Every finding on record at Medilodge of GTC

This citation pertains to intake #3095103Based on observation, interview and record review, the facility failed to accurately assess, document, provide appropriate treatment, and update nursing interventions resulting in the worsening of existing pressure injuries and the development a new pressure injury for 1 of 3 sampled residents (R100) for pressure injuries. R100 experienced a new pressure injury that was not documented in medical records and the worsening of 3 pressure injuries that developed from MASD (moisture associated skin damage) into stage 2 (skin breaks down and forms a shallow ulcer into partial-thickness skin loss) and stage 3 (damage goes through the skin into the fat layer into full-thickness skin loss).Findings include:Review of R100s Hospital Discharge Documents dated 6/7/26, revealed, .Reason for Presentation.multiple pressure wounds.6. Multiple pressure wounds-appreciate wound care consult, continue care.wound complex care.per wound care team.6/2/26-buttocks, 6/2/26-left posterior thigh, 6/2/26 left posterior lower leg, . Location: Sacrum Type: Stage 3 pressure injuries times 2. Size (cm): Length Width Depth: Multiple.Wound base: 50% yellow slough, 50% red viable tissue Periwound: Moist, intact Drainage (color/amount): serosanguineous, scant . present on admission. Location: Left mid-back Type: Fat layer exposed full thickness Size (cm): Length Width Depth: Inferior - 1.3cmx4cmx0.3cm Size (cm): Length Width Depth: Superior - 2cmx5cmx0.3cm Wound base: 90% yellow/brown necrotic tissue, 10% red viable tissue Periwound: scar tissue, intact Drainage (color/amount): serosanguineous, scant Undermining/Tunneling: none Present on admission: yes Hospital Acquired: noReview of R100's skin and wound pictures dated:-5/18/26-rear left trochanter picture presented with a deep read area containing three open wounds with slough and eschar. The facility described the injury as MASD, in-house acquired, with progress that had stalled and was previously improving wound characterizes plateaued. Measurements included 6.47 cm in length, 5.77 cm in width, and an area that covered 23.21 cm. The wound bed had 100% granulation with moderate serosanguineous fluid mixture of serous and sanguineous fluid, typically pale, red, and watery. Treatment included cleansing with normal saline solution, and no dressing was to be applied. It was noted the resident was incontinent of bowel. The picture of R100's left rear hip (trochanter) was inconsistent with the weekly Skin assessment dated [DATE] with no updated Skin Assessment provided. -5/20/26-rear left trochanter picture presented with a deep red area containing three open wounds with eschar that was in-house acquired. The facility described the injury as MASD with progress that was unknown. Measurements included 5.42 in length, 7.81 cm in width, and an area that covered 28.87 cm. It was noted that the injury area had increased from the Skin assessment dated [DATE]. No wound bed and treatment description was documented by the facility. The picture of R100's left rear hip (trochanter) was inconsistent with the weekly Skin assessment dated [DATE] with no Skin assessment dated [DATE]. -5/18/26-left gluteus picture presented with light pink base with peeling skin and an open area revealing a hole covered in granulation and slough that was stated to be in-house acquired. Progress was described as stable previously deteriorating wound characteristics plateaued. The entire area measured 2.78 cm in length, 1.99 cm in width, and total area 4.2 cm. The picture of R100's left gluteus was inconsistent with the weekly Skin assessment dated [DATE] with no updated Skin Assessment provided. -5/20/26-left gluteus picture presented with an open red area described as MASD that was in-house acquired with no known progress. The area appeared weeping with a circular deeper open area. The area measured 10.59 cm in length, 4.56 cm in width, and a total surface area of 15.05 cm. No wound bed description or treatment was documented. The picture of R100's gluteus was inconsistent with the weekly Skin assessment dated [DATE] with no Skin assessment dated [DATE]. -5/18/26-coccyx-picture presented with deep pink area containing 3-open areas and peeling skin described by facility as MASD that was in-house acquired that was stable: previously deteriorating wound characteristics plateaued. The area measured 1.41 cm in length, 185 cm in width, and a total surface area of 1.53 cm. Wound bed had 100%, exudate amount was a light serosanguineous mixture of serous and sanguineous fluid, typically pale red and watery. Treatment included cleansing with normal saline. The picture of R100's coccyx was inconsistent with the weekly Skin assessment dated [DATE] with no updated Skin Assessment provided. -5/20/26-coccyx- picture presented a purple red area with two open areas and no peeling skin. The facility described it as MASD that was acquired in-house. The progress was unknown. According to facility documentation, the injury had increased to 4.01 cm in length, 8.17 cm in width, and a total area of 12.06 cm. No wound bed or treatment documentation had been done. The picture of R100's coccyx was inconsistent with the weekly Skin assessment dated [DATE] with no Skin Assessment provided for 5/20/26. -5/23/26-rear left trochanter picture presenting with an open lesion that was in-house acquired with no known progress. The pressure injury measured 6.35 cm in length, 9.05 cm in width and a total surface area of 36.17 cm. Granulation was 80%, slough was 20% with a moderate amount of exudate. Treatment included a cleansing solution of normal saline and a foam dressing. It was noted there was no Skin Assessment provided for 5/23/26.According to R100's Face Sheet, the resident had been admitted /readmitted on several occasions with her most recent admission dated 3/20/26.Further review of R100's most recent Face Sheet and Diagnoses provided by the facility did not include pressure ulcers upon admission date of 3/20/26.Review of R100's Nursing admission Evaluation dated 12/9/25, stated the resident had identified skin conditions/wound including a pressure injury to the right buttock. Care Plans were put into place for R100 that included impaired skin integrity with a purple area to the left flank.According to R100's Minimum Data Set (MDS) dated [DATE] (quarterly review) revealed Section M-Skin Conditions the resident did not have a pressure ulcer but was at risk of developing one. Review of R100's Skin assessment dated [DATE] did not include skin integrity issues to the resident's buttocks, sacrum, or coccyx. Review of R100's Skin Assessment (weekly) dated 4/3/26 indicated upon conducting a full skin assessment, there were no new abnormal areas observed. The existing abnormal skin areas consisted of an open pressure sore to the right and left buttocks. Review of R100's weekly skin and wound pictures dated 4/7/26, did not include the existing abnormal skin areas of an open pressure sore to the right and left buttocks. Review of R100's Skin Assessment (weekly) dated 4/12/26 indicated upon conducting a full skin assessment, there were no new abnormal areas observed. The existing abnormal skin areas consisted of redness of the buttocks. Review of R100's weekly skin and wound pictures dated 4/14/26 did not contain a picture of the abnormal redness of the buttocks stated in the resident's Skin assessment dated [DATE]. Review of R100's Skin Assessment (weekly) dated 4/20/26 indicated upon conducting a full skin assessment, there were no new abnormal areas observed. The existing abnormal skin areas consisted of redness to buttocks including blanching (blanching test: Press on the red, pink or darkened area with finger. The area should go white; remove the pressure and the area should return to red, pink or darkened color within a few seconds, indicating good blood flow. If the area stays white, then blood flow has been impaired and damage has begun). Review of R100's weekly skin and wound pictures dated 4/21/26 did not contain a picture of the abnormal redness to buttocks including blanching as stated in the resident's Skin assessment dated [DATE]. Review of R100's Skin Assessment (weekly) dated 5/3/26 indicated upon conducting a full skin assessment, there were no new abnormal areas observed. The existing abnormal skin areas consisted of open wounds to the right and left buttocks. Review of R100's weekly skin and wound pictures taken 5/6/26 revealed, did not contain a picture of existing abnormal skin areas consisting of open wounds to the right and left buttocks. Review of R100's Skin Assessment (weekly) dated 5/11/26 indicated upon conducting a full skin assessment, there were no new abnormal areas observed. The existing abnormal skin areas consisted of MASD to the coccyx, left gluteus, and left rear hip. Review of R100's weekly skin and wound pictures dated 5/11/26 revealed a picture of the rear left trochanter (hip) with an red open areas. It was described as a new in-house acquired MASD that measured 5.39 cm in length, 5.74 cm in width, with a total area measuring 25.32 cm. The surrounding tissue was black/blue. Review of R100's Skin Assessment (weekly) dated 5/19/26 indicated upon conducting a full skin assessment, there were no new abnormal areas observed. The existing abnormal skin areas included an open area to the left rear iliac crest (the thick, curved upper border of the ilium, the largest bone of the pelvis that forms the prominent top ridge of your hip that you feel when you place your hands on your waist) and left trochanter (hip), and open areas to the left and right sides of the sacrum (a large, triangular bone located at the base of the spine and the back of the pelvis). It was noted in the Skin assessment dated [DATE], existing abnormal skin areas consisted of MASD to the coccyx, left gluteus, and left rear hip which would indicate upon the current skin assessment dated [DATE], there were new abnormal areas observed. Review of R100's skin and wound pictures dated 5/20/26 and 5/21/26, did not contain pictures of an open area to the left rear iliac crest and open areas to the left and right sides of the sacrum. Review of R100's Skin Assessment (weekly) dated 5/27/26 indicated upon conducting a full skin assessment, there were new abnormal skin areas. No new abnormal skin areas were described in the designated description area. The reader was directed by the author to the existing abnormal skin areas which did not list the abnormal skin areas from the skin assessment dated [DATE]. The comment section revealed, multiple areas of open excoriation from lt. (unknown meaning) mid-back thru (through) buttocks without s/s (signs/symptoms) infection. It was noted in the Skin assessment dated [DATE], existing abnormal skin areas did not consist of multiple areas of open excoriation from mid-back through buttocks. Which would indicate upon the current skin assessment dated [DATE], there were new abnormal areas observed. There were no skin and wound pictures provided for R100's weekly Skin assessment dated [DATE]. Review of R100's Order Summary and Medication/Treatment Administration Record dated 5/1/26-5/31/26 revealed, -Left lower extremity cleanse with wound cleanser, pat dry apply xeroform to open areas, cover with non-adherent dressing ad wrap with kerlix in the evening for wound care start date 4/20/26-6/2/26. It was noted on 5/7, 5/18, and 5/27 the treatment was not documented as administered.-Sepsis precautions one time a day for purulent drainage right flank start date 5/22/26 discontinue date 6/2/26. It was noted the assessment was not documented as completed on 5/27 and 5/28.-Left flank (mid back right) wash with wound cleanser, apply calcium alginate with ag and cover with dry dressing, two times daily two times a day for wound care start date 5/21/26 discontinue date 6/2/26. It was noted on 5/22 2000, 5/26 2000, 5/27 0800 and 2000, 5/28 0800, and 5/30 2000 the treatments were not documented as completed.-Apply (brand name) cream (sterile, zinc oxide-based hydrophilic paste) to coccyx and buttocks every shift and after incontinent episode every shift for wound care start date 3/23/26 discontinue date 6/2/26. It was noted on 5/7 (evening), 5/18 (evening), 5/27 (day and evening), 5/28 (day), and 5/31 (day and evening) the treatments were not documented as completed. -(brand name) cream to all red/open areas on left gluteus (buttock), coccyx, left rear hip three times a day for skin care start date 5/11/26 discontinue date 5/19/26. It was noted on the evenings of 5/12, 5/13, 5/16, and 5/18 the treatments were not documented as completed. -(brand name) cream to all red/open areas on left gluteus (buttock), coccyx, left rear hip three times a day for skin care start date 5/19/26 discontinue date 6/2/26. It was noted on 5/22 (2000), 5/26 (2000), 5/27 (all 3 opportunities), 5/28 (0800 and 1200), 5/30 (2000), and 5/31 (all 3 opportunities) were not documented as completed.R100's Care Plan date initiated 12.9.25 with revision date of 6/5/26, identified the R100 had impaired skin integrity as evidenced by wounds to coccyx, right flank, and right/left gluteus. The goal was to show signs of healing and/or improvement by following interventions that included reporting new skin issues and completing skin inspections weekly and as needed and completing wound evaluation to observe the progress of the resident's skin condition.During an interview on 8/4/26 at 2:48 PM, Family Member (FM)/Durable Power of Attorney (DPOA) C stated she would call back on 8/5/26 as they were traveling. No call back from FM/DPOA C by end of day 8/5/25. During an interview and record review on 8/5/26 at 2:42 PM, regarding R100, Unit Managers/Registered Nurses (UM) E, F, and G, stated, (R100) had a history of wounds. Some of her wounds were in-house acquired. Expectations are for staff to report new areas, CNAs (certified nurse assistant) are to report to nurses and if UM is not available then nurses are to take a picture with the unit tablet. UM E stated, A pressure ulcer, dependent on the stage it is in, that is reddened and on a bony prominence that is not blanchable, in a few hours can develop into a stage1 pressure ulcer. I did not test (R100) for areas of blanchable skin. I did not physically do wound care for (R100). Nurses on the floor do the daily wound care. (R100) had open areas on her including her mid-back, left gluteus, coccyx, right rear and left hip. (R100) had bed baths on 5/12, 5/15, 5/19, 5/26. Staff should have reported any skin concerns to the nurse. There are no pictures of (R100) open areas to midback. There should have been. It was an expectation. The assessment of the wounds, treatments, and care plan changes should have been updated when seen to treat the wound. I see in (R100's) medical records some of those were not done as expected. UM F stated, In March 2026 (R100) had a red area on her bottom that was non-blanchable. It was an in-house acquired pressure wound. I did not test (R100) skin to see if areas were blanchable. (R100) was incontinent of bowel with a check and change every two hours so her back would have been observed by staff who should have reported skin concerns to the nurse. I took the doctor into (R100's) room and did not document the wounds that were seen. Blanching a wound indicates if there is blood return. No blood return indicates necrotic tissue which is a pressure injury (wound). UM G stated, I believe MASD can develop into a pressure ulcer. I assisted (UM F) with (R100's) with skin and wound pictures on 5/31/26. Pictures of skin and wound are to be done every seven days along with measurements for comparison and progress. (R100) was discharged from the facility after being transferred to the hospital 0n 5/29/26. UM G stated upon reviewing R100's medical records, I don't see that I charted the resident's skin was blanchable. A (Licensed Practical Nurse (LPN) H did (R100's) last skin assessment on 5/27/26. Skin assessments are to be done weekly. Nurses that do skin assessments are to take skin pictures and measurements. (R100) had multiple areas with open excoriation from mid-back to buttocks. (R100's) skin assessment dated [DATE] showed she had open areas on her buttocks, coccyx, and hip areas. (R100) did not have the open areas to mid-back described in her 5/11/26 skin assessment mid back so the mid-back open area had to open between the 5/11 and 5/19. (R100) would have had daily care many times during 5/11/26 to 5/19/26. (R100) would have been a check and change for her bowels and bed bath as well. The staff should have reported any abnormalities to the nurse on that shift. UM E, F, and G reviewed R100's medical records and agreed they could not find documentation of new open area to mid-back of R100. CNA charting alerts stated No to new skin area 5/11-5/19 (2026). UM E, F, and G reviewed R100's medical records of skin/wound picture dated 5/23/26 and agreed (R100's) left rear trochanter was a pressure ulcer. UM E, F, and G reviewed R100's medical records of skin/wound picture dated 5/23/26 and agreed (R100's) left gluteus was a pressure ulcer. UM E, F, and G reviewed R100's medical records of skin/wound picture dated 5/23/26 and agreed there no picture of (R100's) right gluteus. UM E, F, and G stated there had been no designated wound nurse since around the first of the year 2026 and unit managers were responsible for their resident's wounds.During an interview on 8/6/26 at 8:55 AM, CNA K stated, When a resident's skin looks different like a red area or a new open area, we (CNAs) are to tell the nurse immediately.During an interview on 8/6/26 at 9:24 M, Licensed Practical Nurse (LPN) J stated, When a resident is an admission they are to have a head-to-toe skin assessment. It should be done as soon as possible to have a baseline of the resident's skin. Managers put in a UDA (skin assessments, evaluations, etc.) to correlate with shower days. At that time the nurse has on their task list to do a general head-to-toe skin assessment. When a new skin breakdown is found, a picture of it should be taken by the nurse with a new picture taken each week until it is resolved. There is a tablet available for the nurse to do this with or a management approved app on our personal phones to install and use. The app charts right into the resident's chart only.During an interview on 8/6/2026 at 9:50 AM, Director of Nursing (DON) B stated, Nurses are to follow policy when a new wound is discovered. They are to chart in medical records the description of the wound, including the wound bed, drainage and size. Then the nurse is to put in the treatment given by the doctor and that they have notified the family.During an interview and record review, on 8/6/26 at 9:55 AM, Nurse Practitioner (NP) I stated while reviewing R100's medical chart, (R100) had a cycle of skin breakdown and healing. Once she stopped being positioned the wounds got worse. I knew about the mid spinal wounds. R100's coccyx and gluteal wounds had been broken and healed before. Those wounds were unstageable on a prior staged ulcer. I was trying to learn documentation with facility charting. Not all my wound documentation went under the wound notes. Facility new wound charting system had been in place since April 2026. At the point of (R100's) skin breakdown, one of the unit managers served as a wound care nurse. I would give the unit manager the treatment plan but did not determine the staging. Pressure wound staging was up to the nursing staff. I would look at the pictures that were provided and work with the clinical staff to determine the best plan of care. Moving forward, I will work with the clinical staff to make sure documentation of resident care refusals are done. I see refusal of care was not always done in nursing notes compared to what I was told because I would document what I was told. I understand the If documentation wasn't done it didn't happen.Review of R100's Progress Note dated 5/29/26 11:25 PM stated the resident was sent to a local hospital per provider's (doctor) orders.Review of R100's Progress Note dated 5/31/26 at 2:28 AM stated the resident was admitted to a local hospital related to kidney stones.Review of facility policy, Pressure Injury Prevention Guidelines revised 3/20/2024, revealed, Policy: To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for residents who are assessed at risk or who have a pressure injury present. Individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). The effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound. Considerations for needed modifications include a. Development of a new pressure injury. b. Lack of progression towards healing or changes in wound characteristics. Review of facility policy, Pressure Ulcer/Skin Breakdown-Clinical Protocol revised 03/20/2024, revealed, Policy- Based on the comprehensive assessment of a resident, a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing. 1. An admission evaluation helps identify residents at risk of developing a pressure ulcer/pressure injury (PU/PI), and residents with existing PU/PIs. Because a resident at risk can develop a PU/PI within hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent PU/PI. The admission evaluation helps define those initial care approaches. 2. Multiple factors, including pressure intensity and pressure duration, significantly affect the potential for the development and healing of PUs/PIs. The comprehensive assessment, which includes the RAI, evaluates the resident's intrinsic risks, the resident's skin condition, and other factors (including causal factors) which place the resident at risk for the development of or hinder the healing of PU/PIs. An individual may also have various intrinsic risks due to aging, such as decreased subcutaneous tissue and lean muscle mass, decreased skin elasticity, and impaired circulation or sensation. 3. The comprehensive assessment will address those factors that have been identified as having an impact on the development, treatment and/or healing of PU/PIs, including, at a minimum: risk factors, pressure points, under-nutrition and hydration deficits, and moisture and the impact of moisture on skin. The assessment also helps identify the resident who has multi-system organ failure or an end-of-life condition or who is refusing care and treatment. If the resident is refusing care, an evaluation of the basis for the refusal, and the identification and evaluation of potential alternatives is indicated. If appropriate, review hospital discharge records regarding skin alterations, bruising, skin tears, chronic conditions, or recent surgery. All PU/PI (pressure ulcer/pressure injury) or other skin related issues are measured and documented (electronic medical record in EMR facilities). Staging will be documented per National Pressure Ulcer Advisory Panel (NPUAP) and Resident Assessment Instrument (RAI) guidelines. Certified Nurse Aid completes a skin worksheet/point of care (POC) documentation with bath/shower; A resident with current PU/PI's is evaluated/assessed by the licensed nurse at each treatment and as needed. Notify Physician and Resident Representative of all new and/or non-healing/worsening PU/PIs. The staff will examine the skin of a new admission for ulcerations and/or indications of a Stage I pressure area that has not yet ulcerated at the surface. The physician will help the staff define the type (for example, arterial or stasis ulcer) and characteristics (necrotic tissue, status of wound bed, etc.) of an ulceration as needed. The IDT team will review each pressure ulcer weekly for progress and changes. During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or non-healing wounds. The physician will help the staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. According to National Pressure Injury Advisory Panel (NPIAP) at https://npiap, Stage 2 (non-blanchable erythema (redness of the skin) Intact skin with a localized area of persistent redness that does not turn white (blanch) when pressed; coloring may vary in darker skin tones. Stage 2 (Partial-Thickness Skin Loss): Loss of skin with exposed dermis. The wound bed is viable, pink or red, and moist; adipose (fat) and deeper tissues are not visible. Stage 3 (Full-Thickness Skin Loss): Full-thickness loss of skin making adipose (fat) visible in the injury. Granulation tissue and rolled wound edges (epibole) are often present, but deeper structures like muscle or bone are not exposed. Stage 4 (Full-Thickness Skin and Tissue Loss): Full-thickness skin and tissue loss with directly exposed or palpable muscle, tendon, cartilage, ligament, or bone. Slough or eschar may be visible. Unstageable Pressure Injury: Full-thickness skin and tissue loss where the true extent of damage cannot be confirmed because the extent is obscured by slough or eschar (yellow, tan, brown, or black tissue).

