical record revealed an admission on 11/28/2024 with diagnoses that included Anxiety, Depression and generalize weakness. A review of the most recent Cognitive Patterns assessment revealed Resident #27 had severely impaired cognition. A review of the self-care performance deficit care plan revealed . BED MOBILITY: 2 person assist . DRESSING: 2 person assist . On 4/03/25, at 8:43 AM, The DON was interviewed regarding the lack of privacy for Resident #27 on the day prior and the DON offered that both CNAS were written up and should know better. Call Lights: On 4/02/25, at 2:15 PM, a confidential group of residents complained their needs don't always get met and had the following voiced complaints: they will come in and turn off the call light and not come back they say they will come back but never do you have to put your call light on again and again they will cancel your light and say, I'll tell your aide what gets me is they say I'm not your aide, I cant do that they split the halls and 40's aide doesn't help 50's aide and vice versa when I turn my light on, in about 5 minutes they turn it off and then they forget about me they will say, I'll go get your aide and they can help you they will come back in an hour or so it upsets me I don't like it, I feel forgotten I feel left out I don't want to complain because they're probably busy with someone else it's hard to wait especially when you have to go to the bathroom 37666 Resident #35: Dignity On 4/01/2025 at 10:11 AM, while touring the end of the hall on the dementia unit outside room [ROOM NUMBER], it smelled strongly of urine. Upon entering the room, the smell of urine was even stronger. The smell was noted in the attached bathroom, near the doorway, and across the room. The smell had not been noted anywhere else in the hallway or in any other room. On 4/1/2025 at 11:20 AM, a housekeeper was observed cleaning in the hallway on the dementia unit. She was asked about the smell outside and inside room [ROOM NUMBER]. She said she had just cleaned in the room and bathroom. Upon entering room [ROOM NUMBER] with the housekeeper, the room smelled strongly of urine. The bathroom was entered, and it also had an overwhelming smell of urine. The housekeeper said she had mopped and cleaned both the bathroom and room earlier that day. There were no apparent stains on the floors. She was asked if the fall mats or bed had a urine smell, and it was difficult to determine if they smelled like urine because of the smell in the room. The resident (#35) was not in the room. On 4/1/2025 at 11:30 AM, Resident #35 was noted in the day room. Upon walking by him, there was no smell of urine. A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #35 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Dementia, anxiety, history of intestinal cancer, and heart disease. The MDS assessment dated [DATE] revealed the resident had severe cognitive loss with a Brief Interview for Mental Status/BIMS score of 3/15 and the resident needed some assist with all care. On 4/01/2025 at 2:15 PM, the Dementia unit was toured with the Director of Nursing/ DON and Corporate Nurse U. When room [ROOM NUMBER] was approached the door was closed. The door to room [ROOM NUMBER] was opened and the room continued to smell strongly of urine. With the door opened the hallway smelled of urine. The DON was asked how the room could smell like urine when it had been cleaned. She said both the current resident and resident in room next door urinate on the floor. Entered the room next door and it did not smell like urine. The DON said the resident previously in room [ROOM NUMBER] also urinated on the floor and said the floor had to be replaced. The floor in the room and bathroom appeared new and without stains. The Corporate Nurse said she also smelled it. The DON was asked what the plan was for the room, to remove the urine smell; she said they had previously thoroughly cleaned the room and would let me know what the plan was. On 4/02/2025 at 9:28 AM, room [ROOM NUMBER]-B continued to smell strongly of urine. The facility brought a cleaning plan for room [ROOM NUMBER]. They said the room was cleaned and an air purifier was added, and a new deodorizer was used. The cleaning plan was reviewed, and it said a new cleaning product that contained a deodorizer would be used along with the air purifier. 22347 Resident #24: Review of the Face Sheet, Minimum Data Set (MDS, resident assessment tool) dated 3/31/25, Physician orders dated 2023 through 2025, and care plans revealed resident #24 was [AGE] years old, admitted to the facility on [DATE], confused and not able to make his own healthcare decisions, and dependent on staff for Activities of Daily Living/ADL's. The resident's diagnosis included, hemiplegia and hemiparesis (flowing a brain bleed), Dysphagia (swallowing deficit), anxiety, major depression, weakness, and high blood pressure. During an observation on 4/2/25 at 11:40 a.m., Resident #24 was sitting on his bed toward the top and watching TV. The resident's call light that was laying on the floor at the bottom of his bed. When this surveyor asked the resident where his call was, he did not know, and he was unable to reach it when asked if he could get it. Review of the facility Promoting/Maintaining resident Dignity policy dated 10/26/23, stated All staff members are involved in providing care to residents to promote and maintain resident dignity and respect residents rights. Respond to requests for assistance in a timely manner (including access to call light to call for assistance).

Based on observation, interview and record review, the facility failed complete assessments to determine the need for bed rails, monitor residents' continued use of bed rails, obtain physicians' orders, and implement care plans for 4 residents (#8, #14, #19, #43) and obtain consent prior to use for Resident #14, for 4 of 5 residents reviewed for entrapment. Findings include: Resident #8: Observation on 4/1/2025 between 9:00 AM and 10:00 AM during the initial screening process of Resident #8 was observed with silver metal bilateral half siderails in use. Resident #8 appeared confused and was not responding to questions related to the use of the siderails. Record review of resident #8' minimum Data Set (MDS) dated [DATE] revealed an elderly male with cognitive skills for daily decision making as severely impaired never/rarely make decisions. Medical diagnosis included: Dementia, cardiovascular accident (CVA), aphasia, hypertension, renal insufficiency, diabetes, seizure disorder and anxiety. Record review of Resident #8's electronic medical record of all the miscellaneous file folder under the heading of consents, revealed there was no consent or assessment found for the use of bilateral half siderails noted. Record review of resident #8's care plans pages 1- 46, noted a Falls/Injury related to contractures date 11/1/2024. Interventions identified: Ensure the resident's room is free from accident hazards (e.g., providing adequate lighting, ensure there are no trip hazards, providing assistive devices), Observe for changes in mobility, place call light within reach. There were no interventions or care plan that addressed the use/consent, assessment and monitoring of half siderails noted. Resident #14: Observation and interview on 04/01/25 at 09:05 AM of Resident #14 was noted to be lying in a large bed with silver metal Bilateral half side rails in use. The Resident stated that the siderails came with her bed. Record review of Resident #14's 5-day re-entry Minimum Data Set (MDS) dated [DATE] revealed an elderly female with cognitively intact able to make decisions. Medical diagnosis included: heart failure, cardiovascular accident (CVA), hypertension, renal insufficiency, pneumonia, urinary tract infection, diabetes, anxiety and depression. Record review of resident #14's 'Therapy to Nursing Communication Form' dated 2/25/2025 revealed that the resident was a two person assist with transfers via Hoyer lift with mobility device of wheelchair. There was no recommendation for bilateral half siderails noted. Record review of Resident #14's electronic medical record of all the miscellaneous file folder under the heading of consents, revealed there was no consent or assessment for the use of bilateral half siderails noted. Record review of Resident #14's April 2024 physician orders revealed there was no order for bilateral half siderails noted. Record review of Resident #14's March 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR) had no daily/weekly monitoring of bilateral half siderails for entrapment performed by nursing. Record review of resident #14's care plans pages 1- 20, noted a Falls/Injury related to contractures dated 3/14/2025. Interventions identified: Educate resident on safety interventions (none identified), Encourage resident to keep needed items within reach. Encourage resident to use call light. Ensure the resident's room is free from accident hazards (e.g., providing adequate lighting, ensure there are no trip hazards, providing assistive devices). There were no interventions or care plan that addressed the use/consent, assessment and monitoring of half siderails noted. Resident #19: Observation on 4/1/2025 between 9:00 AM and 10:00 AM during the initial screening process of Resident #19 was observed with silver metal bilateral half siderails in use. Record review of resident #19's care plans pages 1- 23, noted a Falls/Injury related to contractures dated 9/07/2023. Interventions identified: Educate resident on safety interventions (none identified), Encourage resident to keep needed items within reach. Encourage resident to use call light. Ensure the resident's room is free from accident hazards (e.g., providing adequate lighting, ensure there are no trip hazards, providing assistive devices), Transfer assist device enabler bar to bilateral of bed for increased mobility. There were no interventions or care plan that addressed the use/consent, assessment and monitoring of half siderails noted. Record review of Resident #19's 'informed Consent for Use of Bed Rails' form dated 2/20/2024 resident overview: What assessed medical needs would be addressed by the use of bed rails for this resident? Blank/no documented assessment. What are the possible benefits of bed rail use for this resident and what is the likelihood of these benefits? Blank/no documented assessment. What are the possible risks of bed rail use for this resident and how will these risks be mitigated? Blank/no documented assessment. Alternatives to bed rails have been attempted, but failed to meet the resident's needs, or were not attempted because they were considered to be inappropriate, describe: Blank/no documented assessment. Resident #43: Observation on 04/01/25 at 09:31 AM during the initial screening process of Resident #19 was observed with silver metal bilateral half siderails in use. Record review of Resident #43's 'informed Consent for Use of Bed Rails' form dated 7/2/2024 resident overview: What assessed medical needs would be addressed by the use of bed rails for this resident? Blank/no documented assessment. What are the possible benefits of bed rail use for this resident and what is the likelihood of these benefits? Blank/no documented assessment. What are the possible risks of bed rail use for this resident and how will these risks be mitigated? Blank/no documented assessment. Alternatives to bed rails have been attempted, but failed to meet the resident's needs, or were not attempted because they were considered to be inappropriate, describe: Blank/no documented assessment. The form did not identify the type (full/partial) or location (upper/lower) side rails to be used. Observation and interview on 04/02/25 at 12:02 PM with the Director of Nursing (DON) during a walking tour of the East unit rooms 40 through 56. The DON stated 'We don't have any siderails. We don't use them'. The DON walked with the state surveyor through the East hallway unit to observed rooms with half silver bed rails in place. Resident #14's bed observed with bilateral silver metal half side rails. Resident #43's bed observed with bilateral silver metal half side rails. Resident #8's bed observed with bilateral silver metal half side rails. Resident #43's bed observed with bilateral silver metal half side rails. The Director of Nursing (DON) stated that those are assist bar's. Requested siderail policy. In an observation and interview on 04/02/25 at 12:09 PM with regional maintenance support staff T observed resident rooms with silver half siderails and stated, Those are assisted bars for the larger residents to reposition. In an interview on 04/02/25 at 12:33 PM with the Nursing Home Administer (NHA) stated that they (silver half bed rails) are half bed rails. I immediately ordered one set of the assist bar to get the correct bars. The silver ones have been in the building forever. I saw the maintenance man carrying the silver half rails down the hall. I said what are you doing?. the state surveyor asked Why did you leave them on the beds? The NHA stated because we needed to have something with the intention of ordering the appropriate ones for the beds. In an interview and observation on 04/02/25 at 12:50 PM with the Director of Maintenance F, stated The silver half siderails the facility had those already in the building. I took over the job last June 2024 as director of maintenance, Those Silver rails are what they have always used. I researched the correct rails, for the beds we have. I have ordered one set of assist rails, just to make sure it fits. I have siderail measurements. Director of Maintenance F and the state surveyor walked to the environmental office and received 'Bed Inspection Record' dated March 2023. That's the last time I did the siderails measurements and now the beds are not in the same rooms as back then. There were no other measurements documented, or information provided to the surveyor for the current bed siderails in use. Record review of the facility 'Proper Use of Bed Rails' policy dated 10/24/2022 revealed appropriate alternative approaches are attempted prior to installing or using bed rails . Resident assessment: .the following components will be considered when determining the resident's needs, and whether, or not the use of bed rails meets those needs: (a.) Medical diagnosis, conditions, symptoms, and/or behavioral symptoms, (d.) medications, (I.) cognition, (k.) communication, (k.) mobility . 2. The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the residents' assessed needs. 3. The resident assessment must also assess the resident's risk from using bed rails: (a.) Accident hazards. (b.) Barrier. (c.) Physical restraint . Informed consent: Informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails . Ongoing Monitoring and Supervision: This should be evidenced in the resident's records, including their care plan, including, but not limited to the following information: (a.) the type of specific direct monitoring and supervision provided during the use of bed rails, including documentation of the monitoring. (b.) The identification of how needs will be met during the use of the bed rails, such as for repositioning, hydration, meals, use of the bathroom and hygiene. (c.) Ongoing assessment to assure that the bed rail is used to meet the resident's needs. (d.) Ongoing evaluation of risks. (e.) The identification of who may determine when the bed rail will be discontinued, (f.) the identification and interventions to address any residual effects of the bed rail (e.g., generalized weakness, skin breakdown) On 4/3/2025 at 2:10 PM discussion during exit conference with the facility staff on updated bed rail measurements per unit manager, Nursing Home Administrator and Maintenance staff, they plan to copy list and upload into egress system for documents.

Based on observation, interview and record review, the facility failed to ensure medication labeling, storage and discard of medications in 4 of 4 medication carts reviewed, resulting in a lack of dating of multi-dose medications with specified time frames for use after opening. Findings include: Observation and interview on [DATE] at 08:01 AM on the [NAME] unit medication cart with Licensed Practical Nurse (LPN) P revealed that: Unsampled female resident had Trelegy Ellipta 100mcg/62.5mcg/25 mcg multi-dose medication, opened/used and not dated with either open date or expirations date once opened. Resident #67- Ipratropium Bromide Inhalation 0.02%, ampules located within the box not in the foil packet. Resident #52- Ipratropium Bromide and Albuterol Sulfate 0.5mg & 3mg/3ml. 3 ampules located in box and not in foil packets. LPN P stated that the ampules are to be in the foil packets not loose. [NAME] with green lettering open and expiration date stickers on some medications were noted by the surveyor. Observation, interview and record review on [DATE] at 08:22 AM of the secured dementia unit medication cart with Licensed Practical Nurse (LPN) O revealed that: Resident #53 had glargine injection pen opened/used date [DATE] with no expiration date on pen noted. (Open 29 days, expired at 28 days). Unsampled male resident- Lantus Solostar pen/used open date [DATE] no expiration date on pen. Unsampled female resident- glargine injection insulin pen open date [DATE], no expiration date noted on pen. licensed Practical Nurse (LPN) O stated We are supposed to write the expiration dates on the insulin pens, and they are only good for 28 days or shorter, when we open them, we date them with the open and expiration date. Record review of the 'Stability of Common Insulin's in Vials and Pens' forms located within the secured dementia unit narcotic binder identified shortened expiration dates for insulin pens and bottles of glargine insulin. Observation and interview on [DATE] at 08:51 AM of the East Wing (,d+[DATE] rooms) medication cart with Registered Nurse (RN) N revealed: Resident #27- Nitro glycerin sublingual 0.4mg with red sealed tape missing with no open date or expiration date found on bottle or pharmacy medication container. Observation of blood glucose strips bottle of 50 strips opened with no date. State surveyor observed 15 strips in bottle, of a 50-count bottle. RN N stated that the glucose strips were Good for 30-days after opening. Observation and interview on [DATE] at 08:40 AM of East unit medication cart rooms ,d+[DATE] with licensed Practical Nurse (LPN) M revealed that: Observed one loose white tablet in the second drawer of the cart. Resident #14- Latanoprost 0.05% Ophthalmic drops open/used date of [DATE] with no expiration date noted on the bottle. licensed Practical Nurse (LPN) M accessed the computer and looked up the medication Latanoprost 0.05% Ophthalmic drops that once opened used in time frame of 6 weeks. Surveyor requested ophthalmic medications open date policy. Record review of the facility-provided 'Medication Storage' policy, dated [DATE], revealed it was the policy of the facility to ensure all medications housed on the premises are stored according to the manufactures recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. (6.) Light protection: All drugs, which require light protection while in storage, remain in the original package . Record review of facility-provided 'Medications and Biological's labeling of' policy, dated [DATE], revealed all medications and biological's used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. (8.) labels of multi-use vials must include: (a.) the date the vial was initially opened or accessed. (b.) All opened or accessed vials should be discarded within 28 days unless the manufacture specifies a different (shorter or longer) date for that opened vial. In an interview and record request on [DATE] at 11:37 AM, the Nursing Home Administrator (NHA) was asked about a multi-dose medication policy? NHA stated no. NHA was asked about Open medication and expiration date policy? NHA stated, no, we do not have that either. An interview and record review on [DATE] at 9:30 AM with the infection control preventionist/Staff education/registered Nurse (RN) A revealed that there it was no ophthalmic medication policy. RN A was to call the pharmacy and ask about the expiration once open Latanoprost 0.05% expectation. At the end of the survey no further documents were provided for this concern.

Based on observation, interview and record review, the facility failed to 1) Maintain food preparation and kitchen equipment in a sanitary and good working condition and 2) Maintain a correct thawing procedure for hamburger. Findings Include: Review of the Public Health Service 2009 Food Code, adopted by the Michigan Food Law, effective October 1, 2012, Chapter 4-501.14 directs that equipment cleaning frequency is to be throughout the day at frequency necessary to prevent recontamination of equipment and utensils. Review of the facility Food Receiving and Storage policy dated 1/1/2022, revealed food items open and partly used need opened on and use by dates. On 4/1/25 at 8:00 a.m., a kitchen walk through was done accompanied by [NAME] C. The following concerns were identified during the walk through: -At 7:55 a.m., observation of the large can opener sitting on the food prep table was noted sitting on the food cart to have dried on food on the blade and around the blade was found to also have dried food on it. -At 8:00 a.m., observed the small toaster with an excessive amount of crumbs. During an interview done on 4/1/25 at 8:00 a.m., [NAME] C said they only use the small toaster for glutton free toast. -At 8:07 a.m., the large mixer was observed to have dried-on batter like substance on the attachment directly above the mixing bowel. -At 8:08 a.m., the plate warmer was observed to have dried on food drippings on the inside next to were clean plates wound be. -At 8:10 a.m., the black food cart with plastic bowels on it and cereal, was found to have food on the all the 3 shelves and 3 black plastic bowels were found to have dried on food inside. -At 8:15 a.m., in the freezer, was observed a log of hamburger sitting in an extensive amount of blood. During an interview done on 4/1/25 at 8:15 a.m., [NAME] C said she did not know if leaving thawing meat in a pool of blood on a tray was ok. During an interview done on 4/2/25 at 9:31 a.m., Infection Control Nurse, RN A stated This is extremely wrong; first of all food borne illness, once it thaws it generates bacteria. It's like a Petri dish growing. -At 8:30 a.m., Observation of the gray plastic food tray cart was found to have dried on food and drippings on it. This cart is where clean food trays are put. -At 9:00 a.m., a small brush was observed on the hand washing sink. This can transfer bacteria from staff to staff during use. During an interview done on 4/1/25 at 9:16 a.m., Dietary Aide/Cook J stated We use it (the small brush) for my nails when I wash my hands. Review of the facility Food Preparation and Service policy dated 1/1/22, stated Potentially hazardous foods (PHF), including raw meats, which might contaminate other foods or the food preparation area, will be prepared in specified areas using appropriate measures to prevent cross contamination. This policy included Thawing Frozen Food. During an interview done on 4/2/25 at approximately 11:00 am. with registered dietitian/RD B,she verbalized the hamburger loaf should not be sitting in blood; the meat should be on a clean pan, it's a cross contamination issue. RD B said this will increase bacteria and has the potential for illness. Review of the facility Infection Control walk through Validation Checklist Kitchen Observation sheet dated 1/23/2025, revealed #3 meat thawing was satisfactory. Review of this check list for 1/25, revealed everything checked off was satisfactory, no concerns were found. During an interview done on 4/3/25 at 8:50 a.m., RD B gave this surveyor a dietary staff education done on 4/1/25 (after the observation made of hamburger thawing sitting in blood), with signatures regarding proper thawing technique. The dietary education stated When meat is thawing, if blood begins to pool excessively under thawing meat, change drip pan. Changing drip pan will prevent the potential of cross contamination. Review of the facility Supervisor Dietary Job Description (un-dated), stated Provides training, direction and guidance for the dietary staff (including proper thawing technique).

Based on observation, interview, and record review the facility failed to abide by one resident's (Resident #3) assessed level of assistance during incontinence care, resulting in Resident #3 rolling off of her bed and onto the floor during care and sustaining a preventable femur fracture that required surgical intervention. This citation was cited at Past Non-Compliance with a Compliance Date of 11/06/2023. Findings Include: Resident #3: On 4/29/2024 at 12:15 PM, an interview was conducted with Resident #3 regarding her stay at the facility. She reported while she recently has shown improvements, she had a fall in October 2023 when she rolled out of bed during a brief change and broke her leg. Resident #3 reported she required surgical intervention and screws in her leg from the ordeal. Resident #3 stated she is a two-person assist and the Certified Nursing Assistant (CNA) placed her on the bedpan and attempted to change out her brief alone. Resident #3 alerted the CNA she needed to use the bedpan and the CNA went to obtain one and then placed it underneath her. The CNA removed the bedpan and placed the brief underneath the resident; as she completed that task, Resident #3 heard the brief tear. The resident started she was already close to the edge of the bed, but the CNA was not paying much attention to her positioning in the bed and was on the left side of the bed (the resident fell to the right side of the bed). As the CNA was changing out the briefs, the resident was rolled toward the right and she continued to roll and hit the floor. On 4/29/2024 at approximately 1:30 PM, a review was completed of Resident #3's medical records, and it indicated she was admitted to the facility on [DATE] with diagnoses that included, femur fracture, spinal stenosis, syncope and collapse and hyperlipidemia. Resident #3 is cognitively intact and able to make her needs known. Further review yielded the following: Care Plan: .Bed Mobility: a 2 person assist with b/l (bilateral) enabler bar to increase mobility .Toileting: 2 Person assist . initiated on 8/23/2023. Kardex: .Bed mobility: 2 person assist with b/l enabler bars to increase mobility .toileting: 2 person assist . Incident and Accident Report: I asked for the bed pan. She got the bed pan under me. I used the bathroom. She took the bed pan off. the brief was wet and I head I tear. So, I tried to help and lift up the best I could to give her some help to put the new brief on and the other off. I wind up falling over the bed. The last tug I was real close to the end of the bed and I feel off the bed .Nurse assessed resident, no new skin issues observed at this time .Resident hoyered back to bed .Resident continues to complain of bilateral knee pain. Resident cried out in pain when moving each knee . Progress Notes: Nurse Notes: 10/26/2023 at 16:25: Taken from nurse notes: Resident stated to nurse . I asked for the bed pan. She got the bed pan under me. I used the bathroom. She took the bed pan off. The brief was wet and I heard it tear. So, I tried to help and lift up the best I could to give her some help to put the new brief on and the other off. I wind up falling over the bed. The last tug I didn't realize I was close to the end of the bed and I fell off the bed. 10/26/2023 at 17:07: Resident was sent to hospital following a fall out of bed. She c/o (complaints of) pain 10/10 in her r (right)/leg . Hospital Discharge Summary: Admission diagnosis: fall from bed, other closed fracture of distal end of right femur .Right knee showed displaced, comminuted fracture of the distal femoral metadiaphysis .CT knee right showed significant comminuted fracture of distal femoral metadiaphysis fracture extends to femoral trochlea articular surface .Patient went over reduction internal fixation of the right femur with orthopedic surgery .wound vac in place . Practitioner Notes: 10/26/2023 00:00: New fall from bed while rolling during bed change. Complaints of knee and hip pain. Requests send out. 11/6/2023 00:00: [AGE] year-old female patient seen today to reestablish care. Patient had a fall and incurred a femur fracture. She underwent surgical repair. She was then stabilized and sent back to this facility for further medical care and rehab . On 4/30/2024 at 5:37 PM, an interview was conducted with CNA X regarding Resident #3's fall from the bed as she was providing incontinence care. CNA 'X shared Resident #3 requested to be placed on the bedpan and when removing the bedpan some of the urine splashed onto Resident #3's brief causing her to have to change the brief out. CNA X stated she was on the left side of Resident #3 and lightly pushed her to the right side as Resident #3 held onto her right enabler bar. CNA X stated she attempted to prevent the resident from falling but was unsuccessful as the resident rolled off the bed toward the right side and landed face down on the floor. CNA X reported she rolled Resident #3 away from her as that was how she was trained in their CNA certification class. She admitted she knew Resident #3 was a 2-person assist, but still completed incontinence care alone as other staff were busy, but she knows now she should have waited for someone to assist her. On 4/30/2024 at 8:45 PM, an interview was held with Nurse P regarding Resident #3's fall with fracture. Nurse P reported upon arrival to the resident's room she was observed undressed and face down on the right side of the bed. Nurse P and Nurse W assessed the resident, and she had pain in her side but was agreeable to be being turned over. They moved everything out the way to provide ample space to assess Resident #3 and place her back in bed. Upon turning her over they assessed, covered her, and placed he back in bed. Resident #3 did not have any obvious injuries and she assessed the resident within her limitations as she does not move that much. Nurse P questioned CNA X who explained Resident #3 requested the bedpan which the aide provided and as she either removed the bedpan or placed the brief is when the resident fell . Nurse P stated Resident #3 can use the bilateral assist bars to pull up some to assist during care. Nurse P reported Resident #3 is care planned for 2 persons assist but this was not followed in this instance. On 5/1/2024 at 11:20 AM, an interview was conducted with Nurse W regarding Resident #3's fall with fracture. Nurse W reported the CNA rolled Resident #3 and she went over the bed and onto the ground. Upon arrival to the room Resident #3 was face down on the floor. Nurse W reported Resident #3 is a 2-person /max assist and she asked CNA 'X if she checked the residents Kardex prior to providing care and the CNA knew that she did not utilize the appropriate assistance. The facility completed a Past Non-Compliance (PNC) related to Resident #3's fall with femur fracture due to improper assist level. Facility Past Non-Compliance (PNC): One CNA was performing bed mobility with resident when the care plan stated 2 staff for bed mobility .Facility sweep was completed on like residents requiring 2 staff for bed mobility. We identified 19 like residents requiring 2 staff assistance for bed mobility CNA staff completed education to include competency checks on residents that required 2 person bed mobility. Witness Statements: Nurse W on 10/26/2024: She was turned over on her side, she was holding herself up with the railing. I told her we needed to change the brief, (it got wet removing bed pan. I took the old one out. When I was placing the new one on. Resident pulled herself up and over to help. Resident flipped over railing. I tired to grab her. Unsuccessful trying. I yelled for the nurse to come immediately as I stayed with her. Resident #3: I asked for the bed pan. She got the bed pan under me. I used the bathroom. She took the bed pan off. the brief was wet and I head I tear. So, I tried to help and lift up best I could to give her some help to put the new brief on and the other off. I wind up falling over the bed. The last tug I was real close to the end of the bed and I feel off the bed. CNA X Training: - Turning and repositioning competency signed on 10/18/2023. - CNA X was reeducated on 11/6/2024 You much read each residents Kardex before providing care and if it says 2 person than 2 person much be present and hands on to assist. Never roll a resident away from you when providing care. On 5/1/2024 at 2:50 PM, a interview was conducted with the DON (Director of Nursing) regarding the facility PNC (Past Non-compliance). The DON reported since Resident #3's fall there have been no other falls in the facility due to improper transfer. Upon CNA X being interviewed she was truthful that she used the incorrect assistance and and knew the resident was a two person assist. The DON stated she a new CNA but was training on turning on repositioning on 10/18/2023. Since the incident they have completed monitoring of residents who require two person assist. Their audits went into 2024 to ensure substantial compliance but their PNC date is 11/6/2023. Review was completed of training document entitled Turning and Repositioning, It stated, .Always check how many staff are required to turn and reposition .If the resident is 2 person assist for tuning and repositioning bot staff should be present .Ensure the person is in the center of the bed . During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which include facility sweep of like residents who required two person assist for bed mobility, audits to ensure compliance but management staff, education and competency for CNA regarding following correct level of care and followed in QAPI. for The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on observation, interview and record review, the facility failed to ensure that the causative factors and a complete fall analysis were addressed on investigations regarding two falls with one injury (fracture) for one resident (Resident #46), resulting in a fracture of the right wrist, discomfort, hospitalization and pain. Findings Include: Resident #46: Review of the Face Sheet, Minimum Data Set (MDS, resident assessment tool dated 3/17/22), Physician orders, Progress Note's, Diagnosis Sheet and care plans, revealed Resident #46 was [AGE] years-old, alert and interviewable, admitted to the facility on [DATE], ambulated with a walker, gait belt and 1 assist for transfers and toileting, and required staff assistance with Activities of Daily Living (ADL's). The resident's diagnosis included, anxiety, stroke, metabolic [CONDITION(S)] (brain function disturbed due to toxins in body), diabetes, irritable bowel syndrome, deconditioning and [CONDITION(S)]. Review of the facility MDS dated [DATE], revealed the residents BIMS (cognitive assessment tool) was 11 (alert and interviewable.) Resident #46 had two falls, the first fall was on 3/4/22 with no injuries and the second fall was on 3/7/22, resulting in a fracture of the right wrist. Resident #46's Medications dated 2/18/22: 1. Bethanechol Chloride 25 MG three times per day: Urinary antispasmotic, for urinary retention, side effects: dizziness, lightheadedness, increased urination. 2. [MEDICATION(S)] 6/25 MG twice daily: Cardiac, Beta blocker, for heart failure, side effects: dizziness, orthostatic hypotention (low blood pressure when going from laying/sitting to standing, dizziness). 3. [MEDICATION(S)] 25 MG daily: A diuretic, for increased blood pressure, heart failure, side effects: hypotention (low blood pressure), dizziness. 4. [MEDICATION(S)] HCI/[MEDICATION(S)] 40 MG daily at bedtime: Antidepressant to treat [CONDITION(S)], side effects: dizziness, drowsiness. 5. Tamsulosin HCL .4 MG daily: [CONDITION(S)] to treat increased urination, side effects: weakness 6. [MEDICATION(S)] 500 MG twice daily: Anticonvulsants to treat seizures, side effects: Drowsy, dizziness, fatigue and decreased coordination. The medications listed above have the strong likelihood of contributing to a major fall with injury (fracture); the Resident #46 was on all of them at the time of both falls. First Fall dated 3/4/22: Review of the facility fall occurrence report dated 3/4/22, revealed on 3/4/22 at 1:45 p.m., Resident #46 fell and was heard yelling help by staff who found her laying on the floor near her bathroom. The fall was un-witnessed. The resident stated, I was trying to go to the bathroom, and I fell . The resident complained of pain, so the facility ordered an x-ray. Per documentation on the occurrence report, the facility implemented the intervention for gripper socks. The fall occurrence report revealed the page titled This section for Falls or Accidents, was incomplete and only partly filled out, page 5 had only the name of the nurse on duty, the Fall Investigation Report page was partly filled out. The re-creation of last 3 hours before fall and Root Cause of this Fall, Initial interventions to prevent future falls, summary of meeting, conclusion and additional data sections were all blank. The Quality Assessment & Assurance Investigation (page 7) and Statement of Witness page were also left blank. Review of the facility Falls care plan dated 2/18/22, revealed on 3/4/22, the intervention of gripper socks to be worn was initiated; no other intervention dated 3/4/22 was implemented. The interventions stating offer assist and encourage resident to use toilet upon awaking, before and after meals and at bedtime were not initiated until 3/7/22 (after the second fall which resulted in a fracture). Review of the facility Fall Risk Evaluation dated 3/7/22 (done for the 3/4/22 fall), revealed the resident was at risk for falls due to, having a fall (on 3/4/22), heart disease, electrolyte imbalance, orthopedic conditions (pain, generalized skeletal osteopenia), psychiatric conditions (depression, past stroke, and anxiety disorder) and she was on 3 or more medications that had the likelihood of side effects that would contribute to a fall. The facility identified the resident was at high risk for falls after her first fall on 3/4/22. Review of the facility Fall care plan dated 2/18/22, stated Determine causative factors of fall and resolve or minimize. Second Fall dated 3/7/22: During an interview done on 3/30/22 at 12:59 p.m., Resident #46 when asked by this surveyor why did she have a cast on her wrist stated, Two Saturdays ago, I fell by my wheelchair. I went to grab my wheelchair and I just fell . I was in here with a nurse and I thought she was going to grab the wheelchair. I broke my arm. I went in and got a brace on my arm and came home (returned to the facility). They give me pain medications. No one talked to me about it. Review of the facility fall occurrence report dated 3/7/22, revealed on 3/7/22 at 7:00 p.m., the resident had a second fall while attempting to take herself to the bathroom. This fall was un-witnessed. Review of page two of the occurrence report revealed a hand drawn picture of the resident (stick figure) only; no walker or room placement was done. The second page said the resident had lost her balance while ambulating to the bathroom un-attended. The third page of the report stated, the resident has device (walker) but not in use, she was receiving an antidepressant, cardiovascular and [CONDITION(S)] medication (all would contribute to a fall), she had gripper socks on at the time of her fall, her mental status was baseline, and she was toileted an hour prior to her fall. Page 4 of the report stated patient was in bed just finished dinner; no name of title of the staff member who had witnessed her in bed was documented. Review of the Fall Investigation Report dated 3/7/22, on the fifth page revealed no documentation regarding summary of meeting, contributing systemic or operational conditions, patterns/trends, a conclusion, additional care plan updates, and no signatures with date and time (all areas that were left blank). Page 2 of the report had fall/Accident checked at the top with all other sections left blank. Page 5, 6, and 7 (results of the whole investigation) of the report were also left blank. Review of the facility Standards of Care (SOC) Falls meeting notes dated 3/8/22, stated that on 3/7/22, Resident stated she was using her walker to go to the bathroom and lost her balance. The SOC Fall report (dated 3/8/22), had documented the resident had and used her walker with the second fall on 3/7/22; the occurrence report of the fall on 3/7/22, had documentation the resident had a walker but did not use it on 3/7/22, prior to her fall. These two reports were inconsistent regarding the use of the walker. Review of the Fall SOC meeting notes dated 3/7/22, stated At 1900 (7:00 p.m.) the resident was observed between the bed area and bathroom. Resident stated that she was using her walker to go to the bathroom and lost her balance. Resident c/o (complained) pain to right wrist. Tylenol administer, 2-view X-ray ordered. Fracture of right wrist. Factors involved: 3/7/22 gripper socks on at time of fall, call light was in reach but not triggered by resident. Resident toileted at 1800 (6:00 p.m.), 1 hour prior to fall. This was the only documentation found in the SOC notes regarding the residents fall on 3/7/22. No documentation dated 3/7/22, was found under the analysis of interventions to implement section regarding the fall. Review of the X-ray report dated 3/7/22, stated Conclusion: Subtle transverse fracture of the distal radius and non-displaced fracture ulnar styloid, new from comparison forearm (x-ray done on 3/4/22). Review of the facility physician order dated 3/16/22, revealed an order for [MEDICATION(S)]-Acetaminophen Tablet 5-325 MG, give 1 tablet by mouth every 4 hours as needed for pain. Review of the hospital documentation dated 3/8/22 at 2:16 a.m., stated Wrist and Hand: Osteopenia of the visualized bones. There is acute posttraumatic mildly displaced fracture of the distal end of radius along with ulnar styloid fracture. No dislocation seen. [CONDITION(S)] changes involving the intercarpal joints. The wrist joint is maintained. Soft tissue swelling. Impression: Acute posttraumatic mildly displaced fracture of the distal end of radius along with ulnar styloid fracture. Follow-up is recommended. [CONDITION(S)] changes involving the intercarpal joints. Soft tissue swelling. Review of the facility Incontinence care plan dated 3/7/22, stated Check frequently and change prn (as needed), encourage fluids during the day, check frequently for incontinence, monitor for s/sx (signs & symptoms) [CONDITION(S)] (urinary tract infection), monitor for possible causes of incontinence. This care plan and all interventions were documented as being initiated on 3/7/22, the day of the residents second fall resulting in a fracture. Review of the SOC Falls meeting notes dated 3/8/22, stated Resident has had 2 falls while at the facility. One on 3/4/22 at 1:45 PM, when she was attempting to go to the bathroom without staff assistance and reported slipping due to regular socks. No injuries at this time. X-ray obtained and negative. Factors involved: 3/3/22 resident c/o (complained) abdominal pain, foul odor, and pain to catheter site. Order to obtain urine culture & Sensitivity and to remove catheter. [MEDICATION(S)] ordered upon results (resident had a urinary tract infection). Analysis of interventions to implement: Initial fall intervention for 3/4/22 was to ensure resident is wearing gripper socks. Toileting before and after meals and at bedtime. Resident is experiencing some [CONDITION(S)]. Referrals: Therapy evaluation, Urology consult post hospital. The resident was found to have a urinary tract infection on 3/4/22, three days prior to the second fall on 3/7/22. During an interview done on 4/5/22 at 9:00 a.m., the Nurse Manager, RN H stated I think the investigations were good, I am sure. Nurse Manager H said she felt the both fall investigations for Resident #46 were well done; she was satisfied with both of them. During an interview done on 3/31/22 at 8:25 a.m., Nurse, LPN N stated the name of the staff member who was interviewed as the witness to the resident having ate her dinner and was in bed was a CNA. When asked by this surveyor why the name and title was not documented, she had no answer. Nurse, LPN N stated If no one see's it (a resident fall), then there is no witness. I feel when you go ask an aide (CNA), they don't even understand what it means. I was told if no witnesses, we don't have to do any interviews with staff. I feel that staff should have been interviewed; it's not a complete investigation. We put the I & A (incident/accident/occurrence report) in the DON's (Director of Nursing) box. If they would of done a complete investigation of the 3/4 (3/4/22) fall night, the 3/7 (3/7/22) fall night would not of happened. During an interview done on 4/5/22 at 10:20 a.m., Education Nurse, LPN L revealed the facility had done an in service on 2/25/21, regarding falls, however no fall preventive measures were gone over during this in service. Nurse Educator L stated, I have only been here for 1 and a half months, I have not done any education on falls. The resident falls both occurred in 3/22. During an interview done on 4/5/22 at 10:23 a.m., the previous education nurse (currently the Infection Control Nurse, RN M) stated No fall preventive measures education was done during the fall education (on 2/25/21), I try to hit everything, it should be and will be done (an education/in service regarding fall preventive measures). Review of the Record of In-Service education sheets dated 2/25/21, revealed the title was Fall Precautions, however the objectives of the in service sheets were all blank. During an interview done on 4/4/22 at 9:40 a.m., the facility Administrator was asked by this surveyor what the procedure was regarding a resident fall. The Administrator stated, Call Administrator, do I & A, go over it in the 24 hour meeting, if resident not alert, look at environment and body (resident's body), interview room mate, interview staff. Interview the staff even if no witnesses (to the fall). Review of the facility Quality Assessment & Process Improvement Committee Agenda/Minutes dated 3/2/21 (prior to Resident #46's falls) stated, Old Business: Fall precautions root cause, CP (care plan) interventions. The facility had identified a quality improvement concern area regarding falls, root causes and preventive measures in 2021. During an interview done on 4/5/22 at 9:40 a.m., Corporate Nurse, RN O stated We don't document. We have a soft file (documentation regarding falls/investigations), it would have all the information in one place; that's what you're looking for, we don't have it. It's not in the progress notes. She didn't have walker, lost balance and fell (regarding 3/7/22 fall). The walker is confusing, not on analyzing of 3/7 (3/7/22) fall and no demonstration was done on either (look at environment and re-in-act fall for investigation). Review of the facility Investigations handout (un-dated), stated Start a manila file (soft file): last name, first name, date of incident. Documentation needed for each resident affected: -Copy of Incident Report, make sure it's complete -Employee interviews summary sheet. Signed by the employee and the person conducting the interview and type of interview, in person via phone. Date and time -Resident interview -Detailed Nurses note -Physician note to address resident's condition (upon request from DON on 3/28/22, surveyor did not receive) -Social Work note -Most current BIMS score -Updated care plans -Hospital records -Copies of any orders -Completed investigation report indicating what happened, the plan to correct and why the decision was made to report or not to report. Also, how are we going to keep the resident safe moving forward. Review of the facility Falls-Clinical Protocol dated 4/2016, stated Post fall analysis items to be considered a. The A/I (Accident/Incident report) b. The nurses note c. Review for med changes d. Review previous lab findings e. Review for other acute clinical changes f. Review for staff statements g. Review care plan and CNA assignments/Kardex h. Observe any equipment (includes walker and wheelchair in residents' room) i. Observations of the resident's room j. Reenactment (document reenactment of incident) k. Analysis of causative factors and rational for interventions developed and implemented should be documented in the Standards Of Care notes (SOC meeting notes).

