Every finding on record at Medilodge of Grand Blanc

Based on observation, staff interviews, and record review, the facility failed to ensure that clean linens were consistently available to meet residents' needs. This resulted in delayed incontinence care and bathing for one resident (Resident #103) of four residents reviewed for quality of care. Findings include: Resident #103 (R103):A record review of the face sheet and Minimum Data Set (MDS) assessment indicated R103 was admitted to the facility on [DATE] with diagnoses: diabetes mellitus (DM), failure to thrive, muscle weakness, protein calorie malnutrition, bipolar II (mental health disorder of mood cycling between high and low) and difficulty in walking. The MDS assessment dated [DATE] indicated the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15/15 and was dependent on care for toileting and shower/bathing.On 05/27/2026 at 12:10PM, Nurse A was asked to open the linen closet on west 100 hall, the observation of the linen closet revealed the following contents: 5 blankets; 0 fitted/ 8 flat/ 0 draw sheets; 0 pillowcases; 2 wash cloths, 4 towels; 9 clothing protectors; 0 gowns were present. Nurse A was asked how many residents were on that hall and she responded 36. Nurse A was asked if 2 wash cloths and 4 towels were enough to provide care for the 36 residents on the hall at any given time and she said that the staff had used them and if they needed more, they could borrow from another hall until the laundry delivered more. Nurse A was able to identify what time a laundry deliver occurred and indicated every shift.On 05/27/2026 at 12:12PM, Unit Manager (UM) B was asked to open the linen closet on east 100 hall, the observation of the linen closet revealed the following contents: 0 blankets; 2 fitted/ 12 flat/ 12 draw sheets; 2 pillowcases; 5 wash cloths, 12 towels; and 12 clothing protectors; 2 gowns were present. UM B was asked how many residents were on the hall and he stated 16. UM B was asked if this was enough to support the needs of the 16 residents on the hall, he said this is the linen closet for the hall, but the main laundry supply was in the basement. UM B was asked to escort the SA to the laundry in the basement.On 05/27/2026 at 12:15PM, observed of the laundry folding room there were 2-3 yellow bins of clean linens waiting to be folded and laundry staff C was folding sheets and had a table partially full of folded laundry. Laundry staff C was asked how often linens were delivered to the closets on the halls and she stated, every two hours. Laundry staff C was asked if that was even throughout the night and weekends, she stated yes. Laundry staff C was asked what the were the laundry department hours and she said 6 am to 1 pm, she was quired and confirmed no deliveries were made between the hours of 1am to 6 am throughout the night, as the department was not operational those hours. At 12:18 PM our interview was cut short when the laundry manager D arrived. On 05/27/2026 at 12:18PM, during an interview with laundry manager D, she was asked if they had any complaints from staff about not having enough linen supplies and she said that she had and that the night laundry worker had not been able to keep up with the demands. Laundry manager D said it's a hard building and you can't stop; it's an ongoing cycle and went on to say that they had trialed a new schedule for the laundry services and that it lasted less than a month because it was not working out with supply and demand. Laundry manager D was asked if she had any specific complaints , she said yes that a Nurse had called her on 05/17/2026 at 3:30AM (referenced the calendar) in a panic and said the whole building was out of linens and there were none in the closets, the laundry room and they was no laundry worker available on site. laundry manager D said she lived an hour away and she got ready and went in early, stated she arrived at 5:45AM. Laundry manager D said she had a back stock room of new linens that she kept in a locked room, she was asked who had access and she said maintenance and herself. laundry manager D, was asked why the limited access and she said because the staff would take them instead of washing the used ones. Observation of the stockroom with supply of new blankets, sheets, towels, pillowcases and wash clothes. Laundry manager D was asked to supply the order histories and inventory logs. On 05/27/2026 at 12:41PM, Certified nurse aide (CNA) F was asked to open the linen closet on west 500 hall, the observation of the linen closet revealed the following contents: 0 blankets; 12 fitted / 12 flat sheets; 5 wash cloths, 5 towels; 24+clothing protectors; and 12 gowns. CNA F was asked how many residents were on the hall and he stated 16, she said that there was about 7-8 residents that are on check and change. CNA F was asked what check and change meant and she said it meant to check and change the residents brief when needed, every two hours. CNA F was asked if they ever ran out of laundry supplies and she said that during the week the supply was better but, on the weekend, it was not uncommon for them to run out of wash cloths. CNA F was asked what they did if they ran out of wash cloths, she said they used towels or other linens that are available. CNA F was asked how often laundry was delivered to the hall and she said they come once a shift but not on weekends, and that she did not think the laundry staff worked on weekends. CNA F was asked to open the linen closet on west 400 hall, an observation of the linen closet revealed the following contents: 0 blankets; 12 fitted / 12 flat sheets; 4 wash cloths, 7 towels; 24+clothing protectors; and 12 gowns. On 05/27/2026 at 12:47PM, SA was approached by R102 in the hallway and R102 shared that the scant linen supply in the closets was not uncommon and said that staff will use towels and bibs if they run out of wash cloths. R102 had no specific incident recalled when quieried.On 05/27/2026 at 12:49PM, CNA G was asked to open the linen closet on front and back 600 hall, the observation of the linen closets combined revealed the following contents: 4 comforters; 10 blankets; 6 fitted/22 flat sheets; 15 wash cloths, 20 towels; 24+clothing protectors; 12 pillowcases. CNA G was asked if they ever ran out of linen supplies and she stated Actually, yes and They are supposed to deliver laundry once a shift, but they do it whenever they get around to it followed by We run out of washcloths a lot. CNA G was asked what happened when they ran out of wash cloths, she said they used what ever linen there was until the next laundry was delivered. On 05/27/2026 at 1:13PM-2:30PM, During a follow up interview with laundry manager D, she was asked about the phone call from the nurse on 05/17/2026 and asked to verify what was said. Laundry manager D said she had the text voicemail.According to a record review of the voice/text message from Nurse I left on 05/17/2026 at 03:55AM, .the last I knew you were the head of the linen services, and I just needed to make sure somebody else is coming in tonight for because this entire building has almost like no linens again already and went on to explain 'at the start of the shift 7PM, half the building had little to no washcloths, towels and fitted sheets and on (her hall) there was none. At 9 PM there was still no delivery of linens and so she when down to the laundry room where the laundry person told her they had just arrived, it was by then 2 hours with no linens. The laundry worker told her the shift before had hardly left anything clean, but she would fold what was available and bring it to her, she then brought up a small stack. She said the rest of the building was also out of linens again, so she went back down again to ask for more and the staff was gone.' The message ended with So, we need wash cloths and towels so that we can wash people, give us a call back at the building when you get this message let us know if someone else is coming in thank you.Laundry manager D said she was unable to return the phone call, and she got ready and went in early, she arrived at 5:45AM and the first shift laundry worker arrived at 6 AM. She said we got busy folding and delivered to the floors in about 30 minutes. Laundry manager D said she had heard that CNA's had cut up towels to use in place of wash cloths to clean residents and said I believe it because she observed there were cut up towels in the returned laundry.Laundry manager D was further queried about the schedule change in laundry services and she said that the last week in April they had changed the hours but changed back to the old schedule after the incident on 05/17/2026. Old and current hours: 7 days a week, first shift 6AM to 2PM (1 staff, facility laundry), Second shift 12 Noon to 8PM (1 staff, resident personal laundry), third shift 7PM to 3AM (1 staff, facility laundry). Laundry manager D said the only change was made to third shift and that was from 5PM to 1AM, she said that lasted about 3-4 weeks. Laundry manager D said that the 100, 200 and 300 halls had linens delivered twice a shift, because they use more linens, and 400, 500 and 600 halls had linens delivered once a shift. According to a record review of the monthly linen inventory:In March wash clothes: 1365 in circulation and 1120 new in storage for a total of 2485 in facility In April wash clothes: 658 in circulation and 84 new in storage for a total of 742 in facilityWhich revealed a difference of 1742 wash clothes unaccounted for between March and April facility wide. May's inventory was not completed at time of survey advised it was to be done at end of month according to laundry manager D. Laundry manager D had no explanation for the large quantity difference and said she continued to order to meet the PAR. When asked what that meant she said it was number of items in use needed per resident and was based on census. Laundry manager D said she was unsure of who was in charge of setting the number per resident needed. PAR on wash clothes was set at 10 per resident.On 05/27/2027 At 2:36PM, during an interview NHA was asked who set the PAR for the facility and she said, at first, it was the contract company however we had an issue last year with laundry and decided to up the PAR on linens / wash clothes. NHA said we had a huge issue before with staff who flushed or thrown them away. NHA said that it had gotten better but could not verify that they don't do that still. NHA was asked about the 1700+ wash cloth inventory from March to April that was unaccounted for according to the inventory sheets, she had no explanation.On 05/27/2027 At 3:13PM, during a telephone interview with CNA H said for a few weeks the staff has had to go searching up and down halls and look for enough linens to complete care for residents, specifically washcloths and sheets to change bedding. CNA H said that on her shift 5/16 to 5/17 that she had a resident refuse (identified as R103) to get a shower because there were no washcloths available and only had a towel. CNA H said she had checked on all the halls and could not find any wash clothes and that she told her nurse. CNA H said the nurse went to the basement to get some laundry from the laundry staff so we could do resident showers and incontinence care, but no one was there. CNA H was asked if there was any additional linens in a back up that they could access and she said there was not, if there was none in any hall closets and no one was available in laundry. On 05/27/2027 At 3:24PM, an observation of R103 resting in bed and was agreeable to interview, she was asked if they ever ran out of items to provide her care and she said that last week on Saturday (05/16/2026) that she wanted to get her shower but they did not have any wash cloths or towels and she said she did not want to use a sheet. R103 said that she was upset and stated, I felt dirty, and was stinking in my underarms. R103 said that she had to wait over two hours in a dirty brief because of the same reason, no linens. R103 said she was upset that they did not offer to make up the shower and that she had to wait until her next shower day for a shower which was days later on Wednesday (05/20/2026). R103 stated it's not my fault they didn't have the linens and said the guy in laundry wasn't doing his job, and there are times when linens were low but that was not right. A record review of R103's treatment administration record (TAR) for May 2026 revealed: Showers - Wednesday and Saturday 2nd shift. Every night shift Wed, Sat ensure shower is provided and documented in POC (plan of care) and noted that on Saturday May 16th resident refused a bath/shower. Nurse to ensure CNA's offer resident to change clothes, wash face and hands. Nurse to document ADL care was completed in (electronic medical record) enter a progress note for any refusals and include reason why resident refused.According to a record review of R103's progress notes dated for May 17th, 2026, at 5:55AM revealed: note text: Showers . Washcloth unavailable and resident was offered assistance with showering using clean towels of which she refused. Message left for linen manager and nurse on call manager.On 05/27/2027 At 3:48PM, during a telephone interview with Nurse I she was asked the night of the phone call to laundry manager D, and she said they were out of linens on her hall and just about everywhere else was low, she said that it happened on a regular basis over the past few weeks. Nurse I said she had been getting complaints from the CNA's about not having enough linens. Nurse I said they had an in-service with the CNAs about check and changes not getting done on nights and said that they don't have the linens to use for incontinence care. Nurse I said that on her shift which is 7PM to 7AM she does not see the laundry get delivered until about 10 PM. Nurse I said that the second shift laundry only delivered personal clothes to residents and no linens to the closets. Nurse I said there is a big gap between deliveries and that is part of the problem. Nurse I confirmed that R103 refused her shower because there was not any washcloths available on her 5/16/2026 shift. On 05/27/2027 At 4:02PM, during a phone call interview with CNA L she verified she worked the night shift on 5/16/2026 and said that running out of linens was a regular issue and we have to try and hunt them down to complete our resident's care. CNA L said it is hard for the residents to understand when staff cannot complete their care until we have the linens. On 05/27/2027 At 4:24PM, during a telephone interview with laundry staff E, he was asked about his routine. Laundry staff E said he worked 5PM to 1AM shift and that he was responsible for washing, drying folding and delivering linens. Laundry staff E said there are 8 closets to deliver to. Laundry staff E said he delivered to 100 hall at start of shift, then a couple hours later to the 200-300 halls, then a couple hours to the 400-500 and then a couple hours later to the 600 hall. Laundry staff E stated I try to then make it up to the 100 hall again because they use a lot of laundry. Laundry staff E said somedays there were not a lot of wash cloths and others it was fine. Laundry staff E said staff will come down and ask for more, but he could only give them what he had, and he did not have access to any back stock to give out.On 05/27/2027 At 4:40PM, during a follow up interview with laundry manager D she was asked if the second shift laundry staff that was in charge of personal laundry delivered linens as well, and she said they were supposed to be checking linens and stocking as needed. She agreed that the floors would run out of linens if they had a 5-hour span that was replenished.On 05/27/2026 at 4:46PM, during a follow up phone call with laundry staff C verified she worked on 5/16/2026 the 5PM to 1AM shift and admitted that she was 2 hours late and arrived at 9PM. Laundry staff C said she did not work over to cover. Laundry staff C said that she arrived and delivered what was available, that she had a nurse come down and ask for linens and she took up a small stack after she got them folded. Laundry staff C said she completed what she could and delivered to the closets and said it was her first week and she could have missed some. Laundry staff I said she left at 1AM. On 05/27/2027 At 5:28PM, During a follow up interview with NHA she was if she had any complaints or grievances filed related to linens or care, she said no official grievances but she was aware that staff called the laundry manager on 05/17/2026 and said they were out of linens, the laundry manager came in and got the linens to the floor right away. The NHA was asked if 2 wash cloths was adequate to provide care for 36 residents, and she said no it was not. The NHA was asked if 5 washcloths was adequate to provide care for 16 residents and she agreed it was not. Reviewed the other observations made and NHA agreed residents deserved to have quality care provided at all times and that included available supplies for the staff to do so. According to a record review of R103's care plan: Focus: Resident has an ADL self-care performance deficit related to Malnutrition, Failure to thrive, anxiety, depression, generalized weakness, pain, shortness of breath (SOB) with intervention: BATHING: 1 person assist for bed bath. 1-person extensive assist for bathing while in shower chair; TOILETING: 1-person extensive assist resident prefers to use bedpan in bed. and Focus: Resident is at risk for impaired skin integrity related to needs assistance with Activities of Daily Living, with intervention: Provide incontinence care as needed; Yellow dot program: encourage/assist resident with turning/repositioning every 2 hours and as needed. And Focus: Resident is frequently incontinent of bowel and bladder. With intervention: Check at regular intervals and change as needed.According to a record review of R103's physician orders revealed: Showers - Wednesday and Saturday 2nd shift and Nurse to ensure CNA's offer resident to change clothes, wash face & hands, clip nails, shave or trim facial hair (if applicable), apply deodorant, brush hair, offer oral care & teeth to be brushed.Nurse to document ADL care was complete in PCC. Enter a progress note for any refusals & include reason why resident refused.According to a record review of (laundry contract company) schedules: Laundry delivery: 6 AM Deliver any clean linens left from previous shift; 10:30Am Deliver Clean Linens to ALL Closets; 12:30PM Deliver Clean Linens to ALL Closets; 2PM deliver to hallways; 4PM deliver to hallways; 7PM Deliver Clean Linens to ALL Closets;1 AM Deliver Clean Linens to ALL Closets.According to a record review of the facilities policy titled incontinence: Policy: Based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services with .guidelines; 4. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible.According to a record review of the facilities policy titled activities of daily living: Policy: the facility takes measures to minimize the loss of resident's functional abilities including activities of daily living. 1. Bathe, dress, groom; 3. Toilet. With .guidelines: 3. President who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.According to a record review of the facilities policy titled Promoting/Maintaining resident dignity: 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 with Guidelines: 6. Respond to requests for assistance in a timely manner; 9. Groom and dress residents according to resident preference.According to a record review of the facilities policy titled Safe and Homelike environment:Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment. and defines Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but is not limited to, equipment used in the completion of the activities of daily living. With Guidelines: 4. The facility will provide and maintain bed and bath linens that are clean and in good condition.

This Citation pertains to intake Number 3011645.Based on interview and record review, the facility failed to ensure that comprehensive, resident centered care plans were implemented as written for one resident (Resident #105) out of five residents reviewed for care plan implementation.Findings include: Resident #105 (R105):A record review of the face sheet and Minimum Data Set (MDS) assessment indicated R105 was admitted to the facility on [DATE] with diagnoses: chronic respiratory failure with a tracheostomy (artificial patent airway) dependent on ventilator (machine that supports breathing), muscular dystrophy (MS / loss of muscle mass), muscle weakness, depression and anxiety. The MDS assessment dated [DATE] indicated the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15/15 and was functionally dependent on assistance for care.On 05/20/2026 at 1:15PM, during an interview, R105expressed concern that his nails had not been clipped and his facial hair was unshaven. R105 was observed to have a goatee style facial hair growth, which he said he preferred. R105's full beard area on face had additional facial hair overgrowth present outside the goatee area. R105 had visibly long fingernails past the tip of the fingers free edge and were unkempt. R105 stated they are not following my care plan. R105 said they were supposed to shave his face and clip his nails on his shower days, Saturdays and Wednesdays. He said he was unsure when the last time they clipped his nails and he had not been shaved in about a week. R105 said he was tired of asking them to perform the grooming care and the staff usually gave excuses or simply told him they would be back to do it and never get around to it. R105 said his nails are so long it was uncomfortable for him to grab the control shifter for his automated wheelchair. R105 said he had talked to the assistant director of nursing (ADON) about it several times. A record review of R105's care plan revealed: Focus: Resident has an ADL (activities of daily living) self-care performance deficit related to VDRF (ventilator-dependent respiratory failure) via trach (tracheostomy) with Muscular Dystrophy diagnoses; (R105) needs total support by staff for all of his ADL care needs. Uses electric wheelchair. with Interventions: (R105) likes to direct his own care and therefore will be offered an opportunity for a bed bath or a shower for grooming and personal hygiene care; resident prefers nail care, shaving done on shower days unless requested otherwise; SHOWER: Wednesday /Saturday 2nd shift. resident can be assisted with 4 staff members to manually transfer onto shower bed using a draw sheet. Request made by resident and resident responsible party; Honor resident's choices and preferences whenever possible; PERSONAL HYGIENE: 1-person total assist.And Focus: Resident has a history of refusing meals, getting out of bed, medications, complying with weights, bathing, repositioning, vital signs, skin assessments, & wearing his vest. With intervention: Resident will verbalize his concerns or rationale explaining why he wishes to have refusals.; Resident's family will be notified to provide additional support, encouragement, & education to resident regarding his refusals during facility stay; Social Services & Unit Manager will provide additional support and encouragement to resident, while probing the resident's concerns at hand if the refusals continue to occur; Staff will continue to provide support/encouragement/education to this resident and will re-approach this resident as needed to encourage resident to acceptance from the staff versus his refusals.According to a record review of R105's treatment administration record (TAR) for the month of May 2026 revealed documentation of targeted behavior 1. refusing to get out of bed for showering and bathing there were no documented refusals of care; and bathing Wed/Sat 1st shift shave and trim nails with shower was documented as completed on 05/02/2026; 05/06/2026; 05/09/2026; 05/13/2026; 05/16/2026; and 05/20/2026, with no refusals or incompletes documented.On 05/20/2026 at 02:20PM, during an interview with the ADON she was queried about R105's concern over his ADL care and staff not following his plan of care. The ADON said that R105 often refused care. She said that R105 complained that it took too long for the staff to complete the tasks and would send them away. The ADON was asked to review the May TAR for R105, and she verified there was no refused care behaviors documented and that the grooming care (shaving and nail care) were all documented as complete. The ADON was asked to observe R105's nails and facial hair. She agreed that R105 had extra facial hair outside the preferred goatee and that his nails were long and unclipped. The ADON said we will get his nails clipped when he returned to his room from activity and that she would address the facial hair as well. On 05/20/2026 at 4:20PM, during an interview, the NHA she was asked about R105's care plan with regards to showering and grooming. NHA said R105 is known to refuse care and then later complain about it, she said it is care planned as well. NHA was aware that R105 was concerned with his nails and facial hair grooming and was asked to review his May TAR and chart for any documentation for refusals. She could not identify any for May 2026. NHA reviewed the TAR and agreed that all May shower/facial hair/nails clipped task had been marked as completed, NHA said that she will separate the nails and the facial hair tasks from the shower task to better capture if R105 refused one of the areas of care, so it was documented separately from now on. According to a record review of the facility policy labelled comprehensive care plans revealed the Policy: it is the policy of this facility to develop and implement A comprehensive person centered care plan for each resident, consistent with the resident's rights, that includes measurable objectives and time frames to meet residents medical, nursing, and mental and psychosocial needs that are identified in the residence comprehensive assessment. with .guidelines: 1. Care planning process will include an assessment of the individual's strengths and needs, will incorporate the resident's personal and cultural preferences in developing goals of care. and defined person-centered care: means to focus on the resident as the focus of control and support the resident is making their own choices and having control over their daily lives.According to a record review of the facility policy labelled promoting / 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 as well as care for each resident in a manner and in an environment, that maintains or enhances residents quality of life by recognizing each individuality. With compliance guidelines: 2. During interactions with residents, staff must report, document and act upon information regarding residence preference; 9. Groom and dress the residents according to resident preference.According to a record review of the facility policy labelled activities of daily living (ADL) the Policy explanation and compliance guidelines: 3. 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 2997144.Based on observation, interview, and record review, the facility failed to ensure that residents were treated with respect and dignity during the provision of care for one resident (Resident #102) of five residents reviewed for dignity with care. Findings include: Resident #102 (R102): A record review of the face sheet and Minimum Data Set (MDS) assessment indicated R102 was admitted to the facility on [DATE] with diagnoses: acute respiratory failure with a tracheostomy (artificial patent airway), cardiac arrest (heart attack), dependance on renal dialysis, diabetes mellitus (DM), muscle weakness and obesity. The MDS assessment, dated 05/14/2026, indicated that the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15/15 and was functionally dependent on assistance for care. On 05/20/2026 at 9:05 AM, during an interview with Family Member A she said that CNA B had apologized to R102 for her behavior, and that CNA B told them, 'She was having a bad day and should have taken more time with the resident' and 'had more patience.'On 05/20/2026 at 11:35 AM, during an interview, R102 was resting in bed and was agreeable to an interview. R102 said that he was restless and that the CNA had been called several times to help reposition him because he was unable to reposition independently. R102 said that CNA B was upset when he called for help and said, 'I don't know how you get yourself in these positions' and 'that is not how I left you' when she came in to assist him. R102 said it made him feel upset and nervous about the level of care he needed. R102 said that a couple of days later that CNA B had come to him and apologized for 'being short with him and said that she had been frustrated that day'. A record review of quality assistance form a grievance filed by family at care conference on 04/28/2026 about the resident's care from CNA B' and family notification concerns. Listed in the findings NHA noted: Administrator interviewed CNA and nurse regarding concerns. Findings determined that the education regarding customer service was needed for the CNA with Plans/action: education re: customer service given to CNA.On 05/20/2026 at 12:13 PM, during a phone call interview, CNA B was asked about the incident with R102 on the day of 04/23/2026. CNA B said that R102 was very restless that shift and that she had been in and out of his room to reposition him several times that evening. CNA B said that R102 was not acting in his normal demeanor and that the nurse, who was aware and had assessed him, called the provider. CNA B said that R102 had rolled out of bed and was sent out due to dislodgement of his Foley (catheter) and change in demeanor. CNA B said that a few days went by and she was taking care R102 when he told her, You hurt my feelings with something you said the night I fell out of bed. CNA B said she did not recall saying anything but that she did apologize because R102 was upset by it. On 05/20/2026 at 353PM, during an interview, the NHA said during a care conference with R102 and his family that R102 complained that CNA B was rude and 'I felt like she was taking her frustrations out on me' and said 'she was one person and could not do everything' when I asked for assistance to be repositioned. The NHA was asked about the grievance outcome, she said that she found that CNA B was unprofessional during care with R102 and that she received a verbal write up for customer service issues and was re-educated. The NHA said that CNA B had apologized to the resident and family. A record review of R102's care plan revealed: Focus: (R102) has decreased functional ability and unable to carry out his own ADL care (activities of daily living) due to debility with decreased strength and endurance with poor balance and coordination. with Interventions: BED MOBILITY: 2 person total assist; DRESSING: 2 person total assist; TOILETING: 2 person total assist; TRANSFERS: with 2 person total assist AND use of mechanical lift; Encourage resident to use call light when assistance is needed.According to a record review of the facility policy labelled promoting / 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 as well as care for each resident in a manner and in an environment, that maintains or enhances residents quality of life by recognizing each individuality. With compliance guidelines:1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights; 8.Conversation should be resident focused and resident centered; 10. Speak respectfully to the residents.

Based on interview and record review, the facility failed to implement care plan interventions for one resident (Resident #3) of three residents reviewed for falls, resulting in a fall with fracture. Findings include:Resident #3 (R3): R3 most recently admitted to the facility on [DATE] with diagnoses that include a right femur fracture, a left femur fracture, muscle wasting and repeated falls. On 02/22/2026 at 1:07PM, during an interview, R3 was asked if he had sustained any falls while in the facility. R3 stated that in September he fell out of bed while receiving a bed bath. R3 stated that one staff member left the room while another staff member performed the bed bath. R3 stated the staff member had rolled him in the bed and was behind him drying his back. R3 said he told the staff member performing the bed bath that he was sliding off the bed and they didn't help me and then I hit the floor. R3 stated that he broke both of his legs, chipped his tooth and was hospitalized . R3 was asked if either of the staff members from that day still work in the facility. R3 stated, one of them still works here and the other one was fired as far as i know. On 02/24/2026 at 12:02PM, record review of an incident report from 9/24/25 revealed that R3 fell out of bed during care and sustained multiple injuries. R3 was sent to the emergency room for evaluation and treatment of his injuries. X-rays showed a comminuted impacted supracondylar/intercondylar fracture of left femur and impacted supracondylar fracture of the right femur. R3 stated he rolled out of the bed as the aide was trying to dry his back. On 2/24/2026 at 12:12PM, record review of care plans for R3 revealed he is a two-person total assist for bed mobility currently and was a two-person total assist at the time of the fall for bed mobility. At the time of the fall R3 was a one-person total assist for bathing, the care plan has been updated to a two-person total assist. The activities of daily living (ADL) definition of bathing refers to the ability to wash oneself in the bathtub or shower. On 02/24/2026 at 12:22PM, an interview was conducted with the Director of Nursing (DON). The DON was asked why the fall for R3 was not reported. The DON stated there was no deficient practice we could identify, we were following the care plan and there was no indication of abuse. We suspended the CNA pending investigation and did a thorough investigation. On 02/24/2026 at 1:41PM, an interview was conducted with Certified Nursing Assistant (CNA) K. CNA K was asked to describe what happened that lead to R3 falling out of bed. CNA K stated we (another CNA was present at the time) were about to give R3 a bed bath and I had to grab an extra person to help me. R3 and the other employee got into it, the other aide said well I'm not your aide I am just helping, and she left. CNA K stated, I gave him a bed bath alone, he was agitated and rushing me to get him up and ready by 11:45am. CNA K was asked if it is a common practice to roll residents away from you when providing care. CNA K stated, yes, we do it all the time, we roll them away and they grab the rail. CNA K was asked if there should have been a second staff member with them to perform the bed bath. CNA K stated, yes, I should've had another person with me. Review of the policy titled, Falls, Clinical Protocol, revealed: 5. Interventions should be developed and implemented per the assessed needs. Additional items to remember when developing the plan of care include;-Resident's abilities and deficits-Balance (sitting/standing)-Adaptive equipment needs-Proper use of mechanical lifts and transfer devices, shower beds, shower chairs, bathroom safety On 02/24/2026 at 1:52PM, during the onsite survey, Past Non-Compliance (PNC) was cited after the facility implemented actions to correct the non-compliance which included: 1. The facility implemented interventions for the resident involved.2. All facility residents are at risk for improper ADL care. An audit was completed by the unit manager to ensure Kardex and Care Plans are accurate, consistent and appropriate to meet the resident's needs. Any issues were addressed upon discovery. 3. Education was provided to the nursing staff on following the Kardex to perform ADL care and notifying the nurse manager if there are any discrepancies/inconsistencies in how to provide care. ADHOC was completed on 9/25/25.4. Audits are being completed to ensure compliance.5. Date of compliance: 9/25/2025.

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 02/23/2026 at 8:55am during the kitchen tour with Certified Dietary Manager D and Regional Dietician E, observed a loose cap to the atmospheric vacuum breaker on the water line to the dishwasher. During this observation, CDM D was interviewed on the broken backflow preventer, and she stated that a contractor came out to repair it a couple weeks ago because it was spewing out water. According to the FDA 2022 Food Code, 5-205.15 System Maintained in Good Repair, A plumbing system shall be: repaired according to law.and maintained in good repair. On 02/23/2026 at 9:01am observed the drain line to the ice machine sitting directly inside a drain. According to the 2022 Food Code, 5-202.13 Backflow Prevention, Air Gap, An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). On 02/23/2026 at 9:05am observed two pans covered with aluminum foil sitting on the counter. During this observation, CDM D was asked what was in the pans and she stated she wasn't sure. CDM D uncovered the pans to find gravy stored inside the pans. Both pans of gravy were temped at 130 degrees F and 135 degrees F using thermometer. When interviewed CDM D on how long the gravy has been sitting on the counter, she stated it's been sitting there since 8am and the gravy is being used for lunch. On 02/23/2026 at approximately 10:50am observed a cooler with the interior lined with a bag with ice stored inside, located in the 100 hallways. On 02/23/2026 at approximately 10:52am observed a cooler with the interior lined with a bag with ice stored inside, located in the 400 hallways. On 02/23/2026 at approximately 11:50am interviewed CDM D on whether the bags lining the interior of the ice coolers are approved for food contact, and she presented the box labeled Sysco Classic Can Liners and stated that these are the bags they've always used for the ice coolers. According to the FDA 2022 Food Code, 4-101.11 Characteristics, Materials that are used in the construction of utensils and food-contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be .safe .durable, corrosion-resistant, and nonabsorbent. According to the specification sheet of the Sysco Liners provided by the facility, the product is called Liner Trash 38 Inch X 58 Inch 0.95 Mil [NAME] Linear Low-Density Polyethylene with the product described as Sysco Classic linear low-density can liners feature high-quality resin construction for durability, and the star seal on each liner fits neatly inside of waste bins. There is no mention of this product being food contact safe on the specification sheet. On 02/23/2026 at 11:55am observed [NAME] F handle uncooked breaded chicken while wearing gloves, removed gloves and put on new gloves before proceeding to prepare and temp ready-to-eat food without washing hands. On 02/23/2026 at 12:40pm observed a pan of cooked breaded chicken sitting on top of steam table and it was temped at 101 degrees F with thermometer in the main kitchen. On 02/23/2026 at approximately 12:48pm interviewed CDM D on when should staff wash their hands, and she stated hands should be washed whenever it's needed and before moving onto the next thing. 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. According to the facility's policy on Dietary Employee Personal Hygiene, Hands must always be washed after using the restroom, eating or drinking, smoking, coughing, sneezing, blowing nose, before putting on gloves and after removing gloves. 02/23/2026 at 12:49pm interviewed CDM D on the pan of breaded chicken sitting on the steam table in the kitchen, and she stated it was left over from the dining room, and she wasn't sure if the intent was to use the leftovers or throw them out. According to the facility's policy on hot holding, Holding - staff shall monitor food temperatures while holding for delivery to ensure proper hot and cold holding temperatures are maintained. Staff shall refer to the current FDA Food Code and facility policy for food temperatures as needed. According to the 2022 FDA 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 57 degrees C (135 degrees F) or above. On 02/22/2026 at 10 AM, During an observation before entering the kitchen there was a file outside the kitchen area marked hair nets it contained empty paper holders with no hair nets available. On 02/22/2026 at ~(approximately)10 AM During the initial walk through of the kitchen with certified dietary manager (CDM) D the sink at the main wash station had no soap available and CDM C said there was an order placed for it however it had not come in yet, staff had to use the secondary sink to wash hands, and walked through the kitchen by the dishwashing station to a secondary sink to wash hands. 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. According to the facility's policy on Dietary Employee Personal Hygiene, Hands must always be washed after using the restroom, eating or drinking, smoking, coughing, sneezing, blowing nose, before putting on gloves and after removing gloves. On 02/22/2026 at ~(approximately)10 AM During the initial walk through of the kitchen an observation of the back sink was dirty and had used pitcher in it, in the same sink there was a ¾ full prepared large container (used to fill pitchers) labelled lemonade dated 02/21/2026 with expiration of 02/27/2026. CDM C was asked about the unclean sink being used for the storage location and she said it should not be stored like that and would dispose of it. On 02/22/2026 at ~(approximately)10 AM During the initial walk through of the kitchen an observation of the cook prep area revealed a large used food scoop and dirty knife on the counter; the sink was unclean with food particles present. CDM observed and verified staff was not actively present performing food preparation. An observation was made of the clean equipment rack that held 2 sauté pans that had peeled Teflon coating and a vegetable mandolin slicer that had a soiled handle and mold in the grove. The CDM C verbalized verified observation and put them in her office to throw out. According to the 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 02/22/2026 at ~(approximately)10 AM During the initial walk through of the kitchen an observation of the refrigerator contained: A tin pan labelled chicken rice soup with an expiration date of 2/20/26; A container of cooked ground beef that was labelled with a discard date of 2/19/26; 4 individual servings of yogurt dated with expiration 2/21/26; A box that contained ham lunchmeat slices with expiration date of 2/18/26. CDM observed and verbally verified expired dates and removed items from the refrigerator to discard. According to the facility's policy on food safety requirements, . food will be stored, prepared, distributed and served in accordance with professional standards for food service safety and defined food service safety as .handling preparing and storing food in ways that prevent foodborne illness. And 3. Iv. Labeling, dating, and monitoring refrigerator food, including, but not limited to leftovers, so it is it is used by its use by date or frozen (if applicable) /discarded . Facility

Based on observation, interview and record review, 1) The facility failed to implement and operationalize a comprehensive infection control program, encompassing outcome surveillance, accurate data documentation/analysis resulting in potential infection and the spread of microorganisms and illness to all 126 facility residents, and 2) the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility. Findings include: DPS One: Based on observation, interview and record review, the facility failed to implement and operationalize a comprehensive infection control program, encompassing outcome surveillance, accurate data documentation/analysis resulting in potential infection and the spread of microorganisms and illness to all 126 facility residents. Findings include: An interview and review of the facility infection control program was completed on 2/25/26 at 1:02 PM with Infection Control Registered Nurse (RN) P and the Director of Nursing (DON). A review of January 2026's infection control data was completed. When queried, RN P revealed they use a mapping tool and a line listing for surveillance. A review and comparison of the mapping tool and the line listing revealed the number of infections included on the line list did not match the number of infections indicated on the mapping tool. When queried regarding the discrepancy, RN P indicated they were not sure. A comparison of the infections was completed with RN P and revealed a Resident with a skin infection was included on the mapping tool but not on the line list for infections. When asked why the skin infection was not included on the line list, RN P revealed the infection was missed. When asked to review their monthly infection control analysis, RN P reviewed the documentation and revealed an analysis had not been completed. The DON then provided a two-page form titled, Monthly Analysis and Summary/QAPI Committee Infection Prevention/Control Report for January 2026. The form included the total infections for the month but did not include any analysis of the infections to identify any potential trends. The total number of infections listed was different from both the number on the line list and the number indicated on the mapping tool. When queried regarding the discrepancy, an explanation was not provided. Further review of the line listing for the month revealed each infection listed received treatment with an antimicrobial medication. When queried regarding potential infections and/or infections which did not require antimicrobial treatment, RN P revealed they did not maintain a line list of infections/potential infections which did not receive treatment. The DON added that the facility had respiratory surveillance documentation due to a Covid outbreak in the facility during January 2026. When asked how infections/potential infections are tracked when there is not an outbreak, both the DON and RN P verbalized the facility did not have a method in place to clearly track potential infections. The line listing had a section titled, Symptom but signs/symptoms of infection for each infection listed were not specified on the documentation. Resident #122 was noted on the line list as having a Healthcare Associated Infection (HAI). The infection site was listed as other. There were no signs/symptoms listed. When queried regarding lack of documentation of signs/symptoms and accurate tracking of infections to prevent spread, both RN P and the DON verbalized understanding. No further explanation was provided. Review of another resident revealed they were treated for a HAI Urinary Tract Infection (UTI). The onset date and the treatment start date for the infection was listed as 1/14/26. The line listing specified a urine sample was obtained on 1/9/26. When queried why a sample was collected on 1/9/26 if the resident's symptoms began on 1/14/26 and if that the actual date the symptoms began, RN P revealed it did not make sense and verbalized they had noticed that previously. Further review of the line listing revealed other residents who were listed as having treatment initiated on the same day as symptoms began. When queried the dates, RN P revealed they would need to review each resident's chart to determine if there were any signs/symptoms of infection documented prior to the date of antimicrobial treatment initiation. When queried regarding the importance of accurate symptom onset date for infection tracking, RN P verbalized understanding. RN P revealed they stepped into the Infection Control Nurse role at the facility within the last few weeks and they had not completed the infection control tracking data for January 2026. With further inquiry, RN P and the DON revealed the prior Infection Control nurse left the position abruptly and both staff verbalized understanding of concerns. Review of Facility policy/procedure entitled, Infection Prevention and Control Program (Reviewed/Revised: 12/27/23) revealed, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 3. Surveillance: a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases. DPS Two: Based on observation, interview, and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility. Findings include: On 02/24/2026 at 9:01am during the housekeeping tour with Housekeeping Manager G and District Manager H, observed the cap to the atmospheric vacuum breaker missing on the utility sink, located in the janitor's closet in main hallway. On 02/24/2026 at approximately 9:10am observed an uncapped flush valve and an unused atmospheric vacuum breaker, located in the in the soiled utility room in the main hallway. During this observation, Housekeeping Manager G stated there used to be a hopper in the soiled utility room. On 02/24/2026 at approximately 9:15am observed an unused atmospheric vacuum breaker above a flush valve from a removed hopper and below the flush valve is a shut off utility sink, located in the soiled utility room between the 400 and 500 hallways. On 02/24/2026 at 9:21am observed a loose cap to an atmospheric vacuum breaker to the utility sink in the janitor's closet in the rehab dining room. On 02/24/2026 at 9:25am observed an unused hopper with a counter built on top of the basin, located in soiled utility room in the 100 hallways. According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, Eliminate dead legs, which are sections of no- or low-water flow. According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, Flush low-flow piping runs and dead legs at least weekly. Flush infrequently used fixtures (e.g., eye wash stations, emergency showers) regularly as needed to maintain water quality parameters within control limits. On 02/24/2026 at 10:41am during the environmental tour with Maintenance Director I, when asked whether the hopper is flushed in the soiled utility room in the 100 hallways, he stated he removes the counter over the hopper basin and lets the water run, but they do not have flushing logs. On 02/24/2026 at 10:43am chlorine residual was zero on both hot and cold water taken at the hand sink, using free chlorine strips in room [ROOM NUMBER]. Record review of the facility's monthly assessment log, on 12/18/25 disinfectant residual on hot water was .0 at the utility sink in 100 east and on 9/2/25 disinfectant residual at MSU utility was at .0. The corrective action boxes at the bottom of the logs for 9/2/25 and 12/18/25 are empty. Record review of the facility's water management plan states, When control limits are not maintained, corrective actions will be taken and documented accordingly. and Protocols and corrective actions will reflect current industry guidelines (i.e. ASHRAE, OSHA, CDC). According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, Ensure disinfectant residual is detectable throughout the potable water system.

Based on interview and record review, the facility failed to implement and operationalize a comprehensive antibiotic stewardship program including analysis and ongoing evaluation of appropriate antibiotic use resulting in the potential development of antibiotic-resistant organisms and inappropriate antibiotic use for all 126 facility residents. Findings include:An interview and review of the facility infection control antibiotic stewardship program was completed on 2/25/26 at 1:02 PM with Infection Control Registered Nurse (RN) P and the Director of Nursing (DON). January 2026's infection control data was reviewed with RN P. When asked what criteria the facility utilizes to assess resident for infection and initiation of antibiotics, RN P stated, McGeer. The line listing documentation did not include if infection/antibiotic use criteria had been met. Additionally, the symptoms section was blank on several of the residents listed who had received antibiotics. When queried if criteria was met for each antibiotic and/or antimicrobial medication prescribed on the line list including how the criteria was met for January 2026, RN P revealed they would need to review each residents Electronic Medical Record (EMR). Upon request to review the monthly summary and analysis for antibiotic use during January 2026, RN P reviewed the Infection Control documentation and revealed an analysis had not been completed. The DON then provided a two-page form titled, Monthly Analysis and Summary/QAPI Committee Infection Prevention/Control Report for January 2026. The form included a section titled Antibiotic Stewardship which detailed, Antibiotic Use Reported to Providers: Yes. Annual Antibiogram (cumulative which summarizes the percentage of individual bacterial pathogens susceptible to specific antimicrobial agents) Review Date: Yes. RN P was asked what Yes meant for the date of the Annual Antibiogram review and was unable to provide an explanation. When queried if they had a copy of the antibiotic report provided to Providers, RN P revealed they did not have a copy of the information. When asked how the facility monitors to ensure residents do not receive antibiotics unnecessarily and those who do require antibiotics receive the appropriate antibiotic for the correct duration without thorough analysis, RN P did not provide further explanation. RN P revealed they stepped into the Infection Control Nurse role at the facility within the last few weeks and had not completed the infection control and antibiotic stewardship data for January 2026 due to the prior Infection Control Nurse leaving the position. When asked, both RN P and the DON verbalized understanding of the importance of summary and analysis of antibiotic usage as part of the infection control and antibiotic stewardship program. Review of facility provided policy/procedure entitled, Antibiotic Stewardship Program (Reviewed/Revised: 12/13/23) revealed, It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. b. Monitoring antibiotic use: i. Monitor response to antibiotics, and laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made. ii. Antibiotic orders obtained upon admission, whether new admission or readmission, to the facility shall be reviewed for appropriateness. iii. Antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness. iv. Monitor during each monthly medication regimen review when the resident has been prescribed or is taking an antibiotic, or any antibiotic regimen review as requested by the QAA committee. v. Random audits of antibiotic prescriptions may be performed to verify completeness and appropriateness (process measure). vi. Antibiotic use shall be measured by (monthly prevalence, antibiotic starts, and/or antibiotic days of therapy). vii. At least one outcome measure associated with antibiotic use will be tracked as part of QAPI program monthly, as prioritized from the facility's infection control risk assessment and other infection surveillance data. viii. A review of the facility's antibiogram will be performed every 18-24 months to guide development or revision of antibiotic use protocols or prescribing practices. 8. Data obtained from antibiotic stewardship monitoring activities is discussed in the facility's QAPI meetings.

This Citation Pertains to Intake Number 2627046. Based on observation, interview and record review, the facility failed to implement and operationalize procedures to ensure that Activity of Daily Living (ADL) care was provided to six residents (#1, #2, #9, #16, #82, and #123) of eleven residents reviewed, resulting in a lack of daily and hygiene care for dependent residents.Findings include:Resident 82 (R82): On 2/22/26 at 12:35 PM, an observation was made of Resident 82 in his room. The Resident was interviewed, answered questions and engaged in limited conversation with some answers/conversation not understood. An observation was made of R82 with facial hair. When asked if he liked to be close shaven or would rather have a beard, the Resident reported he liked a goatee and indicated he liked the mustache, around his mouth and over his chin. When asked about the hair growth that was on his checks, the Resident reported it was long there. An observation was made of R82's fingernails that were long, a couple broken and jagged. The nails were clean underneath. When asked if staff had offered to trim his nails the Resident answered, I don't think so. When asked if he would let them trim them f they offered, the Resident stated, Yeah. A review of R82's medical record revealed an admission on [DATE] with diagnoses that included metabolic encephalopathy, dementia, muscle weakness and difficulty in walking. A review of R82's Minimum Data Set (MDS) assessment revealed a Brief Interview of Mental Status score of 12/15 that indicated moderately impaired cognition and the Resident needed substantial/maximal assistance with shower/bathe self and dressing and needed partial/moderate assistance with personal hygiene. A review of R82's care plan revealed no focus or intervention for refusal of nail care and a lack of a focus of a care plan for refusals of care. A review of Resident 82's task for the last 30 days for Shower/Bath: (to be given) Tuesday and Friday revealed a shower documented as given on 1/27/26, 2/3/26 and 2/10/26. O 2/25/26 at 2:57 PM, an interview was conducted with the Unit Manager, Nurse (UM) M regarding Resident 82's lack of showers and nail care. The UM observed with the surveyor of Resident 82's long, broken and jagged fingernails. The UM indicated that the Resident has been known to refuse care, and a CNA reported that he last refused his nail care with the last shower. A review of the progress notes with the UM revealed no documentation of refusal of nail care. When asked about facility policy of refusals of care, the UM reported the CNA would notify the nurse and then the nurse would put documentation into the medical record if the Resident continued to refuse the care. A review with the UM of progress notes that lacked documentation of the refusals for some of the showering and nail care was conducted and the lack of a care plan focus for refusal of care. When asked if the Resident should have a care plan for refusals, the UM stated, Yes, absolutely. I will make sure it is in there. Resident #2: On 2/23/26 at 4:01 PM, Resident #2 was observed sitting on the edge of their bed in their room. Upon crossing the doorway into the Resident's room, a rank and offensive odor was immediately noted. The odor was pervasive, overwhelming, and became more intense closer to Resident #2. When queried regarding the care they receive in the facility, Resident #2 indicated some things were okay and some were not so good but did not provide more specific information when asked. One side of the Resident's bed was positioned directly against the wall. A fall mat, with visible tears and holes, was in place on the floor. Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses which included bilateral above the knee amputations, diabetes mellitus, cognitive communicative deficit, and end stage renal disease with dialysis dependance. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required moderate to total assistance to complete Activities of Daily Living (ADLs). Review of Resident #2's Electronic Medical Record (EMR) revealed a care plan entitled, Resident has an ADL self-care performance deficit. Needs 2 staff assist for all ADL and functional mobility. (Initiated: 1/21/26; Revised: 12/30/26). The care plan included the intervention, Bathing: 2 person total assist. Review of Resident #2's EMR Documentation Survey Report for February 2026 revealed the task, Bathing Wednesday and Saturday 2nd Shift. Per the documentation, Resident #2 received the following: - 2/3/26: Scheduled bathing task documentation was blank indicating the task was not completed. - 2/6/26: A bed bath with staff assistance to bathe self, including washing, rinsing, and drying. was provided. - 2/10/26 and 2/13/26: The report detailed the Resident refused any bathing. - 2/17/26: Resident #2 had a bed bath and washed themselves completely independently. - 2/20/26: Scheduled bathing task documentation was blank indicating the task was not completed. Review of progress note documentation in Resident #2's EMR revealed no documentation of attempts to reapproach the Resident following bathing refusals and/or reasons why bathing was not completed on 2/3/26 and 2/20/26. An interview was conducted with the Director of Nursing (DON) on 2/24/26 at 2:50 PM. When queried regarding the overwhelmingly strong odor in Resident #2's room which was stronger nearer the Resident, the DON replied, They had a UTI (Urinary Tract Infection) recently. When queried how much urine Resident #2 produces as they were dependent upon dialysis, a specific answer was not provided. The DON was queried further regarding the pervasiveness of the odor and verbalized that the room would be cleaned. Review of Resident #2's Health Care Provider (HCP) orders and Medication Administration Record (MAR) revealed the Resident received two separate courses of antibiotic therapy in February 2026. One course of antibiotics from 2/6/26 to 2/10/26 and a different antibiotic from 2/11/26 to 2/17/26. Resident #9: On 2/22/26 at 12:14 PM, an observation was completed of Resident #9. The Resident was in bed, positioned on their back. The Resident had a tracheostomy in place and was receiving mechanical ventilation. Resident #9's eyes were closed and did not respond when their name was spoken. The Resident had visible, dark colored, long chin hairs. Record review revealed Resident #9 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dysphagia (difficulty swallowing), aphasia (difficulty speaking and expressing self verbally), pain, and respiratory failure with tracheostomy (surgically created opening in the neck to the trachea to allow for air exchange) placement and mechanical ventilator (machine which assist and/or breaths for individuals who are unable to breathe for themselves) dependance. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and was dependent upon staff for completion of Activities of Daily Living (ADLs.). Review of Resident #9's Electronic Medical Record (EMR) revealed a care plan entitled, Resident has an ADL self-care performance deficit. has bilateral hearing loss, legally blind (Initiated: 6/24/24; Revised: 2/11/25). The care plan included the interventions: - Resident will request to have her nails trimmed but often refuses when staff approach to cut. (Initiated: 4/24/25) - Bed Mobility: 2 Person total assist (Initiated: 6/24/24; Revised: 11/8/24) - Personal Hygiene: 1-person total assist (Initiated: 6/25/24; Revised: 11/8/24) Resident #9 did not have a care plan and/or intervention in place which addressed chin hair. On 2/24/26 at 12:15 PM, Resident #9 was observed in their room in bed. The long, dark colored hairs remained visible on Resident #9's chin. The Resident's hands and fingernails were above the blanket and visible. A dark colored, unknown substance was observed under the fingernails on both of their hands. At 12:21 PM on 2/24/26, an observation of Resident #9 was completed with Registered Nurse (RN) A. When asked about Resident #9's fingernails, RN A confirmed the presence of an unknown dark colored substance under their nails and indicated they would clean the Resident's nails. An interview was conducted with the DON on 2/24/26 at 2:50 PM. When queried regarding the substance under Resident #9's fingernails, the DON verbalized staff should ensure the Resident's hands and fingernails are clean. When asked about the long, dark colored chin hair, the DON replied, I think chin hair is on the care plan. Resident #9's care plan was reviewed with the DON at this time. The DON confirmed the Resident did not have a care plan and/or interventions related to care of chin hair and indicated they would address the concern. Resident #16: On 2/22/26 at 12:09 PM, Resident #16 was observed in their room. The Resident was in bed, positioned on their back with their head turned slightly to the left. Resident #16 had a tracheostomy and was receiving mechanical ventilation. Resident #16's lips were dry and cracked. An unknown, dried substance was present around the Resident's mouth and left cheek. Various areas of unknown light brown to brown colored areas were present on the Resident's pillow and blankets. Resident #16's eyes were closed and mucous was present in the corners of both eyes. Record review revealed Resident #16 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included heart failure, dysphagia, gastrostomy (surgically created opening in the abdomen to the stomach for the administration of nutrition and medications), and respiratory failure with tracheostomy placement and mechanical ventilator dependance. Review of the MDS assessment dated [DATE] did not include a cognitive assessment but specified the Resident was dependent upon staff for completion of all ADLs. Review of Resident #16's EMR revealed a care plan entitled, Resident has an ADL self-care performance deficit. (Initiated: 7/22/24; Revised: 5/3/25). The care plan included the intervention, Personal Hygiene: 1-person total assist (Initiated: 8/8/23; Revised: 8/9/23). On 2/24/26 at 11:17 AM, Resident #16 was observed in their room. The Resident was in bed with their head positioned slightly to the left. Dried and moist mucous was present on both sides of the Resident's mouth. An interview was completed with the DON on 2/24/26 at 3:15 PM. The DON was informed of observations of Resident #16. When asked about Resident #16's observed lack of hygiene, the DON stated, That is not okay. Resident #123: On 2/23/26 at 9:41 AM, Resident #123 was observed in their room in bed. The Resident's hair was long with a greasy appearance. Various sizes of visible chunks of an unknown substance were present in the Resident's hair. Resident #123 had a long, unkempt beard. The head of the Resident's bed was elevated at 15 degrees, and they did not have a pillow under and/or near their head. An interview was completed at this time. Resident #15 was asked if they did not like using a pillow and revealed they do. When asked why they did not have a pillow, Resident #15 did not provide a response. When queried if they liked having a beard, Resident #123 responded that they liked to be shaved. When asked if they had a beard now if they preferred to be shaved, Resident #123 replied that the facility staff have not offered to assist and they are unable to shave themselves. Resident #123's right upper extremity appeared to be flaccid, and their hand was in a fist. When asked if they were able to move their right arm, Resident #123 indicated they could not. When queried if they were able to open their right hand, the Resident responded that it was stuck and they could not move and/or open it. Record review revealed Resident #123 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included heart disease, dependence upon supplemental oxygen, cerebral infarction (stroke) with resulting dysphagia (difficulty swallowing), aphasia (difficulty with speech), and right sided hemiplegia and hemiparalysis (one-sided paralysis). Review of the MDS assessment dated [DATE] revealed the Resident was severely cognitively impaired and required moderate to total assistance to complete ADLs with the exception of oral care/eating. Review of Resident #123's EMR revealed a care plan entitled, Resident has an ADL self-care performance deficit. (Initiated: 10/3/24; Revised: 12/15/25). The care plan included the intervention, Personal Hygiene: 1-person extensive assist (Initiated and Revised: 9/28/23). On 2/24/26 at 3:16 PM, an observation of Resident #123 was completed with the DON. Resident #123 was asked if they preferred a beard or be shaved and informed the DON they preferred to be shaved. Resident #123's right hand remained in a fist. When queried regarding hand and fingernail care for the Resident's right hand, the DON lifted the Resident's hand for observation. The fingernails on Resident #123's right hand were long, unkempt, and digging in the skin on their palm. When asked, Resident #123 verbalized their hand hurt from their fingernails digging into the skin. After exiting the Resident's room with the DON, an interview was completed. When asked about the cleanliness of the Resident, being unshaven when they prefer to be shaved, and their fingernails, the DON indicated that it was not acceptable and they would address the concerns immediately. Resident #1 (R1): R1 was admitted to the facility on [DATE] with diagnoses that include a history of cerebral infarction, cognitive communication deficit and acute respiratory distress syndrome. On 02/22/2026 at 12:57PM, during an interview with R1, it was observed that R1 had long fingernails. R1 was asked if they like their fingernails that long. R1 stated no, they are a little long for me. R1 was asked if the staff had offered to cut her fingernails or if she had asked to have her fingernails cut. R1 stated, I have asked for them to be cut, and they didn't cut them and the staff doesn't offer to cut them. R1 was asked if they would accept getting their nails cut if staff offered. R1 stated yes, I would accept it if they did. R1 stated that she has not had her nails cut once since being in the facility. On 02/22/2026 at 01:05PM, record review of the electronic medical record (EMR) did not reveal documentation of nail care being completed for R1. Review of the EMR revealed a care plan for activities of daily living (ADL), R1 requires extensive assistance of one staff member for personal hygiene care.