Based on interview and record review, the facility failed to ensure comprehensive pain assessments were completed prior to the administration of opioid medications for three of three residents (Residents #1, #2, and #3) reviewed for unnecessary medications resulting in Resident #1 experiencing an opioid overdose requiring hospitalization and the use of intravenous (IV) drip administration of opioid reversal medications medications. without appropriate evaluation of pain characteristics, severity, or need placing residents at risk for adverse effects including oversedation, respiratory depression and ineffective pain management. Findings include:Resident #1 (R1)Review of R1's electronic medical record (EMR) showed physician orders for Morphine Sulfate ER (Extended Release) 15 mg (milligram) every 12 hours and Morphine Sulfate ER 30 mg every 12 hours for chronic pain syndrome, totaling 45 mg twice daily. R1 also had an order for Hydrocodone Acetaminophen 7.5 325 mg, one tablet three times daily for moderate pain.Documentation did not contain evidence of pain assessments prior to multiple administrations of the Hydrocodone Acetaminophen, including intensity, quality, or non verbal pain indicators necessary to support a moderate pain score of 4 out of 10 per the facility's pain scale.Further review revealed R1 demonstrated symptoms consistent with opioid overmedication requiring emergency intervention early on 7/11/26. R1 was administered naloxone and transported to the hospital. Hospital records indicated R1 required two additional doses of naloxone and a continuous naloxone drip until 7/12/26, due to opioid overmedication.Resident #2 (R2)R2's EMR indicated a 6/30/26 order for scheduled Morphine Sulfate ER totaling 45 mg twice daily for cancer pain, and Morphine Sulfate 15 mg every six hours as needed for severe breakthrough pain with reassessment in 14 days. Medication Administration Records (MARs) failed to show documentation that R2's pain reached severe prior to administration of the PRN (as needed) Morphine 15 mg dose. There was no evidence the required reassessment of the PRN Morphine order was completed by 7/14/26.Resident #3 (R3)Record review showed repeated administration of Oxycodone HCl (hydrochloride) every four hours as needed for severe pain. There was no documentation verifying severe pain prior to administration, no evidence of contributing factors warranting opioid use, and no documentation that alternative interventions were considered. The record did not reflect whether the resident's response to previous opioid doses informed subsequent use.On 7/15/26 at 1:16 PM, Licensed Practical Nurse (LPN) A reported she thought moderate pain was between 3 and 5 on the pain scale but stated she would need to check with another nurse. LPN A did not demonstrate knowledge of the facility's pain scale despite actively preparing medications for administration.On 7/15/26 at 1:51 PM, acting Medical Director B stated nurses should hold scheduled opioids ordered for moderate to severe pain when a resident reports pain less than 7 out of 10. He further stated that other prescribed medications can potentiate opioids, and nurses must be vigilant for signs of overdose.At 2:16 PM on 7/15/26, Registered Nurse (RN) C stated that scheduled opioids should be administered regardless of parameters such as moderate pain, and that pain assessment was not required prior to scheduled opioid doses.During a phone interview on 7/16/26 at 2:32 PM, LPN D, who administered R1's third dose of Hydrocodone Acetaminophen on 7/10/26 with a documented pain level of 1, stated she administered it to stay ahead of the pain. LPN D reported that per the facility's pain scale, a pain level of 2 was considered moderate and therefore should be medicated.At 3:40 PM on 7/15/26, the Director of Nursing (DON) stated facility policy requires documentation of pain levels prior to administering all pain medications. However, the DON also stated she believed pain assessment was unnecessary for scheduled pain medication and thought the facility was going to change that. When asked how the facility would evaluate the need for gradual dose reductions without assessing pain before scheduled opioid administration, she was unable to respond.The facility policy titled Pain Management, revised 10/26/23, directs staff to assess pain characteristics, intensity, and need per professional standards of practice and to note such assessments prior to administering analgesic medications, including opioids.

Based on interview and record review the facility failed to ensure timely assessment and intervention for a significant change in condition (hypotension) for one Resident (#1) of three residents reviewed for quality of care.Findings include:Resident #1 (R1)Review of the Electronic Medical Record (EMR) for R1 showed on 5/13/26 at 12:29 AM, R1's blood pressure was documented as 87/38 mmHg (millimeters of mercury-pressure measurement). Review of R1's baseline vital signs indicated usual systolic readings ranging from 118-188 mmHg. According to the American Heart Association's 2025 guidelines, a normal blood pressure is 120/80 mmHg.Further review of the EMR revealed no documented nursing assessment, repeat blood pressure measurement, or evaluation of symptoms until 5:56 AM, when Licensed Practical Nurse (LPN) A documented: resident lethargic and experiencing SOB (shortness of breath). repositioned in bed and VS (vital signs) obtained. with O2 (oxygen) sat (saturation) clear to auscultation with slight wheezing noted in rt. (right) lower lobe. O2 applied via nasal cannula for comfort. [sic]. No vital signs were entered into the EMR for that time.There was no documentation indicating that the physician was notified of the hypotensive episode. Physician notes entered at 8:00 AM on 5/13/26 reflected that R1 was evaluated for abnormal urine analysis and culture; however, there was no indication that the physician had been informed of the hypotensive event.During a phone interview conducted on 6/30/26 at 4:00 PM, LPN A confirmed that a blood pressure of 87/38 mmHg would be considered significantly abnormal and would warrant immediate reassessment and provider notification. LPN A was unable to recall whether she was made aware by the CNA (Certified Nurse Aide) of the hypotensive reading and therefore could not explain the delay in reassessment and intervention for R1.The facility's failure to promptly recognize, assess, and respond to significant change in condition constituted a breakdown in clinical monitoring and nursing judgment, and placed the resident at risk for avoidable complications.The Nursing Home Administrator (NHA) sated the expectation was that CNA's would report to nursing, but could not define what they were to report as too low or too high.

Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services to prevent the development and promote the healing of pressure injuries for two Residents (#9 & #1) of three residents reviewed for wounds. This deficient practice resulted in the development of an unstageable pressure ulcer on the right foot of Resident (#9) and the deterioration of a left gluteus pressure injury from a stage three to an unstageable wound for Resident (#1).Findings include: Resident #1 (R1) Review of the Minimum Data Set (MDS) assessment, dated 1/6/2026, revealed R1 was admitted to the facility on [DATE] and had diagnoses including Parkinson's Disease, central cord syndrome (spinal cord damage), left side hemiparesis (weakness) and polyneuropathy. Further review of the MDS assessment revealed R1 required substantial/maximal assistance with bed mobility and transfers, was cognitively intact and exhibited no rejection of care behaviors during the assessment period. On 3/3/2026 at 7:35 a.m., R1 was observed in his room seated in a wheelchair watching television. It was noted during the observation, R1's lower legs, ankles and feet were swollen. R1 reported the swelling in his lower legs happened from sitting up in his wheelchair for long periods and it often improved upon laying down. When asked if he had any open wounds, R1 reported having a wound on his buttocks. R1 stated, I think it's from sitting too long and from my clothes, it was healed once. R1 reported he required assistance from staff and a mechanical lift to reposition and transfer due to spinal cord damage he obtained from a fall prior to being admitted to the facility. On 3/3/2026 at 11:35 a.m. R1 was observed in his room seated in a wheelchair watching television. R1 was asked if staff had been in to assist him to bed to reposition to which he reported he had been seated in his wheelchair since this Surveyor's previous observation at 7:35 a.m. It was noted four hours had lapsed between observations, indicating R1 was seated in his wheelchair for four hours without offloading pressure from his buttocks. During an interview on 3/3/2026 at 11:38 a.m., Certified Nursing Assistant (CNA) A reported R1 was very cooperative during care and did not have a history of declining interventions. CNA A was queried regarding R1's turning and repositioning schedule. CNA A reported R1 was assisted with transferring to lay down or sit in his recliner after meals. On 3/3/2026 at 12:43 p.m. R1 was observed seated in his wheelchair in the hall outside of the dining room. R1 was asked if he had been out of his chair since he was last observed in his room at 11:35 a.m. R1 reported he had remained in the chair then stated he would, probably after lunch, I'll go in the recliner. It was noted that more than five hours had elapsed since R1 was initially observed seated in his wheelchair at 7:35 a.m. Review of the March 2026 point of care (POC) documentation titled, Turn and reposition per care plan and PRN [as needed], revealed CNA A documented R1 was turned and repositioned at 6:00 a.m., 8:00 a.m., 10:00 a.m. and 12:00 p.m. It was noted the documentation was contrary to R1's report and the continued observations of the Resident seated in his chair. On 3/3/2026 at 1:25 p.m., R1 was observed in the dining room seated in his wheelchair. During an interview on 3/3/3036 at 1:30 p.m. CNA A reported she planned on transferring R1 from the wheelchair to his recliner after lunch. When asked about R1's routine for offloading pressure from his buttocks, CNA A stated R1, Usually wakes up around 5:00 a.m. and nightshift gets him up. CNA A reported she provided catheter care to the resident every four hours. When asked about her documentation of turning and repositioning R1 this day at 8:00 a.m., 10:00 a.m. and 12:00 p.m., CNA A confirmed she did not reposition R1 every two hours and stated, We do lift him up, when I do catheter care, I use the sit-to-stand to lift him up. When asked to clarify, CNA A reported she used the sit-to-stand mechanical lift to assist the resident to stand while she performed catheter care every four hours then sat the resident back down in the wheelchair and counted the care as repositioning. Review of R1's wound evaluation, dated 2/25/2026 at 4:53 p.m. revealed the following: Left gluteus . Pressure ulcer/injury. Progress: Deteriorating: wound characteristics deteriorated . Stage 3 Pressure ulcer/injury – full thickness skin . Wound acquired in-house. Signs and symptoms of infection: non-healing wound . Further review revealed wound measurements as: length 2.56 cm (centimeters), width 4.07 cm, depth 1.1 cm, and an area 7.8 cm2 (centimeters squared). The description of the wound bed was assessed as being 90 percent (%) covered with slough (yellow, white or tan colored dead tissue) with 10% of the wound bed left without description. The peri-wound (area directly surrounding the wound) was assessed as having rolled edges (epibole, indicating stalled healing) and unattached. The tissue surrounding the wound was assessed as, fragile. Review of R1's wound evaluation, dated 2/18/2026 at 2:31 p.m., revealed the following: Left gluteus . Pressure ulcer/injury. Progress: Improving: overall wound characteristics improved . Stage 3 Pressure ulcer/injury – full thickness skin . Wound acquired in-house . Length (cm) 3.06. Width (cm) 1.97. Depth (cm) 1.6. Area (cm2) 4.41 . The wound bed assessment was documented as 90% granulation (red or pink healing tissue) and 10% slough with attached wound edges. No epibole was noted in the assessment. The surround tissue was documented as, fragile. In review of the wound evaluations it was noted R1's left gluteal wound increased in size from 2/18/2026 to 2/25/2026 as indicated by the increased size of the wound of 2.10 cm in width, 0.5 cm in depth and 3.39 cm2 in area and the wound bed progressing from 90% healing tissue to 90% covered with slough with epibole of the peri-wound area. Further review of R1's EMR, including all wound evaluations, revealed the wound was documented as a new wound on 12/8/2025. Review of the wound evaluation dated 12/8/2025 revealed the left gluteal wound was assessed as MASD (moisture-associated skin damage) with measurements of 2.9 cm length, 1.8 cm width, 0.2 cm depth and an area of 3.8 cm2. No description of the wound bed was included in the evaluation. Review of the left gluteal wound evaluation dated 12/22/2025 revealed R1's was documented as an unstageable, pressure ulcer. Review of R1's comprehensive care plan revealed the following: Resident has an ADL [Activities of Daily Living] self-care performance deficit . Transfers: with 2 person assist and use of mechanical lift. Initiated: 12/22/2024. Resident has impaired skin integrity as evidenced by [history] of chronic MASD sacrococcygeal/glutes area . Assist resident with turning and repositioning upon rising and after meals/therapy, as HS [bedtime] and during care rounds at night. Dated Initiated 12/22/2024. Resident is at risk for impaired skin integrity related to wounds . Assist resident with turning and repositioning as needed. Dated Initiated: 12/22/2024. It was noted in review of R1's care plan, no new interventions were initiated after the Resident's left gluteal wound progressed from MASD to an unstageable pressure ulcer as documented on 12/22/2025. During an interview on 3/4/2026 at 10:30 a.m., Unit Manager/Registered Nurse (RN) D revealed R1's weekly wound evaluations were completed in the afternoons, and she would attempt to complete an evaluation later that day as R1, likes to wait until afternoon. RN D reported R1's most recent evaluation, dated 2/25/2026, revealed worsening of the wound from a healing Stage 3 wound to an unstageable (wound bed covered with necrotic tissue) due to nearly 100% of the would bed obscured. RN D was asked about R1's turning and repositioning scheduled to which she stated, We usually try to do after meals. He likes to be in his chair most of the time. Asked if the provision of catheter care constituted turning and repositioning to which she answered, Depends on how they do the care. RN reported resident lift with sit to stand while catheter care is provided may work as repositioning depending on how the resident was seated when placed back in the wheelchair. When asked if she was aware staff were documenting every two-hour repositioning, she stated they are supposed to be doing rounds every two hours and offering repositioning at that time. RN D reported all refusals by R1 to reposition should be documented in the EMR. During an interview on 3/4/2026 at 10:40 a.m. the Director of Nursing (DON) reported all refusals of care should be documented in the EMR. The DON stated if a resident refused at one time to turn/reposition or offload pressure that staff should still be approaching the Resident on a consistent basis to offer assistance and provide education related to the need to offload pressure from wounds. The DON reported refusals to turn and reposition should never be normalized as the refusal may only be situational and documentation of refusals was necessary to determine ongoing care planning. The DON confirmed the CNAs lifting R1 to stand during catheter care and immediately placing the Resident back in the chair seated on his buttocks did not constitute turning and repositioning or provide enough offloading to allow tissue to recover from the continued pressure of being seated in the wheelchair. Review of the facility policy titled, Pressure Injury Prevention and Management, last revised 3/20/2024, revealed the following: Interventions for Prevention and to Promote Healing . Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to . redistribute pressure (such as repositioning, protection and/or offloading .) . Review of the National Pressure Injury Advisory Panel (NPIAP) guideline titled, Repositioning for Pressure Injury Prevention dated 2/25/2025 and accessed on 3/12/2026 (https://www.internationalguideline.com/repositioning), revealed the following: Extended periods of lying or sitting on a particular part of the body without redistributing the pressure leads to deformation of tissues and, ultimately if damage thresholds are exceeded, tissue damage in the form of a PI [pressure injury]. Repositioning and mobilization are essential preventive measures for reducing PI occurrence. The recommendations and good practice statements presented below are generally relevant to all individuals at risk of PIs . Good Practice Statement: It is good practice to reposition the individual in such a way that optimal offloading of pressure points and maximum redistribution of pressure are achieved . It is good practice to determine appropriate and individualized repositioning intervals based on a comprehensive assessment of the individual's: level of activity and mobility; ability to independently reposition; skin and tissue tolerance; . goals of care . It is good practice to assess for signs of early skin and tissue injury that may meal the individual requires more frequent repositioning or preferential positioning off damaged areas . Resident #9 (R9): Review of R9's Electronic Medical Record (EMR) revealed initial admission to the facility on 1/28/26 with diagnoses including paraplegia (an impairment in motor and/or sensory function of the lower extremities) and aftercare following surgery on the skin and subcutaneous tissue (the deepest layer of the skin, primarily composed of fat and loose connective tissue). Review of R9's acute care Discharge Summary on 1/27/26 read, in part: .Procedures and Treatments Provided: Left ischial (a bone located in the pelvis that bears weight while sitting or lying) pressure wound reconstruction with V-Y advancement flap (a reconstructive surgical technique used to repair skin defects by advancing a triangular island of tissue into a wound, with the donor site closed in a Y-configuration). Patient education: .[Brand Name] bed (a specialized air-fluidized therapy bed designed for advanced wound care) only. Review of a physician order, dated 2/5/26 at 20:48 [8:48 PM], read: Staff to monitor resident to ensure that his feet are not resting against the inner ridge of sand bed causing pressure areas - may use pillow or other appropriate device. Review of R9's EMR revealed the following entries: Skin Issue on 2/17/26 at 12:07 PM: .New skin Issue. Location: Right lateral [outside] foot. Issue type: Pressure ulcer / injury. Progress: New: new wound. Pressure ulcer staging: Unstageable pressure ulcer / injury. Wound acquired in-house. Length (cm) [centimeters]: 0.82 Width (cm): 0.98 Depth (cm): 0 Area (cm2): 0.61. Skin Issues Note: Resident is on a Sand bed and part of the air flow was and is not working properly. The air ring around the sand part of the bed was/is not filling with air and resident's right foot was leaning against it causing this wound, call to schedule repair made and is set for tomorrow. Pertinent Charting – Skin on 2/17/26 at 14:06 [2:06 PM]: Location of skin area being documented: right lateral foot. Resident is on a Sand bed and part of the air flow was and is not working properly. The air ring around the sand part of the bed was/is not filling with air and resident's right foot was leaning against it causing this wound. On 3/4/26 at 12:55 PM, an interview was conducted with Unit Manager/Registered Nurse (RN) D regarding the development of the unstageable pressure injury to R9's right foot. RN D stated when she came into R9's room to complete wound treatments on 2/17/26, she noted his right foot was in contact with a malfunctioning deflated portion of a cushion made of a hard plastic surrounding the perimeter of the bed. RN D estimated the air flow had become compromised at some point during the night and R9's foot had been in contact with the inner edge of the sand bed for approximately 12 hours until it was discovered the next day which had ultimately caused the injury. This Surveyor attempted to contact R9 who was hospitalized on [DATE] for an unrelated concern; R9 was unavailable for interview.

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 that consume food from the kitchen. Findings Include:On 3/2/2026 at 11:20 AM, the floor, sewage drain lines and floor drain under the three-compartment sink were observed soiled with dirt and food debris. On 3/2/2026 at 11:22 AM the drain line coming from the 2-compartment vegetable wash sink was observed soiled. On 3/2/2026 at 12:04 PM The floor under the hand sink was observed soiled. On 3/2/2026 at 12:05 PM, when asked who was responsible for cleaning of floors and equipment in the kitchen Dietary Director (DD) confirmed, that the dietary staff are responsible for these tasks, not the maintenance staff. According to the 2022 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions. (A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. On 3/2/2026 at 12:08 PM 12 room trays were observed with uncovered cake on the Hall B North delivery speed rack. On 3/2/2026 at 12:26 PM during meal pass observed CNA K remove the lunch tray from the speed rack. The meal was covered with a protective lid and the cake was uncovered. CNA K took the tray into the resident's room. According to the 2022 FDA Food Code section 3-307 Preventing Contamination from Other Sources 3-307.11Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 -3-306. During lunch observations on 3/2/26 at 12:08 PM, a cart used to transport meal trays to residents eating in rooms was noted to be placed in the south hallway. When the cart was opened, it was observed that 12 chocolate cakes were not covered in plastic wrapping. Staff were observed to be transporting the uncovered chocolate cakes from the cart down the hallway to resident rooms. At 12:17 PM a second cart was observed to have 11 uncovered chocolate cakes. At 12:52 PM a third cart was observed with eight uncovered chocolate cakes.

Based on observation, interview, and record review, the facility failed to store medications securely and discard expired medications in two of two medications rooms and two of three medication carts reviewed for medication storage.Findings include:On 3/3/26 at 12:30 PM, an observation was made of medication cart located on East Hall and was found to be out of compliance with the following 14 loose medications in the second and third drawers where a moderate amount of medication debris and paper backings were also noted:Lamotrigine 200 mg (milligrams) with imprinting of D 96 and scored on the back side and light blue in color shaped like a shield with six-sides,Klor-Con M20 20 mEq (milliequivalents) with imprint KC M20, white oblong,Haloperidol 10 mg (half tab) pill card was found to have full tabs, light green in color and oblong with imprint 08,Levetiracetam Extended Release 500 mg white oblong with imprint HH 172,Losartan Potassium 50 mg green oval with imprint E 46 (2 tabs found),One white round pill without any markings and unable to identify,Metoprolol Succinate Extended-Release 25 mg white oblong with imprint I 25,Amlodipine Besylate 5 mg white round with imprint C 127 (2 tabs found),Apixaban 5 mg pink oval with imprint 894 5,Amlodipine Besylate 5 mg with round with imprint V 21,Olanzapine 2.5 mg white oblong with imprint R 2.5 / 0163,Metoclopramide Hydrochloride 5 mg white round with imprint TV / 2204,Three insulin pens were dated after being opened, but lacked an expiration date.On 3/3/26 at 12:40 PM, an interview was conducted with Licensed Practical Nurse (LPN) N who was asked why there were so many loose pills in the medication cart and replied, I guess it is because the pill cards are so tightly packed in there. LPN N was asked how often the medication carts were cleaned out and replied, I am not sure, but night shift does that.On 3/3/26 at 12:45 PM, an observation was made of the medication storage room for East Hall which was found to be out of compliance. One opened vial of tuberculin purified protein derivative 1 ml (milliliter) with an opened date of 1/13/26 was in the storage area and had no expiration date written.On 3/3/26 at 12:50 PM an interview was conducted with LPN N who was asked how long the vial was good for after opening and if it should still be in the active medication storage supply and replied, It should only be kept for 30 days after opening and have an expiration date. The vial should not still be in the refrigerator and needs to be thrown away.On 3/3/26 at 1:00 PM, an observation was made of medication cart located on North Hall and was found to be out of compliance with the following 3 loose medications in the second and third drawers where a moderate amount of medication debris and paper backings were also noted:Carbidopa and Levodopa 25/100 mg yellow round tab with imprint APO 25/100,Amlodipine 2.5 mg white round with imprint 2.5,Levetiracetam 500 mg yellow oblong with imprint H 88.On 3/3/26 at 1:10 PM, an interview was conducted with Registered Nurse (RN) Q who was asked about loose pills in the medication cart and replied, The Unit Manager just looked in the medication cart, and I am not sure why the loose pills are still in there. RN Q stated, The cards are tight and that she did dispense the Levodopa/Carbidopa this morning.On 3/4/26 at 8:05 AM, an interview was conducted with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) who both were asked about medication storage expectations and acknowledged that loose pills, clean medication carts, and expired medications were unacceptable. The DON stated, The medication carts and rooms are audited by the night shift nurse. The DON was asked if there was a check off sheet indicating the task was competed and dated and replied, I would have to check. No definitive documentation was provided by the close of survey indicating when the last cleaning or audit of the medication carts and storage was performed.Review of policy titled, Medication Storage, 1/30/24, read in part, Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines.7. Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs Policy.Review of policy titled, Medication Administration, 1/17/23, read in part, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 1. Keep medication carts clean, organized, and stocked with adequate supplies.