This Citation pertains to Intake Number MI 3592. Based on interview and record review, the facility failed to monitor the hydration status of one resident (Resident #40) out of two residents reviewed for hydration, resulting in a decline in condition and hospitalization . Findings include: Resident #40: According to the Admission Record, printed 11/4/2021, Resident #40 was an [AGE] year old male admitted to the Covid Recovery Unit of the facility on 9/10/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #40 had an admission nursing assessment performed by the nursing staff on 9/10 and 11/2021. On 9/10/2021 at 7:50 PM, Resident #40 had no signs or symptoms of active Covid infection. On 9/11/2021 the Dehydration risk was not assessed completely, the squares for Elevated temperature and/or infection processes; Renal disease, and Use of diuretics, or cardiovascular agents were not checked. The nurse noted in the progress note at the same time that Resident is experiencing some weakness and shortness of breath from respiratory infection. The Hydration Risk Evaluation for Resident #40 was not completed accurately on 9/11/2021 at 7:56 PM, in the Health conditions section with the instructions to identify if the resident has any of the following, the only check was for Presence of infection; Diabetes, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Then the next question was number of Health conditions checked which was not checked for 3 or more items. Another question asked about abnormal lab values, Resident #40 had lab values from 9/5/2021 sent from the hospital with him to the facility, the items that were not checked but should have been were: [MEDICATION(S)], Blood urea [MEDICATION(S)], Hematocrit, and Hemoglobin. The answer to the next question about the number of abnormal lab value items checked in the previous question, was checked as none and should have been 2 or more. The next question was for Medications/treatments taken by resident in last 7 days, Antidepressants, Cardiovascular agents, and diuretics should have been checked and were not, then leading to incorrect coding for the number of items checked in the next question, where none were checked and 3 or more should have been checked. The Summary of Evaluation was incorrect because the resident was deemed NO for risk for dehydration based on incorrect coding of answers. No care plan for Resident #40 for a risk of dehydration was completed by the staff as reviewed in the electronic medical record (EMR) on 11/4/2021. During a phone interview with the Speech/Language Pathologist, Staff E, on 11/4/2021 starting at 1:00 PM, she stated that she had seen Resident #40 on 9/14/2021 and 9/15/2021 because of a referral from the physical therapist and what she (the physical therapist) had observed as coughing during drinking. On 9/14/2021, Resident #40 was safe with his swallowing, but, on 9/15/2021 the notes revealed that Resident #40 was having difficulty with safe swallowing on 9/15/2021 and had prolonged coughing with larger sips and reduced control, requiring constant verbal cueing to use a small sip and to initiate the swallow so, his liquids were downgraded to nectar thick. There was no care plan initiation for the change of diet due to the difficulty swallowing. There was no note in the chart that the dietician had been notified. There was no care plan for Resident #40 related to difficulty swallowing or the altered texture of the fluids to nectar thick. The order had been written by a Registered Nurse as a phone order from the physician at 7:22 PM on 9/15/2021. The Speech/Language Pathologist, Staff E stated during the interview that she had not seen Resident #40 again until 9/21/2021. On 9/21/2021, Staff E had documented that she had been notified by Nursing that patient with dehydration, requiring intravenous supplementation on this date. Staff E also noted that Resident #40 was very tired and lethargic, reduced participation in oral trials, requiring total assistance for feeding and drinking. The Nutrition Data Collection/Evaluation for Resident #40 was completed on 9/14/2021 at 11:10 AM. The estimated fluid needs were calculated as 2427 milliliters (ml) every 24 hours. Resident #40's weight was recorded as 247.7 pounds. The intake and output records for Resident #40 were requested and provided. According to the intake and output records, Resident #40 had 720 ml of intake on 9/11/2021; 780 ml on 9/12/2021; 0 ml on 9/13/2021; 120 ml on 9/14/2021; 1250 ml on 9/15/2021; 630 ml on 9/16/2021; 1060 ml on 9/17/2021, 0 ml on 9/18/2021; 720 ml on 9/17/2021; 720 ml on 9/20/2021; 70 ml on 9/21/2021; and 90 ml on 9/22/2021. On no day did Resident #40 meet his required estimated fluid needs of 2427 ml. On 11/5/2021, the attending physician, Dr. N was interviewed at 2:45 PM. Dr. N was asked if there was a treatment protocol for the residents in the Covid Recovery Unit (CRC) where Resident #40 had been placed and replied, we have criteria for the monoclonal therapy, we monitor respirations, pulse oximetry, and administer oxygen accordingly, but have no treatment protocol. According to the Monoclonal Antibody Eligibility Criteria Checklist, done 9/11/2021, Resident #40 had received Remdesivir treatment at the hospital. Dr N continued, We get labs when they come in, I see each resident when they come in and the physician's assistant (PA) comes in throughout the stay. I had ordered a complete blood count (CBC) and a comprehensive metabolic panel (CMP) when he came in. Resident #40 had no blood work done for laboratory evaluation until 9/22/2021. We would leave them on whatever they come in on for prophylaxis for blood clots, Resident #40 was on aspirin therapy, but no other medications for embolytic therapy. Dr N continued, I saw Resident #40 on 9/13/2021, and the PA saw him four or five times, including the day he went to the hospital. Dr N stated that Labs have been an issue here. Dr N was shown the fluid and nutrition intake forms and had no comment. According to the Order Summary, printed 11/4/2021 for the orders for Resident #40 from 9/1/2021 through 11/30/2021, the only Laboratory orders were for a CBC and CMP on 9/21/2021 and a STAT CBC and CMP on 9/22/2021. On 9/21/2021, the PA had written a note that Resident #40 had been hypotensive (low blood pressure) and was expressing volume depletion. The PA ordered intravenous (IV) fluid and stat labs to evaluate his volume. On 9/22/2021, the PA wrote another note that stated, Resident #40 was being seen today for reassessment following order of IV fluid resuscitation, he remains hypotensive despite fluid resuscitation. However, blood pressure is moving towards normal. The note continued, that the PA was Awaiting lab results, called lab and despite lab draw being conducted they stated they had no record of patient. Labs were reordered stat. The lab results for the CBC Resident #40, dated 9/22/2021, were: the white blood cell count was 10.63 (normal range 4.5 to 10.00), red blood cell count 3.10 (normal range 4.5 to 5.6); Hemoglobin 9.0 (normal range 13-17); Hematocrit 30.1 (normal 39.6 to 50.0); mean corpuscular value 97.1 (normal 80 to 97); mean corpuscular hemoglobin concentration 28.9 (32-37). These were measures of [CONDITION(S)] for Resident #40, similar to the counts in the hospital on 9/5/2021. The CMP results for Resident #40 on 9/22/2021 were: sodium 154 (reference range 135-145); Potassium 5.7 (reference range 3.5-5.5): [MEDICATION(S)] 16.1 (21.6-31.8): Anion Gap 19.90 ( 4.0-12.0); Glucose 214 (70-110); BUN 204.0 (9.0-27.0); Creatinine 7.2 (0.6-1.5); BUN/Creat Ratio 28.33 (12.0-20.0); all indicators that something was seriously wrong with the metabolic function of Resident #40 and must be corrected to prevent death. The facility policy for Resident Hydration, dated 1/1/2021, stated, This facility will endeavor to provide adequate hydration and to prevent and treat dehydration. According to the nurses progress notes, on 9/22/2021 at 6:37 PM, Resident #40's blood pressure was 84/41 and his pulse was 100 beats per minute. This is a low blood pressure and a pulse on the faster end of normal. According to the Admission Record, printed on 11/4/2021, Resident #40 had been discharged to an acute care hospital on 9/22/2021 at 11:00 PM. On 11/4/2021 at 3:00 PM, Licensed Practical Nurse (LPN) R was interviewed on the telephone. LPN R stated that she had not worked for a few days and when she returned to work on 9/22/2021, Resident #40 had declined in condition, she had called his daughter and sought approval to sent him to the hospital. She stated that she had completed a copy of his current physician orders, the admission sheet, and wrote his current condition on the bottom of the papers I had printed from the EMR. His blood pressure was low and he was on intravenous (IV) fluids. The only note in the Progress Notes was on 9/22/2021 at 11:28 PM that read hospitalized .

Based on observation, interview and record review, the facility failed to ensure appropriate interventions were in place and supervision was provided to prevent a fall with injury for one resident (Resident #20) of six residents reviewed for falls, resulting in Resident #20 falling face forward out of his wheelchair while unsupervised in the dining room, suffering a facial and head injury and being transported to the emergency room . Findings Include: Resident #20: On 12/10/19 at 8:45 AM, Resident #20 was observed in a wheelchair in his room with two dark purple bruised areas under his eyes and a large protruding bump with a dry scabbed area on his left forehead. The resident said he fell but was unable to provide details. A record review of the Face Sheet and MDS assessment indicated Resident #20 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS assessment dated [DATE] revealed the resident had severe cognitive decline and needed assistance with all care. A review of the progress notes revealed the resident was transferred to the emergency roiagnom on [DATE] after falling in the dining room at 7:50 AM and hitting his head. A hospital Emergency Care Center, After Visit Summary, document provided Reason for Visit - Fall, Traumatic ecchymosis of forehead, initial encounter. Further review of the progress notes revealed the following: 12/8/19 at 4:11 PM, . Resident was observed on floor face down at 0750 in dining room. Assessment: Head impact suspected due to 7 x 7 bump on forehead. Resident sent to hospital . Resident was observed bending over in wheelchair by another resident immediately prior to fall. Resident was also dressed and in wheelchair before first shift arrived, then assisted to dining room before any toileting by first shift . A note by Nurse Q said, 12/8/19 at 6:39 PM . on the floor face down at 0750 on 12/8/19. He was observed by another resident leaning forward and hit the floor with his head hard. The witness resident alerted staff, and a fall code was initiated, where I came to the dining room to see the resident laying on the floor face down . resident had little pupillary reaction in the left eye, and he has a skin tear that is 1.5 cm on the left hand. A review of the Incident and Accident Reports (I&A) revealed Resident #20 had 2 recent falls dated 7/12/19 at 6:15 AM and 12/8/19 at 7:50 AM. On 7/12/19 the I&A said the resident fell forward out of his wheelchair while sitting in his room alone and unattended. It was determined the resident was incontinent of urine and an anti-thrust wheelchair cushion used to aid the resident from slipping from the wheelchair was placed backwards. The I&A dated 12/8/19 at 7:50 AM, provided: . Memory Impaired, Physically Impaired, Decision Making Impaired . Fall . Was Incident Observed-'Yes,' Witness: (a Resident) . Resident was observed by staff lying face down on floor near front left of wheelchair. Staff was alerted by (a resident) . Injury Type: Head Injury, Skin tear . Resident lost their balance, fall to the floor, dining room/day room, attempting self-transfer, alone and unattended . Time last toileted . 3rd shift, unknown . The Fall Investigation Report, completed by Nurse Q, dated 12/8/19 at 4:07 PM revealed a witness statement by Certified Nursing Assistant R. Resident was up and dressed at time of shift start. Resident was assisted to dining room, as staff returned to assist other residents, He was observed fall by hall mate. Nurse Q wrote, Resident is woken and dressed too earl for optimal comfort . Resident will be dressed, and assisted to chair with 1st shift, not 3rd shift. Resident will be checked at beginning of each shift for incontinence . Staff to offer resident option to get up on 1st or 3rd shift. Resident's get up time will be based on preference. Ten staff, including 5 nurses (#'s Q, S, T, V, Z) and 5 nurse aides (#'s R, U, W, Y, AA) were interviewed during the facilities investigation. None of the staff were present in the dining room when the incident occurred. On 12/12/19 at 10:50 AM, Confidential Resident X was interviewed, It was a freak thing. It was early morning. There was no staff in there. I saw him (Resident #20) leaning forward in his wheelchair with nobody in there. They (the staff) were out doing other stuff. He just continued to lean forward and crumbled; I said, Hey, you better get somebody over here. When they lifted him up, he had blood on his face from his forehead. He hit his head; there was an immediate black mark and on his eyes. The ambulance came right away and took him to the hospital. Most people would try to reach their hands out, but he just fell forward. There is a group of guys we always sit at the same table. He sits there too. We all come in about the same time about 6:00 AM and Breakfast is about 8:00 AM. The staff come in gradually. They have us sit there and we say, Come on. It's dark outside and we are just sitting there. We are like, come on, we would like coffee, they just keep bringing more people in and leave people sitting there. I imagine the kitchen staff was in the back making food. A review of the Care Plan titled, At risk for falls related to deconditioning, gait/balance problems, incontinence, unsteady gait, balance deficits, date initiated 10/22/18 and revised on 1/14/19 with Interventions: Be sure (resident's) call light is within reach . dated initiated 12/31/2018, Encourage rest periods as needed to avoid overtiring, date initiated 1/14/2019. There was no mention of supervision and monitoring related to the falls. On 12/12/19 at 12:50 PM, during an interview with Unit manager D related to Resident #20's fall, she stated, (the Director of Nursing (DON)) took the call on Sunday when it happened. We got an OT (Occupational Therapy) eval for the wheelchair. He has a new wheelchair now; he has a high back and higher sides for support. Nurse D was asked if the residents were left unattended in the dining room early in the morning and said the staff were in and out of the room. She said the resident was observed falling by another resident and there were no staff in the dining room during the incident. On 12/12/19 at 2:20 PM, Unit Manager D and the DON were interviewed, they said they had interviewed (Nurse Q) again and he said he had helped the resident with his shoe about 30 minutes prior to the incident. They also said Nurse S was administering medications outside the dining room, but no staff were in the dining room monitoring the residents at the time of the fall. A review of the facility policy titled, Accidents and Incidents- Investigating and Reporting, dated revised 12/1/17 revealed there were no preventive measures listed. The policy did not address resident supervision or residents left alone in the dining room for extended periods of time.

Based on observation, interview and record review the facility failed failed to assure nutrition and hydration status for 2 Residents (#13 and #152) of two reviewed for nutrition and hydration with Total [MEDICATION NAME] Nutrition (TPN) resulting in Medilodge of Frankenmuth being placed in Immediate Jeopardy for 1.) its failure to ensure that interventions were in place to monitor and assess the nutrition and hydration status for one resident (Resident #13); 2.) its failure to obtain physician orders for Total [MEDICATION NAME] Nutrition (TPN); 3.) its failure to administer TPN; 4.) its failure to meet hydration and nutrition needs for one resident (#13); 5.) its failure to educate staff and assess competency for the preparation, inserting of additives to the solution, and administering (TPN); and 6.) its failure to maintain a sanitary environment during preparation of TPN. This failure to manage the TPN resulted in the potential of complications, that could include electrolyte imbalance, infection, cardiac symptoms, dehydration/fluid overload, and embolism or phlebitis. This deficient practice resulted in one identified resident (Resident #13), being admitted to the hospital on [DATE], diagnosed with [REDACTED]. Findings include: Immediate Jeopardy was identified at F-692 on 12/17/18 at 2:25 PM. Resident #13 was a [AGE] year-old female, who was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #13 was readmitted to the hospital on [DATE] for gastroparesis (a condition that affects the stomach and prevents the stomach from emptying), had been on TPN at the hospital and recommended to be started on TPN upon discharge from the hospital on [DATE] ). Although the TPN was included in the hospital discharge instructions on 12/5/2018, there was no facility physician order for [REDACTED]. There was no documentation that the TPN was administered in the facility until 12/10/18. TPN is a method of feeding that bypasses the gastrointestinal tract. Fluids are given into a vein to provide most of the nutrients the body needs. The method is used when a person cannot or should not receive feedings or fluids by mouth On 12/10/18 at 5:22 PM, Resident #13 was observed in bed with eyes closed. TPN was observed running at 70 cc/hr. Review of physician progress notes [REDACTED].#13 was placed on TPN feeding with clear liquid diet and all orders clearly explained with good understanding verbalized. There were no noted documented physician orders for the TPN or the clear liquid diet in the electronic medical record (EMR). Review of Nurse Practitioner's progress note dated 12/7/18 and completed 12/10/18 at 12:31 PM, revealed TPN infusing as ordered. Review of Resident #13's EMR physician orders revealed there was not a facility physician order initiated for the TPN until 12/10/18 at 11:34 AM. At that time an order was written for Total [MEDICATION NAME] Nutrition, Use at 70 ml/hour intravenously. On 12/10/18 at 2:05 PM, an order was written to Change administration set every four hours with new bag change as clinically indicated when infusing total [MEDICATION NAME] nutrition or partial [MEDICATION NAME] nutrition. The physician order for [REDACTED]. There were no specific directions of what the blue and white vials were. According to the pharmacy policy the a administration set with a 1.2 micron filter must be used due to the lipid concentration. This was not specified. Review of Resident #13's hospital records revealed resident was discharged from the hospital on [DATE] on an antibiotic for a urinary tract infection. Resident refused IV medications at that time. According to the facility Medication Administration Record (MAR) Start date of 9/17/18 Medi-Port flush every month with 10 cc NS (normal saline) and 5 cc [MEDICATION NAME]. Stop date of 11/6/18 (admitted to the hospital). There were no documented physician ordered flushes by the facility for (MONTH) (YEAR) or (MONTH) (YEAR) for the central line (mediport) noted in the clinical record. Review of Resident #13's Situation/Background/Assessment/Recommendation (SBAR) on 11/5/18 revealed vomiting, distended stomach. Physician was notified and Resident was sent to the ER for evaluation. Resident was admitted to the hospital on [DATE] with complaint of chest pain. Review of Resident #13's hospital history and physical dated 11/13/18 revealed resident was treated for [REDACTED]. Discharge [DIAGNOSES REDACTED]. Resident #13 was admitted to the hospital on [DATE] with a complaint of abdominal pain. Review of Resident #13's hospital discharge summary revealed Clinical course . Patient is in mild distress. Abdomen feels distended, bowel sounds are hypoactive. Patient does have a mediport, therefore it was accessed to obtain laboratory studies, give IV fluids, as well as the nausea medications. KUB (kidney, ureter, bladder x-ray study) obtained. There is large gastric distension. NG tube is in place . Resident was admitted to the hospital on [DATE] and discharged from the hospital on [DATE] and admitted to the facility with TPN discharge instructions that included the following your medications have changed. Start taking fat [MEDICATION NAME] 20% infusion, [MEDICATION NAME] 15 mg/ml injection (torodol), [MEDICATION NAME] ([MEDICATION NAME]) 750 mg, [MEDICATION NAME] edisylate 10 mg/2 ml sol ([MEDICATION NAME]), sodium chloride 0.9 % infusion. Review of physician orders revealed there were no orders documented to flush the mediport. There were no noted documented flushes on the (MONTH) (YEAR) MAR. There was no documentation in the facility clinical records that Resident #13 had a mediport until the nursing admission assessment dated [DATE]. (see below) Review of Physician orders on 12/11/18 at 09:24 AM, revealed there was not a noted physician order for [REDACTED]. Review of nurse progress note revealed on 12/10/2018 at 17:56 (5:56 PM) Orders - Administration Note Note Text: [MEDICATION NAME] Solution 10 % Use 70 ml/hr intravenously as needed for nutrition Give [MEDICATION NAME] 10% at 70 ml/hr when TPN not available. PRN Administration was: Effective. There was not an physician order for [REDACTED]. Review of Physician orders revealed on 12/12/18 at 3:41 PM a physician order dated 12/10/18 at 12:55 PM, for a physician order [MEDICATION NAME] Solution 10 % at 70 ml/hr intravenously as needed for nutrition. Give [MEDICATION NAME] 10% at 70 ml/hr when TPN not available. There were not orders in the computer system at that time. Review of Resident # 13's MAR for (MONTH) (YEAR) revealed the TPN was not signed out as administered from 12/5/18 through 12/10/18 on the Day shift. [MEDICATION NAME] 10 % was dated 12/10/18 and signed out on 12/10/18 at 13:24 PM (1:24 PM) at 70 ml/hr when the TPN was not available. TPN was signed out as administered on night shift on 12/10/18, day shift on 12/11/18 and night shift on 12/11/18 for a total of 3 times. Review of Resident #13's Nursing Admission assessment dated [DATE] Section M. Nutrition and Dehydration risk was blank, Section R. Resident #13 was identified to have a medi port in the right upper chest. dressing was blank. The most recent comprehensive assessment by the facility of Resident #13's nutrition and hydration needs was performed by the Registered Dietician (RD) G on 1/22/2018. At that time, her fluid needs were estimated to be 2,100 ml per day. Resident #13 was also ordered a clear liquid diet and her oral intake was recorded as 340 milliliters (ml) on 12/6/2018, 720 ml on 12/7/18, 960 ml on 12/8 and 12/9, and 480 ml on 12/10/18. Review of Resident #13's weight log revealed a weight on 12/5/18 a weight of 176 pounds on readmission from the hospital. The 110 # weight loss was 40.14% of Resident #13's body weight. There was no reweight requested to verify the weight loss/discrepancy. There was no request of recent discrepancy of weights of -8.8 #, +33#, -39 #, -36# -49# weight loss as listed below. According to Resident # 13's facility weight log. Resident # 13's weight on 1/2/2018 21:31 307.8 Lbs Mechanical Lift, 3/6/2018 22:27 291.4 Lbs Mechanical Lift, 3/9/2018 22:36 252.8 Lbs Mechanical Lift, (-39.8 #) 3/12/2018 16:42 292.6 Lbs Mechanical Lift, 4/3/2018 21:53 331.8 Lbs Mechanical Lift, (-39.2#) 4/12/2018 21:41 332.4 Lbs Hoyer, 4/16/2018 11:25 283.4 Lbs Mechanical Lift, (-49#) 4/23/2018 22:04 283.2 Lbs Mechanical Lift, 5/4/2018 10:45 288.8 Lbs, 6/6/2018 16:59 288.2 Lbs Mechanical Lift, 6/19/2018 16:51 291.6 Lbs Mechanical Lift, 7/12/2018 16:24 292.4 Lbs Mechanical Lift, 7/28/2018 11:26 281.4 Lbs Mechanical Lift, 7/31/2018 15:25 245.0 Lbs Hoyer, (-36.4#) 8/1/2018 16:49 278.5 Lbs Mechanical Lift, (+33.5#) 8/2/2018 13:59 278.3 Lbs Mechanical Lift, /9/2018 14:07 281.4 Lbs, 8/10/2018 15:30 279.0 Lbs Hoyer, 9/18/2018 10:46 288.0 Lbs (Manual) +7.5% change ( Comparison Weight 7/31/2018, 245.0 Lbs, +17.6% , +43.0 Lbs ) -10.0% change ( Comparison Weight 4/3/2018, 331.8 Lbs, -13.2% , -43.8 Lbs, 10/5/2018 21:19 290.0 Lbs Wheelchair (Manual) +7.5% change ( Comparison Weight 7/31/2018, 245.0 Lbs, +18.4% , +45.0 Lbs ) -10.0% change ( Comparison Weight 4/12/2018, 332.4 Lbs, -12.8% , -42.4 Lbs 10/9/2018 13:53 294.2 Lbs Hoyer (Manual)+7.5% change( Comparison Weight 7/31/2018, 245.0 Lbs, +20.1% , +49.2 Lbs ) -10.0% change ( Comparison Weight 4/12/2018, 332.4 Lbs, -11.5% , -38.2 Lbs ), 10/9/2018 21:48 294.2 Lbs Hoyer, 11/7/2018 14:33 285.4 Lbs, (-8.8 #) 11/16/2018 22:13 286.2 Lbs Mechanical Lift, 12/5/2018 22:36 176.0 Lbs Mechanical Lift. (-110.2 #) Weight loss of 131.8 pounds since 1/2/18. Review of Resident # 13's care plan revealed, Nutrition: (Resident) may have potential nutritional risk as she -receives a therapeutic diet of Controlled carb dx of HTN, DM, dysphagia Diuretic therapy in place. Weight loss may be anticipated with changes in fluid. elevated BMI reflecting obesity revised on 10/28/18 with interventions that included Provide diet of controlled carb, monitor and record intakes q meal. HS snack daily per her preference: likes graham cracker or cookies and milk. Review of Resident #13's care plan was not updated to include resident had a central venus catheter (mediport on the right chest) (a tube that goes in to a vein in your chest and ends in your heart), signs and symptoms to assess and monitor the mediport, was receiving TPN (Total [MEDICATION NAME] Nutrition), clear liquid diet or [DIAGNOSES REDACTED]. Review of Resident #13's care plan (Resident) [MEDICAL CONDITION]/t obesity, gastroparesis initiated 10/20/17 and revised 7/30/18 revealed Monitor/document/report to Nurse/MD s/sx of GERD: Belching, coughing/choking when lying down, heartburn, dyspepsia, n/v, indigestion, Regurgitation, increased salivation, swallowing problems, bitter taste in mouth, dysphagia, substernal chest pain, increased gag response. There were no interventions related to monitoring blood sugar levels, weight loss, malnutrition, severe dehydration related to vomiting, abdominal pain or an abdominal assessment. On 12/12/18 at 4:00 PM, during an interview, Registered Dietician (RD) G reviewed Resident #13's weight log and stated, I just noticed that today and she was discharged before we got a reweigh. RD G reported resident #13 was on a clear liquid diet. RD G stated she was aware resident was receiving TPN but had not updated the care plan. RD G reviewed physician orders for Resident #13 and agreed there was no order for a clear liquid diet and agreed the care plan reflected resident was currently receiving a therapeutic diet with controlled carbohydrates. On 12/12/18 at 8:55 AM during a tour of the East Medication room with Nurse W, it was observed there were 4 bags of TPN all dated 12/7/18 noted in the medication room. During the observation, the medication room was noted to have very dusty and soiled floors. There was limited counter space due to clutter. The ceilings tiles were old, cracked and water stained. Three of the four light cylinders were not working and the protective covering for the fixture was missing. According to the facility pharmacy policy for [MEDICATION NAME] Nutrition: Additives, with a revision date of 7/1/2012, medications would be prepared in a clean environment and the medication room was unsanitary for the preparation and inserting of additives to the solution of TPN. On 12/12/18 at 4:30 PM, during an interview with Director of Nursing (DON) staff B and Registered Nurse (RN) W and Corporate Nurse D. RN W reported she prepared the TPN prior to administering TPN by adding from a multi-dose vial insulin and a multi-dose vial of folic acid into the TPN, and from single dose vials one blue top vial and one white top vial. The DON B reported she had provided verbal TPN education to RN W but had not documented the education. DON B was unable to identify where she had gotten her TPN education. The facility was requested to provide a copy of the TPN policy on 12/12/18 at 9:30 AM and were unable to locate or provide a policy for TPN administration for over seven hours. Then the facility's administration of TPN was the only policy provided. Corporate Nurse D asked, Would you like the pharmacy TPN policy. DON agreed there was no documented physician order for [REDACTED]. DON agreed that it was unclear what the multivitamin dose was other than a white top and a blue top vial. On 12/12/18 at 4:30 PM, during the interview with Director of Nursing (DON), Corporate Nurse D and RN W, Resident #13's TPN homecare order dated 12/5/18 (unsigned) and TPN bag (bag #5 not administered to resident) was reviewed and revealed the contents of the TPN was dated 12/11/18 with a use by date of 12/20/18 and included: Travasol 10% (amino acid) 75 gram, [MEDICATION NAME] 250 gram, Intralipid 30% 42 gram, additives, Sodium Chloride 50 mEq (milliequivalents), Potassium Chloride 30 mEq, Potassium [MEDICATION NAME] 35 mMol (millimole/liter), Calcium [MEDICATION NAME] 5 mEq, Magnesium Sulfate 24 mEq, Zinc 10 mg, M.T. E. -5 (multitrace 5 concentrate- 5 trace elements) 3 ml, [MEDICATION NAME] (nurse to add) 10 ml, Folic Acid (RN to add) 1 mg, Reg Insulin (NURSE to add) 10 units. Flow Rate: 1680 ml at 70 ml/hr for 24 hours. A review of a nurse's progress note, dated 12/11/18 at 11:50 AM, revealed that Resident #13 was pale and sweaty; with a very low blood pressure of 73/53; oxygen saturation of 85 %; reported nausea; and her eyes were rolled back. The resident was placed in bed. Resident #13 then became unresponsive with documentation of the nurse performing a sternal rub to resident's chest to arouse the resident. The resident then opened her eyes and said what. (ambulance) arrived to take to (Hospital). A review of Resident #13's Situation/Background/Assessment/Recommendation (SBAR), dated 12/11/18 at 11:51 AM, revealed that Resident #13 was sweaty, nauseated, had low blood pressure and documented vitals from 12/9/18. There were no current vitals on the SBAR other than the blood pressure. Review of laboratory results for Resident #13, dated 12/10/18 at 3:05 AM, revealed potassium level of 5.5 (normal 3.5 - 5.3) that indicated a high level, a creatinine level was elevated at 1.8 milliequivalent/liter (normal 0.61 -1.30) and her blood urea nitrogen (BUN) level was elevated at 29 milligram/deciliter (mg/dl) (normal 7-25) which both indicated kidney failure and was a decline from 12/5/18 for resident. Laboratory results from 12/11/18 indicated a potassium level of 5.8, creatinine elevated at 2.67, and a BUN of 47. According to Merck Manual (wwwmerckManual.com) and Mayo clinic (mayoclinicwww.com), high potassium can cause symptoms of neuromuscular irregular heart rate, nausea, vomiting, chest pain, trouble breathing, paralysis, heart failure, irregular or slow heart rate, kidneys not to excrete potassium and can cause your heart to stop. A review of Resident #13's Skilled Daily Assessments, dated 12/7/18 through 12/11/18, revealed there was no documentation of the resident's upper right mediport site for the TPN (central line). The 12/9/18 vital signs were recorded on documentation for 12/10/18. The Skilled Daily Assessment, dated 12/11/18, was completed at 10:39 AM. The resident was discharged the same day and the vital signs were again recorded from 12/9/18. The last documented vital signs were obtained on 12/9/18. No additional vital signs were taken until just before Resident #13 was transferred to the hospital on [DATE]. A review of a physician's order, dated 12/11/18 at 1:25 PM, revealed that Resident #13 was sent to the emergency room for an evaluation. On 12/13/18 at 3:49 PM, 6 Registered nurses, including Nurse W and the Director of Nursing's (DON's) education was reviewed for training and competency to prepare and administer TPN. There was no documentation that the Nurses had received education for preparation and administration of TPN. On 12/17/18 at 9:45 AM, during an interview, Pharmacy IV Specialist, RN U reported it is standard of practice to have a physician order for [REDACTED]. The facility had a home care order (discharge order from the hospital) the nurses get the signature from the physician, we transcribe the order and we put everything in the TPN bag except for the multivitamin, insulin and folic acid. Usually it is sent to the pharmacy initially for preparation time, and it inherently may not have been returned for a signature to the physician. The pharmacy should have gotten order verified. Nurses were unable to compare label on the bag of TPN/bag as there was no physician/pharmacy order. Pharmacy IV Specialist, RN U reported it is not recommended to stop TPN abruptly and it is recommended to replace with DW10 or gradually reduce. It could cause such concerns affecting the pancreas and which produces the insulin making the blood sugar to crash, potassium needs to be adjusted affecting the heart/cardiac issues, dehydration, nausea and vomiting. Pharmacy IV Specialist, RN U recommended that resident be monitored for vital signs, temperature, weight, cardiac, respiratory lung sounds, and IV site every 2 hours. Pharmacy IV Specialist, RN U reported 8 total bags of TPN had been sent to the facility (2) on 12/5/18, (4) on 12/7/18, and (2) on 12/11/18. On 12/17/18 at 11:45 AM, during an interview, RN Unit Manager W reported she may have prepared TPN on 12/7/18 and on 12/10/18 but could not recall and did not document either, and stated it was the floor nurses responsibility to do the documentation. On 12/17/18 at 12:00 noon, during an interview, DON reported that she had received a TPN order from the hospital physician, called the pharmacy with the TPN recommendation on 12/4/18 prior to Resident #13 coming to the facility, had not discussed the TPN recommendations with attending physician I at facility. On Resident #13's admission Attending physician I gave a verbal order for Resident's orders and DON agreed there was no written signed physician order for [REDACTED]. DON reported she had received an order from the hospital to administer [MEDICATION NAME] 10% on 12/5/18 to run at 70 ml/hr, verified she had not received an order from the attending physician, had not documented the physician order as a verbal order and had not documented the [MEDICATION NAME] on the Medication Administration Record (MAR). DON reported that [MEDICATION NAME] 10% was given on 12/5/18 as the TPN was not available. There was no physician order for [REDACTED]. DON reported that Resident #13 was refusing TPN on 12/8 and 12/9/18. DON reported she was unable to find any documentation to support Resident #13's refusal for the TPN. DON reported she had prepared the TPN one day possibly on 12/10/18 at 4:00 PM but agreed she had not documented it. There was no documentation the physician was notified of Resident #13 not receiving the TPN. On 12/17/18 at 3:35 PM, during an interview Dietician stated, Oral fluids is just additional in PO (oral) intake when (a resident is) on TPN. According to the the facility Parental Nutrition, policy dated 3/21/11 (5 years old) revealed Preparation 1. A Physician's order is necessary for this procedure. 2. Review the resident's care plan to assess for any special needs of the resident. 3. Assemble the equipment and supplies as needed. 4. The licensed nurse responsible for administering PN shall be knowledgeable of: a. the types of [MEDICATION NAME] nutrition; b. indications for use. c. appropriate doses and [MEDICATION NAME]; d. side effects; e. monitoring parameters; f. toxicities g. incompatibilities; h. stability; i. storage requirements; and j. potential complications. 5 . 6 . General guidelines 1 .7. Use aseptic technique when adding medications to PN solutions. Equipment and supplies 1 .2 .3 .4. Saline or [MEDICATION NAME] for flush, as appropriate.; 5 .6 .9 Assessment. 1. Inspect intravenous catheter site for signs of infection and/or complications at scheduled intervals and upon routine site care and administration set changes. 2. Prior to administration of [MEDICATION NAME] nutrition assess resident's a. age, diagnosis, overall physical status; b. nutritional status; c. baseline vital signs, height and current weight, ideal weight; d. laboratory results, including glucose, BUN , and electrolytes (assess for appropriateness of therapy); and e. history of allergies [REDACTED]. Review physician's order for a. [MEDICATION NAME] nutritional solution formula, including [MEDICATION NAME] and amino acid content and addition of lipids; b. additives and concentration; c. volume to be infused daily; d. rate of administration; e. frequency of administration; f. route of administration; and g. duration of therapy . Documentation 1. The date and time the PN was administered. 2. The type of PN solution administered. 3. Type of flow-control device. 4. Any medication administered:the dosage, route and rate. 5. Notification of the physician, if any. 6. Resident's response. 7. The signature and title of the person recording the data. Reporting 1. Notify the supervisor if the resident refuses the procedure. 2. Report other information in accordance with facility policy and professional standards of practice. According to the facility policy Nutrition (Impaired) / Unplanned Weight Loss - Clinical Protocol, dated 6/20/16 revealed, 1. The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits readily available comparisons over time. 2. As part of the initial assessment, the staff and physician will define the individual's current nutritional status (weight, food/fluid intake, and pertinent laboratory values) and identify individuals with anorexia, recent weight loss, and significant risk for impaired nutrition; for example height risk residents with acute symptoms such as vomiting, diarrhea, fever and infection, or those taking medications that may be causing or increasing the risk of anorexia or weight loss .2. The Physician, with the help of the multidisciplinary team, will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. For example: a. Cognitive or functional decline; b. Chewing or swallowing abnormalities; c. Pain; d. Medication-related adverse consequences; e. Environmental factors (such as noise or distractions related to dining); f. Increased need for calories and / or protein; g. Poor digestion or absorption; h. Fluid and nutrient loss; and /or i. Inadequate availability of food or fluids. Review of the pharmacy policy 9.4 [MEDICATION NAME] Nutrition: Additives, dated 1/15/04 revision 7/1/2012 (6 years old) revealed Procedure 1. Verify physician LIP (Licensed Independent Practitioner) order. 2. Perform hand hygiene. 3. Assemble equipment and supplies on clean work surface. Final preparation for patient administration by facility nurse is performed in a clean area that is free of dust and currents of air . 8. Vigorously cleanse injection port of [MEDICATION NAME] nutrition solution bag with alcohol. Allow to air dry. 9. Insert sterile needle/syringe into injection port. Inject medication. 10 . 11. Gently rotate [MEDICATION NAME] nutrition solution bag/container to mix additives after each addition. 12 . 13. Label [MEDICATION NAME] nutrition solution bag with medication added label , to include the following: 13.1 Patient's name 13.2 Medication added 13.3 Medication dose 13.4 Time medication added 13.5 Date medication added 13.6 Nurse's initials . 16. Documentation in the medical record includes, but is not limited to: 16.1 Date and time 16.2 Medication added 16.3 Dose. Review of the pharmacy Infusion Therapy Education Program [MEDICATION NAME] Nutrition, dated (YEAR) revealed Verbal orders are not acceptable. The attending physician/LIP (Licensed Independent Practitioner) may request that the previous provider's formulation be continued. The pharmacist will use the previous provider's formulation as a template for reducing the formulation to writing and converting ingredient units of measure to match the units of measure on pharmacy label. Fax current hospital [MEDICATION NAME] nutrition orders to infusion pharmacy as soon as admission is anticipated. Call infusion pharmacy to verify receipt of orders. Pharmacist will convert order to (pharmacy) [MEDICATION NAME] Nutrition prescription and fax back to facility. This formulation will NOT be considered a valid order until the physician/LIP has reviewed and authorized by telephone order. Physician/LIP orders should include: [MEDICATION NAME] nutrition solution, Additives, Volume and rate, Continuous or cyclical (if cyclical, may be ordered to auto ramp/tapered per pump, or custom taper), VAD flush protocol, Laboratory monitoring, Daily/weekly weights, Vital signs, Blood glucose monitoring, intake and output, Orders should also include physician/LIP notification, Back-up D10W solution or pre-made standard TPN formulation in the event of unplanned interruption of TPN solution, D10W may be administered through a peripheral access device via manual flow control device if an electronic infusion device is not available. Turn -around time for PN orders may vary based on complexity of formula. Turn-around time starts from the time a valid (signed) order is received at the pharmacy. Labs: Ongoing labs per physician/LIP order, physician order is required to withdraw labs from a patient's [MEDICAL CONDITION] (central vascular access device) Baseline recommended on admission. Fax all lab results to infusion pharmacy as soon as they are available from lab provider. Call pharmacy to verify receipt of results. Adjustments to formula are based on lab results. Abnormal lab results may also indicate presence of PN related complication(s). Weights: Baseline recommended on admission, Ongoing weights per physician/LIP, Must be accurate: same time each day, same scale, same clothing, etcs. Vital Signs: Base line recommended on admission; per physician / LIP orders. Glucose monitoring should be performed per physician/LIP orders .Intake and Output per physician/LIP orders . Document every shift . Documentation: MAR and Progress Notes Date and time; Flushing/locking agents; medication additives/solution; volume and rate; tapering schedule, if ordered; site assessment; complications and interventions; patient response to procedure and/or medication. Intake and output totals; weights and vital signs . components of [MEDICATION NAME] Nutrition Solution Water . Carbohadrates .Protein . Fats . Lipids Concentration of 10-30% ; Lipids can be mixed with PN solution (3:1 solution) * must use a 1.2 micron filter to infuse [MEDICATION NAME] nutrition if lipids are added. Review of the facility policy Physician and Representation Notification- Change in a Resident's Condition or Status, dated 10/7/10 revealed 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: a . f. Refusal of treatment or medications . Immediate Jeopardy is due to the facility's failure to prevent a transfer to the hospital for Resident #13 with a life-threatening condition with a critically high potassium level, acute [MEDICAL CONDITION] with placement on a ventilator, shock resulting from a low blood fluid volume, and acute multi-organ failure. On 12/18/18 at 11:13 AM the facility provided the following abatement plan: Identified Resident #13 is currently out of the facility in an acute care setting. There are no other residents currently in the facility receiving TPN and the facility will not admit or re-admit any other residents that require TPN until competency and compliance is attained and approved through QAPI process. * The facility has ensured that the medication prep area (med room) has been thoroughly cleaned and will be maintained in a sanitary manner. Started on 12/13/18 and was completed on 12/16/18. Director of nursing/designee will audit room daily to ensure med room is maintained in a clean and sanitary manner. This will start 12/18/18. Director of nursing and Housekeeping has been educated by the Infection Control Preventionist regarding the significance of medication prep area to be kept in a clean and sanitary manner on 12/13/18. Audit findings will be presented to the facility QAPI Committee and will only be discontinued with substantial compliance and with approval of the facility QAPI Committee. The Administrator is responsible for achieving and sustaining compliance. * The facility reviewed current PCC orders on new admissions for the last 30days to ensure accurate and timely transcription of acute care discharge orders are in place. Started on 12/17/18 and was completed 12/17/18. All new admission orders [REDACTED]. Licensed nursing staff education started on 12-17-2018 on timely and accurate transcription and communication of orders by the director of nursing/designee. Licensed nurse will not work until education is complete. Director of Nursing will audit new admissions and validate all required documentation specific to orders including and up to Kardex and care plans at the daily clinical meeting to ensure compliance along with timely communication to pharmacy and attending physician. This will start on 12/18/18. Audit findings will be presented to the facility QAPI Committee and will only be discontinued with substantial compliance and with approval of the facility QAPI Committee. The Director of Nursing is responsible for achieving and sustaining compliance. * The facility has conducted education on the standard of practice for Total [MEDICATION NAME] Nutrition care and services for all licensed nursing staff. Started on 12/13/18 and was completed on 12/17/18. Licensed nurses will not work unless education is complete. * Weights have been reassessed on every resident in the facility per policy. 54 of out of 54 residents have been reviewed for the completion of a nutrition and hydration assessments. Care plans have been updated as indicated. Started 12/17/18 and completed 12/17/18.< (TRUNCATED)