Based on observation, interview and record review, the facility failed to maintain nebulizer equipment (a medical device that turns liquid medication into a fine mist to be inhaled directly into the lungs for treatment of respiratory conditions) in a sanitary manner for four residents (#16, $#84, #118 and #119), of seven residents reviewed for respiratory care and ventilator/tracheostomy care. Findings include:Resident #16: On 2/22/26 at 12:09 PM, Resident #16 was observed in their room. The Resident was in bed, had a tracheostomy and was receiving mechanical ventilation. The Resident did not respond when spoke to. A connected nebulizer administration set dated 1/25 was present in a clear bag hanging behind the ventilator machine. A visible, dried, crystalized substance was observed in the medication administration chamber of the nebulizer. Record review revealed Resident #16 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included heart failure, dysphagia, gastrostomy (surgically created opening in the abdomen to the stomach for the administration of nutrition and medications), and respiratory failure with tracheostomy placement and mechanical ventilator dependance. Review of the MDS assessment dated [DATE] did not include a cognitive assessment but specified the Resident was dependent upon staff for completion of all ADLs. On 2/23/26 at 8:50 AM and on 2/24/26 at 11:17 AM, Resident #16 was observed in their room in bed. The nebulizer administrator set remained connected in a plastic bag with a dried, crystalized substance in the medication administration chamber of the nebulizer. Resident #84: On 2/22/26 at 12:19 PM, Resident #84 was observed in their room in bed. The Resident was receiving respiratory support via tracheostomy and mechanical ventilation. A nebulizer administration set was observed behind the ventilator in a clear plastic bag. The nebulizer administration set was connected, and a dried whitish colored substance was observed in the medication administration chamber. Record review revealed Resident #84 was most recently admitted to the facility on [DATE] with diagnoses which included vegetative state, gastrostomy, respiratory failure, and ventilator dependence with tracheostomy. Review of the MDS assessment dated [DATE] did not include a cognitive assessment and revealed the Resident was dependent upon others for all ADLs. On 2/23/26 at 8:21 AM, an observation of Resident #84 was completed in their room. The nebulizer administration set remained connected and hanging behind the ventilator in a clear plastic bag. The same dried, whitish colored substance was observed in the medication administration chamber. Resident #118: Resident #118 was observed in their room on 2/22/26 at 12:32 PM. The Resident was in bed, positioned on their back. Resident #118 was receiving mechanical ventilation via tracheostomy and did not respond when spoke to. A connected nebulizer administration set was present in a clear bag hanging behind the ventilator machine. A visible, dried substance was observed in the medication administration chamber of the nebulizer. On 2/23/26 at 8:42 AM, an observation of Resident #118 was completed. The Resident was in bed, positioned on their back. Mechanical ventilation via tracheostomy was in place. The connected nebulizer administration set remained hanging in a clear bag behind the ventilator, and the visible dried substance was still present in the medication administration chamber. Record review revealed Resident #118 was originally admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke) with resulting right sided hemiplegia/hemiparalysis (one sided paralysis) and dysphagia (difficulty swallowing), dementia, gastrostomy (surgically created opening in the abdomen to the to stomach for the administration of nutrition and medications), neuromuscular dysfunction of the urinary bladder, respiratory failure with tracheostomy (surgically created opening in the neck to the trachea to allow for air exchange) placement and mechanical ventilator (machine which assist and/or breaths for individuals who are unable to breathe for themselves) dependance. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was rarely/never understood and dependent upon staff for completion of all Activities of Daily Living (ADLs). An interview was completed with Respiratory Therapist (RT) O on 2/24/26 at 4:36 PM. When queried regarding procedure for care of nebulizer equipment following treatment administration, RT O stated, We empty and then shake, put back together and in bag. An observation of Resident #16's nebulizer administration set was completed with RT O at this time. When queried, RT O confirmed the present of the crystalized substance in the medication administration chamber and stated, Should not be like that. When asked if they rinse the medication administration chamber and let it air dry, RT O replied, They are disposable and we get a new one every week, so we don't do that. An interview was completed with the Director of Nursing (DON) on 2/24/26 at 4:38 PM. When queried regarding the facility policy/procedure related to care of nebulizer equipment following treatment administration, the DON stated, We rinse and air dry. Resident 119 (R119): On 2/22/26 at 10:27 AM, an observation was made of Resident 119 lying in bed watching a hockey game on the television. The Resident was interviewed, answered questions and engaged in conversation. The Resident had a tracheostomy and was connected to a ventilator. An observation was made of nebulizer apparatus that was assembled together and stored inside a bag that was hanging on oxygen supply on the wall. The nebulizer was in a bag, and the medication chamber was observed to be stored moist. A review of R119's medical record revealed an admission into the facility on 1/9/26 with diagnoses that included acute and chronic respiratory failure with hypoxia, dependence on respirator (ventilator) status, stroke and tracheostomy status. On 2/24/26 at 4:39 PM, an observation was made with the Director of Nursing (DON) of R119's nebulizer treatment equipment in the Resident's room. The nebulizer was stored in the bag and assembled together. The DON took out the nebulizer equipment out of the bag and the medication chamber was observed with moisture and multiple whiteish crystals on the inside of the medication chamber. The DON removed the nebulizer equipment and rinsed it out. When asked about facility policy on storage of the nebulizer equipment, the DON reported it should be cleaned out and set on a barrier to dry. When asked if it should have crystals in the medication chamber, the DON said, No, it shouldn't.

Based on observation, interview and record review, the facility failed to ensure that residents were treated in a dignified manner, call lights were within reach, and needs were met timely for five residents (#4, #42, #45, #53, #122) and a confidential group of residents. Findings include:Resident 4 (R4): On 2/22/26 at 1:16 PM, an observation was made of R4 lying in bed. The Resident was interviewed, answered questions and engaged in conversation. The Resident was asked about concerns with care received by the facility. The Resident expressed concerns with call light, when she put it on, sometimes it took a long time for staff to answer. When asked if she had times when the call light was not answered for 30 minutes or longer, the Resident stated, Oh hell yes, especially at nighttime. The Resident reported using the call light for assistance, getting ice or ice water, and for pain medication. The Resident reported that when she used the call light to get pain medication, she would have to wait for them to answer the call light which could be 30 minutes to an hour then have to wait longer to actually get the pain medication. A review of Resident 4 (R4) medical record revealed an admission into the facility on 6/12/25 with diagnoses that included chronic obstructive pulmonary disease, chronic pain, respiratory failure, history of falling and need for assistance with personal care. A review of the Minimum Data Set (MDS) assessment revealed a Brief Interview of Mental Status (BIMS) score of 15/15 that indicated intact cognition. Resident 45: On 2/24/26 at 11:51 AM, an observation was made of R45 lying in bed with the bed up in the high position. The Resident was interviewed, answered simple questions and engaged in limited conversation. An observation was made of the Resident's call light on the Geri chair and covered by items in the chair. The call light was positioned over the arm of the chair, and the items were on top of the call light apparatus and cord. The Resident's bed was up in a high position with the head of the bed elevated. The Resident could not see or reach the call light cord or call light apparatus. When asked about the call light not in reach, the Resident stated, It falls on the floor a lot, and that he throws things at the door to get someone's attention. Nurse N was alerted to the call light not in reach. When the Nurse entered the room with the Surveyor, the Resident started asking for his call light. The Nurse placed the call light in R45's reach, clipped it in place and lowered his bed down. When asked if the Resident should have the call light in reach, the Nurse stated, Oh, absolutely he should have had it in reach. A review of R45's MDS revealed a BIMS score of 7/15 that indicated moderately impaired cognition and needed substantial/maximal assistance with personal hygiene, rolling from side to side and was dependent on helper for transfers, dressing and toileting hygiene. Resident 122 (R122): On 2/22/26 at 1:10 PM, an observation was made of R122 lying in bed. The Resident was interviewed, answered questions and engaged in conversation. The Resident was asked about concerns with care at the facility. When asked about call light response times, the Resident stated, Sometimes you have to wait for them to answer your call light, I was left on the toilet for 30 minutes. When asked if he has had to wait more than 30 minutes, the Resident stated, yes, off and on, sometimes day shift but mostly night shift. The Nurse will answer the light and turn it off and say, 'I will let them know', then you got to wait and wait. I turn the light back on after about 10 minutes of no one showing up. A review of R122's MDS assessment revealed a BIMS score of 15/15 that indicated intact cognition and needed substantial/maximal assistance with toilet transfer and chair/bed to chair transfer and dependent on helper with toileting hygiene. On 2/25/26 at 3:07 PM, Nurse, Unit Manager M was asked about facility policy for responding to call lights. The Unit Manager stated, We should answer as soon as they go off. When asked about call lights in reach for Resident's the Unit Manager reported they should be clipped in reach for the Resident. Resident #53 (R53): A review of Resident 53's (R53) medical record revealed an admission into the facility on 6/27/24 with diagnoses that included hemiplegia and hemiparesis (weakness and paralysis affecting left dominant side), muscle wasting and atrophy, attention and concentration deficit, cerebrovascular disease (decreased blood flow to the brain). A review of the Minimum Data Set (MDS) assessment revealed a Brief Interview of Mental Status (BIMS) score of 00/15 that indicated severe problems with memory or thinking. On 02/23/2026 at 8:12 AM, An observation was made of R53's call light laying on the floor at the head of the bed and not in the residents reach. On 02/23/2026 at 8:18 AM, CNA Q was asked about R53's location of her call light and she said it was on the floor but should not be, she picked it up and clipped it to R53' blanket. Record review of R53's care plan revealed: Focus: Resident has an ADL self-care performance deficit related to generalized weakness. with Interventions that included: Place call light within reach. A record review of the facilities policy titled Call lights: accessibility and timely response revealed: Policy. assure the facility is adequately equipped with a call light at each resident's bedside, toilet and bathing facility to allow for residents to call for assistance. Confidential Group of Residents On 02/23/2026 at 2:38PM, a meeting was held with a confidential group of residents and family. The following concerns were brought up by the group. -The confidential group agreed they all wait a long time to have their call light answered. The confidential group stated, the nursing staff has a habit of coming in the room and turning off the call light without completing the task or they say, I'll be right back and they never come back. The confidential group agree that the nursing staff will then get upset if they turn their call light back on after they leave the room. -The confidential group agrees that their call lights are on the floor a lot or out of reach. -The confidential group are concerned that the nursing staff have personal conversations they can hear. Stating they will talk about other residents and can be overheard. The confidential group stated that staff will talk to each other and not to the resident when providing care, often times talking about other residents or their personal lives. The confidential group stated that the staff likes to visit in the room and not complete tasks timely. -A confidential family member was present at the meeting and stated there have been times she will have to call the facility to get her brother help because he cannot reach his call light and is in need of suctioning. The family member stated this occurs a lot on the weekends or after 7:00pm. Resident #42 R42 most recently admitted to the facility on [DATE] with diagnoses that include chronic respiratory failure, ventilator dependence and muscular dystrophy. On 02/24/2026 at 4:11PM, R42 stated that he has limited use of his hands and his call light is a press pad that gets placed on the headrest of his power chair, so he is able to turn it on by moving his head backwards. R42 stated that his call light is out of reach at times and he has to yell to get help.

Based on interview and record review, the facility failed to ensure advance directives were completed appropriately and the care plan for advance directives was updated for one resident (R130) of six residents reviewed for advance directives, resulting in one cognitively impaired resident changing their code status and an inaccurate care plan. Findings include:Resident #130 (R130): R130 admitted to the facility on [DATE] with diagnoses that include peripheral vascular disease, heart disease, hypertension and cognitive communication deficit. R130 expired at the facility on [DATE]. On [DATE] at 10:18AM, record review revealed a physician's order for do not resuscitate (DNR) dated [DATE] at 10:39am. Record review also revealed a physician's order for Full Resuscitate, dated [DATE] and it was discontinued on [DATE], when the DNR order was placed. On [DATE] at 10:21AM, the care plan for R130 was reviewed, a care plan for advance directives was present and stated, Resident has chosen not to formulate advanced care planning. The care plan was dated [DATE] and had not been updated with changes. On [DATE] at 10:30AM, review of the Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. On [DATE] at 11:03AM, an interview was conducted with Social Worker (SW J. SW J was asked what the process is for completing advance directives for residents who are cognitively impaired. SW J said if a resident is cognitively impaired, we will get a competency from the physician. SW J stated that R130 had a BIMS of 11 on admission, which is in the moderate area. SW J stated that R130's advance directive at that time was to be a DNR and that was on [DATE]. SW J stated that R130 was seen by psych in October, her psych note does not indicate that she was incompetent. SW J stated, we do have forms for decision making, however this resident does not have one in the chart. The psych group did not indicate that she needed this form filled out. SW J was asked why R130 was able to sign her own paperwork for DNR on [DATE] if her BIMS was documented as a 3, indicating severe cognitive impairment. SW J stated, to the best of my knowledge, after the nursing staff talked with R130, they felt she was cognitively intact and able to make that decision to be a DNR. Then I approached her and filled out the paperwork with her to be a DNR. SW J was asked what they would do in a code status situation where a resident has a low score on the BIMS, indicating severe cognitive issues. SW J stated we would check the BIMS score for a score of zero to seven (0-7), then we are going to have the doctor look at them for a competency, then I would call the family and have them come in and we would discuss the code status. SW J stated we didn't have any competency form to go off of and that is why she was able to make the decision on code status. SW J was asked if they thought R130 should have had a competency check prior to signing the DNR status and if family should have been involved in the decision making. SW J stated, I agree that we should have completed the competency for her before deciding on a code status. At the end of the conversation SW J provided this surveyor with a completed BIMS, dated [DATE] with a score of 11, indicating mild cognitive impairment. On [DATE] at 1:21PM, record review of the electronic medical record (EMR) revealed there was no documentation indicating a conversation had taken place to discuss code status with R130 or the responsible party. On [DATE] at 1:25PM, record review of the EMR revealed a progress note dated [DATE] at 02:50AM that read, resident confused at baseline, calling out, frequently using call light. Resident has call light in hand and states that she doesn't need anything but wants the light to remain on. Resident attempted to self-transfer several times, redirection and education provided. Further education needed. On [DATE] at 10:10AM, record review of the EMR revealed a psychiatry initial evaluation, which states that R130 has a BIMS of 3. Review of the policy titled, Resident's Rights Regarding Treatment and Advance Directives, revealed: Policy Explanation and Compliance Guidelines: 4. The facility will periodically assess the resident for decision-making abilities and approach the health care proxy or legal representative if the resident is determined not to have decision making capacities.8. Decision's regarding advance directives and treatment will be periodically reviewed as part of the comprehensive care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions.

Based on observation, interview and record review, the facility failed to ensure that residents' Minimum Data Set (MDS) assessments accurately reflected the residents' status for one resident (Resident #32) of one resident reviewed for MDS discrepancies.Findings include:Resident #32 (R32):A review of R32's medical record revealed an admission into the facility on [DATE] with diagnoses that included dementia, sciatica, and the history of falling. A review of the Minimum Data Set (MDS) assessment revealed a Brief Interview of Mental Status (BIMS) score of 3/15 that indicated severe problems with memory or thinking.A record review of R32's MDS assessment dated [DATE], section N-Medications indicated: N0300. Injections: Record the number of days that injections of any type were received during the last 7 days or since admission/entry. entry 7 (days). and N0350. A. Insulin injections: Record the number of days that insulin injections were received during the last 7 days. entry 7 (days); B. Orders for insulin: Record the number of days the physician (or authorized assistant or practitioner) changed the resident's insulin orders. entry 0 (days). That Indicated R32 had an order for and received insulin without a change in orders by a physician. The MDS assessment Signature of RN assessment coordinator verifying assessment completion was signed on 01/22/2026 by MDS Nurse C.On 02/24/2026 at 8:00AM, During medication pass an observation of R32, no insulin was given and observed there was no insulin ordered on the medication administration record (MAR) for R32.A record review of R32's Orders revealed no orders for insulin. R32's medical chart did not include a diagnoses that indicated the need for insulin.On 02/25/2026 at 10:45AM, During an interview with MDS Nurse S was asked to review MDS assessment dated [DATE] for R32 and she confirmed it indicated it identified 7 days of insulin injections with 0 changed orders for the identified time period. MDS Nurse S was asked to review and confirm R32's medical diagnoses that required insulin use, she could not. MDS Nurse S was asked to review orders for R32 for insulin, she could not. MDS Nurse S was asked to review progress notes that indicated use of insulin for R32, she could not. MDS Nurse S reviewed the MAR for R32 and verified no insulin had been administered to R32. MDS Nurse S confirmed that R32's MDS assessment for 01/19/2026 was not accurate. MDS Nurse S stated I have time to correct it and resubmit it to the state and that she was doing that as we spoke.On 02/25/2026 at ~(approximately) 11:25AM, MDS Nurse S produced a revised CMS submission report for NH MDS 3.0 validation report with ID #35344505 that had been accepted on 02/25/2026.

Based on observation, interview and record review, the facility failed to implement planned interventions for contracture management for one resident (Resident #16) of three residents reviewed resulting in lack of application of splints. Findings include:Resident #16:On 2/22/26 at 12:09 PM, Resident #16 was observed in their room. The Resident was in bed, positioned on their back with their head turned slightly to the left. Resident #16 had a tracheostomy and was receiving mechanical ventilation. The Resident's eyes were closed, and they did not respond to verbal stimulation. Resident #16's hands were bent towards their inner arm at the wrist joint as though contracted and their legs were bent at the knees. The Resident did not have any devices including splints/braces in place on their upper and/or lower extremities. Record review revealed Resident #16 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included heart failure, right and left knee contractures, gastrostomy (surgically created opening in the abdomen to the stomach for the administration of nutrition and medications), and respiratory failure with tracheostomy placement and mechanical ventilator dependance. Review of the MDS assessment dated [DATE] did not include a cognitive assessment but specified the Resident was dependent upon staff for completion of all ADLs. The MDS further detailed the Resident had impaired Range of Motion (ROM) in both upper and lower extremities. Review of Resident #16's Electronic Medical Record (EMR) revealed a care plan entitled, Resident would benefit from a restorative splinting program related to contracture, decreased strength in extremities, limitation in range of motion (Initiated: 7/24/25). The care plan included the intervention, Donn sidelyn (sic) leg and knee abductor wedge, left hand splint and left elbow support and remove after 4-5 hours. Continue with daily skin checks as protocol of facility. Perform hand hygiene daily prior to placement of orthotic. Position with pillow on left side of knee to promote neutral position (Initiated: 7/24/25; Revised: 10/16/25). On 2/24/26 at 11:17 AM, Resident #16 was observed in their room. The Resident was in bed with their head positioned slightly to the left. Splints were in place on both of the Resident's arms by their wrists. The Resident's knees remains bent at their knees with no devices and/or braces in place. - Restorative Nursing: PROM (Passive Range of Motion)-BLE (Bilateral Lower extremities) move in all planes and motions to each extremity and each joint with a goal of 10 reps and 2 sets each (as tolerated) 3-5 days/week (Ordered: 1/8/26). Review of Resident #16's Health Care Provider (HCP) Orders and Documentation Survey Report for February 2026 (from 2/1/26 to 2/24/26) revealed the following:- Restorative Nursing: Splint/Brace Assistance (12h) Donn sidelyn leg and knee abductor wedge, left hand splint and left elbow support and remove after 4-5 hours. Continue with daily skin checks as protocol of facility. Position with pillow on left side of knee to promote neutral position.Per the legend, documentation of the code 4 meant the task was not completed. The task was documented as not completed on 2/3/26, 2/6/26, 2/7/26, 2/10/26, 2/13/26, 2/21/26, 2/22/26 Day Shift.On Night Shift, the task was documented as not completed 22 out of 24 times.There was no documentation (blank) of the task being completed on 2/2/26, 2/16/26, 2/17/26, and 2/18/26 Day Shift. On 2/24/26 at 2:43 PM, an interview was conducted with the Director of Nursing (DON). When queried regarding observations of Resident #40 not having their brace in place as ordered and documentation indicating the task was not completed, the DON indicated staff should complete the task and document as completed. Review of facility policy/procedure entitled, Restorative Nursing Programs (Reviewed/Revised: 1/1/22) revealed, Restorative documentation requirements include. Documentation of implementation should be completed on the Restorative Service Delivery Record or EMR as applicable. This includes each description of the intervention or modality to be provided. Time in minutes each time provided. Staff initials each time provided. Comments if refused, withheld or change in status (improvement/decline) as applicable.

Based on observation, interview and record review, the facility failed to ensure that tube feeding was administered per professional standards of practice and the plan of care for one resident (Resident #40) of two residents reviewed. Findings include: Resident #40: On 2/23/26 at 10:40 AM, Resident #40 was observed in their room. The Resident was in bed, positioned on their back. The head of Resident #40's bed was elevated at 17 degrees per protractor tool, and they were receiving tube feeding via infusion pump at a rate of 43 milliliters (mL) per hour. At 10:47 AM on 2/23/26, Registered Nurse (RN) Z was asked to come into Resident #40's room. When asked how high the head of the Resident's bed was elevated, RN Z stated, I don't know. 20 or 30 degrees, I'm not good at that. RN Z was then asked was the head of the head should be elevated to when a resident is receiving tube feeding and replied, 30 degrees in a questioning tone. RN Z proceeded to elevate the head of Resident #40's bed and exit the room. Record review revealed Resident #40 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cerebrovascular disease, skin transplant, gastrostomy (surgically created opening in the abdomen to the stomach for the administration of nutrition and medications), and colostomy (surgically created opening in the abdomen to the colon to redirect fecal waste into an external bag). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was rarely/never understood and required total assistance with mobility and ADLs with the exception of maximum assistance for oral hygiene completion. A review of Resident #40 Electronic Medical Record (EMR) revealed a care plan entitled, Resident has an impaired gastrostomy status related to gastrostomy tube for enteral feeding. (Initiated: 2/24/25; Revised: 7/11/25). The care plan included the intervention, HOB (Head of Bed) >30 (degrees) when tube feed is being administered. Encourage resident to stay upright for a short time after meals (Initiated and Revised: 2/24/25). An interview was conducted with the Director of Nursing (DON) on 2/24/26 at 4:15 PM. When queried how high the head of the bed should be elevated when a resident is receiving tube feeding, the DON responded that it should be elevated to a minimum of 30 degrees. The DON was informed of observation involving the head of Resident #40's bed and interview with RN Z. The DON responded that RN Z is new and they will educate them. A policy/procedure related to tube feeding administration was requested at this time but not received by the conclusion of the survey.

Based on observation, interview and record review, the facility failed to ensure that physical restraints were not used for staff convenience for one resident (Resident #118) of one resident reviewed, resulting in restriction of mobility. Findings include: Resident #118:Resident #118 was observed in their room on 2/22/26 at 12:32 PM. The Resident was in bed, positioned on their back. The bed was at normal height and fall mats were in place. The two upper side rails on the Resident's bed were raised. Resident #118 was receiving mechanical ventilation via tracheostomy and did not respond when spoke to. Record review revealed Resident #118 was originally admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke) with resulting right sided hemiplegia/hemiparalysis (one sided paralysis) and dysphagia (difficulty swallowing), dementia, gastrostomy (surgically created opening in the abdomen to the to stomach for the administration of nutrition and medications), neuromuscular dysfunction of the urinary bladder, respiratory failure with tracheostomy (surgically created opening in the neck to the trachea to allow for air exchange) placement and mechanical ventilator (machine which assist and/or breaths for individuals who are unable to breathe for themselves) dependance. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was rarely/never understood and dependent upon staff for completion of all Activities of Daily Living (ADLs) including bed mobility. The MDS further detailed the Resident did not have any restraints in place and bed rails restricting movement were not in place. On 2/23/26 at 8:42 AM, an observation of Resident #118 was completed in their room. The Resident was in bed, positioned on their back. Resident #118 was receiving mechanical ventilation via tracheostomy. The bed was a hospital bed, positioned at normal height with all four separate bed rails raised. A gap was present on each side of the bed between the upper and lower bed rails. Fall mats were observed on both sides of the bed and the Resident was observed to have a contracture in their left upper extremity/hand. Review of Resident #118's Electronic Medical Record (EMR) revealed a care plan entitled, Resident is at risk for falls/injury. has decreased strength and endurance with poor balance and coordination. non ambulatory. total assist with care for all ADL and functional mobility (Initiated and Revised: 11/17/23). The care plan included the interventions:- 5/15/24- fall mat to bilateral sides of resident's bed (Initiated: 5/16/24; Revised: 8/1/24)- Low bed (Initiated: 11/16/23)- Discuss and document the risks and benefits, when evaluating bed modifications, and any other concerns or issues related to the bed modification with the resident/representative (Initiated: 10/2/25)- Scoop mattress LAL (Low Air Loss) to provide resident with tactile barrier to improve spacial awareness (Initiated and Revised: 4/19/24)- [NAME] bed (brand)- side rails for safety and support (Initiated and Revised: 10/2/25)The care plan did not indicate the number of side rails which should be raised/elevated. Review of Progress Note documentation in Resident #118's EMR revealed no documentation pertaining to use of side rails. A scanned document titled, Informed Consent for Use of Bed Rails was present in Resident #118's EMR. The form detailed, Resident Overview: What assessed medical needs would be addressed by the use of bed rails for this resident? Immobility; Mobility loss. What are the possible benefits of bed rail use and what is the likelihood of these benefits: Increased bed mobility, safety, security. What are the possible risks of bed rail use for this resident and how will these risks be mitigated: entrapment. Alternatives to bed rails have been attempted but failed to meet this resident's needs, or were not attempted because they were considered to be inappropriate, describe PT (Physical) therapy. Recommendation. Full side rail Right. Left. recommended at all times when resident in bed. The form indicated verbal consent was obtained by Resident #118's representative on 9/17/25. On 2/24/26 at 11:56 AM, an observation of Resident #118 in their room was completed. The Resident was in bed with three side rails elevated including both upper rails and the bottom left rail (closest to room door). An interview was completed with Certified Nursing Assistant (CNA) C on 2/24/26 at 11:59 AM. When queried how many side rails were supposed to be raised on Resident #118's bed, CNA C replied, Probably two. CNA C was asked how they know how many side rails should be raised/elevated and stated, I assume supposed to be two because it would be restraint with more side rails raised/elevated. When queried regarding the number of side rails currently raised/elevated on Resident #118's bed, CNA C stated, There were three (side rails) up when I got here so I just left them. CNA C was asked why there were three side rails raised and replied, (Resident #118) wiggles. With further inquiry CNA C verbalized three side rails were raised so Resident #118 don't wiggle off the bed. When queried why the bed rails were elevated instead of completing frequent checks to ensure appropriate positioning in bed, CNA C did not provide an explanation. CNA C was then informed of observation of all four side rails being elevated on 2/23/26 and asked if they knew why the rails would be elevated. CNA C revealed staff will raise the bed rails so Resident #118 does not wiggle down and attempt to put their leg over the side of the bed. On 2/24/26 at 12:02 PM, an interview was conducted with Registered Nurse (RN) A. When queried how they know how many side rails are supposed to be raised/elevated on a resident's bed, RN A responded, It should say on the Kardex. When asked how many side rails Resident #118 should have raised/elevated, RN A reviewed the Resident's Kardex in the EMR and responded, It doesn't say. RN A then stated, I would say two (side rails elevated) because otherwise it would be a restraint. At 12:10 PM on 2/24/26, the same three side rails remained elevated on Resident #118's bed. An interview was completed with the Director of Nursing (DON) on 2/24/26 at 2:42 PM. When queried how many side rails Resident #118 should have raised/elevated on their bed, the DON stated, Two. Observations of Resident #118 having three and four side rails raised/elevated were reviewed with the DON at this time. When queried regarding the use of three or four side rails, the DON stated, That would be a restraint. The DON was then queried regarding the reason staff were raising three to four side rails and replied, I can only assume why staff were doing that and indicated they did not have an answer. On 2/24/26 at 3:51 PM, a follow up interview was completed with the DON. When queried regarding the Informed Consent for Use of Bed Rails form in Resident #118's EMR pertaining to full rails, the DON replied that the consent was for the use of the two upper bed rails only. Review of facility policy/procedure entitled, Restraints (Reviewed/Revised: 10/26/23) revealed, Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. 1. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). An evaluation will be completed to determine the medical symptom requiring the device and to determine the least restrictive device to treat the symptom. 2. Restraints with locking devices shall not be used. 6. Physical restraints shall only be used on the signed order of a physician, except in an emergency. Care plans which include the use of physical restraint for behavior control shall specify the behavior to be eliminated, the method to be used, and the time limit for the use of the method. Review of facility policy/procedure entitled, Proper Use of Bed Rails (Reviewed/Revised: 3/20/24) revealed, It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance. Ongoing Monitoring and Supervision: 15. The facility will continue to provide necessary treatment and care to the resident who has bed rails in accordance with professional standards of practice and the resident's choices. This should be evidenced in the residents' 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 the bed rails, including documentation of the monitoring. 16. Responsibilities of ongoing monitoring and supervision are specified as follows: a. Direct care staff will be responsible for care and treatment in accordance with the plan of care.

This citation pertains to Intake Number 2607274.Based on observation, interview, and record review, the facility failed to obtain an appropriate resident assessment, physician's order, develop a care plan, and provide entrapment measurements to ensure that a resident is free from physical restraint for one resident (Resident #107) (R107) of 3 residents reviewed for use of side rails. Findings include:Resident #107 (R107):R 107 was observed in his room on September 10, 1925, at 2:00 PM. R107 was awake, lying in bed with an ongoing continuous tube feeding via pump being delivered, while R107 was restless in bed. The bed was observed in the lowest position; however, R107 appeared to be attempting to get out of bed, but the side rail was preventing him from falling out of the bed. It was noted that the floormat was placed on the floor on his right side. R107 had a padded full rail attached to the bed.During observation, Nurse K on 9/10/25 at 2:05 PM, was asked why R107 had a bedrail. Nurse K revealed he is a fall risk and may often get confused at times. Nurse K explained she was not the nurse assigned to R107 today.A review of R107's Electronic Medical Record (EMR) was conducted on September 10, 2025, at 12:00 PM. R107 was [AGE] years old and was admitted to the facility on [DATE], with the diagnosis of End Stage Renal Disease with dependence on Renal Dialysis, Gastrostomy feeding, difficulty walking, and muscle weakness in addition to other diagnoses. R107's Brief Interview of Mental Status (BIMS) Score assessed on 6/24/25 was 04/15. A BIMS score of 4 /15 indicates severe cognitive impairment. R107's Care Plan for Activities of Daily Living (ADL) required two-person assistance for Bathing, Bed Mobility, Dressing, Personal Hygiene, and Transferring.Further review of R107 Clinical Record revealed:No care plan for the use of bed rails was found in the R107 Plan of Care. There was no mention of side rails in the fall prevention care plan.No Informed Consent was found for the Use of Side rails, and no side rails assessment for R107 was found.No Initial entrapment measurements/grid of R107's bed/side rails were found.No physician orders for the use of siderails/bedrails were obtained.On 9/11/25 at 11:35 AM. The Director of Nursing (DON) and the Unit Manager were both interviewed.The DON and Unit Manager both confirmed that they did not find a consent for R107's side rails, no assessment was done for the appropriateness of side rails, no entrapment grid/measurements were taken, no physician orders were given for side rails, and no care plan was created for R107 regarding the use of side rails. The DON stated, R107 was admitted sometime in May of 2025, and he had a fall in June 2025. We missed following the protocol for R107 siderails. The Social Services Director (SSD) was interviewed on September 11, 2025, at 11:30 AM. The SSD revealed that she only does consent for the residents' Advanced Directives and Antipsychotic Meds. The consents for side rails are nursing responsibilities. R107 was deemed incapacitated, but the wife may also have dementia issues and can not be reliable with obtaining consents. SSD revealed that they have started a court-appointed guardian process for R107. Policy Review revealed:I. Restraints Policy (Date Reviewed/Revised: 10/26/2023)Policy: Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Policy Explanation and Compliance Guidelines: Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). An evaluation will be completed to determine the medical symptom requiring the device and to determine the least restrictive device to treat the symptom.II. Side Rails Policy date reviewed/revised 10/26/23Policy: It is the policy of this facility to utilize a person-centered approach when determining the use of side rails. Alternative approaches are attempted prior to installing a side or bed rail. If used, the facility ensures correct installation, use, and maintenance of the rails.The facility's definition of:Physical restraint is defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria:a. Is attached or adjacent to the resident's body;b. Cannot be removed easily by the resident; andc. Restricts the resident's freedom of movement or normal access to his/her bodyThe Policy Explanation and Compliance Guidelines:.c. Obtain informed consent from the resident or the resident's representative for the use of bed rails before installation/use.d. Determine whether or not the side/bed rail is a restraint. Side/bed rails will be considered a physical restraint when they limit the resident's freedom of movement and cannot be removed easily by the resident. In such cases, the facility shall follow procedures related to physical restraints.e. Document the medical diagnosis, condition, symptom, or functional reason for the use of the side/bed rail.f. Obtain physician orders for the use of side/bed rails . 4. The facility will assure the correct installation and maintenance of bed rails, prior to use. This includes:a. Checking with the manufacturer(s) to make sure the bed rails, mattress, and bed frame are compatible.b. Ensuring that the bed's dimensions are appropriate for the resident.c. Confirming that the bed rails are appropriate for the size and weight of the resident using the bed.d. Installing bed rails using the manufacturer's instructions to ensure a proper fit.e. Inspecting and regularly checking the mattress and bed rails for gaps and areas of possible entrapment.f. Checking rails regularly to make sure they are still installed correctly, and have not shifted or loosened over time.5. The use of side rails will be specified in the resident's plan of care.a. Side rails that are permanently installed on the bed frame shall not be used, even incidentally, without proper assessment, informed consent, and physician orders.b. Once side/bed rails are installed, the facility will ensure side rail/bed rail usage does notprohibit necessary treatments and resident care. Care and treatments will continue to beprovided in accordance with professional standards of practice and resident choices.

This citation pertains to intake Number 2607274.Based on observation, interview, and record review, the facility failed to ensure that Enhanced Barrier Precautions (EBP) were implemented according to the plans of care for two residents (Resident #107 and Resident #104) of the three residents reviewed for Infection Prevention and Control. Findings include: Resident #107 (R107): A review of the Electronic Medical Record (EMR) was conducted on 9/10/25 at 12:00 PM. R107 was [AGE] years old and was admitted to the facility on [DATE], with the diagnosis of End Stage Renal Disease with dependence on Renal Dialysis. R107 had a gastrostomy, a hemodialysis port, difficulty walking, and muscle weakness in addition to other diagnoses. R107's Brief Interview of Mental Status (BIMS) Score assessed on 6/24/25 was 04/15. A BIMS score of 4 /15 indicates severe cognitive impairment. R107's Care Plan was noted: Activities of Daily Living (ADLs) required two-person assistance for Bathing, Bed Mobility, Dressing, Personal Hygiene, and Transferring. Enhanced Barrier Precaution (EBP) Care Plan specified: Resident requires enhanced barrier precautions related to central line, dialysis, and feeding tube (initiated on 57/25 revision on 6/17/25) Use a gown and gloves when providing direct care. `Face protection may be needed if performing an activity with a risk of splash or spray. Utilize EBP 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). Review with visitors and family member show to follow the recommended precautions when visiting if prolonged physical contact is anticipated. During observation, R107 was in his room on September 10, 2025, at 2:00 PM. R107 was observed awake, lying in bed with an ongoing continuous tube feeding being delivered. During observation, Nurse “K” on 9/10/25 at 2:05 PM, went into R107 and noticed that there was no signage of EBP outside or anywhere by the door of R107's room. Nurse “K” revealed that the roommate of R07 also goes to hemodialysis. Nurse “K” was asked how a visitor, family member, or guest would know if a resident requires special precautions to prevent the spread of infection. Nurse “K” stated, “There should have been a sign right by the door to alert everyone.” Nurse “K and the surveyor searched inside R107 room and did not find the laminated EBP sign. Nurse “K” was asked where she would find Personal Protective equipment if she were to unhook the Gastrostomy Tube feeding from the feeding tube. Nurse “K” looked everywhere in the room and did not find PPE in R107's room. There was no Personal Protective Equipment (PPE) Cart outside the hallway and inside the R107 room. There were no carts found anywhere in the 500 hallway. Nurse “K” was asked where she would go to get PPE. Nurse “K” stated that she would go inside other residents' rooms that have PPE carts inside their rooms. The surveyor asked Nurse “K”. Is that what you're supposed to do each time you need PPE? Get the PPEs in other residents' rooms. Nurse “K” hesitated and said, “I guess not.” On September 11, 2025, at 11:00 AM, an interview with the Infection Control Nurse (ICP Nurse) was conducted. She admitted that there should have been a sign and a cart nearby for PPE. R107 is vulnerable because he has a feeding tube and a port used for hemodialysis. The Care Plan was not followed. We conducted a sweep to ensure that carts were available for staff, signs were posted, and PPEs were readily accessible. On 9/11/25 at 11:25 PM. The surveyor discussed the EBP findings of R107 to both the Director of Nursing and the Unit Manager. The Facility Policy for Enhanced Barrier Precaution and Infection Control Protocol was reviewed on 9/11/25 at 2:30 PM. Resident #104 (R104): Record review of Resident 104's (R104) Medical records revealed medical diagnosis of: Traumatic Brain Injury (TBI) with major neurocognitive disorder (non-verbal), seizures, chronic sacral stage IV (full thickness) pressure ulcer and thoracic spine wound with infection (Pseudomonas Aeruginosa and Methicillin Susceptible Staphylococcus Aureus (MSSA) infection), muscle wasting, and needed assistance with personal care. On 09/10/2025 at 1:48 pm, an observation of R104 was made of resident resting in bed with eyes closed, R104's call light was on the floor and in the corner of the room and not in reach of resident. On 09/10/2025 at 2:02PM, During an interview with Nurse “F” about R104, she reported that R104 was recently at the hospital for a declining wound on sacrum/back. She stated, “she (R104) used to be on intravenous (IV) antibiotics (ABX) but is not on IV ABX anymore, she was recently put on oral ABXs for diagnosis of cellulitis (infection), I think it is for Pseudomonas and MRSA (methicillin resistant staphylococcus aureus)”. She said R 104 was no longer on tube feed and currently had a urinary catheter in place. It was confirmed by a record review of R104's medical chart progress notes dated 08/14/2025 that the resident was sent to hospital on [DATE] and returned to facility 08/20/2025. According to record review of hospital discharge notes from 08/18/2025 R104's diagnosis included: “T-Spine significant cellulitis of upper back concern for necrotizing fasciitis…”. Review of labs from hospitalization revealed, “MSSA and Pseudomonas infection” and that R104 received IV Vancomycin (antibiotic) while hospitalized . On 09/11/2025 at 12 Noon, An observation of R104 room with no enhanced barrier precautions posted neither inside nor outside. On 09/11/2025 at 12:02 PM, During an interview with nurse “F” she was asked how she would identify a resident in enhanced barrier precautions (EBP) and she stated, there would be a sign outside residents' door. Nurse “F” was asked if she could show where the signage was located that identified the precautions for R104. Nurse F walked over to the R 104 room door and verified that there was no sign present inside nor outside of R104's room. Nurse F stated, “I am not sure where it is”, and “one should be there for her”. Nurse “F” agreed that R104 had both a PICC and a tube feeding recently discontinued, and that R104 currently had an indwelling urinary catheter and infected wounds. Nurse “F” further agreed R104 was highly susceptible to transmission of pathogens. Nurse “F” points out an EBP personal protection equipment (PPE) drawer unit that is inside R104's room. The PPE drawer unit she pointed out was in front of R104's roommates' bed and the observation of contents revealed it had scant PPE in it, consisting of only a couple of gowns. On 09/11/2025 ~2 PM, During interview with DON she confirmed that residents in precautions will have sign indicating the type of precautions (enhanced, contact etc.…) needed outside the residents' room doors to alert staff, family and visitors. A record review of facility progress notes dated 08/22/2025 stated, “Resident recently hospitalized for declining wound. Patient presented to the hospital with worsening wounds of the sacrum and lower back. Patient has a history of chronic sacral ulcer which has been treated at our facility stage IV. Patient was also having cellulitis of the thoracic spine there was a concern for necrotizing fasciitis. Patient had a debridement done on August 15, 2025 by surgery. Patient was seen by infectious disease placed on IV antibiotics. Patient was subsequently stabilized and transferred back to our facility. Patient continues to be on IV antibiotics…”. A record review of R104's medical chart there was an order dated 08/21/2025 that read: “Use enhanced barriers while performing high-contact activity with the resident. PEG – Wound”. A record review of R104's physician and pharmacy section there was an order dated 09/04/2025 that read, “Cipro Oral Tablet 500 MG Give 1 tablet by mouth every 12 hours for Wound infection for 14 Days give with meals. Amoxicillin-Pot Clavulanate 875-125 MG Tablet Give 1 tablet by mouth every 12 hours for Wound infection for 14 Days give with meals”. A record review of R104's care plan revealed, Interventions: Use gown and gloves when providing direct care. Face protection may be needed if performing activity with risk of splash or spray. Date Initiated: 03/14/2025; Utilize Enhanced Barrier Precautions when providing high contact resident care activities (dressing, bathing, transferring, personal hygiene, changing linens, changing briefs/assisting with toileting, device care: central lines, urinary catheters, feeding tubes, tracheostomy/ventilators, wound care, dialysis) Date Initiated: 03/14/2025; Review with visitors and family members how to follow the recommended precautions when visiting if prolonged physical contact is anticipated Date Initiated: 03/14/2025”. According to a record review of the facility's Policy & Procedure labeled infection control plan revealed, Isolation signs are used to alert staff, family members and visitors of transmission-based precautions”. According to the facility's policy on Enhanced Barrier Precautions: “Enhanced barrier precautions refer to an infection control intervention designed to reduce the transmission of Multidrug-resistant organisms that employs targeted gown, and gloves use during high-contact resident care activities” and “Initiation of enhanced barrier precautions… iii. Infection colonized with a CDC-targeted MDRO when contact precautions do not apply”.

This citation pertains to Intake #1223361Based on observation, interview, and record review the facility failed to ensure that an adequate supply of clean linen was distributed and consistently delivered to residents' areas on a daily basis.Findings include:An observation tour with the Administrator was conducted on [DATE], between 2:55 PM and 3:15 PM. All six linen closets were checked. The Administrator agreed there was not a lot in each closet for the census of 125 residents in the facility, considering the time of day. She stated she is unsure of the laundry department schedule for hall deliveries.On [DATE] at 3:30 PM, an interview with Certified Nursing Assistant B (CNA B).CNA B has worked at the facility for 2 years and stated, Linen is a problem every day. I have to look for linen all the time. I go to the basement to find the linens I need because it is not in the closet. We had to go to nearby units, and sometimes they are all empty or lack the necessary items. I work a 12-hour shift from 7:00 AM to 7:00 PM. There are not enough linens. I have to go to both ends of the hall and then go down to the basement to get more sheets, towels, and washcloths. There's only one laundry staff every 8-hour shift, and sometimes I find housekeeping helping. When CNA B was asked if she had cut sheets/linens to use for washing and personal care on residents, she admitted she had not done it herself but had heard it being done by other aides. There are no delivery times set for laundry department to deliver the clean linens. Oftentimes, we have to get them from the laundry room.According to Registered Nurse D (RN D) on [DATE] at 4:00 PM, linens are an issue. Most often during residents' showers and peri care, there are no towels and wash cloths available in the closet. There's nobody consistently restocking the linen closet in each unit. Since the facility got rid of the wipes, the lack of adequate linens made the problem worse. Our aides are off the floor trying to find their supplies. There are not enough staff to attend to patient care and call lights. Nurse D stated, I don't know what they're working on, but they (Administration) said they are working on it. I sometimes feel my CNAs are not in their unit because they are constantly looking for linens. Showers may take longer, and there is a delay in incontinence care, causing skin breakdown, because they have to find sheets or if the resident requires two-person assistance. Sometimes, I end up the only one in the unit because all CNAs have to look for their linens to provide basic care. Nurse D revealed there is no set schedule for laundry delivery of clean linens.An interview with a certified Nurse Aide C (CNA C) was conducted on [DATE] at 4:35 PM. CNA C (who wanted to remain anonymous) revealed there were not enough linens in the entire shift. If you need two people, you can't find any other staff to help you because they try to find linens in different units or go down to the laundry. They don't distribute it on a consistent schedule. We had to get them downstairs, or sometimes no staff in the laundry. Because of that, staff are not immediately present for patient care, and floats are not available to cover all halls. We sometimes wait and grab the unit manager. CNA C further explained that: The facility have an outside agency for the entire laundry department. When shift start, we barely have linens. Some staff cut sheets to provide care. She stated that: Although I have not done it, I have heard and seen linens cut up to use for care in desperate times. When I come in, I immediately go to the basement. I have noticed the staff:Throw away towels in the trash. They are soiled. They may not want residents to reuse them after being discolored with brown stains after washing. Staff throw away towels and washcloths.It takes a long time to find linen supplies because they are in short supply.Leave the unit to find available linens. As a result, CNAs are not accessible, and staff are away too long to attend to residents' care needs.Leave the unit, and residents are left wet for a prolonged time with skin breakdown.On [DATE], at 9:30 AM, the surveyor met with the Administrator. The second linen closet tour was conducted. This time, there were linens, but they were not full at each unit: Ambassador East & West, the Memory 300 hall, 400, 500, 600, and 650 halls. The Administrator confirmed there is no set delivery and distribution schedule for linens to the floors.R#505On [DATE] at 9:41 AM, Resident #505 (R505) was interviewed regarding linen availability. R505 indicated that there is often a shortage of linens, particularly the washcloths & towels. R505 expressed having to wait until it is washed in the laundry, and it seemed that they don't have enough people to do the laundry. R505 verbalized, They come and change me because they don't let me get up. I had to wait wet and soaked until they gathered the needed supplies from the laundry. Sometimes it could take a while.R505 was [AGE] years old, alert and oriented, with a BIMS (Brief Interview for Mental Status score of 15/15 assessed on [DATE]. A score of 15 means that the individual is cognitively intact. R505's Electronic Medical Record revealed that she was admitted to the facility on [DATE]. Her care plan [DATE], specified resident at risk for impaired skin integrity related to weakness, and decreased mobility, respiratory failure, COPD, type II Diabetes Mellitus, obstructive sleep apnea, CPAP use, and heart failure in addition to other diagnoses.An interview with Nurse E was conducted on [DATE] at 9:51 AM. Nurse E checked and tidied up R505's fitted sheet as it was coming off the bed. Nurse E stated, It is true that some days, linen shortage is a problem.R#507An interview with R507 was conducted on [DATE], at 10:12 AM. R507 stated that she always kept the wipes she purchased with her. R507 explained that she would only need a top sheet and usually would take a bit of a wait. Furthermore, she stated, Washcloths are rough to old and very fragile skin, and some washcloths are brown. It's almost tea colored and not white. I wonder if they wash the linens well enough to be used for residents' faces. R507 insisted, I can see it (implying the tea-colored washcloth), but others may not be able to tell. Staff take a while to come back with linens because they spend more time searching for them. In my opinion, the facility must take proper care of its patients. They need to have adequate linens for staff to provide care properly.R507 was [AGE] years old, admitted at the facility on [DATE], with a diagnosis of hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. , cerebral aneurysm, dysphagia, and generalized muscle weakness with difficulty in walking, in addition to other diagnoses. R507's BIMS Score was 15/15, assessed on [DATE]. A score of 15 means that the individual is cognitively intact.Registered Nurse F (RN F) was interviewed on [DATE]/2025, at 10:45 AM. She revealed that they always lack draw sheets, fitted sheets, towels, and wash cloths. We have had an issue ever since the new laundry department agency took over shortly after RN F started in April last year. RN F recalled and stated that there was, at times, no laundry staff, and it was not consistent with providing adequate linens for nursing care. I am not sure why. But it happened a month ago. Laundry was not distributed to different halls. Then the basement flooded, and there was a shortage of staff. RN E denied observing tan or tea colored face towels. RN E confirmed that oftentimes Bari-bed sheets are a challenge. RN E indicated that residents are allowed to purchase their supply of wipes. Eliminating the wipes facility-wide was a corporate decision. It must be because it is cheaper to use washcloths than to buy disposable wipes.The facility's laundry supply and distribution policy was reviewed on [DATE], at 11:45 AM.The Policy for Promoting/Maintaining Resident Dignity, dated [DATE], was reviewed on [DATE] at 11:45 AM. The Policy specifies: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 the resident's quality of life by recognizing each resident's individuality.Compliance Guidelines: 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights.The Policy for Laundry Handling and Processing dated [DATE] was reviewed on [DATE] at 11:50 AM. It specified the following:Par Levels: Adequate par levels shall be maintained to meet the needs of the residents.Delivery: Delivery times should meet the needs of residents (e.g., before showers, before bed changes, or during meal service) .

This Citation Pertains to Intake Number MI00153753. Based on observation, interview and record review, the facility failed to ensure measures were in place to prevent constipation for two Residents (#1 and #3) of 3 reviewed for constipation, resulting in the potential for discomfort, restlessness and adverse reactions. Findings Include: Resident #1: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Diabetes, End stage renal disease, renal dialysis, Cardiac arrest, seizures, Hepatitis B, anemia, acute and chronic respiratory failure, dysphagia, feeding tube, hypertension and pneumonia. The MDS assessment dated [DATE] revealed the resident had cognitive loss and needed assistance with all care. On 7/3/2025 at 11:25 AM, Resident #1 was observed lying in bed in his room, sleeping. Nurse Aides A and B assisted the resident to reposition in bed. They said he would wiggle lower in the bed. The Resident continued to sleep. A record review of the progress notes indicated Resident #1 had fallen on 6/3/2025. A progress note dated 6/3/2025 revealed the resident's roommates family saw the resident slide out of bed onto the floor. A record review of the Incident and Accident reports for Resident #1 identified the following: 6/3/2025- Resident roommates wife came and alerted floor staff that resident had slid himself out of bed . A review of the Tasks documentation for Bowel Elimination for 6/9/2025-7/8/2025 revealed Resident #1 did not have a bowel movement on the following dates: 6/11/2025, 6/12/2025, 6/13/2025, 6/14/2025, 6/15/2025, 6/16/2025, 6/16/2025, 6/17/2025, 6/18/2025, 6/19/2025, (10 days) then 6/26/2025, 6/27/2025, 6/28/2025, 6/29/2025/, 6/30/2025, 7/1/2025 and on 7/2/2025 he had a small bowel movement. 7/6/2025, 7/7/2025 and had not yet had one on 7/8/2025. A review of the June 2025 and July 2025 Medication Administration Record/Treatment Administration Records (MAR/TAR) for Resident #1 identified the following: On 6/18/2025 and 6/30/2025 Resident #1 received Polyethylene glycol via peg tube and there was no documentation on the MAR/TAR for June 2025 that he received a suppository or enema for constipation. A nurses note on 6/17/2025 indicated he had an emesis (vomiting) and a nurses note dated 6/19/2025 said he received a Bisacodyl suppository. There was also a nurses note identifying he had emesis and a loose stool on 6/20/2025; the day after receiving the suppository; this was during the 10-day timeframe with no bowel movement. A review of a provider note dated 6/21/2025 identified, Situation: ABD (abdominal) x-ray results are ready for your review. Treatment: Finding suggestive of constipation, as compared with prior examination dated 6/2/2025. 6/26/2025, an Encounter note, C/o (complaints of) nausea, emesis episodes . 6/26/2025 at 6:33 PM, a Pertinent Charting-Change in Condition note, . Emesis: Patient had emesis twice on my shift . 6/28/2025 at 3:14 PM, a Behavior note, . Refusing care, resisting care and combativeness . 6/29/2025: a Behavior note, Resident continues kicking legs and swinging arms . 6/30/2025 at 2:12 AM, a Behavior note, Resistant to care. 7/2/2025: an Encounter note, Notified by nursing staff that Resident unable to attend dialysis due to being combative with dialysis staff . On 7/2/2025 Resident #1 received Polyethylene glycol via peg tube. 7/3/2025 at 6:50 AM, a progress note Patient had another episode of emesis this morning . 7/3/2025 at 7:05 PM, a Behavior note, When giving patient his suppository he was kicking and swinging legs. 7/7/2025 at 4:39 AM, Resident had emesis episode this shift . There were additional progress notes related to behaviors during the episodes of constipation. On 7/8/2025 at 10:45 AM, during an interview with Nurse G she said resident #1 became very restless at times and would wiggle around, she said he had constipation at times and this was flagged in the electronic medical record after the resident had no bowel movements for 3 days. Reviewed there were instances of no bowel movement for longer than 3 days without being addressed. A review of the Care Plans for Resident #1 identified the following: Resident is incontinent of bowel and bladder, dated initiated and revised 5/15/2025 with Interventions including: Observe for no BM in 3 days, date 5/15/2025; Administer medications as ordered, date initiated 5/15/2025. Resident #3: A record review of the Face sheet and MDS assessment indicated Resident #3 was admitted to the facility on [DATE] with diagnoses: Diabetes, chronic kidney disease, end stage renal disease, renal dialysis, respiratory failure, Myocardial infarction, heart disease, hypertension, anemia, weakness, dysphagia, feeding tube, arthritis. The MDS assessment dated [DATE] revealed the resident had moderate cognitive loss and needed assistance with all care. On 7/3/2025 at 11: 27 AM, Resident #3 was observed lying in bed awake and answered questions. A record review of the progress notes for Resident #3 revealed he fell on 6/12/2025 and 6/29/2025. Each fall occurred in his room from bed to floor. Further review of the progress notes identified the following: 6/12/2025, an Encounter note, Nurse reports pt (patient) had unwitnessed falls. He has some abrasions on both knees but he denies pain . 6/29/2025 at 6:17 PM, a Nurse's Note, Observed resident sitting on floor at bedside . A record review of the Incident and Accident reports for Resident #3 identified the following: 6/12/2025: Pt observed on the floor next to his bed in a sitting position with his bac leaning up against the bed . Injuries observed at time of Incident: Abrasion left elbow; Abrasion right knee front; Abrasion left knee front . Injuries Report Post Incident: Bruise right thigh rear; Swelling right knee front . 6/29/2025: Observed resident sitting on floor next to bed with back leaning against the bed, facing the doorway . A review of the Tasks documentation for Bowel Elimination from 6/9/2025 to 7/8/2025 revealed Resident #3 had multiple instances of constipation. The resident did not have a bowel movement on 6/9/2025, 6/10/2025, 6/11/2025, 6/12/2025 and 6/13/2025. The resident did not have a bowel movement on 6/16/2025, 6/17/2025, 6/18/2025, and 6/19/2025. The resident did not have a bowel movement on 6/21/2025, 6/22/2025, 6/23/2025, 6/24/2025 and 6/25/2025. On 6/27/2025 the resident had a small bowel movement and the resident did not have bowel movements on 6/28/2025, 6/29/2025, 6/30/2025, 7/1/2025 and 7/2/2025. On 7/3/2025 and 7/4/2025 the resident had a small bowel movement and no bowel movement on 7/5/2025. A review of the June and July 2025 Medication Administration Record and Treatment Administration Record (MAR/TAR) for Resident #3 indicated he had received Polyethylene glycol for constipation via the feeding tube on 6/13/2025, 6/18/2025, 7/2/2025 and 7/7/2025. The resident also received a Bisacodyl rectal suppository on 6/14/2025, 6/19/2025 and 6/28/2025. Resident #3 fell on 6/12/2025 and 6/28/2025. Both falls occurred during the time the resident had not had a bowel movement for an extended period of time. During the review of bowel elimination from 6/9/2025 to 7/8/2025, there was no period of time that the resident had a routine bowel movement. On 7/8/2025 at 1:10 PM, interviewed Confidential Person I, she said the resident had fallen several times trying to get out of bed. She was assisting the resident with eating and said he had recently started a food diet to attempt to wean him off the tube feedings. A review of the Care Plans for Resident #1 identified the following: Resident is incontinent of bowel and bladder, dated initiated 5/9/2025 and revised 5/16/2025 with Interventions including: Observe for no BM in 3 days, date 5/9/2025; Administer medications as ordered, date initiated 5/9/2025. On 7/8/2025 at 1:25 PM, Nurse H was interviewed and said she frequently was assigned to care for Resident's #1 and #3. She was asked about the residents falling and she they had both fallen from bed. She said Resident #1 was often fidgety and would move around a lot in bed. She said after he was repositioned he would continue to move in bed. Nurse H said Resident #3 would become restless and place his legs out of bed. She said they usually transferred him to a Geri-Chair and brought him out of his room, and he would be more content. During the interview on 7/8/2025 at 1:25 PM with Nurse H, she was asked about the facilities bowel protocol. She said if a resident had not had a Bowel Movement/BM in 3 days then on the next day (day 4) they would receive (Miralax/Polyethylene glycol) and then if the resident didn't have a BM by the next shift they would receive a suppository (sometimes this would be day 5 with no BM). She said both residents had recently received the Miralax and a suppository. 7/8/2025 at 1:45 PM, the Director of Nursing/DON was interviewed related to Residents #1 and #3 each experiencing multiple episodes of constipation, each receiving Polyethylene glycol and a rectal suppository to aid in bowel elimination. Reviewed that each resident also experienced falls during the time they were constipated and had received the medication to encourage elimination. The DON provided a copy of document titled, Standing Bowel Protocol and said if the resident did not have a bowel movement in 3 days, it would flag in the electronic medical record and when the alert was identified, the bowel protocol would be initiated. The DON said Polyethylene glycol was given first, if no BM on that shift (12 hour shift), the next shift would administer a Bisacodyl rectal suppository, if no results on that shift, the next shift would administer an enema (This could be day 5). Reviewed with the DON that Residents #1 and #3 had a pattern of repeated constipation and often wouldn't go for 4, 5 or more days at a time. She said they would look at their process.