This citation pertains to intake #2732400Based on observation, interview, and record review, the facility failed to:Provide Resident #49 (R49) sanitary catheter care,Provide a sanitary barrier and administration for medication,Implement and utilize enhanced barrier precautions (EBP) while performing Resident #12 (R12) high contact care administering medication via feeding tube,Maintain facility equipment in a sanitary manner, and;Ensure personal protective equipment (PPE) was stored in a sanitary manner.Findings include:On 3/3/2026 at 9:21 AM, the B Side Nurses Station soiled utility room hopper was observed soiled. The water was clean but observed the bowl with grime build up. Personal Protective Equipment (PPE) items including opened and closed boxes of gloves, face shields and face masks were observed stored on wire racks directly across from the bowl of the hopper. One closed box was within 10 inches of the bowl, and opened boxes were within 18 inches of the soiled hopper. This practice exposed all these items ot overspray from the hopper spray nozzle. On 3/3/2026 at 11:24 AM observed Registered Nurse (RN) M getting face shields and other PPE out of the Soiled Utility room to dispense to staff. Record review of the facilities policy – Personal Protective Equipment Revised 12/7/2023 stated Policy Explanation and Compliance Guidelines: 6. PPE Supply Management: a. The central supply clerk is responsible for ordering and maintaining adequate PPE supplies and stocking in appropriate facility locations to ensure access to staff who need them. Resident #49 (R49) On 3/2/26 at 12:43 PM, an interview was conducted with R49 who was asked if he had any recent urinary tract infection (UTI) and replied, Yes, I have had a few over the last couple of months. R49 was asked if the care assistance use PPE while providing cares and replied, They do not always wear a gown while performing catheter care. Review of R49's Minimum Date Set (MDS), dated [DATE], indicated that R49 had intact cognition. On 3/2/26 at 2:19 PM, a chart review was conducted for R49, which revealed a recent hospitalization on 12/12/25 and 1/13/26 for a UTI and a recent hospitalization on 2/19/26 for another UTI. During an observation on 3/3/26 at 9:40 AM, with Certified Nurse Aide (CNA) O who was performing catheter care on R49 the following occurred: CNA O gathered washcloths (four) and added warm water, CNA O came out of the bathroom and placed the washcloths over the right-side bedrail of R49's bed, CNA O wiped R49's peri area with the first washcloth then proceeded to remove the trash bag form R49's garbage can and remove a clear bag to add the dirty linens in (no visible soap residue was observed after using the first wash cloth, CNA O continued to clean R49's peri area with the other three washcloths, CNA O then removed the soiled brief from R49 and replaced it with a clean one, CNA O did not change her gloves or use hand sanitizer during the entire process, CNA O knocked over R49's water bottle with a rubber straw on to the floor that had visible dirt and old French fries on the floor and placed it back on to R49's bedside table. An interview was conducted with CNA O on 3/3/26 at 9:53 AM, who was asked about hand hygiene and why she did not use a barrier for the washcloths or change her gloves while providing catheter care and replied, I don't know. I should have. I normally use a barrier. On 3/3/26 at 7:25 AM, an observation was made of Licensed Practical Nurse (LPN) N drawing up insulin for Resident #28 (R28). LPN N drew up R28's insulin lispro and placed it on the top of her medication cart without a barrier. On 3/3/26 at 7:28 AM, an observation was made of LPN N entering R28's room and placing the insulin syringe on the top of the dresser without a barrier. On 3/3/26 at 7:30 AM, an interview was conducted with LPN N regarding barriers to ensure medications were sanitary and replied, I forgot to place a barrier and should have. Resident #12 (R12) On 3/3/26 at 9:03 AM, an observation was made of LPN N administering medications to R12 via peg tube without wearing a gown. During an interview on 3/3/26 at 9:20 AM, LPN N was asked if she should have been wearing PPE during the administration of medication via feeding tube with R12 and replied, I forgot. I should have been wearing a gown. I did not mean to do that. It was an error on my part. Review of R12's physician order, dated 2/2/26, revealed an order to Use enhanced barriers while performing high-contact activity with the resident r/t (related to) Tube Feed. On 3/4/26 at 12:35 PM, an interview was conducted with R12 in her room who was asked if staff are consistently wearing PPE while providing care related to her tube feed and replied, No, they do not wear a gown while providing cares. Review of R12's MDS, dated [DATE], indicated that R12 had intact cognition. Resident #8 (R8) On 3/3/26 at 12:20 PM, an observation was made of LPN N dispensing an antianxiety medication for R8. LPN N touched the antianxiety medication with her bare hands and then administered the medication to R8. On 3/3/26 at 12:22 PM, an interview was conducted with LPN N who was asked why she touch the medication for R8 with her bare hands and did not give him a different medication and replied, I touched it because it was stuck in the packaging and I should have put gloves on. On 3/4/26 at 7:35 AM, during an interview, Registered Nurse (RN)/Unit Manger R was made aware of the breaches in infection control during cares between staff and residents and replied, I will let the infection control nurse know and they can address this. On 3/4/26 at 12:05 PM, an interview was conducted with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) who were both asked about infection control and resident cares. Both the NHA and the DON acknowledged errors and breaches with the above observations in staff to resident interactions. Review of policy, Personal Protective Equipment, dated 12/7/23, read in part Policy: This facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff.Policy Explanation and Compliance Guidelines: 1. All staff who have contact with residents and/or their environment must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious materials is likely.4. Indications/considerations for PPE use.Change gloves and perform hand hygiene between clean and dirty tasks.

Based on observation, interview and record review, the facility failed to monitor for acute illness and provide timely physician notification of change in condition for two Residents (#68 & #78) of five residents reviewed for hospitalization. This deficient practice resulted in delay of treatment and the potential for worsening of condition.Findings include: Resident #78 (R78) Review of R78's EMR revealed initial admission to the facility on 6/25/21 with diagnoses including presence of a tracheostomy (a surgical procedure which creates an opening through the neck to provide an alternative airway), presence of a gastrostomy (a surgical procedure that creates an opening through the abdominal wall directly into the stomach to insert a feeding tube), and chronic obstructive pulmonary disease (COPD). Review of R68's most recent MDS assessment, dated 1/7/26, revealed a BIMS score of 15, indicative of intact cognition. On 3/3/2026 at 7:55 AM, R78 was observed lying in bed. R78 acknowledged they were recently hospitalized but they were unable to provide specific clinical details. Review of R78's EMR revealed the following entries: Encounter Note on 12/26/25 at 8:00 AM: Situation: Hypotension [low blood pressure] persists – Midodrine [a medication used to treat low blood pressure] administered at 12:30 [PM], blood pressure taken just now showed 88/33. Nursing Evaluation Summary on 1/7/26 at 21:06 [9:06 PM]: 81 yo [year-old] alert and oriented man re-admitted .following extended hospital stay for UTI [urinary tract infection] and strept [sic] throat. Client has been long time enteral feeding patient [delivering nutrition via a feeding tube], NPO [nothing by mouth] as well as indwelling foley catheter and trach [tracheostomy]. Patient as well as [sic] 02 [supplement oxygen] dependent. Review of the facility census revealed R78 was hospitalized from [DATE] – 1/7/26. Further review of R78's EMR revealed no further monitoring after identification of a critically low blood pressure on 12/26/26 and no documentation outlining the clinical justification for R78's hospitalization on 12/28/26. Review of an Infectious Disease Progress Note from a local acute care hospital, dated 1/2/26 at 13:49 [1:49 PM], read, in part: [R78] is an 81 yo [year-old] man admitted to [hospital name] with 1-2 day history of sore throat, fevers, weakness, and hypotension. He was found to have streptococcal bacteremia [strep throat]. Review of R78's Hospital Summary from a local acute care hospital, dated 1/7/26 at 14:49 [2:49 PM], read, in part: .All diagnoses this visit: hypovolemic shock (a life-threatening, emergency condition caused by a severe, rapid loss of blood or bodily fluids), sepsis (a life-threatening condition which occurs when blood pressure drops to a dangerously low level after an infection), streptococcal bacteremia, chronic respiratory failure with hypoxia, COPD. On 3/4/26 at 12:30 PM, an interview was conducted with the DON regarding her expectation with monitoring, following up, and notifying the physician about changes in medical conditions. The DON stated the facility had already identified this as an area as an opportunity for improvement. The DON confirmed the EMR should reflect ongoing monitoring of a change in condition (including vitals), notification of a physician given a significant change in clinical status and ensuring transfer forms are completed when sending a resident out of the facility for further evaluation. The DON verified all three elements should have been included in R78's EMR prior to his 12/28/25 hospitalization. Resident #68 (R68) Review of the Minimum Data Set (MDS) assessment, dated 2/20/2026, revealed R68 was admitted to the facility on [DATE] and had admitting diagnoses including sarcoidosis (chronic abnormal collections of inflammatory cells in lungs, skin and lymph nodes) of the lung, pneumonia, and pneumothorax (abnormal collection of air in the lung space. Section C of the MDS revealed R68 scored 15 out of 15 on the Brief Interview for Mental Status, indicating he was cognitively intact. An observation on 3/3/2026 at 8:45 a.m. revealed R68 seated in a recliner in his room. R68 was noted to be receiving supplemental oxygen via a nasal cannula with tubing attached to a portable concentrator set to deliver 3L (liters)/minute. During an interview at the time of the observation, R68 reported he was recently hospitalized due to increased weakness and shortness of breath. Review of the electronic medical record (EMR) revealed R68 was transferred to the hospital on 2/17/2026 and returned to the facility on 2/21/2026. Review of R68's, Hospital Summary, dated and signed 2/21/2026 at 8:50 a.m., revealed the following: [R68} presents from [facility] with shortness of breath and hypotension [abnormally low blood pressure], found to have acute anemia [lack of sufficient red blood cells secondary to] . GI bleed. Acute blood loss anemia secondary to esophagitis with esophageal ulcer. Presented with Hgb [hemoglobin] of 7.1, decreased from 12 on 2/6 [2/06/2026]. Received a total of 2 units packed red blood cells . Review of R68's vital sign documentation, gleaned from the EMR, revealed a change in the Resident's condition occurred when his blood pressure dropped from 101/71 mmHg [millimeters Mercury] on 2/16/2026 at 9:04 a.m. to 70/43 mmHg on 2/16/2026 at 4:39 p.m. Review of the EMR revealed no documentation of physical assessment, manual blood pressure rechecks or physician notification by R68's attending nurse to correspond with the change in condition or any other documentation referencing the drop in the Resident's blood pressure on 2/16/2026 at 4:39 p.m. It was noted R68's blood pressure reading of 70/43 mmHg on 2/16/2026 at 4:39 p.m. was documented as completed by non-Certified Nursing Assistant (nCNA) B. Further review of the EMR revealed R68's next recorded blood pressure reading was 75/52 mmHG on 2/17/2026 at 3:23 a.m. and documented as completed by CNA E. Review of the EMR revealed no documentation of physical assessment, manual blood pressure rechecks or physician notification by R68's attending nurse or any documentation referencing the Resident's continued hypotension. During an interview on 3/4/2026 at 7:50 a.m., Registered Nurse (RN) C was asked what the process was for responding to a resident with a change in condition, such as a drop in blood pressure indicating hypotension. RN C reported he had instructed the CNAs to report to him immediately of any abnormal vital signs, so he is able to follow up with an assessment of the resident to determine need for intervention and physician notification. RN C reported he was aware of R68's condition warranting transfer to the hospital on 2/17/2026. RN C reported he was assigned to the care of R68 for the day shift (6:00 a.m. – 6:00 p.m.) on 2/16/2026. During a record review at the time of the interview, RN C confirmed there was no documentation in reference to R68's blood pressure reading of 70/43 mmHG on 2/16/2026 at 4:39 p.m. RN C stated he was unsure if he worked a full shift that day as he did not remember R68's condition changing until he arrived the morning of 2/17/2026 at which time he obtained an order for midodrine (a medication to raise blood pressure). RN C was asked if CNA vital sign documentation required verification by licensed nursing staff to which he answered, yes, I would have had to sign-off on it. RN C did not remember being notified by nCNA B on 4/16/2026 of R68's blood pressure reading of 70/43 mmHg. During an interview and record review of R68's EMR on 3/4/2026 at 8:59 a.m., the Director of Nursing (DON) confirmed there was no documentation on 2/16/2026 in reference to the Resident's drop in blood pressure from 101/71 mmHg on 2/16/2026 at 9:04 a.m. to 70/43 mmHG on 2/16/2026 at 4:39 p.m. The DON reported she was unable to determine through review of the EMR if a follow-up assessment or physician notification had occurred in response to the change in condition but would continue to review and report back to the survey team. On 3/04/2026 at 10:35 a.m., the DON presented documentation of physician notification through the notification messaging application used by the facility. Review of the notification documentation with the DON revealed a message was sent to the covering provider by RN C on 2/16/2026 at 8:30 p.m. The DON confirmed the provider was notified of the initial blood pressure reading of 70/43 mmHg nearly four hours after the Resident's blood pressure was recorded at 4:39 p.m. The DON reported messages conveyed via the application were not part of the EMR. The DON reported R68 was seen by two providers on 2/16/20026. Review of the documentation provided by the DON revealed R16 was assessed by Nurse Practitioner (NP) F on 2/16/2026 at 10:00 a.m. Review of NP F's progress note revealed no mention of R68's hypotension and listed the Resident's blood pressure as 122/56 mmHg, which correlated with the blood pressure documented under vital signs in the EMR on 2/16/2026 at 1:39 a.m. Further review of the documentation provided by the DON revealed a New Follow Up Note ., dated and signed by NP G for a date of service listed as 2/16/2026 at 3:04 p.m. It was noted in review, NP G documented [R68} is also having some light headedness . may need midodrine if not able to stay above 90 SBP [systolic blood pressure] . Vitals . BP [blood pressure] 101/71 [mmHg] . It was noted R68's blood pressure reading referenced by NP G in the progress note correlated with the Resident's blood pressure documented under vital signs in the EMR on 2/16/2026 at 9:04 a.m. It was noted in review of the documentation provided by the DON that both NP assessments were conducted prior to R68's blood pressure dropping to 70/43 on 2/16/2026 at 4:30 p.m. The DON also presented the following documentation: Pertinent Charting Follow-Up – Infections/Signs & Symptoms – V2, dated 2/16/2026 at 2:06 p.m. Follow up to infection/signs & symptoms that occurred on: 2/06/2026 . Pneumonia . No s/sx of infection noted or reported today. It was noted in review, the document did not apply to the Resident's change in condition noted by the drop in blood pressure on 2/16/2026 at 4:39 p.m. Review of a Progress Note, dated 2/17/2026 at 8:00 a.m., signed by Nurse Practitioner (NP) F, revealed the following: . [R68] was having low blood pressures this morning, midodrine was added with no relief as the day went on, he continued to have significantly low blood pressure without explanation . Vital signs . Blood pressure: 86/55 mmHg . Will be sent to the emergency department for evaluation as a differential for this is broad. Review of R68's February 2026 Medication Administration Record (MAR), revealed an order for Midodrine HCL Tablet 5 MG [milligram]. Give 1 tablet by mouth one time only for hypotension for 1 day. Start Date: 2/17/2026 0815 [8:15 a.m.]. One dose of the midodrine was documented as administered at 9:00 a.m. Further review revealed a subsequent order for Midodrine 5 MG Tablet. Give 1 tablet by mouth two times a day for hypotension. Start Date: 2/17/2026 1100 [11:00 a.m.]. One dose of midodrine 5mg was documented as administered on 2/17/2026. The dose administration was not time stamped therefore the time of administration could not be verified. It was noted the intervention initiated to treat R68's hypotension did not occur until nearly 16 hours after the initial drop in blood pressure on 2/16/2026 at 4:39 p.m. Review of the SBAR Communication Form and progress note – V4, dated 2/17/2026 at 1:13 p.m., revealed the following: Situation: The change in condition, symptoms, or signs I am calling about is/are: Low blood pressures . This started on 2/17/2026 . Most recent blood pressure . 79/50 (mmHg) . One time order for midodrine given this morning with no results, second dose given with no change in BP. Resident is no reporting some minor dizziness . Transfer to the hospital . Reported by [NP G] on 2/17/2026 [no time entered] . On 3/4/2026 at 12:45 p.m., the DON reported no more documentation was available related to the response for R68's drop in blood pressure from 2/16/2026 at 4:39 p.m. through the Resident's hospitalization on 2/17/2026.