Based on observation, interview and record the facility failed to ensure the nurses were competent to care for residents with Total [MEDICATION NAME] Nutrition (TPN)-including preparation and administration for 2 (#13 and 152) residents, Central Line dressing changes for 2 (#35 & 152) residents, Pressure Ulcers for 1 (#6) resident and 1 resident with a gastric tube (#150), resulting in the potential for serious complications, harm, hospitalization and death. Findings Include: Nurse Competencies On 12/13/18 at 3:49 PM, 6 Registered nurses, including Nurse W and the Director of Nursing's (DON's) education was reviewed for training and competency to prepare and administer TPN. There was no documentation that the Nurses had received education for preparation and administration of TPN. On 12/13/18 at 4:45 PM, the DON was interviewed and said she had provided education to the nurses, but didn't record it. She was not able to verbalize, or show in writing a date that the education was provided. The Registered Nurses education review was discussed with the DON, related to a lack of education or competency for TPN preparation and administration for the DON and RN's reviewed. She was queried if she had received education prior to training the nurses and was not able to identify when or where the training occurred. A review of the Facility Assessment, on 12/13/18 at 4:05 PM, revealed the facility admitted Resident's receiving Total [MEDICATION NAME] Nutrition/TPN. The Education section of the assessment said the facility had a List of topics for training Attached. There was no list provided from the facility. On 12/13/18 at 4:15 PM, the Administrator was queried about the List of topics and said, Yes, we have a list. A list of educational topics was not received prior to exit. On 12/17/18 at 8:30 AM, the facility provided a sign in sheet indicating some of the nurses received competency training from the Pharmacy nurse trainer, on 12/14/18, related to TPN preparation and administration. Five nurses had not yet received the education- 2 RN's and 3 Licensed Practical Nurse/LPN's. Agency for Healthcare Research and Quality (AHRQ) Patient Safety Network, Published (MONTH) (YEAR), Standardized competencies for [MEDICATION NAME] nutrition prescribing: The American Society for [MEDICATION NAME] and Enteral Nutrition Model. Guenter P, Boullata JI, Ayers P, et al; [MEDICATION NAME] Nutrition Safety Task Force, American Society for [MEDICATION NAME] and Enteral Nutrition. Nutr Clin Pract. (YEAR);30:570-576 .[MEDICATION NAME] nutrition (PN) provision requires careful interpretation of clinical and laboratory data, multidisciplinary communication, and vigilant surveillance for unintended complications. The process is prone to a variety of potential errors during each step, from PN prescription to its delivery .Without documented competencies, an assessment of an individual at regular intervals cannot be performed and, therefore, compromises the ability to effectively and safely perform a role within their job . Resident #6 According to the Admission Record, dated 12/12/2018, Resident #6 was a [AGE] year old female initially admitted to the facility on [DATE]. Resident #6's [DIAGNOSES REDACTED]. The Minimum Data Set Resident Assessment (MDS), dated [DATE], indicated that Resident #6 required extensive assistance from two staff members to move in bed. The MDS, dated [DATE], identified that Resident #6 was at risk for the development of pressure ulcers but did not have any pressure ulcers at the time of the assessment. Resident #6 had a care plan that identified the risk for an impairment to skin integrity that had been dated as revised on 11/21/2018. Interventions included: to avoid scratching; educate the resident and caregivers of causative factors for skin impairment and measures to prevent skin injury; encourage good nutrition and hydration; follow protocols for treatment of [REDACTED]. According to the National Pressure Ulcer Advisory Panel, the pressure points at risk for skin breakdown include the sacrum, coccyx, buttocks, heels, ischium, trochanters, and elbows. There were no interventions directed to offload the pressure on Resident #6's heels. During an observation of care provided to Resident #6 on 12/11/18 at 09:57 AM, her heels were observed to be laying on the mattress as care was begun. While being turned for care, it was noted that Resident #6's right heel was red. Upon completion of care, Resident #6 was left positioned on her back with her heels laying on the bed. One of the recommendations of the National Pressure Ulcer Advisory Panel was to avoid positioning an individual on an area of redness. On 12/12/18 at 5:39 PM, Resident #6 was observed to have developed a boggy fluid filled blister on her right heel. Licensed Practical Nurse (LPN) measured the area as 4 centimeters by 3 centimeters. According to the National Pressure Ulcer Advisory Panel (NPUAP) (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/), A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. A Deep Tissue Pressure Injury is described by the NPUAP as Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. On 12/13/2018, Resident #6 had a Skin Assessment performed that did not identify the presence of the pressure injury to her right heel. The assessment documented that there were no new abnormal skin areas. On 12/18/18 at 08:02 AM, the Director of Nursing (DON) B stated that she didn't know why heel was not mentioned on most recent skin assessment. DON B said she had spoken with the Registered Nurse who had performed the assessment and had provided education. The nursing staff failed to demonstrate competence related to the development and implementation of care planning to prevent pressure ulcers and to assess and document the presence of skin abnormalities. Resident #35 According to the facility policy for Peripheral IV and Midline IV Dressing Changes, dated 5/2018, PICC dressings were to be replaced by sterile procedure every seven days or when the dressing became damp, loosened or soiled. The catheter insertion site was to be inspected for signs of infection or complications at scheduled intervals and upon routine site care and administration set changes. The measurement of the catheter should have been taken and recorded during the documentation of the catheter care and the measurement of the arm circumference was to be taken and recorded with each dressing change. Any changes of these measurements can indicate a sign of an infection or a complication with the IV catheter. During the medication administration task on 12/10/18 at 4:09 PM, Resident #35 was observed to have a PICC line on her right upper arm. The dressing over the PICC was dated 11/28, twelve days ago. Resident #35 stated, no one has changed it (the dressing) since I have been here. Written on the dressing was a notation, 45 centimeters total exterior length. The dressing was loose at the outer lower edge, slightly rolled at the edge and a bruise was observed above the dressing. On 12/17/18 at 07:46 AM , all of the notes in the medical record for Resident #35's PICC line were requested. According to the documentation, the PICC for Resident #35 had been inserted on 11/28/2018. At that time, the documentation on the total catheter length was 45 cm, 43 cm were internal and 2 cm external. The arm circumference had been measured as 37 cm. There were no measurements recorded for the next twelve days. On 12/10/18 at 5:09 PM, the Director of Nursing (DON), Staff B was asked about the twelve day old dressing on Resident #35's PICC. DON B stated she had been informed by her staff and had directed that the dressing be changed immediately. Resident #152 The physician Order Listing Report for Resident #152 contained an order for [REDACTED].#152 had an insertion of a PICC line. Resident #152's Treatment Administration Record (TAR) for (MONTH) (YEAR) indicated the transparent dressing had occurred one time, on 7/30/2018. No measurements of the catheter length or arm circumference had been recorded. Resident #152's TAR for (MONTH) (YEAR) indicated the transparent dressing change for the PICC had been performed weekly, but no measurements of the catheter length or arm circumference had been recorded. The nurses failed to demonstrate competence in the care of PICC lines. Resident #150 On 12/11/2018 at 08:00 AM, Licensed Practical Nurse (LPN) LL was observed as she prepared and administered medications to Resident #150. At the medication cart in the hall, LPN LL crushed the [MEDICATION NAME] 75 milligram (mg) tablet, a [MEDICATION NAME] 500 mg tablet, and a folic acid 400 mg tablet. LPN LL opened a capsule of [MEDICATION NAME] 20 mg, and mixed all four now powdered medications into one cup. At 12/11/18, 08:23 AM, LPN LL entered the room of Resident #150. The head of Resident #150's bed was elevated at 15 degrees, according to LPN LL who had checked the gauge on the bed. LPN LL said it is supposed to be higher and elevated bed to 30 degrees. A tube feeding formula of [MEDICATION NAME] 1.5, dated 12/10 at 7 PM was running at 50 cubic centimeters (cc) per hour. On 12/11/18 at 08:30 AM, LPN LL administered all four powdered medications together through Resident #150's PEG tube without first checking for placement of the PEG tube either through listening with a stethoscope or checking for a return of residual feeding. On 12/17/18 at 09:05 AM when the Director of Nursing B and the Regional Corporate Registered Nurse D were informed of the observation of medication administration to Resident #150 through the peg tube, the both agreed that the head of the bed should remain elevated at 30 degrees during and for 30 minutes following the administration of the tube feeding and that the medications should have been separated and given one at a time, not all together. According to the facility policy, Administering Medications through an Enteral Tube, dated 12/21/2010, prior to the administration of medications, the placement of the gastrostomy tube should be checked as well as the gastric contents by listening with a stethoscope as about 10 cc's of air was injected into the tube and the tube should be aspirated to check the amount of the stomach content. If more than one medication was to be administered, the tube was to be flushed with 5 to 10 cc's of water between the medications. The resident was to maintain a semi or high Fowler's position, the head of the bed elevated, for at least 30 minutes following the administration of the medication. LPN LL failed to demonstrate competence for the care and management of an enteral tube and the administration of medication through an enteral tube. Resident #152 According to the Admission Record, printed on 12/17/2018, Resident #152 was a [AGE] year old male admitted to the facility on [DATE]. According to the Electronic Medical Record (EMR), Resident #152 had been discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. The Admission Record listed [DIAGNOSES REDACTED]. The Medical Conditions listed on the Medication Administration Record [REDACTED]. The EMR indicated that resident #152 had been discharged from the facility on 9/10/2018. According to the Order Listing Report, printed on 12/17/2018, Resident #152 received Total [MEDICATION NAME] Nutrition (TPN). TPN is a method of feeding that bypasses the gastrointestinal tract. Fluids are given into a vein to provide most of the nutrients the body needs. The method is used when a person cannot or should not receive feedings or fluids by mouth. Resident #152's physician order [REDACTED]. During an interview on 12/17/18 at 04:42 PM, the Medical Records Staff member EE stated that she was responsible to scan paper documents into the EMR. Staff EE provided the only pharmacy [MEDICATION NAME] Nutrition Prescription form that was available and stated that it had been scanned into the EMR today. The prescription was dated 7/19/2018 and listed the specific formula for the TPN. The form also listed the Additional Additives to be added by facility nurse to each bag just prior to hanging. The additives were to be a multivitamin, 10 milliliters and folic acid 1 milligram. The orders for the additives were not on the physician Order Listing Report or on the Medication Administration Records for (MONTH) (YEAR) or (MONTH) (YEAR). The Pharmacy [MEDICATION NAME] Nutrition Prescription had additional orders for laboratory tests that were to be performed every week. The laboratory test results would be faxed to the pharmacy every week. The results of the laboratory tests would be used to calculate the specific formula required by Resident #152 to meet his nutritional needs for the following week. There were no additional pharmacy [MEDICATION NAME] Nutrition Prescription forms for Resident #152's stay at the facility from 7/29/2018 until his discharge on 9/10/2018 that would have indicated the specific formula and additives for the TPN. Resident #152's physician order [REDACTED]. During an interview on 12/17/18 at 04:42 PM, the Medical Records Staff member EE stated that she was responsible to scan paper documents into the EMR. Staff EE provided the only pharmacy [MEDICATION NAME] Nutrition Prescription form that was available and stated that it had been scanned into the EMR today. The prescription was dated 7/19/2018 and listed the specific formula for the TPN. The form also listed the Additional Additives to be added by facility nurse to each bag just prior to hanging. The additives were to be a multivitamin, 10 milliliters and folic acid 1 milligram. The orders for the additives were not on the physician Order Listing Report or on the Medication Administration Records for (MONTH) (YEAR) or (MONTH) (YEAR). The Pharmacy [MEDICATION NAME] Nutrition Prescription had additional orders for laboratory tests that were to be performed every week. The laboratory test results would be faxed to the pharmacy every week. The results of the laboratory tests would be used to calculate the specific formula required by Resident #152 to meet his nutritional needs for the following week. There were no additional pharmacy [MEDICATION NAME] Nutrition Prescription forms for Resident #152's stay at the facility from 7/29/2018 until his discharge on 9/10/2018 that would have indicated the specific formula and additives for the TPN. The MARs for (MONTH) (YEAR) indicated that the TPN had been administered to Resident #152 from Night on (MONTH) 19, (YEAR) through Eveni on (MONTH) 23, (YEAR), Night on (MONTH) 29, and all three shifts on (MONTH) 31, (YEAR). The MARs for (MONTH) (YEAR) indicated that the TPN had been administered to Resident #152 from Day on (MONTH) 1, (YEAR) through Night on (MONTH) 31, (YEAR) with blank spaces for Day on (MONTH) 6, (YEAR) and on Eveni on (MONTH) 23 and 29, (YEAR). The nursing staff failed to demonstrate competence related to following physician orders [REDACTED].

Based on observation, interview, and record review, the facility failed to implement interventions to prevent the development of a deep tissue injury on the heel of one resident (#6) out of five residents reviewed for pressure ulcers resulting in Resident #6 developing an unstageable pressure ulcer (deep tissue injury) on her right heel. Findings include: According to the Admission Record, dated 12/12/2018, Resident #6 was a [AGE] year old female initially admitted to the facility on [DATE]. Resident #6's [DIAGNOSES REDACTED]. The Minimum Data Set Resident Assessment (MDS), dated [DATE], indicated that Resident #6 required extensive assistance from two staff members to move in bed. The MDS, dated [DATE], identified that Resident #6 was at risk for the development of pressure ulcers but did not have any pressure ulcers at the time of the assessment. Resident #6 had a care plan that identified the risk for an impairment to skin integrity that had been dated as revised on 11/21/2018. Interventions included: to avoid scratching; educate the resident and caregivers of causative factors for skin impairment and measures to prevent skin injury; encourage good nutrition and hydration; follow protocols for treatment of [REDACTED]. According to the National Pressure Ulcer Advisory Panel, the pressure points at risk for skin breakdown include the sacrum, coccyx, buttocks, heels, ischium, trochanters, and elbows. There were no interventions directed to offload the pressure on Resident #6's heels. During an observation of care provided to Resident #6 on 12/11/18 at 09:57 AM, her heels were observed to be laying on the mattress as care was begun. While being turned for care, it was noted that Resident #6's right heel was red. Upon completion of care, Resident #6 was left positioned on her back with her heels laying on the bed. One of the recommendations of the National Pressure Ulcer Advisory Panel was to avoid positioning an individual on an area of redness. On 12/12/18 at 5:39 PM, Resident #6 was observed to have developed a boggy fluid filled blister on her right heel. Licensed Practical Nurse (LPN) measured the area as 4 centimeters by 3 centimeters. According to the National Pressure Ulcer Advisory Panel (NPUAP) (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/), A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. A Deep Tissue Pressure Injury is described by the NPUAP as Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. On 12/13/2018, Resident #6 had a Skin Assessment performed that did not identify the presence of the pressure injury to her right heel. The assessment documented that there were no new abnormal skin areas. On 12/18/18 at 08:02 AM, the Director of Nursing (DON) B stated that she didn't know why heel was not mentioned on most recent skin assessment. DON B said she had spoken with the Registered Nurse who had performed the assessment and had provided education. The facility policy Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated as revised (MONTH) 28, (YEAR), directed that the physician was to be notified of all new pressure ulcers or pressure injuries. The physician was to authorize orders related to wound treatments. On On 12/18/18 at 08:02 AM, DON B was asked to provide documentation that the physician had been notified of the pressure injury on Resident #6's right heel and to provide documentation of new treatment orders for the area. DON B said she had notified the physician who came and looked at the right heel but, neither she or the physician had documented. On 12/18/18 at 09:16 AM, DON B provided an undated, unsigned handwritten note that she stated was from the physician. The note documented a tender to touch reddened area of the right heel. On 12/18/18 at 09:18 AM, DON B stated that the physician had not yet entered the documentation into the electronic medical record. DON B confirmed that no orders had been written for skin treatment to the right heel

Based on observation, interview and record review, the facility failed to ensure appropriate interventions were in place to prevent falls with injury for 4 (#'s 39, 42, 46 and 251) of 6 residents reviewed for accidents from a total sample of 17 residents, resulting in Resident #39 residing in a room unsafely cluttered with medical equipment after falling, Resident #42 experiencing a fall with injury and transfer to the hospital, Resident#46 experiencing multiple falls and Resident #251 experiencing multiple falls with injury, pain and a femur fracture of unknown origin. Findings Include: Resident #39 On 12/11/18 at 9:25 AM, Resident #39's room was observed cluttered with equipment, wheelchairs, a mechanical lift, broda chair and a commode chair with little space between to maneuver from the resident's roommates' bed to Resident #39's bed. Resident #39's bed was near the window on the opposite side of the room, with the headboard in front of the window and the bed was facing the door. There was about 2 feet between the bed and the wall and when the bathroom door was opened, it almost touched the bed. A record review of the Face Sheet and Minimum Data Set (MDS) assessment for Resident #39 revealed the resident was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS assessment dated [DATE] indicated the resident had memory loss and needed 1-2 person/extensive-total assistance with all care. On 12/12/18 at 9:50 AM, equipment was again noticed filling the open space in Resident #39's room; The Director of Nursing (DON) entered the room and stated, That is (points to roommate) his equipment. The wheelchair, walker and commode chair sitting haphazardly on Resident #39's side of the room did not belong to him. A review of the Incident and Accident Reports for Resident #39 revealed the resident fell out of bed on 10/1/18 and was found kneeling on the floor between the wall and bed, Patient noted to be kneeling on cords .Patient incontinent (wet with urine) .Care Plan updated . The Incident and Accident report said the resident had sustained an abrasion on his knees. A review of the Fall, Care Plan, initiated 9/11/17 and revised 12/21/17 indicated the Interventions were last updated 12/19/17. The Care Plan had not been reviewed or updated after the fall on 10/1/18 or reviewed for appropriate measures with the most recent MDS on 11/17/18. The Care Plan did not reference keeping the room free of clutter. Resident #46 On 12/10/18 at 3:03 PM, Resident #46 was observed wandering up and down the hall with a rolling walker. The resident walked into her room and appearing confused said, I don't have a bed here. The name tags outside the door listed Resident #46 in the first bed in the room, but her roommate was sleeping in that bed. On 12/10/18 at 3:10 PM, during an interview with Nurse N she said Resident #46 was assigned to the first bed in the room, but the roommate often slept there. Nurse N said Resident #46 liked to sleep in her recliner, but the resident was not able to acknowledge that. A review of the Face Sheet and Minimum Data Set (MDS) assessment for Resident #46 indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE], after a non-responsive event, with Diagnoses: [REDACTED]. The MDS dated [DATE] revealed the resident had severe cognitive impairment and needed supervision with mobility. A review of the Incident and Accident reports for Resident #46 indicated the resident had falls on, 12/6/18, 11/26/18, 9/19/18 and 9/7/18. The fall on 12/6/18 at 9:45 PM revealed, Patient was observed on the floor slightly on right side .Root Cause: Patient tends to nap in recliner .Not sure if patient fell asleep and fell over possibly . Initial Interventions: Encouraged patient to sleep in chair with legs elevated or in bed with legs elevated. Bed lowered, and wheels locked. Assisted patient to bed and reaffiliated with call light system, remove clutter .Immediate Interventions Implemented: Counsel staff to encourage resident to lay in center of bed . It did not indicate the Care Plan was updated. The 11/26/18 at 11:55 PM, fall report said the resident became non-responsive, vomited and was incontinent of urine, Was ambulating in hallway with walker most of night prior to incident. Became weak and stated she did not feel well. Lowered to floor .Sent to ER (emergency room .). The Incident and Accident report was blank in the categories for Planned Interventions in place and Updated Care Plan. The 9/19/18 at 6:45 AM, fall report said Patient attempted to get out of arm chair without putting foot rest down and tipped it forward; sliding to her knees .Initial Interventions: Have staff assist with foot rest when awake. Should be kept down. The resident stated, I was just trying to get up and this darn thing broke on me. Results of Investigation: .Looking into getting different chair . The fall report for 9/7/18 at 5:45 PM (supper time) revealed, A patient alerted me to come to the dining room someone had fell . Found resident on floor sitting next to a chair. The resident stated, I went to sit and missed the chair. There was no staff monitoring the residents in the dining room during the incident. A review of Resident #46's Fall, Care Plan initiated 9/14/17 and reviewed 11/27/18 with updated interventions 12/7/18. The resident requires the following positioning when in bed, encourage pt lay in the bed (including legs). The Fall Care Plan was not reviewed or updated after the falls on 9/19/18 or 11/26/18. There was no mention on the Fall Care Plan of the resident's Chair in her room. On 12/10/18, during the survey, the Activities of Daily Living, Care Plan was updated to reference the resident's roommate sleeping in her bed, (Resident #46) likes to share her space with roommate for a more home like environment . The Care Plan does not address that the resident appeared confused by someone in her bed and was unable to identify where her bed was. No one addressed if this contributed to wandering. Resident #251 A review of the Face sheet and MDS assessment for Resident #251 indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] after hospitalization with Diagnoses: [REDACTED]. The MDS dated [DATE] revealed the resident had severe cognitive decline and needed 2-person extensive assistance with bed mobility and transfers and extensive 1-person assistance with all other care. On 12/10/18 at 2:30 PM, Certified Nursing Assistant II was observed sitting in Resident #251's room, talking to the resident, who was sitting in a reclining broda chair. The Certified Nursing Assistant said, I haven't seen her for a while. She has changed since she fell . She doesn't try to get up now. A review of the Incident and Accident Reports for Resident #251 revealed the resident had fallen several times: On 9/23/18 the resident was observed in bed and later lying on the floor by the bed incontinent wet and soiled. A Nurses Note dated 10/21/18, written by Nurse Z indicated Resident #251 fell on [DATE] while attempting to get into bed. The facility did not provide an incident report for this day, after a request for all incident reports during this time period. On 10/18/18 the resident fell from the wheelchair in her room to the floor. Per the Incident report the resident did not have fall mats on the floor of the room at the time of the fall. The intervention had been care planned since 1/24/16- Fall mats landing strips on exit side of bed. The resident also did not have hip savers on at the time of the fall. Hipsavers were care planned on 1/24/16-Hip savers at all times, remove for hygiene. The Fall incident report revealed Were planned interventions in place? The Yes box was checked and beside it stated, Except for fall mat and hip savers. 10/18/18 at 5:10 PM revealed, Assessment: Min (minimum) pain to left shoulder has dx (diagnoses), ROM (range of motion) intact, VSS (vital signs-but no results were provided). There was no further assessment. A review of the progress notes indicated the physician did not assess the resident until 11/6/18 (3 weeks after the 10/18/18 fall) and stated, Patient remains active and feisty. Her activity is confined to what she does in her chair and what she touches in her room. She has been known to work herself out of her chair, although it is designed to encourage her to stay in it . There was no documented assessment of her shoulder pain or range of motion to her extremities. A review of a Progress Note dated 11/18/18 at 11:09 AM and written by Nurse O indicated Resident #251 experienced pain and swelling of the right knee and pain in the right hip and a range of motion deficit to the right lower extremity. A review of the facility investigation indicated an x-ray of the right hip on 11/18/18 revealed There is a fracture involving right lateral distal femur .right knee fracture . The resident was transferred to the hospital on [DATE]. A Review of the POS [REDACTED]. The MDS assessments dated 7/17/18 (annual) and 10/17/18 (quarterly) indicated the resident was not independent with any care and needed extensive 1-person assistance with toileting and 2-person assistance with bed mobility and transfers. A review of Resident #251's Fall, Care Plan initiated 1/24/16 indicated it was not updated with interventions after the resident fell on [DATE] or 9/25/18. After the resident fell on [DATE], the care plan wording was updated with Nursing to place bed in low position when not providing care, this intervention was initially started on 1/24/16. An interview with the Administrator on 12/12/18 at 1:53 PM provided, We couldn't find any recent falls. We couldn't find anything that was strange. We couldn't find any cause. When the nurse aide went to change her, she was having pain in the one leg, saying Ow! The Administrator was queried about Resident #251's fall and the lack of assessment on 10/18/18 and said, That was so long ago. On 12/12/18 at 1:58 PM, the Director of Nursing was asked if the resident's physician had assessed the resident after the incident on 11/18/18 and stated, No, there is no documentation in the medical record from the doctor. She is supposed to come in tomorrow. When asked if that was almost one month since the incident, the DON responded Yes, I know. The Director of Nursing was also queried about the lack of a complete nursing or physician assessment in the medical record for the 10/18/18 fall and stated, I think the doctor wrote something. The following facility policies were reviewed: Falls-Clinical Protocol, dated revised 6/2018 provided, Based on the assessment a care plan will be developed and implemented to address identified risk. The MDS .will be utilized to develop the comprehensive plan of care to minimize falls and injuries from falls .If the individual continues to fall the interdisciplinary team should re-evalutate the situation and consider other possible reasons for the resident's falling and will re-evaluate the continued relevance of current interventions. Resident #42 According to the Admission Record, printed on 12/12/2018, Resident #42 was a [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Resident Assessment (MDS), dated [DATE], indicated that Resident #42 was severely cognitively impaired. The MDS, dated [DATE], revealed that Resident #42 had fallen one time since her admission to the facility. On 12/11/18 at 05:00 PM, a request was made to the Registered Nurse (RN) Director of Nursing (DON) Staff B for all of the incident/accident reports pertaining to falls for Resident #42. The provided incident reports were dated 7/23/2018, 8/10/2018, 11/7/2018, 11/17/2018, 11/22/2018, and 11/24/2018. No incident/accident was provided that correlated to the time frame of the indicated fall on the MDS for 5/17/2018 to 5/24/2018. During an interview with Resident #42's spouse on 12/10/18 at 12:23 PM, he stated that he came to visit several times a week. Resident 42's spouse commented that, she falls a lot out of bed. A slight scar was observed over Resident #42's left eye. Resident #42's husband explained the scar by saying, she rolled out of bed last week and went to the emergency room . Resident #42 had a care plan for a risk of falls related to reduced mobility, Dementia, weakness, fatigue, and difficulty walking initiated on 5/18/2018. One intervention implemented to reduce the risk of falls on 5/18/2018 was to Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. During an interview with the DON Staff B on 12/13/18 at 02:25 PM, she agreed that reminding Resident #42 to use the call light for assistance was not an appropriate intervention because Resident #42 did not have the mental capacity to use the call light. Another intervention implemented on 5/18/2018 to reduce the risk of falls was that Resident #42 should wear clothing that was easy to remove for toileting. However, the MDS dated [DATE] indicated that Resident #42 was always incontinent of her bowel and bladder and was not on a toileting schedule. An intervention implemented on 5/18/2018 to reduce the risk of falls was that Resident #42 was to be referred to Physical Therapy/Occupational Therapy to evaluate and treat as ordered or as needed. During an interview with the DON B on 12/13/18 at 02:25 PM, she stated that after each fall, a request for a therapy screening was initiated. DON B explained that the referrals were sent electronically. DON B said that neither she or the nurses had access to the electronic documentation by the therapy department. The therapy screens for all of the referrals, including therapy response or recommendations was requested. The incident report, dated 7/23/2018, documented that Resident #42 had tipped her chair in the hallway and was on the foot rest of the chair and the floor. The section of the incident report where the type of mobility device used was blank so there was no identification of the type of wheel chair in use at that time. The action taken following the fall was to evaluate chair. After further questioning, it was reported by RN Z on 12/13/18 at 02:25 PM that after the fall on 7/23/2018, the chair had been evaluated by maintenance to assure the chair was working properly. Maintenance did not find anything wrong with the chair. According to RN Z, the staff have therapy screen all residents who fall. However, the Interdisciplinary Therapy Screen, dated 7/23/2018, documented that Resident #42 has all needed adaptive devices in place for self feeding including thermal mug with a lid for hot beverages and that no occupational therapy was indicated at that time. There was no mention of the fall in the therapy screen. The incident report, dated 8/10/2018, documented that Resident #42 had been found on the floor of her room on her knees sitting on the foot rest of the chair watching TV and going through her night stand at 4:15 PM. According to the mobility device used section, Resident #42 had been in a broda chair. A broda chair has a higher back than a regular wheel chair and the seat of the broda chair can be tilted to allow for a more reclined position. The action taken following the unobserved fall was to leave her in the hallway, encourage Resident #42 to lay down after meals and not to leave her unattended in her room. During an interview with RN Z on 12/13/18 at 02:25 PM, she stated that after the fall on 8/10/2018, the interventions added to the care plan for fall risk included to not leave Resident #42 in her room unattended and to lay her down after meals. No Interdisciplinary Therapy Screen was provided that corresponded to the incident date of 8/10/2018. The incident/accident report for 11/8/2018 documented that Resident #42 had been found on the floor on the mat next to her bed at 10:45 PM. The facility investigation report stated that the Certified Nursing Assistant had not been in Resident #42's room to check on her since 4:30 PM. In addition, the pillow that was supposed to have been placed next to her while she was in bed had not been put in place. During an interview with RN Z on 12/13/18 at 02:25 PM, she stated that Resident #42 should have been checked every two hours and that she should not have gone ten hours without a check by nursing staff. RN Z also stated that a body type pillow was supposed to be in use as an extra prevention to keep Resident #42 from rolling out of bed at that time. However, the use of an additional pillow was not listed as an intervention on the care plan. The Interdisciplinary Therapy Screen dated 11/8/2018, documented that Resident #42 had been seen with no change in her status. The note stated that Resident #42 was currently receiving therapy services and that the recent fall would be addressed. The incident/accident report for 11/22/2018 was documented at 10:25 AM. Resident #42 was observed on the floor of the dining room on her butt leaning against the chair. The incident report indicated that Resident #42's husband was present at the time of the incident. The type of chair was not identified in the report and the use of a mobility device was checked as no. The Action Taken was described as family education. The root cause of the fall was stated as Family unfamiliar with chair. The initial interventions to prevent future falls was described as Family education about falls and what to do when a resident falls and proper use of chair. There was no care plan intervention that identified a different chair had been provided for Resident #42. On 12/11/18 at 09:41 AM, Resident #42 had been observed reclining in a geri-chair which was more of a lazy-boy type of reclining chair. No Interdisciplinary Therapy Screen was provided that corresponded to the incident date of 11/22/2018. The incident/accident report for 11/24/2018 was documented at 3:12 PM. Resident #42 was observed on the floor next to her bed laying on her left side with a cut to her left eye. The drawing on the fall description details indicated that Resident #42 was laying between the bed and the mat on the floor. There was no description of the cut or any indication that Resident #42 had been sent to the hospital for treatment for [REDACTED].#42 had been sent to the emergency room for treatment of [REDACTED]. No notes were provided regarding the emergency room visit for Resident #42 on 11/24/2018 by the end of the survey.