This Citation pertains to Intake Number MI00152171. Based on interview and record review, the facility failed to notify the resident's representative of a change in condition for one resident (Resident #2) of three residents reviewed, resulting in the family not being notified of a change in condition. Findings include: Resident #2 (R2): R2 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include cerebrovascular disease, hypertension, apnea and peripheral vascular disease. R2 had a brief interview for mental status (BIMS) score of 15, indicating they are cognitively intact. On 04/24/25 record review of a progress noted dated 12/30/24 at 11:09 revealed, Resident is extremely tired this morning. He refused breakfast and has not gotten dressed or out of bed as he usually does. Resident also will not speak to nurse he was able to mumble that he was tired. Resident tested for Covid and flu A and B, all negative. Resident is afebrile and vitals are wnl. Provider aware. On 04/24/25 record review of an assessment in the electronic medical record (EMR) titled, Pertinent Charting Initial-Change in Condition-V2, dated 12/30/24 at 14:30, revealed that R2 experienced a change in condition. The change identified section indicated that the resident did not want to get out of bed which is not typical. Resident stated that he was really tired. The nursing intervention portion of the assessment stated, Resident placed on O2 via non-rebreather. Provider wanted CPAP placed on resident with O2 bled in. O2 came back up. O2 sats were at 98-100% on 2L. BS was 116. BP 114/75. Resident was given fluids by Provider. Vital were stable. STAT CBC and CMP labs were drawn and picked up by [NAME]. The section of the assessment titled responsible party notification was left blank. On 04/24/25 record review of a progress noted dated 12/30/24 at 14:57 revealed, Resident O2 decreased to 61% room air. Resident not able to answer questions appropriately and kept nodding off. Nurse placed a non-rebreather on resident with 8L of O2. O2 increased to 96%. Nurse notified [NAME] (educator) and she notified the provider [NAME]. Bp was 100/66 hr 110, afebrile. Provider had nurse place CPAP on resident with 8L O2. O2 maintained at 96%. Bs was 116. Provider placed an IV in residents R hand and administered 1L of D5. One dose of PRN Narcan given in right arm. Resident not retaining urine or stool, bladder scan confirmed. At 1440 resident O2 was 99%, bp 114/75, hr 103. O2 decreased to 4L, 98%, decreased to 2L 100%. Resident is maintaining 100% on 2L with CPAP in place. Labs drawn and waiting on [NAME] to pick up. Will continue to monitor resident O2. Resident resting in bed at this time. On 04/24/25 record review of an assessment titled, SBAR Communication Form and progress note- V4, dated 12/31/24 at 08:40 revealed that R2 was in respiratory distress and had a reduced level of consciousness (LOC) and it started on 12/30/24, his status has worsened. Under mental status changes' the boxes are checked for decreased consciousness and unresponsiveness. On 04/24/25 at 11:54 AM, an interview was conducted with Unit Manager (UM) C. The director of nursing (DON) was present as well. UM C was asked about the change in condition for R2. UM C stated, I was present that day and I had heard about the change in condition, when I got to his room the Nurse Practitioner was already in there. She was the provider that ordered the fluids to be run and the IV to be started. UM C was asked if the family was notified of the changes in the residents status. UM C stated, I would have to look back at notes, but I am certain they were notified. I was assuming that the nurse on the floor that day would have notified the family of the changes. UM C could not locate any documentation that indicated the family was notified of the change in condition. UM C was asked if the family should have been notified of the change. UM C stated, Absolutely, the family should have been notified. We (me and the nurse providing care) had a conversation about that (notifying family) and the nurse was supposed to be making a call to the family. The DON was asked if the family should have been notified of those changes on 12/30/24. The DON replied, yes, they should have been notified. On 04/24/25 at 12:20 PM an interview was conducted with licensed practical nurse (LPN) D. LPN D was asked about the change in condition for R2 on 12/30/24. LPN D stated, I went and got a nurse manager to notify her of the change. The nurse practitioner (NP) was present in the building, she went to assess the resident. The NP asked if R2 was on narcotics, and I stated that he was taking Tramadol for pain and the NP said to give him a dose of Narcan (reverses the effects of opioids) since R2 was in out and of consciousness. The NP wanted to administer fluids, she started an IV and we started fluids. His oxygen was stabilized, she had me draw labs and monitor until the end of my shift at 7 PM. Did you notify the family about the change in condition. LPN D stated I tried to call his daughter; it went to voicemail, and I did not document that I made the call. LPN D was asked if they left the family a message or passed it along to the oncoming nurse to follow up. LPN D stated, no. On 04/24/25 at 12:30 PM an interview was conducted with LPN B. LPN B provided care from 7:00 PM on 12/30/24 until 7:00 AM on 12/31/24. LPN B stated that the condition of R2 had changed throughout the day of 12/30/24, prior to my shift, R2 was started on continuous passive airway pressure (CPAP) and started on intravenous (IV) fluids. When I came in, R2 had the CPAP on and his IV running, R2 took meds for me with no issues. I was under the impression that the family had been contacted about his change. I notified the family at the end of my shift on 12/31/24 that there had been a change the previous day, the family was very upset that they were not aware that the resident had started on CPAP and had an IV started. R2 was sent out later that morning (12/31/24) while the family was present. LPN B stated they were upset that the family wasn't contacted initially, and I feel he should have been sent out sooner than that. LPN B stated R2 should have been sent out the day before when the first change was noticed. Review of the policy titled, Notification of Changes, reviewed/revised on 08/29/24 revealed: Policy The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, resident's representatives when there is a change requiring notification. Definitions Need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences (such as adverse drug reaction) or commence a new form of treatment to deal with a problem. Compliance Guidelines The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative where there is a change requiring such notification. Circumstances requiring notification include: 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. Life-threatening conditions, or b. Clinical complications. Additional considerations: 1. Competent individuals: a. The facility must still contact the resident's physician and notify resident's representative, if known. b. A family that wishes to be informed would designate a member to receive calls. c. When a resident is mentally competent, such a designated family member should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally, especially in the case of sudden illness or accident. 2. Residents incapable of making decisions: a. The representative would make any decisions that have to be made. b. The resident should still be told what is happening

Based on observation, interview, and record review, the failed to prevent the development of facility-acquired pressure ulcers for two residents (Resident #10 and Resident #53) out a total of 6 residents reviewed for pressure ulcers, resulting in the development of new pressure ulcers while Resident #10 and Resident #52 resided in the facility. Findings include: Record review of the facility 'Pressure Injury Prevention and Management' policy dated 1/1/2021, revealed the facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries. Pressure ulcer/injury refers to localized damage to the skin and/or underlying soft tissue over a bony prominence or related to a medical or other device. Avoidable means that the resident developed a pressure ulcer/injury, and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. Record review of the facility 'Pressure Ulcer/Skin Breakdown- Clinical Protocol' dated 1/1/2021, revealed based on the comprehensive assessment of a resident, a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individuals clinical condition demonstrates that they are were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing. Record review of the facility-acquired Pressure Ulcer list dated 5/16/2022, revealed Resident #10 did have a coccyx wound Stage IV, start date of 3/4/2017 and Resident #53 to have acquired rear of head pressure ulcer Stage IV, start date of 4/28/2022 and a left medial calf Stage III, start date of 11/10/2021. There was no mention of a left medial thigh pressure ulcer noted on the list for Resident #53. Resident #10: Record review on 05/16/22 at 12:18 PM facility sample matrix (CMS 802 form) revealed Resident #10 developed a facility-acquired Stage IV pressure ulcer. Record review of Resident #10's Minimum Data Set (MDS) dated [DATE] revealed an elderly male with a cognitive skill for daily decision making as severely impaired never/rarely made decisions. MDS section G: Functional status assessment, Resident #10 was noted to be non-ambulatory and totally dependent on two staff assistance with bed mobility, transfers, dressing, toileting use and personal hygiene. Functional impaired range of motion on both upper and lower extremities was noted. Section M: Skin conditions noted one stage III and one Stage IV pressure ulcers. Record review of Resident #10's April 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 05/17/22 at 11:59 AM, Registered Nurse/Assistant Director of Nursing (ADON) A, who was educated in wound care, revealed, when asked about the CMS 802 assessment of Resident #10. that she started 3 years ago at the facility doing wound care and that the facility switched from the Gentell wound care system to the current electronic records wound care system. RN/ADON A stated that Resident #10, as far as she knew, was admitted with the coccyx wound. RN/ADON A further stated that the wound is a Stage 4 and has Osteo. The facility did antibiotic therapy and packs the wound with dressing changes. It is getting smaller in size. RN/ADON A stated that Resident #10 did develop a right trochanter pressure ulcer/injury in December 2021 and that she was able to resolve the trochanter wound in April 2022 and that it was a pressure wound. Resident #10 did have a Bari bed, which is larger but it broke. and the facility was trying to get another bigger bed for him. Surveyor observed that Resident #10's feet were on the foot boards, with padded boots (bilateral) on. Resident #53: Record review on 05/16/22 at 11:59 AM facility sample matrix (CMS 802 form) revealed Resident #53 developed facility-acquired Stage IV pressure ulcer. Record review of Resident #53's Minimum Data Set (MDS) dated [DATE] revealed a young male in a persistent vegetative state/no discernable consciousness. MDS section G: Functional status assessment, Resident #53 was noted to be non-ambulatory and totally dependent on two staff assistance with bed mobility, transfers, dressing, toileting use and personal hygiene. Functional impaired range of motion on both upper and lower extremities was noted. Section M: Skin conditions noted one Stage III pressure ulcer. Record review of Resident #53's May 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #53's Treatment Administration Record (TAR) treatments revealed cleanse with wound cleanser. Pat dry. Apply calcium alginate to left lateral scalp wound, cover with non-boarder foam. Every night shift for wound care 5/4/2022. Record review of the TAR noted the treatment was signed out for 5/14/2022 and 5/15/2022. treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #53's Treatment Administration Record (TAR) treatments revealed cleanse with wound cleanser. Pat dry. Apply calcium alginate as directed to Stage III left rear calf wound. Skin barrier wipe to peri wound. Cover with bordered foam every evening shift for wound care 4/27/2022. Record review of the TAR noted the treatment was signed out for 5/14/2022 and 5/15/2022. treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation was made on 05/16/22 at 12:37 PM of Resident #53's skin during a brief change with Certified Nurse Assistant (CNA) K, who removed the covers and rolled resident toward the window with the white wooden slat blind open to the courtyard out the window. No dressing on coccyx. Two dressings were noted to the posterior left leg at calf and thigh levels. The left posterior thigh dressing was dated 5/14/22, and the left calf dressing was dated 5/14/22. Observation of head half concave shaped with ridge with small pressure IV to the head area. Head pressure ulcer dressing was crinkled up and not on the wound site. Surveyor was unable to read a date on dressing of a small 2 x 2 white foam dressing. Registered Nurse (RN) CC was in the room and observed dressings to left posterior calf (below knee posterior) and left posterior thigh (above the knee posterior) and stated that he had not changed the dressing yet that day. In an interview on 05/17/22 at 12:05 PM, Registered Nurse/Assistant Director of Nursing (R/ADON) A, who was educated on wound care, stated that the left lateral scalp wound developed on 4/27/2022 to the head as a stage IV pressure ulcer. RN A stated that the left calf wound, Stage III- developed 11/7/2021. Both wounds developed while residing in facility. They are not chronic. They are acute. All dressings are done daily, as of 4/26/2022 when the order was written. Record review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #53's May 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review, the facility failed to prevent falls/accidents and provide safety with positioning for four residents (Resident #13, Resident #23, Resident #32 and Resident #51) of 7 residents reviewed, resulting in falls with injuries for Resident #23 and Resident #32 with positioning, and Resident #13 and Resident #51 observed during care with the likelihood for falls/accidents. Findings include: Record review of facility 'Fall-Clinical Protocol' dated 1/1/2021, revealed as part of an initial and ongoing resident assessment, the staff will help identify individuals with a history of falls and risk factors for subsequent falls . #2.) Based on the assessment an initial plan of care will be developed and implemented to address identified risk. This will be revised as necessary, #3.) The minimum Data Set (MDS) will be utilized to develop and comprehensive plan of care to minimize falls and injuries from falls. #6.) Interventions for direct care givers should be placed on the CNA care card or similar format. Record review of the facility 'Comprehensive Care Plan' Policy dated 1/1/2021, revealed it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with residents' rights, that includes measurable objectives and timeframes to meet the residents medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment (Minimum Data Set). (#1.) The care planning process will include an assessment of the resident's strengths and needs and will incorporate the residents personal and cultural preferences in developing goals. Services provided or arranged by the facility, as outlined by the comprehensive care plan . Resident #23: In an interview on 05/16/22 at 10:43 AM with Resident #23 stated that she was dropped out of the lift, and had to have surgery on her right knee. resident stated it was a couple of weeks ago. resident #23 stated that she had broken her right leg and went to the hospital. Resident noted with ventilator dependence. Record review of Resident #23's CAA (Care Area Assessment) for falls dated 3/17/2022, revealed noted that transfers surface to surface: Not steady, only to stabilize with staff assistance. Physical performance limitations: Difficulty maintaining sitting balance and impaired balance during transitions. Internal risk factors: Anxiety, depression, cognitive impairment, [CONDITION(S)], and mobility activity of screaming, cursing . Care plan considerations: avoid complications and minimize risk. Observation on 05/16/22 at 11:34 AM with Certified Nurse assistant (CNA) L of Resident #23's right leg dressings from upper thigh to lower foot, with dressings in place, with ABD dressings and white tape. There was no date noted on dressings. Resident herself stated I think last night, but not sure Record review of Resident #23's incident report form dated 5/3/2022 at 5:44 PM, revealed that the resident was assisted up via a lift machine and two newer aides. The incident report noted that the resident was not all the way in her chair when the aides helping her transfer tried putting her (Resident #23) down. They lowered her to the floor because she was screaming and wiggling around. The Resident #23 was noted to state her right knee was sore. Record review of Resident #23's right leg x-ray results taken on 5/5/2022 (2 days after incident) revealed: Spiral fractures of the proximal tibia and fibula. Record review of Resident #23's SBAR communication form dated 5/5/2022, revealed the resident was complaining of increased pain to right knee. X-ray performed in house; results not obtained yet. PRN (as needed) Motrin 800, and [MEDICATION(S)] 5-325 given before transfer. Record review of Resident #23's hospital emergency room notes dated 5/5/2022, revealed resident with complex history including [CONDITION(S)], subsequently has intellectual disability, severe physical deconditioning, bedbound, non-ambulatory, [CONDITION(S)] dependent, resides in a nursing home, presents to the ED (emergency Department) via ambulance after what sounds to be accidental injury to her right knee x-ray shows a proximal tibia as well as distal fibula fracture of the right lower extremity. Hospital record noted rod placement in right leg. Observation on 05/17/22 at 11:15 AM of Resident #23 up in wheelchair in hallway with shorts on. The surveyor observed right leg skin observed with right thigh with 21 staples, knee 6 staples, ankle 5 staples noted to leg. No drainage noted. Staples open to the air. Resident #23 stated that she had to have metal rods put in her leg after her fall. In an interview and records review on 05/17/22 at 01:51 PM with the Director of Nursing (DON) in charge of Fall investigations, revealed that Resident #23 sustained a fall on 5/3/2022 around 10:00 PM. The Don stated that what happened was the Certified Nurse Assistants (CNA) went into the resident's room to transfer from bed to chair with a Hoyer lift, with two (2) CNAs. Once in the chair the Resident #23 let the CNAs know that she was not back far enough in her chair, and to please adjust her. Resident #23 is Intellectually disabled. She has the mindset of a [AGE] year old. The CNAs told her (Resident #23) that she was as far back as she could get. When Resident #23 was in the chair she started to wiggle in the chair until the point where the CNA's had to lower her to the floor. Resident #23's right leg was behind the left leg when she went down and twisted the leg and fractured. It was newer aides in the facility, and Resident #23 tends to get upset with new care givers. Resident #23 was introduced by licensed Practical Nurse DD to the aides. the staff left the room, resident #23 was not positioned to her liking and started to squirm around until she fell out of the chair. The nurse did an assessment at the time of the incident that what is on the incident report. Record review of Resident #23's nursing home progress notes and assessment forms from 5/3/2022 through 5/5/2022 revealed that there was no mention of lower extremity rotation or swelling/[CONDITION(S)] of the lower extremities. Resident #32: Observation on 05/16/22 at 11:44 AM of Resident #32's room revealed the resident to be in bed with bilateral fall mats to sides of bed noted. Record review of Resident #32's activity of daily living care plan dated 3/9/2021, revealed the resident to be dependent with bed mobility with assist of two staff members. Resident #32 was noted to be ventilator and enteral feeding dependent. Record review on 05/17/22 at 10:48 AM of Resident #32's 'Incident Report' dated 3/19/22 revealed resident was rolled from bed during brief change with 1 person assist with bed in waist high position. Injuries were noted of right front top of head 8 cm x 5 cm raised (swollen) area, right elbow skin tear, right thigh abrasion, right foot bruise. Incident report noted the bed in high position and staff members was changing brief and resident was rolled away from staff member. Fall mats were noted to be on the same side of bed. Staff statement noted that when the staff member had rolled the resident away from them to tuck in the new brief and draw sheet. When the staff member grabbed the sheet, Resident #32 rolled out of the bed. The staff member had written that they were alone in the room when the incident happened. The staff member noted that the mattress had slid slightly from over the frame, and it took a seven person assist with Hoyer lift to get the resident back into be. In an interview on 05/18/22 at 07:45 AM with the Director of Nursing (DON) Registered Nurse (RN), and who was also the falls/incident coordinator, reviewed Resident #32's incident report of fall incident dated 3/19/2022 report revealed that the bed was waist high when a single aide rolled the resident out of bed during brief change. The Aide was disciplined. The Surveyor explained the observed Resident #51 cares on Monday 5/16/2022 with two (2) Certified Nurse Assistant's (CNAs) that stood on the same side of the bed while giving care to resident with the bed at waist height. The surveyor asked if All staff education was given when Resident #32 was rolled from bed? The DON stated that No, just the aide involved. Resident #51: Observation on 05/16/22 at 01:53 PM of Resident #51 in residents' room with Certified Nurse Assistant K and L into room to assist resident. Resident #51 complained of itching to his back from rash. The blankets were removed, and resident exposed. Both CNAs stood on left side of the bed, elevated the bed to waist height and rolled resident #51 to right side facing the window with the slatted white wood blinds open. Aide L left the bedside and went into the bathroom and returned with wet wash clothes to wash the residents back off from sweating in the bed. Both CNAs remained on the same side of the bed close to room entrance and provided care. The bed remained at waist height throughout the care with both CNAs on the same side of the bed. Record review of Resident #51's medical record revealed Minimum Data Set (MDS) assessment of two people assist with care. Resident #13: According to admission face sheet, Resident #13 was admitted to the facility on [DATE], with diagnoses that included, Brain injury, Asthma, [CONDITION(S)], Dysphagia (diff swallowing), Contractures, Anxiety, Gastrostomy status, and other complications. Review of the Minimum Data Set (MDS) dated [DATE], reflected Resident #13 was not scored on the Cognition Assessment, indicating severe cognition impairment, and was also coded as requiring Extensive 2 P A (two person assist) with Activities of Daily Living (ADL) care to include Bed Mobility, Toileting, Transfers, and Personal Hygiene. (Resident #13 received all nutrition/hydration through Enteral feeding.) The following observation occurred on 5/18/22 at 8:05 AM, in Resident #13's room. Upon entering room, Nursing Assistant C and Licensed Practical Nurse B were in with Resident #13. NA C indicated Resident #13 had just pulled out his peg tube. Observation reflected a Peg tube laying on Resident #13's abdomen, and a moist open pink stoma where the tube had been. LPN B was holding Resident #13's hands with her hands. Further observation reflected the Trapeze bar that was over the head of the bed, was hung up high, over the top of the bar it was connected to, and out of reach for Resident #13 to hold. Resident #13 was noted to have tan colored Tube Feed leaking all over the bed sheets, pad, and under Resident #13. NA C was preparing to provide Activities of Daily Living (ADL) care, after Resident #13 pulled his peg tube out of his abdomen. NA C said she had to do a total on him (total care). NA C had washed her hands and donned gloves as well as LPN B prior to care. NA C began to wash Resident #13's face, upper body, upper extremities, working her way down to Resident #13's perineal area. All the while the ADL care was going on, LPN B just held Resident #13's hands. NA C washed the front perineal area to include scrotal area and penis. NA C rinsed the area she washed. NA C rolled soiled brief (urine and feces) up under Resident #13's buttock area. NA C rolled Resident #13 toward LPN B using both hands while LPN B was holding residents hands. LPN B and was standing at the head of the bed, on opposite side of the bed, as NA C washed feces off Resident #13's buttocks, while Resident #13 was rolled on his right side, facing LPN B. NA C removed rolled soiled brief. NA C was holding Resident with one hand and washing him with the other hand. NA C continued holding Resident #13 up with one hand, while pushing the sheet under Resident #13, with the other hand. LPN B was not helping move Resident #13, only holding his hands. (Resident #13 is documented as 2 person assist for Bed Mobility) During the care, NA C said He will hit you when your not expecting it. That is why she is holding his hands. NA C then began to wash the mattress, that was wet from tube feed leaking on sheets and onto the mattress with one hand and holding resident with the other. NA C adjusted Resident #13 to his back. NA C then moved to the same side of the bed that LPN B was on. NA C rolled Resident #13 toward herself, and dried the mattress with a towel. NA C was the only one who rolled Resident #13. LPN B continued to hold Resident #13's hands. There was no staff on the opposite side of the bed. Both staff were on the same side of the bed at that time. At that point, LPN B let go of Resident #13's hands, and left the room to get clean linen because only wash clothes and towels were brought in for care. During the time that LPN B was gone, NA C continued care, and was observed removing the soiled sheet. NA C was on Resident #13's right side of the bed now, and began loosening the sheet from Resident #13's right side. NA C rolled Resident #13 onto his left side, and held him with one hand, while pulling the dirty sheet out with the other hand, and then rolled him back toward her. LPN B was not back in the room yet. LPN B returned to the room, washed her hands, donned gloves, and handed the linen to NA C. Resident #13 was laying flat again. NA C laid the bottom sheet out along the side of the bed. Surveyor seen a large brown stain in the middle of the sheet, at the same time NA C seen the large brown area. NA C indicated it was an old stain from feces. NA C said I am getting rid of this one and placed in a bag. LPN B left the room again, and returned shortly with another clean sheet and barrier cream. While LPN B was gone, NA C removed the pillow case, and placed a clean one on the pillow, with same soiled gloves on. NA C also began to placed a clean brief under Resident #13 while LPN B was out of the room a second time. NA C rolled Resident #13 toward her, leaned over Resident #13, and pushed the brief up close to Resident #13's buttocks, then rolled him away from her, pushing at the mid thigh to knee area. LPN B was not present for the bed mobility that is documented a 2 staff assist. (NA C continued with ADL care.) The Director of Nursing was informed on 5/18/22, of the care observations and the hand hygiene concern.

This Citation pertains to Intake Number MI 682. Based on observation, interview, and record review, the facility failed to maintain and/or ensure the safety of one resident (Resident #103) out of eight residents care/safety reviewed, by its failure to follow Safety Care Planned Interventions for a 2-person assist with Bed Mobility, failure to perform post-fall assessment before staff transferred the resident back to bed, and failure to use a mechanical Hoyer Lift to transfer Resident #103 off the floor post- fall as Care Planned, resulting in Resident #103 being sent to an acute care setting, pain, and surgical repair for femur fractures bilaterally (both legs). Findings include: Review of 'Fall Prevention Program' policy, dated as revised 10/30/20, documented Each Resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls. A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level. but may not be a result of overwhelming external forces .When a resident experiences a fall, the facility will: -Assess the resident, complete post-fall assessment, complete an incident report, notify physician and family, review the resident's care plan and update as indicated, document all assessments, obtain witness statements in the case of injury . Review of 'Falls-Clinical Protocol', dated as revised 10/30/20, documented As part of an initial and ongoing resident assessment, the staff will help identify individuals with a history of falls and risk factors for subsequent falling. This will be accomplished by the following task .Admission Evaluation Data Form completed on admission, quarterly, and with significant change in status .The Fall section is inclusive of; History of Falls, cognitive status/behavioral status, vision, continence, mobility, balance, vital signs .Based on the assessment an initial plan of care will be developed and implemented to address identified risk .The Minimum Data Set (MDS) and subsequent CAAs will be utilized to develop the comprehensive plan of care to minimize falls and injuries from falls .For the individual who has fallen, staff should attempt to define possible causes within 24 hours of the fall .Once a fall occurs, it is important to gather as much information as possible .Observe for evidence of Trauma, determine what the resident was attempting to do, Observe for Environmental hazards, If Resident is able, what did he/she say that happened, Provide Emergency Care and assessments as indicated . Resident #103: According to admission face sheet, Resident #103 was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included [CONDITION(S)], [CONDITION(S)], Anxiety, Depression, [CONDITION(S)], and other complications. According to the Quarterly Minimum Data Set (MDS,) dated 01/26/21, Resident #103 scored an 11 on Cognition Assessment indicating moderate cognition impairment, and also required extensive 2-person assist with Activities of Daily Living (ADL) care to include Bed Mobility, Toileting and Transfers. According to the vital signs section in the medical record, dated 2/26/21, Resident #103's weight was documented at 121.6 pounds. According to the medical record, Resident #103 also had 40 degree leg flexion contracture's on both legs. Review of Resident #103's Activities of Daily Living (ADL) Care Plan, with an initiation and revision date of 1/26/21, documented: Resident to be 2 staff assist for safe Bed Mobility, 2 staff assist with Hoyer Lift for Transfers (Mechanical Lift), and 1 staff assist for dressing, at times may use 1 - 2 person assist with dressing. Resident #103 was documented as on 'Yellow Dot Program' for turning and reposition. An intervention documented that 'Resident refuses to be repositioned on right side.' An interview was conducted on 5/27/21 at 3:34 PM, with the Social Worker from the acute setting (hospital) that Resident #103 had been discharged to on 03/16/21. The Social Worker indicated she had received a call from one of the Registered Nurses in the acute setting, that had received and provided care to Resident #103 on 3/16/21. The Social Worker indicated the RN was upset by the condition Resident #103 arrived in. The Social Worker verbalized that Resident #103 had been sent to the acute setting post- fall from the facility, in the evening on 3/16/21. The Social Worker indicated per review of her notes, that the facility rolled Resident #103 out of bed, and onto the floor, which resulted in Resident #103 being sent to the acute setting, and was noted 2 days later to have bilateral femur fractures. Social Worker was asked why it took 2 days to discover the fractures while in the hospital. The Social Worker verbalized that review of her notes indicated, that in the hospital, Resident #103 had a chest x- ray done, Computed Tomography (CT) of the spine, brain, chest, abdomen, and pelvis, but not the legs at that time. Social Worker indicated that Resident #103 was unstable in her condition and complaining of pain all over, at the time of arrival, per documentation and phone call from the receiving Registered Nurse. Social Worker verbalized she had contacted Adult Protective Services (APS) and was referred to the State Agency. Social Worker indicated due to increase in pain and multiple complaints of pain, Resident #103 had her bilateral legs x-rayed which indicated two fractured femurs (legs), not discovered until 03/18/21. Review of Incident/Accident report dated 3/16/21, documented a Fall that occurred in Resident #103's Room 506 at 7 PM. The report reflected, the fall was witnessed by Nursing Assistant C and the report was completed by Licensed Practical Nurse B. Documented on the report, Resident was getting her sheet changed and she fell out of bed. Vital signs documented as: Temp-97.5, Pulse at 83, Resp. 18, B.P.( Blood Pressure) at 119/77, O2 SATs at 90 %, mental status-alert, and pain scale at 8 (out of 10). Also documented on the report was no apparent injury. The report reflected Resident #103 was sent to the hospital. Guardian, Director of Nursing and physician notified. On the report under Environmental Factors was documented as 'N/A'. Under the question of 'what was resident doing' was documented as 'being changed' and documented Nursing Assistant C who was changing Resident. Under the heading of 'Level of Assistance required', was documented as '1 assist'. Under 'Any other important information to know' documented Resident was pushing self with the corner of the night stand. Bed in lowest position. Fall mats (bilaterally) in place. Under 'Immediate Intervention Implemented' documented Resident to be 2 assist with Bed Mobility. Under Interview of Staff involved, was listed as Nursing Assistant C and LPN B dated 3/16/21 at 8:00 PM. The Incident/Accident report was signed by LPN B. Review of the medical record documented a 'Fall Assessment' completed on 3/16/21, by LPN B. The Fall Assessment had documented a score of 18 indicating interventions required, and that Resident had no falls in past 90 days. On the form, was documented that the resident's Cognition had not changed in past 90 days. Under Mobility, was documented as 'confined to chair, and resident is unable to stand.' Review of the medical record documented a 'Pain Evaluation' completed on 3/16/21 at 21:38 (9:38 PM) by LPN B. The Pain Evaluation reflected 'Yes' to pain over past 5 days documented as 'Occasionally'. Under 'Intensity' documented an '8' out of 10 scored for pain level. Under 'Location' for pain was documented as Not assessed, resident sent to hospital [SIC]. Review of 'Progress Notes' in the medical record documented on 3/16/21 at 22:40 (10:40 PM), At approximately 1900 (7:00 PM), Resident was being changed in bed when resident rolled out of bed. Resident assistance was per care plan and bed was in lowest position and bilateral fall mats in place. Resident was rocking/pushing with hand against night stand . (Resident #103's current/active Care plan, at the time of the incident, was for a 2-person assist with bed mobility, and also per MDS). An interview was conducted on 6/2/21 at 9:52 AM, with Staff A. Staff A indicated she receives the referrals for admissions and readmission to the facility. Staff A indicated that she heard about Resident #103 discharging from the facility on the night of 3/16/21, when it was discussed in morning meeting with the Interdisciplinary Team, and had heard it was related to a fall. Staff A indicated she couldn't remember if it was a true fall or just a lower to the floor. Staff A indicated she knew Resident #103 was out of the facility for a couple of days and called the hospital for an update on possible return. Staff A indicated she spoke with Bill, the Case Manager at the hospital and asked how Resident #103 was doing. Staff A said that he (Case Manager) made a comment about APS and said they were notified. Staff A verbalized she initially thought they had a run in with Resident #103's boyfriend. Staff A indicated the Case Manager would not say why APS was contacted. Staff A verbalized she went into the online referral for Resident #103, which indicated Resident not ready for discharge and 'Resident scheduled for Surgery'. Staff A also verbalized that nothing was voiced to her about any fractures. Staff A indicated she called the Case Manager back and he then told her that Resident #103 had two broken femurs. Staff A indicated she shared that information with the Director of Nursing and Administrator who then started gathering documents, taking statements and an investigation. Staff A verbalized she asked for the emergency room notes and the Case Manager would not send them to her. I stayed on him for 2 days and It was no luck. He would not send them. Resident #103 discharged to another facility after surgical repair of femurs because of APS involvement and could not come back to our facility. She went to another facility. Review of Written Witness Statement dated 3/24/21, taken by the Director of Nursing, from LPN B documented LPN B's events of the Incident/Accident that occurred on 3/16/21. LPN B's Statement I was coming back to the unit after getting supplies. Nursing Assistant was heading down the unit coming towards me. She told me Resident had fallen. I immediately went into the room. Another Nursing Assistant was in the room with Resident. Nursing Assistant followed me in. When I went into the room, Resident was in bed slightly to the left side. I asked what happened. Resident said 'I fell .' I asked if she was having any pain and she said chest pain. She had a BM (bowel movement). The girls were rolling her back and forth to clean her up. She did not verbalize any pain, grimacing, or hollering. After they cleaned her, I assessed her skin, palpated her hips bilaterally. She denied pain. Because of her contracture's, I could not perform ROM (range of motion) to BLE (bilateral lower extremities). None of her extremities were abnormal. She denied pain to her body, except chest pain, denied hitting her head . This Written Statement was signed and dated by LPN B on 3/24/21. An interview was conducted on 6/2/21 at 10:06 AM, with LPN B. LPN B was asked if she recalled an Incident/Accident when she was in care of Resident #103 on 3/16/21. LPN B indicated she did. LPN B was asked what Resident #103 was like and verbalized Resident #103 to be Alert and Oriented and that she was familiar with the resident ever since she was admitted to the facility. LPN B also verbalized that Resident #103 previously had a [CONDITION(S)] and was on a vent, but no longer was. LPN B was asked if Resident #103 could move her extremities and said she could. LPN B also indicated Resident #103' legs were contracted and bent slightly towards the body at about 40 to 50 degrees flexion. LPN B also indicated that Resident #103 was now 2 person assist with ADL care and movement in bed. LPN B was asked if she recalled the incident and said she did. LPN B was asked what happened on 3/16/21. LPN B verbalized that Nursing Assistants C and D came to her on 3/16/21, at around 7 PM. Surveyor asked, if 2 Nursing Assistants came to her, who stayed with the resident. LPN B then verbalized that Nursing Assistant D stayed with Resident, and only Nursing Assistant C came to her and said Resident fell out of bed. LPN B was asked what she seen. I went into Resident #103's room (room 506-2). I saw Resident down on the floor, on the right side of the bed, on her right side, between the window and the bed. (witness statement doc resident in bed when nurse entered room). LPN B was asked what she had been doing at the time of the fall, and verbalized she had finished with medication pass. I went to get sterile water for a resident on the 600 hall. I was at the other end of the building when Nursing Assistant C ran to me and said Resident had a fall, she fell out of bed. I walked briskly and the aid was with me. When I entered the room, I saw Resident on the floor, on the right side of the bed, The Head of the Bed was up, on the right side of the room. She was positioned on her right side and both legs were contracted to almost fetal position. (Nurse demonstrated position of legs to Surveyor by drawing legs up toward body.) I assess her vitals, pain, checked for bruising, marks, red areas, or any other abnormalities. She had a BM in her brief. Me, and 2 Nursing Assistants got the Hoyer pad, placed it under her while she was on the floor and lifted her onto the bed. Surveyor was asking more questions at that point, after reading witness statements, and statements not matching what LPN B was verbalizing. Surveyor asked how they got the Hoyer pad under Resident #103 while she was on the floor. LPN B said, We rolled her from side to side and she never complained of pain. I started an investigation. I gave her nitro tabs 3 times after calling the Doctor. He (Dr) said if Nitro does not help, then send her to the hospital. He did not give me orders for x- rays, because I only said she was having chest pain. Surveyor asked LPN B if she was being accurate on her description of events that occurred because her Written Statement did not match what LPN B was verbalizing. Surveyor asked several more questions and LPN B became very upset and tearful. Surveyor stopped the interview and asked LPN B if she needed some time or wanted to start again. LPN B changed her recall of the events that occurred on 3/16/21. A second interview was conducted on 6/2/21 at 11:00 AM. LPN B was asked what happened the day the Resident #103 fell out of bed. LPN B said that Nursing Assistant C came to her and indicated resident fell out of bed. I entered the room and Resident was already in the bed. I asked how she got in bed and Nursing Assistant C said that she lifted Resident back into the bed by herself. Then Nursing Assistant D came in and we all cleaned Resident up and finished changing her bed linens. LPN B verbalized that through her investigation of the events that occurred that night, Nursing Assistant C had been changing a brief and linens by herself. Nursing Assistant C indicated she had rolled Resident up on her right side and was holding her with her left hand and pulled the sheets with her right hand. Resident was pushing on the night stand and rocking back and forth during that time. LPN B verbalized that Resident rolled out of bed during that time and landed down on the floor matt. LPN B was shown that the MDS and Care Plan had previously been documented as 2 person for Bed Mobility, Toileting and Transfers. LPN B indicated she was aware and had made a mistake when reviewing the medical record and had seen that Resident was 1 person assist with dressing and thought she was 1 person assist with all ADL care. I was wrong and the Nursing Assistant was wrong as well. We were educated. I did not tell the DON the night I called her, that the Nursing Assistant put the resident back to bed herself. They found out later through statements from Nursing Assistants involved. The Nursing Assistant did not follow the Care plan or the Fall Protocol. I never got to assess the Resident until after she was placed back in bed. LPN B was asked why she changed her recall of the events and indicated, she knew the safety protocol, and knew what was supposed to have been done and was telling Surveyor protocol, but verbalized that was not what really happened or the way it happened. Review of Nursing Assistant C written Witness Statement reflected documentation dated 3/22/21, taken by the DON from Nursing Assistant C. I was tucking sheet under her, because I had just changed her. She was facing the window. (Resident's right side). I was standing in the front. She had her hands out pushing on the dresser. When she was rocking, she rolled out of the bed on her left side. The bed was below my waist. She did not hit her head. I did not hear a popping sound or cracking sound. She fell on the matt. She did not say her legs hurt. I poked my head out in the hallway. I did not see anyone. I helped her get up by standing in front of her and lifting her up. The nurse was walking by and I called her in the room. 2 other staff came in to help. The other aids helped me clean the resident up by rolling her from side to side. She never said her legs hurt. I saw a red spot on her left thigh and I rubbed it. She stayed in bed until the Ambulance got there. A phone interview was conducted with Nursing Assistant C on 6/2/21 at 1:03 PM. Nursing Assistant C verbalized she did not sit for the testing yet due to Covid-19, but had a certificate of completion of Nurse Aid training that was on file with the facility and considered a Waiver Aid. Nurse Assistant C was asked if she recalled what happened on the day of 3/16/21, with Resident #103 and verbalized she did. Nursing Assistant C indicated she was getting ready to change the brief of Resident #103 who was in bed and facing the window. My left hand was on the resident holding her, and my right hand was changing the sheets. She had BM (feces) all over. She was rocking back and forth. I was working by myself. She was over on the right edge of the bed. I was taking off the old sheets and removed the corners on my side. I was on the right side of the bed. I still had my hand on resident. I started removing the sheets at the end of the bed and was working my way up the bed. She was near the edge. She fell off the bed into my legs then onto the floor. She was pushing the dresser that was near the right side of the bed or holding the corner. She rolled onto her left side. I asked if anything was hurting. She was on the matt. I pushed the call light and no one came for several minutes. I went in the hall looking for a nurse. I went out of the room into the 500 hall to the cafeteria/break room. (The break room is on the opposite end of the hall from where room 506 is located through double doors). I found another Nursing Assistant in the cafeteria and asked her to help me. Before I went to the hallway, I put Resident Back in the bed. CNA C was asked how she got Resident #103 back into bed. CNA C said, I lowered the bed. I put my arms under Resident armpits. I was hugging her and tried to see if she could stand up. Surveyor asked if she used any devices such as a gait belt, lift or anything. I did not use a gait belt,or lift. I was panicking. This was my very first fall. Surveyor asked if resident could bear weight or stand. CNA C said Resident #103 could not stand. I tried to stand her up. She couldn't do it, so I got her upper body, head and butt, on the bed. Once I got the upper part of the body on the bed, I came around and lifted her legs up and got her all the way on the bed. Surveyor asked if it was difficult to get the legs up due to the contracture's. Nursing Assistant C said what is that. Surveyor asked was it hard to get the resident on the bed due to the bent legs. Nursing Assistant C said It was hard to get her up on the bed period. I was freaking out. This was my first experience with something like this. Do I need to get a lawyer. Nursing Assistant C was asked how tall she was and said, I am 5'3 and weigh about 135 pounds. (Resident #103 is almost 122 pounds). Nursing Assistant C was asked who helped her. That's when I went and got an aid who was in the cafeteria/break room on her phone. I asked her to help me. We went back to the room. Resident was complaining of head pain/headache, not chest pain. The call light was still on, and that's when the nurse came into the room. I told the nurse what happened. She told me to take some vitals. I used my own equipment. I had a Blood Pressure cuff. I got a Blood Pressure, pulse, temperature, and pulse ox. I gave the nurse the vitals. The nurse went to get some medication for a headache and checking orders. Me, and the other aid finished getting her cleaned up and changed the sheets. The nurse did not help with that, only me and the other aid. The nurse said the vital signs were normal, when I gave them to her. The other aid saw the red spot on the left thigh. I was the one who rubbed it. The nurse called the Doctor, the Ambulance, and got the paper work ready. She did look at the skin though. The resident never complained of any chest pain the whole time. The resident's boyfriend called her cell phone. I heard her tell her boyfriend she was pushed out of bed. I stayed in the room until the Ambulance people came. They were asking what happened. Me, and the other aid said her head hurt. They took her to the hospital. The nurse got a statement from me and asked how the resident got off the floor with out the Hoyer Lift. I told her. I couldn't find anyone, and no one came to help. I said, I hugged the resident and lifted her under her armpits and got her up onto the bed. Nursing Assistant C was asked if she was in front of Resident or behind resident when she got her into the bed. Nursing Assistant said again, she was in front of resident and hugged her trying to get her up off the floor onto the bed. The DON took my statement. The billing lady, Administrator, and Human Resources were all there and made me demonstrate what happened and what I did. They also told me that Resident was 2 person assist with Bed Mobility, and that I violated the Fall Policy. A nurse is supposed to come in and check the resident out before they are moved off the floor, and that anytime there is a fall, the facility is a no lift by arms, but to use the mechanical Hoyer Lift to get them off the floor. They taught me where/how to find the Kardex/Care Plan. I got a write up education for all of this. They told me if I did this again, there would be consequences. I no longer work there. Not because of this, but because of personal health issues. An interview was conducted with Nursing Assistant D on 6/2/21 at 2:05 PM, related to the fall on 3/16/21. Nursing Assistant D was asked about Resident #103 and verbalized She could be a handful at times. She screams out, will not use the call light, but is Alert and Orients and knows what's going on. Her boyfriend calls up here a lot and accuses us of not changing the resident as needed. That isn't true. I take care of her a lot. I change her all the time. I know he tells lies. Nursing Assistant D was asked how much help Resident #103 required and indicated she was 2 person assist with all ADL's except for dressing her. Her legs are bent slightly and contracted. Nursing Assistant D was asked about what happened on 3/16/21, and indicated she had been in the break room, on the phone with her husband. Nursing Assistant C came in and got me and said she needed some help. I got up and went to help her. She said, I need you, Resident fell . I walked in the room and expected to see the resident on the floor, but she was in bed. I was shocked. We seen the nurse going by and got her. The nurse asked us to get vital signs, and we ended up doing a complete bed change. The Resident was not complaining of any pain at that time. The other Nursing Assistant never said how she got the resident off the floor. I never asked. If someone falls, you get the nurse, and they assess the resident. This is a no arm lift facility. All falls are lifted by the mechanical Hoyer Lift. I left after helping the aid and went to care for my people. I never heard anything about the fall until later. I know that you check the Kardex/care Plan for any changes, and things can change from the last time you take care of a resident. I also find information out doing walking rounds and report. An observation and interview was conducted on 6/3/21 at 08:40 (8:40 AM), with Resident #103, by another Surveyor. Resident #103 was residing in another Long Term Care Facility. The Surveyor documented the observation and interview: Resident was observed lying in bed on her left side with her legs bent, facing the window. She was awake, alert, and oriented x 3. The Resident was asked how long she was at the facility, A few months. Resident was asked if she was in the hospital prior to coming to the facility. Yes. Resident was asked where was she prior to going to the hospital. I was at (gave the name of the facility).They dropped me at (gave the name of the facility). Kapow! They threw me on the floor. Surveyor asked if they were using a mechanical lift. No, they were using their hands. They were being mean! They broke my legs! Surveyor asked Resident #103 if she fell while in the hospital. No, just there (gave the name of the facility). Surveyor asked what time of day it was when the fall happened. It was dark out. They picked me up and threw me down. It was horrible. Surveyor asked how she was doing now. I'm better than when they dropped me. Its been months. Surveyor asked Resident if she had any pain after the fall. Horrible pain. I went right to the hospital. Review of Ambulance Report (Run report) documented an incident date 3/16/21. Review of the report reflected 2 crew members dispatched to the facility for an Emergent call with lights and sirens activated. The type of call was documented as 911 call, for ground transport to room 506-2. The incident number was documented as and the time was 20:30 (8:30 PM). The report reflected vital signs taken as: ECG Rhy (rhythm) as [MEDICATION(S)] Rhythm, (12 lead -left sided, Normal Rhythm). BP-117/82 (cuff-Manual) Auscultation P (pulse) as 97, Spo2 at 73 percent, Respirations at 18, Co2 was blank, Gluc was blank. GCS (glascow coma scale, determines level of consciousness) as 13 (out of 15). Pain was documented at level '10'. Resident was on room air. Also documented left the scene at 20:39.40. (8:39 PM and 40 seconds) and arrived at destination scene 20:53.01 (8:53 PM and 1 second). Under 'Pt Care Report Narrative' reflected Vehicle, Night Shift, ALS (Advanced Life Support) arrived at pt-3/16/21 @ 20:22:21, female pt (FO) born 4/19/67 seen, chief complaint. Pt has no listed meds, no listed allergies, vs taken, cardiac rhythm as [MEDICATION(S)] rhythm, transported to hospital (gave name) Ambulatory Imaging .Anatomic Location is chest, meds administered- No. Pt lying in bed at (gave name of facility), paperwork obtained from staff, 'staff dropped pt off the bed at 7 PM, pt did not hit head. Pt began having chest pain at 8:15 PM. Pt given 325 ASA, and Nitro times 3 by staff. Pt still states chest hurt. Pt moved from facility bed to stretcher using 2 person sheet draw, secured .Pt arrived to room 13. Pt moved from stretcher to hospital bed using a 2 person sheet draw and secured . Review of hospital transcript notes provided by the facility, documented on 3/16/21, Resident #103 was in the emergency room and several test were completed at the hospital to include: CT of brain with findings of no Intercranial Hemorrhage. Chest X-ray performed related to trauma and pain. CT of chest, abdomen, pelvis related to fall out of bed. There were no acute findings. There were x-rays taken on 3/18/21 at 6:15 PM related to trauma. The findings of the bilateral femur X-rays: Femur, 2 views: There is a comminuted (bone broken in 2 places) and impacted fracture (broken ends of bone are jammed together by the force of injury) fracture involving distal right femoral shaft (area of the thigh bone just above the knee). There is a severely comminuted fracture of the distal shaft of the left femur, minimal angulations (the normal axis of bone is altered and points in different direction). Impression: Comminuted distal femoral fracture bilaterally. There was also a comparison x-ray completed on 3/19/21 at 02:39 (2:39 AM), of bilateral femurs with findings: There is re-demonstration of a Comminuted fracture of the mid to distal femoral diaphysis (central region on bone) with posterior (back) displacement of fragment bone by at least 1.7 cm in left and 1.3 cm in right femurs. Further review of the report documented hospital course as: Bicytopenia (reduction of two cells lines in blood, such as red blood cells or platelets), Femur fracture, Fall-accidental, chest pain, Dyspnea (shortness of breath), increase in Troponin level, shock . Narrative of the hospital course: Transfer from facility due to distress and fall. Found to have bilateral femur fractures. She was in shock. Given fluid Blood pressure. Brought up with hydration and vasopressor (meds that contract blood vessels to raise blood pressure). She was given antibiotics. Her X-rays show bilateral femur fractures. Orthopedics Team consulted and due to prior Trachea and adhesions, Resident's Anesthesiologist felt better treated at an Ortho Hospital with expertise in [CONDITION(S)] and Orthopedics. To be discharged to another acute care hospital. Also documented on the report as problem: Septic Shock: Initially presented from (name of facility) after becoming hypoxic, Short of Breath, and chest pain. Lactic Acid increased at 3.81 on admission (normal is 0.50-2.20), trending down. Leukocytosis (high white blood cells) of 21.0 on arrival. Negative for Covid-19. Blood Cultures negative. Chest X-ray clear. Urine culture grew Proteus, sensitive to [MEDICATION(S)]. Will continue with cefapime for now. Problem 2: Femur fractures. Bilateral distal femur fractures 2/2 (2 of 2) likely fall at ECF (extended care facility). Ortho Surgery to follow. To Operating Room on 3/22/21. An interview was conducted with the Administrator on 6/3/21, related to the Fall that occurred on 3/16/21, in the facility. The Administrator verbalized she had started an investigation after Staff A had told them about the information on the referral about not being able to accept Resident #103 back to the facility and that Resident #103 was scheduled for Surgery related to bilateral Femur fractures. The Administrator indicated she was aware that her Nursing Assistant did not follow the safety Care Plan for Resident #103 for Bed Mobility and had discovered that through an investigation. The Administrator also verbalized she was aware the Nursing Assistant got Resident #103 up off the floor with out the use of the Hoyer Lift before the nurse could assess her. The Administrator verbalized she did not believe the bilateral fractures happened as a result from the fall out of bed onto a matt. She also verbalized why it took 2 days before the hospital obtained X-rays of the legs. She also verbalized that the pain would be excruciating. The Administrator also verbalized that education had been provided to her staff in regards to following Fall Protocol and safety Care Plans, The Administrator also had the Medical Director provide a document reflecting his professional opinion why he believe the fractures did not occur as a result of the fall. An interview was conducted on 6/3/21, with the former Director of Nursing, who also indicated she did not believe the fractures occurred in the facility as a result of the fall. She also verbalized a good working relationship with the hospital and that they work closely together. The Former DON indicated things got weird when Resident #103 was supposed to return to the facility and then they found out she had 2 fractures and was set up for surgery. The DON verbalized that she believes the resid [TRUNCATED]