Based on interview and record review, the facility failed to ensure the Long-Term Care Ombudsman was notified of a resident's discharge from the facility for two Residents (#7 & #12) of two residents reviewed for discharge practices.Findings include:Resident #7 (R7) Review of R7's Electronic Medical Record (EMR) revealed the resident was discharged from the facility on February 20, 2026, to an apartment. Review of the documentation provided to the Long-Term Care Ombudsman in February, indicated they were not notified of the resident's discharge from the facility. Resident #12 (R12)Review of R12's EMR indicated R12 was sent to the emergency department on February 28, 2026. Review of the documentation provided to the Long-Term Care Ombudsman in February, indicated they were not notified of the resident's discharge from the facility.On 3/3/2026 at 1:49 PM, an interview was conducted with the Nursing Home Administrator (NHA), she stated the Ombudsman notification had only to consist of emergent transfers that were discharged from the facility. Review of the facility's policy titled Transfer and Discharge (including AMA) indicated in part: .7. Emergency Transfers/Discharges.k. Social Services Director, or designee, shall provide notice of transfer to a representative of the State Long-Term Care Ombudsman via monthly list. There was not designation in the facility's policy to notify the Long-Term Care Ombudsman under .Anticipated Transfers or Discharges - initiated by the resident.

Based on observation, interview, and record review, the facility failed to accurately dispense insulin to one Resident (Resident #28) of one resident reviewed for insulin administration resulting in a significant medication error.Findings include:On 3/3/26 at 7:25 AM, an observation was made of Licensed Practical Nurse (LPN) N drawing up insulin for Resident #28 (R28). LPN N drew up R28's insulin lispro and placed it on the top of her medication cart, locked her computer screen, and her cart. LPN N was proceeding to R28's room to administer his insulin and this Surveyor asked LPN N how many units R28 was to receive and to see the insulin she had drawn up in the syringe. This surveyor had observed LPN N had drawn up the incorrect dose of insulin for R28 and returned the syringe to LPN N who returned to R28's insulin order and then realized that she had the incorrect amount in the syringe. LPN N had drawn up 14 units and R28 was only to receive 9 units. LPN N commented, I should have double checked the dose.On 3/3/26 at 7:28 AM, LPN N was observed administering insulin to R28 and held the subcutaneous injection site for four seconds.On 3/3/26 at 7:30 AM, an interview was conducted with LPN N regarding how long she was to hold the injection site and replied, Ten seconds. LPN N was made aware she only held the needle in place for four seconds. LPN N remarked, I guess I counted fast .Review of R28's insulin order, dated 3/2/26, revealed an order for insulin lispro on a sliding scale and a blood glucose level of 144. Reflecting R28 was to receive 9 units of insulin and not 14 units of insulin LPN N had originally drawn up.On 3/4/26 at 7:35 AM, an interview was conducted with Registered Nurse/Unit Manager R, who was asked what his expectations were for medication administration and acknowledged nurses should be double checking insulin doses as well as all other medications administered prior to administration.On 3/4/26 at 8:05 AM, an interview was conducted with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) both were asked about medication administration expectations and acknowledged nurses should follow the five rights of medication administration and double check all medication doses including insulin.Review of policy titled, Medication Administration, dated 1/17/23, read in part, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines.10. Review MAR (Medication Administration Record) to identify medication to be administered. 11. Compare medication source with MAR to verify resident name, medication name, form, dose, route, and time of administration.

Based on interview and record review, the facility failed to complete, readily act upon, and implement monthly pharmacy recommendations for two Residents (#2 e) of five residents reviewed for medication review.Findings include: Resident #2 (R2) Review of R2's Electronic Medical Record (EMR) revealed initial admission to the facility on 4/3/25 with diagnoses including dementia, repeated falls, and post-traumatic stress disorder (PTSD). Review of R2's EMR revealed Pharmacy Medication Review Progress Notes on 9/20/25 and 12/1/25 that read, Monthly medication regimen review performed. Comment/Recommendation noted – see report. On 3/3/26 at 1:59 PM, this Surveyor requested a copy of both reports from the Nursing Home Administrator (NHA) and Director of Nursing (DON). The reports were not provided by the time of survey exit. Review of a Nursing Recommendation written by Consultant Pharmacist H on 11/7/25 read, in part: [R2] has an order for [antipsychotic medication] which may cause orthostatic hypotension (a sudden, significant drop in blood pressure that occurs within three minutes of standing up). Please consider periodic checks for possible orthostatic hypotension by taking BP [blood pressure] reclining and then standing. A drop of 20 points in systolic or 10 points in diastolic pressure points in diastolic pressure indicates orthostatic hypotension which may be a cause of falls. Please add monthly OR quarterly checks to MAR [medication administration record]. Review of the EMR revealed no physician response but a hand-written note on the recommendation reading, orthos [blood pressure checks for orthostatic hypotension] added in 2/1/26 quarterly, over two months after the initial recommendation. Review of the facility policy titled, Addressing the Medication Regimen Review Irregularities, revised 12/28/23, read, in part: It is the policy of this facility to provide a Medication Regimen Review (MRR) for each resident to identify irregularities and respond in a timely manner to prevent the occurrence of an adverse drug event. Any irregularities noted by the pharmacist during this review must be documented on a separate, written report which may be in paper or electronic form. The report will be sent to the attending physician, the facility's medical director and director of nursing and lists, at minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. The attending physician must document in the resident' medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. The report should be submitted to the DON within 10 working days of the review. If documentation of the findings is not in the active record, it will be maintained within the facility and will be readily available for review. R101 Review of R101's EMR revealed initial admission to the facility on [DATE] with diagnosis including chronic systolic heart failure. Review of R101's EMR revealed Pharmacy Medication Review Progress Note on 11/20/25 that read, Monthly medication regimen review performed. Comment/Recommendation noted – see report. Review of R101's Nursing Recommendations- Includes the following Classifications: MRR (Monthly Medication Review) for recommendations created between 11/1/25and 11/27/25 revealed the following recommendation, Lidocaine Patches may remain in place for up to 12 hours in any 24-hour period. Please add a note to the MAR (Medication Administration Record) Date 11/20/25 lidocaine patch order that clarifies the patch should be left on for 12 hours and then removed. It was noted that a physician signature, undated, signed off on this recommendation. Review of R101's MAR for March 2026 revealed the following order, Lidocaine Pain Relief Patch 4%; Apply to right knee topically in the morning for pain, on AM off PM; Start Date: 2/7/26. An interview conducted with the Nursing Home Administrator (NHA) on 3/4/26 at 11:43 AM confirmed that R101's MRR for November 2025 was not correctly entered into R101's EMR.

Based on observation, interview, and record review, the facility failed to ensure smoking paraphernalia was stored in a secure location for one Resident (#52) of two residents reviewed for smoking.Findings include:Resident #52 (R52)Review of R52's electronic medical record (EMR) revealed initial admission to the facility on 8/25/17 with diagnoses including chronic obstructive pulmonary disease (COPD), malignant neoplasm of the lung (cancer), and personality disorder. On 3/2/2026 at 1:45 PM, an interview was conducted with R52 who confirmed he was a smoker. A vape (a battery-operated electronic device used to heat liquid into a vapor that can be inhaled), approximately the size of a pen, filled with a light brown liquid, was observed in R52's lap. An unopened package of four pocket lighters was observed on an unused electric fireplace underneath the windowsill. An oxygen concentrator was positioned next to the bed with a nasal canula laying over an adjacent bedside table. On 3/2/2026 at 4:09 PM, R52 was observed ambulating out to the designated smoking area at the predetermined smoking time. R52 was observed removing a lighter from his jacket pocket and removing a box of cigarettes from a bag attached to his four wheeled walker. R52 subsequently lit the cigarette and began smoking and returned the items to their respective places.On 3/4/2026 at 9:58 AM, an interview was conducted with R52 who verified he keeps his own cigarettes and lighter because he's independent and can leave the building when he wants to smoke. R52 indicated there are other residents in the facility who also keep their own cigarettes in their room. R52 confirmed he did have a vape but only uses it outside. When asked about the oxygen concentrator, R52 said he utilizes it when his oxygen gets below a certain saturation. The pocket lighter package was observed to be opened on top the unused electric fireplace with one lighter missing.Review of R52's Plan of Care reviewed a Focus initiated on 8/22/23 which read, Resident chooses to smoke. An intervention, dated 11/16/23, read, Keep oxygen away from smoking materials. Ensure removal prior to resident smoking, if applicable.On 3/4/26 at 12:30 PM, an interview was conducted with the Director of Nursing (DON) regarding the facility's smoking policy. The DON indicated all smoking paraphernalia should be locked up and stored by staff when not in use.Review of the facility policy titled, Smoking Policy Smoking Campus-Residents, revised 12/31/25, read, in part: It is the policy of this facility to establish and maintain safe resident smoking practices. This policy also includes electronic cigarettes. smoking items (cigarettes, lights, etc.) will be kept secured in a designated area with limited staff access. Residents with smoking privileges small not be permitted to retain any types of smoking articles, to include cigarettes, tobacco, etc., either on his or her person or within his/her living or sleeping area, at any time.

Based on observation, interview and record review, the facility failed to appropriately assess and implement timely interventions for weight loss for one Resident (R54) of three reviewed for weight loss. Findings include:Review of R54's Electronic Medical Records (EMR) revealed admission to the facility on 7/11/25 with diagnoses including vascular dementia with anxiety and muscle weakness. R54's 1/23/26 Quarterly Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 2/15, indicating severe cognitive impairment.On 3/3/26 at 9:05 AM, R54 was observed sitting in a geri chair in her room. An interview was attempted with R54, but she was unable to answer questions appropriately. R54 appeared well dressed but thin with fragile skin. A review of R54's weights revealed the following entries: 8/5/25 - 142 lbs (pounds) 9/2/25 - 142.4 lbs 10/1/25 - 140.8 lbs 11/1/25 - 138.4 lbs 12/1/25 - 138.9 lbs 1/9/26 - 130.8 lbs 2/8/26 - 124.4 lbs 2/12/26 - 125.4 lbsThese results showed that R54 had a 9.4% weight loss in three months and an 11.7% weight loss in six months.Review of R54's Progress Notes read, in part, 1/19/26 weight 131# (pounds).was 141# 180 days ago.recommend med pass 2.0 60 cc (cubic centimeters) daily.written by Registered Dietitian (RD) T 2/26/26; 125.4 pounds; weight down 6# from last month.unintentional weight loss.recommend increase (med pass 2.0) to BID (twice a day).for desired planned weight gain.recommend weekly weights.written by RD T)An interview was conducted with the Nursing Home Administrator (NHA), Director of Nursing (DON), and Regional RD S on 3/3/26 at 2:45 p.m. The NHA, DON, and Regional RD S confirmed RD T was late to document R54's more recent weight loss and implement interventions for unintentional weight loss.RD T was unable to provide rationale why the documentation and intervention was delayed two weeks after R54's most recent weight loss.An interview was conducted with R54's Designated Power of Attorney (DPOA) U for medical decisions on 3/4/26 at 8:34 AM. DPOA U stated the facility had not been in contact regarding R54's weight loss stating that he did not know what R54 currently weighed now but appeared to be [NAME] when he came to visit last. DPOA U stated that he would like to be informed and could offer ideas of different foods R54 might like to try. When asked if DPOA U was informed of R54 starting med pass 2.0, he stated, No. I have no idea what that is.Review of the facility's Weight Monitoring policy dated 10/26/23, read, in part, Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status.interventions will be identified, implemented, monitored and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status.A weight monitoring schedule will be developed upon admission for all residents: Residents with weight loss - monitor weight weekly.Documentation: The Registered Dietitian or Dietary Manager should be consulted to assist with interventions; actions are recorded in the nutrition progress notes.