Based on observation, interview, and record review, the facility failed to obtain physician orders for Total [MEDICATION NAME] Nutrition for two residents (#13 and #152) out of two residents reviewed for physician orders for intravenous nutritional therapy resulting in the intravenous nutritional therapy being administered without a physician's order and a negative outcome for one resident (#13) that resulted in hospitalization . Findings include: Resident #152 According to the Admission Record, printed on 12/17/2018, Resident #152 was a [AGE] year old male admitted to the facility on [DATE]. According to the Electronic Medical Record (EMR), Resident #152 had been discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. The Admission Record listed [DIAGNOSES REDACTED]. The Medical Conditions listed on the Medication Administration Record [REDACTED]. The EMR indicated that resident #152 had been discharged from the facility on 9/10/2018. According to the Order Listing Report, printed on 12/17/2018, Resident #152 received Total [MEDICATION NAME] Nutrition (TPN). TPN is a method of feeding that bypasses the gastrointestinal tract. Fluids are given into a vein to provide most of the nutrients the body needs. The method is used when a person cannot or should not receive feedings or fluids by mouth. Resident #152's physician order for [REDACTED]. During an interview on 12/17/18 at 04:42 PM, the Medical Records Staff member EE stated that she was responsible to scan paper documents into the EMR. Staff EE provided the only pharmacy [MEDICATION NAME] Nutrition Prescription form that was available and stated that it had been scanned into the EMR today. The prescription was dated 7/19/2018 and listed the specific formula for the TPN. The form also listed the Additional Additives to be added by facility nurse to each bag just prior to hanging. The additives were to be a multivitamin, 10 milliliters and folic acid 1 milligram. The orders for the additives were not on the physician Order Listing Report or on the Medication Administration Records (MAR) for (MONTH) (YEAR) or (MONTH) (YEAR). The Pharmacy [MEDICATION NAME] Nutrition Prescription had additional orders for laboratory tests that were to be performed every week. The laboratory test results would be faxed to the pharmacy every week. The results of the laboratory tests would be used to calculate the specific formula required by Resident #152 to meet his nutritional needs for the following week. There were no additional pharmacy [MEDICATION NAME] Nutrition Prescription forms for Resident #152's stay at the facility from 7/29/2018 until his discharge on 9/10/2018 that would have indicated the specific formula and additives for the TPN. The MARs for (MONTH) (YEAR) indicated that the TPN had been administered to Resident #152 from Night on (MONTH) 19, (YEAR) through Eveni on (MONTH) 23, (YEAR), Night on (MONTH) 29, and all three shifts on (MONTH) 31, (YEAR). The MARs for (MONTH) (YEAR) indicated that the TPN had been administered to Resident #152 from Day on (MONTH) 1, (YEAR) through Night on (MONTH) 31, (YEAR) with blank spaces for Day on (MONTH) 6, (YEAR) and on Eveni on (MONTH) 23 and 29, (YEAR). Resident #13 was a [AGE] year-old female, who was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident was admitted to the hospital on [DATE] and returned to the facility on [DATE] with a mediport in place. Resident #13 was admitted to the hospital on [DATE] with abdominal pains, abdominal distention and [DIAGNOSES REDACTED]. Resident #13 was readmitted to the hospital on [DATE] for gastroparesis and was started on TPN on 12/3/18 while at the hospital and recommended to be continued on TPN upon discharge from the hospital on [DATE]). Although the TPN was included in the hospital discharge instructions on 12/5/2018, there was no facility physician order for [REDACTED]. TPN is a method of feeding that bypasses the gastrointestinal tract. Fluids are given into a vein to provide most of the nutrients the body needs. The method is used when a person cannot or should not receive feedings or fluids by mouth. Review of Resident #13's Hospital records was discharged from the hospital on [DATE] on an antibiotic for a urinary tract infection. Resident refused IV medications at that time. According to the facility Medication Administration Record [REDACTED]. Stop date of 11/6/18 (admitted to the hospital). There were no documented physician ordered flushes by the facility for (MONTH) (YEAR) or (MONTH) (YEAR) for the central line. Resident was admitted to the hospital on [DATE] with complaint of chest pain. Review of Resident #13's hospital history and physical dated 11/13/18 revealed resident was treated for [REDACTED]. Discharge [DIAGNOSES REDACTED]. Resident #13 was admitted to the hospital on [DATE] with a complaint of abdominal pain. Review of Resident #13's hospital discharge summary revealed Clinical course . Patient is in mild distress. Abdomen feels disended, bowel sounds are hypoactive. Patient dies have a mediport, therefore it was accessed to obtain laboratory studies, give IV fluids, as well as the nausea medications. KUB obtained. There is large gastric distension. NG tube is in place . There were no physician orders documented to flush the mediport. There were no noted documented flushes on the MAR. There was no documentation in the facility clinical records that Resident #13 had a mediport until the nursing admission asssessment dated 12/5/18. (see below) Review of Physician orders revealed there were no documented physician orders for Resident #13's TPN 12/10/18 at 11:34 AM and there were no physician orders for a flush for the mediport that had been in place. There were no noted documented flushes on the MAR. There was no documentation in the facility clinical records that Resident #13 had a mediport until the nursing admission asssessment dated 12/5/18. (see below) On 12/10/18 at 5:22 PM, Resident #13 was observed in bed with eyes closed. TPN was observed running at 70 cc/hr. Review of physician progress notes [REDACTED].#13 was placed on TPN feeding with clear liquid diet and all orders clearly explained with good understanding verbalized. There were no documented physician orders for the TPN or the clear liquid diet. Review of nurse progress note revealed on 12/10/2018 at 17:56 (5:56 PM) Orders - Administration Note Note Text: [MEDICATION NAME] Solution 10 % Use 70 ml/hr intravenously as needed for nutrition Give [MEDICATION NAME] 10% at 70 ml/hr when TPN not available. PRN Administration was: Effective. Review of Physician orders on 12/11/18 at 09:24 AM, revealed there was not a noted physician order for [REDACTED].>Review of Physician orders revealed on 12/12/18 at 3:41 PM a physician order dated 12/10/18 at 12:55 PM, for a physician order [MEDICATION NAME] Solution 10 % at 70 ml/hr intravenously as needed for nutrition. Give [MEDICATION NAME] 10% at 70 ml/hr when TPN not available. Review of Resident # 13's MAR for (MONTH) (YEAR) revealed the TPN was not signed out as administered from 12/5/18 through 12/10/18 on the Day shift. [MEDICATION NAME] 10 % was dated 12/10/18 and signed out on 12/10/18 at 13:24 PM (1:24 PM) at 70 ml/hr when the TPN was not available. TPN was signed out as administered on night shift on 12/10/18, day shift on 12/11/18 and night shift on 12/11/18 The most recent comprehensive assessment by the facility of Resident #13's nutrition and hydration needs was performed by the Registered Dietician (RD) G on 1/22/2018. At that time, her fluid needs were estimated to be 2,100 ml per day. Resident #13 was also ordered a clear liquid diet and her oral intake was recorded as 340 milliliters (ml) on 12/6/2018, 720 ml on 12/7/18, 960 ml on 12/8 and 12/9, and 480 ml on 12/10/18. The most recent comprehensive assessment by the facility of Resident #13's nutrition and hydration needs was performed by the Registered Dietician (RD) G on 1/22/2018. At that time, her fluid needs were estimated to be 2,100 ml per day. Resident #13 was also ordered a clear liquid diet and her oral intake was recorded as 340 milliliters (ml) on 12/6/2018, 720 ml on 12/7/18, 960 ml on 12/8 and 12/9, and 480 ml on 12/10/18. Review of Resident #13's physician orders revealed there was not a facility physician order initiated for the TPN until 12/10/18 at 11:34 AM. At that time an order was written for Total [MEDICATION NAME] Nutrition, Use at 70 ml/hour intravenously. On 12/10/18 at 2:05 PM, an order was written to Change administration set every four hours with new bag change as clinically indicated when infusing total [MEDICATION NAME] nutrition or partial [MEDICATION NAME] nutrition. The physician order for [REDACTED]. On 12/12/18 at 4:30 PM, during an interview with Director of Nursing (DON) staff B and Registered Nurse (RN) W and Corporate Nurse D. RN W stated she prepared the TPN prior to administering TPN by adding from a multi-dose vial insulin and a multi-dose vial of folic acid into the TPN, and from single dose vials one blue top vial and one white top vial. The DON B reported she had provided verbal TPN education to RN W but had not documented the education. DON B was unable to identify where she had gotten her TPN education. The facility was requested to provide a copy of the TPN policy on 12/12/18 at 9:30 AM and were unable to locate or provide a policy for TPN administration for over seven hours. Then the facility's administration of TPN was the only policy provided. Corporate Nurse D asked, Would you like the pharmacy TPN policy. There was no documented physician order for [REDACTED]. On 12/17/18 at 12:00 noon, DON reported that she had received a TPN order from the hospital physician, called the pharmacy with the TPN recommendation on 12/4/18 prior to Resident #13 coming to the facility, had not discussed the TPN recommendations with attending physician I at facility. On Resident #13's admission Attending physician I gave a verbal order for Resident's orders and DON agreed there was no written signed physician order for [REDACTED].#13's refusal for the TPN. DON reported she had prepared the TPN one day possibly on 12/10/18 at 4:00 PM but agreed she had not documented it. There was no documentation the physician was notified of Resident #13 not receiving the TPN. On 12/17/18 at 11:15 AM, RN Pharmacy IV Specialist U stated, I asked the pharmacist about the TPN order and they said they had an homecare order (discharge order from the hospital) but may have inadvertently forgot to send the pharmacy copy order for the TPN to the facility. The nurses are to get the signature from the physician and we transcribe the order. The pharmacy prepares the TPN except for any medications that may not be stable such as additives (multivitamin, insulin and folic acid). RN Pharmacy IV U specialist stated, A physician order is required for all supplements added to the TPN and a label is required listing all medications added, date and initials of nurse. On 12/17/18 at 3:35 PM, during an interview Dietician stated, Oral fluids is just additional in PO intake when on TPN. A review of Resident #13's laboratory results revealed abnormal laboratory lab values, dated 12/11/18 at 3:05 AM, and no documentation that the physician was notified of the results. Review of facility policy Admissions to the Facility, dated 10/7/10 revised 1/2017 revealed 2. Prior to or at the time of admission, the resident's attending Physician must provide the facility with information needed for the immediate care of the resident, including orders covering at least: a. Type of diet (e.g. regular, mechanical, etc.); b. Medication orders, including (as necessary) a medical condition or problem associated with each medication; and c. Care orders to maintain or improve the resident's function until the physician and care planning team can conduct a comprehensive assessment and develop a more detained Interdisciplinary Care Plan. Review of facility policy Physician Services, dated 10/7/2010 revealed 2. The resident's Attending Physician is responsible for prescribing new therapy, ordering a transfer to the hospitall, conducting required routine visitins, deligating and supervising follow-up visits from Nurse Practitioners or Physician Assistants, etc., to ensure that the resident receives quality care and medical treatments. 3. Physician orders and progress notes shall be maintained in accordance with current OBRA regulations and facility policy. Review of the facility policy Medication Administration General Guidelines, dated (no date) revealed 1. 2. Medications are administered in accordance with written orders by attending physicians, manufacturer's specifications, and professional standards of practice .3 . 4 . 5. All current medications and dosage schedules are listed on the resident's Medication Administration Record [REDACTED]. The residents MAR/TAR is initialed by the person administering a medication, in the space provided under the date and on the line for that specific medication dose administration. Initials on each MAR/TAR are verified with a full signature in the space provided. 12. When PRN medications are administered, the following documentation is provided; a. Date and time of administration, dose, route of administration (if other than oral), and if applicable the injection site. b. Complaints or symptoms for which the medication is given. c. Results achieved from giving the dose and time results noted. d. Signature of initials of person recording administration and signature or initials of person recording effects, if different from person administering.

Based on observation, interview and review the facility and pharmacy failed to 1) assure TPN procedures were implemented so all medication orders were processed consistently and accurately through the stages of ordering, receiving, labeling and administering medications (including transfer orders, admission orders [REDACTED]. 2) its failure to administer TPN; 4.) its failure to meet hydration and nutrition needs for one resident (#13); 5.) its failure to educate staff and assess competency for the preparation, inserting of additives to the solution, administering and documentation of (TPN); and 6.) its failure to educate and maintain a sanitary environment during preparation of TPN and educate and address sterile compounding (inserting of additives to the solution) of TPN. This failure to manage the TPN resulted in the potential of complications, that could include electrolyte imbalance, infection, cardiac symptoms, dehydration/fluid overload, and embolism or phlebitis. This deficient practice resulted in one identified resident (Resident #13), of 17 reviewed for pharmacy services being admitted to the hospital on [DATE], diagnosed with [REDACTED]. Resident #13 Resident #13 was a [AGE] year-old female, who was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #13 was readmitted to the hospital on [DATE] for gastroparesis (a condition that affects the stomach and prevents the stomach from emptying), had been on TPN at the hospital and recommended to be started on TPN upon discharge from the hospital on [DATE]. Although the TPN was included in the hospital discharge instructions on 12/5/2018, there was no facility physician order in the electronic medial record for the administration of the TPN at the facility until 12/10/18. There was no documentation on the Medication Administration Record (MAR) that the TPN was administered in the facility until 12/10/18. On 12/10/18 at 5:22 PM, Resident #13 was observed in bed with eyes closed. TPN was observed running at 70 cc/hr. Review of physician progress notes [REDACTED].#13 was placed on TPN feeding with clear liquid diet and all orders clearly explained with good understanding verbalized. There was no order for a flush or documentation of a flush for the central line according to the policy. On 12/12/18 at 8:55 AM, during an observation, the medication room was noted to have very dusty and soiled floors. There was limited counter space due to clutter. The ceilings tiles were old, cracked and water stained. Three of the four light cylinders were not working and the protective covering for the fixture was missing. According to the facility pharmacy policy for [MEDICATION NAME] Nutrition: Additives, with a revision date of 7/1/2012, medications would be prepared in a clean environment and the medication room was unsanitary for the preparation and inserting of additives to the solution of TPN. On 12/13/18 at 3:49 PM, 6 Registered nurses, including Nurse W and the Director of Nursing's (DON's) education was reviewed for training and competency to prepare and administer TPN. There was no documentation that the Nurses had received education for preparation and administration of TPN. Review of Resident #13's physician orders revealed there was not a facility physician order initiated for the TPN until 12/10/18 at 11:34 AM. At that time an order was written for Total [MEDICATION NAME] Nutrition, Use at 70 ml/hour intravenously. On 12/10/18 at 2:05 PM, an order was written to Change administration set every four hours with new bag change as clinically indicated when infusing total [MEDICATION NAME] nutrition or partial [MEDICATION NAME] nutrition. The physician order for [REDACTED]. There were no specific directions of what the blue and white vials were. Review of nurse progress note revealed on 12/10/2018 at 17:56 (5:56 PM) Orders - Administration Note Note Text: [MEDICATION NAME] Solution 10 % Use 70 ml/hr intravenously as needed for nutrition Give [MEDICATION NAME] 10% at 70 ml/hr when TPN not available. PRN Administration was: Effective. Review of Physician orders on 12/11/18 at 09:24 AM, revealed there was not a noted physician order for [REDACTED]. Review of Physician orders revealed on 12/12/18 at 3:41 PM a physician order dated 12/10/18 at 12:55 PM, for a physician order [MEDICATION NAME] Solution 10 % at 70 ml/hr intravenously as needed for nutrition. Give [MEDICATION NAME] 10% at 70 ml/hr when TPN not available. Review of Resident # 13's Medication Administration Record (MAR) for (MONTH) (YEAR) revealed the TPN was not signed out as administered from 12/5/18 through 12/10/18 on the Day shift. [MEDICATION NAME] 10 % was dated 12/10/18 and signed out on 12/10/18 at 13:24 PM (1:24 PM) at 70 ml/hr when the TPN was not available. TPN was signed out as administered on night shift on 12/10/18, day shift on 12/11/18 and night shift on 12/11/18. There were no specific times noted on the MAR. On 12/12/18 at 4:30 PM, during an interview with Director of Nursing (DON) staff B and Registered Nurse (RN) W and Corporate Nurse D. RN W stated she prepared the TPN prior to administering TPN by adding from a multi-dose vial insulin and a multi-dose vial of folic acid into the TPN, and from single dose vials one blue top vial and one white top vial. RN W reported the multi-dose vials were then returned to the medication cart following preparation of the TPN. The DON B reported she had provided verbal TPN education to RN W but had not documented the education. DON B was unable to identify where she had gotten her TPN education. The facility was requested to provide a copy of the TPN policy on 12/12/18 at 9:30 AM and were unable to locate or provide a policy for TPN administration for over seven hours. Then the facility's administration of TPN was the only policy provided. Corporate Nurse D asked, Would you like the pharmacy TPN policy. DON agreed there was no documented physician order for [REDACTED]. DON agreed that it was unclear what the multivitamin dose was other than a white top and a blue top vial. On 12/12/18 at 4:30 PM, Review of Resident #13's TPN homecare order dated 12/5/18 (unsigned) and TPN bag revealed the contents of the TPN were dated 12/11/18 use by 12/20/18 Travasol 10% (amino acid) 75 gram, [MEDICATION NAME] 250 gram, Intralipid 30% 42 gram, additives, Sodium Chloride 50 mEq (milliequivalents), Potassium Chloride 30 mEq, Potassium [MEDICATION NAME] 35 mMol (millimole/liter), Calcium [MEDICATION NAME] 5 mEq, Magnesium Sulfate 24 mEq, Zinc 10 mg, M.T. E. -5 (multitrace 5 concentrate- 5 trace elements) 3 ml, [MEDICATION NAME] (nurse to add) 10 ml, Folic Acid (RN to add) 1 mg, Reg Insulin (NURSE to add) 10 units. Flow Rate: 1680 ml at 70 ml/hr for 24 hours. On 12/17/18 at 11:45 AM, RN Unit Manager W reported she may have prepared TPN on 12/7/18 and on 12/10/18 but could not recall and did not document either, and stated it was the floor nurses responsibility to do the documentation. On 12/17/18 at 12 noon, DON reported she had received an order from the hospital to administer [MEDICATION NAME] 10% on 12/5/18 to run at 70 ml/hr, verified she had not received an order from the attending physician, had not documented the physician order as a verbal order and had not documented the [MEDICATION NAME] on the Medication Administration Record (MAR). DON reported Resident #13 had not received TPN on 12/8/18 and 12/9/18 over the weekend as she was refusing. DON reported she was unable to find any documentation to support Resident #13's refusal for the TPN. DON reported she had prepared the TPN one day possibly on 12/10/18 at 4:00 PM but had not documented it. On 12/17/18 at 9:45 AM, during an interview, Pharmacy IV Specalist, RN U reported it is standard of practice to have a physician order for [REDACTED]. The facility had a home care order (discharge order from the hospital) the nurses get the signature from the physician, we transcribe the order and we put everything in the TPN bag except for the multivitamin, insulin and folic acid. RN Pharmacy IV Specialist U stated, I asked the pharmacist about the TPN order and they said they had an homecare order (discharge order from the hospital) but may have inadvertently forgot to send the pharmacy copy order for the TPN to the facility. Nurses were unable to compare label on the bag of TPN/bag as there was no physician/pharmacy order. RN Pharmacy IV U specialist stated, A physician order is required for all supplements added to the TPN and a label is required listing all medications added, date and initials of nurse. Pharmacy IV Specalist, RN U reported it is not recommended to stop TPN abruptly and it is recommended to replace with DW10 or gradually reduce. It could cause such concerns affecting the pancreas and which produces the insulin making the blood sugar to crash, potassium needs to be adjusted affecting the heart/cardiac issues, dehydration, nausea and vomiting. Pharmacy IV Specalist, RN U recommended that resident be monitored for vital signs, temperature, weight, cardiac, respiratory lung sounds, and IV site every 2 hours. Pharmacy IV Specalist, RN U reported 8 total bags of TPN had been sent to the facility (2) on 12/5/18, (4) on 12/7/18, and (2) on 12/11/18. On 12/17/18 at 12:00 noon, DON reported that she had received a TPN order from the hospital physician, called the pharmacy with the TPN recommendation on 12/4/18 prior to Resident #13 coming to the facility, had not discussed the TPN recommendations with attending physician I at facility. On Resident #13's admission Attending physician I gave a verbal order for Resident's orders and DON agreed there was no written signed physician order for [REDACTED]. DON reported she had received an order from the hospital to administer [MEDICATION NAME] 10% on 12/5/18 to run at 70 ml/hr, verified she had not received an order from the attending physician, had not documented the physician order as a verbal order and had not documented the [MEDICATION NAME] on the Medication Administration Record (MAR). DON reported that [MEDICATION NAME] 10% was given on 12/5/18 as the TPN was not available. There was no physician order for [REDACTED]. DON reported that Resident #13 was refusing TPN on 12/8 and 12/9/18. DON reported she was unable to find any documentation to support Resident #13's refusal for the TPN. DON reported she had prepared the TPN one day possibly on 12/10/18 at 4:00 PM but agreed she had not documented it. There was no documentation the physician was notified of Resident #13 not receiving the TPN. According to the the facility Parental Nutrition, policy dated 3/21/11 (5 years old) revealed Preparation 1. A Physician's order is necessary for this procedure. 2. Review the resident's care plan to assess for any special needs of the resident. 3. Assemble the equipment and supplies as needed. 4. The licensed nurse responsible for administering PN shall be knowledgeable of: a. the types of [MEDICATION NAME] nutrition; b. indications for use. c. appropriate doses and dilutents; d. side effects; e. monitoring parameters; f. toxicities g. incompatibilities; h. stability; i. storage requirements; and j. potential complications. 5 . 6 . General guidelines 1 .7. Use aseptic technique when adding medications to PN solutions. Equipment and supplies 1 .2 .3 .4. Saline or [MEDICATION NAME] for flush, as appropriate.; 5 .6 .9 Assessment. 1. Inspect intravenous catheter site for signs of infection and/or complications at scheduled intervals and upon routine site care and administration set changes. 2. Prior to administration of [MEDICATION NAME] nutrition assess resident's a. age, diagnosis, overall physical status; b. nutritional status; c. baseline vital signs, height and current weight, ideal weight; d. laboratory results, including glucose, BUN , and electrolytes (assess for appropriateness of therapy); and e. history of allergies [REDACTED]. Review physician's order for a. [MEDICATION NAME] nutritional solution formula, including [MEDICATION NAME] and amino acid content and addition of lipids; b. additives and concentration; c. volume to be infused daily; d. rate of administration; e. frequency of administration; f. route of administration; and g. duration of therapy . Documentation 1. The date and time the PN was administered. 2. The type of PN solution administered. 3. Type of flow-control device. 4. Any medication administered:the dosage, route and rate. 5. Notification of the physician, if any. 6. Resident's response. 7. The signature and title of the person recording the data. Reporting 1. Notify the supervisor if the resident refuses the procedure. 2. Report other information in accordance with facility policy and professional standards of practice. According to the pharmacy policy 9.4 [MEDICATION NAME] Nutrition: Additives, dated 1/15/04 revision 7/1/2012 (6 years old) revealed Procedure 1. Verify physician LIP (Licensed Independent Practitioner) order. 2. Perform hand hygiene. 3. Assemble equipment and supplies on clean work surface. Final preparation for patient administration by facility nurse is performed in a clean area that is free of dust and currents of air . 8. Vigorously cleanse injection port of [MEDICATION NAME] nutrition solution bag with alcohol. Allow to air dry. 9. Insert sterile needle/syringe into injection port. Inject medication. 10 . 11. Gently rotate [MEDICATION NAME] nutrition solution bag/container to mix additives after each addition. 12 . 13. Label [MEDICATION NAME] nutrition solution bag with medication added label , to include the following: 13.1 Patient's name 13.2 Medication added 13.3 Medication dose 13.4 Time medication added 13.5 Date medication added 13.6 Nurse's initials . 16. Documentation in the medical record includes, but is not limited to: 16.1 Date and time 16.2 Medication added 16.3 Dose. Review of the pharmacy Infusion Therapy Education Program [MEDICATION NAME] Nutrition, dated (YEAR) revealed Verbal orders are not acceptable. The attending physician/LIP (Licensed Independent Practitioner) may request that the previous provider's formulation be continued. The pharmacist will use the previous provider's formulation as a template for reducing the formulation to writing and converting ingredient units of measure to match the units of measure on pharmacy label. Fax current hospital [MEDICATION NAME] nutrition orders to infusion pharmacy as soon as admission is anticipated. Call infusion pharmacy to verify receipt of orders. Pharmacist will convert order to (pharmacy) [MEDICATION NAME] Nutrition prescription and fax back to facility. This formulation will NOT be considered a valid order until the physician/LIP has reviewed and authorized by telephone order. Physician/LIP orders should include: [MEDICATION NAME] nutrition solution, Additives, Volume and rate, Continuous or cyclical (if cyclical, may be ordered to auto ramp/tapered per pump, or custom taper), VAD flush protocol, Laboratory monitoring, Daily/weekly weights, Vital signs, Blood glucose monitoring, intake and output, Orders should also include physician/LIP notification, Back-up D10W solution or pre-made standard TPN formulation in the event of unplanned interruption of TPN solution, D10W may be administered through a peripheral access device via manual flow control device if an electronic infusion device is not available. Turn -around time for PN orders may vary based on complexity of formula. Turn-around time starts from the time a valid (signed) order is received at the pharmacy. Labs: Ongoing labs per physician/LIP order, physician order is required to withdraw labs from a patient's [MEDICAL CONDITION] (central vascular access device) Baseline recommended on admission. Fax all lab results to infusion pharmacy as soon as they are available from lab provider. Call pharmacy to verify receipt of results. Adjustments to formula are based on lab results. Abnormal lab results may also indicate presence of PN related complication(s). Weights: Baseline recommended on admission, Ongoing weights per physician/LIP, Must be accurate: same time each day, same scale, same clothing, ects. Vital Signs: Base line recommended on admission; per physician / LIP orders. Glucose monitoring should be performed per physician/LIP orders .Intake and Output per physician/LIP orders . Document every shift . Documentation: MAR and Progress Notes Date and time; Flushing/locking agents; medication additives/solution; volume and rate; tapering schedule, if ordered; site assessment; complications and interventions; patient response to procedure and/or medication. Intake and output totals; weights and vital signs.

Medilodge of Frankenmuth is placed in Immediate Jeopardy for failing to prevent the development of pressure ulcers when they did not implement interventions, get doctor's orders, assess and treat 12 current residents (Resident's 6, 8, 9, 10, 11, 12, 13, 14, 16, 17, 18 and 19) and one closed record Resident (#5), who were admitted to the facility without pressure ulcers, resulting in the development of a stage 3 (III) pressure ulcer for Resident #14, a suspected deep tissue ulcer for Resident #11, an infected stage 4 (IV) pressure ulcer for Resident #5 which required hospitalization and surgery, 5 stage 2 ( II) pressure sores and 4 Stage I Pressure ulcers with the potential for increased severity of facility acquired pressure ulcers. This deficient practice placed Residents #11, #14 and #5 in harm and places all other residents identified as being at risk for pressure ulcers, at risk for serious harm, injury, infection and/or death. The IJ started on 11/22/17. Immediate Jeopardy was identified at F-686 on 2/1/18. The Administrator was notified of the Immediate Jeopardy on 2/1/18. A plan to remove the immediacy was requested. The immediacy was removed on 2/6/18 based on the Facility's implementation of an acceptable plan of removal as verified on-site by the surveyor team. Although the immediacy was removed the Facility's deficient practice was not corrected and remained widespread with actual harm that is not immediate jeopardy. Review of facility Policy and Procedure titled, Pressure Ulcers/Pressure Injury Prevention and Treatment-Clinical Protocol dated 11/28/17 revealed based on comprehensive assessment of a resident, and 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 are 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. Item (4.) Because deep tissue injuries may not be visible upon admission and can develop in as little as 2 hours, they should be investigated for causation within the prior 7 days. (#9.) Change of condition/New skin alteration: (a.) complete head to toe skin assessment, document in the medical record. (b.) Notify the physician. (c.) Obtain new orders as needed. (d.) Notify Resident and Residents Representative of all new and/or non-healing/worsening PU/PI's. According to the facility's Wound and Skincare Guidelines, no date, Note: Care is based upon individual resident needs and physician orders. These guidelines are provided for reference only, and are not policy. These guidelines should not be implemented without advice or approval of supervising physician and are qualified in all respects to physician's orders [REDACTED]. Stage I pressure ulcer -Intact skin with non-bleachable redness or a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Unstageable- Full thickness tissue loss in the base of the ulcer is covered by slough (yellow, tan, gray , green or brown) and /or exchar (tan, brown or black) in the wound bed. Stage II- partial thickness wound Stage III -IV Shallow/Full Thickness Stage III-IV Deep Full Thickness. The facility information provided no other specific information as to the description of a Stage III or Stage IV pressure ulcer. On 1/30/18 at 2:30 PM, 2/1/18 at 4:30 PM, and 2/6/18 at 2:30 PM Director of Nursing B was asked for a policy on Gentell skin progress notes. On 2/6/18 at time of exit there was no facility policy provided for Gentell skin progress notes. On 2/1/18 at 10:30 AM, Unit Manager Registered Nurse (RN) D reported she had received in-services from the facility nurse consultant HH and used her for recommendations and protocol for the treatment of [REDACTED]. Unit Manager D was asked for the facility protocol at that time. Unit Manager D reported she had not attended any formal training for wound care, and was often pulled to the floor to work as a nurse due to staffing concerns frequently unable to complete measurements and monitor wounds. On 2/1/18 at 1:00 PM, Unit Manager Licensed Practical Nurse (LPN) C reported she had received in-services from the facility nurse consultant HH and HH would provide wound consults, and help decide course of wound care. LPN C was requested to provide a copy of the protocol for the treatment of [REDACTED]. In an interview on 2/1/18 at 4:30 PM with the Director of Nursing Services B stated that the facility needed more staff, but that it takes time to get staff there. DON B was asked if the staffing was a direct result of the increase in the increase of the number of Residents with pressure ulcers and stated the change over of staff has not helped. In an interview on 2/6/18 at 1:30 PM with the Director of Nursing B stated that the QA committee meets once a month and that the topics are care plans from the annual survey, pressure ulcers were added on 1/31/18 after 7 more pressure ulcers developed after our past non-compliance on 1/21/18. Staffing is also in QA continuously. On 1/31/18 at 1:00 PM, Nurse Practitioner N stated, see a lot of people at the facility, was not concerned because no one said Oh, look at this Did not interpret that there was a major change at that time. We need some clarification on communication, if there are wounds need to be more alert to concerns. I was being informed of pressure ulcers but was not communicated as urgent. NP N stated had recalled being informed Resident #5 was going to the wound clinic and had not recalled seeing the wounds, had documented on the wound 1/5/18 but had not visualized the wound for Resident #5. NP N stated had triggered us yesterday to take it more seriously and learned how to access the skin assessments as they were available in a different program in the computer. NP N was asked if had observed any of the pressure ulcers and responded, I can not recall. On 1/31/18 at 1:45 PM, Physician M stated, I was on vacation and was not informed of the wounds. Physician M stated, skin assessments are available in the computer electronic records, PCC progress notes -S[NAME] skin. View all, go to Custom. The Doctor was not aware of the Genteel program being used to track skin assessments. Physician M stated, I Do not give orders over the phone. She probably called the NP. Physician M responded, Be very vigilant and correct and communicate and this would not have happened. Resident #14 Resident #14 was a [AGE] year old male admitted on [DATE], with an MDS dated [DATE] with [DIAGNOSES REDACTED]. MDS indicated no skin issues and coded a 3 for bed mobility which indicated she required extensive assistance of 2 staff for repositioning and turning. MDS dated [DATE] indicated resident had a Stage III pressure ulcers and was documented 2.0 cm x 1.0 x 0.4 with granulation tissue. On 1/30/18 upon entry to the facility a list Residents with facility acquired pressure ulcers was provided with the stage of each ulcer. Resident #14 was listed to have a pressure ulcer that developed on 11/22/18. Review of Resident #14's physician progress notes [REDACTED]. Review of Resident #14's Norton Plus Pressure Ulcer Scale dated 11/15/17 indicated resident risk had improved. The next Norton Plus Pressure Ulcer Scale was dated on 1/19/18 and indicated a decline. According to Resident #14's Care Plan Resident is at risk for pressure ulcers, initiated on 1/24/17, revised on 12/21/17 and on 1/18/18, revealed an intervention avoid positioning the resident on bony prominence's, encourage resident to reposition Q 2 hours and PRN, Encourage resident to stay off of right side. If resident refuses, reeducate to risks of not preposition. initiated on 1/20/18 (required assist of 2 per MDS. Intervention to Monitor/document report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection , wound size (length x width, depth) , stage. canceled on 12/21/17 air mattress - Resolved. 1/20/18 According to Resident #14's Skin assessment dated [DATE], revealed an abnormal skin area was identified and measured 2.6 x 1.0 x UTD pressure area to Right calf no drainage no s/s of infection no pain. According to Resident #14 skin assessments documented on Gentell skin wound notes, Resident #14 developed a stage III pressure ulcer to right lower rear leg. Record review of Resident #14's Genteel skin/wound measurements dated 11/29/17 through 1/26/18 wound measurements were not completed weekly. Measurements were completed on 11/22/17, 11/29/17 12/6/17, no observation for 2 weeks until 12/22/17, 12/29/17, 1/9/18, no observation for 2 weeks until 1/26/17, and 2/2/18 Review of Facility Certified Nurse Aide documentation from 11/20/17 through 11/26/17 revealed no documentation of Resident #14 having any new skin condition. Review of Resident #14's Treatment Records (TAR) dated (MONTH) (YEAR) revealed there was no treatments for honey alginate as prescribed on 12/11, 12/19 and 12/19/17. Review of Resident #14's Treatment Records (TAR) dated (MONTH) (YEAR) revealed there was no treatments for honey alginate as prescribed on 1/2, 1/23, and 1/26/18. On 2/5/18 at 10:30 AM, Director of Nursing B provided second resident pressure ulcer list that showed Resident #14 had a Stage II pressure ulcer. DON B was asked to verify the stage of the pressure ulcer and was asked if pressure ulcers were back staged and responded, we do not back stage pressure ulcers. DON B reviewed the weekly Gentell wound documentation for Resident #14 and agreed the wound notes were not completed weekly. On 2/6/18 at 4:55 PM, DON B verified Resident #14 had a Stage III pressure ulcer, and resident's pressure had developed on 11/22/17 according to the documentation reviewed, DON B reported all the Pressure ulcers had been observed on 2/2/18 but had not looked at that one herself. On 2/6/18 at 11/20/18 there was a noted yellow dot on Resident #14's door to his room the dot was blank which indicated he was to be turned and repositioned every 2 hours per the facility policy. Resident #5 Resident #5 was an [AGE] year-old female, who was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #5 required assistance with all activities of daily living. Resident #5 was coded a 3 for bed mobility which indicated she required extensive assistance of 2 staff for repositioning and turning. Review of Resident #5's hospital admission information (10/6/17) that included a cardiovascular consult dated 10/2/17 included information with laboratory studies WBC of 13.5, hemoglobin 10.5. platelet count 376,000 , BUN 17, and creatinine of 0.8 which indicated current available studies were available up on the facility's request. Review of Resident # 5's clinical record revealed a CBC with differential was completed on 11/24/17. Review of Resident #5's Norton Plus Pressure Ulcer Scale dated 10/6/17 and 10/23/17 indicated there were no recent labs available for assessment resulting in inaccurate assessments. According to Resident #5's Minimum Data Set ((MDS) dated [DATE], identified the resident was not admitted with a pressure ulcer. On 1/30/18 at 2:45 PM, Licensed Practical Nurse G stated, on 12/21/17 was informed by a CNA (Certified Nurse Aide) that resident #5 had open areas following a shower, observed Resident #5's wounds and described them as one on her bottom and suspected deep on right or left heel. One on buttock that was 4 cm x 2.5 cm toward the left cheek of her buttock on the outside, left lateral. LPN G stated, I could not stage it as it had a necrotic spot in it. LPN G stated, had obtained an order from the physician. Wrote it that night on scrape piece of paper and it got misplaced, and then stated, it (the physician order) was written 9 days later. LPN G stated she had worked during 12/21/17 and 1/8/18 and had not completed the treatment for [REDACTED]. Resident #5's Incident Report dated 12/21/17 revealed Left heel SDTI 4 cm x 2.5 cm, L inner (lateral [DIAGNOSES REDACTED] Great toe 1.5.cm x 2.6 cm, Coccyx open area 2.1 cm x 3 cm with maceration noted. Review of Resident #5's Treatment Record dated 12/22/17, revealed coccyx 2.3 cm x 3 cm open area with maceration noted peri wound, left heel 4 cm x 2.5 cm SDTI with maceration noted, left toe(s) Left lateral great toe- [DIAGNOSES REDACTED] noted 1.5 cm x 2.6 cm. Review of Resident #5's Physician orders [REDACTED]. 2) cleanse left heel with wound cleanse, pat dry. apply skin prep every day and evening shift was ordered. Review of Resident #5's Treatment record revealed for (MONTH) (YEAR) the treatment record documentation started on 12/28/17 for the coccyx area and there were no treatments documented on the heel wound for the afternoon shift on 12/30/17 and day shift on 12/31/17. There were no descriptions of the wound documented according to the treatment record. According to the (MONTH) (YEAR) Treatment Record the coccyx wound was not documented as treated on 1/4/18 day shift and 1/7/18 afternoon shift and there was no documentation of description of wound on the treatment record. The heel wound was not documented as treated on 1/3/18 day or afternoon shift, 1/4/18, 1/5/18 afternoon shift and 1/7/18 day and afternoon shift. And there was no documentation or description of the wound on the treatment record. Review of Resident #5's Care Plan (Resident) is at risk for ulcer development ., with interventions that were initiated on 10/8/17 that included Float heels when in bed, Instruct /assist to shift weight in w/c q (every) 60 minutes and Educate (resident) and or /family/caregivers as to causes of skin breakdown; importance of pressure taking care during ambulating/mobility, good nutrition and frequent repositioning initiated on 10/8/18 and revised on 12/18/17. Review of Resident #5's Care Plan (Resident) has actual impairment to skin integrity to the coccyx related to bowel and bladder - left heel SDTI (suspected deep tissue injury), left inner lateral [DIAGNOSES REDACTED] great toe, coccyx open area with maceration noted. initiated 10/8/17 with interventions that included consult wound clinic dated 1/4/18 other interventions were dated 10/8/17 that included float heels when in bed, keep skin clean and dry and use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface. On 1/31/18 at 4:50 PM, Unit Manager C reported had reviewed the treatment records and dates treatments were not completed and assessed Resident #5 had assessed her on 1/4/18 and it had gotten worse called and scheduled her for an appointment for the wound clinic which was for 1/8/18 which was the quickest I could get her in the wound clinic. On 1/31/18 at 1:00 PM, Nurse Practitioner N stated, she did not recall providing an order for [REDACTED].#5 was going to the wound clinic and had not recalled seeing the wounds, had documented on the wound 1/5/18 but had not visualized the wound. NP N stated had triggered us yesterday to take it more seriously and learned how to access the skin assessments as they were available in a different program in the computer. On 1/31/18 at 1:45 PM, Physician M stated, I was on vacation and was not informed of the wounds. Physician M stated, skin assessments are available in the computer electronic records, PCC progress notes -S[NAME] skin. View all, go to Custom. The Doctor was not aware of the Genteel program being used to track skin assessments. Physician M stated, I Do not give orders over the phone. She probably called the NP. According to Resident #5's discharge MDS dated [DATE] section M. identified one un-stag able Pressure Ulcer and one 3 or 4 eschar deep tissue injury with measurements documented of 5.8 cm x 4.0 cm. According to Resident #5's Hospital history and physical examination [REDACTED]. Resident #8 According to MDS dated [DATE], Resident #8 was an [AGE] year old female admitted on [DATE], with [DIAGNOSES REDACTED]. MDS dated [DATE] identified a stage II pressure ulcer. On 1/30/18 upon entry to the facility a list Residents with facility acquired pressure ulcers was provided with the stage of each ulcer. Resident #8 was listed to have a pressure ulcer that developed on on 1/18/18. Record review of Resident #8's (MONTH) (YEAR) treatment records noted on 1/20/18, 1/23/18, 1/25/18 and 1/30/18 revealed there was no documentation for treatments signed out by nursing staff. Resident #9 According to Resident #9's significant change MDS dated [DATE], resident was a [AGE] year old male admitted [DIAGNOSES REDACTED]. According to Resident #9's Gentell/Skin assessments dated 12/26/17 who developed a stage II pressure area to right buttocks. Review of Resident #9's Care Plan actual impairment to skin of the right buttocks related to incontinence bladder and bowel (c-dif), dated 12/20/17 revised 1/9/18, revealed interventions of air mattress in place initiated 1/9/18, encourage resident not to lay on his back, initiate yellow dot program and check and change (resident) every two hours, if incontinent wash, dry and apply thin layer of barrier cream dated 12/20/17. Record review of Resident #9's (MONTH) (YEAR) treatment record noted for the dates 1/2/18, 1/11/18, 1/16/18, 1/18/18, 1/23/18 and 1/26/18 there were no treatments signed out by nursing staff. Resident #10 According to Resident #10's quarterly MDS dated [DATE] Resident #10 was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. with bed mobility that was coded with a 4 that indicated total dependence with assistance of one staff. According to Resident #10's physician order [REDACTED]. According to Resident #10's Gentell/skin note dated 1/26/18 revealed, acquired Stage II pressure ulcer right trochanter 0.8 x 0.4 x 0.2 cm. According to Resident #10's care plan resident has actual skin breakdown. He has developed a stage II ulcer to his right hip, date initiated 12/18/17 and revised 1/21/18 intervention included, (Resident) needs assistance to turn/reposition at least every 2 hours, more often as needed or requested., Initiate yellow dot program. Encourage (Resident) to avoid positioning on the right hip. Administer treatments as ordered and evaluate for effectiveness. Evaluate/ record. monitor wound healing weekly and PRN. Measure length, width, and depth were possible. Evaluate and document status of wound perimeter, wound bed and healing progress. Report improvements and decline to the MD. Resident #11 According to Resident #11 quarterly MDS dated [DATE] resident was a [AGE] year old female admitted on [DATE], with [DIAGNOSES REDACTED]. According to Resident #11's Skin assessment dated [DATE] Left heel 1.5 x 2.6 SDTI brown discoloration tender w touch. According to Resident #11's Care Plan (Resident) has developed actual impairment of the skin on her left heel SDTI related to immobility due to cerebral infarct, [MEDICAL CONDITION] cell initiated 12/20/17 revised 1/25/18 with interventions that included Encourage good nutrition and hydration in order to promote healthier skin, initiate yellow dot program (1/20/18), encourage (resident) to float bilateral heels while she is in bed, the following interventions were not initiated until 1/25/18 Monitor/document location, size and treatment of [REDACTED]. se cauthion during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Observation on 2/1/18 at 11:55 AM of Resident #11's left lateral heel revealed there was no dressing in place and that Registered Nurse (RN) D could not give a reason as to why the pressure area occurred. On 2/6/18 at 11:10 AM, a plain yellow dot was observed on Resident #11's door indicating Resident #11 was to be repositioned every 2 hours per the facility policy. Resident #12 According to Resident #12's MDS dated [DATE] resident was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. bed mobility was scored as limited assist with one staff, According to Resident #12 Skin assessment dated [DATE] resident developed three open areas to the sacrum area measuring 1 x 1 cm, middle measuring 3 x 2 cm and last open area 1 x 1 cm, TX in place see orders. Record review of Resident #12's (MONTH) (YEAR) treatment records noted on 1/30/18 and 1/31/18 revealed there was no documentation for coccyx wound treatments signed out by nursing staff. Resident #12's Care Plan impaired skin integrity related to surgical wound and open area to sacrum, dated 1/6/18 and revised 1/29/18 included the following interventions: Initiate yellow program. Encourage resident to avoid laying flat on back, medications/Treatments as ordered . , observe wound for condition and document specifics related to securing device and observe for complications indicative of infections (redness, [MEDICAL CONDITION], drainage) notify physician as needed. Observation on 2/1/18 at 11:45 AM of Resident #12's sacrum pressure ulcer dressing change with registered Nurse (RN) D and Hospice nurse E, there was no barrier to the surface where the wound dressing supplies were set-up, RN D washed the wound and applied the honey medication to the wound bed and covered the wound with an ABD dressing pad and taped the pad in place with the same gloves and returned the dressing supplies to a dresser drawer with personal belongings and candy in the drawer. Resident #13 Resident #13 was an [AGE] year old female admitted on [DATE], with an MDS dated [DATE] with [DIAGNOSES REDACTED]. Resident #13's bed mobility was scored as a 2 which indicated required limited assist with 1 staff, transfer was 3 which indicated extensive assistance of 2 staff. Review of Resident #13 Gentell skin assessment dated [DATE] revealed a stage II pressure ulcer to the right buttocks on 1/18/18. Record review of Resident #13's (MONTH) treatment record revealed that on 1/13/18, 1/20/18, 1/26/18, 1/27/18 and 1/31/18 that there were no treatments signed out by the nursing staff. Review of Resident #13's Care Plan has developed a stage II pressure ulcer to her right buttock initiated 1/10/18, revealed interventions of imitate yellow dot program. Evaluate/record, monitor wound healing weekly .were not initiated until 1/28/18. Immediate Jeopardy is identified due to the facility's failure to prevent the development of facility acquired pressure ulcers for 7 current residents (Resident #8, #9, #10, #11, #12, #13, and #14) and one closed record Resident (#5). This deficient practice placed Residents #11, #14 and #5 in harm and places all other residents identified as being at risk for pressure ulcers, at risk for serious harm, injury, infection and/or death. The following 5 additional residents were identified to have developed pressure ulcers after the IJ was identified when the facility completed skin assessments following the past non-compliance dated 1/21/18. Resident #6 Resident #6 was a [AGE] year old admitted to the facility on [DATE], MDS dated [DATE] with [DIAGNOSES REDACTED]. Resident #6 was coded as a 3 for bed mobility which indicated she required extensive assistance of 2 staff for repositioning and turning. According to Resident #6's Nurse progress note assessment note dated 1/5/18 the pressure ulcer that had healed and according to Resident #6's Gentell's skin note had re-opened on 2/2/18 on the sacral at a Stage II at a 2.0 x 0.5 x .0 cm area. According to Resident #6's Care plan Is at risk for pressure ulcer development initiated on 10/8/17 and revised on 1/19/18 with interventions to shift weight while sitting in wheel chair every 30-60 minutes, turn and reposition every 2 hours and use pillows to assist with reposition placement, encourage not to lay on her back and yellow dot program initiated on 1/20/18. Review of Resident #6's (MONTH) (YEAR) TAR (Treatment Administration Record) indicated [MEDICATION NAME] was not documented as prescribed on 11/22/17 to the coccyx. Review of Resident #6's (MONTH) (YEAR) TAR revealed [MEDICATION NAME] cream was not documented as prescribed on 12/16/17 and 12/29/17 and 1/1/18. Review of Resident #6's (MONTH) (YEAR) TAR revealed skin prep to was not documented as completed PM 1/5, 1/16, 1/17 0 1/30/18 Review of Resident #6's (MONTH) (YEAR) TAR revealed Dermaseptin to Bilateral thighs/buttocks and coccyx was not documented as completed on 2/2/18. Resident # 16 Resident #16 was a [AGE] year old female admitted on [DATE], with an MDS dated [DATE] with no skin issues noted with bed mobility that was scored with a 3, that indicated extensive assistance of 2 staff. Review of Resident #16's Care plan actual impairment of skin dated 2/2/18, reveled interventions that included a pressure reduction mattress and wheelchair cushion, float (resident's) bilateral heels while in bed with heels up on pillow was initiated on 1/27/18, and the yellow dot program for repositioning was initiated on 1/20/18. Resident #16's Nurse Practioner progress note dated 2/2/18 stated, healed [MEDICAL CONDITION] bilateral upper buttocks, Rt heel red, non-blanchable, mushy. Resident #16's Bathtime skin anatomy note dated 2/2/18 stated, Bilateral buttocks Stage 1, right heel stage I. Resident #16's Gentell wound note dated 2/2/18, stated, acquired Right buttock open pressure Ulcer Stage I, measure 2.0 x 1.5 x 0.0 cm; acquired left buttock stage I pressure ulcer measured 2.0 x 1.6 x 0.0 cm. Review of Resident #16's Treatment records reveal there is no documentation of the bilateral buttocks pressure ulcer for signs and symptoms of drainage, infection, pain, odor, skin color, necrotic on 2/2/18 and there is no record of any physician order [REDACTED]. Resident #17 According to Resident #17's MDS dated [DATE] Resident was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Bed mobility was scored as a 3 which indicated extensive assistance of 2 staff. According to Resident #17's Bathtime skin sheet an area was identified on the left buttock on 2/2/18. According to Resident #17's NP progress note dated 2/2/18 at 20:15 (8:15 PM) Rt upper buttock Stage I pressure ulcer . Resident #18 According to Resident #18's MDS dated [DATE] Resident was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #17 was coded with a 3 for bed mobility which indicated she required extensive assistance of 2 staff for respositioning and there were no skin issues indicated on 1/14/18. According to Resident #18's Bathtime skin sheet dated 2/2/18 an area was identified on the sacral/coccyx area (2.5 x 2.0 x 0.0) Stage II. According to Resident #17's Gentell skin note dated 2/2/18 stated Area is fungal related, total size of area is 2.5 x 2.0 x 0.0) Stage One in center 1.5 x 1.5 x 0.0 According to Resident #17's NP note dated 2/2/18 stated left upper buttock stage I - 1.5 cm diameter, dark red / purple in color, non blanchagle, Bilat buttocks (lower) sacral stage I - diffuse, difficult to measure, red and nonblanchable, also very macerated with indentations of w/c cussion imprinted. Resident #19 According to Resident #19's MDS dated [DATE] resident was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #19 was coded a 3 for mobility which indicated required extensive assistance of 2 staff and was admitted with no skin issues. According to Resident #19's physician orders [REDACTED].