Based on observation, interview and record review the facility failed to prevent the development of pressure ulcers for 2 residents (Resident #12 and Resident #41) of 4 residents observed for pressure ulcers, resulting in Resident #41 developing a facility-acquired unstagable pressure on the left heel, which was documented as a Stage II pressure ulcer, and Resident #12 developing a facility-acquired Stage III/Stage IV sacrum/coccyx pressure ulcer and a facility-acquired unstageable right ankle pressure ulcer. The facility also failed to consistently assess, consistently implement intervention measures and consistently monitor the progress, or lack thereof, of those interventions to treat and heal the pressure ulcers. Findings include: Review of facility Policy 'Pressure Ulcer/Pressure Injury Prevention and Treatment, dated (MONTH) 28, (YEAR), documented Based on Comprehensive Assessment of resident, a resident receives care, consistent with Professional Standards of Practice, to prevent Pressure Ulcers, and does not develop Pressure Ulcers unless the clinical condition demonstrates they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with Standards of Practice to promote healing, prevent infection, and prevent new ulcers from developing. The National Pressure Ulcer Advisory Panel redefined the definition of a pressure injuries during the NPUAP (YEAR) Staging Consensus Conference that was held (MONTH) 8-9, (YEAR) in Rosemont (Chicago), IL. The updated staging definitions were presented at a meeting of over 400 professionals. Using a consensus format, Dr. Mikel Gray from the University of Virginia adeptly guided the Staging Task Force and meeting participants to consensus on the updated definitions through an interactive discussion and voting process. During the meeting, the participants also validated the new terminology using photographs. The updated staging system includes the following definitions: Pressure Injury: 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. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin: Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis: Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. According to National Pressure Ulcer Advisory Panel's (NPUAP) Prevention and treatment of [REDACTED].npuap.org/wp-content/uploads/2014/08/Updated-10-16-14-Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-16Oct2014.pdf Pressure on Category/Stage III, IV, and unstageable heel pressure ulcers should be completely offloaded as much as possible. Elevation of the heel on a pillow is usually inadequate. The facility policy Repositioning, dated 3/24/17, revealed, 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 of all bed or chair bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents . A turning/repositioning program includes a continuous consistent program for 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 individualized assessment and takes into account pressure redistribution devices and surfaces as well as the resident wishes and rights. Basic recommendations . 3. For residents with a Stage 1 or above pressure ulcer, q 2 hour turning may be inadequate. Resident #41: Resident #41's Electronic Medical Record (EMR) physician's orders [REDACTED]. admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #41 also developed a facility-acquired unstageable pressure ulcer on 3/29/19, which was documented as a stage 2 pressure ulcer 100% eschar on the left heel. On 05/15/19 at 09:27 AM, during an interview, Resident # 41 stated have one (pressure ulcer) on heel now. Review of MDS 'Quarterly Assessment', dated 3/25/19 (end date), documented Yes at risk for developing pressure ulcers; M0210- unhealed pressure ulcers-documented 0. M1030-number of venous or arterial ulcers- documented 0. The MDS was a 7 day look back period from 3/18/19 -3/25/19 and was incorrectly coded according to the (MONTH) 2019 treatment record. Review of Resident #41's (MONTH) 2019 Treatment Record revealed that Resident #41 was treated from 03/17/2019 at 1500 through 03/24/2019 at 0716 for a venous stasis ulcer and was at an increased risk for a pressure ulcer. Review of Resident #41's EMR revealed that on 2/11/19 the Norton Plus Pressure Ulcer Scale was V 2-a Moderate risk of 14. Review of Resident #41's EMR revealed that the resident had a fall on 3/28/19, prior to the heel blister on 3/29/19 increasing the risk of a deep tissue injury. Review of Resident #41's nurses' progress note, dated 3/29/19 at 1:54 PM, revealed Note Text: resident has a noted fluid filled blister to her left heel. Does not know how it developed. Discussed having her heels restig (resting) on any surface for a period of time or rubbing her heel against any surface could create enough friction to cause a blister to develop. New order to apply dry dressing to left heel daily. On 05/16/19 at 08:42 AM, Resident # 41 was observed for a left heel pressure ulcer dressing change with Registered Nurse (RN) Wound Nurse Z. RN Unit Manager AA, reported both staff started working at the facility around (MONTH) 1, 2019 and thought Resident #41's wound had started around 4/1/19, but that the wound was open prior (to that date). Resident #41's left heel was observed with no dressing in place prior to the treatment. RN Wound Nurse Z measured the area on left heel as being 1.6 cm x 1.4 cm. The area was noted to have dark brown eschar covering the wound base and the surrounding area was pink with the outer area peeling. RN Wound Nurse Z stated, Resident #41's Pressure Ulcer was currently logged as a blister, not a Stage 2 Pressure ulcer. RN Wound Nurse Z reported, when she would come in to do the dressing change the dressing on the heel was frequently not on the wound, as it was today. RN Wound Nurse Z reported that she had not mentioned that Resident #41's dressing had been removed but, the concern had been discussed in morning clinical meetings. RN Wound Nurse Z reported that the Nurse Practitioner had seen the resident on 5/13/19 and she would see if the documentation was available to determine if the wound had been staged. RN Wound Nurse Z reported that the Nurse Practitioner had staged the wounds. Review of Resident #41's Nurse Practitioner's progress note, dated 5/13/19, revealed that the pressure ulcer was on the left heel stage II 100 % eschar and was measured as 1.8 cm x 1.0 cm and was documented as with no dressing in place at time of assessment. treatment of [REDACTED]. Review of Resident #41's S[NAME] (standard of care) skin note, dated 5/2/2019 at 17:03 (5:03 PM), revealed Explain(new/existing/size/description/etc.): Left heel 1 cm x 2 cm x 0.2 cm Pink wound bed, PUSH score 9 .Care plan (current/revised/new) interventions: off load with popliteal support while in bed, off load on pillows while in chair. Review of Resident #41's Physician's progress note, dated 5/1/19, revealed improvement of granulation of heel ulcer, The patient was seen and examined .Skin: warm and dry. right heal (heel) app. (approximately) 3 inches in diameter, clean ulcer with good granulation . assessment: Large heal ulcer. Review of Resident #41's S[NAME] skin note, dated 4/25/19 at 16:11 (4:11 PM), revealed, Left heel, blister, stage II PI. Wound has increased in size. 6 cm x 4 cm x 0.2 cm. Review of Resident #41's nurses' progress note, dated 4/22/19 at 13:40 PM (1:40 PM), revealed Late Entry: Note Text: Wound assessment completed. Wound has declined since previous assessment. Wound has increased in size, no signs of infection. Periwound is intact, with maceration. Wound bed is superficial, pink with minimal drainage. Measurements: 6 cm x 4 cm x 0.2 cm . Review of Resident #41's S[NAME] skin note, dated 4/18/19 at 10:06 AM, revealed, Left heel blister partial thickness, light exudate 2.0 x 2.0 x 0.1 Push score 7. Review of Resident #41's S[NAME] skin note, dated 4/11/19 at 14:54 PM (2:54 PM), revealed left heel blister 4.0 x 4.0 x 0.10 partial thickness with light drainage, push 9 . Care plan (current/revised/new) interventions: elevate leg in bed. Comments: resident is not compliant with elevating her leg. Interventions were not noted on the care plan. Review of Resident #41's IDT note, dated 4/5/19 at 16:14 PM (4:14 PM), revealed Note Text: IDT TEAM: Resident has a [DIAGNOSES REDACTED]. She is followed by Psychiatry Services for tx. Resident has visual hallucinations and delusions. She will see people on her shoulder, and see people sitting on her bed. There were no interventions noted on the care plan related to hallucinations/delusions and the resident's refusal to elevate her legs. Review of Resident #41's Physician's progress note, dated 4/3/19 at 11:24 AM, revealed Late Entry: Note Text: Called to evaluate patient legs, there is moderate swelling and large heal ulcer, The Patient was seen and examined Large heal ulcer. There was no documentation in the progress notes or assessments of nursing staff evaluating the resident's [MEDICAL CONDITION] of her legs Review of Resident #41's care plan, dated 1/29/19, revealed, The resident has actual impairment to skin integrity. Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Follow facility protocols for treatment of [REDACTED]. Keep skin clean and dry. Use lotion on dry skin. Do not apply on skin impairment area(s). Monitor/document location, size and treatment of [REDACTED]. Report abnormalities, failure to heal, signs and symptoms of infection, maceration etc to physician/provider Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Review of Resident #41's care plan, dated revised on 3/29/19, revealed, fluid filled blister to left heel. The resident has actual impairment to skin integrity, intervention, monitor left heel so s/s of infection or skin breakdown. treatment as ordered till healed. According to Resident #41's Care Plan (current/revised/new) note of 4/11/19, interventions to elevate the leg in bed were not listed in the interventions. According to Care Plan (current/revised/new) note of 5/2/19, interventions to off load with popliteal support while in bed and to off load on pillows while in chair are not listed in the above interventions. There was no documentation of resident education or consideration of the resident's hallucinations/delusions in regard to impacting the plan of care for prevention of the pressure ulcers. On 05/16/19 12:15 PM, during an interview, Director of Nursing (DON) stated, after reviewing Resident #41's treatment order, If the dressing is off, the nurse should put it back on, per the PRN order. DON agreed that Resident #41 had a facility-acquired pressure ulcer. DON was requested to provide a copy of the facility's skin / pressure ulcer policy. Resident #12: According to electronic clinical record, Resident #12 was a [AGE] year-old female, who was admitted to the hospital on [DATE] and re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #12 received all nutrition via Enteral Feeding and nothing by mouth. Resident #12 was non-verbal, dependant on staff for all Activities of Daily Living (ADL) care, and required extensive physical assistance to include bed mobility, positioning, and transfers. Review of Resident #12's electronic care plans revealed a Skin Care plan indicating At risk for pressure ulcer development r/t (related to) Hx (history) of ulcers, Immobility, Incontinence of Bowel and Bladder, contractures. Listed under Interventions were LAL (low air loss) mattress, Gerichair cushion, pillows for off loading, and use mild cleanser for peri care. Another care plan documented Alteration in musculoskeletal status r/t Contracture Bilateral upper extremities, right/left hand contracture One of the Interventions documented Assist to change positions q (every) 2 hours and as needed. Alternate periods of rest with activity out of bed in order to prevent respiratory complications, dependant [MEDICAL CONDITION], flexion deformity, and skin pressure areas. Review of the care plan for Incontinence for Bowel and Bladder r/t Activity Intolerance, Dementia, Impaired Mobility, and Limited ROM (range of motion) listed Interventions as Brief use-The resident use disposable briefs. Check q 2 hours and change PRN (as needed). Incontinent--Check (2 hours) and as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinent episodes. The Activities of Daily Living (ADL) care plan documented ADL self-care performance deficit r/t Limited ROM, Musculoskeletal impairment, Contractures, Limited Mobility, History [MEDICAL CONDITION]. Interventions listed included Dependant on Geri Chair on/off unit. Resident is unable to communicate needs. Staff to anticipate and meet residents ADL's, wants, and needs. Further review of care plans revealed, The resident has actual impairment to skin integrity of the following location 'Sacral Pressure Ulcer' injury and a Right Ankle pressure injury, dated 5/16/19 as revised. Interventions were documented as Prevalon boot to RLE (right lower extremity) while in bed. Remove Q shift to assess the skin, and also Yellow Dot Program, turn and reposition Q2H and PRN. This Care plan was provided to the Surveyor after the Surveyor observed the wounds on 5/16/19. A review was conducted of 'Discharge', Minimum Data Set (MDS), dated [DATE]. Section 'M' Skin Conditions was documented under M0210 Unhealed Pressure Ulcers and was coded as 'No'. It was also documented as 'No' to pressure ulcers being present on the prior assessment.' A review was conducted of the MDS, dated [DATE]. 'Annual Assessment' documented 'Yes' to being at risk for pressure ulcers, and 'No' to having unhealed pressure ulcers. A review was conducted of the MDS 'Quarterly Assessment', dated 2/18/19, where it was documented Yes to being at risk for developing pressure ulcers, and 'No' to having unhealed pressure ulcers. A review was conducted of the readmission (from the hospital to the facility) skin assessment, dated 2/12/19. Under the area of 'Skin Evaluation' and the area of 'Any areas of abnormal skin', Resident 12 was documented as 'Yes', and listed the location of the 'Sacrum'; Skin tear measuring 1.5 cm x 0.5 cm x 0.0 cm (centimeters). Under the section for 'Comments', documentation read, Patient had skin tear prior to hospitalization . Upon readmission, skin tear still present. Appropriate treatment in place. An observation of Resident #12 was made on 5/16/19 at 7:45 AM. Resident #12 was sleeping and positioned on her right side. During an additional observation three hours later at 10:45 AM, Resident #12 was still sleeping in the same position. There had been no repositioning. An observation was made on 5/16/19 at 10:50 AM, of the Sacrum/coccyx wound and Right Ankle wound with RN AA and RN Z. RN Z had supplies set up to perform the treatment of [REDACTED]. Upon pulling the sheets back, RN Z said Oh No, she is soiled. I find her like this quite often. No wonder why this wound has reopened. She is incontinent of feces and urine. RN AA verified that Resident #12 was soiled of urine and feces. Surveyor was at bedside and observed several large yellow tinted stains, which RN Z said were urine rings on the sheet under Resident #12. The first larger ring was almost dried on the sheet and extended out from the resident approximately 5 inches. Further observation revealed that the resident was laying in feces, as well as urine, and her gown was soiled. The bed sheets, and low air loss mattress were also wet. RN AA and RN Z proceeded to clean up Resident #12. The surveyor asked who was the assigned staff member caring for Resident #12. Both nurses indicated that they were not sure, but would find out. RN AA left the room. RN Z began to remove the soiled sheet and when the sheet was moved away from the mattress, there were multiple discolorations in circular form stained on the mattress. RN Z indicated that they were from multiple incontinence episodes. RN Z stated that she had previously noted that the mattress had been soiled multiple times and stained, and had requested a new mattress from central supply. RN Z stated that they would have to get one today, and that Resident #12 could not stay on the mattress even with clean sheets because urine was soaked into the mattress. RN Z indicated that she had to request new Prevalon boots a few times over the past three weeks for the right ankle wound and that staff were not applying the boot as ordered. I have had to get after staff numerous times. They are not using the boot as they are supposed to. When I come to check on this resident, usually I can't find the boot and have to search for it. The resident's right ankle opened up recently. Certified Nursing Assistant HH entered the room about 11:00 AM, with RN AA and was asked when she last moved the resident and checked to see if Resident #12 was clean and dry. CNA HH verbalized she was not positive, but thought somewhere around 8:00 AM or 8:30 AM. CNA HH was asked if she repositioned the resident off of her right side during that check and said, No, I am new and not familiar with her. CNA HH was asked if she looked at the Kardex (CNA Care Guide) for Resident #12 and replied No. CNA HH, RN Z, and RN AA began to clean the urine/feces off of Resident #12, before proceeding with the treatment for [REDACTED]. RN AA and RN Z stated that Resident #12 had to have been soiled longer than a couple of hours, due to the presence of the soiled sheets, the dried rings of urine, and the saturation through to the mattress. RN AA said, No way has this been since 8:00 or 8:30 AM. RN Z removed the old dressing off of Resident #12's Sacrum/ coccyx area to reveal a wound with an area of 1.6 cm x 0.7 cm x 0.3 centimeter with a pink base and some slough to the center of the wound. The wound had macerated edges, and irregular borders. RN Z called the wound a Stage III pressure ulcer. Observation of the surrounding skin revealed old scar tissue. The wound was measured in front of the Surveyor. RN Z cleansed the wound and applied the ordered treatment of [REDACTED]. RN Z then began the treatment on the Right Ankle. RNZ indicated this was a new wound that had recently opened up and that the Right Ankle was not open during rounds on 4/1/19. RN Z removed the old dressing, cleansed the area, and measured the Right Ankle wound at 2.0 cm x 1.4 cm x 0.1 cm, with 95 percent yellow slough to the wound base. RN Z indicated that the Right Ankle looked worse since the last time she seen the wound on 5/6/19. RN Z indicated a larger purplish area to the bony part on the Ankle that was not there the week before. RN Z stated, I am not surprised that it has got worse, because staff are not putting the blue Prevalon boot on the wound like they are supposed to or off loading the pressure. I have gotten after them quite a few times. RN AA was asked if Resident #12 gets up out of bed, as this Surveyor has seen her in the bed multiple times over the past three days positioned only on her right side. RN AA indicated that Resident #12 was bedbound and did not get up. An inspection of the room did not reveal that a Geri chair was available, as was documented on the care plan to have Resident #12 get up. An interview was conducted with RN Z on 5/16/19, who indicated that she was new to the facility. RN Z indicated that during rounds with the previous Nurse Practitioner, she was told that the Sacrum/coccyx area was closed. RN Z indicated she did not actually see the wound, but the Nurse Practitioner indicated the Sacral/coccyx area was closed. RN Z stated that she was only assisting because she had only been at the facility one or two weeks at that time. RN Z stated that she was informed on 4/10/19, that Resident #12 had a Stage I Pressure Ulcer (not opened) noted to the Right Ankle. The Surveyor asked RN Z if any interventions were implemented at that time and she responded , No, and there was not a treatment put in place at that time. RN Z verbalized that there had been no communication to her regarding the pressure ulcer to the Right Ankle until 4/25/19 when the Director of Nursing informed RN Z that the Right Ankle had opened up. On 4/25/19, the Right Ankle was measured at 1.0 cm x 1.0 cm with 95 percent yellow slough tissue noted, and treatment was initiated at that time including use of the blue Prevalon boot. RN Z reiterated again, that she has had to get the blue boots two times in three weeks, because they kept disappearing. RN Z also stated that the former Nurse Practitioner measured the Sacral/coccyx wound on 4/29/19. The measurements were 2.0 cm x 0.4 cm x 0.3 cm. RN Z indicated her measurements on 5/7/19, of the Sacrum/coccyx were 2.0 cm x 1.0 cm x 0.2 cm with a pink base and slough noted to the base. On 5/7/19 the Right Ankle pressure ulcer measurements were 0.5 cm x 0.5 cm x 0.1 cm and looked like a bull's eye, with 50 percent slough to the base. The right ankle pressure ulcer appeared to look worse with some bruising or dark area surrounding the open area. RN Z said It looked like a bull's eye. Review of skin assessments provided by the facility documented: - 3/12/19, No new abnormal skin areas, and no existing abnormal skin area. - 3/19/19, No new abnormal skin areas, and no existing skin areas. - 3/26/19, No new abnormal skin areas, and 'Yes' to existing abnormal skin areas with no description documented in the boxes provided. - 4/2/19, No new skin areas, and 'Yes' to existing areas with no description documented. - 4/10/19, No new abnormal skin areas, and 'Yes' to existing areas with a description of Scalp, Right Ankle (outer), and abdomen. There were no further skin assessments completed and documented until 5/7/19. - 5/7/19, No to new abnormal areas, and no description documented. The facility provided a skin assessment dated [DATE], but it was blank (not completed). There were no documented skin assessments completed by staff from 4/10/19 through 5/7/19. On 5/14/19 a skin assessment documented No new abnormal areas and 'Yes' to existing areas describing Coccyx PI (Pressure Injury), and Right Outer Ankle PI (Pressure Injury). Review was done of a Wound Care Progress, note, dated 5/13/19, by the former Nurse Practitioner for Resident #12. Pain was documented as 'moderate 4-6 while removing [MEDICATION NAME] from ankle'. On 'Support Surfaces' it was documented, No Boots on, and Right Ankle as a Stage II, measuring 1.2 x 1.0 x 0.1, and documented, Do not apply [MEDICATION NAME]. 3 layer Xeroform cut to size, may cover with Kerlix and ABD pad (dry dressing). A review was conducted of Gentell wound notes for the right ankle provided by the facility, which documented, Right lateral Malleolus (Ankle) dated 4/25/19, as 1.0 cm x 1.0 cm x 0.1 cm, as unstageable with 95 percent slough to base, and documented as Pressure Ulcer. On 4/29/19, Right lateral Malleolus 1.0 cm x 1.7 cm x 0.2 cm, unstageable, granulation, documented as Pressure Ulcer. On 5/6/19, Right lateral Malleolus 0.8 cm x 1.0 cm x 0.1 cm, unstageable, Pressure Ulcer. Wound notes were documented by RN Z. A review of was conducted of Gentell wound notes for the coccyx provided by the facility, which documented on 4/29/19, coccyx, open, 2.0 cm x 0.4 cm x 0.3 cm, Stage III, Pressure Ulcer. On 5/6/19, coccyx, 1.0 cm x 0.2 cm x 0.20 cm, Stage IV (Stage 4), Pressure Ulcer, slough present. Wound notes were documented by RN Z. RN Z stated that staff were not repositioning Resident #12 as they should. She further stated that staff were not placing the blue Prevalon boot on the Right Ankle as they are supposed to, and that she often finds Resident #12 soiled with feces and urine, and that the wounds are not going to heal until they do better with Resident #12. A review was conducted of the facility policy. 'Pressure Ulcer/Pressure Injury Prevention and Treatment, dated (MONTH) 28, (YEAR). The policy stated, Based on Comprehensive Assessment of resident, a resident receives care, consistent with Professional Standards of Practice, to prevent Pressure Ulcers, and does not develop Pressure Ulcers unless the clinical condition demonstrates they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with Standards of Practice to promote healing, prevent infection, and prevent new ulcers from developing. The Administrator and Director of Nursing were informed by facility staff regarding the condition that Resident #12 was observed in during the wound care observations. The Surveyor also informed the DON and Administrator on 5/16/19, after wound care was provided by RN Z AND AA, of the condition and circumstances that Resident #12 was observed in, including the feces and the urine-soaked bedding, clothing, and mattress. The Administrator informed the Surveyor that Staff had placed a clean mattress on the bed for Resident #12.

This Citation pertains to Intake Numbers MI 913, MI 105 Based on observation, interview and record review, the facility failed to provide and document suctioning of a tracheotomy tube for 2 Residents (# 2 and #3) of 3 residents reviewed for management of the tracheotomy tube, resulting in a build-up of tracheal secretions for Residents #2 and #3, which lead to an inability to self-clear their airways, and anxiety related to the feeling of not being able to breathe for Resident #2 and airway obstruction with decreased oxygenation, resulting in respiratory distress and hospitalization for Resident #3. Resident #2: A record review of the Face Sheet and Minimum Data Set (MDS) assessment indicated Resident #2 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The MDS, dated [DATE], indicated the resident needed total ,[DATE] person assistance with all care. On [DATE] at 4:03 PM, Resident #2 was observed lying in bed, awake and breathing with the assistance of a ventilator. The resident mouthed words and communicated with the assistance of an electronic computer with a voice module. During the interview, the resident said she did not always receive timely assistance when she needed to be suctioned, due to an accumulation of airway secretions in her [MEDICAL CONDITION]. She said on one occasion ([DATE]) she asked to be suctioned about 5:00 PM and waited for about 2 ½ hours for the nurse to suction her. She said the nurse aides answered her light and said they would tell the nurse, but neither a nurse or Respiratory Therapist came to assist her. Resident #2 stated, I just waited, and waited and waited. Resident #2 said she felt like she couldn't breathe and was uncomfortable until the nurse came in to suction the tracheal secretions. A review of Resident #2's Care Plan .Ventilator dependent related to [MEDICAL CONDITION], date initiated [DATE], revision [DATE], Goal: .Mobilize secretions, with Interventions: Use in-line suction catheter for suctioning, dated [DATE] and .Periods of Anxiety, date initiated [DATE] with Interventions: Anticipate and meet the resident's needs On [DATE] at 12:18 PM, an interview with Nurse G revealed the nurse was assigned to care for Resident #2 on [DATE], Most of the time, I [MEDICAL CONDITION] if the RT (Respiratory Therapist) is busy. They usually do it. I suction if there is gurgling or the vent alarms and they are gurgling. There may have been one instance where she asked the aide about suctioning and they didn't tell me right away. Resident #3: A review of the Face Sheet and Minimum Data Set (MDS) assessment for Resident #3 indicated the resident was originally admitted to the facility on [DATE], discharged to the hospital for respiratory distress on [DATE] and again on [DATE] for respiratory distress. Resident #3 was readmitted to the facility on [DATE] and died at the facility on [DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident had severely impaired cognition and needed total assistance with all care. A review of the Hospital transfer documents from the [DATE]-[DATE] hospital admission, revealed Resident #3 was transferred to the hospital via ambulance after becoming unresponsive at the facility. A Hospital discharge summary note, dated [DATE], said during the ambulance transport with Emergency Medical Services (EMS) personnel (on [DATE]), they were able to fill a canister full of thick mucus as they continuously bagged the patient. On arrival to the ER, patient was placed on [MEDICAL CONDITION] (a continuous positive airway pressure machine to aid in breathing) mode to assess for spontaneous respirations, however no spontaneous respiratory effort was noted and he was .hooked back up to the ventilator. Since arrival to the ER, patient has not had thick mucus suctioning after being suctioned by EMS . An Infectious Disease Consult Note, dated [DATE], while in the hospital revealed, Respiratory distress and [MEDICAL CONDITION] with history of multi-drug resistant organisms . He was brought by EMS from (the facility) due to respiratory distress. Per EMS records they were able to suction large amount of secretions with possible mucous plug. Patient is not on ventilation machine at baseline but has been during this admission . Per medical records, he was found by staff members to be blue and not breathing and they (facility) were unable to suction any secretions. Also, per records, EMS suctioned a full container of thick mucus secretions Patient's baseline is [MEDICAL CONDITION] use [MEDICAL CONDITION] but not dependent upon ventilator. He was placed on ventilator in ED due to poor respiratory effort and remains ventilated . A review of the physician orders [REDACTED]. A review of the (MONTH) (YEAR) Medication Administration Record (MAR) and physician orders [REDACTED]. to wheezing, start date [DATE]; [MEDICATION NAME]-[MEDICATION NAME] Solution 0XXX,[DATE].5 mg/3 ml, 3 ml inhale orally every 4 hours as needed for Shortness of Breath or wheezing via nebulizer, start date [DATE]. There was no documentation that the medications were administered. A review of the (MONTH) 2019 MAR and physician orders [REDACTED]. wheezing via nebulizer, started [DATE]. The [MEDICATION NAME]-[MEDICATION NAME] breathing treatment was given once to Resident #3 on [DATE] at 12:43 PM. There was no breathing treatment administered on the day the resident died , [DATE]. A further review of the physician orders [REDACTED]. Clean stoma bid (twice a day) Change inner cannula once per day, start date [DATE]; [MEDICAL CONDITION] every 3 days and as needed, start date [DATE]; oxygen to maintain sp02 (oxygen saturation rate) greater than 90%, start date [DATE]. [DATE] at 6:23 PM, an interview with Confidential Person [NAME] revealed, The hospital said (Resident #3) was not being cared for. He was sent there multiple times (from the facility). When he went to the emergency room (ER), he had poor mouth care. It was green. They said he was like that every time. He went in (MONTH) ([DATE]), his mouth was green that time. One time they (facility) called and said they were moving him to a different floor. I walked in the room and his bed was lying flat. He had a tube feed and was not supposed to lie flat. He had green sputum around his trach. I went and got the Administrator and they said they would tell the DON (Director of Nursing) and it would never happen again. It was after that he went to the hospital ([DATE]). Another time he sounded raspy and I asked the nurse How often do you clean that out? and she said it was time to clean it now. They were not doing what they were supposed to be doing. During an interview with Nurse A, on [DATE] at 8:05 AM, the nurse was asked if she had cared for Resident #3 and said she was assigned to the resident on [DATE]-[DATE] on the night shift, He was one you had to suction a lot. Respiratory only came down when we needed them to. They are normally on the vent unit (on the other side of the building-about 200 feet away). When asked where the nurse documented if she suctioned the resident and the resident's response to the treatment she responded, I didn't know we had to chart that. Nurse A said she was responsible for residents on 2 halls on [DATE]-[DATE], including residents with tracheostomies. The nurse revealed she left the halls and went to the other side of the building to get help from a Respiratory Therapist for Resident #3's roommate and was gone for about 15 minutes prior to the resident being found unresponsive. Nurse A said a nurse aide had contacted her earlier in that shift, because the resident had a lot of secretions. Nurse A said she gave the resident a breathing treatment, I'm not sure if I documented I gave a breathing treatment. On [DATE] at 3:10 PM, an interview with the Administrator and Corporate Administrator revealed there was no Respiratory Therapist (RT) assigned to the residents with [MEDICAL CONDITION] the night shift; only to residents on a ventilator. The nurse assigned to the resident was responsible to provide clinical care including assessment, medications, respiratory treatment and suctioning. When asked where the nurse would document respiratory care including suctioning, the Corporate Administrator said the nurse would document on the Respiratory Administration Record or in the progress notes. A review of the Respiratory Administration Record for (MONTH) 2019 indicated there was no documentation that Resident #3 received suctioning. A review of the progress notes for Resident #3 from [DATE]-[DATE] indicated no documentation that the resident received suctioning of the [MEDICAL CONDITION] for a build up of secretions, which could make it more difficult for the resident to breathe, including the time that he was found to be unresponsive on [DATE] at 1:15 AM. Progress notes dated [DATE] at 10:20 AM and [DATE] at 12:47 AM referenced the resident had an increased Heart rate (pulse). There was no mention of treatment. A review of the Weights and Vitals, Pulse Summary, for (MONTH) 2019 revealed Resident #3's pulse was usually between ,[DATE] beats per minute (bpm). A normal range is ,[DATE] bpm per the American Heart Association. On [DATE] at 2:38 PM the resident's pulse was 105 bpm and at [DATE] at 10:17 PM it was 107 bpm. There was no documentation that the increasing heart rate was rechecked or further assessed. A review of the resident's respiratory rate for (MONTH) 2019 showed an average of ,[DATE] breaths/minute, Cleveland Clinic- A normal respiratory rate is ,[DATE] breaths/minute. On [DATE] at 8:18 AM, 2:38 PM and 10:17 PM Resident #3's respiratory rate was 24 breaths/minute. Respiratory Care, Tulaimat A, et al, 2014, Association between respiratory distress and vital signs . Higher distress levels were associated with higher breathing frequency and heart rate . There was no documentation that the physician had been notified of the changes in vital signs. A review of the Respiratory Therapist's Respiratory [MEDICAL CONDITION] Rounds, dated [DATE] at 2:37 PM, indicated the resident was receiving oxygen at 5 liters/minute via a T-Piece (a T shaped tube to breathe through), the residents lungs had rhonchi (National Institute of Health (NIH) U.S. National Library of Medicine, 2019 . Rhonchi: Sounds that resemble snoring. They occur when air is blocked, or air flow becomes rough through the large airways) and the resident's airway was suctioned by the Respiratory Therapist. There was no further documentation that the resident received respiratory care after 2:37 PM on [DATE]-prior to the resident becoming non-responsive at 1:15 AM on [DATE] and dying. A review of the facility policies titled, Suctioning the Lower Airway, dated ,[DATE], revealed The purpose of this procedure is to remove secretions, maintain a patent airway and minimize infection of the lower respiratory tract .document procedure, findings and pertinent information in the resident's medical record . and Acute Condition Changes-Clinical Protocol, dated ,[DATE] The facility identifies changes of condition through several processes .weights/vitals fluctuations .notification of the primary or on-call physician should be made .

This citation pertains to intake # MI 439 Based on interview and record review the facility failed to supervise, assess, monitor and document for 1 resident (#403) a fall with a head injury of 2 residents reviewed for falls, resulting in the potential for a subdural hematoma, coma and potential death. Findings include: Resident #403's significant change Minimum Data Set (MDS) assessment, dated 10/31/18, revealed that the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident was coded as severely impaired for cognition. Activity of Daily Living (ADL) Section G-0110. C-F. (walk in room, corridor, on unit and off unit), were each coded as a (1) supervision oversite encouragement or cueing. and Section G-0300. A-C. were each coded as a (1) not steady but able to stabilize without human assistance. Review of Resident #403's EMR (electronic medical record) revealed 3 falls for the month of (MONTH) (YEAR) on 11/4/18, 11/11/18 and 11/19/18, 2 falls in (MONTH) (YEAR) on 12/21/18 resulting in a head injury with no neurological checks and one fall on 1/1/19 at 10:00 PM, an unwitnessed fall with no neurological checks. Review of Resident #403's Incident Report revealed an Unwitnessed fall, dated 1/1/19 at 9:00 PM, Resident found in her room sitting upright with legs crossed on floor next to her bed. No apparent injuries at this time. ROM performed bilateral arms and legs WNL. No pain or discomfort at this time. Husband notified. Doctor notified. Vitals Signs WNL. Pupils normal and reactive to light. Will continue to monitor. Treatment: Assessment and Neurocheck no boxes checked, Type of injury none. witnessed no. :unobserved in resident room. care plan updated. call light in reach, anticipate needs, based on assessments, bed in low position. Investigation Report: confused, gripper socks, no statements. Review of Resident 403's EMR revealed no documentation of ongoing neurological assessments (neuro checks) from 1/1/19 at 9:15 PM, through 1/3/19 at 00:42 AM. for a fall that occurred at 9:00 PM, Review of Resident #403's IDT note, dated 1/2/19, revealed poor safety awareness, inability to follow directions/redirections r/t [DIAGNOSES REDACTED]. Resident's future falls may be anticipated r/t poor safety awareness, & related diagnosis. Staff will continue with P[NAME] and frequent monitoring to promote safety. Review of Resident #403's next nurse progress note related to the fall was a Late entry, dated 1/3/19 at 00:42 AM, for 1/1/19. Situation (observed on floor/witnessed fall/etc.) : 9:00 PM resident was found in her room sitting upright with legs crossed on floor next to her bed. Vital Signs WNL. Assessment if unwitnessed or suspected head impact, consider neuro checks: neuro checks started WNL, Pupils normal and reactive to light. Will continue to monitor. Review of Resident #403's Incident Report revealed a fall dated 12/21/19 at 4:40 PM. Documentation included Resident stood up from wheel chair, lost strength fell and landed on buttocks on floor. Treatment: Assessment and Neuro check both boxes checked, Type of injury none. Review of the Fall investigation report revealed: Fall occurred in the hallway, witnessed unknown, ambulating, wearing socks, Root cause:, medical status Initial interventions to prevent future falls: staff redirection, resident re-education. Summary of meeting notes: Confusion, poor safety awareness. Conclusion, Resident stood up and lost strength and landed on buttocks on floor. MD and Representative notified. Staff to provide frequent usual observation and redirect resident during attempts to self transfer or ambulate. Hospice to do med review. care plan updated Witness name was incomplete on the form. Review of Resident #403's Incident Report revealed a fall dated 12/21/18 at 5:30 PM. Documentation included Resident stood up from wheel chair, lost strength fell to bottom on floor.Treatment: Assessment and Neurocheck both boxes checked, Type of injury none; Review of the Fall investigation report revealed: Fall occurred in the hallway, witnessed by CNA P, ambulating, wearing socks, Root cause:, medical status Initial interventions to prevent future falls: staff redirection. Summary of Meeting: Resident tried to stand up and walk. Conclusion: Resident stood up from wheel chair, lost strength fell to bottom of floor. Care pan to provide activity of daily living to transfer and ambulation. Additional. Hospice to do med review. Care plan updated. There was no evaluation/root cause of resident wearing socks or Hospice recommendation to wear gripper socks versus regular socks on the care plan for either of the 2 falls on 12/21/18. Review of Resident #403's Hospice charting, dated 12/21/18 at approximately 5:50 PM (20 minutes after 2 falls), revealed Bruising right back side of head, pain indicated by facial cues, and verbal cues (whining, whimpering or moaning), Tylenol given, Reviewed pain findings with husband, RN G, Hospice physician M and Attending physician N. Narrative: Pt sitting in wheel chair at nurses desk due to increased anxiety and fall x 2. Bump noted to right side of head. Pt fall witnessed by facility CNA O. PT stood up ambulated for short distance then fell unto bottom and hit head on ground. Ice applied to head. Pt did not like it and moved head away. Husband notified and declined Ct/head x-ray or any other testing. No n/v (nausea /vomiting)or noted SE (side effects) from hitting head during visit. Tylenol given and new order for [MEDICATION NAME] obtained. Care giver education provided: Hospice 24 hour phone number and nurse availability, to notify Hospice with any uncontrolled symptoms questions or concerns. Monitor frequently with increased anxiety. case collaboration/coordination with husband, RN (G), Dr (M) Dr (N) pts fall and increased anxiety. Spoke with hospice SW in regards to status and P[NAME]. email sent out to team. Reviewed with husband and facility RN G : 1. Assessed sensory/neurological status. 2. Initiated/reinforced fall precautions to minimize incidence of falls. Reviewed safety precautions including low bed, non skid socks and frequent monitoring. 3. Instructed regarding cause of anxiety/terminal agitation. 4. Instructed regarding measures to manage anxiety/agitation. New order for [MEDICATION NAME]. 5. Reviewed hospice plan of care with facility staff. Review of Resident #403's electronic medical record revealed there was no documented neurological assessment by the facility for the 2 falls on 12/21/18 at 4:40 PM and 5:30 PM as indicated by Incident Report box being checked for the neurological assessment and per nurse progress note on 12/21/18 at 8:06 PM that revealed presence of a welt developing on posterior scalp. Review of Resident #403's initial fall nurse progress note, dated 12/21/18 at 20:06 (8:06 PM), revealed hospice nurse in to assess resident, noted that resident had a welt developing on posterior scalp. Doctor notified, family notified, per guardian - requesting further testing not be performed. welt r/t (related to) fall. The next documented nurse progress note related to the fall for Resident #403's Pertinent Charting-Falls was dated 12/24/18 at 11:03 by Director of Nursing (DON). It stated, Note Text: Date of Fall: 12/21/2018 Situation Details: Resident attempted to stand from wheelchair twice during first shift and experienced two falls Assessment: falls were observed, no injuries noted r/t either fall none observed Mitigating Factors: resident is confused and exhibits poor safety awareness environmental Factors: n/a Interventions: care plan to be updated with new intervention MD Notification: Dr. (name). Review of Resident #403's Pertinent Charting-Falls, dated 12/24/18 at 19:03 (7:03 PM), revealed Note Text: Date of Fall: 12/23/2018 (inaccurate date of fall) resident observed ambulating down Windsor hallway, with out assistance. unsteady gait when ambulating. resident difficulate (sp) to redirect, will not stay seated in w/c and will not stay in bed. difficulate (sp) for staff to monitor. Review of Resident #403's nurse progress note, dated 12/25/18 at 15:03, by LPN F, revealed, Note Text: Date of Fall: 12/23/2018 (inaccurate date of fall) Res is alert to name, not verbal speaking, eyes open to verbal command. No signs of pain. Swelling and redness at top/back of head. Dr. (name) ordered X-ray of head. No signs of distress. Res slept intermittently throughout this shift. Gave ice pack to back of head for swelling. Call light within reach. Res needs are anticipated. Bed in low position. Will continue to monitor. Review of Resident #403's care plan revealed The resident has h/o falls related to: Balance deficits, Confusion , History of falls. pt has dx of ALS. poor balance and coordination. pt has poor safety awareness, difficult to redirect due to patients progressing ALS. coordinate all care with (Name) hospice, interventions included: Pt. to be monitored every half hour around the clock; Anticipate and meet the resident's needs based on nursing assessments; Bed in lowest position when not providing care; Determine causative factors of fall and resolve or minimize; Educate the family/caregivers about safety reminders and what to do if a fall occurs; Encourage resident to be out of room in common area when awake to provide more frequent staff observation; Encourage rest periods as needed to avoid overtiring; Ensure eye glasses are clean and on resident when awake; Hospice assess medication as needed; If resident observed to be awake and restless in bed, resident to be assisted to activities and encouraged to participate; Provide for activities of daily living such as incontinence care, transfers, ambulation, as written in the activities of daily living plan of care; Pt. to be monitored every half hour around the clock; Contact family to request additional support to stay with resident; Staff to offer toileting following meal times (scheduled bolus feedings/PRN); Staff education to monitor resident for common area; Notify hospice staff for further follow-up as needed or indicated; MD to be notified as indicated or needed; staff to provide frequent visual observation and redirect patient during attempts to self transfer or ambulate. There was no intervention related to evaluation/root cause of falls on 1/21/18 (Resident wearing regular socks, wanting to walk, pain .) or Hospice recommendation to wear gripper/non-skid socks versus regular socks on the care plan to prevent a fall. Review of Resident #403's Kardex revealed Anticipate and meet the resident's needs based on nursing assessments, Bed in lowest position when not providing care; Encourage the resident to use call bell to request assistance, ;Ensure eye care glasses are clean and on resident when awake; If Resident observed to be awake and restless in bed, resident to be assisted to activities and encouraged to participate; Maintain consistent daily routine and consistent bedtime routine; Observe for acute process which may increase wandering; Pt to be monitored every half hour around the clock. There was no intervention related to evaluation/root cause falls on 1/21/18 (Resident wearing regular socks, wanting to walk, pain .) or Hospice recommendation to wear gripper/non-skid socks versus regular socks on the care plan to prevent a fall. Review of Resident #403's physician progress notes [REDACTED].#403's five (5) falls between 11/14/18 and 1/16/19 and the potential risks related to the falls. On 1/23/19 at 12:58 PM, during a phone interview, Hospice Nurse I, reported she had visited Resident #403 on 12/21/18 at approximately 5:50 PM, and was informed by a CNA of 2 falls, that the Resident had hit her head with one of the falls, had been assessed and identified with a head injury that consisted of bruising right back side of head. Hospice Nurse I reported she had contacted the spouse, attending physician and hospice physician and received orders for Tylenol, ice pack for pain on the area on the head and [MEDICATION NAME] related to increase anxiety. Hospice Nurse I reported she had assessed resident and identified the bruise on the right back side of the head. Hospice Nurse I stated that the plan of care/safety concerns/ recommendations for revision of care plan (gripper socks, bed lowered, frequent monitoring, neuro checks per fall protocol) were all discussed with RN G prior to leaving the facility. On 1/18/19 at 3:30 PM, during an interview, DON reviewed Resident #403's documentation and agreed there was no documentation in the nurse progress notes on 12/21/18, 12/22/18 or 12/23/18 related to information about Resident's fall/Assessments pertinent charting. DON reported the charge nurse at the time had completed a fall assessment that had not included a head injury, and completed a pain assessment but there was no pertinent fall charting initiated. DON reported the documentation on the pertinent fall charting was started by the DON on 12/24/18 based on the 2 incident reports. DON reported both falls were observed by RN G and had been documented. According to the incident reports, Resident #403 kept standing from wheel chair. DON reported according to the incident report the nurse had assessed Resident #403 with no injuries. It was later noted according to the documentation by Hospice Nurse I there was a bump on the head and swelling. There was no documentation as to how that injury happened. DON stated, Can not see what happened. They (nurses) are to call immediately. The documentation should be there for communication. DON reported Resident #403 had several falls back-to-back. DON reported staff should have been monitoring falls, have reported on the communication 24 hour sheet of Resident #403's falls, they are supposed to call DON with any falls, complete the fall assessment, pain assessment, pertinent charting initially and document for 3 days, complete neuro checks with any head injury, complete a skin assessment, and update the care plan with new intervention. DON agreed there was no incident report or further documentation/incorrect documentation for 12/25/18 related to bruising on top of head. There is no incident report related to the area of bruising on the top of the head or for a possible fall incident related to 12/25/18. DON reported the 12/25/18 was probably inaccurate documentation. On 1/18/19 at 4:00 PM, during an interview with Minimum Data Set (MDS) nurses RN D and RN E both reported Resident #403's Falls -Care plans should have been updated with Fall intervention documentation. Resident #403 was reported by both MDS nurses D and E as difficult to reorient, poor safety awareness, staff try to look at intervention to fit resident needs, very mobile in her wheel chair, difficulty following instructions, poor cognition, does not remember, lot of oversight needs to be provided, offer different activities, and food for distraction. On 1/23/19 at 11:15 AM, during an interview, LPN F reportedly had documented on 1/25/19 related to Resident #403's fall but was unsure of the fall date and had assumed the fall was on 12/23/19 and had also assumed the swelling was from a previous fall. LPN F reported Resident #403 had a little area on back of head with some swelling and for extra precaution placed an ice pack on the area to reduce the swelling. LPN F reported she had been aware an x-ray was ordered and reviewed and that the x-ray and was negative. Resident #403's x-ray was not available when reviewing the electronic medical record. LPN F stated, I know resident did not fall on my shift. last 2 weeks no strength to get up any more. before was getting up and down often and at the times of the falls was very active, and could go in the bathroom brush her teeth on her own. LPN F reported at times the staff were taking her for a walk, OT, PT would take her for a walk. LPN F reported Resident #403 had night dementia. Staff were redirecting her versus walking her at night. LPN F reported she had received a report from the night shift that Resident would get up and wheel around in her wheel chair. LPN F reported Resident #403 was recently put on an antianxiety medication and was sleeping more. LPN F stated, the facility had enough staff to supervise but not to take Resident #403 for walks and keep occupied, Activities would take her to an activity then she would wonder off from Activities, not pay attention, and staff would bring her back to room/hall where she would again be wandering and getting up and down in w/c. LPN F reported that, following an initial fall, there is a fall packet that is completed, that included pain assessment, fall assessment, incident report . do not address care plans unless it is a new intervention. The MDS team addresses care plans with any new interventions. On 1/23/19 at 2:45 PM, during an interview, LPN H reported the fall dated 12/23/18 was for 12/21/18. A document from the computer triggered daily charting, LPN H reported she had incorrectly filled in the date of 12/23/18 for fall charting, Chart falls for 72 hours every shift, following the initial fall in the progress notes. Notify the physician, family and DON and the computer generates the 24 hour report. The staff are aware they are to complete an Incident Report and with any unwitnessed fall, neuro checks are to be completed. LPN H reported she was aware Resident #403 had received a bump on the head and a x-ray was ordered with safety precautions of low bed, flat call light and resident to be in view of staff. LPN H agreed she had not completed any neuro checks. 1/23/18 at 3:15 PM, during an interview, DON reported there were no neuro checks because it was a witnessed fall. DON agreed there was a head injury noted, but neuro checks were not initiated, and should have been initiated. DON agreed Hospice notes should have been reviewed and care plan interventions implemented following a discussion between Hospice nurse I and RN G regarding the fall protocol related to the head injury. Ice packs should have been applied and neurological checks completed. On 1/23/19 at 3:25 PM, during an interview with DON and Consultant K, DON and Consultant K agreed staff documented that Resident #403 was difficult to redirect. They were asked what interventions are staff assessing for resident's needs and why is resident trying to get up out of chair? DON and Consultant K responded,root cause, is she trying to walk, pain, activities, 1/23/19 at 3:28 PM, during an interview, RN G reported during the initial assessments following Resident #403's the 2 falls on 12/21/18, she did not notice any injuries, did a quick neuro check, notified physician, and notified spouse-spouse did not want any follow up done. RN G stated that she had let Attending Physician N know of fall and then Hospice nurse I came in and noted a mass had developed with bruising and some pain. RN G was asked if she had documented a nurse note related to the welt. She responded, pretty sure I did. RN G was queried if documentation was made on the incident report related to the head injury and stated.Probably not. RN G was queried if she had completed neuro checks and responded, No it was against the guardian's wishes. He did not ant any further testing done. RN G was queried what the facility policy was for a head injury to initiate neuro checks and responded, I have to follow up on that- on the facility policy. RN G stated, Did not realize that monitoring was required, do not think there is any specific monitoring in place, did not think there was anything continued and husband refused testing so did not think it required for the neuro checks to be completed. RN G was queried about a report from Hospice nurse I and responded, Hospice nurse, let me now the head injury developed, let know she had called the Dr., in some pain, and recommended Tylenol, get something for anxiety and restlessness order for [MEDICATION NAME]. RN G was queried if she had assessed Resident #403's head injury and responded, No. Hospice Nurse I gave me report and I did not feel it was necessary, Resident #403's head was reported as bruised and welted, not sure if she had fallen again or from one of the 2 falls on 12/21/18. RN G stated, I watched her pretty close the rest of the shift. No ice pack (denied) then stated,There might have been a request for a glove for ice. RN G was queried if Hospice Nurse I had recommended any further interventions for safety? and responded, Make sure the bed was in a low position, if she tried to get up again, do not recall any more interventions, I do not think so. I put charting in and was out of building by 7:00 PM. Reviewed Hospice notes with RN G for safety interventions and RN G agreed that Hospice nurse I had, discussed a low bed, gripper socks and frequent monitoring stated, normally resident is cruising in the hall, the building watches her and assumed the Hospice nurse would do the documentation. RNG agreed she had not updated the care plan to include gripper/non-skid socks versus regular socks following Resident #403's falls on 12/21/18 with a head injury. Review of the facility policy Falls - Clinical Protocol, dated 6/2018, revealed 1. Based on the assessment a care plan will be developed and implemented to address identified risk. This will be revised as necessary.4. Interventions should be developed and implemented per the assessed needs. 5. In addition interventions for direct care givers should be placed on the KARDEX or similar format. 6. The care plan and KARDEX should be updated as interventions change. 1. For an individual who has fallen, staff should attempt to define possible causes within 24 hours of the fall. a. Causes refer to factors that are associated with or that directly result in a fall; for example a balance problem caused by an old or recent stroke. b. Often, multiple factors in varying degrees contribute to a falling problem. c. Once a fall occurs it is important to gather as much information as possible; i. Observe for evident trauma ii. Observe to determine what the resident was attempting to do if possible iii. Observe for environmental hazards which may have contributed iv. If the resident is able, .v. Staff present and responders, what did they see/hear. d. Provide emergency care and assessment/s as indicated. e. Residents who have fallen and have been witnessed to hit their head or have suspected to have hit their head should have neurochecks per Md orders or resident's conditions warrants. All un-witnessed falls should have neurochecks completed, regardless of resident's cognitive status, per MD orders or residents' condition. f. g. Document findings in the resident's medical record per standard protocol. h. An accident/incident report will be completed and forwarded to the DON as part of the facility's internal Quality Assessment and Assurance Program. 1. Post fall analysis will review (not all inclusive); a. The A/I b. The nurses notes c. Review of recent medication changes d. Review previous lab findings if applicable e. Review for other acute clinical changes f. Review staff and resident statements g. Observe the resident's room or area of fall. 2. Analysis of the causative factors and rationale for interventions developed and implemented should be documented in the Standards of Care notes. 3. Update the plan of care with new or revised interventions. 4. Update the KARDEX or similar format with new or revised interventions . 1. The staff will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling .

This citation pertains to Intake #MI 096. Based on observation, interview and record review, the facility failed to ensure safe medication administration and timely/documented assessment after the occurrence of a significant medication error for one Resident (#902) of three residents reviewed for medication administration resulting in Resident #902, who had a documented history of an allergy to [MEDICATION NAME], was given [MEDICATION NAME] IR (immediate release) 15 mg (milligrams), on 12/14/18 at approximately 2:30 AM, through the PEG tube (percutaneous endoscopic gastrostomy tube, a tube placed into the stomach through the abdominal wall to provide a means of feeding or giving medication when oral intake is not adequate) and the potential for adverse reactions to the narcotic medication, [MEDICATION NAME], to go unrecognized and untreated, resulting in possible death. Findings include: A review, of Resident #902's medical record, revealed an admission into the facility on [DATE] and a reentry on 12/17/18 with [DIAGNOSES REDACTED]. A review of the Minimum Data Set assessment revealed the Resident was in a persistent vegetative state/no discernible consciousness. Further review of Resident #902's medical record, revealed the following: A progress note, dated 12/14/18 at 3:30 AM, revealed, [MEDICATION NAME] administered to resident. Resident has an unknown allergy to [MEDICATION NAME]. Dr (doctor) has been notified. Will monitor per Dr order. DON (Director of Nursing) and family has been notified. Resident VSS (vital signs stable). Resident afebrile temp (temperature) 98.4. SpO2 (oxygen saturation) 99. Resident has no s/s (signs/symptoms) of respiratory distress at this time, author Nurse C. A SBAR Communication Form and progress note, dated 12/14/18, revealed, S. Situation 1. The change in condition, symptoms, or signs I am calling about is/are hypotensive state before not being able to obtain a BP, [MEDICAL CONDITION] in bilateral arms . Most Recent Blood Pressure 75/43, Date: 12/14/2018 11:19 (AM) A. Assessment or Appearance, LPN. The resident appears: very lethargic and non-responsive. Unable to obtain any kind of vitals. Retaining a lot of fluid and should be sent to ER for further evaluation. Weights and Vitals Summary that listed vital signs on 12/14/18 at 2:00 AM: BP 80/36, pulse 84 bpm (beats per minute), respirations 22 breaths/min (per minute), temperature 97.6 degrees F (Fahrenheit) Axilla. Weights and vitals Summary that listed vital signs on 12/14/18 at 11:19 AM: Bp 75/43, pulse not listed, respirations not listed, temperature not listed. On 1/3/19 at 12:44 PM, an interview was conducted with the Director of Nursing (DON) regarding Resident #902's medication administration of [MEDICATION NAME] and a review was conducted of the Medication Error Report provided by the DON. The DON stated, The Nurse gave the [MEDICATION NAME] that was intended for the roommate (Medication Error Report documented the time at 2:30 AM on 12/14/18) . She didn't follow correct medication administration . I went over the five rights of medication administration with her. The DON was queried regarding an assessment and vital signs after the significant medication error of the narcotic medication, [MEDICATION NAME], that had been given to Resident #902, with a documented allergy of [MEDICATION NAME]. The DON stated, The patient was stable into the morning when I got here. The blood pressure went down when she was getting [MEDICAL TREATMENT]. A review was conducted with the DON of the blood pressure documented at 2:00 AM of 80/36 and queried regarding the time the [MEDICATION NAME] had been administered and stated, Approximately 2:30 AM. A document of the [MEDICAL TREATMENT] communication that the DON provided, revealed vital signs on 12/14/18 at 7:00 AM of BP 92/40, pulse 79 and respirations 16 and that the medication [MEDICATION NAME] (a medication used to treat low blood pressure, [MEDICAL CONDITION]) was given at 6:00 AM. When queried regarding the Resident's assessment and vital signs from approximately 2:30 AM, when the medication error occurred, and 7:00 AM, when the next vital signs were documented, the DON stated, Sometimes things still need to be scanned in. They might be on a neuro sheet or a separate piece of paper. I will try to track down the neuro sheet if that is where she put it. On 1/3/19 at 1:25 PM, a review was conducted, with the DON and Medical Records Staff K, regarding vital signs for Resident #902 after being administered [MEDICATION NAME] in error. The Medical Records Staff reviewed the Resident's chart and stated, I don't see it in there. It still might need to be scanned in. The Medical Records Staff indicated a pile of papers that were still needing to be scanned into Residents' charts. The DON reviewed the pile of papers and was able to locate a document entitled Neurological Evaluation Flow Sheet, with neurological assessment and vital signs that started at 7:00 AM on 12/14/18. A review of the document entitled Neurological Evaluation Flow Sheet, with a date on 12/14/18 revealed vital signs: 7:00 AM, BP 92/40, Pulse (P) 79, Respirations (Resp) rate 16, Pattern N. 7:30 AM, BP 92/39, P 76, Resp Rate 16, Resp Pattern Wheeze. 7:45 AM, BP 92/32, P 76, Resp Rate 16, Resp Pattern Wheeze. 8:00 AM, BP 79/43, P 76, Resp Rate 16, Resp Pattern, N. The DON indicated further vital signs were not recorded on the document due to the Resident going to [MEDICAL TREATMENT] and the [MEDICAL TREATMENT] staff would be monitoring the vital signs. The DON stated, Normally the vital signs or neuro checks are given to the Unit Manager or myself and we do an oversight of them, then they get scanned into the medical record. They should be able to be found in the documents (of the electronic medical record.) I remember her telling me the vital signs. I didn't know she had not recorded them. She should have recorded the vitals from when it (the medication error) first happened. On 1/3/19 at 1:54 PM, an interview was conducted with Nurse C regarding the medication [MEDICATION NAME] given to Resident #902. The Nurse stated, I was going in to get (Resident #902's) IV pump. It was beeping. I had the meds (medication, [MEDICATION NAME] IR 15 mg) set up for the roommate. I had set them down and fixed the pump and then gave the medication in the PEG tube. As soon as I gave it ([MEDICATION NAME]) I knew it was the wrong person. I checked the allergies [REDACTED]. When queried regarding an assessment or monitoring after the medication was given, the Nurse stated, I monitored her vitals but I didn't document them. When queried regarding communication with Doctor G, the Nurse stated, (The Doctor) said to monitor her, I did not get specifics. I was monitoring (Resident #902) for any changes. A review was conducted of Resident #902's documented vital signs, on 12/14/18 at 2:00 AM, of a BP (blood pressure) 80/36 and at 7:00 AM of a BP of 92/40, with Nurse C. When queried regarding the documentation of assessment and vital signs, the Nurse stated, I don't believe I made a second progress note. I was monitoring her blood pressures but I didn't document it. On 1/3/19 at 2:20 PM, an observation was made, of Resident #902, lying in bed. The Resident was positioned on their back with the head of the bed elevated. The Resident's eyes were open and looking around. Upon speaking the Resident's name, the Resident did not make eye contact. Lips and tongue moved but there was no exchange of conversation. The Resident had a PEG tube that was infusing nutrition via a tube feeding pump. The Resident's [MEDICAL CONDITION] was clean and connected to oxygen. The Resident had splints on both hands and an identification bracelet was not observed. An observation was made of the Resident's name posted outside the door prior to entering the room. On 1/4/19 at 2:30 PM, an interview was conducted with the DON regarding the administration of the narcotic medication to Resident #902 in error and the follow up assessment of the significant medication error. The DON indicated the Nurse did not verify the Resident prior to administering the medication and stated, (The Nurse) needed to get everything documented and watch for trends with the vital signs. When queried if writing VSS was adequate information, the DON stated, She should have listed them out. If she had put them in there (medical record), it would have given us information on the Resident's condition. A review of the facility policy entitled Administering Medications, with a revised date on 5/2018, revealed, Medications must be administered in accordance with the orders . The individual administering medications must verify the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: a. Checking identification band; b. Checking photograph attached to medical record; c. Calling resident by name; and d. If necessary, verifying resident identification with other facility personnel . 11. The following information must be check/verified for each resident prior to administering medications: [REDACTED]. Vital signs, if necessary. A review of the facility policy entitled Medication Error Reporting and Adverse Drug Reaction Prevention and Detection, with a date of 9/10, In the event of a significant medication error or adverse drug reaction, immediate action is taken, as necessary, to protect the resident's safety and welfare . d. The following information is documented in the resident's medical record and/or on the incident report: . Resident's condition for 24 to 72 hours or as directed.

This citation pertains to Intake # MI 81 Based on interview and record review, the facility failed to assess, monitor, provide physician-ordered treatments and notify the physician of a change of condition for 1 resident (#2) reviewed for a Stage III/ IV pressure ulcer, resulting in Resident #2 being hospitalized with a decline of condition of the pressure ulcer and the resident expiring related to an infection. Findings include: According to Resident #2's nurse's progress note, dated [DATE], the resident was admitted to the facility on [DATE] at 6:30 PM. A review of Resident #2's physician History and Physical, dated [DATE], revealed that the resident was admitted to the facility secondary to generalized weakness, status [REDACTED]. The report further stated, Skin: warm and dry, abdominal surgical wound with good granulation. Plan: Wound dressing. There was no documentation of the sacral wound. A review of Resident #2's physician's order, dated [DATE], revealed, Cleanse with wound cleanser. Pat dry. Apply Calcium Alginate as directed to ABD. (Abdomen). Skin barrier wipe to peri wound. Cover with ABD pad. One time a day related to Pressure Ulcer of sacral region, Stage 4. A review of Resident #2's physician's progress note, dated [DATE], revealed Skin: warm and dry, abdominal surgical wound with good granulation. A review of Resident #2's physician's progress note, dated [DATE], revealed, Integument: no rash. There was no documentation of a sacral wound. A review of Resident #2's Nurse Practitioner's (NP) progress note, dated [DATE], revealed a Stage 4 sacral ulcer. Review of Resident #2's NP progress note, dated [DATE], revealed, Inspection; location: buttocks wound care team following. Review of Resident #2's NP progress note dated, [DATE], revealed, Inspection; location: buttocks wound care team following. Review of Resident #2's NP progress note, dated [DATE], revealed, Inspection; location: buttocks wound care team following. Review of Resident #2's NP progress note, dated [DATE], revealed, Inspection; location: buttocks wound care team following. Review of Resident #2's Pain note, dated 11//,[DATE], written by MDS nurse N revealed precipitating factors: PU 4, GERD, [MEDICAL CONDITION], multiple falls, [MEDICAL CONDITION]. Review of Resident #2's nursing admission/readmission evaluation revealed that the resident was readmitted to the facility on [DATE] with a Stage III pressure ulcer that measured 7 x 8 x 0.3 centimeters (cm) . Review of Resident #2's physician's orders, dated [DATE], revealed, apply [MEDICATION NAME] gel as directed to sacrum and cover with non border foam every day shift and PRN. Apply Dermaseptine to peri wound every day and PRN. Review of Resident #2's weekly treatment records revealed the following: On [DATE] revealed sacrum unstageable pressure ulcer with measurements of L (length) 9.0 x W (width) 9.0 x D (depth) 0.1 with light exudate. On [DATE] revealed Stage III Right buttock with measurements of 2.5 x 4.0 x 0.3 with moderate exudate. Skin surrounding dark purple. On [DATE] revealed Stage III Left buttock with measurements of 3.5 x 1.0 x 0.1 with moderate exudate. Skin surrounding dark purple. On [DATE] wound documentation revealed sacrum area Resident #13 was readmitted with sacrum wound, wound has bridged and made right/left buttock wounds. No measurements documented. On [DATE] revealed Stage III sacrum wound with measurements of 7.0 x 8.0 x 0.2 with moderate exudate. Skin surrounding intact. On [DATE] revealed Stage III sacrum wound with measurements of 7.0 x 8.0 x 0.3 with light exudate. Skin surrounding intact. On [DATE] revealed Stage III sacrum wound with measurements of 6.5 x 7.0 x 0.3 with moderate exudate. Skin surrounding [DIAGNOSES REDACTED]/redness. There was no documentation that the physician was notified of the change in skin. Review of Resident #2's Treatment Administration Record from [DATE] through 11/ ,[DATE] revealed that the pressure ulcer dressing to the sacrum was noted as a (7) on 7 days, which indicated that the resident was sleeping and the treatment was not applied and the dressing was not changed. The pressure ulcer dressing to the sacrum was noted as a (5) on 1 day ([DATE]), which indicated that the treatment and dressing change were a hold and neither was applied or completed This means that Resident #2 did not have the treatment applied or the dressing changed for 8 of 12 days. There was no documentation that the physician was notified that the treatments were not completed or held. On [DATE] at 2:10 PM, during an phone interview, RN J, who is an ICU nurse at the hospital, reported that the resident was admitted to the hospital from the facility on [DATE]. RN J stated, The pressure ulcer dressing to the pressure wound was dated [DATE] (which meant that it was 5 days late for a daily treatment), it's appearance and odor was the consistency of stagnate algae like the top of a pond and you could have wrung the dressing out it was so saturated. It was such a horrible odor the staff had to wear 2 masks to complete the dressing change. RN J reported that Resident #2 died [MEDICAL CONDITION] at the hospital, approximately 2 hours after the dressing change was completed. On [DATE] at 2:30 PM, during an interview, Licensed Practical Nurse (LPN) K reported that she worked the day shift and completed the treatments at the end of the shift. LPN K reported that if Resident #2 was sleeping she did not complete the treatments, did not pass the information on to the next shift nurse, and did not inform the physician. LPN K reported she was aware that she was to follow physician's orders. LPN K stated, Registered Nurse (RN) M often has treatments already done when I arrived in the morning. On [DATE] at 2:50 PM, during an interview, Corporate RN L reported that LPN K and RN M had not worked the same days between [DATE] and [DATE] or crossed shifts. On [DATE] at 3:00 PM, during a phone interview, RN L stated, I date, time and initial my treatments in the computer on the treatment record. I have not completed them (treatments) for another shift. On [DATE] at 2:55 PM, during an interview, Director of Nursing (DON) reported she had addressed a concern with LPN K regarding pressure ulcer treatments and documentation the previous week and had issued a verbal warning. DON reviewed Resident #2's progress notes, treatment records, and physician's progress notes and agreed that there was no documentation that the treatment was completed. DON further stated that the physician had not been notified of the condition of the wound, the physician had not documented an assessment of the wound and there was an inconsistency of the stage of the wound between a Stage III and a Stage IV. DON stated, the nurses are expected to notify the physician if the resident has a missed treatment with a Stage III or IV wound and they are to notify the responsible party. On [DATE] at 3:50 PM, during an interview, Wound Nurse N reviewed Resident #2's wound records and physician's progress notes and stated, I looked at the wound and it is a Stage III on the sacrum. Wound Nurse N agreed there was no physician's documentation available. Wound Nurse N reported she received physician's orders for recommendations on the wounds but had not requested the physician to observe the wound. Review of the facility policy Pressure Ulcers/Skin Breakdown - Clinical Protocol, revealed 7. Continued assessment and management: .d. A resident with current PU/PI's (pressure ulcer / pressure injury) is evaluated/assessed by the licensed nurse at each treatment and as needed; . 8. Change of condition/New ski alteration: a. Notify Physician and Resident Representative of all new and /or non-healing/worsening PU/PIs 1. The nurses and IDT (interdisciplinary team) will help identify factors contributing or predisposing residents to skin breakdown; for example, medical comorbidities such as diabetes or [MEDICAL CONDITION], overall medical instability, cancer [MEDICAL CONDITION] causing a catabolic state, and macerated or friable skin. 11. The physician will help clarify relevant medical issues; for example, whether there is a soft tissue infection or just wound colonization, whether the wound has necrotic tissue, the impact of comorbid conditions on wound healing, etc. as needed. 1. The physician will authorize pertinent orders related to wound treatment, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.) , and application of topical agents 12. The physician will help identify medical interventions related to wound management; for example, treating a soft tissue infection surround an ulcer, removing necrotic tissue, addressing comorbid medical conditions, managing pain related to the wound or to wound treatment, etc. Treatment selection is based on what the wound bed looks like, if it is draining, signs of infection, tunneling, etc. Review the wound care formulary for guidance.