Based on observation, interview, and record review, the facility failed to ensure appropriate consents for restraints were in place for two Residents (#54 & #107) of three residents reviewed for restraints.Findings include:Resident #54 (R54)Review of R54's Electronic Medical Records (EMR) revealed admission to the facility on 7/11/25 with diagnoses including vascular dementia with anxiety and muscle weakness. R54's 1/23/26 Quarterly Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 2/15, indicating severe cognitive impairment.On 3/3/26 at 9:05 AM, R54 was observed sitting in a geri chair (a specialized recliner for limited mobility) in her room. An interview was attempted with R54, but she was unable to answer questions appropriately.A request to the Nursing Home Administrator for R54's consent was emailed on 3/3/26 at 12:16 PM.On 3/4/26 at 8:12 AM, review of R54's consent revealed it was electronically signed by the Designated Power of Attorney (DPOA) on 3/3/26.Review of R54's EMR revealed a Physical Restraint Elimination Review for the use of R54's geri chair began on 9/18/25 and was reviewed monthly, with the last completed assessment on 2/23/26.Review of R54's Physical Restraint Elimination Review dated 9/18/25 was marked for the following categories for the use of a geri chair restraint, Disoriented, Unable to follow directions, waits for needed assistance, no fears/anxieties expressed, not taking psychotropic medications, unsteady gait, unstable balance, non-ambulatory/uses wheelchair for assistance, non-weight bearing, no falls, requires assistance with ADL's (activities of daily living). R54's Physical Restraint Elimination Review read, in part, Resident utilizes geri chair for positioning and comfort . R107Review of R107's EMR revealed admission to the facility on 5/21/25 with diagnoses including Alzheimer's disease and history of falling. R107's 12/8/25 Quarterly MDS assessment revealed a BIMS score of 3/15, indicating severe cognitive impairment.On 3/3/26 at 11:45 AM, R107 was observed sitting in a geri chair out in the main hallway. R107 was currently sleeping.On 3/4/26 at 11:28 AM, R107 was observed sitting in a geri chair in the hallway. R107's head was reclined all the way back, with R107 attempting to lift her legs to lift herself out of the geri chair. A request to the Nursing Home Administrator for R54's consent was emailed on 3/4/26 at 8:25 AM.On 3/4/26 at 8:56 AM, review of R107's consent revealed it was electronically signed by the Designated Power of Attorney (DPOA) on 3/3/26.Review of R107's EMR revealed a Physical Restraint Elimination Review for the use of R107's geri chair began on 9/19/25 and was reviewed monthly, with the last completed assessment on 2/23/26.Review of R107's Physical Restraint Elimination Review dated 9/18/25 was marked for the following categories for the use of a geri chair restraint, Disoriented, Unable to follow directions, waits for needed assistance, no fears/anxieties expressed, not taking psychotropic medications, unsteady gait, unstable balance, non-ambulatory/uses wheelchair for assistance, non-weight bearing, no falls, requires assistance with ADL's (activities of daily living). R107's Physical Restraint Elimination Review read, in part, Resident utilizes geri chair for positioning and comfort . An interview with the Nursing Home Administrator (NHA) was conducted on 3/4/25 at 11:43 AM, The NHA stated that the facility did not feel geri chairs were being used as a restraint, despite labeling them as a restraint in both R107 and R54's EMR. The NHA agreed that consents should have been signed when the geri chairs were set into place in September 2025 for both residents. Review of the facility's Restraint Policy dated 10/26/23 read, in part, Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully.Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor).

This deficient practice pertains to Intakes 2704447 and 2691458.Based on interview and record review, the facility failed to perform timely emergency medical care and Cardiopulmonary Resuscitation (CPR) for one Resident (#1) of five residents reviewed for quality of care, resulting in the death of Resident #1.Findings include:The Immediate Jeopardy (IJ) began on 12/7/25 at 9:15 AM when Registered Nurse (RN) Q discovered R1 without pulse or respirations and failed to initiate emergency life-sustaining measures resulting in the death of R1 at 9:51 AM on 12/7/25 despite his designated full code status. The Nursing Home Administrator (NHA) was notified of the IJ on 1/6/26 at 12:27 PM. At that time, a written immediacy removal plan was requested from the facility. This surveyor confirmed by interview and record review the immediacy was removed on 1/7/26 at 11:51 AM, however, noncompliance remained at the potential for more than minimal harm due to sustained compliance which has not been verified by the State Agency (SA).Resident #1 (R1):Review of the Electronic Medical Record (EMR) revealed R1 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses including malignant neoplasm (cancerous tumor) of the tonsil and lymph node, dysphagia (difficulty swallowing food or liquids), and pneumonitis (inflammation or swelling of the lung tissue). R1's EMR revealed a physician's advance directive order, initiated 11/17/25, that read, Full Resuscitate (the complete medical effort to revive an individual from apparent death or unconsciousness). Review of R1's Brief Interview for Mental Status (BIMS) Examination, dated 11/22/25, revealed a score of 15, indicative of intact cognition. Review of a document titled, Advanced Directives Acknowledgements/CPR Consent signed by R1 on 11/17/25 read, in part: .CPR is an attempt to restart your heart and breathing. It could include pressing hard on your chest to try to restart your heart and placing a tube in your windpipe to connect to the breathing machine. Electric shock to your heart and medications to support your heart may be included . R1 selected, Resuscitation: in the event of a cardiac arrest I am requesting CPR.Review of an Interdisciplinary (IDT) Progress Note on 12/7/25 at 12:00 PM written by the NHA read, in part: .9:15 AM - [Certified Nursing Assistant (CNA) Z] entered [R1's] room to obtain vitals; noted resident with eyes and mouth open, resident was not responsive to touch or name. RN [ Q] assessment included feeling for pulse, felt ankles, oral mucous dry, mottling from waist to feet and listened for respirations with stethoscope for 1 minute. 9:24 AM - RN Q notified NHA and DON [Director of Nursing] that [R1] is deceased and it was an irreversible death. 9:28 AM - RN M verified [R1's] code status was a full code. 9:30 AM - CPR initiated by RN M. 9:39 AM - CPR stopped. 9:47 AM - EMS [emergency medical services] and police arrived. 9:51 AM - Patient TOD [time of death] called by [acute care hospital] Physician.On 1/6/26 at 9:24 AM, a telephone interview was conducted with CNA Z who verified she was the primary nurse aide on duty for R1's unit on the morning of 12/7/25. CNA Z stated at 9:15 AM on 12/7/25, she walked into R1's room to obtain his morning vitals and observed R1 lying in bed. CNA Z recalled as she walked closer to the bedside, it appeared as if R1 was not breathing. CNA Z stated after R1 did not respond to touch or his name, she immediately notified RN Q of an emergency, who was standing at the medication cart at the opposite end of the hallway. CNA Z reported after she called out to RN Q for help she replied, What is it? instead of making her way down the hall. CNA Z stated she ran down the hall and told RN Q that R1 was unresponsive in his bed. CNA Z recalled RN Q had many medications on the cart as pharmacy just made a delivery and approximated it took RN Q two minutes to put away the medications and walk to R1's room. CNA Z stated when RN Q arrived to R1's room she assessed his wrist pulse, his ankle pulse, stated, he's passed, and covered his entire body with a sheet. CNA Z stated they both walked out of the room and RN Q indicated she would have to verify R1 was deceased with her stethoscope which was located back at the medication cart. CNA Z recalled RN Z returned to her medication cart and administered another resident their morning medications before returning to R1's room with a stethoscope. CNA Z stated upon arrival to R1's room, RN Q pulled back the sheet, listened to R1's heart, covered R1 back up with the sheet and walked out of the room. CNA Z remembered she was confused when approximately 15 minutes later [at 9:30 AM] she heard a code blue (an emergency code signaling a patient needs immediate resuscitation prompting trained staff to rush to the location to provide life-saving interventions) called on the overheard speakers for R1's room number after a nurse on the opposite unit [RN M] discovered R1's full-code designation. CNA Z indicated she assisted in the code by recording events and times throughout the code and recalled, Every nurse in the building was in that room [R1's] but her [RN Q]. CNA Z stated RN Q came into the room in the middle of performing CPR and indicated R1's code status had changed, and life sustaining measures could be stopped. CNA Z said, I remembered everybody was so confused [how R1's code status changed]. Maybe we were missing something. Maybe [the DON] got a hold of the physician or something we were unaware of. When asked if she was surprised by R1's sudden death, CNA Z said, I was very much so a shock this happened. he was supposed to be discharged that coming Friday [12/12/25].Review of a witness statement written by RN M on 12/8/25 at 10:06 AM read, in part: At approximately 9:30 [AM on 12/7/25] I became aware that there was a patient who had died on A-North [hall]. I remember it's striking me as odd that the CNA had such a [NAME] attitude about a patient death. When I became aware of it, I secured my Hall and my patients and I went to A North to talk to the nurse [RN Q], who said she had a death. I immediately asked for the code status and she said it was a DNR [do not resuscitate]. I noticed the chart she was reading was not the patient who died. I pointed that out and directed her to the patient's chart where it said full code where I directed her to immediately begin CPR call code blue and call 911. While she called the code blue and called 911 I grabbed the crash cart and went down to the patient's room when I opened the door I observe[d] the patient with a sheet draped completely over the body. I removed the sheet and checked response of of [sic] the patient. He [R1] was not responsive. He was pulseless and not breathing. During CPR the pads were applied no shock was advised and CPR was continue[d] . shortly after that, [RN Q] came to the room on the phone and advised us we could stop CPR under order of a doctor. She had [the DON] on the phone. we noted the time and discontinued CPR.On 1/6/25 at 2:52 PM, a telephone interview was conducted with RN M who confirmed the events in his witness statement written on 12/8/25. RN M recounted upon his initial arrival to the room, audible tones could be heard coming from R1's trachea. RN M verified R1 was pulseless and breathless upon arriving and when asked if R1 displayed signs of, irreversible death, RN M stated, Absolutely not. RN M further explained he did not witness mottling (patchy, web-like, or marbled discoloration of the skin), lividity (the purplish-red skin discoloration that occurs after death from blood settling in the lowest parts of the body due to gravity), or rigor mortis (muscle rigidity). When asked the temperature of R1's body upon assessment, RN M replied, I do not recall him being cold to the touch, and that's not something I would rely on in an emergency situation to indicate death anyway. RN M stated shortly after beginning bag-valve-mask (BVM) ventilation (a handheld device used to provide manual positive pressure ventilation to individuals who can't breathe adequately on their own), RN Q entered R1's room with a phone to her ear and said to stop CPR. RN M stated he was hesitant to stop so he questioned RN Q as to who was on the other end of the phone and she replied, [the DON]. RN M verified CPR stopped at that point.On 1/5/26 at 1:50 PM, an interview was conducted with Licensed Practical Nurse (LPN) O who verified she was working on the morning of 12/7/25. LPN O stated she heard the code blue paged overhead and ran to the opposite side of the building where she saw RN Q sitting at the nurse's station on the phone. LPN O remembered asking RN Q where the emergency was to which she replied, Don't be too worried, I think he's been gone for a couple hours. LPN O stated upon her arrival to the scene there were two CNAs and three nurses in the room and she took over compression when RN Q walked into the room and said, Stop, stop, stop! LPN O stated RN Q was questioned on who told them to stop the code and she replied, [the DON]. LPN O stated RN Q was the charge nurse that morning and she therefore followed the orders of her direct supervisor [and stopped the code].On 1/7/26 at 8:43 AM, a follow-up interview was conducted with LPN O regarding her initial clinical assessment of R1. LPN O recalled R1 was gray in color but did not show signs of irreversible death including rigor mortis, lividity, or mottling of the lower extremities.On 1/6/25 at 7:48 AM, an interview was conducted with the DON who confirmed she received a call from RN Q on the morning of 12/7/25. The DON recollected RN Q stating that there was, a dead guy in room [ROOM NUMBER] and he's been dead for hours. When asked how RN Q knew the duration of R1's death, the DON guessed it was because RN Q indicated R1 was, cold. The DON stated she informed RN Q if the resident was a full code to run the code and stop when EMS arrived or a physician order was received. The DON denied giving RN Q an order to stop life sustaining efforts on R1. When the DON asked if there was ever a situation in which life-sustaining measures are not expected to be called for a full code resident, she replied, A full code is a full code is a full code. I want to eliminate any gray area. I'd prefer they [staff] run it.On 1/6/25 at 9:02 AM, a telephone interview was conducted with RN Q who verified she was alerted by CNA Z that R1 was unresponsive in his room on the morning of 12/7/25 at approximately 9:15 AM. RN Q stated, When I first got in there, he was obviously cold. I felt he was very cold and very dead. When asked the outcome of her clinical assessment, RN Q stated she recalled taking a wrist pulse which was absent. RN Q remembered leaving R1's room to retrieve her stethoscope. Upon returning, RN Q stated she listened for R1's apical pulse (the heartbeat heard at the apex of the heart) and pulled down the sheet where she observed mottling in R1's legs. When questioned, RN Q stated, I did not know his [R1's] code status. When asked if she would have called a code blue after the first assessment had she known R1's full code status, RN Q replied, Yes. RN Q stated during her phone call with the DON, she misunderstood and thought the DON said she had contacted a doctor and had received an order to stop CPR. RN Q stated it was not until after the events that she learned the DON told her she [RN Q] would have to get a physician's order or wait until EMS arrived before stopping CPR.On 1/6/25 at 9:44 AM, a follow-up telephone interview was conducted with RN Q who recalled in the middle of the code blue, she contacted an on-call provider to change R1's code status to a DNR [do not resuscitate]. When asked how R1's code status could be changed from a full code to a DNR without his consent, RN Q replied, That's a good question, I don't know the answer to that.Review of R1's EMR revealed the following telehealth encounter note written by Physician Assistant (PA) BB, effective 12/7/25 at 8:00 AM and created 12/7/25 at 11:28 AM: .Notified by nursing staff resident [R1] passed away.CPR started, code status changes to DNR. On 1/6/26 at 2:00 PM, a telephone interview was conducted with PA BB who verified she had been contacted on the morning of 12/7/25 regarding R1's condition. PA BB stated RN Q asked her to change R1's code status to a DNR because, imminent death was suspected. When asked how R1's code status could be changed from a full code to a DNR without his consent, PA BB replied, Isn't it the same thing? I was just going based off what nursing staff told me.On 1/6/25 at 11:58 AM, an interview was conducted with Nurse Practitioner (NP) L regarding R1's sudden change in code status. NP L replied, That's impossible. NP L further explained a code status change required a signature of the declarant, a physician signature, and the signature of two witnesses. In regard to R1's overall health, NP L stated, I was very surprised he died. I wouldn't be surprised if he went back to the hospital, but I was surprised he died. When asked about emergency life-sustaining measures expectations for full code residents, NP L stated qualified facility staff are obligated to perform CPR until an order to stop is received from an on-site physician or med control (the physician oversight of EMS).On 1/6/25 at 9:25 AM, a telephone interview was conducted with CNA AA who verified she was working on R1's unit on the morning of 12/7/25. When asked how many minutes elapsed between finding R1 unresponsive and initiating CPR, CNA AA replied, Too many. and I'm a CPR instructor.On 1/6/25 at 11:04 AM, an interview was conducted with the Director of Rehabilitation (DOR) who stated R1 was progressing in therapies and planning to discharge soon. The DOR stated, I was surprised [R1] died.Review of R1's Physical Therapy Evaluation and Plan of Treatment, dated 11/18/25, read, in part: .Patient Goals: 1. To walk again and move to [State]. Potential for Achieving Rehab Goals: Patient demonstrates good rehab potential.Review of the facility policy titled, Cardiopulmonary Resuscitation (CPR) & Basic Life Support (BLS), reviewed 12/1/22, read, in part: The purpose of this policy is to provide guides for the initiation of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) in victims of sudden cardiac arrest. Cardiac arrest is defined as inadequate cardiac contraction resulting in adequate blood flow; pulselessness. Procedures for administered CPR shall incorporate the steps covered in the American Heart Association, BLS training from the American Red Cross. The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advanced Life Support (ALS). If a resident experiences a cardiac arrest or respiratory arrest and the resident does not show obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition), facility staff must provide basic life support, including CPR, prior to the arrival of emergency medical services in accordance with the resident's advanced directives and any related physician order, such as code status. the licensed nurse or designed licensed personnel on each shift is response for coordination the rescue effort and directing other team members during the rescue effort until EMS has arrived.Review of the American Heart Association's 2025, Adult Basic Life Support Algorithm for Health Care Professionals, read, in part: .check for responsiveness.look for no breathing and check pulse.no breathing or only gasping, pulse not felt.start CPR.continue until ALS professionals take over or person starts to move.Review of Michigan Public's Health Code, Section 333.1053 read, in part: .MICHIGAN DO-NOT-RESUSCITATE PROCEDURE ACT. (1) Subject to section 5, an individual who is [AGE] years of age or older and of sound mind may execute a do-not-resuscitate order on his or her own behalf. A patient advocate of an individual who is [AGE] years of age or older may execute a do-not-resuscitate order on behalf of that individual. (2) An order executed under this section shall be on a form described in section 4. The order shall be dated and executed voluntarily and signed by each of the following persons: (a) The declarant, the declarant's patient advocate, or another person who, at the time of the signing, is in the presence of the declarant and acting pursuant to the directions of the declarant. (b) The declarant's attending physician. (c) Two witnesses [AGE] years of age or older, at least 1 of whom is not the declarant's spouse, parent, child, grandchild, sibling, or presumptive heir. (3) The names of all signatories shall be printed or typed below the corresponding signatures. A witness shall not sign an order unless the declarant or the declarant's patient advocate appears to the witness to be of sound mind and under no duress, fraud, or undue influence.The Immediate Jeopardy that began on 12/7/25 was removed on 1/7/26 at 11:51 AM when the facility took the following actions to remove the immediacy: Licensed Nurses are receiving education on the policy for CPR, including confirming code status in the medical record, assessing when to initiate CPR, when CPR can be stopped, and pronouncing death. Education was initiated with licensed nurses on properly assessing prior to initiating CPR: -Check for pulse -Observe chest rise -Listen and feel for breathing -Observe skin and body findings Education was initiated with licensed nurses on Cardiopulmonary Resuscitation (CPR) & Basic Life Support (BLS) policy which identifies the following: -If the resident is a full code, facility staff must provide basic life support, including CPR, prior to the arrival of emergency medical services unless obvious clinical signs of irreversible death are present. -Clinical signs of irreversible death include rigor mortis, dependent lividity, decapitation, transection, or decomposition. -The licensed nurse on each shift is responsible for coordinating the rescue effort and directing other team members during the rescue effort until EMS has arrived. Education was initiated with licensed nurses that a resident may be declared dead by a Licensed Physician or Registered Nurse with physician authorization in accordance with state law per policy. Licensed nurses will be educated prior to working their next shift.