Based on observation, interview and record review the facility failed to reposition 13 (#5, #8, #9, 10, #11, #12, #13, #14 #15, #16, #17, #18 #19 dependent residents according to the facility policy resulting in the developement of stage I to stage IV pressure ulcers. Findings: According to the facility policy Repositioning, the policy was revised 3/24/13 and was not noted to have been signed by administration, The purpose of this procedure is to provide guidelines for the assessment of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed- or chair bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. 1. Review the resident's care plan to assess for any special needs of the resident.3. Repositioning is critical for a resident who is immobile or depend upon staff for repositioning. 4. The care plan for a resident at risk of friction or shearing during repositioning may require the use of lifting devices for repositioning. 5. Positioning the resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing Assessment for Appropriate Repositioning: 1. Assess residents who can reposition independently to determine the following: a. I a positioning device needed to maintain independent positioning? b. Does the resident need instruction about why turning is important? c. Does the resident need encouragement to reposition? d. Does the resident require monitoring to assure that turning occurs? 2. Assess the resident for an existing pressure ulcer .3. Assess residents who sit or recline in a chair with the back of the chair (or the back of the bed) elevated to or above a 30 degree angle: a. Does the resident need hourly position changes? b. Does the resident position changes more frequestnly than hourly? A turning /repositioning program includes a continous consistent program tfor changing the resident's position and realigning the body. A program is defined as a specific approach that is organized, planned, documented ,monitored and evaluated. The plan is based on the resident's ondividualized assessment and takes in to account pressure redistribution devides and surfaces as well as the resident wishes and rights. Basid recommentations. 1. Residents who are in bed should be on a q 2 hour turning plan based on individual assessment. 2. Independent residents may reposition independently. 3. For residents with a Stage I or above pressure ulcer q 2 hour turning may be inadequate. 4. Residents wuo are in a chair may need to be ion a 1-2 hour repositioning program based on individual assessment. 5. If ineffective, the turning and repositioning frequency may be increased. Review of facility Policy and Procedure titled, Pressure Ulcers/Pressure Injury Prevention and Treatment-Clinical Protocol dated 11/28/17 and was not noted to have been signed by administration, revealed Based on comprehensive assessment of a resident, and 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 are 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. Item (4.) Because deep tissue injuries may not be visible upon admission and can develop in as little as 2 hours, they should be investigated for causation within the prior 7 days .#5 .h. The facility should have a turning and repositioning program which allows staff to know resident's individual intervention and monitoring. The following is but one example of such a program: I. Yellow dot - Residents who are at high risk for the development of PU/PI based on the Norton's Plus evaluation will have a yellow dot on the door/nameplate of the resident's room and wheel chair: 1. Plain Yellow dot - Turned and repositioned every 2 hours 2. Yellow dot with slash - Special schedule and see car e plan /Kardex; 3. Yellow dot with R - Turned and repositioned every 2 hours but unable to lay on right side; 4. Yellow dot with L - Turned and repositioned every 2 hours but unable to lay on left side; 5. Yellow dot with B- Turned and repositioned every 2 hours but unable to lay on back; 6. Yellow dot with R,L or B and slash - unable to lay on that area and special schedule see care plan/Kardex. On 1/31/18 during a review of the facility's past non-compliance dated 1/21/18 it was noted there was no information noted for audits related to residents being repositioned or being monitored for positioning or turning related to the facility policy (yellow dot program). On 2/6/18 at 2:00 PM, Director of Nursing B stated, agreed there were no audits for the monitoring of residents being monitored for positioning and turning and stated, we missed that on our audits, the program got going and the staff were not fully educated to make sure they (the residents) were turned. Resident #5 Resident #5 was an [AGE] year-old female, who was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #5 required assistance with all activities of daily living. Resident #5 was coded a 3 for bed mobility which indicated she required extensive assistance of 2 staff for repositioning and turning. Resident #5's Incident Report dated 12/21/17 revealed Left heel SDTI 4 cm x 2.5 cm, L inner (lateral [DIAGNOSES REDACTED] Great toe 1.5.cm x 2.6 cm, Coccyx open area 2.1 cm x 3 cm with maceration noted. Review of Resident #5's Care Plan (Resident) is at risk for ulcer development ., with interventions that were initiated on 10/8/17 that included Float heels when in bed, Instruct /assist to shift weight in w/c q (every) 60 minutes and Educate (resident) and or /family/caregivers as to causes of skin breakdown; importance of pressure taking care during ambulating/mobility, good nutrition and frequent repositioning initiated on 10/8/18 and revised on 12/18/17. Review of Resident #5's Care Plan (Resident) has actual impairment to skin integrity to the coccyx related to bowel and bladder - left heel SDTI (suspected deep tissue injury), left inner lateral [DIAGNOSES REDACTED] great toe, coccyx open area with maceration noted. initiated 10/8/17 with interventions that included consult wound clinic dated 1/4/18 other interventions were dated 10/8/17 that included float heels when in bed, keep skin clean and dry and use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface. Resident #5's care plan was not updated timely to include appropriate interventions according to the facility repositioning policy. Resident #8 According to MDS dated [DATE], Resident #8 was an [AGE] year old female admitted on [DATE], with [DIAGNOSES REDACTED]. MDS dated [DATE] identified a stage II pressure ulcer. On 1/30/18 upon entry to the facility a list Residents with facility acquired pressure ulcers was provided with the stage of each ulcer. Resident #8 was listed to have a pressure ulcer that developed on on 1/18/18. Resident #8's care plan was not updated timely to include appropriate interventions according to the facility repositioning policy. Resident #9 According to Resident #9's significant change MDS dated [DATE], resident was a [AGE] year old male admitted [DIAGNOSES REDACTED]. According to Resident #9's Gentell/Skin assessments dated 12/26/17 who developed a stage II pressure area to right buttocks. Review of Resident #9's Care Plan actual impairment to skin of the right buttocks related to incontinence bladder andbowel (c-dif), dated 12/20/17 revised 1/9/18, revealed interventions of air mattress in place initiated 1/9/18, encourage resident not to lay on his back, initiate yellow dot program and check and change (resident) every two hours, if incontinent wash, dry and apply thin layer of barrier cream dated 12/20/17. Resident #9's care plan was not updated timely to include appropriate interventions according to the facility repositioning policy Resident #10 According to Resident #10's quarterly MDS dated [DATE] Resident #10 was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. with bed mobility that was coded with a 4 that indicated total dependence with assistance of one staff. According to Resident #10's Gentell/skin note dated 1/26/18 revealed, acquired Stage II pressure ulcer right trochanter 0.8 x 0.4 x 0.2 cm. According to Resident #10's care plan resident has actual skin breakdown. He has developed a stage II ulcer to his right hip, date initiated 12/18/17 and revised 1/21/18 intervention included, (Resident) needs assistance to turn/reposition at least every 2 hours, more often as needed or requested., Initiate yellow dot program. Encourage (Resident) to avoid positioning on the right hip. Administer treatments as ordered and evaluate for effectiveness. Evaluate/ record. monitor wound healing weekly and PRN. Measure length, width, and depth were possible. Evaluate and document status of wound perimeter, wound bed and healing progress. Report improvements and decline to the MD. Resident #10's care plan was not updated timely to include appropriate interventions according to the facility repositioning policy Resident #11 According to Resident #11 quarterly MDS dated [DATE] resident was a [AGE] year old female admitted on [DATE], with [DIAGNOSES REDACTED]. According to Resident #11's Skin assessment dated [DATE] Left heel 1.5 x 2.6 SDTI brown discoloration tender w touch. According to Resident #11's Care Plan (Resident) has developed actual impairment of the skin on her left heel SDTI related to immobility due to cerebral infarct, [MEDICAL CONDITION] cell initiated 12/20/17 revised 1/25/18 with interventions that included Encourage good nutrition and hydration inorder to promote healthier skin, initiate yellow dot program (1/20/18), encourage (resident) to float bilateral heels while she is in bed, the following interventions were not initiated until 1/25/18 Monitor/document location, size and treatment of [REDACTED]. se cauthion during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue andexudate and any other notable changes or observations. Observation on 2/1/18 at 11:55 AM of Resident #11's left lateral heel revealed there was no dressing in place and that Registered Nurse (RN) D could not give a reason as to why the pressure area occurred. On 2/6/18 at 11:10 AM, a plain yellow dot was observed on Resident #11's door indicating Resident #11 was to be repositioned every 2 hours per the facility policy. Resident #11's care plan was not updated timely to include appropriate interventions according to the facility repositioning policy Resident #12 According to Resident #12's MDS dated [DATE] resident was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. bed mobility was scored as limited assist with one staff, According to Resident #12 Skin assessment dated [DATE] resident developed three open areas to the sacrum area measuring 1 x 1 cm, middle measuring 3 x 2 cm and last open area 1 x 1 cm, TX in place see orders. Resident #12's Care Plan impaired skin integrity related to surgical wound and open area to sacrum, dated 1/6/18 and revised 1/29/18 included the following interventions: Initiate yellow program. Encourage resident to avoid laying flat on back, medications/Treatments as ordered . , observe wound for condition and document specifics related to securing device and observe for complications indicative of infections (redness, [MEDICAL CONDITION], drainage) notify physician as needed. Resident #12's care plan was not updated timely to include appropriate interventions according to the facility repositioning policys. Observation on 2/1/18 at 11:45 AM of Resident #12's sacrum pressure ulcer dressing change with registered Nurse (RN) D and Hospice nurse E, there was no barrier to the surface where the wound dressing supplies were set-up, RN D washed the wound and applied the honey medication to the wound bed and covered the wound with an ABD dressing pad and taped the pad in place with the same gloves and returned the dressing supplies to a dresser drawer with personal belongings and candy in the drawer. Resident #13 Resident #13 was an [AGE] year old female admitted on [DATE], with an MDS dated [DATE] with [DIAGNOSES REDACTED]. Resident #13's bed mobility was scored as a 2 which indicated required limited assist with 1 staff, transfer was 3 which indicated extensive assistance of 2 staff. Review of Resident #13 Gentell skin assessment dated [DATE] revealed a stage II pressure ulcer to the right buttocks on 1/18/18. Review of Resident #13's Care Plan has developed a stage II pressure ulcer to her right buttock initiated 1/10/18, revealed interventions of imitate yellow dot program. Evaluate/record, monitor wound healing weekly .were not initiated until 1/28/18. Resident #13's care plan was not updated timely to include appropriate interventions according to the facility repositioning policys. Resident #14 Resident #14 was a [AGE] year old male admitted on [DATE], with an MDS dated [DATE] with [DIAGNOSES REDACTED]. MDS indicated no skin issues and coded a 3 for bed mobility which indicated she required extensive assistance of 2 staff for repositioning and turning. MDS dated [DATE] indicated resident had a Stage III pressure ulcers and was documented 2.0 cm x 1.0 x 0.4 with granulation tissue. On 1/30/18 upon entry to the facility a list Residents with facility acquired pressure ulcers was provided with the stage of each ulcer. Resident #14 was listed to have a pressure ulcer that developed on 11/22/17. Review of Resident #14's physician progress notes [REDACTED]. Review of Resident #14's Norton Plus Pressure Ulcer Scale dated 11/15/17 indicated resident risk had improved. The next Norton Plus Pressure Ulcer Scale was dated on 1/19/18 and indicated a decline. According to Resident #14's Care Plan Resident is at risk for pressure ulcers, initiated on 1/24/17, revised on 12/21/17 and on 1/18/18, revealed an intervention avoid positioning the resident on bony prominences, encourage resident to reposition Q 2 hours and PRN, Encourage resident to stay off of right side. If resident refuses, reeducate to risks of not preposition. initiated on 1/20/18 (required assist of 2 per MDS. Intervention to Monitor/document report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection , wound size (length x width, depth) , stage. canceled on 12/21/17 air mattress - Resolved. 1/20/18 According to Resident #14's Skin assessment dated [DATE], revealed an abnormal skin area was identified and measured 2.6 x 1.0 x UTD pressure area to Right calf no drainage no s/s of infection no pain. According to Resident #14 skin assessments documented on Gentell skin wound notes, Resident #14 developed a stage III pressure ulcer to right lower rear leg. Record review of Resident #14's Genteel skin/wound measurements dated 11/29/17 through 1/26/18 wound measurements were not completed weekly. Measurements were completed on 11/22/17, 11/29/17 12/6/17, no observation for 2 weeks until 12/22/17, 12/29/17, 1/9/18, no observation for 2 weeks until 1/26/17, and 2/2/18 Review of Facility Certified Nurse Aide documentation from 11/20/17 through 11/26/17 revealed no documentation of Resident #14 having any new skin condition. On 2/5/18 at 10:30 AM, Director of Nursing B provided second resident pressure ulcer list that showed Resident #14 had a Stage II pressure ulcer. DON B was asked to verify the stage of the pressure ulcer and was asked if pressure ulcers were back staged and responded, we do not back stage pressure ulcers. DON B reviewed the weekly Gentell wound documentation for Resident #14 and agreed the wound notes were not completed weekly. On 2/6/18 at 4:55 PM, DON B verified Resident #14 had a Stage III pressure ulcer, and resident's pressure had developed on 11/22/17 according to the documentation reviewed, DON B reported all the Pressure ulcers had been observed on 2/2/18 but had not looked at that one herself. On 2/6/18 at 11/20/18 there was a noted yellow dot on Resident #14's door to his room the dot was blank which indicated he was to be turned and repositioned every 2 hours per the facility policy. Resident #15 According to Resident #15's MDS dated [DATE] resident was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/6/18 at 11:30 AM, Resident reported it would be much easier for him to reposition if he had a side rail or repositioning bar on his bed and reported he had a trapeze on his previous bed. It would be much easier if I could help the staff when they are trying to move me around. Resident stated, My wife has asked for me to have one and they have said I can not have a side rail. On 2/6/18 at 11:30 AM, CNA KK agreed Resident 15 would be able to assist more if he had something to grab and assist when repositioning him. On 2/6/18 at 1:20 PM, DON B was asked if Resident #15 had been assessed for a repositioning bar or trabeze and stated, HI rolled him over when I assessed him to look at his skin and he was able to move pretty good for me yesterday, I will have to look in to that with therapy. According Resident #15's Care plan Resident has an actual impairment for skin impairment of the coccyx, He also has actual impairments to bilateral buttocks r/t shearing dated 11/4/17 revised 1/19/18 with interventions that were not updated until for the following until 1/20/18 that included the following Avoid positioning the resident on back, Initiate yellow dot, The resident requires pressure relieving/reducing device on bed. Resident #15's care plan was not updated timely to include appropriate interventions according to the facility repositioning policys. Resident # 16 Resident #16 was a [AGE] year old female admitted on [DATE], with an MDS dated [DATE] with no skin issues noted with bed mobility that was scored with a 3, that indicated extensive assistance of 2 staff. Resident #16's Bathtime skin anatomy note dated 2/2/18 stated, Bilateral buttocks Stage 1, right heel stage I. Resident #16's Gentell wound note dated 2/2/18, stated, acquired Right buttock open pressure Ulcer Stage I, measure 2.0 x 1.5 x 0.0 cm ; acquired left buttock stage I pressure ulcer measured 2.0 x 1.6 x 0.0 cm. Resident #16's Nurse Practioner progress note dated 2/2/18 stated, healed [MEDICAL CONDITION] bilateral uppper buttocks, Rt heel red, non-blanchable, mushy. Review of Resident #16's Care plan actual impairment of skin dated 2/2/18, reveled interventions that included a pressure reduction mattress and wheelchair cushion, float (resident's) bilatreal heels while in bed with heels up on apillow was initiated on 1/27/18, and the yellow dot program for repositioning was initiated on 1/20/18. Resident #16's care plan was not updated timely to include appropriate interventions according to the facility repositioning policys. Resident #17 According to Resident #17's MDS dated [DATE] Resident was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Bed mobility was scored as a 3 which indicated extensive assistance of 2 staff. Resident #18 According to Resident #18's MDS dated [DATE] Resident was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #17 was coded with a 3 for bed mobility which indicated she required extensive assistance of 2 staff for respositioning and there were no skin issues indicated on 1/14/18.

Based on interview and record review the facility failed to provide and document sufficient preparation and document a safe and orderly discharge for 2 (#2, #3) of 19 sampled residents, resulting in (1.) Resident #2 being discharged from the nursing home to an Adult Foster Care (AFC) home with no nursing assessment at 12:30 PM and admitted to the hospital at 2:14 PM the same day with elevated temperature, low blood pressure and increased respirations with increased confusion with peripheral inserted central catheter (PICC) line in the left upper extremity. (2.) Resident #3 being discharged with a peripheral inserted central catheter (PICC) line in the left upper extremity to the community with no PICC line education or follow-up medical services resulting in potential for injury or harm. Findings: Record review of facility 'Orienting Residents to Transfers and Discharges' policy dated 5/8/17 revealed that the facility shall prepare a resident for a safe transfer or discharge. Policy interpretation and implementation: (3.) an inter-departmental team (IDT) meeting is held at 72 hours to discuss the discharge orientation plan with the resident and/or representative. (4.) The purpose of the orientation is to provide the resident and representative with sufficient preparation and to ensure a safe and orderly transfer or discharge from the facility. Record review of facility 'Documentation of transfer/Discharges' policy dated 5/8/17 revealed when a resident is transferred or discharged , his or her medical records shall be documented as to the reasons why such action was taken. Policy interpretation and implementation: (1.) all documentation concerning the transferred or discharge of a resident must be recorded in the resident's medical record. (4.) Documentation from the Care Planning Team concerning all transfers or discharges must include, as a minimum, and as they may apply: (a.) the reason for the transfer or discharge. (g.) The new location of the resident. (i.) A summary of the resident's overall medical. Physical and mental condition. (l.) Services upon discharge. (m.) Education upon discharge. Record review of facility 'Discharge Summary and Plan' policy dated 5/8/17, revealed upon admission to the facility, the discharge summary and post discharge plan will be developed to assist the resident to adjust to his/her new living environment. Policy interpretation and implementation: (2.) When the facility anticipates a resident's discharge to a private residence, another nursing care facility, (i.e., skilled, intermediate care, ICF/MR, etc.) a discharge summary and a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment. (6.) A nursing representative will review medications/treatments and follow-up appointments with the resident and/or responsible party prior to discharge. Resident #2: Record review of Resident #2's initial/admission Minimum Data Set ((MDS) dated [DATE] revealed a [AGE] year old male with Brief Interview of Mental status (BIMs) score of 8 out of 15, cognitive impairment. Medical [DIAGNOSES REDACTED]. Under section G of the MDS, Resident #2 was assessed as a one person transfer, one person assist with ambulation, one person assist with dressing, supervision and set of meal for dining and one person assist with bed mobility. Record review of Resident #2's IDT progress notes dated 11/22/17 revealed that the resident had PICC line to the left upper arm for antibiotic therapy. Record review of Resident #2's discharge Minimum Data Set ((MDS) dated [DATE] revealed a [AGE] year old male with Brief Interview of Mental status (BIMs) score of 5 out of 15, severe cognitive impairment. Under section G of the MDS, Resident #2 was assessed as a two person (extensive assist) transfer, non-ambulation, two person (extensive assist) assist with dressing, one person assist with meal for dining and two person (extensive assist) assist with bed mobility. Record review of Resident #2's 'Discharge to home/community' form dated 12/19/17 revealed other than the date of discharge the form was not filled out. There was no nursing physical assessment of heart rate, blood pressure, temperature, lung sounds, psychosocial status or pain assessments noted. There was no assessment or removal of the left upper arm PICC line, no educational material on the care of the PICC line. No documentation of community services follow-up for care of the PICC line. There was no signature of the discharging nurse or responsible party. Record review of Resident #2's nursing progress note dated 12/19/17 at 12:39 PM written by Licensed Practical Nurse (LPN) G revealed 'Resident discharged to AFC (Adult Foster Care) home per order. There was no nursing physical assessment of heart rate, blood pressure, temperature, lung sounds, psychosocial status or pain assessments noted. There was no assessment or removal of the left upper arm PICC line, no educational material on the care of the PICC line. No documentation of community services follow-up for care of the PICC line. Record review of Resident #2's progress note dated 12/19/17 at 4:24 PM written by the social services staff L noted that they had spoken to the residents guarding services and instructed the facility to call the adult foster care home related to the residents ability to climb steps. The Social services staff L spoke with therapy services and documented in the progress note that the resident could do steps if he had both hands on rails on either side and was also assisted by staff. Resident discharged at 12:30 PM. Record review of Resident #2's Physical Therapy discharge summary dated 11/22/17 through 12/18/17 revealed on 11/22/17 baseline ambulation of up to 300 feet using a rolling walker with contact (touch) guard. Discharge 12/18/17 ambulation of 31-40 feet using a rolling walker. In an interview on 2/6/18 at 7:45 AM with the Director of Nursing (DON) B, reviewed with the state surveyor, Resident #2's 12/19/17 discharge to home form, progress notes and requested to see the 'Health Appraisal' form that AFC homes use. There was no Health Appraisal for found. The 12/19/17 discharge to home form, contained no nursing assessment, no blood pressure, no heart rate, no respiratory assessment/rate, and no pulse rate. The DON B described the discharge procedure as with therapy discharge at maximum potential, insurance discharges. Nursing discusses clinical side of resident (antibiotic, wounds, respiratory status and any declines. Social services speak with resident or representative and set up outside services. If any decline a nurse practioner or physician would come see resident for evaluation. DON B identified the 'Discharge to home/community' form as the discharge instructions given to the resident. The 'Discharge to home/community' form should include: Medication list, any treatments/dressings, management of PICC line, fall precautions. DON B stated that if a nursing assessment had been done and a decline was noted the legal guarding would have been updated to the resident's status prior to discharge. Record review of Resident #2's 12/19/17 Hospital emergency room record revealed that at 2:19 PM (less than two hours after nursing home discharge) ED (Emergency Department) clinical course: patient seen in ER. Patient was confused, not able to answer year or month, but alert and controlling his airway. The patient does flag [MEDICAL CONDITION], temperature 103, [MEDICAL CONDITION] and with blood pressure of around 90 systolic.[MEDICAL CONDITION] was initiated. Given IV fluids, cultures drawn and started on [MEDICATION NAME]/[MEDICATION NAME]/[MEDICATION NAME]. Chest x-ray pneumonia. Patient was sent for CT of head given his altered mental status, which did show an intracranial bleed. History of presenting illness: [AGE] year old male patient with past medical history of [REDACTED]. The patient was admitted about 1 month ago for dehydration, [DIAGNOSES REDACTED] and eventually discharged to rehab. The patient was going to be sent home from rehab today when the (assisted living) staff found him to be worse than his baseline Resident #3: Record review of Resident #3's initial/admission Minimum Data Set ((MDS) dated [DATE] revealed a [AGE] year old male with Brief Interview of Mental status (BIMs) score of 15 out of 15, cognitive intact. Medical [DIAGNOSES REDACTED]. Under section G of the MDS, Resident #3 was assessed as a one person transfer, wheelchair assist with ambulation, one person assist with dressing, supervision and set of meal for dining and one person assist with bed mobility. Record review of Resident #3's IDT progress notes dated 12/18/17 revealed that the resident had PICC line to the left upper extremity for antibiotic therapy for 6 weeks. Record review of Resident #3's 'Discharge to home/community' form dated 1/15/18 revealed the form had no medication list, PICC line care instructions or education of signs and symptoms of infection to the site. There was no nursing physical assessment of heart rate, blood pressure, temperature, lung sounds, psychosocial status or pain assessments noted. There was no assessment or removal of the left upper arm PICC line, no educational material on the care of the PICC line. The document did list a home care agency. There was no signature of the resident. No [MEDICATION NAME] sodium (antibiotic) 2 grams intravenously every 8 hours for [MEDICAL CONDITION] right lower leg until 1/27/18 was sent with the resident for continued antibiotic treatment. Record review of Resident #3's progress note dated 1/15/18 at 4:40 PM written by Social work designee staff I revealed medications, skilled therapies (including nursing) and waiver are unable to provide planned services due to lack of insurance. Social service designee spoke to administrator about these concerns In an interview on 1/30/18 at 3:40 PM with the Social work designee staff I revealed that she was notified by the business office manager on 1/10/18 during a Medicare meeting that Resident #3 had no insurance coverage and he needed to be discharged . Social work designee staff I stated that Resident #3 was non-weight baring with an [DEVICE] to the right ankle with IV antibiotics through a PICC line. Social work designee staff I revealed that on 1/11/18 she advised Resident #3 that his insurance lapsed on 1/1/18 and we needed to find him placement or his bill goes up (financial stress). Social work designee staff I revealed that on 1/12/18 discharge plan was to send Resident #3 to a hotel and set-up skilled services for therapy, nursing and infusion/IV care. Social work designee staff I revealed on 1/15/18 day of discharge for Resident #3 the pharmacy called to state that there was no insurance for medications and out of pocket cost for Resident #3. Social work designee staff I revealed that was her first notice home care services would not be covered. Resident #3 knew he was racking up a bill and said he was going to call for a ride. Social work designee staff I revealed she notified the Nursing Home Administrator (NHA) A and the corporate director AA and that they advised her to talk to the business office manager HH. Social work designee staff I revealed she called and left a voice mail message for the business office manager and that the business office manager emailed her that Resident #3 had an outstanding bill and that he needed to be discharged . Social work designee staff I revealed she called NHA A with her concerns of discharge with no medications and no nursing services. Social work designee staff I revealed the NHA stated she would touch base with her legal and supervisors and get back to the social work designee. Social work designee staff I revealed she went to speak with Resident #3 who told her his ride was coming and Social work designee staff I asked the Resident #3 to stay until the facility figures something out. The Resident #3 discharged on [DATE]. Social work designee staff I revealed that after the discharge the NHA A called back and stated that it was unsafe to discharge the resident and that he needed to stay. Record review of Resident #3's Hospital physician noted dated 1/16/18 at 9:16 PM revealed: This [AGE] year old male with history of recent hospitalization secondary to injury to his right ankle who has an [DEVICE] in place and has been on antibiotics out patiently for presumed chronic osteo[DIAGNOSES REDACTED] (Resident #3) presents to the emergency department today for evaluation. He states that he was kicked out of his rehab facility yesterday because his insurance lapsed.