This citation pertains to Intake MI 471. Based on interview and record review, the facility failed to 1) assess and monitor 1 resident (Resident #10) for a change in condition (an increased temperature, pneumonia), 2) follow physician's verbal order for a chest x-ray and 3) follow facility policy regarding a change in condition, of 4 residents reviewed for assessment and monitoring, resulting in delayed treatment for [REDACTED]. Findings Include: Resident #10 was not able to be observed or interviewed at the time of the survey (9/10/18), due to being hospitalized . Review of the Face Sheet, Minimum Data Set (MDS), resident assessment tool) dated 1/19/18, physician's notes dated 7/10/18 through 8/16/18, nurses' notes dated 1/12/18 through 9/8/18, and physician's orders [REDACTED].#10 was 79-years-old, alert, required total staff assistance with all Activities of Daily Living (ADL's), was respiratory ventilator dependent, admitted to the facility in 1/18, and after several hospitalization s, re-admitted on [DATE]. Resident #10's [DIAGNOSES REDACTED]. Review of Resident #10's facility admissions and discharges dated 2/15/18 through 8/7/18, revealed a total of 9 transfers to the hospital due to condition change prior to the 9/8/18 transfer. Review of the infection control antibiotic log dated 8/18, revealed Resident #10 was last hosptalized on [DATE], prior to 9/8/18, due [MEDICAL CONDITION] (severe infection throughout the body). Review of the hospital records dated 9/8/18, revealed Resident #10 was admitted to the hospital on [DATE] due to, complaint of fever the last 4 days (9/5/18 through 9/8/18), recently admitted (to) the hospital last month with septic shock, has been having copious secretions suctioned from her trach. Fever of 101 for 4 days, she has recently been admitted for septic shock, she is having copious secretions suctioned from her trach. Review of the hospital chest x-ray dated 8/10/18, stated right lower pneumonia process. Review of Resident #10's Cardiovascular, [MEDICAL CONDITION], Impaired Breathing and at risk for return to hospital care plans dated 8/14/18, revealed nursing staff were to monitor, document and report changes in the residents medical and mental condition to the physician as needed. Review of the facility nurse's notes dated 9/8/18 at 12:12 p.m., stated Sent to ER (emergency room ) for temp of 100 and SOB (shortness of breath). Review of the facility nurse's notes dated 9/8/18 at 12:24 p.m., stated Resident sent out for ongoing high temp. Review of the facility nurse's notes dated 9/4/18 at 4:40 p.m., stated At approximately 1300 (1:00 p.m.), CNA (Nursing Assistant) notified writer that resident had an elevated temperature of 101. Review of the facility nurses' notes dated 9/4/18, stated Temp 101. No documentation that the physician was informed of the residents increased temperature (a sign of pneumonia), or that a nursing respiratory assessment was found. Review of nurse's notes dated 9/4/18 through 9/7/18, revealed no documentation of the resident's physician being contacted and informed of the residents increased temperature, or of any nursing respiratory assessments (lung sounds, skin temp/color, increased secretions, shortness of breath, increased anxiety and cognition changes). Several attempts to interview Nurse LPN P per phone during the survey on 9/10/18 by this surveyor and the Director of Nursing were unsuccessful. Review of the facility Respiratory documentation dated 9/4/18 through 9/8/18, revealed on 9/5/18 and 9/6/18, respiratory therapists had only assessed Resident #10 one time during the day. During an interview on 9/10/18 at 11:45 a.m., the Director of Respiratory Services, Respiratory Therapist/RT H stated they (the RT's) should assess the resident and document it every shift (the facility has three shifts per day). Review of the facility Ventilator Unit policy dated 6/27/16, stated Ventilator dependent residents shall have documentation (a respiratory assessment) completed each shift in the medical record or electronic medical record (EMR). During a phone interview on 9/10/18 at 1:40 p.m., Nurse, LPN L stated I heard from other nurses that her temp was high, and I assessed her, and she had a temp of 100. I called the doctor and told him her temp., she was sent out (to the hospital), because of knowing her history I thought she could have pneumonia. I think she should have had a chest x-ray done. The pulmonologist (a lung specialist) told me he gave a verbal order to have an x-ray done, it didn't get done. Review of the [MEDICAL CONDITION] Physician Rounds book (filled out by the Director of Respiratory Service, H) revealed on 9/5/18, a chest x-ray was ordered to be done on Resident #10. Review of the physician orders [REDACTED]. During interviews done on 9/8/18 at 11:20 a.m. and 11:45 a.m., the Director of Respiratory Services, RT H said Pulmonologist M had given a verbal order on 9/5/18, for a chest x-ray to be done on Resident #10 and it did not get ordered. The chest x-ray order was put in the [MEDICAL CONDITION] Physician Rounds book by RT H, however it was never written as an order and therefore not completed per order. During a phone interview done on 9/10/18 at 1:05 p.m., Pulmonologist M confirmed he had given an order for [REDACTED]. During a phone interview done on 9/10/18 at 2:33 p.m., Nurse RN O stated, I had no idea he (the Pulmonologist M) had ordered a chest x-ray, I did do her vitals, but I didn't chart it. I take good care of my residents, I am a good nurse. During an interview done on 9/10/18 at 3:10 p.m., Nurse Manager/Assistant Director of Nursing RN D stated I did not check the orders (on 9/5/18), It was my second day back (Nurse D had been on leave). During an interview done on 9/10/18 at 1:35 p.m., Nurse, LPN I stated she (Resident #10) is at high risk, I would call the physician if she had a temp., that's the first thing I would do. Any time we see a difference in a patient (change in condition), we do a SBAR (Situation Background Assessment Recommendation). Review of the nurse's notes dated 9/4/18 through 9/8/18, revealed on 9/5/18, there was no documentation at all; no nursing assessment or documentation was found. Review of Resident #10's electronic medical record done with the Director of Nursing on 9/10/18, revealed an SBAR for Resident #10 was done on 8/7/18 and not again until 9/8/18 (the day the resident was transferred to the hospital for pneumonia). During an interview done on 9/10/18 at 11:58 a.m., the Director of Nursing (DON) stated, they (nursing staff) should be doing a SBAR with any change of condition. Review of the facility Acute Condition Changes-Clinical Protocol dated 3/17, revealed staff were to use the SBAR process for assessments, documentation and to report to the physician resident changes in condition. Review of the facility Implementation Guide dated 2011, stated The SBAR Form/Acute Change in Condition Progress Note is designed to enhance the nursing evaluation of and documentation on residents who have an acute change in condition, and to structure and improve communication with primary care clinicians. During a phone interview done on 9/10/18 at 2:50 p.m., the facility Medical Director N stated, I will make sure I follow up and educate them (nursing and respiratory staff).

This intake pertains to MI Based on interview and record review, the facility failed to honor 1 (# 501) sampled resident's request to go to the hospital due to abdominal pain and coffee ground emesis out of three residents sampled reviewed for abdominal pain and coffee ground emesis, from a total sample of three residents, resulting in nausea, vomiting and a delay in [DIAGNOSES REDACTED]. Findings include: On 7/21/17 record review revealed that resident #501 was a [AGE] year old male who was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) revealed that the resident required maximum assistance with all activities of daily living. In addition, resident #501 had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points indicating cognitively intact. On 7/21/17 at 1:00 PM, a record review revealed on 3/5/17 at 11:47 PM: resident has dark brown fluid coming [MEDICAL CONDITION]. Resident suctioned then resident started vomiting dark brown fluid. Dr (physician name) notified. Turn off tube feed and monitor through the night . Res (resident) continues to vomit. VS (vital signs) 98.3 (temperature), 93 (heart rate), 27 (respirations) On 3/6/17 at 3:31 AM: Res had times (X) 4 emesis this shift dark brown emesis. VS (vital signs) 100.5 (temperature), 107 (heart rate), 22 (respirations) On 3/6/17 at 8:29 AM: tube feeding on hold per third shift related to coffee ground emesis, abdominal distention. On 3/6/17 at 9:17 AM: unable to administer medications related to large volume black/coffee ground residual. Patient continues to complain of severe abdominal pain and distention is much worse then typically. There is coffee ground secretions coming from around [MEDICAL CONDITION] well. Called Dr (physician name) who gave orders to send out to the hospital. On 3/6/17 at 10:00 AM: Patient transferred to ambulance stretcher . Patient guarding abdomen and facial expression portrays pain. On 3/14/17 at 11:02 AM: Resident was readmitted to this facility from (local hospital). Resident [DIAGNOSES REDACTED].ilius (paralysis of the bowel). On 7/21/17 at 1:10 PM, a review of resident #501's Medication Administration Record [REDACTED]. On 7/21/17 at 1:10 PM, a review of physician's orders [REDACTED].#501's attending physician send to (local hospital) ER (emergency room ) related to large black/coffee ground residual. abdominal distention with pain, decreased bowel sounds, nausea. On 7/21/17 at 2:30 PM, resident #501 was interviewed and was asked about the evening of 3/5/17 when staff refused to send him to the hospital. Resident #501 said he was sick to his stomach and had abdominal pain. On 7/21/17 at 2:35 PM, resident #501's attending physician (MD) was interviewed via phone regarding the delay in sending the resident to the hospital for medical attention. Initially, the MD did not remember the events of the evening and night of 3/5 to 3/6/17. MD did recall that Resident #501 had an ilius of the bowel and not an obstruction. When MD was informed that Resident #501 had multiple documented respiratory rates of 22 respirations per minute, MD stated he did not feel the respiratory rate was accurate. On 7/21/17 at 2:45 PM, the Director of Nursing (DON) was interviewed and stated that the staff should have contacted the physician about the resident's request to go to the hospital. After reviewing the documentation in the nurse's notes, the DON agreed Resident #501 was having coffee ground emesis. The DON felt the progress notes had incomplete documentation as there was no indication that the DON had been notified. The DON stated the staff should have followed the GI (gastrointestinal) pathway with this resident. The DON was asked for a copy of the pathways but this document was not provided by the time of exit.

This citation pertains to intake # Based on interview and record review, the facility failed to transport one (#701) of three residents sampled for falls from a total sample of three, safely out of the shower room, resulting in Resident #701's left foot getting wedged in between the shower chair and the floor causing a femur fracture. Findings include: On 5/23/17 at 9:45 a.m., a record review revealed that Resident #701 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set assessment dated [DATE], Resident #701 was dependent for transfers and bathing and had impaired cognition. On 5/23/17 at 10:30 a.m., a review of the incident report dated 5/13/17 revealed that Resident #701 was observed with her left foot, wedged between the floor and the shower chair. The Certified Nurse Assistant (CNA) A asked the nurse sitting across from the shower room if Resident #701's foot was, dragging and the nurse confirmed that the foot was wedged. The Resident was then transferred to bed and an abrasion was noted to her left great toe and there was swelling to the left knee. According to the report, the physician was notified and ordered for Resident #701 to be transported to the hospital for an evaluation. On 5/23/17 at 10:35 a.m., a review of the hospital notes dated 5/14/17 revealed that Resident #701 had a Cat Scan of her left extremely which revealed the following: Comminuted and mildly impacted fracture of the left femoral metadiaphysis (the long bone located in the leg with a break with bone fragments just above the knee) . On 5/23/17 at 10:45 a.m., a review of the facility policy titled, Falls-Bathroom/Shower room Safety, revised 4/2016 stated, Unless specifically identified in manufacturer's instructions, shower chairs are not appropriate for transport in hallways. On 5/23/17 at 10:55 a.m., CNA A was interviewed via telephone and CNA A stated, I had a shower blanket on her so I could not see her feet but when I tried to move her (in the shower chair) through the door way (of the shower room) the chair would not move so I asked the nurse if her foot was dragging and she said it was. So we fixed it (her foot) and took her to her room. I have worked at other facilities and never knew to not use those chairs (shower chairs) to transport residents. On 5/23/17 at 11:00 a.m., the Administrator was interviewed in regards to the incident. According to the Administrator CNA A felt terrible about the situation and did not know to not transport residents in shower chairs. The Administrator said CNA A was new to the facility and she gave Resident #701 a shower and did not realize that her foot (Resident #701) was caught in between the shower chair and floor. The Administrator also stated, We educated everyone that if there are no foot pedals, the resident cannot be transported with that chair. During this time the Administrator presented a Past Noncompliance, which was accepted with the plan of correction date of 5/19/17. The Past Non-Compliance states the following: Facility Past Non-Compliance Checklist Date of Report: 5.15.17 Date of Event: On May 13, 2017 approximately 8pm Was the resident injured: Yes If yes, describe injury: Left Femur Fx (fracture) Description of Deficient Practice (why and how did it happen): Resident #1 (#701) was sent to the hospital for an evaluation following an incident while being transported back to her room from the shower. The incident occurred at approximately 8:00 p.m. on 5/13/2017 CNA A was transporting resident one (#701) in a shower chair from the shower room. Upon exiting the shower room Resident #1 (#701)'s foot was caught between the floor and the chair. The aide immediately stopped moving the chair and asked the nurse at the nurse's station directly across from the shower room for assistance. Resident #1 (#701) was returned to bed and an assessment was performed. Upon assessment the nurse noted a small abrasion to the residents left great toe and swelling in the resident's left knee. The resident's physician, family and Hospice were notified and the resident was sent to the hospital for evaluation. At approximately 3 am the resident returned to the facility with a brace to the left leg and conformation of a left femoral shaft fracture. The administrator was notified and the incident was reported to the state department. Actions the facility immediately implemented to assure like residents had no potential to be affected: All Nurse Aides in the facility were immediately given a 1:1 in service on the shower safety policy and safe transport of patients within the facility. Immediate actions related to identified resident: Resident was assessed for injury and negative outcomes on 5/13/17 and resident was sent to ER for evaluation. No s/s (signs and symptoms) of pain An IDT (interdisciplinary) meeting regarding (incident) was held on 5/14/17 to review/revise, care plan, care delivery guides to ensure appropriate assessment and interventions are in place. Hospice, resident's daughter and Physician were immediately notified. POA (power or attorney) is involved and agrees with the Plan of Care. Areas of improvement with measures or systemic changes made to mitigate future events: The shower safety policy was reviewed by the administrator and deemed appropriate. All certified nurse aides were in serviced on the shower safety policy on or before 5/19/1 or before the next shift. The shower room and equipment were evaluated and in working order. How facility monitors its quality improvement actions: The DON (Director of Nursing) or designee will audit 3 showers per week for 4 weeks and then monthly or until substantial compliance is met. Results will be brought to the QA (Quality Assurance) committee monthly for review. The Administrator is responsible for compliance. Date of completion of Plan of Correction: The facility alleges substantial compliance on 5/19/17.

Based on observation, interview and record review, the facility failed to administer medications as ordered for 1 (#1001) of 4 residents sampled for medication administration from a total sample of 4 residents, resulting in the potential inability of Resident #1001 from receiving the therapeutic benefits of the medications and experiencing negative side effects. Findings include: A record review on 3/15/17 at 11:45 am revealed, Resident #1001 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The Minimum Data Set assessment (MDS), dated [DATE] indicated the resident had cognitive impairment and required total assistance with all care. The following medications were provided: [MEDICATION NAME] for blood pressure, [MEDICATION NAME]-an antibiotic, [MEDICATION NAME] an antibiotic, [MEDICATION NAME] for [MEDICAL CONDITION], [MEDICATION NAME] for [MEDICAL CONDITION], [MEDICATION NAME] a blood thinner, [MEDICATION NAME] an anti-psychotic medication, [MEDICATION NAME] for pain, [MEDICATION NAME] for [MEDICAL CONDITION], [MEDICATION NAME] for inflammation, [MEDICATION NAME] for diabetes and [MEDICATION NAME] for pain. An interview with Confidential person B on 3/15/17 at 10:55 am revealed, On 10/3/17 (the resident) did not receive their 9:00 am medications until 12:00 pm, at that time the nurse gave the 1:00 pm medications together with the 9:00 am medications: [REDACTED]. A review of the electronic medical record on 3/15/17 at 11:45 am pm revealed, Resident #1004 was given the following medications by Nurse C: 7:00 am, 9:00 am and 1:00 pm medications administered all at the same time, between 11:55am-12:06 pm on 10/3/17: [MEDICATION NAME], [MEDICATION NAME], Modafinil, [MEDICATION NAME] and 2 doses of [MEDICATION NAME]. A review of the facility Staff List, with name, date of hire and phone number, on 3/15/17 at 12:10 pm, indicated Nurse C was no longer employed at the facility. An interview with the Director of Nursing and Administrator on 3/15/17 at 5:10 pm revealed, We know we have a problem. It is a combination of things, when queried on why a nurse would give multiple doses of medications all at the same time and if there were enough staff, including nurses to provide care for the resident's. On 3/15/17 at 5: 35 pm, a review of the facility policy titled, Administering Medications, dated 12/21/2010 provided, Medications shall be administered in a safe and timely manner, and as prescribed, Medications must be administered in accordance with the order, including any required time frame. This citation have 2 Deficient Practice Statements; This citaiton pertains to MI DPS #1 Based on observation, interview and record review, the facility failed to administer medications as ordered for 1 (#1001) of 4 residents sampled for medication administration from a total sample of 4 residents, resulting in the potential inability of Resident #1001 from receiving the therapeutic benefits of the medications and experiencing negative side effects. Findings include: A record review on 3/15/17 at 11:45 am revealed, Resident #1001 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The Minimum Data Set assessment (MDS), dated [DATE] indicated the resident had cognitive impairment and required total assistance with all care. The following medications were provided: [MEDICATION NAME] for blood pressure, [MEDICATION NAME]-an antibiotic, [MEDICATION NAME] an antibiotic, [MEDICATION NAME] for [MEDICAL CONDITION], [MEDICATION NAME] for [MEDICAL CONDITION], [MEDICATION NAME] a blood thinner, [MEDICATION NAME] an anti-psychotic medication, [MEDICATION NAME] for pain, [MEDICATION NAME] for [MEDICAL CONDITION], [MEDICATION NAME] for inflammation, [MEDICATION NAME] for diabetes and [MEDICATION NAME] for pain. An interview with Confidential person B on 3/15/17 at 10:55 am revealed, On 10/3/17 (the resident) did not receive their 9:00 am medications until 12:00 PM, at that time the nurse gave the 1:00 PM medications together with the 9:00 am medications: [REDACTED]. A review of the electronic medical record on 3/15/17 at 11:45 am PM revealed, Resident #1004 was given the following medications by Nurse C: 7:00 am, 9:00 am and 1:00 PM medications administered all at the same time, between 11:55am-12:06 PM on 10/3/17: [MEDICATION NAME], [MEDICATION NAME], Modafinil, [MEDICATION NAME] and 2 doses of [MEDICATION NAME]. A review of the facility Staff List, with name, date of hire and phone number, on 3/15/17 at 12:10 PM, indicated Nurse C was no longer employed at the facility. An interview with the Director of Nursing and Administrator on 3/15/17 at 5:10 PM revealed, We know we have a problem. It is a combination of things, when queried on why a nurse would give multiple doses of medications all at the same time and if there were enough staff, including nurses to provide care for the resident's. On 3/15/17 at 5: 35 PM, a review of the facility policy titled, Administering Medications, dated 12/21/2010 provided, Medications shall be administered in a safe and timely manner, and as prescribed, Medications must be administered in accordance with the order, including any required time frame. DPS #2 Based on interview and record review, the facility failed to treat a Stage 2 pressure ulcer (a partial thicken skin loss involving epidermis, dermis or both) every shift as ordered by the physician for 1 (#1003) of one sampled resident reviewed for pressure ulcers, from a total sample of 4 residents, resulting in the potential development of an infected Stage 4 pressure ulcer. Findings include: On 3/15/17 at 2:00 PM, record review revealed that Resident 1003 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was cognitively intact and required extensive assistance with transfers, eating, and hygiene. The resident was discharged to the hospital at the family request due to a foul smelling pressure ulcer on the resident's buttock. On 3/15/17 at 11:12 AM, review of the Pressure Ulcer care plan indicated that the resident required maximum assist by 1 staff to turn and reposition in bed every 1-2 hours and as necessary. Also, it was revealed the resident had a Stage 2 pressure ulcer. On 3/15/17 at 2:15 p.m., a review of the Treatment Administration Record (TAR), revealed a treatment was ordered to the buttock/sacrum area. It was also noted in the TAR that the skin was normal on 12/20/16, 12/21/16, and 12/23/16. The TAR revealed, the area should be cleansed with normal saline. Pat dry. Apply Dermaseptin every shift as needed. Buttocks/sacrum every shift for wound management, starting 12/19/16 - 1/03/17. Review of the TAR revealed that the resident received wound care treatment only once on 12/19/16 and 12/20/16, twice on 12/22/16 and 12/26/16, and no treatment at all on 1/3/17. The Clinical Care Plan, reviewed on 3/15/16 at 2:08 p.m., revealed the resident had pressure ulcer development to the sacrum related to the disease process hypertension, Muscle Dystrophy, immobility, a Norton score of 7 (Pressure Ulcer Risk Score). Monitor/document report as needed any changes in skin status, appearance, color, wound healing, signs of infections, wound size (length, width and depth), stage. On 3/15/17 at 2:15 p.m., a review of a signed print out (evaluation) received from the Director of Nursing (DON), revealed that on 12/19/16, the Pressure Ulcer was Stage II, tissue type: Granulation, no tunneling, . Treatment: Pressure reducing device for bed/turning, repositioning/program/Nutrition or hydration intervention/Pressure ulcer care/Application of non-surgical dressings. Dermaseptin every shift and as needed. On 12/27/16, Pressure Ulcer was Stage II, tissue type: Granulation, no tunneling, skin intact. Treatment: Pressure reducing device for bed/turning/repositioning/program/Nutrition or hydration intervention/Pressure ulcer care/Application of non-surgical dressings. Dermaseptin every shift and as needed. Amount: Light. On 1/3/17, the Pressure Ulcer was unstageable, tissue type: Necrotic, no tunneling, Exudate type: Sero-sangunous, skin: [DIAGNOSES REDACTED]/Redness-Blanchable . Treatment: Pressure reducing device for bed/turning/repositioning/program/Nutrition or hydration intervention/Pressure ulcer care/Application of non-surgical dressings. Clean pat dry, apply silverkollogen, cover buttock with xeroform cover with border foam change daily and as needed. Also, this evaluation revealed: No odor, no pain. A confidential person D, stated, when entering the room of the resident, it was a really bad smell, and the nurse was asked why it smelled so bad, and she said she didn't know at first, then she said it was the resident's wound. The wound should not have been smelling like that. I asked the nurse to call the ambulance, that resident need to go the hospital. They were not turning her like they should have. Instead of getting better, she got worse. The ambulance was called to take resident to the hospital. The hospital diagnosed the resident's pressure ulcer as Stage 4 with infection and she was put on an antibiotic for seven days. On 3/15/17 at 12:45 p.m., the DON was interviewed regarding resident # 1003 pressure ulcer and stated, yes I am familiar with the wound of the resident, it is a Stage 4 but she was admitted with the Stage 2. Review of the MDS revealed, resident was admitted with Stage 2 pressure ulcer. On 3/15/16 at 4:45 p.m., the DON was queried again about the pressure ulcer of resident #1003, stated, oh yes, I did see it was Stage 2 upon admission in the Care Plan. On 3/15/17 at 5:30 PM, review of the facility's policy, titled Prevention of Pressure Ulcers, revised on 03/23/11, revealed the following: information should be recorded in the resident's medical records which included: the type of skin care given, the date and time skin care was given, the position in which the resident was placed, the name and title of the individual who gave the care, any change in the resident's condition, the condition of the resident's skin (including the size and location of any red or tender areas).

Based on observation, interview and record review, the facility failed to turn and reposition, at a minimum, every two hours, one (#706) of four sampled residents reviewed for pressure ulcers/alterations in skin alterations caused by pressure, from a total of 25, resulting in the development of facility acquired pressure ulcers, right labia erosion and the potential for additional pressure ulcers and the worsening of current pressure ulcers. Findings include: On 1/30/17 at 9:45 a.m., during the initial tour, Resident #706 was observed lying on her right side and connected to a ventilator machine (life support) on the right side of the bed. Resident #706 was resting on a alternating air mattress, the heels of her feet were resting on the mattress (no boot or device in place for pressure reduction). An indwelling urinary catheter was observed draining clear yellow urine into a drainage bag. The head of the bed (HOB) was elevated at 35 - 40 degrees due to infusion of tube feeding by way of a feeding tube at 60 milliliters (ml) per hour. On 1/30/17 at 3:00 p.m., Upon entering Resident #706 room, the assigned nurse positioned Resident #706 on her right side after the dressing changes to her pressure ulcers were completed. On 1/31/17 at 8:50 a.m., Resident #706's husband was at the bedside visiting. The husband reported visiting Resident #706 at least every two days. He reported that Resident #706 had pressure ulcers and stated, She (#706) is not healing quickly enough. The wound doctor comes in every Tuesday. On 1/31/17 at 10:45 a.m., The dressing changes to Resident #706's facility acquired pressure ulcers were observed completed by the Treatment Nurse (Nurse H). The observation revealed the following: Area #1: right lateral scalp pressure ulcer: the dressing was removed and revealed a wound covered with black necrotic (dead tissue) tissue that measured 2.0 centimeter (centimeter) by 2.0 cm. Another area was discovered just below the existing scalp PU was noted by the Nurse H during the time of the treatment. Area #2: right lateral, distal scalp (onset date of 1/31/17). The new area was also necrotic and it measured at 1.0 cm by 1.0 cm. Nurse H stated, This is new. Area #3: right heel: 90% of the right heel was necrotic. The surrounding tissue was macerated. The wound measurements were 4.5 cm by 2.0 cm. On 2/1/17 at 2:55 p.m., review of Resident #706's clinical record revealed the following: Resident #706's face sheet indicated an admission into the facility on [DATE] and a re-admission 12/29/16 with [DIAGNOSES REDACTED]. Resident #706's quarterly Minimum Data Set (MDS) assessment, dated 12/13/16, indicated a vegetative state and was totally dependent upon others for all activities of daily living (ADLs), including turning and repositioning. On 2/1/17 at 9:40 a.m., 11:25 a.m., 12:50 p.m., and 2:10 p.m., Resident #706 was observed positioned on her right side with the right side of her scalp rested on the pillow and the HOB elevated at 35 - 40 degrees. Use of a cervical pillow was not observed in use at those times. On 2/1/17 at 2:15 p.m., Resident #706 was observed by the Treatment Nurse (Nurse H) lying on her back as her right scalp rested on the pillow. Nurse H was queried regarding the constant position of Resident #706 on her right side and the noted lack of pressure relief to the right side of her scalp. Nurse H stated, She can't lay on her left side. Nurse H was queried if the inability to be not be position on the left side was included on the Certified Nursing Assistant (CNA) Care Guide and Care Plan. Resident #706's care plan for the prevention and treatment of [REDACTED]. Per the wound notes provided by Nurse H for Resident #706, the specific intervention pertaining to a turning/repositioning program were indicated for all of the pressure ulcers. Nurse H was then queried regarding the resident specific interventions for Resident #706. Nurse H was unable to provide an answer. On 2/1/17 at 3:45 p.m., review of the wound records provided by Nurse H revealed the following facility acquired pressure ulcers: Area #1: right lateral, distal scalp pressure ulcer, onset date of 1/17/17. Description included; 100% necrotic, with light serous exudate, and attached wound edges. Measurements: length at 2.8 cm by 2.5 cm in width. It was described as unable to determine (UTD), unstageable. Area #2: right lateral, distal scalp, onset date of 1/31/17. Description included; 100% necrotic tissue, with no exudate, and attached edges. Measurements: length at 1.0 cm by 1.0 cm width. It was described as unable to determine (UTD), unstageable. Area #3: right heel, onset date of 1/17/17. Description included; slough and necrotic tissue present. Measurements: length 4.0 cm by 2.5 cm width. It was described as unable to determine (UTD), unstageable. Area #4: right labia, onset date of 1/13/17. It was described as an erosion. Measurements: length at 2.0 cm length by 2.5 cm width and by 0.1 in depth. The wound bed had 50% slough (moist dead tissue) tissue present. On 2/1/17 at 3:50 p.m., review of Resident #706's care plan titled The resident readmitted from the hospital with Pressure ulcer to multiple areas r/t (related to) Immobility, VDRF (vent dependent [MEDICAL CONDITION]), DM (diabetes mellitus), incontinence, contractures ., date initiated 12/2/16 and revised on 1/31/17, revealed the following interventions: Avoid positioning the resident on right side without pillow support to her right neck/face (initiated 11/16/16) Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Pressure relieving devices in place LAL (low air-loss) mattress, wedges for positioning boots, cervical pillow, cushion for chair while up (initiated 12/13/16) The care plan did not reveal an intervention that Resident #706 could not be position on her her left side as described by the Treatment Nurse (Nurse H). On 2/1/17 at 3:55 p.m., review of the physician's orders did not reveal an order that Resident #706 could not be position on her left side. On 2/1/17 at 4:10 p.m., review of the facility's policy entitled Prevention of Pressure Ulcers, dated 3/23/2011, revealed the following interventions: Change position at least every two hours or more frequently if needed. Consider off-loading pressure hourly if the head of the bed is greater than 30 degrees. When in bed, every attempt should be made to 'float heels' (keep heels off of the bed) by placing a pillow from knee to ankle or with devices as recommended by therapist and prescribed by the physician.

This citation refers to Intake# MI 575. Based on observation, interview and record review, the facility failed to monitor blood glucose levels and administer insulin according to the sliding scale for one (#501) of three residents reviewed for diabetes mellitus treatment, resulting in 20 missed doses of sliding scale insulin, blood glucose levels of 946 (reference range 70-120) and transfer to the local hospital. Findings include: On 7/20/16 at 10:15 am Resident #501 was observed in the [MEDICAL TREATMENT] unit of the facility seated in the [MEDICAL TREATMENT] chair and receiving [MEDICAL TREATMENT]. Resident #501's hands appeared [MEDICAL CONDITION] and his eyes were closed. The nursing staff in the [MEDICAL TREATMENT] unit reported Resident #501 was nonverbal. On 7/20/16 at 10:30 am record review revealed that Resident #501 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the initial minimum data assessment instrument, dated 6//29/16, Resident #501 had severe cognitive impairment, nonverbal and was dependant on assistance of two staff persons for bed mobility, transfer, dressing, hygiene bathing and was on tube feeding. Review of a physician order, dated 6/22/16 included insulin to scale every 6 hours, to be administered per accu-check results at 12:00 am, 6:00 am, 12:00 PM and 6:00 PM. Review of laboratory report, dated 7/5/16, revealed Resident #501 had a fasting blood glucose level of 946 (critical high, reference range 70-120). The 'SBAR Communication Form ( incident report), dated 7/5/16, reflected the physician was notified and an order was received to administer [MEDICATION NAME] Insulin 30 units times one dose, repeat an accu-check in one hour and notify the physician. The repeated accu-check was completed and the reading was 'HI.' The physician was notified and ordered transfer to the hospital emergency room . Review of the medication administration record for 6/22/16 - 6/30/16 reflected Resident #501 had received insulin to scale every 6 hours, to be administered per accu-check results at 12:00 am, 6:00 am, 12:00 PM and 6:00 PM. Review of the medication administration record for 7/1/16 - 7/5/16 did not reflect the physician orders [REDACTED]. There was no documented evidence in the clinical record for Resident #501 that the physician orders, dated 6/22/16 for insulin to scale every 6 hours, to be administered per accu-check results at 12:00 am, 6:00 am, 12:00 PM and 6:00 PM were followed from 7/1/16 - 7/5/16. On 7/20/16 at 11:00 am, during an interview, the Director of Nursing (DON) confirmed the facility failed to follow the physician orders [REDACTED]. The DON stated, It was identified on 7/5/16 that the medication administration record (MAR), for Resident #501, monthly change over process was not completed per the facility policy. The MAR for Resident #501, monthly change over process from June to July was completed by one nurse the MAR was not checked by a second nurse to ensure accuracy. The physician orders [REDACTED]. This resulted in the potential for Resident #501 to miss 20 doses of sliding scale insulin as needed for capillary blood glucose results per accu-check. The issue was identified when the facility received a scheduled lab result for a glucose level of 946 (critical high). The physician was notified and Resident #501 was sent to the hospital for evaluation and treatment. Resident #501 was placed on an insulin drip to stabilize his condition. Resident #501 returned to the facility on [DATE] . According to the facility policy titled, Physician Telephone Order, dated 2013 .All telephone orders will be reviewed and confirmed by two nurses during end of the month recap of monthly orders for confirmation and inclusion in the new month's orders. One nurse to read the orders and the other to confirm they are on the new month's orders correctly and included in the appropriate flow records. The facility identified non-compliance and has corrected as follows: How facility will identify other residents having a potential to be affected by practice and what improvement action will be taken. The physician orders [REDACTED]. No further concerns have been noted. What measures will be put in place or what systemic changes you will make to ensure that the practice does not recur. a. The Medication Administration Monthly Change-Over process was reviewed and amended. Current resident MAR ' s for June have been reviewed and validated with MAR ' s for July to ensure accuracy of physician orders [REDACTED]. b. Licensed Nursing staff have been re-educated on the Medication Administration Change-Over process. 53 Licensed nursing staff are employed by the facility. 43 Licensed nursing staff were re-educated on the Medication Administration Change Over process on or before 7/7/16 by the DON or designee. 11 Licensed nursing staff were educated prior to the start of their next shift by the DON or designee. 100% of Licensed nursing staff have been educated on or before 7/11/16 by the DON or designee. c. Current resident MAR's for June have been reviewed and validated with MAR's for July to ensure accuracy of physician orders [REDACTED]. How the corrective action(s) will be monitored to ensure practices will not recur. a. The DON/designee will monitor residents MAR monthly to ensure the Medication Administration Monthly Change-Over process is completed according to the facility policy. All newly admitted residents Medication Administration Records are audited daily by the DON/designee for sliding scale insulin orders and insulins and validating transferring of the physician order [REDACTED]. and to ensure the Medication Administration Monthly Change-Over process is completed according to the facility policy. b. The DON will report findings to the QAPI committee monthly for further recommendations. The QAPI committee will review results for compliance. The Administrator will be responsible for compliance. ( )

Based on observation, interview, and record review, the facility failed to implement interventions to prevent the development of and worsening of a pressure ulcer for one (#803) of five residents reviewed for pressure ulcers in a total sample of five, resulting in an unstageable pressure ulcer to the right buttock and an unstageable ulcer to the left lateral lower leg. Findings include: At 12:20 p.m. on 5/18/16, the daily treatment to Resident #801's unstageable right buttock pressure ulcer was observed along with the treatment to the left lateral lower leg (LLE) wound. The facility's wound care nurse (LPN F), who was also acting as the unit manager, performed the treatments. The following was observed: The old dressing was removed from the right buttock, it was observed that the old dressing was undated and saturated with reddish-brown and yellow wound drainage. The wound was malodorous. The wound measured 6 (cm) centimeters x 7.5 cm; the wound bed was 80 percent (%) brownish tan colored stringy slough (dead tissue) and 20% pink granulation tissue (newly growing tissue) as measured and described by LPN F. The left lateral leg wound was covered with a dressing that was dated 5/16/16. LPN F was queried regarding the date and stated, I guess it was missed yesterday .I know I said I did it but I forgot that I didn't see him yesterday since he is now on hospice. The wound measured 2.5 cm x 1.5 cm x 0.8 cm (depth). A review of Resident #801's clinical record conducted on 5/18/16 at 1:00 p.m. revealed the following documentation: Resident #801 was a [AGE] year old who was originally admitted into the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set assessment ((MDS) dated [DATE] documented that Resident #801 had intact cognition, was totally dependent on staff for bed mobility and all Activities of Daily Living (ADL's). The MDS documented that Resident #801 was at risk for developing pressure ulcers. A document titled Admission Evaluation Data dated 4/7/16 at 3:45 p.m. under Section B Skin Conditions- Skin Concern #2 documented Resident #801's right buttock was excoriated (loss of a superficial layer of skin) with red blood. The left lateral lower leg was documented as 2 x 1 dark brown area. Review of the last page of the document under Additional Notes dated 4/8/16 revealed, Pt (patient) skin assessment done Lt (left) lower leg has a brown unopened area on the lateral side .Right buttock excoriated .Treatment orders written and faxed. A care plan, last updated 3/31/16, documented, The resident admitted with multiple pressure wounds located on the left ischium/hip areas, stage 4. Coccyx stage 2. There was no care plan noted in the clinical record for the right buttock pressure ulcer or the left lateral lower leg wound; however, at approximately 5:45 p.m. while reviewing Resident #801's clinical record with LPN F the care plan, updated 5/18/16 , now included, Right buttock PU (pressure ulcer) unstageable admit on 4.7.16, right/left lateral calf pressure ulcer. LPN F was queried why the care plan was updated that day and stated, I was on vacation and the MDS nurse was supposed to add those .she just did it today. A review of Wound Care Services notes provided by LPN F revealed the following documentation: 4/12/16: Right Buttock is a Partial Thickness Erosion measurements are 2 cm length x 3 cm width .There is a small amount of serous (clear) drainage noted which has no odor Wound Orders: Right Buttock .Dermaseptine (barrier cream). Facility is managing the left leg wound. 4/26/16: Right Buttock wound .Measurements are 4.5 cm length x 5.0 cm width There is a small amount of sero-sanguineous (blood with clear fluid) drainage noted which has no odor. 5/3/16: Right buttock wound .Unstageable with Slough as the tissue type and measured 4.0 cm x 4.5 cm Wound Orders: Foam Dressing. D/C discontinue Dermaseptine. A review of the facility's wound care notes provided by LPN F revealed the following documentation: 5/10/16: The right buttock wound, Thickness/Stage: Unstageable; Tissue Type: Slough; L (length) 3.8, W (width) 4.3, D (depth) UTD (undetermined). Treatment: Clean, pat dry .hydro jel, gauze .cover with border foam, change daily and the left lateral lower leg wound, Thickness/Stage: Partial; Tissue Type: Slough; L 1.6, W 1.0, D 1. Treatment: Clean, pat dry .hydro jel, gauze .cover with border foam, change daily At 5:50 p.m. on 5/18/16, a review of the clinical record, conducted with LPN F revealed a April 2016 Treatment Administration Record (TAR) for Resident #801 and the following was noted: The month of April 2016, the first treatment documented for Resident #801's right buttock and left lateral lower extremity (LLE) wounds was dated 4/26/16. Physicians orders were reviewed with LPN F at this time and revealed no physicians orders for treatment to Resident #801's right buttock wound or LLE wound prior to 4/26/16. LPN F was queried and stated, I'm sure there was another treatment .I wonder if a page is missing he went to the hospital that day and came back with the wound. A review of a nurse's note dated 4/26/16 revealed Resident #801 was transferred to the acute care hospital at 8:45 a.m. on 4/26/16 and returned to the facility at approximately 6:00 p.m. on 4/26/16 with the [DIAGNOSES REDACTED]. There was no readmission note or documentation of a skin assessment being completed on Resident #801 upon return to the facility in the clinical record. During the review of Resident #801's clinical record, LPN F referred to the TAR and stated, Here are the treatments we had in place for those wounds. Review of the TAR revealed: 1. Dermaseptine to BLE (bilateral lower extremities) qshift (every shift) LPN F stated the purpose of the Dermaseptine was to dry the wound bed and protect the skin. Further review of the TAR revealed the Dermaseptine treatment was not documented as being applied to the BLE for 12 applications and not documented as being applied at all April 20th-April 25th 2016 (evidenced by a lack of nurse's initials documenting as completed). 2. Barrier cream to peri-area (area between genitals and buttocks) q shift. 25 applications were not documented as completed for the month of April 2016 (evidenced by a lack of the nurse's initials documenting as completed). LPN F, who was the facility's wound care nurse, was queried regarding the missed treatments and lack of specific treatments to the right buttock and left lateral lower leg and was unable to offer an explanation. The facilities policy on pressure ulcers was requested from LPN F but was not provided prior to the end of the abbreviated survey. The Director of Nursing was interviewed and informed of resident #801's missed wound treatments and offered no verbal explanation. ( )

This citation is related to MI 081 and MI 083. Based on observation, interview and record review the facility 1) failed to assess, monitor and treat 1 of 5 male residents (#04) for Foley catheters insertion sites for injury, and 2) failed to daily assess musculoskeletal/contracture/limited range of motion concerns for 1 of 4 sampled residents (#01), resulting in a urethral meatus tear for Resident #04 and the potential for foreign body entry into flexed/contracted extremities and contractures and/or decreased musculoskeletal changes for Resdent #01. Findings Include: According to the July physician's orders [REDACTED]. On 8/13/15 at 2:35 PM Resident #04 was observed for Foley care performed by Certified Nursing Assistants (CNA's C and D). Both CNA's washed their hands and gloved. They then prepared clean warm water in a basin and had a soap solution on bed side table. Resident #04's Foley/ catheter was noted to be a size 16 French 5 cc (cubic centimeters) balloon. The resident was observed to not have a leg strap (device used to keep catheter secure, prevent pulling on the catheter from the insertion site thereby reducing trauma/injury) for his Foley. CNA C washed the resident's left groin and CNA D right groin with soapy water (turning the towel with each contact area), rinsed the same areas with water towel and patted the area dry. Then CNA C held the Foley near the entrance site to meatus and wiped down with a soapy towel, folding the towel over with each contact to maintain clean technique, repeated with a water towel and patted dry. Resident #04 was noted to have a large tear at his urethral meatus (opening of urethra where urine flows) down to his shaft, with bifurcation, visually measuring at approximately 4-4.5 inches in length. The tear did not appear to be new, as no bleeding or increase swelling at the site was noted. A scant amount of dried dark red/brown drainage was noted on the Foley tubing prior to it being cleaned. During Foley/perineal care Resident #04 stated that the Foley insertion area was tender several times and that CNA D hand gentle hands. Also, Resident #04 was observed to grimace during care. Upon completion, the CNA's secured a clean brief on the resident, bagged supplies, removed their gloves and washed their hands. After exiting the room CNA C was informed that a catheter anchor/leg strap was not present. She stated one should be on there and that she would notify the nurse. physician's orders [REDACTED]. physician's orders [REDACTED].#04 was ordered an antibiotic related to a urinary tract infection No documentation was noted in the doctor's progress notes from 2/3/15 to 8/13/15 related to a urethral meatal tear. Also, urinary continence evaluations dated 6/3/15 and 7/21/15 were negative for documentation related to tear at meatus. The admission Resident Evaluation Form dated 1/21/15 reflected R# 04 had [MEDICAL CONDITION] bladder a 16 French 10 cc balloon, but again no documentation was noted related to tear at meatus. The Significant Change Minimum Data Set (MDS) completed on 7/23/15 reflected Resident #04 had a catheter, urinary ostomy or no urine output for 7 days. Again no documentation related to the urethral meatus tear was documented. Resident #04's indwelling catheter Care Plan with an initiation date of 1/21/15 reflected: Use a possible small size catheter NO. 16 Fr 10 mL (milliliter/cc) balloon as per order, Secure the catheter after insertion to prevent movement, Monitor Peri (perineal) area during cares for alteration in skin integrity. On 8/13/15 at 3:45 PM the Director of Nursing (DON B) was interviewed. DON B when asked if all residents with Foley's were to have catheter anchors, she replied yes, 1 anchor. DON B was informed that Resident #04 had a Foley catheter and a large tear at his urethral meatus, and did not have a catheter anchor when observed during care. On 8/13/15 at 5:08 PM DON B returned and revealed that it wasn't noted on his admission assessment, that Resident #04 had a urethral meatus tear. She continued, I called his wife to ask about it. Wife stated its been wide but does not recall it being that wide. Its been there for several months. Asked when last time he had pain, and she said a couple weeks ago. I grabbed the wound nurse. DON B revealed they were going to call the doctor, use steri strips to treat to get it well approximated. Also, that no documentation was available related to the tear at meatus since Resident #04's admission, or up to this point. On 8/14/15 after writer's intervention an order was observed in Resident #04's chart reflecting the following: 8/13/15 Cleanse head of penis with wound cleanser, pat dry, skin prep surrounding area apply steri strips to close wound q (every) 7 days and prn (as needed). Dx (diagnosis): bifurcation. It wasn't until 8/13/15 that the problem of Bifurcation to head of penis and Treatment as ordered as an intervention was added. Also, Nurses Notes dated 8/13/15 reflected Biforcation (sic) at penis measured at 5 cm (centimeters). The Bard Medical Division Foley Catheter Care & Maintenance Patient Education Guide of 2013 reflected under How Do I Care For My Foley Catheter the following: 2. Use a Foley stabilization device. Foley catheters are often subject to inadvertent pulling forces that can lead to discomfort. A Foley stabilization device is designed to minimize catheter movement and accidental dislodgment, thereby maximizing comfort. Resident #04 who was most recently admitted to the facility on [DATE], Foley insertion site at his urethral meatus was not assessed/monitored for alteration in skin integrity, or treated for [REDACTED]. ( ) According to the admission record Resident #01 was a [AGE] year old male admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission record reflected Resident #01's most recent admission was 5/29/15, yet a timeline produced by the facility on 8/11/15 reflected Resident #01's most recent re-admission was on 7/7/15. Review of the medical record for Resident #01 starting on 8/10/15 reflected he had been discharged to a local hospital from the facility on 7/24/15. The June 2015 Medication Administration Records (MAR's) for Resident #01 reflected he had multiple pressure ulcers at his right/left buttock, and coccyx. The said pressure ulcers did not have daily dressing changes performed on 6/13/15 as ordered. Prevalon boots to bilateral feet around the clock and remove every 2 hours (for skin inspection) was not documented as treated on the following days of June: 13 (x 2), 18 (x 1), and the 22 (x 2). In addition, Foley care every shift and as needed was not performed on the following days of June: 10 (11:00 PM-7:00 AM first shift), 12 (7:00 AM-3:00 PM second shift), 13 (first shift), 14 (3:00 PM-11:00 PM third shift) and 23 (second and third shift). Physician order [REDACTED].#01 was ordered Foley care q (every) shift & prn (as needed). The July 2015 MAR's reflected Resident #01 did not receive Foley care on the following days: 8, 9, 12 and 13 (second shift). Physician order [REDACTED]. The July 2015 MAR indicated [REDACTED]. The Skin Integrity care plan for Resident #01 initiated on 7/8/15 reflected to Monitor/document location, size ant treatment of [REDACTED]. The Bard Medical Division Foley Catheter Care & Maintenance Patient Education Guide of 2013 reflected under 3. Practice Good Hygiene wash skin around the catheter with soap and water daily . Both the Admission (3/18/15) and Quarterly (6/28/15) MDS's reflected Resident #01 had functional limitation in range of motion on both upper extremities and one side of his lower extremity. On 8/7/15 at 4:54 PM the complainant Registered Nurse (RN E) as called related to her complaint made on 7/24/15 at around 11:09 PM. The complainant was read her statement and verified it was accurate. The statement read as the following: Pt has contracted arms and when we slightly moved his arm, flies flew out from under the patients arms. When the patient was log rolled, he had multiple decubitus on his backside. A couple on his upper back and several on his buttocks and coccyx. Three of the wounds on his bottom had thick pus in them and the smell was unbearable. I had to replace th patiens Foley catheter as he had a bladder infection. The urine was very thick and when I was cleaning the penis prior to inserting the new catheter, there were several large chunks of pus that I cleaned out of his meatus, Pt has several open wounds over all his body, some were bandaged and some were open with pus in them. In all my [AGE] years of being an RN, this is the worst case of neglect that I have ever seen. I had to take time off the floor because it made me cry. The complainant was asked if there was any additional information she wanted to provide and revealed the following: The pressure ulcers were open and past the bone, I could have put my fist in them. A diaper was taped over the wound to the resident's upper shoulder. In [AGE] years I have never seen neglect that bad. I literally cried and had to leave the floor. The Physical Mobility care plan initiated on 7/8/15 reflected as an intervention, Monitor/document/report PRN any s/sx of immobility: contractures forming or worsening, thrombus formation, skin-breakdown, fall related injury . During a interview with Resident #01 responsible party on 8/11/15 at 1:09 PM, it was revealed that Resident #01 arms and hand were contracted backwards (facing inward and toward his chest). Licensed Practical Nurse (LPN C) was interviewed on 8/12/15 at 9:40 AM. She was queried if Resident #01 had any contractures. LPN C stated, I don't know if they were true contractures. He would just bring his arms across his chest in a flexed position. Certified Nursing Assistant (CNA D) was interviewed on 8/12/15 at 9:58 AM. She was queried if Resident #01 had any contractures. CNA D stated, He would hold his hands flexed up facing towards his chest and neck. I can't recall if his hands were closed or opened. The Admission Evaluation Data packet (containing 8 pages) dated 6/9/15 reflected Resident #01 was not assessed for Musculoskeletal concerns. Limitations related to range of motion were not noted. The Admission Evaluation Data packet (containing 8 pages) dated 7/7/15 reflected Resident #01 was not assessed for Musculoskeletal concerns. Limitations related to range of motion were not noted. The facility's DAILY SKILLED NURSE'S NOTE (2 of 2 sides) dated 7/18/15 - 7/20/15 and 7/23/15 to 7/24/15 was negative for any assessment of the NEURO/MUSCULAR section. The section was completely empty, with Resident #01 having a known history of functional limitation in range of motion of both the upper/lower extremities. The DAILY SKILLED NURSE'S NOTE (2 of 2 sides) dated 7/21/15 reflected under the NEURO/MUSCULAR section, balance problem marked only for day shift. No other documentation was noted for Resident #01 having a known history of functional limitation in range of motion of both the upper/lower extremities. The note dated 7/22/14 reflected under the NEURO/MUSCULAR section, paralysis weakness only for day shift (side not indicated). No other documentation was noted for Resident #01 having a known history of functional limitation in range of motion of both the upper/lower extremities. ( )

This citation pertains to intake #MI 970 Based on observation, interview and record review, the facility failed to thoroughly and consistently assess and respond timely to repeated complaints of pain and discomfort in the left casted leg for one (#601) of three residents reviewed for pressure sores that was diabetic and at high risk for pressure sores out of a total of three sampled residents, resulting in the development of an unstageable pressure sore to the left heel. Findings include: On 7/23/14 at 10:45 a.m., resident #601 was observed in her room seated in a wheelchair. A leg brace was observed on the resident's left lower leg. A bulky gauze dressing was observed on the resident's mid foot. When asked to explain the reason for the dressing, she (#601) stated, "I have a foot ulcer." The resident explained that when she came to the facility near the end of May 2014 she had a left leg cast which had been changed twice. Resident #601 further stated "When my cast was changed the second time it became too tight after a week or so. They (the facility) failed to notify the "Ortho" doctor that I complained that the cast was tight and that I complained of heel pain and now I have a foot ulcer." On 7/23/14 at 12:53 p.m., resident #601 was observed for a wound care observation that was performed by the Assistant Director of Nursing and Unit Manager "A". Unit Manager "A" was observed as she removed the soiled dressing from the resident's left heel. There was a large amount of grayish drainage on the soiled dressing. The wound bed was observed with greater than 50 percent of grayish slough. Unit Manager "A" was observed as she cleaned the resident's left heel with normal saline. She measured the wound and stated the resident's left heel wound measured 2.5 x 3.0 x 0.25 centimeters (cm). There was a approximately 25 percent of pinkish tissue observed. On 7/23/14 at 1:35 p.m., a review of the clinical record revealed the following: According to the admission face-sheet, resident #601 was admitted to the facility on [DATE]. A review of the admission minimum data set ((MDS) dated [DATE] documented resident #601 was cognitively intact for decision making skills and required extensive assistance for bed mobility with two person physical assist. The MDS assessment coded the resident with one stage two (partial thickness skin loss) pressure sore with an onset date of 5/22/14. The MDS did not list the location of the pressure sore. The MDS coded the resident with [DIAGNOSES REDACTED]. A review of resident #601's admission nursing skin assessment note dated 5/22/14 documented resident #601 had a pressure sore to the right sacrum area. A review of Orthopedics Physician consultation notes documented: On 6/9/14, "...Removed left leg cast applied well padded llc (long leg cast)...follow-up in four weeks for cast change. Next appointment 7/10/14." There was no mention of a left heel ulcer according to the Ortho consultation. On 7/3/14, "Patient seen and examined...complained of left heel pain...(+) positive for heel ulcer stage 2/3 (partial thickness to full thickness skin loss) 2 x 3 centimeters. Assessment/Plan...Left heel ulcer '(cast complication)'...wound care/dressing changes, [MEDICATION NAME] (antibiotic) for 2 weeks, follow-up in 2 weeks..." A Review of Wound Care Physician consultation notes documented: On 7/8/14, "The patient fractured her left tibia and fibula May 2014. She was treated with casting. The casting stayed on for six weeks. Then she had a cast change. Three weeks after the second cast was applied she started having pain in the left heel. It was treated conservatively at first. The pain persisted. She went to her surgeon last Thursday and the wound on the heel was found. She is no longer in a cast. There is a necrotic wound on the posterior left heel...It measures 3.1 x 3.2 cm. The tissue type is 33 % (percent) necrosis (dead tissue), 33 % slough, 34 % granulation." Plan: Treat with Santyl and absorbent dressing every day and as needed. Continue to elevate legs so as no pressure to the heel. Order an X-ray of the left heel to R/O (rule out) osteo[DIAGNOSES REDACTED]." On 7/15/14, "Wound status-left, posterior heel pressure ulcer. 3 x 2.6 cm. Stage: Necrotic Tissue (Unstageable). 51-75 % eschar (dead tissue). 1-25 % granulation. A review of nursing notes documented: On 6/16/14 at 3:30 a.m., "Resident complained of left leg pain rated 9/10...Medicated with [MEDICATION NAME] as prescribed. Resident states she can't take another day of the pain...Resident states her pain has gotten worse since having her cast changed." There was no post pain medication rating documented in the clinical record. On 6/30/14 at 8:00 a.m., and at 10:00 a.m., "Circulation check to left leg WNL (within normal limits). Able to move toes. Equal warmth in both feet." According to the check off section for pain assessment the resident had left leg pain. However, the resident's intensity of "pain" rating was not marked or documented as assessed. On 6/30/14 at 3:30 p.m., "Resident expressed an increase in left lower extremity discomfort during a recent transfer from bed to commode...felt something was 'jarred', upon further discussion she reported pain to be in left heel. Voice mail left for (Ortho Scheduler) "F" to report this change. Received a call back from (Ortho Scheduler) "F" who offered a follow-up appointment on 7/3/14 at 1:30 p.m. Writer spoke with resident (#601..and she reported that would work." There was no documentation that indicated the resident's attending physician was notified of the resident's new and specific complaint of heel pain, nor of the resident's delay in being seeing by the Ortho physician. On 6/30/14 at 6:45 p.m., "...Resident currently has leg elevated on pillow". That was the only nursing note in the clinical record that reflected the resident's leg was elevated on a pillow. A review of the resident's "Fracture" care plan dated 5/22/14 documented: Problem; Resident has a cast on left lower extremity. Goal: Resident will heal fracture within (_?_) weeks, without complication. Intervention: Keep cast dry at all times. Perform neurovascular checks every shift and as needed. Remind resident to report extreme pain or pressure beneath the cast. Observe for drainage or fever for possible infection under the cast. Check skin along the edges of the cast and protect as necessary. If any swellings at edges of cast notify MD. Encourage position change every 2 hours. Monitor and medicate for pain. Left leg lifter. There were no interventions documented on the care plan to off-load pressure, float, nor elevate the heels. A review of the facility's "Skin Integrity Program: Identification and Prevention" policy dated 3/2010 documented: Policy: Resident with risk factors for pressure ulcer development will be identified, and appropriate interventions will be implemented. A review of the facility's undated, "Cast Care" policy documented: Purpose: "To give proper care of resident in a plaster cast to prevent infection, irritation and provide continuos immobilization. General guidelines for assessment may include, but are not limited to: Note allergies [REDACTED]. Monitor vital signs as necessary. Monitor pain. Observe cast for discoloration. Monitor extremity for [MEDICAL CONDITION], change in skin color and temperature. Pain. Tape allergy." On 7/23/14 at 3:00 p.m., during an interview and record review Registered Nurse (RN) Unit Manager (UM) "A" it was identified that she authored the nursing note dated 6/30/14 at 3:30 p.m. According to (RN) (UM) "A", "I was making rounds and resident (#601) told me that she didn't feel right after transferring from her chair back to bed. She (#601)explained her left heel felt 'jarred'. When asked if she (RN) (UM) "R" was assigned to the resident that date stated "No." When asked if she asked the resident if she can express the location (site) of her "increased lower left leg pain. (RN) (UM) "A" explained she did not recall. When asked if she informed the resident's attending (MD) of the resident's compliant of increased left lower leg pain and the delay of an Ortho evaluation until 7/3/14, (RN) (UM) "R" stated, "I don't think so. I would have documented that in my note." On 7/23/14 at 3:50 p.m., during a telephone interview Ortho Medical Assistant (OMA) "C" explained that she recalled the observation of resident #601's heel ulcer on 7/3/14. She (OMA) "C" explained on 7/3/14 she was the staff member who removed the cast from resident #601's left lower leg. She stated, "When I removed the cast, her left leg and heel were slippery and wet and the heel ulcer was observed. Ortho (MD) "G" came in an observed the resident's left heel ulcer. (OMA) "C" explained that all patient's are instructed to seek emergency treatment for [REDACTED]. Additionally, (OMA) "C" explained that upon review of the patient's chart the resident had an appointment scheduled for 7/10/14 and (RN) (UM) "A" had left a message that indicated the resident could wait to be seen on 7/3/14. On 7/23/14 at 4:15 p.m., a failed attempt was conducted to reach Medical Doctor (MD) "E" to inquire about any notification received by the nursing staff related to the resident's new complaint of left heel pain. A voice message was left at (MD) "E's" pager as prompted. However, no response was received to date. On 7/23/14 at 4:25 p.m., during a telephone interview, Licensed Practical Nurse (LPN) "D" was unable to recall if resident #601 had specifically, complained of heel pain on 6/30/14 when she was the resident's assigned nurse. On 7/23/14 at 4:40 p.m., during an interview and record review the Director of Nursing (DON), offered no explanation when asked if the resident's left heel pressure ulcer could have been prevented. ( )