This deficient practice pertains to Intakes 2704447 and 2691458.Based on interview and record review, the facility failed to ensure medical records were accurately documented in accordance with professional standards and practices for one Resident (#1) of five residents reviewed for accurate medical records.Findings include:Resident #1 (R1):Review of the Electronic Medical Record (EMR) revealed R1 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses including malignant neoplasm (cancerous tumor) of the tonsil and lymph node, dysphagia (difficulty swallowing food or liquids), and pneumonitis (inflammation or swelling of the lung tissue).Review of an Interdisciplinary (IDT) Progress Note on 12/7/25 at 12:00 PM written by the Nursing Home Administrator (NHA) read, in part: .9:15 AM - [Certified Nursing Assistant (CNA) Z] entered [R1's] room to obtain vitals; noted resident with eyes and mouth open, resident was not responsive to touch or name. RN [ Q] assessment included feeling for pulse, felt ankles, oral mucous dry, mottling from waist to feet and listened for respirations with stethoscope for 1 minute. 9:24 AM - RN Q notified NHA and DON [Director of Nursing] that [R1] is deceased and it was an irreversible death.On 1/6/25 at 9:02 AM, a telephone interview was conducted with RN Q who verified she was the primary nurse responsible for R1's care on the morning of 12/7/25 and ultimately called a code blue. When asked if the event was documented in R1's medical chart, RN Q stated she remembered charting it in under some area in the EMR but was unsure of the exact location.Review of a report titled, # 1154 Code Blue, dated 12/7/25 at 9:30 AM read, in part: Resident: [R1]. Incident Location: Resident's Room. Person Preparing Report: [DON].On 1/6/25 at 10:10 AM, an interview was conducted with the DON regarding the code blue incident which occurred on 12/7/25. The DON stated she was not at the facility at the time of the incident and had not documented the report titled, # 1154 Code Blue but assumed it was RN Q's documentation. When asked why the incident was not documented under RN Q's own name, the DON surmised RN Q did not know how to open the appropriate assessment herself, therefore it was done for her by another staff member.On 1/6/25 at 10:15 AM, an interview was conducted with the NHA who stated all staff are required to document under their own name in the medical record.

This deficient practice pertains to Intakes 2704447 and 2691458.Based on interview and record review, the facility failed to obtain informed consent prior to changing a code status for one Resident (#1) of five residents reviewed for resident rights.Findings include: Resident #1 (R1):Review of the Electronic Medical Record (EMR) revealed R1 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses including malignant neoplasm (cancerous tumor) of the tonsil and lymph node, dysphagia (difficulty swallowing food or liquids), and pneumonitis (inflammation or swelling of the lung tissue). Further review of R1's EMR revealed a physician's advanced directive order, initiated 11/17/25, that read, Full Resuscitate (the complete medical effort to revive an individual from apparent death or unconsciousness). Review of R1's Brief Interview for Mental Status (BIMS) Examination, dated 11/22/25, revealed a score of 15, indicative of intact cognition. Review of a document titled, Advanced Directives Acknowledgements/CPR Consent signed by R1 on 11/17/25 read, in part: .CPR is an attempt to restart your heart and breathing. It could include pressing hard on your chest to try to restart your heart and placing a tube in your windpipe to connect to the breathing machine. Electric shock to your heart and medications to support your heart may be included . R1 selected, Resuscitation: in the event of a cardiac arrest I am requesting CPR.Review of an Interdisciplinary (IDT) Progress Note on 12/7/25 at 12:00 PM written by the NHA read, in part: .9:15 AM - [Certified Nursing Assistant (CNA) Z] entered [R1's] room to obtain vitals; noted resident with eyes and mouth open, resident was not responsive to touch or name. RN [ Q] assessment included feeling for pulse, felt ankles, oral mucous dry, mottling from waist to feet and listened for respirations with stethoscope for 1 minute. 9:24 AM - RN Q notified NHA and DON [Director of Nursing] that [R1] is deceased and it was an irreversible death. 9:28 AM - RN M verified [R1's] code status was a full code. 9:30 AM - CPR initiated by RN M. 9:39 AM - CPR stopped. 9:47 AM - EMS [emergency medical services] and police arrived. 9:51 AM - Patient TOD [time of death] called by [acute care hospital] Physician.On 1/6/26 at 9:24 AM, a telephone interview was conducted with CNA Z who verified she was the primary nurse aide on duty for R1's unit on the morning of 12/7/25. CNA Z remembered she heard a code blue (an emergency code signaling a patient needs immediate resuscitation prompting trained staff to rush to the location to provide life-saving interventions) called on the overheard speakers for R1's room at approximately 9:30 AM. CNA Z indicated she assisted in the code with two other CNAs and three other nurses. CNA Z recalled RN Q came into the room in the middle of performing CPR and indicated R1's code status and changed to DNR [do not resuscitate] and life sustaining measures could be stopped. CNA Z said, I remembered everybody was so confused [how R1's code status changed]. Maybe we were missing something. Maybe [the DON] got a hold of the physician or something we were unaware of.Review of a witness statement written by RN M on 12/8/25 at 10:06 AM read, in part: At approximately 9:30 [AM on 12/7/25] I became aware that there was a patient who had died on A-North [hall]. I secured my Hall and my patients and I went to A North to talk to the nurse [RN Q], who said she had a death. I immediately asked for the code status and she said it was a DNR [do not resuscitate]. I noticed the chart she was reading was not the patient who died. I pointed that out and directed her to the patient's chart where it said full code where I directed her to immediately begin CPR call code blue and call 911. During CPR the pads were applied no shock was advised and CPR was continue[d] . shortly after that, [RN Q] came to the room on the phone and advised us we could stop CPR under order of a doctor. She had [the DON] on the phone. we noted the time and discontinued CPR.On 1/6/25 at 2:52 PM, a telephone interview was conducted with RN M who confirmed the events in his witness statement which included beginning life sustaining efforts on R1 on the morning of 12/7/25. RN M stated shortly after beginning bag-valve-mask (BVM) ventilation (a handheld device used to provide manual positive pressure ventilation to individuals who can't breathe adequately on their own), RN Q entered R1's room with a phone to her ear and said to stop CPR. RN M stated he was hesitant to stop so he questioned RN Q as to who was on the other end of the phone and she replied, [the DON]. RN M verified CPR stopped at that point.On 1/5/26 at 1:50 PM, an interview was conducted with Licensed Practical Nurse (LPN) O who verified she was working on the morning of 12/7/25 and responded to the code blue for R1. LPN O stated upon her arrival to the scene she took over compression when RN Q walked into the room and said, Stop, stop, stop! [performing CPR]. LPN O stated RN Q was questioned on who told them to stop the code and she replied, [the DON]. LPN O stated RN Q was the charge nurse that morning and she therefore followed the orders of her direct supervisor [and stopped the code].On 1/6/25 at 7:48 AM, an interview was conducted with the DON who confirmed she received a call from RN Q on the morning of 12/7/25. The DON recollected RN Q stating that there was, a dead guy in room [ROOM NUMBER] and he's been dead for hours. The DON stated she informed RN Q if the resident was a full code to run the code and stop when EMS arrived or a physician order was received. The DON denied giving RN Q an order to stop life sustaining efforts on R1. When the DON asked if there was ever a situation in which life-sustaining measures are not expected to be called for a full code resident, she replied, A full code is a full code is a full code. I want to eliminate any grey area. I'd prefer they [staff] run it.On 1/6/25 at 9:02 AM, a telephone interview was conducted with RN Q who verified she had contacted the DON during the code blue on 12/7/25. RN Q stated during her phone call with the DON, she misunderstood and thought the DON said she had contacted a doctor and had received an order to stop CPR. RN Q stated it was not until after the events that she learned the DON told her she [RN Q] would have to get a physician's order or wait until EMS arrived before stopping CPR.On 1/6/25 at 9:44 AM, a follow-up telephone interview was conducted with RN Q who recalled in the middle of the code blue, she contacted an on-call provider to change R1's code status to a DNR [do not resuscitate]. When asked how R1's code status could be changed from a full-code to a DNR without his consent, RN Q replied, That's a good question, I don't know the answer to that.Review of R1's EMR revealed the following telehealth encounter note written by Physician Assistant (PA) BB, effective 12/7/25 at 8:00 AM and created 12/7/25 at 11:28 AM: .Notified by nursing staff resident [R1] passed away.CPR started, code status changes to DNR. On 1/6/26 at 2:00 PM, a telephone interview was conducted with PA BB who verified she had been contacted on the morning of 12/7/25 regarding R1's condition. PA BB stated RN Q asked her to change R1's code status to a DNR because, imminent death was suspected. When asked how R1's code status could be changed from a full code to a DNR without his consent, PA BB replied, Isn't it the same thing? I was just going based off what nursing staff told me.On 1/6/25 at 11:58 AM, an interview was conducted with Nurse Practitioner (NP) L regarding R1's sudden change in code status. NP L replied, That's impossible. NP L further explained a code status changed required a signature of the declarant, a physician signature, and the signature of two witnesses.Review of Michigan Public's Health Code, Section 333.1053 read, in part: .MICHIGAN DO-NOT-RESUSCITATE PROCEDURE ACT. (1) Subject to section 5, an individual who is [AGE] years of age or older and of sound mind may execute a do-not-resuscitate order on his or her own behalf. A patient advocate of an individual who is [AGE] years of age or older may execute a do-not-resuscitate order on behalf of that individual. (2) An order executed under this section shall be on a form described in section 4. The order shall be dated and executed voluntarily and signed by each of the following persons: (a) The declarant, the declarant's patient advocate, or another person who, at the time of the signing, is in the presence of the declarant and acting pursuant to the directions of the declarant. (b) The declarant's attending physician. (c) Two witnesses [AGE] years of age or older, at least 1 of whom is not the declarant's spouse, parent, child, grandchild, sibling, or presumptive heir. (3) The names of all signatories shall be printed or typed below the corresponding signatures. A witness shall not sign an order unless the declarant or the declarant's patient advocate appears to the witness to be of sound mind and under no duress, fraud, or undue influence.