Based on interview and record review, the facility failed to provide care and services according to facility policy and standards of clinical practice for 12 (#3, #5, #6, #8, #9, #11, #12, #13, #14, #15, #16, 19) of 19 sampled Residents, resulting in the potential for infection and harm or actual harm for (1.) Resident #3 being admitted with a peripheral inserted central catheter (PICC) line in the left upper extremity on 12/14/17 and discharged on [DATE] with no PICC measurements, insertion site dressing changes and no PICC cap changes performed. (2.) Residents #5, #6, #8, #9, #11, #12, #13, #14, #15 #16, #19 all being admitted to the facility with no pressure ulcers, acquiring facility acquired pressure ulcers during their stay. Findings: Record review of facility 'Intravenous Therapy-Preventing Catheter-Related Infections' revised (MONTH) 2007, noted the purpose of the procedure is to maximally reduce the risk of infection associated with indwelling intravenous catheters. Catheter site dressing regimens section noted (1.) use sterile transparent semi-permeable membrane (TSM) dressings to cover the catheter site. (3.) Replace catheter dressings as per IV policy and/or physician order. (4.) Replace gauze every 2 days and replace transparent semi-permeable membrane (TSM) dressings on short term central venous catheter sites every 3-7 days Record review of facility pharmacy services policy 'Midline Catheter Dressing Change' dated 7/1/12 provided by the Director of Nursing B, revealed to be performed by licensed nurses according to state law and facility policy. The nurse shall be competent is the safe delivery of infusion therapy within her or his scope of practice. Considerations: the catheter insertion site is a potential entry site for bacteria that may cause a catheter-related infection. A transparent dressing is the preferred dressing. Guidance: Sterile dressing change using transparent dressings is performed at least weekly, Assessment of the venous access site is performed during dressing changes, before and after administration of intermittent infusions and at least once every shift when not in use. Length of external catheter is obtained: upon admission, during dressing changes and if signs or symptoms of complications are present. Documentation in the medical record includes, but not limited to: Date and time, site assessment, length of external catheter, reason for dressing change, resident response to procedure and resident teaching. Record review of 'The (YEAR) Infusion Therapy Standards of Practice' (MONTH) (YEAR), volume 35, Number 1, Lippincott, Williams & Wilkins, pg.10-18, Standard #41: VAD Assessment, Care and Dressing Changes- ongoing care and maintenance of the VAD is critical to reducing the risk of infection. Site care, including skin antisepsis and dressing changes, is performed every 5-7 days when using a transparent semipermeable membrane dressing, every 2 days for gauze dressings, and immediately id the dressing integrity becomes damp, loosened, or visibly soiled, or if moisture, drainage, or blood is present under the dressing. Assess the catheter skin junction site and surrounding area by visual inspection, palpate through the intact dressing, and ask the patient about any discomfort including pain, paresthesia's, numbness, or tingling. The presence of redness, tenderness, swelling and/or drainage may be indications of infection, phlebitis, infiltration, or catheter-associated venous [MEDICAL CONDITION]. Resident #3: Record review of Resident #3's initial/admission Minimum Data Set ((MDS) dated [DATE] revealed a [AGE] year old male with Brief Interview of Mental status (BIMs) score of 15 out of 15, cognitive intact. Medical [DIAGNOSES REDACTED]. Record review of Resident #2's IDT progress notes dated 12/18/17 revealed that the resident had PICC line to the left upper extremity for antibiotic therapy for 6 weeks. Record review of Resident #3's paper and electronic care plans initiated on 12/14/17, page 1 through 21, revealed that there was no care plan for the peripheral inserted central catheter (PICC) line in the left upper extremity used for antibiotic therapy. No care plan for PICC dressing changes weekly or PICC line cap changes and PICC line measurements. Record review of Resident #3's Medication Administration Record [REDACTED]#3's stay at the nursing home. Medication Administration Record [REDACTED]. Record review of Resident #3's 'Discharge to home/community' form dated 1/15/18 revealed the form had no medication list, PICC line care instructions or education of signs and symptoms of infection to the site. There was no nursing physical assessment of heart rate, blood pressure, temperature, lung sounds, psychosocial status or pain assessments noted. There was no assessment or removal of the left upper arm PICC line, no educational material on the care of the PICC line. The document did list a home care agency. There was no signature of the resident. No [MEDICATION NAME] sodium (antibiotic) 2 grams intravenously every 8 hours for [MEDICAL CONDITION] right lower leg until 1/27/18 was sent with the resident for continued antibiotic treatment. According to the facility policy, Dressings, Dry/Clean No Change, with no date and no facility administration signatures revealed, The purpose of this proceduure is to provide guidelines for the application of dry, clean dressings. 1. Verify that there is a physician's order for this procedure. (Note: This may be generated from a facility protocol.). 2. Review the resident's care plan, current orders, and [DIAGNOSES REDACTED]. 3. Check the treatent record . On 1/31/18 during a review of the facility's past non-compliance it was noted there was information noted for audits related to treatments of pressure ulcers. On 2/6/18 at 2:00 PM, Director of Nursing B stated, agreed there were no audits for the pressure ulcer treatments we were not looking at the TAR's (treatment records) and did not realize they were not being completed. Resident #5 Resident #5 was an [AGE] year-old female, who was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #5 required assistance with all activities of daily living. Resident #5 was coded a 3 for bed mobility which indicated she required extensive assistance of 2 staff for repositioning and turning. According to Resident #5's Minimum Data Set ((MDS) dated [DATE], identified the resident was not admitted with a pressure ulcer. On 1/30/18 at 2:45 PM, Licensed Practical Nurse G stated, on 12/21/17 was informed by a CNA (Certified Nurse Aide) that resident #5 had open areas following a shower, observed Resident #5's wounds and described them as one on her bottom and suspected deep on right or left heel. One on buttock that was 4 cm x 2.5 cm toward the left cheek of her buttock on the outside, left lateral. LPN G stated, I could not stage it as it had a necrotic spot in it. LPN G stated, had obtained an order from the physician. Wrote it that night on scrape piece of paper and it got misplaced, and then stated, it (the physician order) was written 9 days later. LPN G stated she had worked during 12/21/17 and 1/8/18 and had not completed the treatment for [REDACTED]. Resident #5's Incident Report dated 12/21/17 revealed Left heel SDTI 4 cm x 2.5 cm, L inner (lateral [DIAGNOSES REDACTED] Great toe 1.5. cm x 2.6 cm, Coccyx open area 2.1 cm x 3 cm with maceration noted. Review of Resident #5's Treatment Record dated 12/22/17, revealed coccyx 2.3 cm x 3 cm open area with maceration noted peri wound, left heel 4 cm x 2.5 cm SDTI with maceration noted, left toe(s) Left lateral great toe- [DIAGNOSES REDACTED] noted 1.5 cm x 2.6 cm. Review of Resident #5's Physician orders dated 12/29/18 revealed,1) cleanse the wound daily with wound cleanser, apply Honey gauze as directed, to coccyx, cover with Low-profile bordered foam dressing and change daily. 2) cleanse left heel with wound cleanse, pat dry. apply skin prep every day and evening shift was ordered. Review of Resident #5's Treatment record revealed for (MONTH) (YEAR) the treatment record documentation started on 12/28/17 for the coccyx area and there were no treatments documented on the heel wound for the afternoon shift on 12/30/17 and day shift on 12/31/17. There were no descriptions of the wound documented according to the treatment record. According to the (MONTH) (YEAR) Treatment Record the coccyx wound was not documented as treated on 1/4/18 day shift and 1/7/18 afternoon shift and there was no documentation of description of wound on the treatment record. The heel wound was not documented as treated on 1/3/18 day or afternoon shift, 1/4/18, 1/5/18 afternoon shift and 1/7/18 day and afternoon shift. And there was no documentation or description of the wound on the treatment record. Review of Resident #5's Care Plan (Resident) is at risk for ulcer development ., with interventions that were initiated on 10/8/17 that included Float heels when in bed, Instruct /assist to shift weight in w/c q (every) 60 minutes and Educate (resident) and or /family/caregivers as to causes of skin breakdown; importance of pressure taking care during ambulating/mobility, good nutrition and frequent repositioning initiated on 10/8/18 and revised on 12/18/17. Review of Resident #5's Care Plan (Resident) has actual impairment to skin integrity to the coccyx related to bowel and bladder - left heel SDTI (suspected deep tissue injury), left inner lateral [DIAGNOSES REDACTED] great toe, coccyx open area with maceration noted. initiated 10/8/17 with interventions that included consult wound clinic dated 1/4/18 other interventions were dated 10/8/17 that included float heels when in bed, keep skin clean and dry and use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface. On 1/31/18 at 4:50 PM, Unit Manager C reported had reviewed the treatment records and dates treatments were not completed and assessed Resident #5 had assessed her on 1/4/18 and it had gotten worse called and scheduled her for an appointment for the wound clinic which was for 1/8/18 which was the quickest I could get her in the wound clinic. On 1/31/18 at 1:00 PM, Nurse Practitioner N stated, she did not recall providing an order for [REDACTED].#5 was going to the wound clinic and had not recalled seeing the wounds, had documented on the wound 1/5/18 but had not visualized the wound. NP N stated had triggered us yesterday to take it more seriously and learned how to access the skin assessments as they were available in a different program in the computer. On 1/31/18 at 1:45 PM, Physician M stated, I was on vacation and was not informed of the wounds. Physician M stated, skin assessments are available in the computer electronic records, PCC progress notes -S[NAME] skin. View all, go to Custom. The Doctor was not aware of the Genteel program being used to track skin assessments. Physician M stated, I Do not give orders over the phone. She probably called the NP. According to Resident #5's discharge MDS dated [DATE] section M. identified one un-stag able Pressure Ulcer and one 3 or 4 eschar deep tissue injury with measurements documented of 5.8 cm x 4.0 cm. According to Resident #5's Hospital history and physical examination [REDACTED]. Resident #6 Resident #6 was a [AGE] year old admitted to the facility on [DATE], MDS dated [DATE] with [DIAGNOSES REDACTED]. Resident #6 was coded as a 3 for bed mobility which indicated she required extensive assistance of 2 staff for repositioning and turning. According to Resident #6's Nurse progress note assessment note dated 1/5/18 the pressure ulcer that had healed and according to Resident #6's Gentell's skin note had re-opened on 2/2/18 on the sacral at a Stage II at a 2.0 x 0.5 x .0 cm area. According to Resident #6's Care plan Is at risk for pressure ulcer development initiated on 10/8/17 and revised on 1/19/18 with interventions to shift weight while sitting in wheel chair every 30-60 minutes, turn and reposition every 2 hours and use pillows to assist with reposition placement, encourage not to lay on her back and yellow dot program initiated on 1/20/18. Review of Resident #6's (MONTH) (YEAR) TAR (Treatment Administration Record) indicated [MEDICATION NAME] was not documented as prescribed on 11/22/17 to the coccyx. Review of Resident #6's (MONTH) (YEAR) TAR revealed [MEDICATION NAME] cream was not documented as prescribed on 12/16/17 and 12/29/17 and 1/1/18. Review of Resident #6's (MONTH) (YEAR) TAR revealed skin prep to was not documented as completed PM 1/5, 1/16, 1/17 0 1/30/18 Review or Resident #6's (MONTH) (YEAR) TAR revealed Dermaseptin to Bilateral thighs/buttocks and coccyx was not documented as completed on 2/2/18. Resident #8 According to MDS dated [DATE], Resident #8 was an [AGE] year old female admitted on [DATE], with [DIAGNOSES REDACTED]. MDS dated [DATE] identified a stage II pressure ulcer. On 1/30/18 upon entry to the facility a list Residents with facility acquired pressure ulcers was provided with the stage of each ulcer. Resident #8 was listed to have a pressure ulcer that developed on on 1/18/18. Record review of Resident #8's (MONTH) (YEAR) treatment records noted on 1/20/18, 1/23/18, 1/25/18 and 1/30/18 revealed there was no documentation for treatments signed out by nursing staff. Resident #9 According to Resident #9's significant change MDS dated [DATE], resident was a [AGE] year old male admitted [DIAGNOSES REDACTED]. According to Resident #9's Gentell/Skin assessments dated 12/26/17 who developed a stage II pressure area to right buttocks. Review of Resident #9's Care Plan actual impairment to skin of the right buttocks related to incontinence bladder and bowel (c-dif), dated 12/20/17 revised 1/9/18, revealed interventions of air mattress in place initiated 1/9/18, encourage resident not to lay on his back, initiate yellow dot program and check and change (resident) every two hours, if incontinent wash, dry and apply thin layer of barrier cream dated 12/20/17. Record review of Resident #9's (MONTH) (YEAR) treatment record noted for the dates 1/2/18, 1/11/18, 1/16/18, 1/18/18, 1/23/18 and 1/26/18 there were no treatments signed out by nursing staff. Resident #11 According to Resident #11 quarterly MDS dated [DATE] resident was a [AGE] year old female admitted on [DATE], with [DIAGNOSES REDACTED]. According to Resident #11's Skin assessment dated [DATE] Left heel 1.5 x 2.6 SDTI brown discoloration tender w touch. According to Resident #11's Care Plan (Resident) has developed actual impairment of the skin on her left heel SDTI related to immobility due to cerebral infarct, [MEDICAL CONDITION] cell date initiated 12/20/17 revised 1/25/18 with interventions that included, Encourage good nutrition and hydration in order to promote healthier skin, initiate yellow dot program (1/20/18), encourage (resident) to float bilateral heels while she is in bed. The following interventions were not initiated until 1/25/18 included, Monitor/document location, size and treatment of [REDACTED]. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue andexudate and any other notable changes or observations. Observation on 2/1/18 at 11:55 AM of Resident #11's left lateral heel revealed there was no dressing in place and that Registered Nurse (RN) D could not give a reason as to why the pressure area occurred. On 2/6/18 at 11:10 AM, a plain yellow dot was observed on Resident #11's door indicating Resident #11 was to be repositioned every 2 hours per the facility policy. Resident #12 According to Resident #12's MDS dated [DATE] resident was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. bed mobility was scored as limited assist with one staff, According to Resident #12 developed three open areas to the sacrum area noted on 1/28/18. Record review of Resident #12's (MONTH) (YEAR) treatment record noted on 1/30/18 and 1/31/18 that there were no treatments signed out by nursing staff. Record review of Resident #12's (MONTH) (YEAR) treatment records noted on 1/30/18 and 1/31/18 revealed there was no treatments signed out as completed for coccyx wound treatments by nursing staff. Review of Resident #12's (MONTH) (YEAR) treatment records noted on 1/10/18, 1/18/18, 1/15/18, 1/18/18, 1/26/18, 1/27/18, and 1/30/18 revealed there was no documentation for treatments for BLE incision dressing changes signed out as completed by nursing staff. Resident #13 Resident #13 was an [AGE] year old female admitted on [DATE], with an MDS dated [DATE] with [DIAGNOSES REDACTED]. Resident #13's bed mobility was scored as a 2 which indicated required limited assist with 1 staff, transfer was 3 which indicated extensive assistance of 2 staff. Review of Resident #13 Gentell skin assessment dated [DATE] revealed a stage II pressure ulcer to the right buttocks on 1/18/18. Record review of Resident #13's (MONTH) treatment record revealed that on 1/13/18, 1/20/18, 1/26/18, 1/27/18 and 1/31/18 that there were no treatments signed out as completed by the nursing staff. Review of Resident #13's Care Plan has developed a stage II pressure ulcer to her right buttock initiated 1/10/18, revealed interventions of initiate yellow dot program. Evaluate/record, monitor wound healing weekly .were not initiated until 1/28/18. Resident #14 Resident #14 was a [AGE] year old male admitted on [DATE], with an MDS dated [DATE] with [DIAGNOSES REDACTED]. MDS indicated no skin issues and coded a 3 for bed mobility which indicated she required extensive assistance of 2 staff for repositioning and turning. MDS dated [DATE] indicated resident had a Stage III pressure ulcers and was documented 2.0 cm x 1.0 x 0.4 with granulation tissue. On 1/30/18 upon entry to the facility a list Residents with facility acquired pressure ulcers was provided with the stage of each ulcer. Resident #14 was listed to have a pressure ulcer that developed on 11/22/18. Review of Resident #14's physician progress notes [REDACTED]. Review of Resident #14's Norton Plus Pressure Ulcer Scale dated 11/15/17 indicated resident risk had improved. The next Norton Plus Pressure Ulcer Scale was dated on 1/19/18 and indicated a decline. According to Resident #14's Care Plan Resident is at risk for pressure ulcers, initiated on 1/24/17, revised on 12/21/17 and on 1/18/18, revealed an intervention avoid positioning the resident on bony prominence's; Encourage resident to reposition Q 2 hours and PRN; Encourage resident to stay off of right side. If resident refuses, reeducate to risks of not preposition. initiated on 1/20/18 (required assist of 2 per MDS. Intervention to Monitor/document report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection , wound size (length x width, depth) , stage. canceled on 12/21/17 air mattress - Resolved. 1/20/18 According to Resident #14's Skin assessment dated [DATE], revealed an abnormal skin area was identified and measured 2.6 x 1.0 x UTD pressure area to Right calf no drainage no s/s of infection no pain. According to Resident #14 skin assessments documented on Gentell skin wound notes, Resident #14 developed a stage III pressure ulcer to right lower rear leg. Record review of Resident #14's Genteel skin/wound measurements dated 11/29/17 through 1/26/18 wound measurements were not completed weekly. Measurements were completed on 11/22/17, 11/29/17 12/6/17, no observation for 2 weeks until 12/22/17, 12/29/17, 1/9/18, no observation for 2 weeks until 1/26/17, and 2/2/18 Review of Facility Certified Nurse Aide documentation from 11/20/17 through 11/26/17 revealed no documentation of Resident #14 having any new skin condition. Review of Resident #14's Treatment Records (TAR) dated (MONTH) (YEAR) revealed there was no treatments signed out as completed for honey alginate as prescribed on 12/11, 12/19 and 12/19/17 by nursing staff. Review of Resident #14's Treatment Records (TAR) dated (MONTH) (YEAR) revealed there was no treatments for honey alginate as prescribed on 1/2, 1/23, and 1/26/18 by nursing staff. On 2/5/18 at 10:30 AM, Director of Nursing B provided second resident pressure ulcer list that showed Resident #14 had a Stage II pressure ulcer. DON B was asked to verify the stage of the pressure ulcer and was asked if pressure ulcers were back staged and responded, we do not back stage pressure ulcers. DON B reviewed the weekly Gentell wound documentation for Resident #14 and agreed the wound notes were not completed weekly. On 2/6/18 at 4:55 PM, DON B verified Resident #14 had a Stage III pressure ulcer, and resident's pressure had developed on 11/22/17 according to the documentation reviewed, DON B reported all the Pressure ulcers had been observed on 2/2/18 but had not looked at that one herself. On 2/6/18 at 11/20/18 there was a noted yellow dot on Resident #14's door to his room the dot was blank which indicated he was to be turned and repositioned every 2 hours per the facility policy. Resident #15 According to Resident #15's MDS dated [DATE] resident was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/6/18 at 11:30 AM, Resident reported it would be much easier for him to reposition if he had a side rail or repositioning bar on his bed and reported he had a trapeze on his previous bed. It would be much easier if I could help the staff when they are trying to move me around. Resident stated, My wife has asked for me to have one and they have said I can not have a side rail. On 2/6/18 at 11:30 AM, CNA KK agreed Resident 15 would be able to assist more if he had something to grab and assist when repositioning him. On 2/6/18 at 1:20 PM, DON B was asked if Resident #15 had been assessed for a repositioning bar or trapeze and stated, HI rolled him over when I assessed him to look at his skin and he was able to move pretty good for me yesterday, I will have to look in to that with therapy. Review of Resident #16's Treatment Record (TAR) dated (MONTH) (YEAR) there was no treatments signed out as completed for the coccyx for [MEDICATION NAME] Cream on 12/1/17, 12/6/17 and 12/16/17 as prescribed . Review of Resident #16's Treatment Record (TAR) dated (MONTH) (YEAR) there were no treatments signed out as completed for the coccyx wound on day shift for 1/20/18, 1/29/18 and 1/30/18 and no treatments were signed out as completed on afternoons for 1/21/18, 1/21/18, 1/22/18 and 1/30/18 for [MEDICATION NAME] Cream as prescribed by the physician on 1/19/18. Review of Resident #16's Treatment Record (TAR) dated (MONTH) (YEAR) there were no treatments signed out as completed for bilateral buttocks for Dermseptin on the day shift on 2/1/18 and 2/2/18 and the afternoon shift on 2/2/18 as prescribed according to the physician order dated 1/18/18 . According Resident #15's Care plan Resident has an actual impairment for skin impairment of the coccyx, He also has actual impairments to bilateral buttocks r/t shearing dated 11/4/17 revised 1/19/18 with interventions that were not updated until for the following until 1/20/18 that included the following Avoid positioning the resident on back, Initiate yellow dot, The resident requires pressure relieving/reducing device on bed. Resident # 16 Resident #16 was a [AGE] year old female admitted on [DATE], with an MDS dated [DATE] with no skin issues noted with bed mobility that was scored with a 3, that indicated extensive assistance of 2 staff. Review of Resident #16's Care plan actual impairment of skin dated 2/2/18, reveled interventions that included a pressure reduction mattress and wheelchair cushion, float (resident's) bilateral heels while in bed with heels up on pillow was initiated on 1/27/18, and the yellow dot program for repositioning was initiated on 1/20/18. Resident #16's Nurse Practitioner progress note dated 2/2/18 stated, healed [MEDICAL CONDITION] bilateral upper buttocks, Rt heel red, non-blanchable, mushy. Resident #16's Bathtime skin anatomy note dated 2/2/18 stated, Bilateral buttocks Stage 1, right heel stage I. Resident #16's Gentell wound note dated 2/2/18, stated, acquired Right buttock open pressure Ulcer Stage I, measure 2.0 x 1.5 x 0.0 cm; acquired left buttock stage I pressure ulcer measured 2.0 x 1.6 x 0.0 cm. Review of Resident #16's Treatment records reveal there is no documentation of the bilateral buttocks pressure ulcer for signs and symptoms of drainage, infection, pain, odor, skin color, necrotic on 2/2/18 and there is no record of any physician order for [REDACTED]. Resident #19 According to Resident #19's MDS dated [DATE] resident was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #19 was coded a 3 for mobility which indicated required extensive assistance of 2 staff and was admitted with no skin issues. According to Resident #19's physician orders dated 1/31/18, stated, right buttocks: wash pat dry and apply fungal cream QS /PRN may be left at bedside. According to Resident #19's Gentell note dated 2/2/18 revealed RT buttock acquired Stage I Pressure Ulcer/ fungal 1.5 x 1.0 . 0.0 cm.

Based on interview and record review, the facility failed to provide care and services according to facility policy and standards of clinical practice for 1 (#3) of 19 sampled Residents, resulting in the potential for infection and harm or actual harm for (1.) Resident #3 being admitted with a peripheral inserted central catheter (PICC) line in the left upper extremity on 12/14/17 and discharged on [DATE] with no PICC measurements, insertion site dressing changes and no PICC cap changes performed or documented. Findings: Record review of facility 'Intravenous Therapy-Preventing Catheter-Related Infections' revised (MONTH) 2007, noted the purpose of the procedure is to maximally reduce the risk of infection associated with indwelling intravenous catheters. Catheter site dressing regimens section noted (1.) use sterile transparent semi-permeable membrane (TSM) dressings to cover the catheter site. (3.) Replace catheter dressings as per IV policy and/or physician order. (4.) Replace gauze every 2 days and replace transparent semi-permeable membrane (TSM) dressings on short term central venous catheter sites every 3-7 days Record review of facility pharmacy services policy 'Midline Catheter Dressing Change' dated 7/1/12 provided by the Director of Nursing B, revealed to be performed by licensed nurses according to state law and facility policy. The nurse shall be competent is the safe delivery of infusion therapy within her or his scope of practice. Considerations: the catheter insertion site is a potential entry site for bacteria that may cause a catheter-related infection. A transparent dressing is the preferred dressing. Guidance: Sterile dressing change using transparent dressings is performed at least weekly, Assessment of the venous access site is performed during dressing changes, before and after administration of intermittent infusions and at least once every shift when not in use. Length of external catheter is obtained: upon admission, during dressing changes and if signs or symptoms of complications are present. Documentation in the medical record includes, but not limited to: Date and time, site assessment, length of external catheter, reason for dressing change, resident response to procedure and resident teaching. Record review of 'The (YEAR) Infusion Therapy Standards of Practice' (MONTH) (YEAR), volume 35, Number 1, Lippincott, Williams & Wilkins, pg.10-18, Standard #41: VAD Assessment, Care and Dressing Changes- ongoing care and maintenance of the VAD is critical to reducing the risk of infection. Site care, including skin antisepsis and dressing changes, is performed every 5-7 days when using a transparent semipermeable membrane dressing, every 2 days for gauze dressings, and immediately id the dressing integrity becomes damp, loosened, or visibly soiled, or if moisture, drainage, or blood is present under the dressing. Assess the catheter skin junction site and surrounding area by visual inspection, palpate through the intact dressing, and ask the patient about any discomfort including pain, paresthesia's, numbness, or tingling. The presence of redness, tenderness, swelling and/or drainage may be indications of infection, phlebitis, infiltration, or catheter-associated venous [MEDICAL CONDITION]. Record review of facility 'Physician Services' policy dated 10/7/2010, revealed that the medical care of each resident is under the supervision of a licensed physician. Resident #3: Record review of Resident #3's initial/admission Minimum Data Set ((MDS) dated [DATE] revealed a [AGE] year old male with Brief Interview of Mental status (BIMs) score of 15 out of 15, cognitive intact. Medical [DIAGNOSES REDACTED]. Record review of Resident #2's IDT progress notes dated 12/18/17 revealed that the resident had PICC line to the left upper extremity for antibiotic therapy for 6 weeks. Record review of Resident #3's physician orders [REDACTED]. Record review of Resident #3's Medication Administration Record [REDACTED]#3's stay at the nursing home. Medication Administration Record [REDACTED]. Record review of Resident #3's paper and electronic care plans initiated on 12/14/17, page 1 through 21, revealed that there was no care plan for the peripheral inserted central catheter (PICC) line in the left upper extremity used for antibiotic therapy. No care plan for PICC dressing changes weekly or PICC line cap changes and PICC line measurements. Record review of Resident #3's 'Discharge to home/community' form dated 1/15/18 revealed the form had no medication list, PICC line care instructions or education of signs and symptoms of infection to the site. There was no nursing physical assessment of heart rate, blood pressure, temperature, lung sounds, psychosocial status or pain assessments noted. There was no assessment or removal of the left upper arm PICC line, no educational material on the care of the PICC line. The document did list a home care agency. There was no signature of the resident. No [MEDICATION NAME] sodium (antibiotic) 2 grams intravenously every 8 hours for [MEDICAL CONDITION] right lower leg until 1/27/18 was sent with the resident for continued antibiotic treatment.

Based on interview and record review the facility failed to provide quality of care for 1 (#2) of 19 sampled residents, resulting in Resident #2 being discharged from the nursing home to an Adult Foster Care (AFC) home with no nursing assessment at 12:30 PM and admitted to the hospital at 2:14 PM the same day with elevated temperature, low blood pressure and increased respirations with increased confusion resulting in potential for injury or harm or actual harm. Findings: Record review of facility 'Admission Assessment and Follow Up: Role of the Nurse' policy dated 11/2013, provided by the Director of Nursing B as the only nursing assessment policy the facility used, revealed that the purpose of this procedure is to gather information about the resident's physical, emotional, cognitive and psychosocial condition within the first shift of admission and not to exceed 72 hours after admission for the purpose of managing the resident, initiating the care plan, and completing required assessment instruments. Note: For facilities utilizing a computerized assessment product, the assessments will be completed in electronic format. Ancillary assessments not included within the electronic format will continue to be completed in the paper format. Record review of facility 'Documentation of transfer/Discharges' policy dated 5/8/17 revealed when a resident is transferred or discharged , his or her medical records shall be documented as to the reasons why such action was taken. Policy interpretation and implementation: (1.) all documentation concerning the transferred or discharge of a resident must be recorded in the resident's medical record. (4.) Documentation from the Care Planning Team concerning all transfers or discharges must include, as a minimum, and as they may apply: (a.) the reason for the transfer or discharge. (g.) The new location of the resident. (i.) A summary of the resident's overall medical. Physical and mental condition. (l.) Services upon discharge. (m.) Education upon discharge. Record review of the 'Physician Responsibilities for Safe Patient Discharge from Health Care Facilities' 2012 American Medical Association. Report of Council on Ethical and Judicial Affairs, CEJA Report 5-A-12, pg. 2, Confirm the patient's clinical readiness for discharge: according to the standard practice and consistent with his/her expertise, the physician should carefully assess the patient and confirm that the individual is medically stable enough to leave the (healthcare) setting and to travel distances before authorizing a discharge. Resident #2: Record review of Resident #2's initial/admission Minimum Data Set ((MDS) dated [DATE] revealed a [AGE] year old male with Brief Interview of Mental status (BIMs) score of 8 out of 15, cognitive impairment. Medical [DIAGNOSES REDACTED]. Under section G of the MDS, Resident #2 was assessed as a one person transfer, one person assist with ambulation, one person assist with dressing, supervision and set of meal for dining and one person assist with bed mobility. Record review of Resident #2's IDT progress notes dated 11/22/17 revealed that the resident had PICC line to the left upper arm for antibiotic therapy. Record review of Resident #2's discharge Minimum Data Set ((MDS) dated [DATE] revealed a [AGE] year old male with Brief Interview of Mental status (BIMs) score of 5 out of 15, severe cognitive impairment. Under section G of the MDS, Resident #2 was assessed as a two person (extensive assist) transfer, non-ambulation, two person (extensive assist) assist with dressing, one person assist with meal for dining and two person (extensive assist) assist with bed mobility. Record review of Resident #2's 'Discharge to home/community' form dated 12/19/17 revealed other than the date of discharge the form was not filled out. There was no nursing physical assessment of heart rate, blood pressure, temperature, lung sounds, psychosocial status or pain assessments noted. There was no assessment or removal of the left upper arm PICC line, no educational material on the care of the PICC line. No documentation of community services follow-up for care of the PICC line. There was no signature of the discharging nurse or responsible party. Record review of Resident #2's nursing progress note dated 12/19/17 at 12:39 PM written by Licensed Practical Nurse (LPN) G revealed 'Resident discharged to AFC (Adult Foster Care) home per order. There was no nursing physical assessment of heart rate, blood pressure, temperature, lung sounds, psychosocial status or pain assessments noted. There was no assessment or removal of the left upper arm PICC line, no educational material on the care of the PICC line. No documentation of community services follow-up for care of the PICC line. Record review of Resident #2's progress note dated 12/19/17 at 4:24 PM written by the social services staff L noted that they had spoken to the residents guarding services and instructed the facility to call the adult foster care home related to the residents ability to climb steps. The Social services staff L spoke with therapy services and documented in the progress note that the resident could do steps if he had both hands on rails on either side and was also assisted by staff. Resident discharged at 12:30 PM. Record review of Resident #2's Physical Therapy discharge summary dated 11/22/17 through 12/18/17 revealed on 11/22/17 baseline ambulation of up to 300 feet using a rolling walker with contact (touch) guard. Discharge 12/18/17 ambulation of 31-40 feet using a rolling walker. Record review of physician progress notes [REDACTED].>In an interview on 2/6/18 at 7:45 AM with the Director of Nursing (DON) B, reviewed with the state surveyor, Resident #2's 12/19/17 discharge to home form, progress notes and requested to see the 'Health Appraisal' form that AFC homes use. There was no Health Appraisal for found. The 12/19/17 discharge to home form, contained no nursing assessment, no blood pressure, no heart rate, no respiratory assessment/rate, and no pulse rate. The DON B described the discharge procedure as with therapy discharge at maximum potential, insurance discharges. Nursing discusses clinical side of resident (antibiotic, wounds, respiratory status and any declines. Social services speak with resident or representative and set up outside services. If any decline a nurse Practioner or physician would come see resident for evaluation. DON B identified the 'Discharge to home/community' form as the discharge instructions given to the resident. The 'Discharge to home/community' form should include: Medication list, any treatments/dressings, management of PICC line, fall precautions. DON B stated that if a nursing assessment had been done and a decline was noted the legal guarding would have been updated to the resident's status prior to discharge. Record review of Resident #2's 12/19/17 Hospital emergency room record revealed that at 2:19 PM (less than two hours after nursing home discharge) ED (Emergency Department) clinical course: patient seen in ER. Patient was confused, not able to answer year or month, but alert and controlling his airway. The patient does flag [MEDICAL CONDITION], temperature 103, [MEDICAL CONDITION] and with blood pressure of around 90 systolic.[MEDICAL CONDITION] was initiated. Given IV fluids, cultures drawn and started on [MEDICATION NAME]/[MEDICATION NAME]/[MEDICATION NAME]. Chest x-ray pneumonia. Patient was sent for CT of head given his altered mental status, which did show an intracranial bleed. History of presenting illness: [AGE] year old male patient with past medical history of [REDACTED]. The patient was admitted about 1 month ago for dehydration, [DIAGNOSES REDACTED] and eventually discharged to rehab. The patient was going to be sent home from rehab today when the (assisted living) staff found him to be worse than his baseline

Based on observation, interview, and record review, the facility failed to prevent the development of a stage IV pressure ulcer for one resident (#7) and failed to follow standards of professional care during treatment of [REDACTED].#3) out of four residents reviewed for pressure ulcers in a total sample of 15 residents resulting in the development of a stage IV pressure ulcer and the potential for contamination and resultant infection of a wound. Findings include: According to the Admission Record, dated 10/12/2015, Resident #7 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An interdisciplinary team progress note, dated 4/15/2015 revealed Resident #7 had been a passenger in a transport rig when the vehicle braked abruptly and she slid forward in her wheelchair and bumped her knee. According to the note, Resident #7 had been taken to the emergency room where x-rays were taken and reported to be negative. According to the note, the facility had received a follow-up call from the hospital and Resident #7 was taken back to the emergency room because of a fracture in the leg and an immobilizer had been applied to the right leg. During an interview on 10/22/2015 beginning at 9:00 am with the Rehab Director Staff O and the Physical Therapist (PT) Staff P, PT Staff P stated that Resident #7 had been treated by the therapy team from 4/19/2015 through 5/1/2015 to train the staff how to put on and remove an immobilizer for Resident #7's right leg. PT staff P stated that the staff was given one on one inservices so they could apply and remove the immobilizer each shift for personal care and to inspect Resident #7's skin. On 10/20/2015 at 3:15 pm, all documentation regarding pressure ulcers for Resident #7 was requested from Medical Records Staff K. A nursing progress note, dated 4/25/2015 identified a red area on the back of Resident #7's right lower leg. The progress note reported that a folded 4 by 4 was placed on the area which was under the leg immobilizer. A nursing progress note dated 5/28/2015 reported that the back of Resident #7's right lower leg was bleeding. A treatment order was initiated on that date for a dressing that was to be changed twice a day. According to the Skin Grid - Pressure/[MEDICAL CONDITION] Ulcer/Other form, that was to be completed weekly, the form that began with the date 8/11/2015 revealed that the initial identification of the pressure wound on the right achilles area was on 5/29/2015. The right achilles pressure wound was initially staged as a 3. According to the National Pressure Ulcer Advisory Panel (NPUAP) stages/classifications web resource page (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/) accessed 10/23/2015, a stage 3 pressure ulcer involves full thickness skin loss that does not expose bone, muscle, or tendon. On 8/11/2015 the documentation on the skin grid reflected a healing stage IV wound on the right achilles area. The NPUAP defines a stage IV (4) pressure ulcer as one that has loss of the full thickness of the skin with exposed bone, muscle, or tendon. During the initial tour of the facility on 10/20/2015 that began at 9:00 am with the Director of Nursing (DON), Staff B, Resident #7 had been identified by the DON as having a stage IV pressure ulcer on her right lower leg that had developed in the facility because of a brace she wore on her leg. A review of Resident #7's care plan, as confirmed by the Registered Nurse (RN) unit manager Staff N on 10/21/2015 at 3:15 pm, revealed no interventions related to the wearing of the immobilizer for her right leg and no interventions for the nursing assistants to follow on the care guide. The care plan for skin integrity Assessment: Prevention and Treatment in the medical record, dated 8/14/2015 did not identify the presence of an immobilizer on Resident #7's right leg or any interventions to prevent further pressure on her leg. According to the physician's orders [REDACTED].#7 was to have an immobilizer on her right lower leg. During an interview on 10/22/2015 beginning at 9:00 am with the Rehab Director Staff O, he stated that he had never received a referral for the therapy department to check the fit of the immobilizer on Resident #7 since her therapy services were completed on 5/1/2015 or since the development of the pressure ulcer on the right leg. ( ) According to the Admission Record, dated 10-22-15, Resident #3 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During observation of wound care for Resident #3 on 10-20-15 at 1:35pm, Registered Nurse (RN) D was changing the dressing of a coccyx pressure ulcer with assistance from Certified Nursing Assistant (CNA) E. RN D put gloves on and turned Resident #3 on her side and opened the incontinent brief. A small amount of feces was noted on the Resident #3's buttock at that time. RN D continued with the dressing change by removing the old dressing, flushing with saline, drying the wound, packing with calcium alginate, tucking a new brief on top of the soiled brief, and placing an ABD (absorbant padded dressing) over the wound, which then fell twice before the brief was secured to hold the ABD in place. Resident #3 was then turned on to her back and CNA E provided peri care and noticed a small amount of bowel movement on the wipes. Resident #3 was then turned back on her side, the brief was opened, the ABD fell again, RN D cleaned the feces off, wiping toward the open pressure ulcer wound. The ABD was then place over the wound again and the brief was secured. On 10-22-15 at 11:40 am, Licensed Practical Nurse (LPN) H was informed of the technique utilized during the pressure ulcer dressing change and peri care. LPN H stated, they did it backwards. They should have cleaned the bowel movement first to prevent contamination to the wound.

This citation pertains to intake number MI 467. Based on interviews and record review, the facility failed to prevent falls in 1 of 4 residents (Resident #101) sampled for fall risk issues, from a total of 4 residents reviewed, resulting in Resident #101 sustaining a right medial malleolar fracture (broken bone of the ankle) and pain. Findings include: The facesheet revealed Resident #101 was an [AGE] year old woman who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the admission Minimum Data Sets ((MDS) dated [DATE], Resident #101 was cognitively intact, experienced no memory issues, could make her needs known, and required extensive assistance from a staff member with activities of daily living (ADL's), including transfers (movements from surface to surface). Review of the Fall Care Plan initiated 1/20/2015, revealed Resident #101 was specified to receive assistance of a staff member, use of a gait belt and a walker during transfers. According to the Care Delivery Guide (undated), Resident #101 was specified to receive assistance of a staff member, use of a gait belt and a walker during transfers. Review of the Resident Lifting, Transferring, and Repositioning Data Collection form dated 1/20/2015 (untimed), Resident #101 was specified to receive assistance of a staff member, use of a gait belt and a walker during transfers. The Transfer From Bed to Wheelchair policy/procedure (revised April 4, 2014, and presented to the State Surveyor on 3/17/2015 at 8:20 AM as the facility's current policy/procedure) included use of a gait belt with transfers to provide a more secure process for lifting, transferring, or repositioning the patient. According to the Facility Investigation summary dated 2/26/2015 at 7:12 AM, Resident #101 was in process of a transfer from her wheelchair to her bed, assisted by Certified Nurse Aide (CNA) A without use of a gait belt or walker, when she fell to the floor, with her right foot positioned beneath her. CNA A and CNA B were documented as returning Resident #101 to her bed. Resident #101 was reported to have complained to CNA A of right ankle pain, for which she received administration of pain medication. During an interview on 3/16/2015 at 9:50 AM, Resident #101 said, I had a fall on 2/25/2015 at 10:00 PM. I was in my wheelchair. She (CNA A) didn't use a harness, a belt. They're supposed to use a belt; I didn't refuse it. I was going from my wheelchair to my bed. I went up out of the chair. She (CNA A) sat me down, hard, on the edge of the bed. I wasn't fully on the bed and I slid off. She let me go. I landed on my right foot. She tried to hang onto me, but she dumped me. I was in so much pain. She came back with another aide (CNA B) and they picked me up and put me in bed. They didn't report it. About 1:00 AM, a nurse (RN C) came in here to give me my medication. I told her I'd fallen; she didn't know a thing about it. During an interview on 3/16/2015 at 2:50 PM, CNA A said, I hadn't read her (Resident #101) Care Delivery Guide; I didn't realize that she needed the use of a walker to transfer, and CNA's at this facility are expected to use gait belts to transfer residents. I didn't put a gait belt on her. I didn't use a walker. I had a gait belt; it was in my pocket. I held my hands out; she grabbed on tightly then stood up. Her foot slipped as she pivoted to get on her bed. I tried to get her to go back to her wheelchair. I tried to steer her back as her left foot was sliding forward. She came down on the edge of the bed and went down on the floor. I don't think holding onto her hands was the best thing to do at that time; I don't think it was safe. I didn't report her fall to the nurse. The Resident told me she had pain. I didn't report the Resident's pain to a nurse at that time; I don't know why. I didn't tell the nurse she had a fall just that the Resident had a hard time getting back into bed and had muscle pain. During an interview on 3/17/2015 at 7:15 AM, Registered Nurse (RN) C said, CNA A and CNA B didn't tell me the Resident (#101) had fallen. About 11:50 PM on 2/25/2015, the Resident used her call light; she wanted to use the bathroom. I moved her blankets. She told me she didn't want to be dropped like she was before; she said her foot slid and she had fallen, earlier. She complained about her right ankle and right shoulder. I gave her scheduled Ultram (pain medication) for her midnight dose. About 3:45 AM she complained of more pain of her right ankle and right shoulder; I gave her 2 Tylenol, assessed her and found her right ankle was swollen. I called her doctor; he ordered x-rays. Before she left her shift at 10:30 PM, her assigned CNA (CNA A), she hadn't told me anything about the Resident's fall. CNA's are supposed to notify nurses about residents' falls. Residents are supposed to remain on the floor after a fall until they're assessed by a nurse. I thought it was strange that she (CNAA) didn't tell me the Resident had fallen. That Resident (Resident #101) was supposed to use a gait belt and a walker. During an interview on 3/17/2015 at 12:15 PM, Physical Therapist D said Resident #101 should not have been guided in her transfer on 2/25/2015 at 10:00 PM with use of hands, but instead should have utilized a gait belt and use of a walker, as the fall would've been controlled and less likely to result in injury. Several unsuccessful attempts were made to contact CNA B for interview, by phone, during the complaint investigation (3/17/2015 at 8:30 AM and 1:00 PM); she was no longer employed at the facility. During an interview on 3/17/2015 at 3:30 PM, the Nursing Home Administrator acknowledged it was her expectation that Resident #101's Care Delivery Guide should've been reviewed by facility staff prior to the start of care, and that specifications regarding use of a gait belt and walker should have been followed. She said that once the fall had occurred, facility staff should not have moved the Resident, but instead, notify the nurse, immediately, to assess the Resident.