This citation pertains to intake number MI 130. Based on interview and record review, the facility failed to provide supervision and to ensure safety devices were appropriately working to prevent a fall for 1 (Resident #506) of 9 sampled residents, from a total sample of 9 residents, resulting in a head laceration, hospitalization , avoidable pain and a skin graft to the scalp. Findings Include: Review of the Face Sheet, Minimum Data Set (MDS, resident assessment tool) dated 12/27/12 and 1/9/13, Physician orders [REDACTED]. 2/13 through 5/13 and Hospital records dated 6/1/13 through 6/3/13, revealed Resident #506 was alert, had been repeatedly admitted to the facility from 12/27/12 through 6/3/13, required extensive staff assistance with all transfers and was non-compliant with using the call light and requesting assistance with toileting. Resident #506's [DIAGNOSES REDACTED]. The resident was originally admitted to the facility for Rehabilitation services with a goal of returning home, however due to the progression of her disease, she became long term care. Observation and interview was done on 6/17/13 (at 8:40 a.m. and 9:15 a.m.), of Resident #506. The resident was in her room, in bed and resting comfortably with her family with her. The resident was alert to name, place and date; she was observed to be neat, clean, well groomed and appropriately dressed with a dry dressing wrapped around her head. When questioned about her fall on 6/1/13, the resident stated "I did put my light on". The resident revealed she had to use the bathroom, she put her light on and no one came so she attempted to take herself when she fell and hit her head. The resident was unsure what she had hit her head on. The resident confirmed she had suffered with headaches after her fall on 6/1/13. Review of the facility investigation (un-dated and un-signed), stated "She (Resident #506) went to the dining room for lunch per staff. After lunch, visitors assisted resident from dining room to visit with her. They assisted her back to dining room for her to participate in activity in dining room. Staff assisted resident back to unit following activity. Resident assisted to area by nurses station. She propelled self in wheelchair into her room, approximately three minutes later, staff heard roommate calling for help and observed resident laying on the floor face down near bathroom". Review of Resident # 506's facility fall assessments prior to her fall on 6/1/13, are as follows: Date: 1/1/12= "20" (10 or higher is at high risk for falls) Date: 2/12/13= "17" Date: 3/14/13= "11" Date: 5/5/13= "14" Review of the physician progress notes [REDACTED]. is 74 yr. old female came from (Hospital), multiple falls, profound weakness. Current Diagnosis: [REDACTED]. Review of the residents fall care plan dated 12/27/12, stated "fall score 17, recent falls, assist of 2 for transfers". Review of the residents fall care plan dated 2/13/13, stated "fall risk score 17, anticipate further decline r/t (related to) loss of independence secondary to progression of Parkinson's disease. Ambulate with 2 assist as needed". Review of Physician orders [REDACTED]. Review of the Incident/Accident Report dated 3/12/13, the residents first fall at the facility: Resident # 506 fell on [DATE] at 3:50 p.m. while in the bathroom, she lost her balance while washing her hands at the sink and fell backwards, causing the therapist with the resident to lower her to the floor. Review of the back side of the Incident report dated 3/12/13, addressing safety devices and fall precautions was left blank. Review of the residents fall care plan dated 5/4/13, stated "5 min. check, 2 assist with all transfers, sensor pad alarm to bed and wheelchair". Review of Physician order [REDACTED]. Review of Physician orders [REDACTED]. Review of the Safety Risk/Interventions Unit record dated 5/1/13, revealed the resident was at "red (high)" risk for falls, had a "w/c (wheelchair) cushion, sensor pad bed-w/c (an alarm on the bed and wheelchair), tab alarm in bathroom". Review of the Continued Assessment-Resident Evaluation dated 5/4/13, stated" safety sensor pad initiation to bed and w/c, staff will observe resident closely when toileting for safety measures, 15 min. monitoring on-going". Review of the Psychological Evaluation dated 5/8/13, stated "Reasoning, insight, judgment currently impaired". Review of the Incident/Accident Report dated 5/14/13, the residents second fall at the facility: Resident # 506 fell on [DATE] at 10:00 p.m., while in the bathroom washing her hands. The resident lost her balance, fell and hit her head on the floor. Review of the back side of the Incident report dated 5/14/13, addressing safety devices and fall precautions was left blank. Review of the Incident/Accident Report dated 6/1/13, the residents third fall at the facility: Resident #506 fell on [DATE] at 4:20 p.m., in her room at her bathroom door. The resident fell backwards, hit her head and was found by staff when her roommate yelled for help. Review of the back side of the Incident report addressing safety precautions dated 6/1/13, was completely blank. No documentation of any safety precautions was found on the Incident Report dated 6/1/13, given to the surveyor at the facility. The incident (dated 6/1/13) report stated "Res (resident) is a 1 person assist with transfers. Res made self-transfer from w/c to bathroom and fell ; Hematoma (extensive bruising, soft tissue trauma)/laceration L left side of head above L (left) ear". Review of the Hospital Trauma Admission History and Physical dated 6/1/13, stated "Fall from standing height head-first into register, c/o (complained) headache, L (left) scalp hematoma, watch closely". Review of the Hospital Trauma Services Progress Note dated 6/2/13, stated "fall against register". Review of the Hospital records dated 6/1/13 through 6/3/13, revealed the resident had been admitted for close observation after her fall with a head injury. Review of Hospital Physician notes dated 6/7/13, stated "Pt. (Patient) is 74 yr. (years old) fall, went to ER (emergency room ), developed L scalp hematoma" and she had a "headache". Review of the Hospital Operative Report dated 6/21/13, stated "Infected wound of the scalp and scalp laceration status [REDACTED]. Review of the Physician consultation dated 6/18/13, revealed documentation regarding the scalp laceration and hematoma; the resident required a skin graft to her laceration on her head. Review of the Hospital discharge records dated 6/21/13, revealed the resident received surgery for [REDACTED]. An interview was done on 6/21/13 at 10:45 a.m., with Family Member # 2 (responsible party). Family Member # 2 stated "I am up-set, she (the resident) had to have surgery because of the fall, she's fallen 3 times since she's been here. I don't even know what happened, I got 3 different stories". Family Member # 2 had just returned with the resident from the Hospital where the resident had a skin graft to the scalp area due to the laceration from her fall on 6/1/13. Review of the Social Service notes dated 6/21/13, confirmed Family Member #2 verbalized to Social Worker #1 that he had received three different accounts of how resident #506 fell on [DATE]. An interview was done on 6/19/13 at 1:30 p.m., with Charge Nurse RN # 4. Charge Nurse RN # 4 stated "she (the resident) starts to get very weak in the evening due to the Parkinson's". An interview was done on 6/17/13 (at 2:20 p.m.) and on 6/19/13 (at 1:45 p.m.), with Charge Nurse RN # 2. Charge Nurse RN # 2 revealed the activities department brought the resident back from an activity at approximately 4:00 p.m. (on 6/1/13) and sat her in her wheelchair in front of the nurses station. Charge Nurse RN # 2 stated "the resident's get congested right there, so I moved (the resident) outside her room in the hall. When she's got to go, she's got to go, she is on Lasix (removes excess fluids, increases urination). She went in her room and got to the bathroom door, I heard (roommate) yelling "she's standing up". She stood up and had a fall. If we would have had her on a toileting schedule, it may have been prevented. I did not hear the alarm going off (wheelchair alarm), I was about 10 feet from her door to my cart doing med's, her door was open". Review of Nurses Progress note's dated 6/1/13 at 10:00 p.m., stated "Res (the resident) returned from activities via w/c, she and other Res were congested at corner of (the unit resident was on) in front of Nrsg. Station. This nurse (Charge Nurse RN # 2) moved the Res to outside her room in hallway. I left and moved another Res. down the hall in his w/c then came back to my med cart. I heard the Res in (the residents room number, the roommate) yelling. This nurse went for the room. As I entered the room, Res (Resident # 506) was on the floor. Her feet were in the doorway of the bathroom, she was face down with her head next to the thermal control unit (register). Res. was observed alert x 3, with a large hematoma and 2 inch laceration to left side of head, 2 inches above left ear. Upon entering room, no call light was on and chair alarm (wheelchair alarm) was not sounding". An interview was done on 6/19/13 at 2:35 p.m., with the Director of Activities # 1 and Activity Aide # 1. The Director of Activities # 1 said Resident # 506 had come in Activities at approximately 2:30 p.m. and did not leave until Bingo was over at 4:00 p.m. Activity Aide # 1 said she had not toileted the resident on 6/1/13, when she was in activities because she was the only Activity Aide in the room and she had a resident on a ventilator, so she could not leave and toilet Resident # 506. Activity Aide # 1 revealed the resident was taken back to her unit and put by the nurse's station at approximately 4:00 p.m. Review of the activity sign-in sheet dated 6/1/13, revealed Resident # 506 attended "card sharks" at 2:30 p.m. and "bingo" at 3:00 p.m. An interview was done on 6/21/13 at 10:25 a.m., with Nursing Assistant (CNA) # 3. CNA # 3 stated "Her (the resident) alarm (wheelchair alarm) was not going off at all (on 6/1/13), I checked the wheelchair, I put my hand on the seat and the alarm did not go off. It was off (on the off position), some body turned it off. The resident told me "I kept putting my light on and nobody came". I told the Nurse (Charge Nurse RN # 2) that her chair alarm was not on". An interview was done on 6/20/13 at 2:35 p.m., with CNA # 4. CNA #4 stated "I was working on the unit (on 6/1/13, second shift), I heard the nurse (Charge Nurse RN # 2) yell for help. I did not hear an alarm, I saw her lying face down on the floor, there was blood on the floor. I moved the wheelchair out of the way, the alarm was not going off, I know for a fact her alarm was not going off, (Charge Nurse RN # 2) would of heard it going off". Review of CNA # 4's facility written statement dated 6/1/13, stated "She was lying on the floor face down near her bathroom. Was the call light on when you came to the room ? "No". Was the chair (wheelchair) alarm sounding ? "No", I moved the w/c when the nurse asked me to, I took off the foot rests". An interview was done on 6/17/13 at 2:00 p.m., with CNA # 6. CNA # 6 stated "She is a fall risk, when she has to go (to the bathroom), she has to go. When she puts her light on, she needs to go; she puts her light on first". An interview was done on 6/20/13 at 3:07 p.m., with CNA # 5. CNA # 5 stated "I was one room down (from Resident # 506's room on 6/1/13), the door was partially open, I did not hear her alarm going off at all. I would of heard her alarm, they are pretty loud and I was one room down". An interview was done on 6/20/13 at 2:20 p.m., with Restorative CNA # 1. Restorative CNA # 1 said he had checked the resident's wheelchair alarm on 6/1/13 at 8:30 a.m. and it was functioning properly. Restorative CNA #1 said he checks all residents alarms only one time a day, in the morning. Review of the facility written statement dated 6/1/13 and signed by Charge Nurse RN # 5, stated "I toileted her before lunch, about 2:00 p.m., I walked passed her room and she wasn't in there so I was told she was in activities. Her normal routine is after lunch I toilet her". An interview was done on 6/21/13 at 7:38 a.m., with Resident # 506's roommate, who was alert and able to recall when Resident #506 fell on [DATE]. When the surveyor asked if she had heard any alarms going off when the resident stood up from her wheelchair on 6/1/13, prior to the fall the roommate stated "no, I did not hear an alarm going off, I yelled for help". Review of Resident #506's facility Physical Therapy Evaluation dated 6/5/13, stated "decreased judgment/reasoning". Review of the Nurses note's dated 6/3/13, 6/4/13, 6/5/13, 6/15/13 and 6/16/13, revealed documentation of the resident complaining of a headache, left sided head pain, left ear pain and neck pain, with requests for pain medication. Review of the Physical Therapy Progress note's dated 6/11/13, revealed the resident had pain in her head, it occurred intermittently and could range from number "8" to "10" (10 being the highest level of pain). Review of physician progress notes [REDACTED]. Review of the facility Falls Management and Identification Program dated 1/1/09 and revision date of 1/12, stated "The Center will provide each resident with: Appropriate interventions to reduce the risk to the resident from falling, A continual process of Performance Review to analyze, trend, review, and/or revise processes to provide a safe environment to each resident/patient. A score of 10 or above represents a high risk for falls". Review of the Falls Management Program (dated 1/1/09), revealed examples of interventions that may be implemented for the safety of the resident and to decrease falls included a "toileting Program" and functioning "chair sensor alarms". ( )

This citation pertains to MI 585 Based on observation, interview, and record review, the facility failed to ensure: 1) safety devices were functional, and 2) appropriate equipment was used during mechanical transfers in 2 (Resident #111 and Resident #112) of 32 sampled residents, from a total sample of 32 resident resulting in Resident #111 sustaining a head injury from a fall where a safety device did not work and, the potential for injury for Resident #112 after an improper sling was used during a mechanical lift transfer. Findings include: Resident #111 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #111 was a [AGE] year old female with [DIAGNOSES REDACTED]. The MDS revealed Resident #111 scored 2/15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS), required total dependence with 2 staff members for transfers and total dependence with 1 staff member for toilet use. The MDS revealed Resident #111 had a previous fall without injury. Review of the Fall Risk Predictive Factors assessment dated [DATE], revealed Resident #111 scored 14 (10 or higher may represent high risk). Review of the physician's orders [REDACTED]. Review of the Potential For Falls Care Plan dated 2/8/13, revealed Resident #111 had decreased safety awareness and a history of falls. The Care Plan revealed Resident #111 transferred with assist of 2 staff and had a sensor pad alarm. An observation on 3/27/13 at 9:35 AM, revealed Resident #111 was sitting in her wheelchair with a sensor pad alarm to her wheelchair. An observation on 3/28/13 at 3:13 PM, revealed Resident #111 was lying in bed with a sensor pad alarm to her bed. Review of the Situation, Background, Assessment/Appearance, Request (SBAR, physician communication note) dated 2/10/13 at 7:30 PM, revealed Resident #111 toileted herself without assistance and was "found in bedroom on bathroom floor face down in pool of blood" and had a "deep cut on forehead". The SBAR revealed "resident (Resident #111) chair alarm did not go off..." During an interview on 3/29/13 at 9:40 AM, Certified Nursing Assistant (CNA) #31 reported she was the CNA assigned to Resident #111 on 2/10/13 at 7:30 PM, CNA #31 reported she left the room for less than 5 minutes, came back and observed Resident #111 face down in the bathroom. CNA #31 stated "when I got to the room (Resident #111's room), the alarm wasn't going off (sounding)". CNA #31 reported that after the incident, she checked the alarm and the switch was in the on position, but not sounding. CNA #31 reported she then turned the switch off and back on and the alarm sounded approximately 2 seconds later. CNA #31 reported for a third time that Resident #111's alarm was not sounding at the time of the fall. During an interview on 3/29/13 at 3:36 PM, Licensed Practical Nurse (LPN) #36 reported she was the nurse assigned to Resident #111 on 2/10/13 at 7:30 PM. LPN #36 stated "her (Resident #111's) alarm did not go off (sound)...the switch was in the on position, but the alarm didn't go off". Review of Resident #111's physician's orders [REDACTED]. Review of the hospital records dated 2/10/13, revealed Resident #111 required laceration repair with sutures to the forehead. Resident #112 Review of the Face Sheet and MDS dated [DATE], revealed Resident #112 was a [AGE] year old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed that Resident #112 scored 12/15 (cognitively intact) on the BIMS and required total dependence of 2 staff members for transfers. Review of the physician's orders [REDACTED]. Review of the Potential For Falls Care Plan (undated), revealed Resident #112 had a history of [REDACTED]. An observation on 3/26/13 at 9:43 AM, revealed staff used the Joerns HPL 700 Hoyer Lift to transfer Resident #112 from the bed to his wheelchair. An observation on 3/27/13 at 12:20 PM, revealed the Joerns HPL 700 Hoyer Lift had a safety notice on it which stated "Not all slings are compatible with this lifting device. It is the policy of Joerns Healthcare to recommend that only Joerns' slings be used with Joerns' lifts". An observation of the lift slings in the Windsor Hall's linen closet, revealed the Joerns' slings were gray in color and the Invacare slings are blue mesh. An observation on 3/27/13 at 1:00 PM, revealed Resident #112 was in his wheelchair with a blue mesh sling. During an interview on 3/27/13 at 10:30 AM, when queried how staff knew what sling and what lift to use for Resident #112, CNA #13 stated "I just know from experience and by looking at him and guesstimating the size and sling". During an interview on 3/27/13 at 11:00 AM, CNA #14 reported that Resident #112 used the "700 lift" (Joerns' HPL 700 Hoyer Lift) for transfers and that the slings used were based on weight. During an interview on 3/27/13 at 11:30 AM, when queried how staff knew what sling and lift to use for residents, CNA #6 stated "just by knowing our residents and what they prefer". During an interview on 3/28/13 at 10:02 PM, when queried how staff knew what sling and lift to use for residents, CNA #5 stated "when you work with them (the residents), you know". During an interview on 3/28/13 at 11:14 AM, CNA #26 reported that Resident #112 "likes the blue sling so that's what we use". An observation and interview on 3/27/13 at 2:03 PM, revealed Resident #112 in bed with a blue mesh lift sling (Invacare brand) under him. CNA #13 and CNA #14 reported they had transferred Resident #112 from the wheelchair to his bed using the Joerns' HPL 700 Hoyer Lift and the blue mesh sling. CNA #14 stated that the blue mesh sling was the "sling he (Resident #112) always uses". When queried how she knew what sling to use, CNA #14 stated "we (staff) just go to the closet and get slings". When queried if she knew that certain slings are to be used with certain lifts, CNA #14 reported she was not sure, but Resident #112 "prefers" the blue mesh sling "we have been using" During an interview on 3/25/13 at 3:53 PM. Director of Nursing (DON) #2 reported the facility did not have a mechanical lift policy and they followed the manufacturers guidelines. Review of the Joerns Healthcare User-Service Manual for Model HPL 700, revealed "Warning: Using other manufacturers' parts and accessories on Hoyer products is unsafe and may result in serious injury to patient and/or attendant. Use only Hoyer parts. Hoyer lifter parts are NOT interchangeable with other manufacturers' products..." and "Warning: Do not use a sling that is not recommended for the lift". Review of the Invacare Patient Sling Owner's Manual revealed "Invacare slings and patient lift accessories are specifically designed to be used in conjunction with Invacare patient lifts". During an interview on 3/28/13 at 3:30 PM, DON #2 reported the facility was told by Joerns' that the lift slings were interchangeable. This surveyor requested documentation showing this, but DON #2 was unable to produce such documentation. During a telephone interview on 3/28/13 at 3:32 PM, Joerns' Customer Service Representative #29 stated "We only recommend our slings. We don't have the specifications for other products so we cannot recommend them to be used with Joerns' lifts". ( )

This citation pertains to intake #MI 374. Based on interview and record review, the facility failed to monitor the anti-coagulant status in 1 of 18 sampled residents (Resident #109), of a total of 21 sampled Residents, resulting in and Immediate Jeopardy when Resident #109 was administered both [MEDICATION NAME] (blood thinner) 5 mg daily and [MEDICATION NAME] (blood thinner) 30 mg subcutaneously twice daily from 12-14-12 until 12-27-12, with no physician orders to monitor INR (laboratory work to monitor blood thinner) blood levels and Resident #109 was found with blood and blood clots in her bed pan on 12-27-12. Resident #109 was transferred to the hospital where she was found to have an INR greater than 10 (normal 2.0-3.0 mg/dl) and was diagnosed with [REDACTED]. This deficient practice placed an additional 23, identified as being prescribed [MEDICATION NAME], at risk for serious harm, injury and or death. Findings include: Review of Resident #109's face sheet revealed she was an [AGE] year old female, admitted to the facility on [DATE] from an acute care hospital with the following diagnoses; post [MEDICAL CONDITION] with Open Reduction Internal Fixation (ORIF-a method of surgically repairing a fractured bone), Muscle Weakness, Difficulty in Walking, Dehydration, and [MEDICAL CONDITION] (weak heart). Review of Resident #109's facility History and Physical (H&P), dated 12-14-12 at 3:13 PM, Revealed Resident #109 was assessed by the attending physician's 3rd year medical student (MS #3). The H&P revealed that, when Resident #109 was admitted , she was taking [MEDICATION NAME] and [MEDICATION NAME] for [MEDICAL CONDITION] Fibrillation. MS #3 documented "d/c (discontinue) [MEDICATION NAME]?" The H&P revealed MS #3's plan was for Resident #109 to have a PT/INR drawn in the "AM" (12-15-12). The H&P was not co-signed by the attending physician. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated but there was no indication or date as to when the lab was to be drawn. Review of the MAR indicated [REDACTED]. Review of the medical record revealed there were no physician's orders, laboratory slips or documentation on the MAR for [MEDICATION NAME] monitoring (laboratory draws) for Resident #109. During an interview on 1-30-13 at 10:05 AM, Licensed Practical Nurse (LPN) #38 reviewed the admission orders [REDACTED]#3) did not order a PT/INR. During an interview on 1-30-13, at 10:40 AM, Registered Nurse (RN) #39 reviewed the admission physician orders for Resident #109 and said she co-signed the physician orders that were written by LPN #38. The Surveyor asked RN #39 why orders are co-signed and RN #39 responded it is to assure no mistakes are made. The Surveyor asked if the note for PT/INR should have had a date and RN #39 stated that there should have been a date for the PT/INR to be drawn and she should have caught the mistake. During an interview on 1-29-13 at 2:50 PM, PH #2 reviewed MS #3's History and Physical note on Resident #109. The Surveyor pointed out that PH #2 did not sign the History and Physical written by MS #3 and PH #2 explained he does not sign the notes until they are reviewed by medical records and he would not have read the note because it is his practice to verbally review the case with the medical student. The Surveyor asked if the medical students are able to write medical orders on the nursing home residents and PH #2 stated medical students do not write orders. The Surveyor asked PH #2 why he did not order a PT/INR for Resident #109 on admission as the MS #3 had written in her note. PH #2 said he verbally told RN #35. The Surveyor asked why PH #2 did not order a PT/INR when he was in to see Resident #109; PH #2 stated he may not have had access to her chart and was not aware she did not have a PT/INR ordered. The Surveyor read PH #2 the nurses note for Resident #109, dated 12-22-12 that read, "called PH #2 for stop date on [MEDICATION NAME], didn't answer call but I left a message waiting for return call", signed by RN #36. When questioned why PH #2 did not return the telephone call, PH #2 stated he tries to return every call but it is not unusual for the telephone to ring 25 to 30 times and he is not able to connect with the person calling him. During a telephone interview with RN #35, on 1-30-13, at 10:55 AM, the Surveyor ask RN #35 if she recalled PH #2 giving her a verbal order to get a PT/INR on Resident #109 on admission. RN #35 said she would have told PH #2 to write the order or write her a note so she would remember to write the order. During a telephone interview with MS #3, on 2-1-13, at 11:15 AM, the Surveyor asked MS #3 if she recalled doing the History and Physical on Resident #109. MS #3 stated she wrote a question mark next to [MEDICATION NAME] so that PH #2 would look at the Residents #109's [MEDICATION NAME] order. The Surveyor asked MS #3 if she wrote the orders on Resident #109, MS #3 reported that medical students are not able to write orders in the nursing home. The Surveyor asked MS #3 if the Physician needs to co-sign her note and she responded, "yes", but did not recall seeing PH #2 sign her note. Review of the Nurse's notes, dated 12-30-12, "late entry" revealed RN #36 documented she called PH #2 (on 12-27-12) to inform PH #2 that Resident #109 had a large amount of dark red blood in her bed pan. PH #2 asked RN #36 why Resident #109 was on [MEDICATION NAME] and [MEDICATION NAME]. RN #36 documented she told PH #2 because that was what PH #2 had ordered. Review of the Nurse's notes, dated "late entry" 12-30-12 (no time) for 12-27-12, revealed that on 12-27-12 at 7:55 PM, Resident #109 was found with blood and blood clots in her bed pan and was sent to the hospital on 12-27-12 at 9:02 PM. Review of the emergency room Physician's Note, dated 12-27-12, revealed Resident #109 had a hemoglobin level of 8.6, an INR of greater than 10, and a [DIAGNOSES REDACTED]. The note indicated that Resident #109 required vitamin K and fresh frozen plasma to stabilize her coagulation status. In an interview on 1-25-12, at 10:05 AM, Director of Nursing (DON) #2 stated, "Resident #109 was in the facility for 11 days and had no INR since admission. On 1-30-13 at 2:50 PM, Administrator #1 was notified an of an Immediate Jeopardy that began on 12/27/12 and was identified on 1/28/13 as a result of the facility's failure to monitor the anti-coagulation status of Resident #109 who was administered both [MEDICATION NAME] 5 mg daily and [MEDICATION NAME] 30 mg subcutaneously twice daily for 13 days with no physician orders to monitor INR and Resident #109 was found with blood and blood clots in her bed pan on 12-27-12, then was transferred to the hospital where she was found to have an INR greater than 10 and a [MEDICAL CONDITION] secondary to anticoagulant therapy. On 2-5-13 the surveyor confirmed the facility implemented the following to remove the Immediate Jeopardy: 1. As of 12/27/12, Resident #109 no longer resides in the facility. 2. On 12/28/13, the 23 residents identified as being prescribed [MEDICATION NAME] charts were reviewed to ensure medication orders and MAR's matched, that a [MEDICATION NAME] Monitoring and Tracking Sheet were in place with the most recent INR levels recorded, care plans were reviewed to ensure accuracy, and all 23 residents were assessed for any sign or symptoms of bleeding. 3. On 1/30/13, a second review of current residents prescribed [MEDICATION NAME] was completed for 26 residents identified. The charts were reviewed for correct [MEDICATION NAME] orders, transcription to the tracking sheet, correct medication dosage in cart, date of most recent PT/INR with results, monitoring of any adverse reactions on the MAR, ensure a [MEDICATION NAME] therapy care plan was in place, and a Pink Monitoring and tracking form was in place. 4. The facility created a Pink [MEDICATION NAME] Monitoring form on 12-31-12 and immediately began education on how to utilize the pink [MEDICATION NAME] Form as of 1-1-13. 5. On January 1, 2013, the facility initiated using the pink [MEDICATION NAME] monitoring and Tracking Sheet. 6. On January 1, 2013, the facility will review New/Re-Admission records in the morning clinical meeting to identify residents receiving [MEDICATION NAME] therapy and validate that appropriate labs are completed as ordered, correct medication dosage is available on hand, and dietary precautions are noted. Documentation of this review is maintained as part of the medical record. 7. On January 31, 2013, Pharmacy services will provide at least a monthly report of residents receiving [MEDICATION NAME] to the Director of Nursing ensure the audit list remains current. 8. On January 2013, monthly a pharmacist will review the medication regimen, dosage and laboratory records of residents receiving [MEDICATION NAME]. This review will require a formal exit with the Director of Nursing for any risk that requires immediate attention. 9. On January 11, 2013, the Unit Manager/designee will audit 50% of residents receiving [MEDICATION NAME], including new/readmission, in a weekly audit to ensure: the medication dosage is adjusted based on PT/INR results are appropriately ordered, ordered dosage is on hand, care planning is complete, and bleeding risk is monitored. 10. Education with scheduled Licensed Nurses has been initiated by the Director of Nursing, Assistant Director of Nursing and Facility Educator on 12-31-12 through 1-30-13 on the [MEDICATION NAME] administration policy including: A.) [MEDICATION NAME] Policy B.) [MEDICATION NAME] monitoring and tracking sheet (pink form created on 12-31-12 for use beginning 1-1-13 C.) Review of PT/INR prior to administering [MEDICATION NAME] 11. As of 1-30-13, 65 of 68 scheduled licensed nurses have received this education with 53 of those nurses having been educated by 1-4-13. Nurses not educated by January 30, 2013 will not resume work responsibilities until education has been received. 12. The facility policy titled "[MEDICATION NAME] ([MEDICATION NAME]) Policy" has been reviewed on 12-31-12 by the Quality Assurance Committee and deemed appropriate. 13. The Director of Nursing Services is responsible for obtaining and sustaining compliance. Although the Immediate Jeopardy was removed on 1-1-13, the facility remained out of compliance at a scope of isolated and a severity of actual harm that is not an Immediate Jeopardy due to all staff had not been educated and sustained compliance had not been verified by the State Agency. ( & )

This Citation pertains to intake # MI 374, MI 310, and MI 095. Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for 1 of 3 sampled residents (Resident #101), from a total sample of 21 residents, resulting in Immediate Jeopardy when Resident #101 who had a history of [REDACTED]. As a result, facility staff obtained a physician's order to send Resident #101 to the hospital on [DATE] at 10:00 pm, but facility staffs did not follow the order. Resident #101 went into [MEDICAL CONDITION] on [DATE] at 11:45 pm, required Cardiopulmonary Resuscitation (CPR), and emergency transfer to hospital. Resident #101 subsequently died . The deficient practice placed all 121 residents, who have the potential to be ordered to the hospital by a physician, at serious risk for harm, injury and/or death. Findings include: Review of the Face Sheet revealed Resident #101 was a [AGE] year old male, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #101 was cognitively intact, required extensive assistance for bed mobility, dressing, and bathing, and total care from staff with transfers, toileting; used a wheelchair for mobility, and was non-ambulatory (did not walk). The MDS revealed Resident #101 had chronic pain with a pain scale of 6 on a ,[DATE] scale (10 being the most severe pain). Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"2012 Nursing Drug Handbook", The medical record contained no physician orders for a stool softener or laxatives. Review of the medical record revealed that there was no Bowel Care Plan in place for Resident #101. Review of the Bowel Movement Monitoring log indicated as protocol, "If no BM by day two, end of night shift (4 shifts), the nurse to notify dietary department for prune juice with breakfast. If no BM on 2nd day am nurse to proceed with: Assess the resident for bowel sounds, assess the abdomen for firmness and or any tenderness, distention, and nausea/vomiting. Check for any firm hard stool, if stool is present and the resident has the urge to defecate, the charge nurse will administer [MEDICATION NAME] suppository to soften and move the stool. Document the assessment and interventions in the nurses' notes. Proceed with the following if no stool present: 1. Second day without BM am administer 30 ml (milliliters) of MOM (Milk of Magnesia) with first am med pass. 2. Second day without BM by HS (hours of sleep) administer [MEDICATION NAME] suppository. 3. Third day without BM in am administer fleets enema. 4. Third day without BM by beginning of 2nd (shift), charge nurse must notify physician for further instruction and orders. Review of the Bowel Movement Monitoring log dated ,[DATE] revealed Resident #101 had no bowel movement (BM) from [DATE] until [DATE] (5 days with no bowel movement), and no bowel movement from [DATE] until [DATE] (7 days with no bowel movement), when a small BM was charted, and no bowel movement from [DATE] until [DATE] (5 days with no bowel movement). There was no documentation on the form that the bowel protocol was initiated per the instructions on the form, nor was any laxatives given until [DATE] when Milk of Magnesia was first given on the ,[DATE] shift, no time. Review of the log revealed Milk of Magnesia was given to Resident #101 on [DATE] on the ,[DATE] shift, and [DATE] on the ,[DATE] shifts, no times listed. In an interview on [DATE] at 4:05 pm, Director of Nursing (DON) #2 reported that the facility has no standing orders and that the bowel protocol on the Bowel Monitoring log is the only bowel protocol in the facility. The signs and symptoms of a bowel obstruction include abdominal pain/discomfort, abdominal distention, nausea, vomiting, ribbon-like stools and/or obstipation (severe constipation), diarrhea if the bowel is partially blocked and constipation and lack of flatulence if the bowel is completely obstructed. (Medical Surgical Nursing; Critical Thinking for Collaborative Care, Ignatavius, D. and Workman, M., Saunders, 2002. page 1266). In an interview on [DATE] at 1:00 pm, Certified Nurse Aide (CNA) #13 reported that she had worked at the facility for 8 years and knew Resident #101 well. CNA #13 reported she had been working with Resident #101 on [DATE] and [DATE]. CNA #13 reported that on [DATE] and [DATE], Resident #101 was saying his stomach was hurting, but it wasn't unusual, that he had multiple BM's that were loose that week, that he wore a brief and the stools were loose and running down his legs, no formed stools, and when she questioned Licensed Nurse (LPN # 7) "why she was giving him so much Milk of Magnesia? The nurse said it was protocol." CNA #13 reported that on [DATE], Resident #101 was nauseated and threw up a little bit of phlegm, and he couldn't eat well. CNA #13 said Resident #101's stomach was not going down and that she gave Resident #101 the emesis basin. CNA #13 reported that she charted the BM's in the ADL (activities of daily living) book and on the daily report sheet for the nurse to put in her book. CNA #13 reported that the nurse is supposed to look at the BM list at beginning of shift and then let the CNA's know when the nurse gives a laxative so the CNA's can watch for BM's. CNA #13 reported "(Resident #101) normally his stomach would go down after a BM, but this time is didn't go down, it was firm, he looked like he was nine months pregnant, it was so tight, I couldn't pinch an inch on it." CNA #13 reported that Resident #101 wore a brief and needed assist with incontinence of bowel, that he didn't have sensation to have a BM, that usually if he smelled the BM, he would call the aides to have them clean him up. Review of the Nurse's notes, dated [DATE] (no time), documented by the second shift nurse Registered Nurse (RN) #8 revealed Resident #101's abdomen was distended and firm, he had hypoactive (decreased) bowel sounds, and Milk of Magnesia (a laxative) was given. Review of the Nurse's notes, dated [DATE], (no time), documented by the first shift nurse Licensed Practical Nurse (LPN) #7, revealed Resident #101's abdomen was distended and that Milk of Magnesia was given. Review of the Nurse's notes, dated [DATE] at 1:00 pm, written by LPN #7, revealed Resident #101 still had no bowel movement and his "bowel sounds were hypoactive (decreased) in the upper (abdominal) quads (quadrants)." The noted indicated that Physician #1 was notified and an order for [REDACTED]. Review of the MAR (Medication Administration Record) and TAR (Treatment Administration Record) for [DATE] revealed neither documentation of an order for [REDACTED]. In an interview on [DATE] at 2:20 pm, LPN #7 reported that she normally works the Windsor unit, and she did work [DATE] on the 7 am to 3 pm shift. LPN #7 reported that on [DATE] around 1:00 pm, she called Physician #1 and reported that Resident #101 had been given Milk of Magnesia earlier in the day, had no bowel movement, that Resident #101 had very soft and diminished bowel sounds. LPN #7 reported she asked Physician #1 for an order for [REDACTED].#101's stool had a very thick heavy consistency, brown in color and had no particular smell. LPN #7 reported that after the enema, she returned to check on Resident #101 and he stated "he hurt all over" and "My belly is too big," and said that Resident #101 was rubbing his distended abdomen. LPN #7 reported that she had asked CNA #10 if Resident #101 had any more stools and the CNA #10 reported just a little small one. LPN #7 reported that she knew Resident #101 had a history of [REDACTED].#6, in shift report, Resident #101's bowel status. Review of the Nurse's notes dated [DATE] at 4:00 pm, revealed Resident #101's abdomen was "very hard and taut". The noted indicated Resident #101 had a "normal saline enema and MOM (Milk of Magnesia) on the day shift but no results per day nurse. Unable to hear bowel sounds." Review of the Nurse's notes dated [DATE] at 9:00 pm, revealed Resident #101 still had no result from bowels, fleets enema given, small soft bowel movement observed. In an interview on [DATE] at 3:11 pm, Respiratory Therapist (RRT #20) reported that she "was working on the MSU (Medical Specialty unit) on [DATE] from 6:00 pm to 6:00 am shift, when RN #3 came and got me around 10:00 pm, she came in and asked me if I could assess Resident #101. I went down and seen him, he already had O2 (oxygen) at 4 liters on nasal cannula, the nurses said they put it on him, he had never used oxygen. I talked to him, he was awake and alert, his lungs were clear, he was not gasping for air. His oxygen saturations were in the 90's on 4 liters. I remember his heart rate was very fast, in the 100's, I used the O2 saturation finger clip that has a pulse rate on it as well. (RN #6) was at the nurses' station. (RN #3) and I both told (RN #6) she she needed to call the doctor. I thought since his abdomen was so distended that it was pushing his diaphragm up making it hard for him to breathe. I asked (Resident #101) if his abdomen was hurting, he said yes." Review of the Nurse's notes dated [DATE] at 10:00 pm, written by RN #6 revealed, Resident #101 "complained of difficulty breathing, SPO2 level (oxygen level) 82%-O2 (oxygen) 3 liters per NC ( nasal cannula)"; and Physician #1 was notified and orders were given to transfer to Hospital #1 to rule out ileus (bowel obstruction). Review of the Physician order sheet dated [DATE] at 10:00 pm, revealed a Doctors telephone order from Physician #1, for Resident #101 to "Transfer to Hospital #1 to rule out Ileus." Review of the Nurse's notes dated [DATE] at 10:36 pm, written by RN #6 revealed, Resident #101 "complained of chest pain- v/s (Blood pressure) -,[DATE] P (pulse)- 116 R (Respirations)-24. Respiratory assessed patient, abdomen still very hard and taut-unable to hear bowel sounds." In a telephone interview on [DATE] at 2:55 pm, RN #6 reported that on [DATE] she had worked the 3:00pm-11:00pm shift on the Windsor unit. RN #6 reported that she knew all of the residents on the unit, including Resident #101. RN #6 reported that the day shift nurse, LPN #7 had given shift report and said "we have a problem with (Resident #101), he had not moved his bowels, she (LPN #7) had given (Resident #101) Milk of Magnesia and an enema on the day shift with no results, LPN #7 said if he didn't have results to repeat the enema, and if that didn't have results to call the doctor and send him out. RN #6 reported that she gave Resident #101 some Milk of Magnesia right away. On [DATE], around 5 or 6 pm, RN #6 said she gave Resident #101 a Fleets enema (a brand name of fluid instilled in the bowel to promote a bowel movement) after dinner on [DATE] around 6:30 pm, and at around ,[DATE] pm her and a CNA (CNA #10) went in to check on Resident #101. RN #6 reported that Resident #101 had very small results of brown, soft stool, and that she (RN #6) then listened to Resident #101 bowel sounds and she "could not hear bowel sounds, went and got a different stethoscope and checked bowel sounds again, still could not hear bowel sounds." RN #6 reported that she then went and got RN #3 who was working on the MSU (Medical Specialty unit) as charge nurse, house supervisor for afternoon shift. RN #6 reported, "I wanted a supervisor to give me her opinion, she (RN #3) said she could hear bowel sounds. RN #6 said. "I listened again, I heard no bowel sounds. His abdomen was hard as a board and abdominal girth was big as his chest, for me that was critical. I told (RN #3) I could not hear the sounds, the Resident (#101) asked me if I was gonna send him to hospital, I told him I would call the doctor, and that based on my assessment if he needed to go to hospital, he should, and Resident #101 consented to go to the hospital. "RN #6 reported that around ,[DATE] pm she called Physician #1 and told him of all the interventions she did and that she "suspected a bowel obstruction", and Physician #1 gave orders to send Resident #101 to the hospital. RN #6 reported she and RN # 5 (who was working the same unit) then started to get paperwork around to ship Resident #101 to the hospital. RN #6 reported that RN #3 had then come back on the unit and said, "What are you doing?" RN #6 reported she told RN #3, I am sending him out, and RN #3 said, "No, we are not sending him out" , then she (RN #3) left and came back in and said she (RN #3) had called the DON #2 (Director of Nursing) and she told me to get an abdominal x-ray instead. RN #6 reported she called mobile x-ray for an abdominal x-ray to rule out ileus and that the x-ray tech came about 11:30 pm to take the x-ray. RN #6 reported that the x -ray tech left and never said anything to her about Resident #101. RN #6 reported that she had punched out of work, but she stayed at nurses desk to chart and at around 11:50 pm on [DATE] a code blue (Resident in [MEDICAL CONDITION] requiring CPR) was called, that she had ran down to the room and Respiratory Therapists were already there initiating CPR on Resident #101. When queried why she did not send Resident #101 to the hospital as ordered by the Physician, RN #6 reported that it was DON #2 who overrode the doctor's orders, that her and RN #3 takes instructions from DON #2, and they told me not to send him, to get an x-ray instead." In an interview on [DATE] at 4:45, RN #5 reported she was working on Windsor unit along with RN #6, on the other end of the hallway, and that she was helping RN #6 get transfer papers around to ship Resident #101 to the Hospital, when RN #3 had come down to the nurses desk and said she had called DON #2 and DON #2 said that "we weren't shipping him out". RN #3 said, "were not gonna send him out, were gonna do a flat plate before sending him out to the hospital." RN #5 reported, "If he (Resident #101) were my patient, he(Resident #101) would have been sent out." In an interview on [DATE] at 2:43 pm, RN #3 reported that she had been at the facility since [DATE], that she was the charge nurse on 2nd shift on the MSU unit and utilized as the afternoon shift house supervisor. RN #3 reported that she did not know the Windsor hall or Resident #101, and yes she was working on [DATE] on the 3 pm -11 pm shift. RN #3 reported that around 7 pm-7:30 pm on her way to lunch, RN #6 stopped her in the hall and asked her to come down and assess Resident #101. RN #3 reported that RN #6 had informed her that Resident #101 had a distended belly and she (RN #6) could not hear bowel sounds and asked if RN #3 would come down and assess Resident #101. RN #3 reported she went down to assess Resident #101 and palpated (pushed on with her hands) the belly and it was distended and that she could hear faint bowel sounds. RN #3 reported that RN #6 asked her if she should give Resident #101 another enema, RN #3 reported that she checked the bowel log and it said Resident #101 had had a bowel movement on [DATE] and told RN #6 not to give another enema, but to call the doctor. RN #3 reported at around 10:00 pm she was informed that Resident #101 was having trouble breathing, called DON #2, who told her to have a Respiratory Therapist go in an assess. RN #3 reported she went and got Respiratory Therapist (RRT #20) and that she and RRT #20 assessed Resident #101. RN#3 reported Resident #101 was not in respiratory distress but his abdomen was firm and distended. RN #3 reported that at 10:30 pm she was unable to reach DON #2 on the phone, so she called the Unit Manager of Windsor hall, RN #4, who was nurse on call to inform him of Resident #101's condition. RN #3 reported that RN #4 had instructed her to call the Physician with the findings and obtain an abdominal x-ray. RN #3 then instructed RN #6 to call the doctor and get orders. In a second interview on [DATE] at 3:30 pm, RN #3 reported that on [DATE] at 10:00 pm she was paged overhead to go down to Windsor hall, but instead she had called the unit and talked to RN #6 to find out what was going on. RN #3 reported that she did not go down to Windsor hall and assess Resident #101 right away, but that she took a verbal report from RN #6 over the telephone. RN #3 reported she called DON #2 on the telephone and told her what was going on with Resident #101, based on RN #6's verbal report. RN #3 reported that later on in the shift, around 10:30 pm, she had tried to call DON #2 who did not answer her telephone. RN #3 reported, that she then called RN Unit Manager #4 who was the on- call nurse, and told him of the situation with Resident #101. RN #3 reported she had gotten instructions from RN #4 to get an abdominal x-ray. RN #3 reported that she herself never called the Physician to obtain an order, instead she told RN #6 to call the Physician and get a flat plate. RN #3 reported to the surveyor, "Yes, I feel that it was clear that he (Resident #101) needed to go to the hospital. A nurse does not have the right to override a doctor's order. I told her (RN #6) to call the doctor back." In an interview on [DATE] at 10:25 am, RN #4 reported that he was the Unit Manager on Windsor unit and that on [DATE] he was the nurse on call. RN #4 reported that he had worked the day shift on [DATE] as the unit manager of Windsor hall and he was not made aware of any issues with Resident #101 on that day, until that evening when he received a phone call from RN #3 who was the charge nurse on duty. RN #4 was unsure of the time of the phone call. RN #4 reported that RN #3 "Informed me that they were going to send Resident #101 to the hospital. She read me all of his vitals which were all normal limits. He was not reporting pain. I asked why they wanted to ship him out, they said they had a doctors order." RN #4 stated, "I told (RN #3) not to send him out, to call doctor and order an abdominal x-ray." RN #4 reported that normal protocol for reporting something out of the ordinary that happened after normal business hours was for nurses to call the on call nurse and inform them of any abnormal events of the shift. RN #4 reported, "Yes, I knew he (Resident #101) had a Doctor's order to be shipped to the hospital, I did not have any conversations with the Doctor. I did not have the right to override a doctor's order." Review of the SBAR (Situation, Background, Assessment, Recommendation) Physician Communication and Progress note written by RN #6, dated [DATE] (no time), revealed Resident #101 had a "pulse rate of 116 and respirations of 30, shortness of breath, chest pain and a very distended abdomen." RN #6 documented at 8:00 pm that Physician #1 "was called, and an order was received at that time to send Resident #101 to the hospital. RN #6 documented "that her nursing supervisor instructed her to not send (Resident #101) to the hospital, but to call Physician #1 and get an order for [REDACTED]. Review of the Physician order sheet dated [DATE] at 10:45 pm, revealed a telephone order for an abdominal x-ray to rule out ileus, the order was never signed by the Physician. There was no order to discontinue the transfer to the Hospital. Review of the Radiology Report dated [DATE], (no time), revealed Resident #101 had "Markedly dilated loops of large and probably small bowel. Large amount of stool in the rectum." Conclusion, "Possible large bowel obstruction or sigmoid volvulus. Recommend further evaluation. The patient (Resident #101) is at increased risk for perforated bowel." In an interview on [DATE] at 3:00 pm, Physician #1 reported that he was never called for an x-ray, but that he had given orders for Resident #101 to be sent to the Hospital. Physician #1 stated he did not get another call from the facility until the staff had begun CPR on Resident #101 sometime before midnight. Physician #1 reported that at that time (sometime before midnight), Physician #1 told the facility. "I ordered him to be sent to the hospital why is he still there?" Review of the SBAR Physician Communication and Progress Note, written by RN #6 on [DATE] at 11:45 pm revealed facility staff were unable to obtain Resident #101's vital signs, a "Code Blue" was called, and CPR was initiated. The note indicated CPR was continued until EMS (Emergency Medical Services) took over. In an interview on [DATE] at 3:11 pm, RRT #20 reported "I was there when he (Resident #101) was in full arrest; we initiated CPR until the EMS arrived. I was bagging and the other two RRT's were alternating compressions. He had a lot of vomit in his mouth, it was spraying everywhere, it was watery brown, we grabbed a towel and wiped it up. We had the crash cart and suctioned him out. EMS was there in about 5 minutes; they intubated and took over CPR." Review of the Hospital emergency room record dated [DATE] at 12:35 AM revealed Resident #101 had no vital signs upon arrival and Resident #101 was pronounced dead on [DATE] at 12:55 AM. Review of the Death Certificate for Resident #101, revealed cause of death: A. Abdominal distention due to ischemic bowel with approximate interval between onset and death of ,[DATE] hours. B. [MEDICAL CONDITION] (years) C. [MEDICAL CONDITION] (years) D. osteo[DIAGNOSES REDACTED] (years) On [DATE] at 3:18 pm, Surveyor # notified Administrator #1 of the Immediate Jeopardy that begun on [DATE] and was identified on [DATE] as a result of the facility's failure to attain or maintain the highest practicable physical well-being Resident #101 who had a history of [REDACTED].#101 to the hospital per a physician's order, and Resident #101 went into [MEDICAL CONDITION] on [DATE] at 11:45 pm, required Cardiopulmonary Resuscitation (CPR), and emergency transfer to hospital. Resident #101 subsequently died . On [DATE] the Surveyors confirmed that the facility staff completed the following to remove the Immediate Jeopardy: 1. Resident #101 no longer resides in the facility and transferred to an acute care setting on [DATE]. 2. [DATE]th-[DATE]th 2013, 8 selected Registered Nurses (including Unit managers, MSU charge nurses) completed a head to toe assessment including abdominal assessments, on all residents currently residing in the center, utilizing the monthly summary form for documentation. The completed assessments were reviewed to identify any deviations from the resident's normal status by DON #2. 3. A total of 121 out of 125 resident head to toe assessments were completed from [DATE] through [DATE]. The remaining 4 of the 125 residents received admission assessments on [DATE] or [DATE]. 5 residents were identified with potential change of conditions with the SBAR communication forms completed, and of those 5 changes none were related to the abdominal/bowel assessments. The Nurses completing the monthly summary forms reviewed the bowel monitoring sheets for bowel movements every 3 days as well as completing an abdominal assessment. The residents with admission assessments had abdominal assessments as part of the admission evaluation. 4. The 5 residents identified with potential change of conditions had potential changes addressed utilizing the SBAR form with notification to the physician and follow up completed as ordered. 5. On [DATE], 8 of 8 Nurse Managers/MSU Registered nurses completing the assessments on all residents were trained on accurate completion of the Monthly Summary form and the SBAR by the Facility Educator and DON #2. The limited numbers of nurses were chosen to perform these assessments to decrease variances in assessments. Nurse in charge of resident change of condition shall complete the SBAR communication form prior to notifying the physician and complete follow up as ordered by physician. 6. Effective [DATE], the facility utilized a 24 hour report to communicated changes in condition shift to shift, such as no BM in 2 days. The 24 hour report sheet is reviewed Monday thru Friday in morning meeting and the information is discussed and followed up on by the Interdisciplinary team. 7. Effective [DATE], Nurse Managers on call will be notified of resident change of conditions including significant abdominal distention and or complaints of abdominal pain requiring calls to physicians on weekends and after hours. 8. Effective [DATE], the facility will review new orders especially related to bowels and abdominal assessments in weekday morning meeting. The orders then are validated by the Unit Managers/designee to ensure they are followed. 9. Effective [DATE], the facility will review new/readmission orders [REDACTED]. Any follow up items are entered on the 24 hour report to ensure resolution. The Unit Manager or designee will oversee this process. 10. Education with Licensed Nurses has been provided by DON #2 or the facility educator on [DATE] through [DATE] on the Change of Resident condition, including accurate conveyance of information, SBAR process, and timely follow up to physician's orders. 11. Effective [DATE], education was initiated including nurse and CNA's for Bowel monitoring, immediate notification to nurse of abdominal pain, bowel changes, BM amount and consistency. Education was provide to nurses on use of the revised bowel monitoring sheets, and notifying physician if no BM in 2 days. 12. Effective [DATE], 25 of 68 scheduled licensed nurses have received this education. Nurses not educated by [DATE] will not resume work until such education has been received. 13. The facility procedure titled, "Change of condition of the Resident":, and the SBAR tool has been reviewed on [DATE] by the Quality Assurance Committee and deemed appropriate. 14. Effective [DATE], new hire nurses will receive education on this plan during their orientation process by the facility educator. 15. DON #2 and Nursing Home Administrator #1 are responsible for obtaining and sustaining compliance of this plan. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at the scope of widespread and a severity of no actual harm, but potential for more than minimal harm, which is not Immediate Jeopardy, due to all staff had not been educated and sustained compliance had not been verified by the State Agency. ( )

This citation pertains to intake #MI 374 Based on interview and record review the facility Medical Director failed to implement resident care policies that involve the use of Medical Students in the facility in 1 (#109) of 21 sampled residents, from a total of 21 sampled residents, resulting in the lack of follow up with medical recommendations (laboratory draw) made when Medical Student (MS) #3 recommended laboratory draws to monitor [MEDICATION NAME] (blood thinner) and Resident #103 suffered a [MEDICAL CONDITION]. Findings include: Review of Resident #109's face sheet revealed she was an [AGE] year old female, admitted to the facility on [DATE] from an acute care hospital with the following diagnoses; post [MEDICAL CONDITION] with Open Reduction Internal Fixation (ORIF-a method of surgically repairing a fractured bone), Muscle Weakness, Difficulty in Walking, Dehydration, and [MEDICAL CONDITION] (weak heart). Review of Resident #109's facility History and Physical (H&P), dated 12-14-12 at 3:13 PM, revealed Resident #109 was assessed by the attending physician's 3rd year medical student (MS #3). The H&P revealed that, when Resident #109 was admitted , she was taking [MEDICATION NAME] and [MEDICATION NAME] for [MEDICAL CONDITION] Fibrillation (irregular heart beat). MS #3 documented "d/c (discontinue) [MEDICATION NAME]?" The H&P revealed MS #3's plan was for Resident #109 to have a PT/INR (lab test to monitor [MEDICATION NAME] levels) drawn in the "AM" (12-15-12). The H&P was not co-signed by the attending physician. During an interview with Licensed Practical Nurse (LPN) #38, on 1-30-13 at 10:05 AM, LPN #38 reviewed the admission orders [REDACTED]#3) did not order a PT/INR. Review of the medical record revealed there were no physician's orders, laboratory slips or documentation on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview on 1-29-13, at 2:50 PM, PH #2 reviewed MS #3's History and Physical note on Resident #109. The Surveyor noted that PH #2 did not sign the History and Physical written by MS #3 and PH #2 explained he does not sign the notes until they are reviewed by medical records and he would not have read the note because it is his practice to verbally review the case with the medical student. The Surveyor asked if the medical students are able to write medical orders on the nursing home residents; PH #2 stated medical students do not write orders. The Surveyor asked PH #2 why he did not order a PT/INR for Resident #109 on admission as the MS#3 had written in her note. PH #2 said he verbally told Registered Nurse (RN) #35. PH #2 stated that he is frequently unable to locate his residents charts while he is in the facility and has to rely on the nurses to write the orders. PH #2 reviewed his progress notes he dictated on Resident #109 during her 14 day stay. The Surveyor asked why PH#2 did not order a PT/INR when he was in to see Resident #109 and he explained he may not have had access to her chart and was not aware she did not have a PT/INR ordered. The Surveyor read PH #2 the nurses note for Resident #109, dated 12-22-12 that read, "called PH #2 for stop date on [MEDICATION NAME], didn't answer call but I left a message waiting for return call" that was signed by RN #36. The Surveyor asked why PH #2 did not return the telephone call and he responded he tries to return every call but it is not unusually for the telephone to ring 25 to 30 times and he is not able to connect with every person calling him. During a telephone interview on 2/1/13 at 11:15 AM with MS #3 the Surveyor asked MS #3 if she recalled doing the History and Physical on Resident #109. MS #3 recalled she wrote a question mark next to [MEDICATION NAME] so that (PH #2) would look at Resident #109's [MEDICATION NAME] order. The Surveyor asked MS #3 if she wrote the orders for Resident #109; MS #3 reported that medical students are not able to write orders in the nursing home. The Surveyor asked MS #3 if the Physician needs to co-sign her note and she responded, "yes", but did not recall seeing (PH #2) sign her note. During an interview on 1-29-13, at 4:00 PM, the Surveyor asked Director of Nursing ((DON) #2 what Medical Students were allowed to do in the facility. DON #2 responded she was not sure what the Medical Students were allowed to do. The Surveyor asked DON #2 for a copy of the policy that showed Medical Students duties and limitations. DON #2 was unable to locate any policy. During an interview with the Nursing Home Administrator (NHA) #1, the Surveyor asked NHA #1 for the facility Medical Student Policy and the NHA responded that the Medical Director did not have a written policy. ( )

This citation pertains to intake #MI 870 Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices in 1 of 21 sampled Residents (#112), of a total of 21 sampled residents, resulting in Resident #112 falling and sustaining a left fractured clavicle. Findings include: According to Resident #112's Face Sheet, he was a [AGE] year old male admitted to the facility on [DATE]. Resident #112 had the following Diagnoses: [REDACTED]. Review of Resident #112's Minimum Data Set date 11-30-12, section C, scored Resident #112's cognitive skills for daily decision making at 2 (Moderately impaired - decisions poor; cues/supervision required) Review of Resident #112 Fall Assessment, dated 11-30-12, scored Resident #112 at 12 (Score of 10 or higher may represent High Risk). Review of Resident #112's fall care plan dated, 12-3-12 revealed he required assist of 1-2 for ambulation and transfers. Review of Resident #112's Total Plan of Patient Care, no date documented, revealed Resident #112 required a wheelchair, cane or walker and assist of 1 person. Review of Resident #112's Incident/accident report dated 12-4-12, at 4 AM, revealed he was observed walking by himself and falling to the floor. He complained of left shoulder pain and an x-ray was taken. His level of consciousness was alert and oriented times 2 with confusion at times. The only safety device in use was a call light that he did not use. Review of Resident #112's Radiology Report dated 12-4-12 documented under conclusion, "Faint lucent line at the outer end of the clavicle and the acromion process of the scapula and an incomplete fracture cannot be excluded". Review of a progress note on the back side of the SBAR Note for Resident #112 dated 12-4-12 at 12:30 PM documented that the x-ray results were back, Physician # 2 was notified and ordered Resident to be sent to the hospital emergency room for a CT scan. Review of the Fall Investigation report for Resident # 112 revealed when Resident #112 was questioned about how he felt prior to the fall he stated, "I don't remember. I was coming from the bathroom." Documented under recommendation to prevent further falls was "utilize sensor alarm pads to wheelchair and bed: reorient to call light and use frequently (despite cognitive score of 2)." Under supervisor review was documented, "Resident was self-transferring to bathroom and back when he tripped and fell against door jam. Nurse was coming to his aid and managed to protect head as resident fell ." Review of the Nurse's Notes for Resident #112, entered as "Late entry" 12-5-12 at 8 PM revealed on 12-4-12 at 12:30 AM Resident #112 was observed out of bed, self -ambulating (walking), without stand-by assist at 12:30 AM, 1:45 AM, 2:30 AM, 3:15 AM. Resident #112 did not use his call light when he was observed out of bed each time. Each time he was observed out of bed he was assisted to the toilet and or the bed and instructed to use his call light. All shift, Resident #112's bed was in low position and his call light was in reach. According to the nurses' note, the Certified Nurses Aides (CNA's) were instructed to observe Resident #112 closely until the morning when sensor pad alarms could be place on his bed and wheelchair. The note was signed by Licensed Practical Nurse (LPN) # 33. Review of the 5 day investigation summary for Resident # 112 dated 12-10-12 revealed that he was promptly sent to the emergency room after the x-ray results were in and Resident # 112 was admitted to the hospital for another condition and was place on hospice care. During a telephone interview on 2-6-13, at 10:55 AM, LPN # 33 recalled caring for Resident #112 on 12-4-12 when he fell . LPN #33 stated she went to the charge nurse for help caring for Resident #112 and was not provide any assistance. LPN # 33 said safety equipment like bed and chair alarms were not readily available. The Surveyor asked LPN #33 if she did anything to increase Residents #112 supervision and safety since he was not responding to using his call light after she educated him 4 times. LPN #33 said she asked the CNA's for help but they did not know where to get equipment. LPN #33 said she did not assign any CNA specific times or criteria to increase Residents #112 supervision, just an open recommendation to all CNA's working to increase monitoring Resident #112. LPN # 33 explained she was provided education after the incident as to the location of the key for the equipment and she should call her supervisor at home if the unit manager is unable to help. ( & )

THIS CITATION HAS TWO DEFICIENT PRACTICES DEFICIENT PRACTICE #1. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE AND MAINTAIN BED RAIL EQUIPMENT IN GOOD WORKING ORDER TO PREVENT ACCIDENTS FOR ONE (#702) OF ONE RESIDENTS REVIEWED FOR SAFETY DEVICES OUT OF A TOTAL OF 24 SAMPLED RESIDENTS, RESULTING IN A FALL WITH HEAD INJURY, HEMATOMA, BACK OF HEAD PAIN, CONTUSIONS OF THE RIGHT HAND AND LEFT SHOULDER. FINDINGS INCLUDE: REVIEW OF RESIDENT #702'S CLINICAL RECORD DOCUMENTED THE RESIDENT WAS readmitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. ACCORDING TO THE MOST RECENT QUARTERLY MINIMUM DATA SET ((MDS) dated [DATE], RESIDENT #702 HAD MODERATELY IMPAIRED COGNITION, WAS TOTALLY DEPENDENT ON STAFF FOR ALL ACTIVITIES OF DAILY LIVING INCLUDING BED MOBILITY REQUIRING TWO PLUS PHYSICAL ASSISTANCE. THERE WAS NO HISTORY OF FALLS SINCE ADMISSION. THE RESIDENT DID NOT HAVE BED RAILS. REVIEW OF THE RESIDENT'S, "SELF CARE DEFICIT" CARE PLAN, DATED 8/31/12, DOCUMENTED :-PROVIDE SAFETY MEASURES, 1/2 SIDE RAILS, TWO PERSON ASSIST TO TURN AND REPOSITION. REVIEW OF "RISK FOR FALLS" CARE PLAN, DATED 9/5/12, DOCUMENTED AS FOLLOWS: "...GRAB BARS TO HELP WITH POSITIONING AS NEEDED. REVIEW OF NURSING NOTE DATED 11/27/12 AT 11:00 P.M., DOCUMENTED : "PATIENT FOUND ON FLOOR. PATIENT BAGGED WAS UNABLE TO CIRCUIT. VITAL SIGNS DONE. NEUROCHECKS STARTED. CALLED DOCTOR AND RESIDENT SENT OUT TO HOSPITAL." REVIEW OF THE "INCIDENT/ACCIDENT" REPORT FOR RESIDENT #702 DATED ON 11/27/12 AT 10:05 P.M., "RESIDENT TURNED TO RIGHT SIDE TO BE CLEANED UP FROM BOWEL MOVEMENT. BED RAIL ON RIGHT SIDE CAME APART FROM BED AND SLID ON FLOOR." TYPE OF INJURY: HEMATOMA, SWELLING BACK OF HEAD PAIN. ENVIRONMENTAL FACTORS AT TIME OF FALL: "EQUIPMENT." ADDITIONAL COMMENTS: EQUIPMENT CHECKED PER MAINTENANCE DIRECTOR. 1/2 SIDE RAILS DISCONTINUED. RECOMMENDATIONS TO PREVENT FURTHER FALLS: "TWO ASSIST FOR ALL CARE". REVIEW OF POST FALL INVESTIGATION DATED 11/28/12, DOCUMENTED, "PATIENT WAS IN BED WITH TWO NURSE ASSISTANTS (CNA) PERFORMING PERICARE. RESIDENT WAS ROLLED TO HIS RIGHT SIDE PER TWO CNA'S. CNA "R" STATED BED RAIL BROKE AND SHE ATTEMPTED TO LOWER RESIDENT TO THE FLOOR. RESIDENT DID NOT DECANNULATE. RESIDENT WAS TRANSFERRED TO emergency room FOR EVALUATION. MAINTENANCE DIRECTOR ASSESSED SIDERAILS AND DETERMINED A "PIN" WAS MISSING FROM SIDERAIL. ONE HALF SIDERAILS DISCONTINUED PER MEDICAL DOCTOR ORDER. CARE PLANS UPDATED. NEURO CHECKS CONTINUE. RESIDENT FAMILY NOTIFIED. FALL ASSESSMENT UPDATED. PAIN EVALUATION UPDATED. BED TO REMAIN IN LOWEST POSITION WITH FLOOR MATS TIMES TWO AS PRECAUTION. BED TO BE EVALUATED TO DETERMINE APPROPRIATE WIDTH." REVIEW OF THE HOSPITAL DISCHARGE INSTRUCTION NOTES FOR RESIDENT #702, DATED 11/28/12, NOTED: "HEAD INJURY. FALL. CONTUSION RIGHT HAND AND LEFT SHOULDER." INSTRUCTIONS: "HEAD INJURY PRECAUTIONS: AN OBSERVER MUST CHECK ON THE PATIENT FREQUENTLY FOR THE NEXT 24 HOURS TO CONFIRM THAT THE PATIENT RESPONDS AS EXPECTED, IS NOT CONFUSED, HAS NO NEW WEAKNESS OR NUMBNESS, AND HAS NO OTHER PROBLEMS. ON 12/7/12 AT 10:30 A.M., DURING A TELEPHONE INTERVIEW, CERTIFIED NURSE ASSISTANT (CNA) "S" WAS QUERIED REGARDING RESIDENT #702'S FALL. CNA "S" STATED THAT SHE WAS WORKING ON THE AFTERNOON SHIFT OF 11/27/12. THE RESIDENT WAS ASSIGNED TO HER. NEAR THE END OF THE SHIFT, THE RESIDENT NEEDED TO BE CLEANED. WE WERE CLEANING HIM. THE RESIDENT HAD BEEN TURNED ON HIS RIGHT SIDE. THE RESIDENT WAS FACING CNA "R". THE SIDE RAIL WAS MIDWAY UP. THERE WAS A PILLOW BETWEEN THE RESIDENT AND THE SIDE RAIL. THE RESIDENT'S BOTTOM WAS "RAW" HE WAS BLEEDING. I WANTED TO CHANGE THE SHEETS, THE FITTED SHEET AND THE DRAW SHEETS. I STEPPED AWAY AND WENT TO THE RESIDENT'S CLOSET TO GET A BRIEF. CNA "R" STARTED SCREAMING "HELP" THE BED RAIL SNAPPED. WE LOWERED THE RESIDENT TO THE GROUND. I STEPPED OUT THE ROOM AND CALLED FOR HELP FROM NURSING AND RESPIRATORY. ON 12/7/12 AT 11:15 A.M., DURING A TELEPHONE INTERVIEW, CNA "R" WAS QUERIED REGARDING RESIDENT #702'2 FALL. CNA "R" STATED "I WAS WORKING ON THE AFTERNOON SHIFT ON 11/27/12. I WAS HELPING CNA "S". WE TURNED THE RESIDENT ON HIS RIGHT SIDE. AFTER WIPING HIM THERE WAS A 'POP'. THE BED RAIL CAME OFF. WE LOWERED HIM TO THE FLOOR. I GRABBED THE TUBING TO KEEP HIS AIRWAY. WE WENT TO GET A HOYER LIFT AFTER RESPIRATORY RESPONDED RIGHT AWAY. I THOUGHT HIS BED WAS SMALL. THEY HAVE SINCE PUT HIM IN A BIGGER BED NOW." ON 12/7/12 AT 1:20 P.M., DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING REGARDING RESIDENT #702'S FALL ON 12/27/12, WHEN QUERIED STATED "I WASN'T HERE. SOMEONE ELSE DID THE INVESTIGATION." REVIEW OF THE FACILITY'S UNDATED, "FALL PREVENTION PROGRAM", DOCUMENTED AS FOLLOWS: "ALL RESIDENTS WILL BE COMPREHENSIVELY ASSESSED AND REVIEWED ON AN ONGOING BASIS TO DETERMINE POTENTIAL FOR INJURY, MANAGEMENT STRATEGIES AND THE USE OF RESTRICTIVE PRACTICES OR DEVICES."( ) DEFICIENT PRACTICE #2 BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO MONITOR THE USE OF POWER STRIP CORDS AND EXTENSION CORDS IN THE FACILITY, IN 12 OF 70 RESIDENT ROOMS (#'S 118, 122, 124, 149, 155, 161, 163, 168, 170, 211, 213, AND 216). THIS HAD THE POTENTIAL TO AFFECT SIX OF 24 SAMPLED RESIDENTS (#'S 701, 702, 703, 708, 710, AND 717), AND 20 SUPPLEMENTAL SAMPLED RESIDENTS (#'S 21, 22, 29, 30, 31, 36, 39, 53, 57, 58, 69, 71, 72, 80, 86, 87, 97, 98, 100, AND 105), RESULTING IN THE POTENTIAL FOR ELECTRICAL FIRES. FINDINGS INCLUDE: DURING THE INITIAL TOUR OF THE FACILITY ON 12/4/12 AT 9:30 A.M., THE FOLLOWING WAS OBSERVED: ROOM 118: THERE WAS AN EXTENSION CORD IN USE FOR A TELEVISION. ROOM 122: THERE WAS A POWER STRIP CORD IN USE FOR A TUBE FEEDING PUMP. ROOM 124: THERE WAS A POWER STRIP CORD IN USE FOR A TUBE FEEDING PUMP. ROOM 149: THERE WAS AN EXTENSION CORD IN USE FOR A TELEVISION. ROOM 155: THERE WAS A POWER STRIP CORD IN USE FOR A BED. ROOM 161: THERE WAS A POWER STRIP CORD IN USE FOR AN AIR MATTRESS. ROOM 163: THERE WAS A POWER STRIP CORD IN USE FOR A NEBULIZER (A MACHINE USED TO ADMINISTER MEDICATION IN THE FORM OF A MIST), A SUCTION MACHINE, AND A HUMIDIFIER. ROOM 168: THERE WAS A POWER STRIP CORD IN USE FOR AN AIR MATTRESS. ROOM 170: THERE WAS A POWER STRIP CORD IN USE FOR A TUBE FEEDING PUMP AND A TELEVISION. ROOM 211: THERE WAS A POWER STRIP CORD IN USE FOR AN OXYGEN CONCENTRATOR. ROOM 213: THERE WAS A POWER STRIP CORD IN USE FOR A SUCTION MACHINE, AN AIR COMPRESSOR AND A BED. ROOM 216: THERE WAS A POWER STRIP CORD IN USE FOR A NEBULIZER, A PULSE OXYGEN MACHINE, A HUMIDIFIER, AND A SUCTION MACHINE. DURING AN INTERVIEW ON 12/5/12 AT 2:00 P.M., THE MAINTENANCE SUPERVISOR STATED THAT EXTENSION CORDS WERE NOT TO BE USED IN THE RESIDENT'S ROOMS. THE MAINTENANCE SUPERVISOR FURTHER CONFIRMED THAT RESIDENT CARE EQUIPMENT WAS TO PLUGGED DIRECTLY INTO THE WALL OUTLETS, NOT INTO POWER STRIP CORDS. WHEN QUERIED ABOUT MONITORING POWER STRIP USAGE IN THE FACILITY, THE MAINTENANCE SUPERVISOR STATED THAT THERE WAS NO REAL PROGRAM FOR MONITORING, AND WAS UNABLE TO PROVIDE WRITTEN DOCUMENTATION THAT POWER STRIPS USAGE WAS BEING MONITORED. REVIEW OF THE FACILITY'S POLICY, "POWER STRIP USAGE POLICY", UNDATED, REVEALED THAT THE POLICY DID NOT ADDRESS THE USE OF RESIDENT CARE EQUIPMENT WITH POWER STRIP CORDS, OR A MONITORING SCHEDULE FOR POWER STRIP USAGE. ( )

THIS CITATION PERTAINS TO INTAKE NUMBERS MI 717, MI 776, MI 538. BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT FALLS IN 1 OF 5 SAMPLED RESIDENTS (#108), IN A TOTAL OF 5 RESIDENTS SAMPLED WITH FALL RISKS, RESULTING IN RESIDENT #108 EXPERIENCING A FALL DURING A TWO-PERSON TRANSFER FROM HER WHEELCHAIR TO HER BED, AND SUSTAINING A LACERATION, TO THE BONE, OF HER LEFT LOWER EXTREMITY. FINDINGS INCLUDE: THE FACE SHEET REVEALED RESIDENT #108 WAS AN [AGE] year OLD WOMAN WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM DATA SETS ((MDS) dated [DATE], RESIDENT #108 WAS SEVERELY COGNITIVELY IMPAIRED AND DEPENDENT ON FACILITY STAFF FOR ACTIVITIES OF DAILY LIVING (ADL'S), INCLUDING TRANSFERS (MOVEMENTS FROM SURFACE TO SURFACE). THE FALL RISK assessment dated [DATE] ASSESSED RESIDENT #108 AT HIGH RISK FOR FALLS. THE TRANSFER ACTIVITIES POLICY AND PROCEDURE (UNDATED), AS PROVIDED TO THE STATE SURVEYOR ON 6/15/2012 AT 10:10 A.M. BY DIRECTOR OF NURSING #2 AS THE CURRENT POLICY AND PROCEDURE FOLLOWED BY THE FACILITY, SPECIFIED TRANSFERS WERE TO BE PERFORMED WITH USE OF A GAIT BELT. THE INCIDENT AND ACCIDENT REPORT (UNDATED), AND THE INJURY INVESTIGATION DATED 4/23/2012 (UNTIMED), REVEALED RESIDENT #108 EXPERIENCED A LACERATION OF HER LEFT LOWER LEG ON 4/20/2012 AT 9:20 A.M., DURING A TRANSFER VIA TWO- PERSON ASSIST, FROM HER WHEELCHAIR TO HER BED. THE RESIDENT WAS REPORTED AS SENT TO A LOCAL HOSPITAL FOR EVALUATION. THE EMERGENCY DEPARTMENT OBSERVATION/ASSESSMENT NOTE DATED 4/21/2012 AT 12:10 A.M., DOCUMENTED RESIDENT #108 SUSTAINED A LEFT LOWER EXTREMITY "DEEP SKIN LACERATION TO THE BONE" WHICH "REQUIRED MULTI-LAYER CLOSURE" WITH SUTURES. DURING AN INTERVIEW ON 6/14/2012 AT 4:25 P.M., REGISTERED NURSE #5 SAID SHE HAD BEEN SUMMONED TO RESIDENT#108'S ROOM AFTER HER FALL AND, "SHE WAS UNABLE TO TELL ME WHAT HAPPENED. SHE HAD AN OPEN WOUND ON HER LEFT LOWER EXTREMITY. HER DERMAL FLAP WAS TORN AND WITH A DEEP CUT; I COULD SEE OPEN MUSCLE EXPOSED. THERE WAS NO HOYER LIFT IN THE ROOM. I'D CARE FOR THIS RESIDENT A LOT OF TIMES BEFORE. SHE WAS FLACCID WITH VERY WEAK EXTREMITIES. SHE HAD NO CONTROL OVER HER LEGS. SHE WOULD NEED 3 PEOPLE TO TRANSFER HER; NOT SAFE FOR ANY LESS THAN 3 PEOPLE. BOTH OF HER LEGS WERE FLACCID. BOTH OF THE AIDES WERE NEW. SHE SHOULD'VE USED THE HOYER LIFT (MECHANICAL LIFT). A TWO-PERSON ASSIST WAS UNSAFE FOR HER.; SHE WAS MORBIDLY OBESE AND FLACCID AND DEAD WEIGHT." DURING AN INTERVIEW ON 6/15/2012 AT 8:50 A.M., CNA #8 SAID, "I'VE CARE FOR HER (RESIDENT #108) A LOT. SHE NEEDED HELP TO GET OUT OF BED. SHE COULDN'T BEAR WEIGHT AT ALL ON BOTH OF HER LEGS. WE LITERALLY HELD HER UP; SHE WAS DEAD WEIGHT. I WAS ASSISTING SOMEONE ELSE. HER ASSIGNED CNA WAS NEW; ONLY THERE A WEEK. I DON'T REMEMBER THAT WE USED A BELT ON HER. NOT EVERY RESIDENT HAD A GAIT BELT. I DIDN'T HAVE MY GAIT BELT THAT DAY. WE TRANSFERRED HER FROM HER WHEELCHAIR TO HER BED. ONE OF US WAS ON EITHER SIDE OF HER. I HAD A HOLD OF HER BACK OF HER PANTS AND UNDER HER SHOULDER. WE WENT TO PIVOT TRANSFER HER AND HER LEG SLIPPED FORWARD TOWARD ME. SHE WAS OBESE, A GOOD SIZED WOMAN. THERE WASN'T A THIRD PERSON TO CONTROL HER LEGS. I SAW HER LEG WAS CUT. THE RESIDENT DIDN'T SEEM TO REALIZE WHAT HAPPENED TO HER. I CALLED OUT FOR A NURSE. I WAS FIRED. I THINK IT WAS BECAUSE OF THIS INCIDENT." DURING AN INTERVIEW ON 6/15/2012 AT 9:10 A.M., CNA #9 SAID, "SHE (RESIDENT #108) WAS VERY CONFUSED. I'D ONLY TAKEN CARE OF HER TWICE BEFORE. SHE COULDN'T STAND. THE DAY THE RESIDENT fell , NEITHER ME OR THE OTHER AIDE HAD GAIT BELTS. I WAS GETTING THE RESIDENT INTO BED FROM HER WHEELCHAIR WITH THE HELP OF ANOTHER AIDE (CNA #8). WE DIDN'T PUT A GAIT BELT ON HER. SHE WAS PRETTY HEAVY. SHE WAS HEAVY FOR ME. I DIDN'T SEE HER CARE CARD. I WASN'T TOLD I COULD USE A LIFT WITH HER. SHE SHOULD'VE BEEN A LIFT, NOT A TWO PERSON ASSIST; SHE WAS TOO WEAK TO STAND. HER LEGS WERE IN BAD CONDITION AND IT WOULD'VE BEEN EASIER AND SAFER FOR HER TO USE THE LIFT. I HELD ONTO HER, ONE HAND ABOVE HER SHOULDER, AND THE OTHER ON THE WAISTBAND OF THE PANTS SHE WORE. WE STOOD HER UP. HER LEGS FLEW OUT FROM BENEATH HER. I DON'T KNOW IF HER LEG HIT THE WHEELCHAIR. SHE DROPPED TO THE BED. SHE DIDN'T EVEN KNOW SHE'D BEEN CUT. IT WAS A DEEP CUT, DOWN TO MUSCLE." DURING AN INTERVIEW ON 6/15/2012 AT 10:45 A.M., PHYSICAL THERAPIST #11 SAID, "THE RESIDENT (#108) WAS LAST SCREENED BY THERAPY ON 12/7/2011. HER FUNCTIONAL LEVEL FOR TRANSFERS WAS DEPENDENT, AND SHE WAS A HOYER LIFT TRANSFER. SHE WAS COMPLETELY DEPENDENT WITH TRANSFERS. IT WASN'T SAFE FOR THIS RESIDENT TO DO A TWO-PERSON ASSIST TRANSFER; SHE NEEDED A MECHANICAL LIFT TRANSFER, ONLY." ACCORDING TO THE REHABILITATION SCREEN DATED 12/7/2011, RESIDENT #108 WAS ASSESSED AS DEPENDENT FOR TRANSFERS (FULL STAFF PERFORMANCE FOR ACTIVITY) WITH UTILIZATION OF A HOYER LIFT (MECHANICAL LIFT). DURING AN INTERVIEW ON 6/22/2012 AT 1:25 P.M., NURSING HOME ADMINISTRATOR #1 SAID IT WAS HIS EXPECTATION FACILITY STAFF "ENSURE THE SAFETY OF MY RESIDENTS, FALL INTERVENTIONS ARE IN PLACE, OPERATING, USED."

THIS CITATION PERTAINS TO INTAKE NUMBERS MI 717, MI 776, MI 538. BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO REVISE CARE PLANS TO REFLECT CHANGES IN RESIDENT STATUS IN 1 OF 5 SAMPLED RESIDENTS (#108), IN A TOTAL OF 5 RESIDENTS SAMPLED WITH FALL RISKS, RESULTING IN RESIDENT #108 EXPERIENCING A FALL DURING A TWO-PERSON TRANSFER FROM HER WHEELCHAIR TO HER BED, AND SUSTAINING A LACERATION, TO THE BONE, OF HER LEFT LOWER EXTREMITY. FINDINGS INCLUDE: THE FACE SHEET REVEALED RESIDENT #108 WAS AN [AGE] year OLD WOMAN WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM DATA SETS ((MDS) dated [DATE], RESIDENT #108 WAS SEVERELY COGNITIVELY IMPAIRED AND DEPENDENT ON FACILITY STAFF FOR ACTIVITIES OF DAILY LIVING (ADL'S), INCLUDING TRANSFERS (MOVEMENTS FROM SURFACE TO SURFACE). THE FALL RISK assessment dated [DATE] ASSESSED RESIDENT #108 AT HIGH RISK FOR FALLS. THE INCIDENT AND ACCIDENT REPORT (UNDATED), AND THE INJURY INVESTIGATION DATED 4/23/2012 (UNTIMED), REVEALED RESIDENT #108 EXPERIENCED A LACERATION OF HER LEFT LOWER LEG ON 4/20/2012 AT 9:20 A.M., DURING A TRANSFER VIA TWO- PERSON ASSIST, FROM HER WHEELCHAIR TO HER BED. THE RESIDENT WAS REPORTED AS SENT TO A LOCAL HOSPITAL FOR EVALUATION. THE EMERGENCY DEPARTMENT OBSERVATION/ASSESSMENT NOTE DATED 4/21/2012 AT 12:10 A.M., DOCUMENTED RESIDENT #108 SUSTAINED A LEFT LOWER EXTREMITY "DEEP SKIN LACERATION TO THE BONE" WHICH "REQUIRED MULTI-LAYER CLOSURE" WITH SUTURES. DURING AN INTERVIEW ON 6/15/2012 AT 9:10 A.M., CNA #9 SAID, "SHE (RESIDENT #108) WAS VERY CONFUSED. I'D ONLY TAKEN CARE OF HER TWICE BEFORE. SHE COULDN'T STAND. THE DAY THE RESIDENT fell , NEITHER ME OR THE OTHER AIDE HAD GAIT BELTS. I WAS GETTING THE RESIDENT INTO BED FROM HER WHEELCHAIR WITH THE HELP OF ANOTHER AIDE (CNA #8). WE DIDN'T PUT A GAIT BELT ON HER. SHE WAS PRETTY HEAVY. SHE WAS HEAVY FOR ME. I DIDN'T SEE HER CARE CARD. I WASN'T TOLD I COULD USE A LIFT WITH HER. SHE SHOULD'VE BEEN A LIFT, NOT A TWO PERSON ASSIST; SHE WAS TOO WEAK TO STAND. HER LEGS WERE IN BAD CONDITION AND IT WOULD'VE BEEN EASIER AND SAFER FOR HER TO USE THE LIFT. I HELD ONTO HER, ONE HAND ABOVE HER SHOULDER, AND THE OTHER ON THE WAISTBAND OF THE PANTS SHE WORE. WE STOOD HER UP. HER LEGS FLEW OUT FROM BENEATH HER. I DON'T KNOW IF HER LEG HIT THE WHEELCHAIR. SHE DROPPED TO THE BED. SHE DIDN'T EVEN KNOW SHE'D BEEN CUT. IT WAS A DEEP CUT, DOWN TO MUSCLE." DURING AN INTERVIEW ON 6/15/2012 AT 10:45 A.M., PHYSICAL THERAPIST #11 SAID, "THE RESIDENT (#108) WAS LAST SCREENED BY THERAPY ON 12/7/2011. HER FUNCTIONAL LEVEL FOR TRANSFERS WAS DEPENDENT, AND SHE WAS A HOYER LIFT TRANSFER. SHE WAS COMPLETELY DEPENDENT WITH TRANSFERS. IT WASN'T SAFE FOR THIS RESIDENT TO DO A TWO-PERSON ASSIST TRANSFER; SHE NEEDED A MECHANICAL LIFT TRANSFER, ONLY." THE SELF CARE DEFICIT CARE PLAN, INITIATED 8/11/2011, SPECIFIED RESIDENT #108 "REQUIRES ASSISTANCE WITH TRANSFERS, TWO PERSON ASSIST." THE CARE PLAN WAS NOT REVIEWED/REVISED UNTIL 4/22/2012 TO INCLUDE "MAY USE HOYER LIFT IF RESIDENT UNABLE TO BEAR WEIGHT." THE REVISION CAME TWO DAYS AFTER THE RESIDENT EXPERIENCED A FALL AND SUSTAINED A LACERATION TO HER LEFT LOWER EXTREMITY ON 4/20/2012. DURING AN INTERVIEW ON 6/22/2012 AT 1:25 P.M., NURSING HOME ADMINISTRATOR #1 SAID IT WAS HIS EXPECTATION FACILITY STAFF "ENSURE THE SAFETY OF MY RESIDENTS."

THIS CITATION PERTAINS TO INTAKE NUMBER MI 296. BASED ON OBSERVATION, INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO ASSESS AND MONITOR 1 OF 5 SAMPLED RESIDENTS (#107) WHO EXPERIENCED FALLS, IN A TOTAL SAMPLE OF 5 RESIDENTS WHO HAD EXPERIENCED FALLS, RESULTING IN DELAY OF CARE FOR RESIDENT #107 WHO fell on [DATE] AT 2:50 P.M., RECEIVED NO ASSESSMENT OF HER RIGHT LOWER EXTREMITY, AND WAS diagnosed BY EMERGENCY DEPARTMENT PERSONNEL ON 5/12/2012 WITH A RIGHT SUPRACONDYLAR [MEDICAL CONDITION]. FINDINGS INCLUDE: THE FACE SHEET REVEALED RESIDENT #107 WAS AN [AGE] year OLD WOMAN WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. ACCORDING TO THE FALL RISK assessment dated [DATE], RESIDENT #107 WAS AT HIGH RISK FOR FALLS. THE MINIMUM DATA SETS ((MDS) dated [DATE] REVEALED RESIDENT #107 WAS SEVERELY COGNITIVELY IMPAIRED, WAS DEPENDENT ON FACILITY STAFF FOR ACTIVITIES OF DAILY LIVING (ADL'S), AND UTILIZED SAFETY MECHANISMS THAT INCLUDED A LOW BED, MATS PLACED ON EACH SIDE OF HER BED, AND USE OF BED BOLSTERS. ACCORDING TO THE INCIDENT AND ACCIDENT REPORT DATED 5/4/2012 AT 2:50 P.M., RESIDENT #107 WAS FOUND ON HER RIGHT SIDE, PARTIALLY OUT OF HER BED, WITH HER HEAD ON THE FLOOR AND HER FEET IN THE BED. IT WAS REPORTED RADIOLOGIC STUDIES DONE ON HER SKULL AND RIGHT UPPER EXTREMITY WERE NEGATIVE. THE RESIDENT WAS DOCUMENTED TO HAVE CONTINUED CARE AT THE FACILITY AFTER HER FALL. DURING AN INTERVIEW ON 6/18/2012 AT 12:00 P.M., REGISTERED NURSE #22 SAID, "A CNA TOLD ME THE RESIDENT (#107) WAS ON THE FLOOR ON 5/4/2012. I FOUND THE RESIDENT LAYING HALF IN AND HALF OUT OF THE BED WITH HER HEAD ON THE FLOOR MAT; SHE HAD CRAWLED OVER THE BED BOLSTER. THE BED WAS LOW. HER LEGS WERE ALL TWISTED; I DIDN'T REPORT THIS TO HER DOCTOR. I WAS ASSIGNED TO HER ON 5/7/2012, 5/8/2012, 5/9/2012, AND 5/10/2012. I ALSO WORKED WITH AN ORIENTEE (IDENTIFIED AS LPN #24) ON 5/9/2012 AND 5/10/2012. SHE MAY HAVE DONE ASSESSMENTS ON THE RESIDENT AND MAY HAVE SEEN THE RESIDENT'S RIGHT KNEE. I ONLY LOOKED AT HER FEET AND ANKLES ON DAYS I HAD HER; THEY LOOKED OK. WE DO PHYSICAL ASSESSMENTS ON RESIDENTS LIKE HER (RESIDENT #107), WEEKLY. IT WASN'T UNTIL 5/12/2012 THAT I SAW THE SWELLING OF HER RIGHT KNEE. I'D HAD THE RESIDENT ON 5/7/2012, 5/8/2012, 5/9/2012, AND 5/10/2012 AND DIDN'T DO A PHYSICAL ASSESSMENT ON HER ON ANY OF THOSE DAYS. AN AIDE TOLD ME ON 5/12/2012 THAT HER KNEE WAS SWOLLEN AND THAT SHE GRIMACED IN PAIN. I DIDN'T RECEIVE REPORT FROM ANY NURSE, OR FROM ANY CNA, THAT THE RESIDENT HAD SWELLING OF HER RIGHT KNEE UNTIL THE DAY SHIFT CNA TOLD ME ON 5/12/2012." DURING AN INTERVIEW ON 6/18/2012 AT 3:30 P.M., LICENSED PRACTICAL NURSE #24 SAID, "DURING ORIENTATION WE WERE TOLD WE'D DO PHYSICAL ASSESSMENTS DAILY; I DON'T REMEMBER DOING ONE ON THIS RESIDENT. A VISUAL INSPECTION OF A RESIDENT WAS NOT EXPECTED OF ME, THAT I KNOW OF, BEYOND WHAT I COULD SEE WITH THEIR CLOTHING ON. PHYSICAL ASSESSMENTS DONE BY ME WERE OF THOSE AREAS NOT COVERED BY CLOTHING. I DON'T REMEMBER LOOKING AT HER RIGHT KNEE." DURING THE COMPLAINT INVESTIGATION CONDUCTED 6/26/2012, RESIDENT #107'S MEDICAL FILE WAS REVIEWED; THERE WERE NO ENTRIES MADE FROM 5/4/2012 THROUGH 5/11/2012 REGARDING AN ASSESSMENT OF THE RESIDENT'S RIGHT LOWER EXTREMITY, AND PRESENCE OF SWELLING. THE 24 HOUR CHANGE OF STATUS REPORT FOR THE PERIOD 5/4/2012 THROUGH 5/12/2012, DID NOT INCLUDE ANY ENTRIES FOR REPORT BETWEEN SHIFTS OF ANY NURSING CONCERNS; THE AREA FOR REPORT ON EACH DAY WAS OBSERVED TO BE BLANK. DURING A PHONE INTERVIEW ON 6/25/2012 AT 10:10 A.M., THE EMERGENCY DEPARTMENT PHYSICIAN (#49) WHO TREATED RESIDENT #107 ON 5/12/2012, SAID, "THIS PATIENT (RESIDENT #107) HAD A NASTY FRACTURE; A SUPRACONDYLAR [MEDICAL CONDITION] RIGHT FEMUR. THIS WAS LIKELY CAUSED FROM HER FALL, AT THE FACILITY, ON 5/4/2012 WHEN HER LEG BECAME TWISTED. HER KNEE INJURY IS CONSISTENT WITH THE WAY IN WHICH SHE WAS FOUND AFTER THE FALL - WITH HER LEG TWISTED. THIS RESULTED IN THE KNEE INJURY I SAW IN THE EMERGENCY DEPARTMENT ON 5/12/2012. IT WAS APPARENT TO ME, GIVEN THE APPEARANCE OF THIS PATIENT'S KNEE ON 5/12/2012, THAT NO ONE ASSESSED HER OR LAID A HAND ON HER TO LOOK AT THIS KNEE IN THE INTERIM FROM 5/4/2012 'TIL 5/12/2012. IF SHE'D HAVE BEEN EXAMINED, THIS KNEE WOULD'VE BEEN SEEN. IT DOESN'T APPEAR ANYONE AT THE FACILITY SAW HER." THE REPORT OF A RADIOLOGIC STUDY OF RESIDENT #107'S RIGHT KNEE, PERFORMED ON 5/12/2012 AT THE EMERGENCY DEPARTMENT OF THE LOCAL HOSPITAL WHO EVALUATED HER, REVEALED PRESENCE OF A RIGHT SUPRACONDYLAR FEMUR FRACTURE. DURING AN INTERVIEW ON 6/22/2012 AT 12:45 P.M., DIRECTOR OF NURSING #2 SAID SHE EXPECTED NURSING STAFF TO PROVIDE RESIDENTS PHYSICAL ASSESSMENTS, AFTER SUCH INCIDENTS AS FALLS, ON A DAILY BASIS MINIMALLY FOR THE NEXT 72 HOURS, INCLUDING ASSESSMENTS FOR BRUISES, BUMPS, AND REPORTS SHOULD BE LOGGED ON THE 24 HOUR REPORT.

THIS CITATION PERTAINS TO INTAKE: MI 035 BASED ON OBSERVATIONS, INTERVIEWS, AND RECORD REVIEWS, THE FACILITY FAILED TO PROVIDE APPROPRIATE CARE RELATED TO THE USE OF A BED PAN FOR 1 OF 3 RESIDENTS (#101) REVIEWED FOR BED PAN USE, FROM A TOTAL SAMPLE OF 3, RESULTING IN RESIDENT #101 SUSTAINING NECROSIS (BLACKENED/DEAD TISSUE) AND BLISTERING OF THE SKIN AROUND THE BUTTOCKS AREA. FINDINGS INCLUDE: ACCORDING TO THE MEDICAL RECORD, RESIDENT #101 WAS A [AGE] year OLD MALE WHO WAS ORIGINALLY admitted to the facility on [DATE] WITH MULTIPLE [DIAGNOSES REDACTED]. RESIDENT #101 HAD A [MEDICAL CONDITION], UTILIZED A MECHANICAL VENTILATOR, AND RECEIVED HYDRATION AND NUTRITION BY A FEEDING TUBE. RESIDENT #101 HAD AN INDWELLING CATHETER FOR URINE COLLECTION. RESIDENT #101 WAS IDENTIFIED TO BE A 2 PERSON ASSIST AND WAS TOTALLY DEPENDENT ON STAFF FOR BED POSITIONING AND TRANSFERS. ON 10/20/11 AT 11:00 A.M., LICENSED PRACTICAL NURSE (LPN) #5 WAS INTERVIEWED. ACCORDING TO LPN #7, ON 10/1/11 AT APPROXIMATELY 1:00 P.M., CERTIFIED NURSE ASSISTANT (CNA) #7 TOLD HER THAT SHE (CNA #7) ATTEMPTED TO PLACE RESIDENT #101 ON THE BEDPAN, PER HIS REQUEST. CNA #7 TOLD LPN #5 THAT SHE (#7) FOUND HIM TO ALREADY HAVE A FRACTURE-TYPE BEDPAN (SHALLOW, FLATTENED TYPE OF BEDPAN WITH SHARPER EDGES, NOT ROUNDED AROUND EDGE OF BEDPAN, USUALLY USED FOR INDIVIDUALS WITH A [MEDICAL CONDITION]) IN PLACE, UNDER HIS BUTTOCKS. CNA #7 SAID NEITHER SHE OR THE OTHER CNA (#6) ON THAT HALLWAY PLACED THE BEDPAN UNDER RESIDENT #101, AND THEREFORE DID NOT KNOW HOW LONG IT HAD BEEN THERE. LPN #5 STATED THAT SHE (#5) HAD EXAMINED THE RESIDENT'S BUTTOCKS AND ONLY NOTED REDNESS ON HIS SKIN IN THE SHAPE OF THE BEDPAN. THERE WAS NO BRUISED OR BLISTERED AREAS. HOWEVER, LATER THAT DAY, AT APPROXIMATELY 3:30 P.M., CNA #7 REPORTED THAT RESIDENT # 101'S SKIN HAD CHANGED IN COLOR. ACCORDING TO LPN #5, SHE (#5) EXAMINED RESIDENT #101'S SKIN FOR A SECOND TIME AND NOTED DARK PURPLE DISCOLORATION AND SEVERAL BLISTERS AROUND THAT AREA THAT PREVIOUSLY HAD ONLY BEEN REDDENED. LPN #5 NOTIFIED THE FAMILY AND THE PHYSICIAN OF THE CHANGES. THE PHYSICIAN PRESCRIBED MEDIDERM OINTMENT TO BE APPLIED TO THE AREA. LPN #5 SAID SHE WAS ASSIGNED TO RESIDENT #101 ON THE DAY AFTER THE INCIDENT, 10/2/11, BUT DID NOT RECALL ANYTHING ABOUT THE CONDITION OF HIS SKIN BECAUSE HE WAS RUNNING A FEVER AND WAS EVENTUALLY TRANSFERRED OUT TO THE HOSPITAL FOR A URINARY INFECTION [MEDICAL CONDITION]. DURING AN INTERVIEW ON 10/20/11 AT 1:00 P.M., CNA #7 SAID THAT ON 10/1/11, AT 1:00 P.M., RESIDENT #101 REQUESTED TO BE PLACED ON THE BEDPAN FOR A BOWEL MOVEMENT. CNA #7 SAID WHEN SHE AND CNA #6 WENT TO POSITION RESIDENT #101 FOR THE BEDPAN PLACEMENT, SHE NOTICED A FRACTURE-TYPE BED PAN ALREADY UNDERNEATH THE RESIDENT'S BUTTOCKS. CNA #7 STATED THAT WHEN SHE (#7) REMOVED THE BEDPAN, SHE NOTICED THAT THE RESIDENT'S SKIN HAD A RED INDENTED RING IN THE SHAPE OF THE BEDPAN AROUND HIS BUTTOCKS. LPN #5 WAS NOTIFIED AND EXAMINED THE RESIDENT. CNA #7 SAID AT APPROXIMATELY 3:30 P.M., ON THE SAME DAY (10/1/11) RESIDENT #101 REQUESTED TO BE PLACED ON THE BEDPAN A SECOND TIME, AND AT THAT TIME SHE (#7)NOTICED THE REDDENED AREA HAD TURNED PURPLE WITH SOME BLISTERING. LPN #5 WAS NOTIFIED AND SHE AGAIN EXAMINED THE RESIDENT'S SKIN AND APPLIED AN OINTMENT. CNA #7 SAID THAT IT WAS NOT HER WHO PLACED THE FRACTURE-TYPE BED PAN UNDER RESIDENT #101. CNA #7 FURTHER STATED THAT SHE DID NOT KNOW OF ANY STAFF MEMBER WHO MAY HAVE PLACED THE FRACTURE-TYPE BEDPAN UNDER RESIDENT #101. CNA #7 SAID THAT SHE USES A REGULAR TYPE OF BEDPAN FOR RESIDENT #101. DURING AN INTERVIEW ON 10/20/11 AT 12:50 P.M., CNA # 6 SAID THAT ON 10/1/11 AT APPROXIMATELY 1:00 P.M., HE ASSISTED CNA #7 WITH REPOSITIONING RESIDENT #101 FOR BEDPAN PLACEMENT. AT THAT TIME, A FRACTURE-TYPE BEDPAN WAS DISCOVERED UNDERNEATH THE RESIDENT. CNA #6 SAID THAT IT WAS NOT HIM OR CNA #7 WHO PLACED THE FRACTURE-TYPE BED PAN UNDER RESIDENT #101. CNA #6 SAID THAT HE AND THE REST OF THE STAFF ALWAYS USED A REGULAR SIZED BEDPAN FOR RESIDENT #101 AND COULD NOT EXPLAIN WHEN OR WHO PLACED THE FRACTURE-TYPE BEDPAN UNDER RESIDENT #101. ON 10/20/11 AT 10:50 A.M., RESIDENT #101 WAS OBSERVED TO BE RESTING QUIETLY IN HIS BED. RESIDENT #101 WAS ABLE TO FOLLOW SIMPLE DIRECTIONS AND ANSWER SIMPLE QUESTIONS. RESIDENT #101 COMPLAINED OF LEG PAIN AND REQUESTED PAIN MEDICATION FROM THE NURSE. RESIDENT #101 COULD NOT ANSWER ANY QUESTIONS REGARDING BEING LEFT ON A BEDPAN, BUT DENIED EXPERIENCING PAIN IN THE BUTTOCKS AREA. OBSERVATION OF THE RESIDENT'S BUTTOCKS AREA, AT 11:00 A.M., ON 10/20/11, REVEALED THAT RESIDENT #101 HAD 3 SEPARATE CRESCENT-SHAPED SKIN INJURIES AROUND THE OUTSIDE OF THE BUTTOCKS AREA THAT CLEARLY MATCHED-UP WITH THE EDGES OF A FRACTURE-TYPE BEDPAN. WOUND #1 WAS A CRESCENT SHAPED, LATERAL LEFT THIGH AREA, THAT MEASURED APPROXIMATELY 13 CM X 2 CM WITH NECROSIS (BLACKENED AREA), WITH AN OPENED BLISTER AREA. WOUND #2 WAS A CURVED SHAPED WOUND, ON THE INNER RIGHT THIGH, PURPLE AND ALMOST COMPLETELY HEALED. WOUND # 3 WAS CRESCENT SHAPED, LOCATED ON THE UPPER LATERAL ASPECT OF THE RIGHT BUTTOCKS, AND MEASURED APPROXIMATELY 5 CM TO 1 CM WITH NECROSIS AND A SMALL OPENED BLISTER AREA. A REVIEW OF THE NURSE'S NOTES FROM 9/29/11 TO 10/2/11 REVEALED THAT LPN # 5 HAD OBSERVED SOME SKIN DISCOLORATION ON RESIDENT #101'S BUTTOCKS ON 10/1/11 AT APPROXIMATELY 1:00 P.M. AND THEN SOME BRUISING AND "OPENINGS" AT 3:30 P.M. THERE WAS NO ADDITIONAL DOCUMENTATION TO INCLUDE DESCRIPTIONS, MEASUREMENTS, OR STAGING OF RESIDENT #101'S SKIN INJURY. RESIDENT #101 WAS TRANSFERRED OUT TO THE hospital on [DATE] AT APPROXIMATELY 9:30 P.M., DUE TO CHANGES IN HIS OVERALL CONDITION. DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) ON 10/20/11 AT 1:30 P.M., SHE SAID AN INVESTIGATION WAS CONDUCTED WHEN RESIDENT #101 WAS hospitalized (FROM 10/2/11 - 10/10/11) AND IT COULD NOT BE DETERMINED WHEN, WHO, OR HOW THE FRACTURE-TYPE BEDPAN WAS PLACED UNDER RESIDENT #101. THE DON SAID THAT RESIDENT #101 HAD BEEN hospitalized MULTIPLE TIMES IN THE LAST FEW MONTHS AND IT WAS POSSIBLE THAT THE SKIN INJURY ON THE RESIDENT'S BUTTOCKS OCCURRED DURING THE LAST hospitalization . ( )

REFER TO INTAKE # MI 893 BASED ON OBSERVATION, INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE ASSISTANCE AND SAFE TRANSFER ACCORDING TO THE PLAN OF CARE FOR ONE (RESIDENT #501) OF 4 SAMPLED RESIDENTS, ALL REVIEWED FOR FALLS, RESULTING IN A FALL WITH INJURIES. FINDINGS INCLUDE: RESIDENT #501 WAS [AGE] years OLD admitted to the facility on [DATE]. THE HISTORY AND PHYSICAL DATED 5/7/2010, REVEALED THAT SHE WAS CONFUSED, WITH [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM DATA SET ((MDS) dated [DATE], RESIDENT #501 REQUIRED EXTENSIVE ASSISTANCE USING 2 PERSON DURING TRANSFER FROM BETWEEN SURFACES (CHAIR , BED, WHEELCHAIR, AND STANDING POSITION). RESIDENT #501 REQUIRED EXTENSIVE ASSISTANCE IN ALL ACTIVITIES OF DAILY LIVING AND WAS NON-AMBULATORY. ON 3/7/11, 4/17/11 AND 7/29/11, RESIDENT #501 WAS IDENTIFIED AS AT HIGH RISK FOR FALL. RESIDENT #501'S CARE PLAN INITIATED ON 5/10/10 SPECIFIED TO ENCOURAGE RESIDENT TO OBTAIN ASSISTANCE FOR TRANSFERS AND AMBULATION (DATED 6/11/11). RESIDENT #501'S CAREPLAN NOTED THAT HER TRANSFER STATUS WAS FOR 2 PERSON ASSISTANCE. RESIDENT #501 SUSTAINED FALLS ON 4/17/11, 8/7/11 AND 8/22/11. NURSE MANAGER #3 WAS INTERVIEWED ON 9/19/11 AT 11:00 AM. NURSE MANAGER #3 STATED THAT RESIDENT #501 HAD DEMENTIA, WAS OFTEN CONFUSED AND FORGETFUL. NURSE MANGER #3 STATED THAT ON 8/23/11, SHE RECEIVED A REPORT THAT RESIDENT #501 HAD FALLEN ON 8/22/11, AT 11:15 P.M. AND WAS SENT TO THE HOSPITAL WITH INJURIES. NURSE MANAGER #3 IMMEDIATELY STARTED AN INVESTIGATION. THE FALL INVESTIGATION DATED 8/23/11, DOCUMENTED THAT ON 8/22/11 AT APPROXIMATELY 11:15 PM, RESIDENT #501 WAS FOUND ON THE FLOOR BY THE CNA (#4) WITH THE WHEELCHAIR AWAY FROM RESIDENT (#501) AND BRAKES UNLOCKED. BLEEDING WAS NOTED FROM RESIDENT #501'S MID FOREHEAD; AND SHE HAD A LACERATIONS UNDER HER LEFT EYE. SKIN TEARS WERE NOTED TO HER LEFT ARM. THE RESIDENT WAS ASSESSED BY THE NURSE ON DUTY, NURSE #5. THE RESIDENT WAS ALERT AND ANSWERED QUESTIONS APPROPRIATELY. THE RESIDENT'S RANGE OF MOTION OF BOTH UPPER AND LOWER EXTREMITIES WERE WITHIN NORMAL LIMITS. BRUISES WERE NOTED TO RIGHT PATELLAR REGION AND AN ABRASION TO LEFT PATELLAR AREA. LACERATIONS AND SKIN TEAR WERE CLEANSED AND DRESSINGS WERE APPLIED. THE PHYSICIAN WAS NOTIFIED AND ORDERED TO SEND RESIDENT TO THE HOSPITAL. FAMILY WAS INFORMED OF THE TRANSFER. UPON RESIDENT #501'S RETURN to the facility on [DATE], STAFF NOTED 6 SUTURES TO THE LACERATION ON HER MID FOREHEAD, 3 SKIN TEARS WERE ON THE RESIDENT'S LEFT ARM AND BRUISING WITH SWELLING ON THE SECOND FINGER OF THE RIGHT HAND. HOSPITAL RECORD DATED 8/23/11 REVEALED THAT RESIDENT #501 WAS EVALUATED AND TREATED AT THE emergency room FOR A FRACTURE OF THE RIGHT 1ST DISTAL PHALANX, LACERATION OF THE FACE REQUIRING SUTURES, AND MULTIPLE LACERATIONS (SUPERFICIAL) SUSTAINED AFTER A FALL 8/22/11 AT THE NURSING FACILITY. CARE INSTRUCTIONS WERE GIVEN AND RESIDENT #501 RETURNED to the facility on [DATE]. WHEN INTERVIEWED ON 9/19/11 AT 11:00 AM, NURSE MANAGER #3 STATED THAT THE INVESTIGATION REVEALED THAT RESIDENT #501 PUSHED HER CALL LIGHT BUTTON FOR BATHROOM ASSISTANCE AT AROUND 11:00 PM. AND ASKED CERTIFIED NURSING ASSISTANT (CNA) #4 TO TAKE HER (#501) TO THE TOILET. AFTER RESIDENT #501 WAS TOILETED, CNA #4 TRANSFERRED RESIDENT #501 INTO THE WHEELCHAIR AND LEFT THE RESIDENT UNASSISTED. RESIDENT #501 WHEELED HERSELF BACK TO HER BED AND ATTEMPTED TO SELF TRANSFER HERSELF INTO THE BED. RESIDENT #501 fell RIGHT NEXT TO HER BED. ACCORDING TO NURSE MANAGER #3, THE RESIDENT #501'S TRANSFER STATUS HAD CHANGED. FOR A WHILE, THE RESIDENT REQUIRED A 1 PERSON ASSIST, BUT A 7/29/11 ASSESSMENT HAD CHANGED THE STATUS TO A 2 PERSON ASSIST. NURSE MANAGER #3 admitted THAT THERE WAS ONLY ONE CNA (#4) DURING TOILET ASSISTANCE AND NO ONE ASSISTED RESIDENT #501 TO BED AFTER TOILETING. RESIDENT #501 fell on [DATE] BECAUSE SHE TRIED TO TRANSFER INTO THE BED UNASSISTED. CNA #3 FAILED TO GET ANOTHER CNA TO HELP WHILE PROVIDING CARE AND FAILED TO ASSIST RESIDENT # 501 TO TRANSFER BACK TO BED. NURSE MANAGER #3 ADDED, "THE FALL INCIDENT COULD HAVE BEEN AVOIDED IF THE SAFETY INTERVENTION AND (RESIDENT #501'S) CARE PLAN WAS FOLLOWED." CNA #4 WAS INTERVIEWED BY TELEPHONE ON 9/21/11 AT 2:41 PM. WHEN ASKED, CNA #4 admitted SHE DID TOILET RESIDENT #501 BY HERSELF. CNA #4 CLAIMED THAT RESIDENT #501 HELPED WITH PIVOTING AND TURNING WHEN INSTRUCTED. CNA #4 RECALLED SHE NEVER OBSERVED ANY STAFF WALK,TRANSFER OR PUT RESIDENT #501 IN BED WITH 2 PERSON ASSISTANCE. CNA #4 STATED SHE HAD WORKED WITH RESIDENT #501 NUMEROUS TIMES BEFORE THE FALL AND DID NOT USE 2 PERSON ASSISTANCE FOR ACTIVITIES OF DAILY LIVING. CNA #4 DID NOT RECALL ANY PROBLEMS ENCOUNTERED WITH 1 PERSON ASSISTANCE. CNA #4 DENIED READING THE CARE GUIDE (KARDEX) SPECIFYING THAT RESIDENT #501 WAS 2 PERSON TRANSFER. SHE DENIED KNOWING THAT THE CARE GUIDE HAD BEEN CHANGED TO REFLECT THE RESIDENT'S 2 PERSON ASSISTANCE STATUS. CNA #4 FURTHER EXPLAINED THAT AFTER SHE TOILETED RESIDENT #501, SHE LEFT HER SITTING IN HER WHEELCHAIR NEXT TO HER BED WHILE CNA #4 CLEANED UP THE BATHROOM BEFORE THE NEXT USE. CNA #4 SAW RESIDENT #501 LEANING FORWARD TO THE SIDE RAILS OF THE BED AND FALL AT APPROXIMATELY 11:15 PM. CNA #4 STATED THAT SHE IMMEDIATELY CALLED FOR HELP WHILE SHE STAYED WITH RESIDENT #501, WHILE THE RESIDENT WAS ON THE FLOOR AND BLEEDING FROM HER FOREHEAD. RESIDENT #501'S TAR (TREATMENT ADMINISTRATION RECORD DATED APRIL 2011, MAY 2011, AND JUNE 2011 SPECIFIED THAT RESIDENT #501 WAS A 2 PERSON ASSIST WITH ALL ADLS (ACTIVITIES OF DAILY LIVING) AND TRANSFERS. THERE WAS NO EVIDENCE THAT THE 2 PERSON TRANSFER INTERVENTION WAS CHANGED OR DISCONTINUED. HOWEVER, THE TAR DATED JULY 2011 AND AUGUST 2011 DID NOT INCLUDE A 2 PERSON ASSIST IN ALL ADLS AND TRANSFERS. THIS WAS NOT CONSISTENT WITH RESIDENT #501'S CARE PLAN AND DAILY CARE GUIDE. SEVERAL ATTEMPTS TO CONTACT NURSE #5 BY TELEPHONE WERE MADE BUT WERE UNSUCCESSFUL. ON 9/19/11 AT 1:30 PM., RESIDENT #501 WAS OBSERVED SITTING IN HER WHEELCHAIR NEXT TO HER BED. WHEN ASKED ABOUT FALLING, RESIDENT #501 POINTED AT HER FOREHEAD FROM WHERE THE STITCHES WERE REMOVED AND POINTED AT HER FINGER. SHE STATED SHE WAS "A LOT BETTER NOW." THE DON (DIRECTOR OF NURSING ) WAS INTERVIEWED ON 9/19/11 AT 11:30 AM. THE DON STATED THAT NURSE AIDE #4 AND NURSE #5 WERE TERMINATED AFTER THE INCIDENT. CNA #4 WAS IN THE BATHROOM CLEANING UP INSTEAD OF ASSISTING RESIDENT #501 BACK TO BED. RESIDENT #501 TRANSFERRED HERSELF ALONE FROM WHEELCHAIR TO BED AND fell on [DATE]. ( )