This citation pertains to intake MI 153. Based on observation, interview and record review, the facility failed to ensure daily assessment and proper treatment were implemented in order to prevent the development of 2 pressure wounds/ulcers for 1 (Resident #2) of 3 residents reviewed for pressure wounds from a total sample of 6 residents, resulting in 2 potentially avoidable pressure wounds (2 un-stageable pressure wounds/ulcers) on the right and left coccyx area for Resident #2. Findings Include: Review of Resident #2's Face Sheet, Minimum Data Set (MDS, Assessment tool) dated 1/8/14, Physician order [REDACTED].#2 was an [AGE] year old male, admitted to the facility on [DATE], alert with intermittent periods of confusion, dependent on staff for all Activities of Daily Living (ADL's), assist of 2 for bed mobility, used a mechanical lift with assist of 2 for transfers and was incontinent of bowel and bladder. The resident's [DIAGNOSES REDACTED]. Review of the facility Nursing Admission Skin assessment dated [DATE], revealed no documentation found of Resident #2 to indicate any red marks, abrasions, open skin areas or pressure wounds/ulcers on his coccyx (tailbone) area. The resident was admitted to the facility free of any pressure wounds. Review of the facility MDS dated [DATE], revealed Resident #2 was at risk for the development of pressure wounds due to dementia, incontinence, and requiring staff assistance for all ADL's, bed mobility and transfers. Review of the facility Mitigating Factors for the Development of Pressure Ulcers document dated 1/4/13, revealed the resident was at risk for the development of pressure wounds/ulcers due to continuous urinary incontinence, chronic bowel incontinence, low [MEDICATION NAME] (low protein, required for tissue repair) and low Hgb (low Hemoglobin/red blood cells, carry oxygen to tissue cells). Review of the facility Braden Risk Assessment (an assessment tool used to score risk of development of pressure wounds/ulcers) dated 7/12/14, revealed Resident #2 was scored a "13", at moderate risk of the development of pressure wounds/ulcers. Review of the resident's Skin Integrity Care Plan dated 3/2/12, stated "Inspect the skin for signs and symptoms of breakdown." Review of Physician order [REDACTED].O. (new order) Allevyn Adhesive (wound dressing) to coccyx, change Q (every) 5 days and PRN (as needed)." Review of Resident #2's facility Pressure Ulcer Healing Chart and Skin Grid dated 7/22/14, revealed documentation of one un-stageable pressure wound/ulcer on his coccyx, length measuring 5.0 cm with a width of 4.0 cm. Review of the resident's Pressure Ulcer Healing Chart and Skin Grid dated 7/29/14 revealed the un-stageable pressure wound was 6.0 cm in length and 5.0 cm in width (reflecting the pressure wound had gotten larger). Review of resident's Physician order [REDACTED]. Review of the Nurses notes dated 7/22/14 through 8/11/14, revealed no documentation of assessment of the resident's pressure wound/ulcer or the surrounding tissue. Observation was made on 8/11/14 at 11:35 a.m., of Resident #2's pressure wound care in his room. Staff member "G" (Charge Nurse, RN) did the resident's dressing change. The resident had many layers of very thick, dried and stuck-on EPC cream on his coccyx area; it took staff member "G" 30 minutes (from 11:20 a.m. to 11:50 a.m.) to clean off enough of the EPC cream so she could assess the wound and surrounding tissue. Staff member "G" had a very difficult time removing the EPC cream due to it being caked on and stuck to the resident's skin from the scrotum up to the top right and left buttock areas. A small amount of blood was noted as staff member "G" (Charge Nurse) was blotting off the cream. The resident verbalized it was very painful when staff member "G" (Charge Nurse) cleaned off the cream by using peri-wash, saline solution and blotting the area (the resident had been pre-medicated before the dressing change with [MEDICATION NAME] 7.5/325 mg, an [MEDICATION NAME], controlled substance). An interview was done on 8/11/14 at 11:50 a.m., with staff member "G" (Charge Nurse, RN). Staff member "G" (Charge Nurse) revealed she was unable to assess the condition of the resident's coccyx area because "it was so covered in white cream, you couldn't see the wound." Staff member "G" (Charge Nurse) said staff should have removed the many layers of EPC cream in order to assess the resident's pressure wound and surrounding skin. When staff member "G" (Charge Nurse) had removed most of the EPC cream, the resident presented with not 1, but 3 separate pressure wounds. The original coccyx pressure wound was 5.0 cm in length, 4.5 cm width, 8 cm depth and was documented as a stage III pressure wound/ulcer (full thickness in depth, down to the muscle layer) and two new pressure wounds were identified, one on the right buttock area measuring 2.5 cm in length and 3.0 cm width (un-stageable) and one on the left upper coccyx measured to be 4.0 cm in length and 5.0 width (un-stageable). Staff member "E" (Unit Manager) came in the resident's room during the resident's treatment (on 8/11/14) and upon inspection of his coccyx area, said staff had not removed the EPC cream from his coccyx area, it was dried and caked onto his skin, staff would not have been able to assess the area and she stated "it (the application of the cream) should not have been that thick." The Centers for Medicare & Medicaid Services Resident Assessment Instrument (RAI) Minimum Data Set (MDS) 3.0 explains that unstageable ulcers are ulcers that cannot be accurately staged, or visualized, due to the wounds being covered by necrotic (dead) tissue (slough or eschar). Inspection of the EPA Cream tube, done on 8/12/14 at 1:00 p.m., revealed on the back of the tube, under directions, it stated "cleanse the affected area and allow to dry." Apply cream liberally as often as necessary." Review of the Skin Equity laminated wound guide, in front of the treatment book on the hall the resident was on, stated "Cleanse soiled area with (a personal cleanser). Apply a thin layer of (EPA) protectant." EPC directions for use are, 1. Change wet/soiled garments. 2. Cleanse the affected area and allow to dry. 3. Apply cream (Smith&Nephew, ww.smith-nephew.com/professional) Even if these products are used, the resident's skin must still be cleaned after each episode of incontinence. Reapply the cream or ointment after cleaning and drying the skin (U.S. National Library of Medicine NIH National Institutes of Health, gov/medlineplus/ency/article/ 6.htm). If staff would have followed the EPC use instructions, and cleansed the area prior to re-application, the two potentially avoidable pressure wounds could have been identified more timely, and early interventions (specific to the type of ulcers) could have been implemented. According to www.smith-nephew.com, EPC cream is not intended for use with deep wounds. Review of the Treatment Record dated 8/14; revealed documentation that nursing staff had assessed the resident's coccyx area every shift, twice a day per Physician order. An interview was done on 8/11/14 at 11:20 a.m., with staff member "D" (Nursing Assistant/CNA), assigned to the hall the resident was on 8/11/14. Staff member "D" (CNA) stated "I wiped it (the EPA cream) off the best I could." When this surveyor asked staff member "D" (CNA) if she had informed the nurse of the condition of the resident's coccyx area, and how much old dried cream was stuck to his skin, she stated "I didn't tell the nurse yet." Staff member "D" (CNA) said she had started her shift on 8/11/14 at 6:00 a.m., 5 hours and 20 minutes prior. An interview was done on 8/12/14 at 12:05 p.m., with staff member "K" (Charge Nurse, LPN). Staff member "K" (Charge Nurse, LPN) said she was one of the nurses who had signed Resident #2's Treatment Record (dated 8/14), indicating she had assessed his pressure wound and the surrounding tissue and had done his treatment per orders. When this surveyor asked staff member "K" (Charge Nurse) how she assessed the resident's skin, and if the existing pressure wound was healing, she stated, "I didn't, years ago we were told don't wipe the cream (barrier cream) off. We (nurses) can't assess it if there's that much cream on the resident or the wound. When we (nurses) sign it (the Treatment Record), it means we assessed the skin area around the wound." An interview was done on 8/12/14 at 11:05 a.m., with staff member "L" (Charge Nurse, LPN), assigned to the hall Resident #2 was on and had signed the Treatment Record dated 8/14, indicating she had assessed his pressure wound and surrounding tissue. Staff member "L" (Charge Nurse) stated, "when I sign on the TAR (Treatment Administration Record), it means that I have assessed the wound and area and have done the treatment. No, I did not see the skin (the resident's coccyx area and pressure wound), I did not assess it." During an interview done on 8/11/14 at 3:10 p.m., in the conference room with the Director of Nursing/DON, staff member "F" (ADON) and staff member "E" (Unit Manager), the DON said staff initials on the Treatment Record (dated 8/14), indicated nurses had assessed the resident's coccyx wound and surrounding area and did the treatments twice a day. When this surveyor asked the DON how staff assessed the coccyx area when it was so heavily coated with dried stuck-on cream, she stated "they couldn't." Staff members "F" (ADON) and "E" (Unit Manager) both said the resident's 2 newly found pressure wounds could have been prevented and staff should have identified them through proper assessment prior to 8/11/14. The DON and staff members "F" and "E" said Resident #2 did not have any pressure wounds upon admission to the facility; on 7/19/14 one area of pressure was identified on his coccyx and Physician orders [REDACTED]. The DON and staff members "F" (ADON) and "E" (Unit Manager) said they were not aware the resident had any other pressure areas on his coccyx area until 8/11/14, when this surveyor observed his dressing change. Review of the Physician order [REDACTED]. Apple Replicare (dressing) to entire coccyx area, change Q (every) 5 days & PRN (as needed)." Review of the facility Clinical Programs Manual dated 10/2013, stated under Treatment Protocol, Wound Prevention and Management "Cleanse buttocks/perineal area with one of the following: Cleanse with soap and rinse with water, pat dry. Cleanse with peri-wash and pat dry. Cleanse with incontinent wipes and pat dry. Apply one of the following treatment: Barrier cream to buttocks following each episode of incontinence. Topical skin protectant daily to reddened area." Review of the facility Treatment Protocol for Deep Tissue Injury dated 10/2010, stated "Daily inspection and care of the skin." ( )

This citation pertains to complaint MI 957. Based on observation, interview, and record review, the facility failed to prevent the elopement and ensure the safety of one severely cognitively impaired resident (Resident #103) out of three sampled residents and 10 supplemental residents reviewed for care plan interventions for elopement, in a total sample of 5 residents, resulting in Resident # 103 eloping from the facility and straying approximately 120 feet from the facility front door until he was "spotted by staff walking in parking lot pushing w/c (wheel chair)", placing Resident #103 at risk for serious harm, injury or death, and placing him in immediate jeopardy to his health and safety. Because the facility's deficient practice also included the failure to ensure functioning alarms, identify safety risks, re-evaluate safety risks after an actual elopement, and report the elopement to the State Agency, twelve additional residents (#101, #104, #105, #106, #107, #108, #109, #110, #111, #112, #113, and #114), identified as being at risk for elopement by the facility, were also determined to be at potential increased risk to their safety. The immediate jeopardy began on 4/30/2014 at approximately 6:30 pm when Resident #103, who was wearing a wanderguard bracelet, wheeled his wheelchair to the front door, got out of the wheelchair and, unbeknownst to facility staff, walked through the front door and out into the parking lot. Resident #103 was observed (an unknown amount of time later) by a facility kitchen employee, who saw the resident in the parking lot in front of the facility. Resident #103 was returned to the facility. During a phone interview on 5/21/2014 at 4:05 pm, Registered Nurse (RN) "E" stated that Resident #103 had eloped on 4/30/2014, and the resident's WanderGuard bracelet did not activate the alarms. RN "E" further stated that it had been raining off and on that day and Resident #103 was wearing slacks, a shirt, a hat, and blue Prafo boots (i.e., boots that were meant for positioning and skin protection, and would present a high risk for slip and fall when used for walking). The Minimum Data Set Assessment, dated 4/6/2014, revealed that Resident #103 had a Brief Interview for Mental Status assessment score of 6 (out of a possible 15), which indicated that Resident #103 was severely cognitively Impaired. A review of the nurses' notes for Resident #103 revealed no documentation related to the elopement that occurred on 4/30/2014. During a phone interview on 5/21/2014 at 4:05 pm, RN "E" confirmed that he had not documented the incident. A nurses' note, dated 5/2/2014 (2 days after Resident #103 eloped), revealed that the facility discontinued Resident #103's WanderGuard bracelet without any additional assessments or interventions to prevent future elopements. The immediate jeopardy was identified at approximately 11:15 am on 5/22/14. The facility's Administrator was notified of the immediate jeopardy at 4:40 pm on 5/22/2014. The immediate jeopardy was removed on 5/23/14 at 2:30 pm, when this surveyor confirmed, by observation, interview, and record review, that the following had been completed: 1. Resident #103 was re-assessed by nursing and social services related to elopement risks and safety on 5/22/2014. Nurse Practitioner "B" examined Resident #103 on 5/22/2014 and a neuro-psych exam was ordered. 2. Resident #103 was placed on 15-minute checks on 5/22/2014. 3. All residents were assessed on 5/22/2014 by the facility interdisciplinary team for the need for elopement precautions. 4. Twelve residents (#101, #104, #105, #106, #107, #108, #109, #110, #111, #112, #113, and #114) were identified as being at risk for elopement by the facility, and their care plans were reviewed and updated as deemed appropriate by the facility. 5. The facility put in place procedures to assure monitoring of WanderGuard devices and door alarms for function and placement. 6. The facility accounted for all residents. 7. Elopement drills were performed on 5/22/2014 for the second and third shifts. 8. Staff education was initiated regarding elopement policy and procedures, including notification of an incident to the supervisor. 9. On 5/23/2014 at 2:30 pm this surveyor and maintenance Staff "L" verified that the WanderGuard door alarms were functioning. Although the immediate jeopardy was removed on 5/23/2014, the facility's deficient practice was not corrected and continues at a pattern level with the potential for more than minimum harm, pending the facility's ability to: 1. Complete the neuro-psych exam for Resident #103. 2. Ensure identification of a responsible party for cognitively impaired residents as appropriate. 3. Demonstrate that incident reports are created if cognitively impaired residents are outside of the building without supervision; elopements are reported to the State Agency per regulatory guidelines, and management staff are notified of any such incident. 4. Demonstrate that resident safety needs have been re-assessed after every elopement; complete elopement risk assessments according to facility policy for newly admitted and readmitted residents and residents exhibiting a change in condition and/or new risk behaviors. 5. Continue with monitoring of function and placement of WanderGuard devices and continue with monitoring of function of the WanderGuard door alarms. 6. Complete staff education related to the facility elopement policies and procedures. 7. Continue with monitoring elopement policies and procedures. 8. Demonstrate that any resident at risk for elopement will be protected from exiting the building unsupervised. 9. Sustain compliance as verified by the state agency. Findings include: According to the face sheet, dated 4/1/2014, Resident #103 was an [AGE] year old male admitted to the facility on [DATE]. The "[DIAGNOSES REDACTED].#103, dated 3/31/2014, included dementia, heart disease, anemia, acute kidney injury, diabetes, high blood pressure and stomach acid reflux disease. According to the Minimum Data Set Assessment (MDS), dated [DATE], Resident #103 had scored a 6 (out of a possible 15) on his Brief Interview for Mental Status (BIMS). According to the Centers for Medicare and Medicaid Services "Resident Assessment Instrument Version 3.0 Manual, Section C: Cognitive Patterns", dated May 2013 and printed from the computer by Registered Nurse (RN) "M" on 5/22/2014 at 10:40 am, a BIMS score of 0-7 suggests severe cognitive impairment, a score of 8-12 suggests moderate impairment, and a score of 13-15 suggests the resident is cognitively intact. According to the "Care Delivery Guide", dated 3/31/2014, Resident #103 required the assistance of one person and a gait belt to transfer and to walk. The facility's "Nursing Comprehensive Admission Data Collection and Assessment" form, dated 3/31/2014, reflected that Resident #103 was determined not to be a risk for elopement because he was not independent in mobility and had no exit seeking behavior at that time. According to the form, Resident #103 did not walk and required a mechanical lift to be transferred from the bed to chair. Resident #103 had an "Elopement Plan of Care: Assessment, Prevention and Management" in place dated 4/14/2014. The assessment included the following risk factors: "Impaired Cognition due to dementia, [DIAGNOSES REDACTED]; independently mobile in w/c (wheel chair); impaired vision; desire to return home." The assessment for a risk for elopement included the following information: "Is at risk for elopement at this time. Res (resident) wanders throughout facility, expresses desire to go home." The two goals were that Resident #103 would continue to wander safely in the facility and would maintain safe mobility. The interventions included "Initiate "Wander Alert System" (dated 3/31/2014), photograph resident and document description on photograph, place on a protected list for at risk residents." A nursing note entry dated 4/28/2014 at 10:00 pm read: "Resident alert, confused at times, very hard to reorient. He keeps pulling off everything, trying to open the exit door, setting off alarms. Res (resident) would not listen to staff while trying to reorient to his room and his stuff, pretty much one on one supervision at this right moment." A nursing note entry on 5/2/2014 at 2:40 pm reflected that the WanderGuard device for Resident #103 had been discontinued. According to a nursing note entry on 5/2/2014 at 3:00 pm, Resident #103 was placed on 15 minute checks related to "exit seeking behavior." A nursing note entry dated 5/5/2014 at 3:20 pm reflected that the 15 minute checks were discontinued; next entry on the same date at 3:35 pm reflected that Resident #103 had attempted to go out the facility's west wing door and was redirected back to east wing where he attempted to go out the doors on the end of the east hall. The note read, "He thought he was at the (Name of) County bank and wanted to get out." The note further reflected: "after supper roaming in the hall." A nursing note entry, dated 5/9/2014 at 6:30 pm, reflected that Resident #103 had been "spotted by staff walking in parking lot pushing w/c (wheel chair)." The note further stated that Resident #103 had been assisted back to the building and a skin assessment was completed with no findings. Licensed Practical Nurse (LPN) "F" who had written this note was interviewed on 5/21/2014 at 2:55 pm. LPN "F" stated that she had not witnessed the event but was told by her Unit Manager, RN "A", that Resident #103 had been seen in the front parking lot by kitchen staff who had brought him back in. LPN "F" named the kitchen staff member as dietary aide "O". LPN "F" stated that she had been instructed to perform a skin assessment on Resident #103 and document that, but was told to not complete an incident report. LPN "F" stated that she did not realize that Resident #103 was outside until after he had been brought back into the building. LPN "F" added that "We try to keep an eye on him the best we can. He can walk and he moves fast." The next nursing note entry was dated 5/9/2014 at 9:00 pm by RN "E". The entry read "Resident was placed on half hour checks by this nurse to ensure that elopement risk is declined. Resident is alert and propels self down hallways, without assist. Resident has history of exit seeking. Encouragement of resident of correct place is discussed. Will continue to encourage resident to stay within east hall and stay inside of building." On 5/21/2014 at 3:20 pm, a phone message was left for Dietary Staff "O". On 5/21/2014 at 3:32 pm, Staff "O" returned this surveyor's phone call and stated she knew nothing about Resident #103 being outside in the parking lot. On 5/21/2014 at 3:25 pm, an interview with dietary aide "D" was conducted. Dietary aide "D" stated that she and another kitchen staff member, Cook "C", had seen Resident #103 outside in the front parking lot from a kitchen window one evening. She was certain the time was after 6:30 pm because they had finished serving the meal and were cleaning up at that time. She was not certain what day that had been, but she was sure that her, Staff "C", and Staff "N" were on duty that evening. Staff "D" stated that when she got outside she asked Resident #103 what he was doing and he said, "I'm going to find my wagon at church." Staff "D" stated that Resident #103 was confused. Staff "D" added that it had been raining, but Resident #103 "wasn't real wet." Staff "D" stated that she and Cook "C" brought Resident #103 back into the facility through the kitchen and, when they got him to the main hall, a female nurse (she couldn't remember who) got his wheel chair from the front door and took Resident #103 down the hall. Although LPN "F" had documented her nurse's note on 5/9/14, LPN "F" had also stated, during her interview on 5/21/2014 at 2:55 pm., that she had not witnessed the resident outside of the building, but dietary Staff "O" had. During the interview on 5/21/2014 at 3:32 pm, Staff "O" stated she knew nothing about Resident #103 being outside in the parking lot. During the interview on 5/21/2014 at 3:25 pm, Dietary Staff "D" remembered Resident #103 being outside the facility in the parking lot, and could not recall the date, but remembered only one incident. In the absence of a facility incident report, crucial information regarding the date, time and circumstances of the incident were missing. On 5/21/2014 at 3:45 pm an interview with Cook "C" was conducted. Cook "C" could not remember the date of the incident but remembered the time as being after 6:30 pm. Cook "C" stated that she had seen a man walking outside in the parking lot from a kitchen window. Cook "C" stated that she had not recognized the man but that he looked confused, like he didn't know where he was or where he was going. Cook "C" stated that she called out to Staff "D" to come look at the man because she was more familiar with the residents in the facility, and she wanted to see if Staff "D" recognized him. Cook "C" said that Staff "D" did recognize him as being Resident #103 and they both ran outside through the kitchen door to the front parking lot. Cook "C" stated that when they approached Resident #103 he at first "snatched his arm away" but Staff "D" was able to talk to him and get him to come inside. Cook "C" stated that when they got Resident #103 through the kitchen and into the main hallway LPN "P" was there, and got his chair from by the front door and took Resident #103 down the hall. Cook "C" also remembered that she and dietary aides "D" and "N" had been the three kitchen staff on duty the evening Resident #103 had been outside alone. Cook "C" went outdoors with this surveyor and stood where she said she had first seen Resident #103 standing in the parking lot. From the front door, a canopy covered sidewalk about 20 feet long led directly to the parking lot. Cook "C" stood about 100 feet east from the sidewalk. On 5/21/2014 at 3:55 pm the dietary work schedule was reviewed by Chef "Q". Chef "Q" stated that the last day that staff members "C", "D", and "N" had worked at the same time was 4/30/2014. On 5/21/2014 at 4:00 pm, a phone message was left for LPN "P". LPN "P" returned the phone call on 5/21/2014 at 4:20 pm. LPN "P" stated that she did not remember having any contact or involvement with Resident #103 when he had been brought back into the building by the kitchen staff. On 5/21/2014 at 4:05 pm, RN "E" was interviewed by telephone. RN "E" stated that he did remember being on duty the evening Resident #103 had been observed outside and brought back into the building by the dietary staff. RN "E" stated that he had not documented or completed an incident report about the incident. RN "E" recalled the date of the incident as 4/30/2014 because of the monthly duty he was performing at the time of the incident. RN "E" stated that the front door alarm had not been sounding as it should have. RN "E" explained that, when the WanderGuard door alarm was activated, it would sound until it was reset by entering a numerical code on the key pad. RN "E" stated that when he had asked, no one had heard the front door alarm. RN "E" stated that he had taken Resident #103's WanderGuard device to the front door, and it had functioned, but he had changed it to a new device, anyway, and put it on Resident #103's "other arm." RN "E" stated that Resident #103 was a "known risk" for elopement. RN "E" added that he had not believed that Resident #103 had gotten any further than the canopy from the front door. RN "E" stated that he had been questioned by the Director of Nursing following the incident, and that she (the Director of Nursing) had seemed upset with him because he had not completed an incident report. RN "E" stated that he did not know why the WanderGuard device had been removed from Resident #103. A follow-up interview was conducted with RN "E" on 5/22/2014 at 4:00 pm by telephone. RN "E" confirmed that Resident #103 had a WanderGuard device on his wrist on 4/30/2014. RN "E" stated that he had asked other nurses and aides on duty that evening and nobody had heard the alarm sound and nobody remembered deactivating the door alarm. RN "E" stated that Resident #103 had been wearing his "day clothes", pants, a shirt and a derby hat, and had Prafo boots on his feet. Prafo boots are intended to assist with positioning and to prevent pressure on the heals. When RN "E" was asked if Prafo boots were meant to walk in, RN "E" replied, "No, absolutely not. It is a fall risk." RN "E" added that Resident #103 had stood up from his wheel chair, before, but he was in the hallway and staff had gotten to him quickly and had sat him back down. An entry on the "Elopement Plan of Care: Assessment, Prevention and Management" for Resident #103, dated 4/30/2014, in the risk factor assessment column read: "exit seeking behavior: Res (resident) open front door. stated wanted fresh air." In the interventions column, the only entry on the same page, an entry read: "Resident assessed following check wanderguard functioning properly & replaced wanderguard & rechecked functioning." This entry was undated. On 5/21/2014 at 3:35 pm, Nurse Practitioner "B" was interviewed by telephone. According to the American Nurses' Association publication "Nursing: Scope & Standards of Practice", Nurse Practitioners are Advanced Practice Registered Nurses who have earned a Masters Degree or higher and who have greater knowledge and more complex skills to provide health care than RNs with less education. Nurse Practitioner "B" stated that she had no idea that Resident #103 had tried to get out of the facility. She further stated that Resident #103 should not be outside unsupervised. On 5/21/2014 an interview was conducted with the Director of Nursing (DON), a Registered Nurse, beginning at 4:30 pm. The DON stated that there was no incident report related to Resident #103's elopement. The DON stated that Resident #103 was "his own person" and he could go outside if he wanted, so there was not a need for an incident report. The DON also stated that residents have to be evaluated, to be determined to be incompetent to make their own decisions, and he (Resident #103) had not been deemed incompetent, so he could make his own decisions. The DON stated that she had just started her position at this facility at the beginning of this month and, when she started going through the chart, she saw Resident #103 was his own person. The DON was asked why the facility applied a WanderGuard on Resident #103. She stated she did not know. The DON stated that Resident #103's admission assessment was that he was not at risk of elopement. The DON was then asked if Resident #103 was re-assessed when he started going to the doors and the DON did not reply. The DON stated that there was no physician order for [REDACTED]. The DON was asked when she first found out about Resident #103 going outdoors unsupervised, and the DON stated that she was not aware when it first happened. On 5/22/2014 at 8:15 am, during an interview with the facility Administrator, he stated that he had been notified that Resident #103 had gone outdoors, but did not remember the date, and that he thought that the resident was just looking around. The Administrator further stated that Resident #103 could go outside if he wanted to. The Administrator was asked for documentation of an assessment that Resident #103 was safe to be outside unsupervised. No assessment was received by this surveyor by the conclusion of the survey. On 5/22/2014 at 8:30 am, Registered Nurse (RN) "G" who was responsible for updating the facility's elopement risk list and book of pictures of residents at risk for elopement stated that Resident #103 had been on the elopement risk list "for a few days", but was not currently on that list. RN "G" was asked if she had any documentation regarding Resident #103's elopement risk assessment or when he had been on the risk list. RN "G" stated that she did not have any documentation about Resident #103, but added, "it should be in his chart." On 5/22/2014 at 9:35 am, the Nurse Practitioner (NP) "B" was interviewed in person. NP "B" stated that Resident #103's judgment was 50%. NP "B" stated that Resident #103's long term memory was good, but his short term memory was 50-50. NP "B" believed that Resident #103 would need help to make big decisions. On 5/22/2014 beginning at 9:50 am, an interview was conducted with the DON, the Social Services Director, Staff "I", and the social worker Staff "J". Staff "J" stated that, upon admission, Resident #103 had scored a 6 out of 15 on his Brief Interview for mental status (BIMS). However, she further stated that Resident #103 was able to follow conversation, make decisions and had understanding of the legal paperwork he was signing. Staff "J" stated that she had administered another BIMS on 5/5/2014 and Resident #103 had scored an 8 out of 15. Staff "J" stated that she had administered a third BIMS on 5/21/2014 and that Resident #103 had scored a 7 out of 15. Staff "J" stated that she had not been involved in the decisions to apply or remove the WanderGuard. During the interview on 5/22/2014 that began at 9:50 am, the DON stated, "as a team we felt he (Resident #103) answered appropriately." When asked who the team was, she stated the social workers, "I" & "J", and RNs "A" and "G". The DON further stated that Resident #103's daughter had been in the facility yesterday and, with the resident's permission, safety and residents rights were reviewed. The DON stated that the daughter had given the staff some history about Resident #103 and how he liked to be outside. The DON reported that the daughter and Resident #103 were told about notifying staff if he wanted to go out and that he would need to sign himself out. The DON stated, "We know his BIMS is low, there is some impairment. The team agrees the resident is safe to make decisions about his plan of care." The DON was asked if Resident #103 had requested that the WanderGuard device be removed and she did not answer. The DON did say that she did not chart about why the decision was made to take off the WanderGuard and that she had not been aware that he had gone outside when that decision was made. The DON stated that Resident #103's care plan had been updated, but when asked about any additional documentation related to the elopement she replied, "there is no documentation other than what you saw." Nurse Practitioner (NP) "B" was interviewed again on 5/22/2014 at 11:00 am after she had seen Resident #103. NP "B" stated that Resident #103 was not oriented to place or time and did not know where he was or what the year was. NP "B" stated that she did not think Resident #103 was safe to be outside unsupervised, even if he was confused only 25% of the time. NP "B" stated that Resident #103's judgment was impaired. NP "B" stated that he should be evaluated by a neuro-psych specialist for determination of competency and that she was not qualified to make a judgment on his competency. NP "B" restated that she did not believe it would be safe for Resident #103 to go outside unsupervised. On 5/23/2014 at 10:30 am, a telephone interview was conducted with the daughter of Resident #103. Resident #103's daughter stated that her father did not make his own decisions and that she was his representative. Resident #103's daughter stated, "he has advanced dementia. Sometimes he is clear and other times not so much. He has severe dementia. He may call me by another sibling's name and goes back in time. He is very obviously confused at times." Resident #103's daughter explained that, up until October of last year, her father had lived at home alone, but his condition had deteriorated, and now he needed to be in a facility where he could be supervised and cared for. Resident #103's daughter stated that the legal papers were all "in order" and she made care decisions for her father. An entry in the nurses' notes, dated 5/18/2014 at 5:00 pm, revealed that Resident #103 continued to self transfer and "Hard for him to remember due to dementia." According to the facility's procedure titled "Elopement Prevention: Resident", dated as revised in October 2008, an "elopement occurs when a resident who needs supervision leaves a safe area without supervision" and "adequate supervision is defined by the type and frequency of supervision, based on the individual residents assessed needs and identified hazards in the resident environment. Supervision may vary resident to resident and time to time for the same resident." According to the facility "Elopement Program Algorithm", dated as revised January 2006, if an elopement occurs the following actions are to be taken: "Initiate the Missing Resident Action Plan: Search facility grounds; notify family, NHA (Administrator), DON, RDO (corporate executive), ADCS (a corporate title) and Physician; Notify police; Notify State agency; Contact ER. Verify contacts; Complete Accident/Incident process". On the evening of 4/30/2014, there was no documentation to demonstrate that the facility had initiated any of the steps of this program, as deemed necessary, such as notifications and documentation. On 5/22/2014 beginning at 8:30 am, the facility door alarms were tested with Registered Nurse (RN) "G". The WanderGuard remote alarm for the front door, located half way down the West Hall wing, had to be tested three times before it alarmed. The WanderGuard remote alarm for the employee entrance, located half way down the East Hall did not work at all. A "Service Order" from a contracted company, dated 5/22/2014, revealed that a technician had been into the facility on that date and had found that the wiring to the remote WanderGuard alarm on the East hall was "never hooked up." The alarm had then been wired and tested and was working. On 5/23/2014 at 2:00 pm, a technician from an outside contractor, Staff "R" was observed working on the wiring above the ceiling in various locations on the West hall. On 5/23/2014 at 2:30 pm, the maintenance worker staff "L" was interviewed and reported that staff "R" had found a "short" in the wiring and that the WanderGuard alarm on the West hall had been working only intermittently. ( )