THIS CITATION PERTAINS TO INTAKE #MI 495 BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE 1 OF 4 RESIDENTS REVIEWED FOR FALLS (#101) FROM A TOTAL SAMPLE OF 5, RECEIVED ADEQUATE SUPERVISION AND ASSISTIVE DEVICES TO PREVENT ACCIDENTS RESULTING A FALL WITH A LEFT HIP FRACTURE FOR RESIDENT #101. FINDINGS INCLUDE: RESIDENT #101 ACCORDING TO THE FACE SHEET DATED 7/07/2010, RESIDENT #101 WAS AN [AGE] year-old FEMALE WHO LIVED AT THE FACILITY SINCE 7/07/2010. RESIDENT #101'S [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM (MDS) data set [DATE], RESIDENT #101 SUFFERED SEVERE COGNITIVE DEFICITS WITH BOTH LONG AND SHORT-TERM MEMORY LOSS. RESIDENT #101 DID NOT WALK AND REQUIRED MINIMALLY TWO STAFF MEMBERS TO PROVIDE TRANSFER ASSISTANCE. RESIDENT #101 COULD NOT BALANCE AND WAS COMPLETELY DEPENDENT ON TWO STAFF MEMBERS FOR ALL BED MOBILITY. ACCORDING TO PHYSICIAN ORDERS [REDACTED].#101 EVERY 2 HOURS, ENSURE BILATERAL BOLSTERS (FOAM ROLLS TO USED TO BUILD UP SIDES OF BED TO PREVENT ROLLING OFF MATTRESS) WERE ON HER BED, AND RESIDENT #101 WAS TO BE TRANSFERRED USING TWO STAFF MEMBERS AND A MECHANICAL (HOYER) LIFT. ACCORDING TO physician progress notes [REDACTED]. A PROGRESS NOTE DATED 6/27/2011, REVEALED RESIDENT #101 WAS "BED RIDDEN", "fell ...WHILE BEING REPOSITIONED" AND SUSTAINED A LEFT HIP FRACTURE. A FALL RISK assessment dated [DATE], IDENTIFIED RESIDENT #101 AT "HIGH RISK" FOR FALLS RELATED TO HER CONFUSION, INCONTINENCE, SEIZURE ACTIVITY, USE OF PREDISPOSING MEDICATIONS, AND HER INABILITY TO BALANCE. A FALL CARE PLAN DATED 7/08/2010 IDENTIFIED RESIDENT #101 AS AT RISK FOR INJURY AND REQUIRED STAFF TO APPLY AND MAINTAIN A BED BOLSTER ON HER RIGHT AND LEFT SIDE. THIS DOCUMENTED RESTATED THAT RESIDENT #101 NEEDED TWO STAFF MEMBERS AND A MECHANICAL LIFT FOR SAFE TRANSFERS. RESIDENT #101'S "ADL (ACTIVITY OF DAILY LIVING) FLOW SHEET" DATED 06/2011, SPECIFIED SHE WAS COMPLETELY DEPENDENT ON TWO STAFF MEMBERS FOR ALL BED MOBILITY. ACCORDING TO A FACILITY INVESTIGATION REPORT DATED 6/21/2011, "FACILITY PRACTICE" REQUIRED "TWO STAFF" ASSIST WITH ALL CARE FOR BED BOUND RESIDENTS. ACCORDING TO NURSING NOTES DATED 6/12/2011 AT 5:30 A.M., A CERTIFIED NURSING ASSISTANT (EMPLOYEE "C") REPORTED TO THE ASSIGNED NURSE (EMPLOYEE "D") RESIDENT #101 HAD FALLEN FROM HER BED. NURSING DOCUMENTED "BILATERAL BED BOLSTERS FAULTY/WEAK". IN NURSING NOTES DATED 6/13/2011 (NO TIME), STAFF FOUND RESIDENT #101'S "LEFT LEG ...LOOSE AND FLOPPY". ON 6/14/2011 THE PHYSICIAN ORDERED A "STAT (QUICK) X-RAY ... (OF THE) LEFT HIP, PELVIS (AND) LEFT LEG". ACCORDING TO NURSING NOTES DATED 6/14/2011 AT 1:30 P.M., THE X-RAYS FOUND RESIDENT #101 HAD A DISLOCATED (OUT OF SOCKET) AND FRACTURED LEFT HIP. RESIDENT #101 WAS SENT TO THE EMERGENCY DEPARTMENT FOR FURTHER EVALUATION AND TREATMENT. DURING AN INTERVIEW ON 8/12/2011 AT 12:40 P.M., EMPLOYEE "C" SAID RESIDENT #101 HAD ALWAYS BEEN DEPENDENT ON TWO STAFF MEMBERS, TO PROVIDE HER HYGIENE NEEDS, BED MOBILITY AND TRANSFERS. EMPLOYEE "C" SAID SHE PROVIDED CARE AND BED MOBILITY INDEPENDENTLY FOR RESIDENT #101 ON 6/12/2011 AT APPROXIMATELY 5:00 A.M. EMPLOYEE "C" SAID SHE STOOD ON THE LEFT SIDE OF THE BED AND BATHED RESIDENT #101 WITHOUT ASSISTANCE. EMPLOYEE "C" SAID SHE THEN ROLLED RESIDENT #101 AWAY FROM HERSELF, TO THE RIGHT SIDE OF THE BED AND RESTED THE RESIDENTS BODY WEIGHT ON THE RIGHT BED BOLSTER. EMPLOYEE "C" SAID THE BOLSTERS WERE ATTACHED TO THE BED BUT IT "GAVE WAY" UNDER THE PRESSURE AND RESIDENT #101 fell TO THE FLOOR. EMPLOYEE "C" SAID SHE SHOULD HAVE WAITED TO GET ANOTHER STAFF MEMBER TO HELP. DURING AN INTERVIEW ON 8/12/2011 AT 12:50 P.M., EMPLOYEE "D" SAID SHE WAS NOTIFIED RESIDENT #101 HAD FALLEN FROM HER BED, TO THE FLOOR ON 8/12/2011 AT APPROXIMATELY 5:30 A.M. EMPLOYEE "D" SAID RESIDENT #101 fell BECAUSE STAFF FAILED TO PROVIDE RESIDENT #101 WITH THE REQUIRED, CARE PLANNED LEVEL OF ASSISTANCE NECESSARY FOR HER SAFETY DURING ADL CARE. EMPLOYEE "D" SAID PRIOR TO THE FALL, THE BED BOLSTERS APPLIED TO RESIDENT #101'S BED NEEDED TO BE REPLACED BECAUSE THEY WERE "WEAK AND FAULTY". ON 8/12/2011 AT 1:45 P.M., THE ADMINISTRATOR WAS INFORMED BY THE DIRECTOR OF NURSING THAT STAFF SHOULD NEVER HAVE ROLLED A COMPLETELY DEPENDENT RESIDENT (#101) AWAY FROM THEMSELVES TO THE RIGHT SIDE OF HER BED, WHERE NO SUPERVISION WAS PRESENT. THE DIRECTOR OF NURSING AND ADMINISTRATOR WERE BOTH PRESENT BUT DID NOT COMMENT ON THE "FAULTY AND WEAK" BED BOLSTER. ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE TREATMENTS, PRESSURE RELIEF DEVICES, REPOSITION, MONITOR, DEVELOP AND IMPLEMENT PLANS OF CARE TO PREVENT THE DEVELOPMENT OF NEW PRESSURE ULCERS/SORES FOR TEN OF 11 SAMPLED RESIDENTS (#502, 505, 510, 514, 515, 516, 517, 519, 525 AND 526), REVIEWED FOR PRESSURE ULCERS/SORES AND WHO ENTERED THE FACILITY WITHOUT PRESSURE ULCERS FROM A TOTAL SAMPLE OF 29, RESULTING IN HARM, SERIOUS INJURY AND THE POTENTIAL FOR SERIOUS INFECTIONS AND DEATH RELATED TO AVOIDABLE FACILITY ACQUIRED PRESSURE ULCERS. THIS RESULTED IN AN IMMEDIATE JEOPARDY. THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON 2/17/11 AT 3:00 P.M. THE ADMINISTRATOR WAS NOTIFIED ON 2/17/11 AT 5:40 P.M. FINDINGS INCLUDE: THE ADMISSION FACE SHEET RECORD, DATED 12/20/10, INDICATED RESIDENT #514 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM (MDS) data set [DATE] INDICATED RESIDENT #514 HAD ONE STAGE IV PRESSURE SORE AT THE TIME OF THE ASSESSMENT (STAGE IV-FULL THICKNESS LOSS WITH EXTENSIVE DESTRUCTION, TISSUE NECROSIS, OR DAMAGE TO MUSCLE, BONE, OR SUPPORTING STRUCTURES). THE RECENT QUARTERLY MINIMUM DATA SET, DATED 8/20/10, INDICATED RESIDENT #514 WAS COMATOSE, REQUIRED TOTAL ASSISTANCE FROM STAFF FOR ALL ACTIVITIES OF DAILY LIVING, INCLUDING BED MOBILITY AND TRANSFERS. RESIDENT #514 RECEIVED HIS NUTRITION VIA GASTROSTOMY TUBE. DURING THE INITIAL TOUR ON 2/15/11 AT 10:15 A.M., RESIDENT #514 WAS OBSERVED IN BED IN A SEMI-FOWLER'S POSITION ( SEMISITTING POSITION WITH KNEES FLEXED) AT 10:30 A.M., 11:40 A.M. , 1:25 P.M. AND AGAIN AT 2:45 P.M. IT WAS OBSERVED THAT RESIDENT # 514'S [MEDICAL CONDITION] RIGHT FOOT AND TOES WERE PRESSED DIRECTLY AGAINST THE FOOTBOARD OF THE BED DURING THOSE TIMES. A DRESSING CHANGE AND WOUND CARE OBSERVATION WAS CONDUCTED ON 2/16/11 AT 10:45 A.M., WITH WOUND/TREATMENT CARE NURSE (H) AND CERTIFIED NURSE ASSISTANT (CNA) (L). IT WAS OBSERVED THAT RESIDENT #514 HAD A TOTAL OF 10 WOUNDS, FOUR OF WHICH WERE IDENTIFIED AS PRESSURE ULCERS AND SIX OF WHICH HAD BEEN IDENTIFIED AS VASCULAR WOUNDS PER THE WOUND PROGRESS NOTES SINCE 9/30/10. THE PRESSURE ULCERS WERE LISTED AS FOLLOWS: 1. RIGHT HIP- STAGE IV, 2 X 7.0 X 3.0 X 1.2 CM- PINK BASE, NECROTIC CORE, MODERATE SEROSANGUINOUS DRAINAGE. 2 . SACROCOCCYGEAL/BILATERAL BUTTOCKS, 5.2 X 7.0 X 1.0 CM- STAGE IV-PINK BASE , MODERATE SLOUGH, HEAVY SEROSANGUINOUS DRAINAGE. 3. LEFT GLUTEAL- STAGE IV, 6.5 X 8.2 X 2.5 CM, PINK BASE,NECROTIC CORE, MODERATE SEROSANGUINOUS DRAINAGE. THE VASCULAR WOUNDS ON RESIDENT #514'S LOWER EXTREMITIES WERE LISTED AS FOLLOWS: 1. LEFT LATERAL LEG, 7.9 X 1.1 X 2 CM, PINK BASE SCATTERED NECROTIC , MINIMAL SEROSANGUINOUS DRAINAGE 2. LEFT DORSAL FOOT, 7.2 X 3.7 X 0.5 CM, PINK BASE, WITH SCATTERED NECROSIS, HEAVY SEROSANGUINOUS DRAINAGE. 3. LEFT HEEL, 6.2 X 4.5 CM, WITH NECROTIC BASE (UNSTAGEABLE- FULL THICKNESS TISSUE LOSS IN WHICH THE BASE OF THE ULCER IS COVERED BY SLOUGH (YELLOW, TAN, GRAY, GREEN OR BROWN OR ESCHAR (TAN, BROWN OR BLACK) IN THE WOUND BED). FIRST IDENTIFIED ON THE 9/25/10 WOUND NOTES. 4. RIGHT LATERAL LEG, 21.5 X 4.7 CM, AND PINK BASE, WITH HEAVY SEROSANGUINOUS DRAINAGE. FIRST IDENTIFIED ON THE 10/28/10 WOUND NOTES. 5. RIGHT DORSAL FOOT, 10.4 X 6.4 CM, PINK BASE, SCATTERED NECROSIS AND HEAVY SEROSANGUINOUS DRAINAGE. FIRST IDENTIFIED ON THE 9/09/10 WOUND PROGRESS NOTES. 6. RIGHT HEEL, DRY ESCHAR. FIRST IDENTIFIED ON THE 9/25/10 WOUND PROGRESS NOTES. AFTER THE WOUND CARE/TREATMENT NURSE (H) AND CNA (L ) COMPLETED THE TREATMENT AT 12:30 P.M., ON 2/16/11, THE TWO STAFF MEMBERS PULLED RESIDENT #514 UP IN BED. IT WAS OBSERVED THAT THERE WAS APPROXIMATELY 12 INCHES BETWEEN THE BED MATTRESS AND THE FOOT BOARD. THE TWO STAFF RAISED TH HEAD OF THE BED APPROXIMATELY 30 DEGREES. THE MATTRESS SLID DOWN TO THE BED FOOTBOARD. THIS CAUSED RESIDENT # 514 ' S [MEDICAL CONDITION] RIGHT FOOT AND TOES TO PRESS DIRECTLY AGAINST THE BED FOOTBOARD. ON 2/16/11 AT 4:00 P.M., RESIDENT #514'S [MEDICAL CONDITION] FOOT AND TOES REMAINED PRESSED AGAINST THE BED FOOTBOARD. ON 2/17/11, FROM 9:00 A.M., UNTIL 12:30 P.M. RESIDENT #514 WAS OBSERVED IN A SEMI FOWLER'S POSITION, WITH A PILLOW BEHIND HIS LEFT SHOULDER. FROM 12:30 P.M. UNTIL 4:00 P.M., IT WAS OBSERVED THAT RESIDENT #514 HAD A PILLOW BEHIND HIS RIGHT SHOULDER. RESIDENT #514 WAS NOT REPOSITIONED TO RELIEVE PRESSURE ON HIS BUTTOCKS AND SACRAL COCCYX AREA. THE BRADEN SCALE (TOOL USED TO PREDICT PRESSURE SORE RISK) DATED 8/06/10 INDICATED RESIDENT # 514 WAS AT SEVERE RISK FOR THE DEVELOPMENT OF PRESSURE SORES. RECOMMENDATION FROM THE WOUND CARE TEAM PROGRESS NOTES, DATED 7/05/10 THROUGH 2/17/11, INCLUDED INTERVENTIONS TO REPOSITION FREQUENTLY AND TO FLOAT RESIDENT #514'S HEELS. THE PRESSURE ULCER PLANS OF CARE, LAST UP DATED 12/19/10 AND AND 1/17/11, INCLUDED THE FOLLOWING INTERVENTIONS. 1. FLOAT HEELS TO PREVENT SKIN TO SKIN CONTACT AND HEEL TO MATTRESS CONTACT. 2. FREQUENT REPOSITION. THE INTERDISCIPLINARY RESIDENT CARE PLAN/KARDEX (USED TO DIRECT CNA CARE) FOR RESIDENT #514 (UNDATED) DID NOT INCLUDE ANY INTERVENTION TO FLOAT RESIDENT' #514'S HEELS AND ALSO DID NOT INCLUDE INTERVENTIONS TO REPOSITION RESIDENT #514 FREQUENTLY. DURING AN INTERVIEW ON 2/17/11, NURSE (I) WAS UNABLE TO EXPLAIN WHY RESIDENT #514 HAD NOT BEEN REPOSITIONED FREQUENTLY AND WHY RESIDENT #514'S HEEL HAD NOT BEEN FLOATED TO HELP PREVENT THE DEVELOPMENT OF NEW PRESSURE SORES. NURSE (I) FURTHER STATED SHE HAD NOT BEEN AWARE THAT THE MATTRESS ON RESIDENT #514'S BED WAS TOO SHORT AND SLID DOWN TO THE FOOTBOARD CAUSING RESIDENT# 514'S [MEDICAL CONDITION] RIGHT FOOT TO PRESS DIRECTLY AGAINST THE BED FOOTBOARD ( ) THE FACE SHEET RECORD DATED 9/14/10 INDICATED RESIDENT #519 WAS A [AGE] year OLD FEMALE ORIGINALY admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #519 RECEIVED HER NUTRITION VIA GASTROSTOMY TUBE (TUBE INSERTED DIRECTLY INTO THE STOMACH). ON 2/16/11 AT 9:15 AM., 11:45 A.M. , 2:30 P.M. AND 4:15 P.M., RESIDENT #519 WAS OBSERVED IN BED IN A SEMI FOWLERS POSITION. RESIDENT #519 HAD NOT BEEN REPOSITIONED TO RELEIVE PRESSURE ON BONY PROMINIENCES ON HIS BACK, ELBOWS, SHOULDER AND BUTTOCKS. THE ADMISSSION MINIMUM (MDS) data set [DATE], INDICATED RESIDENT #519 WAS NON-AMBULATORY, MODERATELY IMPARIED IN COGNITIVE SKILLS FOR DECISION MAKING, INCONTINENT AND TOTALLY DEPENDENT ON STAFF FOR ALL ACTIVITIES OF DAILY LIVING INCLUDING BED MOBILITY AND TRANSFERS. THE NURSING RE-ADMISSION ASSESSMENT, DATED 8/30/10, INDICATED RESIDENT #519 HAD A STAGE IV PRESSURE ULCER ON THE SACRALCOCCYXGEAL AREA AT THE TIME THE ASSESSMENT WAS CONDUCTED. THE ORIGINAL NURSING ASSESSMENT, DATED 8/11/10 WAS REQUESTED FROM THE DIRECTOR OF NURSING BUT NOT PROVIDED BY THE COMPLETION OF THE SURVEY ON 2/18/10. THE DIRECTOR OF NURSING STATED SHE WAS UNABLE TO LOCATE THE ORIGINAL NURSING ASSESSMENT DATED 8/1/10. THE BRADEN SCALE FOR RESIDENT #519 DATED 9/06/10 INDICATED RESIDENT #519 WAS AT SEVERE RISK FOR THE DEVELOPMENT OF PRESSURE SORES. REVIEW OF THE FACILITY WOUND LOGS FOR RESIDENT #519 SINCE ADMISSION TO THE FACILITY INDICATED THE FOLLOWING WOUNDS WERE IDENTIFIED ON RESIDENT #519 IN THE FACILITY ON THE LISTED DATES, NO MEASUREMENTS WERE PROVIDED: 1. LEFT HEEL- 8/31/10 2. SACRALCOCCYZXGEAL, BILATERAL BUTTOCK -8/31/10 3. RIGHT HIP- 11/11 10 4. LEFT GLUTEAL-12/02/10 LEFT HIP-12/02/10 5. RIGHT HEEL- DRY BLISTER-2/17/10 DURING A DRESSING CHANGE AND WOUND CARE OBSERVATION ON 2/17/11 THE FOLLOWING WOUNDS WERE OBSERVED. RESIDENT #519 WAS OBSERVED IN THE SEMI FOWLERS POSITION WHEN WOUND CARE WAS STARTED. 1. SACRALCOCCYGEAL/BILATERAL BUTTOCK, STAGE IV, 7.4 X 6.2 X 1.0 CM-PINK BASE HEAVY SEROSANGUINOUS DRAINAGE. 2. LEFT HIP, STAGE IV, 3.6 X 7.4 X 0.9 CM PINK BASE, NECROTIC CORE, HEAVY SEROSANGUINOUS DRAINAGE. 3. LEFT GLUTEAL, STAGE IV, 3.7 X 4.8 X 2.2 CM, PINK BASE, NECROTIC CORE, HEAVY SEROSANGUIONUS DRAINAGE. 4. LEFT HIP, STAGE IV, 13.5 X 13.2 X 2.7 CM, PINK BASE, SCATTERED HEAVY NECROSIS AND SEROSANGUINOUS ODOROUS DRAINAGE. 5. LEFT HEEL, 3.8 X 4.2 X CM, NECROTIC BASE, MINIMAL SEROUS DRAINGE 6. RIGHT HEEL, DRY BLISTER, 1.5 X 0.8. THE WOUND physician progress notes [REDACTED]. ON 2/17/10 AT 12:30 P.M., AFTER WOUND CARE AND DRESSING CHANGE OBSERVATION WERE COMPLETED, THE TREATMENT NURSE (H) AND CNA (M) REPOSITIONED RESIDENT #519 BACK TO THE SEMI FOWLERS POSITION WHERE SHE WAS OBSERVED AT 2:15 P.M. AND UNTIL 3:00 P.M. AT 3:00 P.M., DURING AN INTERVIEW, CNA (M) HAD NO EXPLAINATION WHY RESIDENT #519 HAD NOT BEEN REPOSITIONED TO HELP ALLEVIATE PRESSURE AND TO HELP PREVENT THE DEVELOPMENT OF NEW PRESSURE SORES FOR RESIDENT #519. ( ) THE FACE SHEET RECORD, DATED 1/20/11, INDICATED RESIDENT #510 WAS A [AGE] year OLD MALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #510 RECEIVED HIS NUTRITION VIA GASTROSTOMY TUBE (TUBE INSERTED DIRECTLY INTO THE STOMACH). THE ADMISSION Minimum Data Set, dated dated [DATE], INDICATED RESIDENT #510 WAS SEVERELY IMPAIRED IN COGNITIVE SKILLS FOR DECISION MAKING. RESIDENT #510 WAS NON-AMBULATORY, TOTALLY DEPENDENT ON STAFF FOR ALL ACTIVITIES OF DAILY LIVING, INCLUDING TRANSFERS AND BED MOBILITY. THE ADMISSION RESIDENT ASSESSMENT FORM FOR RESIDENT #510, DATED 1/20/11 INDICATED RESIDENT #510 WAS admitted WITH A DARK PURPLE BLANCHABLE AREA ON THE BILATERAL BUTTOCK WITH A ROUGH TEXTURE THAT MEASURED 8.9 X 9.5 CM. THE BRADEN SCALE (A TOOL USED TO PREDICT PRESSURE SORE RISK) INDICATED RESIDENT # 510 WAS AT HIGH RISK FOR THE DEVELOPMENT OF PRESSURES SORES. DURING THE INITIAL TOUR OF THE FACILITY ON 2/15/11 AT 10:20 A.M., RESIDENT # 510 WS OBSERVED IN BED IN A SEMI-FOWLER'S POSITION (LYING ON BACK, HEAD RAISED TO APPROXIMATE 30-45 DEGREES). RESIDENT #510'S FAMILY MEMBER WAS AT THE BEDSIDE. THE FAMILY MEMBER STATED RESIDENT #510 HAD BEEN COMPLAINING THAT HIS "BOTTOM" HURTS. LATER THAT SAME AFTERNOON ON 2/15/11 AT 2:45 P.M., DURING INCONTINENT CARE, IT WAS OBSERVED THAT RESIDENT #510'S BILATERAL BUTTOCKS WERE DISCOLORED WITH A PURPLISH COLOR. AN OPEN AREA WAS OBSERVED ON RESIDENT #510 ' S LEFT BUTTOCK. ON 2/16/10 , RESIDENT #510 WAS OBSERVED IN A SEMI- FOWLER'S POSITION FROM 8:45 A.M. UNTIL 11:45 A.M., WHEN RESIDENT #510'S FAMILY MEMBER REQUESTED THAT RESIDENT #510 BE TAKEN OUT OF BED AND SAT UP IN A WHEELCHAIR. THE FAMILY MEMBER STATED SHE OFTEN HAD TO MAKE A REQUEST TO STAFF BEFORE RESIDENT #510 WAS GOTTEN OUT OF BED AND SAT UP IN THE WHEELCHAIR. ON 2/17/10 AT 10:30 A.M., NURSE (I) STATED THAT SHE WAS NOT AWARE THAT RESIDENT #510 HAD AN OPEN AREA ON HIS BUTTOCK. RESIDENT #510'S BUTTOCKS WERE DISCOLORED WITH A PURPLE COLOR. DURING AN OBSERVATION OF RESIDENT #510'S SKIN WITH NURSE (I), A STAGE II PRESSURE SORE (PARTIAL THICKNESS SKIN LOSS INVOLVING EPIDERMIS, DERMIS OR BOTH, SUPERFICIAL AND PRESENTS AS AN ABRASION, BLISTER OR SHALLOW CRATER) WAS OBSERVED ON RESIDENT #510'S LEFT BUTTOCK THAT MEASURED 2.7 X 2.5 CM. AND A PURPLE NON-BLANCHABLE AREA THAT MEASURED 5.0 X 7.0 CM. NURSE (I) STATED THAT RESIDENT #510'S PRIMARY PHYSICIAN HAD NOT BEEN MADE AWARE AND THAT NO TREATMENT HAD BEEN ORDERED FOR THE STAGE II PRESSURE SORE ON RESIDENT #510 LEFT BUTTOCK. ON 2/17/11 AT 11:00 A.M., A REVIEW OF RESIDENT#510 CLINICAL RECORD DATED 1/20/11 THROUGH 2/17/11 REVEALED THAT THERE WERE NO PHYSICIAN ORDERS FOR treatment of [REDACTED]. IN ADDITION, THERE WERE NO NURSING INTERVENTIONS IN RESIDENT #510'S PLANS OF CARE DATED, 1/20/11 THROUGH 1/24/11 RELATED TO SKIN CARE AND PRESSURE ULCER PREVENTION. THE FACILITY'S SKIN INTEGRITY PROGRAM: IDENTIFICATION AND PREVENTION POLICY AND PROCEDURE DATED MARCH 2010 STATED: "RESIDENTS WITH RISK FACTORS FOR PRESSURES ULCER DEVELOPMENT WILL BE IDENTIFIED, AND APPROPRIATE INTERVENTION WILL BE IMPLEMENTED. DURING AN INTERVIEW ON 2/17/11AT 10:30 A.M., NURSE (I) WAS UNABLE TO EXPLAIN WHY INTERVENTION HAD NOT BEEN PUT IN PLACE FOR RESIDENT #510 TO HELP PREVENT THE DEVELOPMENT OF NEW PRESSURE SORES. ( ) PER RECORD REVIEW ON 2/16/11 AT 11:10 A.M., RESIDENT #502 WAS readmitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. ACCORDING TO THE 12/28/10 READMISSION ASSESSMENT SHEET, RESIDENT #502 HAD A STAGE II SACRAL ULCER. THERE WAS NO MEASUREMENTS. THE BRADEN SCORE (TOOL TO PREDICT PRESSURE ULCER RISK) WAS 12, DESCRIBING THE RESIDENT AS HIGH RISK FOR PRESSURE SORE. REVIEW OF THE RESIDENT'S CLINICAL RECORD REVEALED A CARE PLAN DATED 12/31/10 FOR INTERVENTIONS FOR THE "ALTERED SKIN INTEGRITY" FOR THE USE OF PRESSURE RELIEVING MATTRESS AND A WEEKLY SKIN ASSESSMENT. REVIEW OF THE RESIDENT'S CLINICAL RECORD REVEALED A PRESSURE ASSESSMENT SHEET DATED 1/24/11 THAT THE RESIDENT HAD A SACRAL PRESSURE ULCER WHICH MEASURED 1.7 CM. BY 1.0 CM. THE PRESSURE ULCER RECORD DESCRIBED AS NO DEPTH AND HAD SCANT SEROUS (WATERY )DRAINAGE. REVIEW OF THE NURSES NOTES AND TREATMENT ADMINISTRATION RECORD REVEALED THAT THE SKIN CONDITION WAS NOT ADDRESSED FROM 1/25/11 UNTIL 2/1/11. FURTHER REVIEW OF THE NURSES NOTES REVEALED THAT THE SKIN CONDITION WAS NOT ADDRESSED FROM 2/3/11 UNTIL 2/10/11. THE NEXT PRESSURE ULCER ASSESSMENT WAS ON 2/7/11 AND DESCRIBED THE SACRAL ULCER AS 2.6 CM. BY 5.5 CM. (INCREASED IN SIZE) WITH MODERATE SEROUS DRAINAGE. THE WOUND BED WAS DESCRIBED AS INVOLVING THE "ENTIRE" COCCYX AREA. THE CARE PLAN WAS NOT REVISED OR UPDATED. ON 2/10/11, THE RESIDENT WAS SEEN BY THE WOUND CARE PHYSICIAN. THE WOUND CARE NOTES DESCRIBED THE SACRAL WOUND WITH A NECROTIC BASE , PINK PALE TISSUE WERE EXPOSED AND SCATTERED. THE WOUND MEASURED 3.5 CM BY 6.5 CM WITH MODERATE SEROSANGUINOUS DRAINAGE (BLOOD/WATERY DRAINAGE). IT WAS DOCUMENTED THAT THE RESIDENT WAS TO BE PLACED ON A PRESSURE REDUCTION MATTRESS WITH FREQUENT REPOSITIONING. ON 2/15/11 UNTIL 2/18/11, THERE WAS NO PRESSURE REDUCTION MATTRESS OBSERVED ON RESIDENT #502'S BED. DURING AN INTERVIEW ON 2/16/11 AT 12:30 P.M., THE TREATMENT NURSE STATED THAT SHE WAS THE "ASSIGNED STAFF TO DO THE WOUND CARE" AND WILL "ROUND WITH THE WOUND CARE TEAM ONCE A WEEK. THE WOUND CARE NURSE ALSO STATED THAT THE WOUNDS ARE MEASURED BY THE WOUND CARE TEAM. ON 2/17/11 AT 9:40 A.M., RESIDENT #515 WAS OBSERVED IN BED ON HER BACK. THE RESIDENT'S LOWER EXTREMITIES WERE FLOATED ON A PILLOW. AT 10:50 A.M., RESIDENT #515 WAS OBSERVED ON HER BACK ON A REGULAR MATTRESS. ACCORDING TO FLOOR NURSE N, THE TREATMENT NURSE WAS NOT ABLE TO DO THE treatment for [REDACTED]. THE DRESSING WAS NOT DATED. THERE WAS NO PRAFO BOOTS ON THE RESIDENT'S LOWER EXTREMITIES. WHEN THE FLOOR NURSE WAS ASKED WHERE THE PRAFO BOOTS WERE, SHE (NURSE) STATED AND POINTED OUT THE BOOTS WERE IN THE RESIDENT'S CLOSET. ON 2/17/11 AT 1:35 P.M., RESIDENT #515 WAS ON HER BACK AND NO PRAFO BOOTS WERE APPLIED ON HER LOWER EXTREMITIES. PER RECORD REVIEW ON 2/17/11 AT 10:05 A.M., RESIDENT #515 WAS readmitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED].( REMOVAL OF LEFT COLON). RESIDENT #515 WAS RESPIRATOR DEPENDENT. REVIEW OF THE RESIDENT'S CLINICAL RECORD REVEALED A PHYSICIAN'S ORDER DATED 1/26/11 FOR THE APPLICATION OF BILATERAL PRAFO BOOTS ON FOR 4 HOURS, OFF FOR 4 HOURS ATC (AROUND THE CLOCK). THERE WAS NO PRAFO BOOTS OR LOW AIR LOSS MATTRESS AS DIRECTED BY THE PHYSICIAN. REVIEW OF THE READMISSION ASSESSMENT FORM DATED 1/21/11 REVEALED THAT RESIDENT #515 WAS DESCRIBED AS MODERATE RISK FOR PRESSURE SORE (BRADEN SCORE OF 14, TOOL FOR PRESSURE ULCER RISK). REVIEW OF THE READMISSION ASSESSMENT NOTES DATED 1/21/11 REVEALED AN ABRASION ON THE LEFT GLUTEAL AREA AND A PRESSURE SORE ON THE SACROCOCCYGEAL AREA WHICH MEASURED 5 CM BY 4 CM BY 2.5 CM. REVIEW OF THE PRESSURE ULCER RECORD REVEALED THAT ON 1/27/11 THE SACROCOCCYGEAL PRESSURE SORE MEASURED 5.4 CM BY 5.6 CM BY 2.3 CM (INCREASED IN SIZE)WITH LARGE SEROSANGUINEOUS DRAINAGE. THE INTERVENTIONS WERE THE USE OF LOW AIR LOSS MATTRESS AND FREQUENT REPOSITIONING. THE WOUND CARE NOTES BY THE WOUND CARE PHYSICIAN DOCUMENTED THAT THE RESIDENT'S BILATERAL HEELS WERE INTACT. FROM 1/28/11 UNTIL 2/5/ 11, THERE WAS NO DOCUMENTATION ABOUT THE STATUS OF THE PRESSURE SORES. ACCORDING TO THE WOUND CARE NOTES DATED 2/5/11, THE SACROCOCCYGEAL PRESSURE ULCER MEASURED 6.0 CM BY 5.9 CM 1.0 CM (INCREASED IN SIZE) WITH HEAVY BLOODY FLUID DRAINAGE. ON 2/10/11, ACCORDING TO THE WOUND CARE NOTES, THE SACROCOCCYX PRESSURE SORE MEASURED 5.1 CM BY 5.5 CM BY 1.6 CM, WITH HEAVY SEROSANGUINEOUS DRAINAGE. THERE WAS NO DOCUMENTATION OF THE SKIN CONDITION FROM 2/6/11 UNTIL 2/10/11. ON 2/17/11 AT 1:55 P.M.DURING A WOUND CARE OBSERVATION, IT WAS NOTED THAT BOTH FEET WERE FLOATED ON A PILLOW. THERE WAS NO PRAFO BOOTS APPLIED. THE FOLLOWING WOUNDS WERE OBSERVED AND WERE MEASURED BY THE WOUND CARE TEAM: 1) THE SACROCOCCYX PRESSURE SORE MEASURED 5.2 CM BY 12.4 CM BY 1.4 CM (INCREASED IN SIZE) , THE WOUND WAS PINKISH AND EXTENDED TO BILATERAL BUTTOCKS. 2) THERE WAS A "NEW" STAGE II LEFT BUTTOCKS WOUND, SUPERFICIAL 3) NEW RIGHT HEEL WOUND WHICH MEASURED 3.4 CM BY 1 CM. WITH SCANT SEROSANGUINEOUS DRAINAGE 4) LEFT POSTERIOR LEG WHICH MEASURED 2.9 CM BY0.9 CM WITH DRIED DISCOLORED BASE. AND 5) LEFT HEEL PINK TISSUE ABRASIONS. DURING AN INTERVIEW ON 2/17/11 AT 3:00 P.M., THE DIRECTOR OF NURSING HAD NO EXPLANATION WHY THE PRAFO BOOTS HAD NOT BEEN CONSISTENTLY APPLIED. THE DIRECTOR OF NURSING WAS NOT ABLE TO EXPLAIN WHY THE RESIDENT WAS NOT ON A LOW AIR LOSS MATTRESS. ( ) ON 2/17/11 AT 9:30 A.M., RESIDENT #516 WAS OBSERVED IN BED ON HER LEFT SIDE. RESIDENT #516 WAS ALERT BUT WAS NON-VERBAL. AT 10:50 A.M., RESIDENT #516 WAS OBSERVED IN BED ON HER LEFT SIDE. S RIGHT FOOT DRESSING WAS OBSERVED. BILATERAL BED BOLSTERS WERE OBSERVED IN THE RESIDENT'S BED. RECORD REVIEW ON 2/17/11 AT 11:15 A.M. REVEALED THAT RESIDENT #516 WAS readmitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #516 WAS A [MEDICAL CONDITION] (PARALYSIS OF BOTH UPPER AND LOWER EXTREMITIES). REVIEW OF THE RESIDENT'S READMISSION ASSESSMENT FORM, DATED 7/7/10, DESCRIBED THAT THE RESIDENT'S BILATERAL BUTTOCKS WERE "RED AND EXCORIATED". THERE WAS NO PRESSURE ULCER IDENTIFIED. A BRADEN SCALE (TOOL TO PREDICT PRESSURE ULCER) ON READMISSION (7/7/10) DESCRIBED RESIDENT #516 AS HIGH RISK FOR PRESSURE SORE WITH A SCORE OF 11. THE NEXT BRADEN SCALE DATED 10/15/10 WAS 12 (HIGH RISK FOR PRESSURE SORE). HOWEVER, THERE WAS NO SKIN ASSESSMENT OR CONDITION ABOUT THE BILATERAL BUTTOCKS. FURTHER REVIEW OF THE RESIDENT'S CLINICAL RECORD REVEALED A BRADEN SCALE ON 11/6/10 DESCRIBING THE RESIDENT AS HIGH RISK FOR PRESSURE SORE. (SCORE OF 12). HOWEVER, THERE WAS NO EVIDENCE THAT THE BUTTOCKS WERE REASSESSED. ACCORDING TO THE PRESSURE ULCER RECORD, A FACILITY ACQUIRED PRESSURE SORE OF THE LEFT BUTTOCKS WAS IDENTIFIED ON 12/15/10. THE PRESSURE SORE MEASURED 0.3 CM BY 1.0 CM WITH SCANT DRAINAGE. THE WOUND WAS DESCRIBED AS PINK, PALE TISSUE. THE WOUND CARE PHYSICIAN RE-EVALUATED RESIDENT #516 ON 12/16/10. ACCORDING TO THE WOUND CARE PHYSICIAN'S NOTES, THE RESIDENT'S LEFT BUTTOCK PRESSURE SORE MEASURED 0.5 CM BY 0.5 CM WITH MINIMAL SEROSANGUINEOUS DRAINAGE (BLOODY FLUID DRAINAGE). THE WOUND CARE PHYSICIAN DIRECTED THE FACILITY TO FREQUENTLY REPOSITION THE RESIDENT. REVIEW OF THE WEEKLY NOTES BY THE WOUND CARE PHYSICIAN DOCUMENTED AS FOLLOWS: 1) ON 12/23/10, THE LEFT BUTTOCKS PRESSURE SORE MEASURED 0.6 CM BY 0.6 CM ( INCREASED IN SIZE) WITH MINIMAL SEROSANGUINEOUS DRAINAGE. FREQUENTLY REPOSITION 2) ON 12/30/10, THE LEFT BUTTOCK PRESSURE SORE MEASURED 1.0 CM BY 0.6 CM ( INCREASED IN SIZE) FREQUENTLY REPOSITION. 3) ON 1/6/11, THE LEFT BUTTOCKS PRESSURE SORE MEASURED 0.7 CM BY 0.6 CM . FREQUENTLY REPOSITION 4) ON 1/13/11, THE LEFT BUTTOCKS PRESSURE SORE MEASURED 0.6 CM BY 0.7 CM WITH MINIMAL SEROSANGUINEOUS DRAINAGE. FREQUENTLY REPOSITION 5) ON 1/20/11 THE LEFT BUTTOCKS PRESSURE SORE MEASURED 0.4 CM BY 0.6 CM . THE WOUND CARE PHYSICIAN RECOMMENDED TO FREQUENTLY REPOSITION RESIDENT #516. 6) ON 1/27/11 THE LEFT BUTTOCKS PRESSURE ULCER MEASURED 0.5 CM BY 0.6 CM 7) ON 2/10/11 THE LEFT BUTTOCKS PRESSURE ULCER MEASURED 0.3 CM BY 0.4 CM REVIEW OF THE NURSES NOTES AND SKIN ASSESSMENT NOTES FROM 12/10/10 UNTIL 2/10/11 REVEALED NO EVIDENCE THAT THE RESIDENT'S SKIN CONDITION WAS ADDRESSED. THERE WAS NO CARE PLAN TO ADDRESS THE INTERVENTIONS FOR THE PRESSURE SORE. THE LAST CARE PLAN WAS REVIEWED ON 12/ 10/10. REVIEW OF THE RESIDENT'S MDS (MINIMUM DATA SET) DATED 12/31/10 REVEALED THAT RESIDENT #516 WAS TOTALLY DEPENDENT FOR BED MOBILITY AND REQUIRED TWO PERSONS TO ASSIST. RESIDENT #516 WAS TOTALLY DEPENDENT FOR ADL (ACTIVITIES OF DAILY LIVING), WITH BOTH UPPER AND LOWER EXTREMITIES IMPAIRED ON BOTH SIDES FOR VOLUNTARY MOVEMENT. ON 2/17/11 AT 2:00 P.M., A WOUND CARE TREATMENT WAS OBSERVED. THE RESIDENT'S LEFT BUTTOCKS WAS WITH VERY SCANT MOISTURE AND NO MEASUREMENT WAS DONE. ( ) PER RECORD REVIEW ON 2/16/11 AT 10:00 A.M., RESIDENT #505 WAS readmitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #505 WAS ON VENTILATOR SUPPORT FOR [MEDICAL CONDITION] PROBLEMS. REVIEW OF THE RESIDENT'S READMISSION assessment dated [DATE] REVEALED THE FOLLOWING SKIN CONDITIONS: 1) BRUISING AND DISCOLORATION OF THE INNER RIGHT ANKLE 2) AN 11 CM LONG SCAR ON THE ABDOMINAL MIDLINE 3) A RED AREA ON THE RESIDENT'S LEFT SIDE OF THE ABDOMEN 4) A RED ABRASION ON THE LEFT HIP 5) A 6.0 CM BY 6.5 CM BY .75 CM SORE ON THE LEFT GLUTEAL AREA 6) A 7 CM BY 9 CM BY 1.5 CM SORE ON THE RIGHT UPPER HIP AND 7 A 6 CM BY 5 CM BY 1.0 CM SORE ON THE RIGHT GLUTEAL AREA.. FURTHER REVIEW OF THE RESIDENT'S CLINICAL RECORD REVEALED NO SKIN ASSESSMENT UNTIL 2/10/11 BY THE WOUND CARE PHYSICIAN. THE WOUND CARE NOTES DESCRIBED THE RESIDENT'S WOUNDS AS FOLLOWS: 1) SACROCOCCYGEAL PRESSURE SORE WHICH MEASURED 4.1 CM BY 6.5 CM BY 0.5 CM 2) RIGHT HIP WHICH MEASURED 8.0 CM BY 5.9 CM BY 2.2 CM ( INCREASED IN SIZE FROM 2/1/11) 3) RIGHT GLUTEAL WHICH MEASURED 4.7 CM BY 6.5 CM BY 0.5 CM 4) RIGHT LATERAL LEG WHICH MEASURED 10.7 CM BY 1.8 CM . THE WOUND CARE DOCTOR DOCUMENTED THAT THERE WERE 2 RIGHT LATERAL LEG WOUNDS. FURTHER REVIEW OF THE RESIDENT'S CLINICAL RECORD REVEALED NO FURTHER BRADEN SCALE AFTER 2/1/11. THERE WAS NO FURTHER SKIN ASSESSMENT BY THE FACILITY STAFF OR BY THE TREATMENT NURSE. THERE WAS NO CARE PLAN TO DIRECT THE CARE OF THE WOUNDS. DURING AN INTERVIEW ON 2/18/11 AT 10:05 AM, THE DIRECTOR OF NURSING OFFERED NO EXPLANATION WHY THERE WERE NO ASSESSMENTS BY THE FACILITY STAFF AFTER 2/1/11. THE TREATMENT NURSE WAS INTERVIEWED ON 2/18/11 AT 10:30 A.M., WHO STATED THAT THE WOUND MEASUREMENT WAS DONE BY THE WOUND CARE PHYSICIAN'S TEAM WEEKLY. SHE FURTHER STATED THAT SHE "DOES" ALL THE treatment of [REDACTED]. RESIDENT #525 WAS OBSERVED ON 2/17/11 AT 12:15 P.M. IN BED LYING ON HER BACK WITH HEAD OF BED ELEVATED. THE RESIDENT WAS ALERT. DURING THE WOUND CARE OBSERVATION ON 2/17/11 AT APPROXIMATELY 12:45 P.M., IT WAS NOTED THAT THE RIGHT GLUTEAL ULCER WAS STAGE IV AND MEASURED 4.8 CM (CENTIMETERS)( INCREASED IN SIZE) BY 2.1 CM BY 1.7 CM (INCREASED IN SIZE) WITH MODERATE SEROSANGUINOUS DRAINAGE. SANTYL OINTMENT WAS APPLIED TO THE WOUND BED. THE SACRAL/BILATERAL BUTTOCK WOUND WAS STAGE III AND MEASURED 9.9 CM (INCREASED IN SIZE) BY 7.2 CM (INCREASED IN SIZE) BY 0.2 CM (INCREASED IN SIZE) WITH MODERATE SEROSANGUINOUS DRAINAGE. SANTYL OINTMENT WAS APPLIED TO THE WOUND BED. THE LEFT GLUTEAL WOUND WAS STAGE IV AND MEASURED 1.5 CM BY 4.4 CM BY 1.0 CM WITH MODERATE SEROSANGUINOUS DRAINAGE. SANTYL OINTMENT WAS APPLIED TO THE WOUND BED. THE LEFT HEEL UNSTAGEABLE MEASURED 1.5 CM BY 2.5 CM (INCREASED IN SIZE) WITH DRY ESCHAR BASE. A DRY DRESSING WAS APPLIED. ALL WOUND MEASUREMENTS WERE PERFORMED BY THE WOUND CARE NURSE PRACTITIONER. ON 2/17/11 AT 1:45 PM. A REVIEW OF THE CLINICAL RECORD FOR RESIDENT #525 REVEALED THE FOLLOWING: THE ADMISSION FACESHEET, REVEALED RESIDENT #525 WAS INITIALLY admitted to the facility on [DATE] AND REadmitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE QUARTERLY Minimum Data Set, dated dated [DATE], INDICATED THE RESIDENT WAS IDENTIFIED "AT RISK" FOR DEVELOPING PRESSURE ULCERS AND HAD THREE STAGE III PRESSURE SORES ON THE PRIOR ASSESSMENT. REVIEW OF THE RESIDENT'S READMISSION assessment dated [DATE] REVEALED THE FOLLOWING SKIN CONDITIONS PER SITE: 1) STAGE IV RIGHT ISCHIUM 4 CM BY 3 CM BY 0.2 CM 2) STAGE IV LEFT BUTTOCK 7 CM BY 3 CM BY 2.0 CM. 3) STAGE II COCCYX 4 CM BY 3 CM. 4) LEFT HEEL BLACK UNSTAGEABLE NO MEASUREMENTS DOCUMENTED. FURTHER REVIEW OF THE RESIDENT'S CLINICAL RECORD REVEALED A WOUND CARE PHYSICIAN'S NOTES AS FOLLOWS: 1) ON 1/27/11, THE SACRAL WOUND MEASURED 7.5 CM BY 7.9 CM. THE LEFT GLUTEAL MEASURED 2.4 CM BY 5.5 CM BY 1.0 CM. THE RIGHT GLUTEAL MEASURED 7.3 CM BY 2.6 CM BY 1.1 CM. THE LEFT HEEL MEASURED 1.7 CM BY 1.8 CM WITH ORDERS TO FREQUENTLY REPOSITION THE RESIDENT. 2) ON 2/5/11, THE SACRAL WOUND MEASURED 5.5 CM BY 6.0 CM. THE LEFT GLUTEAL MEASURED 5.5 CM BY 3.0 CM BY 2.5 CM. THE RIGHT GLUTEAL MEASURED 3.5 CM BY 4.5 CM BY 2.4 CM. THE LEFT HEEL MEASURED 1.7 CM BY 1.8 CM. WITH ORDERS TO FREQUENTLY REPOSITION AND FLOAT HEELS. 3) ON 2/10/11, THE SACRAL WOUND MEASURED 5.6 CM BY 6.9 CM. THE LEFT GLUTEAL MEASURED 2.8 CM (INCREASED IN SIZE) BY 2.1 CM BY 0.4 CM. THE RIGHT GLUTEAL MEASURED 2.1 CM BY 5.9 CM (INCREASED IN SIZE) BY 0.6 CM WITH ORDERS TO FREQUENTLY REPOSITION AND FLOAT HEELS. REVIEW OF THE OF THE RESIDENTS TREATMENT RECORD (TAR) FOR TURN EVERY 2 HOURS AND AS NEEDED REVEALED NO DOCUMENTATION ON THE 7-3 SHIFT FOR 1/27, 1/28, AND 1/29/11 THAT THE RESIDENT HAD BEEN TURNED EVERY 2 HOURS, NOR ON THE 3-11 SHIFT FOR 1/29/11 OR 1/30/11. ON 2/18/11 AT 2:00 P.M. DURING AN INTERVIEW REGARDING "BLANKS" ON THE AFOREMENTIONED TAR FOR THE EVERY 2 HOUR TURN FOR RESIDENT # 525 THE DIRECTOR OF NURSING STATED "IF THE AREAS ARE BLANK IT MEANS THE RESIDENT WAS NOT TURNED NOR REPOSITIONED". ( ) ON 2/17/11 AT 12:45 P.M. RESIDENT #526 WAS OBSERVED IN BED LYING ON HER BACK FACING TOWARDS THE WINDOW. THE RESIDENT WAS NOT RESPONSIVE TO COMMAND, HER EYES WERE CLOSED. ON 2/18/11 AT 9:30 A.M. A REVIEW OF THE CLINICAL RECORD FOR RESIDENT #526 REVEALED THE FOLLOWING: 1. THE ADMISSION FACESHEET REVEALED RESIDENT #526 WAS INITIALLY admitted to the facility on [DATE] AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. 2. THE QUARTERLY Minimum Data Set, dated dated [DATE], INDICATED THE RESIDENT WAS IDENTIFIED "AT RISK" FOR DEVELOPING PRESSURE ULCERS AND HAD ONE STAGE III PRESSURE ULCER PRESENT UPON ADMISSION/REENTRY. 3. REVIEW OF THE RESIDENT'S READMISSION assessment dated [DATE] ON 2/18/11 AT 9:30 A.M. REVEALED THE FOLLOWING SKIN CONDITIONS PER SITE: 1) STAGE I 7 CM BY 6 CM PINK HEALED SACRUM 2) DRY SCALY POSTERIOR FEET 3) DRY OLD HEALED SCARS BILATERAL LOWER ANTERIOR LEGS. 4. REVIEW OF INITIAL admission orders [REDACTED]. 4. REVIEW OF PHYSICIANS ORDERS DATED 2/3/11, 2/10/11 AND 2/11/11 REVEALED RESIDENT #526 WAS RECEIVING WOUND CARE treatment for [REDACTED]. A PHYSICIAN'S ORDER ALSO DATED 2/11/11 REVEALED an order for [REDACTED]. ON 2/18/11 AT 11:50 A.M. PRIOR TO THE WOUND CARE OBSERVATION WOUND MEASUREMENTS WERE REQUESTED AND WOUND TREATMENT NURSE "J" STATED SHE WAS NOT TRAINED TO MEASURE WOUNDS" AND THUS WOULD NOT PROVIDE MEASUREMENTS. DURING THE WOUND CARE OBSERVATION AT 11:55 A.M. IT WAS NOTED THAT THE RESIDENT HAD A TOTAL OF THREE PRESSURE ULCERS, IT WAS NOTED THAT THE SACRAL ULCER WAS A STAGE II THAT INVOLVED THE LEFT AND RIGHT BUTTOCKS WITH A MODERATE AMOUNT OF SEROSANGUINEOUS DRAINAGE. THE RIGHT HEEL WAS UNSTAGEABLE WITH ESCHAR AND NO DRAINAGE. THE RIGHT LATERAL LEG WAS A REOPENED STAGE III ULCER WITH A MODERATE AMOUNT OF SEROUS DRAINAGE. THE RESIDENT WAS OBSERVED ON A REGULAR MATTRESS. REVIEW OF THE NURSE'S NOTE DATED 1/21/11 AT 3:30 P.M. REVEALED RESIDENT ARRIVED BY PATIENT AMBULANCE SERVICE........VERY DRY SCALY SKIN BILATERAL LEGS...SEVERAL OLD HEALED AREAS NOTED BILATERAL LOWER LEGS AND BUTTOCKS. THE BRADEN SCALE (PRESSURE ULCER ASSESSMENT TOOL) SCORED 12 ON 1/21/11 WHICH INDICATED RESIDENT #526 WAS A HIGH RISK FOR PRESSURE SORES. HOWEVER, THERE WAS NO CARE PLAN FOR PRESSURE SORE PREVENTION OR TREATMENT INTERVENTIONS. REVIEW OF SKIN AND BODY ALERT FORM REVEALED 1) 1/21/11-1/27/11 REVEALED NO NEW AREAS 2) 1/27/11 (NO TIME OR SHIFT INDICATED) REVEALED BOTTOM AREA RED. 3) 1/28/11 SECOND SHIFT REVEALED "BOTTOM VERY RED CALMO ITS GOING TO BREAK DOWN", NOTIFIED WOUND NURSE. 4) 2/3/11 5 A.M. THREE CIRCLES DOCUMENTED RIGHT POSTERIOR THIGH, RIGHT BUTTOCK AND SACRAL AREA INTERVENTIONS WERE LEFT BLANK. 5) 2/14/11 REVEALED NO CHANGES. ON 2/18/11 AT 10:00 A.M. DURING INTERVIEW WITH THE DIRECTOR OF NURSING (DON) NO EXPLANATION WAS GIVEN FOR THE MISSING SKIN AND BODY ALERT FORMS BETWEEN 2/3/11 AND 2/17/11 AND THE DON WAS UNABLE TO EXPLAIN WHY THERE WAS NO CARE PLAN FOR PRESSURE SORE PRESENT IN THE CLINICAL RECORD. THE TREATMENT RECORD (TAR) WAS ALSO REQUESTED ON 2/18/11 AT 3:20 P.M. DURING AN INTERVIEW WITH WOUND TREATMENT NURSE "H" WHEN QUERIED REGARDING WHAT TYPE OF MATTRESS RESIDENT #526 WAS ON, SHE STATED "ITS A REGULAR MATTRESS, NOT A PRESSURE REDUCTION MATTRESS". ( ) RESIDENT #517 WAS INTERVIEWED ON 2/17/11 AT 10:40 A.M. AND REPORTED HE HAD DEVELOPED A PRESSURE SORE IN THE FACILITY AFTER BEING hospitalized IN NOVEMBER 2010. RESIDENT #517'S CLINICAL RECORD WAS REVIEWED ON 2/17/11 AT 1:00 P.M. ACCORDING TO THE FACE SHEET, DATED 11/10/10, RESIDENT #517 WAS REadmitted to the facility on [DATE] FOLLOWING hospitalization FOR A TRACHEAL RESECTION (RECONSTRUCTION). OTHER MEDICAL [DIAGNOSES REDACTED]. THE READMISSION RESIDENT ASSESSMENT FORM, DATED 11/10/10, REVEALED THE RESIDENT HAD A SCAR ON THE LEFT KNEE AND ABDOMEN AND NO OTHER AREAS OF SKIN BREAKDOWN. A BRADEN SCALE (AN INSTRUMENT USED TO IDENTIFY PRESSURE SORE RISK) WAS COMPLETED ON 11/10/10 AND THE RESIDENT SCORED A "17", WHICH INDICATED THE RESIDENT WAS AT "LOW RISK" FOR PRESSURE SORE DEVELOPMENT. REVIEW OF NURSING PROGRESS NOTES REVEALED RESIDENT #517 DEVELOPED PRESSURE SORES APPROXIMATELY THREE WEEKS AFTER READMISSION. NURSING PROGRESS NOTES DESCRIBED THE FOLLOW