Based on observation, interview and record review, the facility failed to initiate assessment, re-evaluate care interventions and conduct a root cause analysis of a resident's demonstrated pattern of trying to get up independently and use the bathroom for 1 of 18 residents (#5) who were reviewed for falls and safety, from a total survey sample of 18 residents and an extended survey sample of 4 residents, resulting in Resident #5, who was cognitively impaired and elderly, sustaining repeated falls and a fractured ankle, and placing her in immediate jeopardy to her health and safety related to the continued risk for additional falls and injuries. In addition to the failures that resulted in immediate jeopardy for resident #5, the facility failed to assess and intervene to prevent falls with injuries for two residents (#1 and #7), resulting in resident #1 being treated in the emergency room for a laceration to his left ear and resident #7 sustaining a hip fracture; the facility also failed to demonstrate the appropriate transfer technique for resident #5, document and implement the required safety supervision for resident #6, and accurately assess and re-evaluate the safety risks for residents #2 and #13, placing these residents at increased risk for additional falls and serious injuries. The immediate jeopardy began at approximately 4:00 PM on [DATE] when, according to the nurses notes, [AGE] year old Resident #5 reported a new onset of confusion and Registered Nurse (RN) "DK" did not assess the confusion or re-evaluate the resident for increased safety needs. The "Resident Incident" report for [DATE] reflected that Resident #5 had sustained a fall at 12:00 AM on [DATE]. At 4:00 PM on [DATE], Resident #5 reported feeling confused. According to the "Resident Incident" report dated [DATE] for 7:15 AM (15 hours after the resident reported feeling confused), Resident #5 sustained another fall and was found on the floor of her bathroom with a fractured ankle. Following the resident's fall and fracture on [DATE], the facility failed to initiate any assessment, re-evaluation of care interventions, or root cause analysis of Resident #5's demonstrated pattern of trying to get up independently to use the bathroom. Review of the "Resident Incident" report dated [DATE] revealed that Resident #5 sustained another avoidable fall at 2:45 PM on [DATE], when she was, again, found on the floor of her bathroom. Review of the facility's 15 minute check sheet revealed the facility had failed to carry out the agreed upon intervention for increased supervision with every 15 minute visual checks. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #5 was assessed with [REDACTED]. The immediate jeopardy was identified by the survey team on [DATE] at 10:30 AM. On [DATE] at 2:12 PM, the Nursing Home Administrator (NHA) was notified of the Immediate Jeopardy, and a request for a written plan for removal was requested. On [DATE] at 2:55 PM, the Immediate Jeopardy was removed when the surveyors verified the following: - On [DATE] at 6:30 PM, hall monitors were put into place on each unit to ensure that resident would not attempt to independently self transfer, until current residents had fall risks reviewed and updated. - On [DATE] at 9:30 PM, the Interdisciplinary Team met and reviewed Resident #5's falls to determine patterns and root cause analysis for the falls. - On [DATE] at 9:30 PM, an additional root cause was identified for Resident #5 and updates were made to her plan of care which included discontinuation of the 15 minute checks and implementation of a toileting program, as her falls were noted to be related to toileting. These changes were communicated to staff and the toileting schedule was placed in care tracker (the facility's electronic medical record). - On [DATE] at 11:00 PM, 91 of 91 residents' charts had been reviewed by clinical team including the DON (Director of Nursing) and unit managers. A review of fall care plans and care delivery guides were done to assure interventions were documented and appropriate, given residents' current status. 15 minute checks were discontinued as appropriate alternate interventions were established as needed. - On [DATE] at 8:00 AM, a QPI (Quality Performance Improvement) conference call was held with the facility's Medical Director. In attendance at the facility were the Administrator (NHA), DON, and other interdisciplinary team members. - On [DATE] at 8:30 AM, department heads were re-educated on falls policy and procedure and root cause analysis. Multiple interventions were discussed as well as evaluating each individual resident's disease processes, goals, history, etc. - On [DATE] at 10:00 AM, re-education on the falls policy and procedure and root cause analysis was initiated with all staff, and this education was continued throughout the day. - As of [DATE] at 6:30 AM, a total of 80 of 110 facility staff had completed this education. A total of 19 of 25 contracted staff completed the education as of [DATE] at 6:30 AM. Staff not receiving the education at this time were not to be allowed to work until education has been completed. - On [DATE] at 10:00 AM, additional education was initiated for nursing staff to include detailed assessment and analysis of change in mental status including use of Interact III Care Path, documentation, safety interventions, communication and documentation. - As of [DATE] at 10:45 AM, assigned Hall monitors continued as residents were being further evaluated. - A plan for a fall prevention and investigation team, to be in place by [DATE], would assist the facility with identifying preventive measures and root cause analysis for residents with falls. - The DON/designee would complete a system fall audit with IDT weekly for 8 weeks, then monthly, to ensure ongoing compliance with the facility's policies and procedures for falls management. - The falls investigation team analysis and weekly system reviews would be forwarded to QPI (Quality Performance Improvement) monthly for review recommendations. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance with a scope and severity of isolated harm that is not immediate jeopardy, due to the injuries sustained by residents #1, #5 and #7 as a result of potentially avoidable falls. Additionally, the facility is required to complete inservicing for remaining staff regarding the falls policy and the assessment of residents and root cause analysis; and, the facility must demonstrate the ability to sustain compliance with the regulatory requirements under F323, pending verification by the State Agency. Findings include: Resident #5 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], revealed Resident #5 was a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Face Sheet, Resident #5 had a Durable Power of Attorney (DPOA) and was not her own responsible party. According to the MDS, Resident #5 had cognitive impairment and required staff assistance to ambulate. In an interview on [DATE] at 12:00 PM, Director of Nursing (DON) stated that Resident #5 had a DPOA (activated on [DATE]) because she had been deemed incompetent to make appropriate medical decision for herself, due to her decline in cognition (and memory) and required the assistance of 1 staff to ambulate and transfer safely. During an observation and interview on [DATE] at 8:20 AM, Resident #5 was observed seated in a wheelchair, wearing an immobilizer to the right lower leg. Resident #5 stated that she broke her leg, but she was unable to answer specific questions regarding recent falls and injuries. Review of the facility's "Fall/Injury Management-Post Fall or Injury" procedure #3.2.1 effective ,[DATE], last revised ,[DATE] revealed that staff were expected to begin: "Determining what may have caused or contributed to the fall...Addressing the contributing factors for the fall...Identify trends...anticipate needs...Revise the residents Care Plan." In an interview on [DATE] at 2:30 PM, Certified Nurse Assistant (CNA) "Z" stated that Resident #5 rarely used her call light before the fall resulting in the ankle fracture and now never used her call light, due to her increased confusion. In an interview on [DATE] at 12:00 PM, Licensed Practical Nurse (LPN) "DB" stated that Resident #5 rarely used her call light before the fall that resulted in the ankle fracture. Review of the "Resident Incident" report dated [DATE] at 12:00 AM, reflected that Resident #5 was found on the floor of her room. Resident #5's description of the incident revealed that she was attempting to go to the bathroom, lost her balance and fell to her knees. It was noted that Resident #5 did not activate the call light for assistance. Resident #5 reported knee pain. The immediate intervention revealed that Resident #5 was educated on the "importance of using call light for assistance to and from restroom and for any ambulation or transfer purposes to prevent fall/injury," with additional interventions implemented that included grip socks (non skid footwear), and follow-up documentation for 72 hours (nursing assessments done every shift, for 72 hours, to evaluate for changes in condition after a fall). Review of the nursing notes date [DATE] at 4:00 PM revealed, "Late entry: Resident (#5) approached this nurse and stated she just didn't feel well. Stated she thought she was 'messing everything up,' when this nurse asked what she meant, she stated, 'I'm confused'." The nursing note did not reflect an assessment of the potential causes of the resident's confusion or re-evaluation of the resident's supervision and safety needs. Review of the nursing notes dated [DATE] at 11:00 PM did not reveal an assessment of Resident #5's complaint of confusion, or the potential causes of her confusion, or any re-evaluation of the resident's supervision and safety needs. Review of the "Resident Incident" report dated [DATE] at 7:15 AM revealed Resident #5 was found on the floor of her bathroom. Resident #5's description of the incident revealed that she took herself to the commode and her "legs just let go." It was noted that Resident #5 did not activate the call light. Resident #5 was transferred to the emergency room and treated for [REDACTED]." Immediate interventions to prevent reoccurrence of falls/injury included increased supervision with every 15 minute checks, and grip socks. (According to the "Resident Incident" report dated [DATE], the grip socks were not a new intervention.) Review of the "Resident Incident" report dated [DATE] at 2:45 PM revealed, Resident #5 was again found on the floor of her bathroom. Resident #5's description of the incident revealed that she was attempting to go to the bathroom (without staff assistance) and did not recall how she fell . It was noted that Resident #5 did not activate her call light for assistance. Review of the "Falls" care plan for Resident #5, dated [DATE], revealed the intervention for "increased supervision, every 15 minute checks" was implemented on [DATE]. However, there were no documented 15 minute checks for the day of [DATE] and [DATE] prior to the fall on [DATE] at 2:45 PM. Review of the nursing notes dated [DATE] at 1:00 PM revealed Resident #5 had attempted to self transfer to the bathroom twice, but the notes did not reflect a re-evaluation of the resident's supervision and safety needs. Review of the nursing notes dated [DATE] at 10:40 AM revealed Resident #5 attempted to self transfer several times, but the notes did not reveal a re-evaluation of the resident's supervision and safety needs. Review of the nursing notes dated [DATE] at 10:00 AM revealed Resident #5 attempted to self transfer to the bathroom, but the notes did not reveal a re-evaluation of the resident's supervision and safety needs. Review of the nursing notes dated [DATE] at 5:50 PM revealed Resident #5 made one attempt to self transfer, but the notes did not reveal a re-evaluation of the resident's supervision and safety needs. On [DATE] at 4:00 PM, when the DON was asked what the facility's root cause analysis was for Resident #5's falls (that occurred on [DATE], [DATE], and [DATE]), the DON acknowledged at that time that each fall had happened while Resident #5 was attempting to transfer herself (without staff assistance) to the bathroom, and it was further identified that Resident #5 needed to be on a toileting schedule and/or toileting program. Review of the MDS dated [DATE] revealed that Resident #5 was "Occasionally incontinent (less than 7 episodes of incontinence) and the Significant Change (decline) MDS dated [DATE] revealed Resident #5 was "Frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). The MDS dated [DATE] identified a decline in Resident #5's normal urinary bladder function. Record review of the nursing notes revealed that Resident #5 had attempted to transfer herself to the bathroom or was found to have transferred herself to the bathroom on the following days: [DATE], [DATE], [DATE], and [DATE]. In an observation on [DATE] at 2:30 PM in resident #5's room, Resident #5 was observed with her upper body on her bed and her lower body extended out and off the bed. Certified Nurse Assistant (CNA) "Z" was observed entering Resident #5's room with a sit-to-stand mechanical lift. This Surveyor observed CNA "Z" transfer Resident #5 independently (without a second staff member present), using the sit-to-stand mechanical lift from the bed to the wheelchair. Review of the "Mechanical Lift" policy 5.4.2 effective ,[DATE], last revised ,[DATE] revealed, "The sit-to-stand mechanical lift is completed with the assistance of two." In an interview on [DATE] at 9:10 AM, Director of Nursing (DON) stated the facility required two staff members to transfer residents using a sit-to-stand mechanical left. In an observation on [DATE] at 9:25 AM in Resident #5's room, CNA "N" and Registered Nurse (RN) "DK" were observed attempting to transfer Resident #5 using a sit-to-stand mechanical lift. After the staff had positioned Resident #5's sling and secured it to the lift, RN "DK" pushed the button to elevate Resident #5. At that point the staff were asked by this Surveyor to stop the lift and re-assess Resident #5 positioning for safety. Neither CNA "N" nor RN "DK" were observed able to identify that Resident #5's feet were half on and half off the foot platform of the lift. RN "DK" stated, "she must have moved her feet back before we started to elevate her." This surveyor advised CNA "N" and RN "DK" that Resident #5 was in direct observation throughout the process, and the resident had not moved her feet, and Resident #5's foot position had not changed since they had assisted her (Resident #5) feet to the platform. (# ) Resident #1 Review of the Face Sheet and Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #1 was a [AGE] year old male who was admitted on [DATE] with a [DIAGNOSES REDACTED]. According to the "Letter of Conservatorship" dated [DATE], Resident #1 was appointed a guardian to make medical decisions. According to the [DATE] MDS, Resident #1 had moderate cognitive impairment and required assistance to ambulate. During an observation and attempted interview on [DATE] at 8:15 AM, Resident #1 was observed sitting in his wheelchair. Resident #1 did not recall how long he has been at the facility and was unable to answer questions regarding falls and injuries. In an interview on [DATE] at 12:00 PM, the facility's Director of Nursing (DON) stated that Resident #1 required the assistance of 1 staff with ambulation and transfers, had cognitive impairment (poor memory), and was appointed a legal guardian by the court. Review of the "Resident Incident" report dated [DATE] (untimed) revealed Resident #1 was found on the floor of his bathroom. The immediate intervention revealed "teach/re-educate how to lock the wheelchair brakes and to use call light for staff assistance." Review of the "Resident Incident" report dated [DATE] at 8:50 AM revealed Resident #1 was found on the floor of his room, "giving milk to the kittens." The immediate interventions to prevent reoccurrence included a landing strip (pad/mat) next to the bed, and provided reassurance that there were no kittens under the bed. Review of the "Falls" care plan dated [DATE] revealed landing strips (pad/mat) had been added to the care plan on [DATE], and this was not a new intervention. However, the mats were not in place at the time of the fall on [DATE] at 8:50 AM. In an interview on [DATE] at 12:00 PM, the DON acknowledged that the intervention (landing strips, pad, mat) would not prevent reoccurrence of the falls, rather, it was "just to reduce injury." Review of the "Resident Incident" report dated [DATE] at 9:00 PM revealed Resident #1 was found on the floor of the main hall yelling for help, complaining that his wheelchair was broken. The immediate interventions included educating Resident #1 to ask for help when trying to transfer. The care plan revealed that the facility increased supervision on Resident #1 to include every 15 minute checks on [DATE]. Review of the Nursing notes dated [DATE] revealed the 15 minute checks were discontinued, but did not reflect a re-evaluation of the resident's supervision or safety needs. Review of the "Resident Incident" report dated [DATE] at 11:55 PM revealed Resident #1 was, again, found on the floor of his room and he was noted to be confused. Immediate interventions included 15 minute checks for 24 hours. The nursing notes did not reveal a re-evaluation of the resident's supervision and safety needs. Review of the "Resident Incident" report dated [DATE] 2:40 AM revealed Resident #1 was found floor of his room, as he had been attempting to self-transfer to the bathroom. Resident #1 was sent to the emergency room where he received a CT of his head and six sutures to close a laceration on his left ear. There were no immediate interventions put into place for Resident #1 upon his return from the hospital on [DATE] at 8:30 AM. Review of the "Resident Incident" reported dated [DATE] at 10:05 PM revealed Resident #1 was found on the floor of his room and it was noted that he was confused. Immediate interventions included (but were not limited to) continuing with 15 minute checks and adding a bed and chair alarm. The nursing notes and care plan were not specific as to when the 15 minute checks started on [DATE]. Review of the 15 minute interval documentation revealed no 15 minute checks prior to the fall on [DATE] at 10:05 PM. Review of the nursing notes dated [DATE] at 10:00 PM revealed Resident #1's bed and chair alarms were discontinued and removed. The nursing note did not reveal a re-evaluation of the resident's supervision and safety needs, nor was an alternative intervention substituted. Review of the "Resident Incident" report dated [DATE] at 9:15 AM revealed Resident #1 was found on the floor (in the Center Hall) next to his wheelchair and he was unable to explain how the incident happened. There were no immediate interventions put into place to prevent further falls and no documented 15 minute checks found prior to the fall as care planed on [DATE]. Review of the "Resident Incident" report dated [DATE] at 7:00 AM revealed Resident #1 was found on the floor of his room next to the bed. Immediate interventions included a fall mat to be placed next to bed but, according to the "Falls" care plan, the landing strip (pad/mat beside bed) was already placed on [DATE]. The landing strip (pad/mat) was not a new intervention and should already have been in place at the time of the fall on [DATE] at 7: AM. Review of the "Resident Incident" report, dated [DATE] at 6:20 PM, revealed Resident #1 was found on the floor of his room and he was noted to be confused. Resident #1 complained of left elbow pain and was noted to have a reddened area (to the left elbow) as a result of the fall. To the question, "Was the resident trying to get to the toilet when the incident occurred?" the documented answer was, "unknown." Immediate interventions included 15 minute checks. During the 6 month period, Resident #1 had 9 falls including 1 with a serious injury requiring a CT of the head and sutures to close a laceration on the left ear. With 5 of the 9 falls, Resident #1 was noted to be confused. Resident #1 had attempted to self-transfer (without staff assistance as care planed) in 7 of the 9 falls when he was either found on the floor of his room or the floor of his bathroom. The "Falls" care plan revealed revisions without dates noted and, when an intervention was found to be ineffective, the facility failed to identify, re-evaluate or show that an alternative intervention was put into place to address the resident's changing safety needs. (# ) According to Resident #7's [DATE] admission record, Resident #7 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Pre-Admission Screening/Annual Resident Review, dated [DATE], Documented Mini Mental exam score was 25 ("...is forgetful") under the Section II screening criteria, signed by the Clinician. A Nurse's note dated [DATE] documented that Resident #7 was alert and oriented "times 2" (i.e., oriented to person and place, but not to time), with periods of forgetfulness related to Dementia, and the resident shared a room with her spouse. On [DATE], an Interdisciplinary Team progress note documented that Resident #7 was confused and her husband did most things for her. A Medical History and Physical, dated [DATE] and documented by the physician, reflected: "Resident is admitted to the facility for higher level of care and left hip fracture with ORIF." (ORIF - Open Reduction Internal Fixation - is a surgical repair of hip fracture with hardware.) The documentation reflected that Resident #7 was oriented ,[DATE], to person and place. The Minimum Data Set (MDS) assessment, dated [DATE], coded Resident #7's BIMS (Brief Interview for Mental Status) score as "12" (moderately cognitively impaired). According to the same MDS, Resident #7 required assistance with activities of daily living. Under section "G" of the MDS (functional status for balance/transfers/walking), Resident #7 was coded as "2" (not steady, only able to stabilize with staff assistance and extensive assistance for walking in room and corridor). The MDS also documented that Resident #7 was occasionally incontinent and was not on a toileting program. Under section "J" in the MDS, the resident was coded, under Falls, as having fallen prior to her re-entry/admission and as having had one fall 2 to 6 months prior to facility admission/re-entry. Resident #7's Admission Care plan, dated [DATE], documented that Resident #7 transferred with 1 person assist and gait belt. Resident #7 was a one person assist with a walker for ambulation. Resident #7's Fall/Injury Care Plan, dated [DATE], documented that Resident #7 had history of falls, was unsteady, had osteoporosis (fragile bones), shuffled gait, Dementia, Alzheimer's and history of fracture. The care plan goal was for her to be free from serious injury if a fall occurred. The Interventions listed were: hipsters (padded underwear), to be worn at all times, educate resident as needed, ambulate 1 assist minimal, 2 assist with walker. Review of Resident #7's Care Plan, dated [DATE], documented the following concerns: Alzheimer's Dementia, BIMS ,[DATE] with partial intermittent periods of disorientation, and short term memory problem; maintain safe environment. According to an Incident/Accident report dated [DATE], Resident #7 had a fall on [DATE] that resulted in a right hip fracture. A review of the facility's Incident/Accident report dated [DATE] reported that Resident #7 had a fall in her room, was observed next to her bed with her walker near the bathroom door and was wearing her hipsters. The report documented that Resident #7 was oriented times 2, but the Intervention listed on the report (to remind Resident #7 to always use her walker when ambulating) required cognitive ability and memory retention in order to be effective. An Interview was conducted with Assistant Director of Nursing/Unit Manager of the Central Wing, Staff "AU" on [DATE] at 10:00 AM. When asked if Resident #7 was able to use her call light, Staff "AU" said, "every once in awhile...she is able to push it, but forgets it is there...she doesn't know it is there most of the time." When asked if Resident #7 ever tried to get up by herself, Staff "AU" said that she (Resident #7) had tried to get up on her own while residing down on the West Hall, but was now too weak, and did not have the strength. Staff "AU" also said that Resident #7 had shared a room with her husband, and the husband had watched over her. Staff "AU" said, if the husband thought she was trying to get up impulsively, he would call for staff assistance. Staff "AU" said that Resident #7's husband had recently passed away in late August or early September of 2013. Staff "AU" said that Resident #7 did not remember that her husband had died . An Interview was conducted on [DATE] at 10:15 AM., with certified nursing assistant, Staff "BQ" who worked on the West Hall when Resident #7 was residing there. Staff "BQ" was asked if Resident #7 was able to use her call light to summon help. Staff "BQ" said, "No, not really, she forgets it is there...her husband used to look out for her before he passed away." Resident #7's Care plan, dated [DATE], post-fall for Interventions, was to remind Resident #7 to use her walker when ambulating. The Care Plan also documented 1 person staff assist with the walker. There were no additional interventions added to the post-fall care plan. The MDS dated [DATE] documented Resident #7's BIMS as "7" (severe cognitive impairment). However, there were no additional interventions added to the Care Plan after her fall that were specific to her deteriorating cognition. The Care Plan still reflected Resident #7 with a BIMS of ,[DATE] (moderate cognitive impairment). An Interview was conducted with the Director of Nursing (DON), on [DATE] at 10:00 AM., for the purpose of discussing Resident #7's fall with fracture. The Director of Nursing was asked if the Interventions in place on the care plan prior to the fall were appropriate for a resident who had memory problems and a [DIAGNOSES REDACTED].#7. The DON said there were several Interventions put into place post fall. The care plans referenced above were reviewed with the DON. As of [DATE], no new Interventions were documented on Resident #7's Care plans to ensure that Resident #7 would not sustain injury from another fall. The facility failed to implement appropriate interventions to prevent a fall with injury resulting in a right hip fracture for Resident #7, who was admitted with a fall history, forgetfulness, and a [DIAGNOSES REDACTED]. ( ) According to the Face Sheet dated [DATE] and the [DIAGNOSES REDACTED]. According to the Resident Incident report dated [DATE], resident #6 sustained a fall with the immediate nursing action documented as "72 hour follow-up, education-resident, resident placed on 15 min needs checks for the next 72 hours." Review of Resident #6's "Fall/Injury Assessment: Prevention and Management Plan of Care", dated as "rewritten [DATE]," stated: "15 min (minute) checks X (times) 72 hrs (hours) [DATE]." However, review of Resident #6's "24 Hour Resident Flow Record" dated [DATE] revealed "Frequency of checks: 15 minutes" started at 1630 (4:30 PM) and continued until [DATE] at 1430 (2:30 p.m.), not the 72 hours as documented were required. Nurses notes/Progress notes for Resident #6's fall on [DATE] revealed documentation entered for [DATE] and [DATE]; the next nurses note was [DATE]. On [DATE] at 9:20 AM, during an interview regarding the 15 minute checks for the 72 hours, Unit Manager "DH" said, "I guess they just did it for 24 hours." The facility policy "Accidents and Incidents: Report, Investigate, Follow-up, and Final Disposition" dated "revised [DATE]" stated: "...8. Document after an accident/injury for a minimum of 72 hours in the resident medical record." There was no documented evidence that the facility had monitored Resident #6 for 72 hours in accordance with their policy and Resident #6's fall care plan. ( ) According to the face sheet, dated [DATE], resident #13 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An incident report for resident #13, pertaining to an incident categorized as a "fall", was dated as submitted on [DATE] for an incident dated [DATE]. On [DATE], beginning at 10:45 AM, Registered Nurse (RN) "E" (who was the reporter and had completed the form) was interviewed. RN "E" stated that the facility incident reports were supposed to be completed and submitted on the day of the incident. RN "E" could not recall why this incident report was submitted the day after the incident. According to the facility policy and procedure 1.2.1 "Accidents and Incidents: Report, Investigation, Follow-up, and Final Disposition", dated as revised [DATE], step #8 instructed that "The "Reporter" will complete their section of the eAI (electronic accident incident) report before the end of their shift." The incident report revealed that the incident had occurred at 1:30 PM when resident #13 was observed laying on the floor of her room. According to the incident report, the time of resident #13's last meal was 8:14 AM. The incident report reflected that resident #13 had last been to the bathroom at 1:14 PM. The incident reporter interview summary reflected that resident #13 had been observed in the hall, in her wheelchair, just after breakfast. The investigation summary reflected that resident #13 had just returned to her room from breakfast and had not been in her room for more than 5 minutes. During the interview with RN "E" on [DATE] at 10:45 AM, she could not explain the inconsistencies (with the times or the location), because of the time that had elapsed since the incident had occurred. ( ) According to the face sheet dated [DATE], Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's annual MDS (Minimum Data Set) Assessment, dated [DATE], documented Resident #2 had two falls in the 90 day period prior to the assessment and one fall after the quarterly MDS assessment dated [DATE]. Review of the interdisciplinary note, dated [DATE], documented Resident #2 had fallen two times in one week; a second note, dated [DATE], documented Resident #2 had slid out of his bed. On [DATE] at 10:30 AM, a request to see Resident #2's incident reports was made to the Director of Nursing. Review of Resident #2's "Resident Incident" form, dated [DATE] at 8:15 PM, documented Resident #2 was "observed in room on floo

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ASSESS AND IDENTIFY NEWLY DEVELOPED PRESSURE ULCERS IN A TIMELY MANNER AND PROVIDE AGGRESSIVE PREVENTIVE MEASURES FOR 2 OF 7 RESIDENTS (#5 AND 17) REVIEWED FOR PRESSURE ULCERS FROM A SAMPLE OF 22 RESIDENTS, RESULTING IN HARM FOR BOTH RESIDENTS RELATED TO A PREVENTABLE STAGE 2 COCCYX PRESSURE ULCER ACCOMPANIED WITH PAIN FOR RESIDENT (#5) AND A PREVENTABLE STAGE 2 LEFT BUTTOCK PRESSURE ULCER FOR ANOTHER RESIDENT (#17). FINDINGS INCLUDE: RESIDENT #5 WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE] AND REadmitted on [DATE] WITH THE FOLLOWING CONDITIONS INCLUDED IN THE "[DIAGNOSES REDACTED]. ON 1/31/12 AT 1:30 P.M., RESIDENT #5 WAS OBSERVED SITTING UP IN A HIGH-BACKED SPECIAL WHEEL CHAIR WHILE THE NURSE AIDE WAS BRAIDING HER HAIR. THE RESIDENT HAD JUST GOTTEN OUT OF BED. RESIDENT #5 WAS ALSO RECEIVING HER STOMACH TUBE FEEDING. WHEN THE NURSE AIDE, (STAFF "V") FINISHED BRAIDING THE RESIDENT'S HAIR SHE POSITIONED THE WHEEL CHAIR ACROSS THE TELEVISION SET. RESIDENT #5 WAS NOT ABLE TO SPEAK BUT COULD NOD HER HEAD TO QUESTIONS. RESIDENT #5'S BOTH HANDS WERE SEVERELY CONTRACTED BUT DID NOT HAVE ANY SPLINTS ON. AT 3:00 P.M., ON THE SAME DAY RESIDENT #5 WAS STILL SITTING IN A WHEEL CHAIR, WATCHING TELEVISION NEXT TO HER BED. AT 4:00 P.M., RESIDENT #5 WAS VISITED BY HER FAMILY MEMBER WHILE SHE REMAINED IN HER WHEEL CHAIR AT THE SAME PLACE. THERE WERE NO ATTEMPTS BY ANY NURSING STAFF TO REPOSITION OR SHIFT THE RESIDENT'S WEIGHT FROM THE SAME SITTING POSITION. ON 1/31/12 AT 4:00 P.M., RESIDENT #5'S FAMILY SHARED THE RESIDENT HAD A [MEDICAL CONDITION] FOR OVER [AGE] years AND SHE WAS TOTALLY DEPENDENT ON STAFF FOR ALL OF HER CARE NEEDS. THE FAMILY MEMBER WAS ALSO CONCERNED ABOUT THE PRESSURE ULCER THAT HAD RECENTLY OPENED ON RESIDENT #5'S BUTTOCK. ON 2/1/12 AT 9:50 A.M., THE DRESSING CHANGE TO RESIDENT #5'S COCCYX (TAIL BONE) WOUND WAS OBSERVED IN HER ROOM. THE COCCYX WOUND WAS ROUND WITH WHITE SLOUGH AROUND THE EDGES AND MEASURED APPROXIMATELY 1.5 CM X 1.5 CM X 0.3 CM. THE SURROUNDING TISSUES WERE VERY FRAGILE, MACERATED AND THE ENTIRE BUTTOCK WAS COVERED WITH DARK RED AND PURPLISH HUE. THERE WAS FRESHLY PEELED OFF EXCORIATED RAW AREA ON BOTH RIGHT AND LEFT BUTTOCK. THE AREA ON THE LEFT BUTTOCK WAS LARGER THAN THE RIGHT BUTTOCK. THE WOUND CARE NURSE, (STAFF "A") STATED THAT THE EXCORIATION HAD OCCURRED FROM THE SECONDARY DRESSING (COVERSITE) THAT HAD BEEN PLACED ON THE COCCYX WOUND. STAFF "A" ADDED THAT RESIDENT #5 WAS ALWAYS AT A HIGH RISK FOR DEVELOPING PRESSURE ULCERS INCLUDING A HISTORY OF HEALED COCCYX PRESSURE ULCER. THE FACILITY HAD MANAGED KEEPING HER SKIN INTACT BY USING EITHER "[MEDICATION NAME]" OR "ALLEVYN" FOR MANY YEARS DESPITE HER MEDICAL CONDITION. THE "SKIN GRID-PRESSURE ULCER" DATED 1/30/12 REFLECTED THE COCCYX WOUND WAS A STAGE 2 (PARTIAL THICKNESS LOSS OF DERMIS PRESENTING AS A SHALLOW OPEN ULCER WITH A RED PINK WOUND BED, WITHOUT SLOUGH) WITH MEASUREMENT OF 1.1 CM LONG, 1.1 CM WIDE AND 0.3 CM DEEP. THE INITIAL IDENTIFICATION OF THE WOUND WAS DONE ON 1/30/12. HOWEVER, THE physician's orders [REDACTED]. [MEDICATION NAME] OINTMENT, AND COVER WITH DRY DRESSING DAILY". THE ORDER REFLECTED THE WOUND HAD BEEN PRESENT ON 1/27/12 RATHER THAN 1/30/12. THE "TREATMENT SHEET" DATED JANUARY 2012 REFLECTED THE TREATMENT HAD BEEN STARTED ON 1/26/12, EXTENDING TO 4 DAYS PRIOR TO ONSET DATE DOCUMENTED ON THE "SKIN GRID" SHEET. ACCORDING TO MAKLEBUST AND SIEGGREEN, "PRESSURE ULCERS: GUIDELINES FOR PREVENTIONA ND MANAGEMENT", CHAPTER 3, THE RESIDENT WHO IS AT HIGH RISK CAN DEVELOP PRESSURE ULCERS WITHIN 2-6 HOURS OF THE ONSET OF PRESSURE; THUS, RESIDENTS WHO ARE AT RISK NEED TO BE IDENTIFIED AND HAVE INTERVENTIONS IMPLEMENTED PROMPTLY TO PREVENT THE DEVELOPMENT OF PRESSURE ULCERS. ON 2/1/12 AT 10:00 A.M., THE WOUND CARE NURSE, STAFF "A" WAS ASKED WHY SHE HAD CHOSEN "SANTYL" FOR THE treatment of [REDACTED]. HOWEVER, THE DESCRIPTION OF MEASUREMENT INDICATED THE WOUND WAS A STAGE 3 (FULL THICKNESS TISSUE LOSS INVOLVING SUBCUTANEOUS, OR MUSCLE. SLOUGH MAY BE PRESENT) PRESSURE ULCER. STAFF "A" ADDED THAT SHE HAD WOUND CARE TRAINING AND USUALLY WROTE MOST OF TREATMENT ORDERS AND HAVE THE PHYSICIAN SIGN THEM AT LATER TIME. HOWEVER, THE DESCRIPTION OF MEASUREMENT INDICATED THE WOUND WAS A STAGE 3 PRESSURE ULCER AS DEFINED IN THE CLINICAL PRACTICE GUIDELINES, PRESSURE ULCERS IN ADULTS:PREDICTION AND PREVENTION PUBLISHED BY THE AGENCY FOR HEALTH CARE POLICY AND RESEARCH, UNITED STATE DEPARTMENT OF HEALTH AND HUMAN SERVICES, PAGE 3. RESIDENT #5'S CLINICAL NOTES INDICATED THE RESIDENT HAD BEEN REadmitted on [DATE] TO THE FACILITY. THE "ADMISSION SKIN ASSESSMENT" DATED 4/15/11 REFLECTED THE RESIDENT HAD 3 OPEN AREAS ON HER COCCYX. FIRST ONE WAS LOCATED IN THE CENTER WITH MEASUREMENT OF 0.7 CM LONG AND 1 CM WIDE. IT HAD ROMAN NUMERIC NUMBER WITH "II," POSSIBLY MEANING A "STAGE 2" PRESSURE ULCER. THE SECOND OPEN AREA ON COCCYX WAS LOCATED NEXT TO THE CENTER WOUND ON RIGHT SIDE. IT HAD A MEASUREMENT OF 0.5 CM X 0.5 CM. THE THIRD OPEN AREA ON COCCYX WAS LOCATED NEXT TO THE CENTER WOUND ON LEFT SIDE. IT HAD A MEASUREMENT OF 0.5 CM X 0.5 CM. BOTH OF THESE WOUNDS HAD A LETTER "U." HOWEVER, THERE WAS NO INTERPRETATION OF THE "U" TO INDICATE THE TYPE OF SKIN IMPAIRMENT. ON 2/2/12 AT 10:00 A.M., THE WOUND CARE NURSE, STAFF "A" COULD NOT EXPLAIN THE MEANING OF "U." IN ADDITION, THE "SKIN GRID-PRESSURE ULCER" DOCUMENTATION SHEET DATED 4/18/11 THROUGH 5/9/11 REFLECTED ONLY ONE AREA (OUT OF THE 3 OPEN AREAS) THAT HAD A WEEKLY MEASUREMENT AND PROGRESS OF THE WOUND. HOWEVER, THERE WAS NO MEASUREMENT OF THIS WOUND AT IT'S INITIAL IDENTIFICATION. IN ADDITION, THERE WAS NO EVIDENCE WHICH OF 3 WOUNDS WERE MONITORED. THE "SKIN INTEGRITY ASSESSMENT: PREVENTION AND TREATMENT PLAN OF CARE" REWRITTEN ON 8/18/11 REFLECTED THE RESIDENT WAS AT RISK OF SKIN BREAKDOWN RELATED TO HER [DIAGNOSES REDACTED]. THE RESIDENT WAS MARKED AT MODERATE RISK (13-14) OF DEVELOPING PRESSURE ULCERS ALTHOUGH THE "BRADEN RISK ASSESSMENT SCALE" DATED 4/15/11 THROUGH 1/28/12 REFLECTED TOTAL SCORE OF 10-12 REPRESENTING HIGH RISK. THE INTERVENTIONS INCLUDED SKIN HYGIENE AND INSPECTION, RANGE OF MOTION EXERCISES, TURNING SCHEDULE, APPLYING SKIN PROTECTION CREAM AND USE OF SPECIALTY MATTRESS. THE CARE PLAN ASSESSMENT DID NOT INDICATE THE RESIDENT WAS AT RISK SINCE THE HEAD OF HER BED WAS NOT ELEVATED AT MORE THAN 30 DEGREES DURING TUBE FEEDING, THERE WERE EXTENDED PERIODS OF TIME SPENT IN HER CHAIR AND HER INABILITY TO COMMUNICATE EFFECTIVELY FOR HER POSITIONING NEEDS. THE CARE PLAN HAD NOT BEEN REVIEWED AND REVISED TO REFLECT THE RESIDENT'S CURRENT SPECIFIC CONDITIONS, RISKS, NEEDS AND PREFERENCES. THE CARE PLAN DID NOT INCLUDE AGGRESSIVE REPOSITIONING TO PREVENT THE DEVELOPMENT OF NEW OR RECURRENT PRESSURE ULCERS. A POSITION CHANGE "OFF LOADING" HOURLY FOR DEPENDENT RESIDENTS WHO ARE SITTING OR WHO ARE IN A BED OR A RECLINING CHAIR WITH THE HEAD OF THE BED OR BACK OF THE CHAIR RAISED 30 DEGREES OR MORE IS STRONGLY RECOMMENDED ACCORDING TO THE "GUIDELINES FOR PREVENTION AND MANAGEMENT OF PRESSURE ULCERS," PP. 12, GLENVIEW, IL: AUTHOR. ON 2/2/12 AT 10:35 A.M., RESIDENT #5 WAS OBSERVED IN A CART BEING TAKEN TO A WEST SHOWER ROOM BY A SHOWER AIDE, (STAFF "G" ). AS STAFF "G" ROLLED THE RESIDENT ON HER SIDE TO EXPOSE THE COCCYX WOUND RESIDENT #5 CRIED OUT IN PAIN. THE WOUND LOOKED A LOT WORSE THAN THE PREVIOUS DAY. THERE WAS LARGE AMOUNT OF SEROSANGUINEOUS DRAINAGE ON THE OLD DRESSING AND THE WOUND BED ALSO LOOKED DEEPER WITH WHITE YELLOW SLOUGH AROUND THE EDGES. IN ADDITION THERE WERE 4 SMALL OPEN AREAS ON RIGHT BUTTOCK AND ONE LARGE, RAW, BLOODY RED OPEN AREA ON THE LEFT BUTTOCK. STAFF "G" STATED, "IT LOOKS BAD, HORRIBLE". AT THIS TIME THE DIRECTOR OF NURSING WAS ASKED TO VIEW THE WOUND. THE NURSING NOTES DATED 1/26/12 REFLECTED, "SHOWER AIDE STATES RESIDENT CRIES NEARLY EVERY SHOWER". A REVIEW OF THE FORM, "MITIGATING FACTORS FOR THE DEVELOPMENT OF PRESSURE ULCERS" DATED 1/28/12, TWO DAYS AFTER THE CURRENT COCCYX WOUND WAS IDENTIFIED WAS DONE. THE FORM INDICATED THAT THE CLINICAL CONDITIONS THAT MADE THE LIKELIHOOD OF THE PRESSURE ULCER TO BE UNAVOIDABLE INCLUDED THE RESIDENT'S [DIAGNOSES REDACTED]. ON 2/3/12 AT 11:00 A.M., THE WOUND CARE NURSE, (STAFF "A") DISAGREED WITH THE NONCOMPLIANCE FACTORS. SHE SAID THAT THE RESIDENT WAS TOTALLY DEPENDENT ON STAFF AND SHE COULD NOT POSSIBLY BE NONCOMPLIANT WITH TURNING, POSITIONING AND TREATMENT. ON 2/3/12 AT 10:45 A.M., THE DRESSING CHANGE TO RESIDENT #5'S COCCYX PRESSURE ULCER WAS OBSERVED IN THE RESIDENT'S ROOM. THE WOUND CARE NURSE, (STAFF "A") STATED THAT SHE HAD CHANGED THE WOUND TREATMENT TO "SOLOSITE" AND A TRIPLE ANTIBIOTIC TO THE PERI-WOUND. STAFF " A" WAS ASKED TO MEASURE THE COCCYX WOUND. IT MEASURED 1.4 CM LONG 1.5 CM WIDE AND 0.5 CM DEEP (SIGNIFICANT INCREASE FROM 1/30/12). THE EXTENSIVE EXCORIATED BUTTOCK WOUNDS WERE STILL LOOKING BLOODY RED. THE RESIDENT HAD AN INDWELLING URINARY CATHETER FOR WOUND HEALING, ALTHOUGH THE FACILITY DID NOT ALLOW FOR AN INSERTION OF A URINARY CATHETER UNLESS THE WOUND WAS A STAGE 4 (FULL THICKNESS SKIN LOSS WITH EXTENSIVE DESTRUCTION, TISSUE NECROSIS, OR DAMAGE TO MUSCLE, BONE, OR SUPPORTING STRUCTURES). STAFF "A" ADDED THAT PHYSICAL THERAPY WAS ALSO LOOKING INTO ANOTHER WHEEL CHAIR BECAUSE THE CUSHION WAS TOO HARD AND DID NOT PROVIDE ADEQUATE PRESSURE RELIEVING SURFACE SUPPORT. ( ) ACCORDING TO THE FACE SHEET, DATED 1/18/2012, RESIDENT #17 WAS AN [AGE] year OLD FEMALE ORIGINALLY admitted to the facility on [DATE]. THE [DIAGNOSES REDACTED]. OTHER [DIAGNOSES REDACTED]. DURING AN INTERVIEW WITH CERTIFIED NURSING ASSISTANT (CNA) "CC" ON 2/2/2012 AT 1:45 PM, SHE REPORTED THAT RESIDENT #17 HAD TWO OPEN AREAS ON HER LEFT BUTTOCK. CNA "CC" STATED THAT SHE HAD DISCOVERED THE OPEN AREAS A FEW DAYS AGO AND HAD REPORTED TO THE NURSE THE PRESENCE OF THE NEW OPEN AREAS. ON 2/2/2012 AT 2:00 PM, TWO AREAS, ONE OPEN STAGE 2 PRESSURE ULCER AND ONE SCABBED OVER AREA WERE OBSERVED ON THE LEFT BUTTOCK OF RESIDENT #17. ON 2/2/2012 AT 2:30 PM, STAFF "A" A LICENSED PRACTICAL NURSE WHO WAS THE FACILITY WOUND CARE NURSE, STATED THAT SHE WAS UNAWARE THAT RESIDENT #17 HAD ANY OPEN AREAS. STAFF NURSE "A" THEN CHECKED THE COMPUTERIZED MEDICAL RECORD AND STATED THAT ON 1/31/2012 ON THE SECOND SHIFT, A CNA HAD CHARTED THAT RESIDENT #17 HAD A NEW SKIN ISSUE AND THAT THE NURSE HAD BEEN INFORMED. A REVIEW OF THE NURSING PROGRESS NOTES ON 2/2/2012 REVEALED THAT NO ENTRY HAD BEEN MADE REGARDING AN ASSESSMENT OF THE OPEN AREAS ON THE BUTTOCK OF RESIDENT #17 ON 1/31/2012, 2/1/2012, OR ON 2/2/2012. A REVIEW OF THE SKIN INTEGRITY ASSESSMENT PREVENTION AND TREATMENT PLAN OF CARE ON 2/2/2012 REVEALED NO ASSESSMENT OR TREATMENT PLAN OF CARE FOR THE OPEN AREAS. ON 2/3/2012 AT 9:00 AM, A SKIN GRID FOR RESIDENT #17 WAS LOCATED IN THE TREATMENT ADMINISTRATION RECORD. THE SKIN GRID, DATED 2/2/2012 REFLECTED THAT A PRESSURE ULCER HAD BEEN INITIALLY IDENTIFIED ON THAT DATE. THE AREA WAS DOCUMENTED AS BEING A STAGE 2 PRESSURE ULCER ON THE LEFT BUTTOCK OF RESIDENT #17 THAT MEASURED 2.1 CENTIMETERS IN LENGTH, 2 CENTIMETERS IN WIDTH AND WAS .2 CENTIMETERS DEEP. THE TREATMENT SHEET, DATED FEBRUARY 2012 FOR RESIDENT #17 REFLECTED THAT A TREATMENT ORDER TO CLEANSE THE WOUND WITH NORMAL SALINE AND TO APPLY A [MEDICATION NAME] DRESSING TO THE LEFT BUTTOCK WAS INITIATED ON 2/2/2012. ON 2/2/2012, AT 3:00 PM, THE DIRECTOR OF NURSES WAS OBSERVED IN THE ROOM OF RESIDENT #17. THE DIRECTOR OF NURSES INFORMED RESIDENT #17 THAT SHE WAS LOOKING FOR THE CREAM FOR HER BOTTOM. RESIDENT #17 RESPONDED, "OH, THAT IS SORE". ALTHOUGH THE OPEN AREAS ON THE LEFT BUTTOCK OF RESIDENT #17 HAD BEEN REPORTED TO THE NURSING STAFF BY CERTIFIED NURSING ASSISTANT "CC" ON 1/31/2012, NO IDENTIFICATION, ASSESSMENT OR treatment for [REDACTED]. ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 325. BASED ON INTERVIEWS AND RECORDS REVIEW, THE FACILITY FAILED TO PREVENT FALLS IN 1 OF 5 SAMPLED RESIDENTS (#102) RESULTING IN RESIDENT #102 EXPERIENCING A CLOSED HEAD INJURY AND A LACERATION OVER HER RIGHT EYE REQUIRING CLOSURE WITH A SKIN ADHESIVE. FINDINGS INCLUDE: THE RESIDENT WAS NO LONGER RESIDING AT THE FACILITY DURING THE COMPLAINT INVESTIGATION. THE FACESHEET REVEALED RESIDENT #102 WAS AN [AGE] year OLD WOMAN admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SETS ((MDS) dated [DATE] REVEALED RESIDENT #102 WAS MODERATELY COGNITIVELY IMPAIRED, COULD MAKE HER NEEDS KNOWN AND WAS ABLE TO UNDERSTAND OTHERS, REQUIRED EXTENSIVE ASSISTANCE FROM TWO FACILITY STAFF MEMBERS WITH TRANSFERS (MOVEMENTS FROM SURFACE TO SURFACE), AND HAD EXPERIENCED A FALL WITHIN THE PAST 31 TO 180 DAYS. ACCORDING TO THE PLAN OF CARE INITIATED 4/29/10, RESIDENT #102 WAS IDENTIFIED AT RISK FOR FALLS. IDENTIFIED AS AN INTERVENTION IN HER CARE WAS "GERI CHAIR IN RECLINED POSITION WHEN NOT IN DIRECT SUPERVISION OF STAFF." ACCORDING TO THE ACCIDENT/INCIDENT REPORT DATED 9/22/10 (UN-TIMED), RESIDENT #102 WAS OBSERVED ON 9/22/10 AT 2:10 P.M., FACE DOWN ON THE FLOOR OF HER ROOM. SHE WAS REPORTED TO HAVE SUSTAINED INJURIES TO HER RIGHT HAND, LEFT KNEE, AND THE AREA ABOVE HER RIGHT EYE AFTER SHE fell FROM A GERI CHAIR (RECLINER). SHE WAS DOCUMENTED TO HAVE BEEN SENT TO A LOCAL HOSPITAL FOR EVALUATION. THE EMERGENCY DEPARTMENT CHART DATED 9/22/10 AT 3:30 P.M., REVEALED RESIDENT #102 HAD EXPERIENCED A CLOSED HEAD INJURY AND "A HORIZONTAL LACERATION LOCATED OVER THE RIGHT EYEBROW WHICH IS ONE CENTIMETER IN LENGTH. THIS WOUND WILL REQUIRE SURGICAL CLOSURE TO STABILIZE WOUND EDGES AND ENSURE OPTIMAL HEALING." WOUND CLOSURE WAS DOCUMENTED AS PROVIDED THROUGH USE OF "SKIN GLUE." DURING AN INTERVIEW ON 12/29/10 AT 10:25 A.M., A NURSE (WITNESS #9) SAID SHE HAD BEEN CALLED TO THE ROOM OF RESIDENT #102 BY A CERTIFIED NURSE AIDE (CNA) ON 9/22/10 AT 2:10 P.M. "SHE (RESIDENT #102) WAS FACE FIRST ON THE FLOOR NEXT TO THE RECLINER. THE RECLINER WAS IN THE UPRIGHT POSITION; IT SHOULD HAVE BEEN IN THE RECLINED BACK POSITION. THE GERI CHAIR CAN ONLY BE IN THE UPRIGHT POSITION IF THE RESIDENT IS EATING, AND AN AIDE NEEDS TO BE WITH HER." DURING AN INTERVIEW ON 12/29/10 AT 11:25 A.M., THE UNIT MANAGER (WITNESS #11) SAID, "I ARRIVED TO THE RESIDENT'S (#102) ROOM WITHIN SECONDS OF THE FALL. SHE WAS ON THE FLOOR, FACE DOWN AND HER BODY WAS LEANING SIDEWAYS. THE GERI CHAIR (RECLINER) WAS IN THE UPRIGHT POSITION, NOT RECLINED." DURING AN INTERVIEW ON 12/29/10 AT 12:05 P.M., A CNA (WITNESS #13) SAID, "I WAS PASSING SUPPLIES ON 9/22/10 AT ABOUT 2:10 P.M., AND WAS THE FIRST PERSON TO SEE SHE'D (RESIDENT #102) HAD FALLEN. I HEARD AN ALARM AND HEARD HER YELLING. I SAW HER FACE DOWN ON THE FLOOR BY THE GERI CHAIR. THE GERI CHAIR WAS IN THE UPRIGHT POSITION. THERE WERE NO STAFF MEMBERS IN THE ROOM WITH HER." DURING AN INTERVIEW ON 12/29/10 AT 12:35 P.M., THE DIRECTOR OF NURSING SAID, "I WAS AWARE, THROUGH INVESTIGATION, THAT THE RESIDENT (#102) WAS LEFT IN HER ROOM ALONE, IN THE GERI CHAIR, WITH THE RECLINER IN THE UPRIGHT POSITION. IT WAS UNSAFE FOR HER. MULTIPLE PEOPLE WERE IN AND OUT OF THE ROOM TO FEED HER. I WASN'T ABLE TO IDENTIFY DURING MY INVESTIGATION, WHO LEFT THE GERI CHAIR IN THE UPRIGHT POSITION, THEN LEFT HER IN THE ROOM ALONE. IT WAS UNSAFE." DURING AN INTERVIEW ON 12/29/10 AT 12:55 P.M., THE IN-SERVICE DIRECTOR (WITNESS #14) SAID, "I DO TEACHING OF CNA'S, NURSES, AND CONTRACTED PEOPLE WORKING WITHIN OUR FACILITY ABOUT THE USE OF GERI CHAIRS; THIS IS DONE DURING NEW HIRE ORIENTATION. IF A RESIDENT WITH A HISTORY OF FALLS IS IN A GERI CHAIR (RECLINER), UNATTENDED, THE CHAIR IS TO BE IN THE RECLINING POSITION. NO ONE SHOULD EVER LEAVE A RESIDENT AT RISK FOR FALLS ALONE IN A GERI CHAIR IN THE UPRIGHT POSITION; THEY'RE GOING TO FALL RIGHT OUT OF THE CHAIR." DURING AN INTERVIEW ON 1/3/10 AT 11:25 A.M., THE NURSING HOME ADMINISTRATOR SAID, "RESIDENTS LEFT IN ROOMS UNATTENDED, WITH A RECLINER OR GERI CHAIR IN THE UPRIGHT POSITION, MUST HAVE A LAP TRAY IN USE ON THE CHAIR. OTHERWISE, FACILITY STAFF ARE TO BE IN THE ROOM AT ALL TIMES, SUPERVISING THE RESIDENT IF THE RECLINER IS IN THE UPRIGHT POSITION."