This deficient practice pertains to Intake 2647525.Based on interview and record review, the facility failed to implement infection control measures and ensure comprehensive infection surveillance to prevent the transmission of scabies (a highly contagious skin condition caused by parasitic itch mites that burrow into the skin). This deficient practice resulted in transmission of scabies with associated physical discomfort for six Residents (#2, #3, #4, #5, #6, #7) of twenty residents reviewed for infection control.Findings include:Resident #2 (R2)Review of R2's EMR revealed initial admission to the facility on 7/13/20 with diagnoses including anoxic brain damage and cognitive communication deficit.On 10/22/25 at 1:44 PM, a telephone interview was conducted with Family Member (FM) K regarding R2's care at the facility. FM K stated R2 had two recent dermatology appointments in which R2 was diagnosed with a scabies infection. FM K voiced concerns regarding the facility's efforts in preventing the spread of the infection.Review of R2's Dermatology Visit Note, dated 9/3/25, read, in part: Chief Complaints: Follow-Up Rash. Location : trunk.Rash type: itchy, red, and bleeding.Since the Last Visit the Rash is: spreading and worse. Impression/Plan: Scabies - Will presumptively treat for scabies given clinical appearance, degree of pruritus and nursing home residency. Plan: Counseling. Scabies is an infestation of mites that is very contagious. Household contacts should be treated. Plan: Prescription. Permethrin 5% topical cream.apply full tube of cream to entire body, from neck to toes at bedtime. Repeat one week later.Review of R2's EMR revealed the following physician's order, initiated 9/4/25: Permethrin External Cream 5 % (Permethrin). Apply to entire body topically one time only for [sic] apply full tube of cream to entire body, from neck to toes until 09/05/2025 21:00 [9:00 PM]. Leave on for 8hrs (hours), then wash off. Change all bedding. Repeat x1 wk (week) AND Apply to entire body topically one time only for [sic] apply full tube of cream to entire body, from neck to toes until 09/11/2025 21:00 Leave on for 8hrs, then wash off. Change all bedding.A review of the facility's monthly infection surveillance for September 2025 with Assistant Director of Nursing (ADON) H on 10/23/25 at 12:15 PM revealed no documentation of R2's treatment for scabies, implementation of transmission-based precautions to prevent spread of the infection or monitoring of other residents for signs and symptoms of the infection. When ADON H was asked why these elements were not recorded as part of the infection control program, she replied R2 was being treated prophylactically, and it wasn't an active infection or confirmed diagnosis. ADON H acknowledged the CDC (Centers for Disease Control and Prevention) guidelines recommended implementation of contact precautions for 24 hours after initiation of therapy for scabies, but it was not put into effect due to the prophylactic nature of R2's medicinal treatment. Review of R2's Dermatology Visit Note, dated 10/8/25, read, in part: Chief Complaint: follow up Rash. Impression/Plan: Crusted Scabies - enact scabies protocols according to facility/state Michigan guidelines. Linear burrows.and crusting distributed on the right radial dorsal hand, arms, legs, and trunk. Status: inadequately controlled. Expectations: scabies is an infestation of mites that is very contagious. Household contacts should be treated. Contaminated clothing should be isolated x 72 hours and washed and dried on high heat. Plan: Scabies Prep. A Scabies prep was performed on the right radial dorsal hand, showing mites.On 10/23/25 at 1:33 PM, a telephone interview was conducted with the Director of Nursing (DON) regarding the facility's response to R2's dermatology appointment on 10/8/25 which indicated crusted scabies. The DON stated the facility conducted skin assessments on all residents and identified 19 residents who presented with a rash of unknown etiology who were subsequently treated with a scabicidal.Resident #3 (R3)Review of R3's EMR revealed an Interdisciplinary Progress Note, dated 10/14/25 at 12:18 PM, which read, in part: .nursing - permethrin cream for suspected scabies.On 10/24/25 at 9:00 AM, an interview was conducted with R3 who confirmed she had an extensive rash on her chest and arms which required treatment. R3 stated the rash, itched terribly and remained, though not as bad.Resident #4 (R4)Review of R4's EMR revealed a Progress Note, dated 10/14/25 at 8:00 AM, which read, in part: .Resident exposed to confirmed scabies case; presenting with pruritic rash consistent with scabies infestation.Resident #5 (R5)Review of R5's EMR revealed a Progress Note, dated 10/14/25 at 8:00 AM, which read, in part: .Resident exposed to confirmed scabies case; presenting with pruritic rash consistent with scabies infestation.Resident #6 (R6)Review of R6's EMR revealed the following entries:Progress Note, 10/16/25 at 8:00 AM: .Chief complaint: rash is spreading. Pt [patient] seen for the above hydrocortisone was ineffective, the rash has spread to his opposite arm and down his abdomen. He complains of severe itch, especially at night. Suspect scabies, recent in outbreak in facility.New Follow Up Note, 10/23/25 at 1:06 PM: .he states he is only uncomfortable due to his full body rash. 10/14: Pt presented with raised red rash on BLE (bilateral lower extremities) and chest over the weekend.Pt reports feeling itchy and uncomfortable.Resident #7 (R7)Review of R7's EMR revealed a Progress Note, dated 10/14/25 at 8:00 AM, which read, in part: .exposed to confirmed scabies case; presenting with pruritic rash consistent with scabies infestation.On 10/24/25 at 9:24 AM, a follow-up interview was conducted with the DON who understood the concern regarding the lack of implementation of infection control measures after R2's scabies diagnosis in September 2025 and the current scabies infestation.Review of the facility policy titled, Infection Prevention and Control Program, revised 10/24/22, read, in part: 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 as per accepted national standards and guidelines. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents.A review of the CDC guidelines titled, Public Health Strategies for Scabies Outbreaks in Institutional Settings, dated 12/18/23, read, in part: Prevention: Early detection, treatment, and implementation of appropriate isolation and infection control practices are essential in preventing scabies outbreaks. Institutions should maintain a high index of suspicion that undiagnosed skin rashes and conditions may be scabies, even if characteristic signs or symptoms of scabies are absent. Establish surveillance.Have an active program for early detection of infested patients/residents and staff. Establish appropriate procedures for infection control and treatment.Maintain records with patient/resident name, age, sex, room number, roommate(s) name(s), skin scraping status and result(s), and name(s) of all staff who provided hands-on care to the patient/resident before implementation of infection control measures: symptoms can take up to 2 months to appear in exposed persons and staff. (https://www.cdc.gov/scabies/php/public-health-strategy/index.html)

This deficient practice pertains to Intake 2646261.Based on interview and record review, the facility failed to ensure a safe community discharge for one Resident (#1) of three residents reviewed for transfer and/or discharge. This deficient practice resulted in the need for repeated emergency room visits for Resident #1 due to the inability to care for a colostomy (a surgical procedure that creates an opening in the abdominal wall to divert fecal matter from the colon to the outside of the body) and infection of the colostomy site.Findings include:Resident #1 (R1)Review of R1's electronic medical record (EMR) revealed initial admission to the facility on 9/20/25 with diagnoses including aftercare following surgery on the digestive system, perforation of the intestine, and colostomy status. Review of R1's discharge Minimum Data Set (MDS) assessment, dated 10/6/25, revealed a Brief Interview for Mental Status (BIMS) score of 13, indicative of intact cognition.Review of an intake submitted by Physician Assistant (PA) A to the State Agency (SA) on 10/20/25 read, in part: I am the primary care provider for [R1]. She was hospitalized .from 9/12/2025 through 9/20/2025 and was discharged . for subacute rehab following her bowel perforation which required surgery on 9/12/2025 unfortunately with end colostomy. [R1]. has poor family support as she only has 1 living relative nearby who works full-time. She went to subacute rehabilitation 9/20/2025 and was discharged home. During the time she was there [at the facility], she had staples in place which were supposed to be removed on day 10-14 postop (post-operative), this was not done. I saw the patient [on] 10/10/2025 and had to send her to the emergency department as she was 28 days postop with staples still in place. They [facility] also made no effort to get her a follow-up with the surgeon, she had no scheduled appointment with the surgery office after she left the facility, and [R1] is not able to do these things on her own. [R1] has now been back in the ER (emergency room) 3 separate times because of complications from being discharged home too early. [R1] cannot ambulate independently.and had spilled her [colostomy] bag all over the floor multiple times.On 10/22/25 at 11:01 AM, a telephone interview was conducted with PA A who verified she evaluated R1 on 10/10/25 in an outpatient clinic. PA A stated, When she [R1] came into the office, I saw she still had staples that needed to be removed because the facility hadn't scheduled a follow-up appointment with the surgeon . I ended up sending her to the ER to have them removed. PA A noted 10/10/25 was 28 days after the initial surgery while R1 was directed to follow-up with the surgeon within 10-14 days. PA A stated she wanted the ER to rule out infection at the incision because the area appeared red and inflamed. PA A stated R1's colostomy was not attached and leaking stool and R1 reported she was unable to secure the leak.Review of an Emergency Department Triage Document, dated 10/10/25, read, in part: Chief Complaint: Sent from post op followup [sic]; sx (symptoms) to see with staple removal. Review of an Emergency Department Triage Document, dated 10/13/25, read, in part: Chief Complaint: c/o (complains of) lightheadedness. Cold, shaking. home health care says [wound] looks infected.Review of a Wound/Skin/Ostomy Care Note in the Emergency Medicine Department, dated 10/13/25, read, in part: .[R1] with colostomy placement 3 weeks ago and discharged to SAR (subacute rehabilitation). Now home a week. I changed the 2-piece appliance that was dated for 11 days ago.Peristomal skin with mild partial thickness contact dermatitis (a condition in which the skin becomes red, sore, or inflamed).Review of a report titled, Emergency/UC [Urgent Care] Documents, dated 10/13/25, read, in part: .This is a.female.with end colostomy. since being home she has had some difficulties. She notes she cannot really empty her ostomy bag and she has only done it once and made a mess. she has had some dehiscence from her wound. Patient presents secondary to abdominal pain, shaking, lightheaded, need for help with ostomy care. Patient lives alone. seems like she is needing increased support in the home setting.her wound culture is growing.E.coli (a type of bacterium commonly found in the intestines of humans), Augmentin would be adequate coverage. Disposition: discharged to Home.Review of a document titled, Misc. [Miscellaneous] Patient Care Documents, dated 10/16/25, revealed additional results of the wound culture collected on 10/13/25 from R1's abdominal wall contained Staphylococcus aureus (a bacterial human pathogen).Review of a Transition of Care document, dated 10/16/25, written by PA A, read, in part: .I saw the patient [R1] in follow-up on 10/10/25 and she still had her staples in place (28 days later), had no idea how to manage her ostomy.and essentially had no one available to available to help her at home. She did go directly to the ER that same day and get her staples removed. She then went to the emergency department on 10/13/25 with essential failure to thrive.they [ER] did collect a wound culture; it shows Staphylococcus aureus. I had a long discussion with the patient today [10/16/25] and I think she is unsafe to be living at home and needs to consider going in for placement. Essentially, she told me on the phone today that she has been trialing changing her own ostomy and it has spilled on the floor multiple times.Review of a report titled, Emergency/UC Documents, dated 10/16/25, read, in part: Chief Complaint: .concerns for taking care of new ostomy. she [R1] is too weak, she does not eat much, she has difficulty caring for herself and difficult caring for her ostomy. She lives alone, she has difficulty performing her ADLs (Activities of Daily Living).On 10/22/25 at 12:37 PM, a telephone interview was conducted with R1 regarding her readiness for discharge from the facility. R1 stated, They didn't teach me how to use that bag [colostomy bag]. I could only change part of it and kept spilling it [fecal matter] on the floor. R1 confirmed she went to ER on three separate occasions due to the inability to care for herself at home including adequate meal preparation and safely mobilizing within the home.On 10/22/25 at 4:20 PM, a telephone interview was conducted with R1's daughter, Family Member (FM) E, regarding the discharge process. FM E stated R1 vocalized her concerns about her new colostomy bag and was, very unsure and nervous about caring for it by herself. FM E continued, I was concerned she had to go home, she didn't seem ready at all. FM E emphasized R1 lived alone and would need to be independent for all aspects of functional mobility and self-care activities, including colostomy management. FM E stated, She [R1] had a couple times where the colostomy bag was leaking [at home] and she didn't know how to fix it. it was so stressful for her. FM E confirmed the facility did not schedule a follow-up appointment with the surgeon's office as indicated in the hospital discharge instructions.Review of a document titled, Hospital Summary, dated 9/20/25, read, in part: .Discharge Recommendations: Follow up in clinic in 1-2 weeks.Review of R1's EMR revealed the following entries: Nurses' Note on 10/2/25 at 8:40 AM: Resident concerned about D/C [discharge] home tomorrow alone . New Follow Up Note on 10/2/25 at 7:19 PM, by Nurse Practitioner (NP) C: .She [R1] is concerned that her colostomy has a small leak at the seal and is concerned about colostomy care at home. [R1's] daughter states she will not be able to stay with patient or provide colostomy care. New Follow Up Note on 10/6/25 at 9:32 PM by NP C: 10/4 -.Patient voices she is unsure how well she will manage at home.On 10/23/25 at 1:58 PM, a phone interview was conducted with Licensed Practical Nurse (LPN) D who indicated she showed R1 how to clean and care for her colostomy during a single session on 10/2/24. LPN D stated, It was a lot of information to give her [R1] in a short amount of time. When LPN D was asked if R1 could perform all aspects of colostomy care independently at the end of their session, she stated, Not exactly. LPN D explained R1 required, a lot of cues to complete the steps correctly. LPN D stated, If it [the colostomy bag] were to spill or leak, I don't think she would be able to manage [the colostomy bag alone]. LPN D was unaware of any further education provided to R1 regarding colostomy care. When asked if she thought R1 was ready to return home and manage the colostomy independently, LPN D said, No.Review of R1's EMR revealed no additional evidence of colostomy training or education.Review of a document titled Discharge to Home/Community/AL [Assisted Living]/Equal Care Setting, with a lock date of 10/3/25, contained an excerpt written by Unit Manager/Registered Nurse (UM/RN) B which read: Nursing Recap: [R1] arrived.for rehab after having a new colostomy established, she is independent with ADLs (activities of daily living) but is unable to care for her incision and colostomy.continued education needed when at home.On 10/23/25 at 11:43 AM, an interview was conducted with UM/RN B regarding discharge planning for R1 and colostomy care requirements at home. UM/RN B stated daily colostomy care would entail emptying the bag when it is approximately half full, monitoring the skin around the ostomy for any signs of breakdown or impairments, and changing the wafer should the seal begin to leak prior to routine replacement every 3-5 days. UM/RN B stated R1 would likely receive home care services but was unsure how many days per week she would qualify for. Review of R1's OT [Occupational Therapy] Discharge Summary, with a discharge date of 10/3/25, read, in part: Functional Skills Assessment: Toileting hygiene = supervision or touching assistance. Toilet transfer = supervision or touching assistance. Shower/bathe self = supervision or touching assistance. Lower body dressing = supervision or touching assistance. Review of R1's PT (Physical Therapy) Discharge Summary, with a discharge date of 10/6/25, read, in part: Functional Skills Assessment: Sit to stand = supervision or touching assistance. Chair/bed-to-chair transfer = supervision or touching assistance. Toilet transfer = supervision or touching assistance. Walk 10 feet = supervision or touching assistance. Walk 50 feet = supervision or touching assistance. Walk 150 feet = supervision or touching assistance. Picking up object = not attempted due to medical conditions or safety concerns.On 10/23/25 at 11:27AM, an interview was conducted with Physical Therapist (PT) G regarding R1's mobility status upon discharge. PT G stated R1 was discharged at the level of supervision for all transfers and ambulation due to her increased fall risk. PT G commented R1 wasn't quite at her functional baseline as far as generalized strength and she was still anxious with movement which contributed to an increased fall risk. PT G reiterated R1 was not safe to go home at a level of independence.On 10/23/25 at 11:24 AM, an interview was conducted with Social Services Director (SSD) J who verified R1 was discharged on 10/6/25 to her prior living environment at the level of independence. SSD J admitted , She [R1] did have hesitations going home independently but would have home health services upon discharge. When asked the frequency of home health services, SSD J replied 2-3 times per week. SSD J acknowledged daily colostomy care requirements and the skilled therapy recommendations of 24-hour supervision and stated other resources were discussed with R1 but not pursued. SSD J stated she was responsible for ensuring follow-up appointments were scheduled for residents upon discharge from the facility. When asked if all the necessary follow-up appointments were scheduled for R1, SSD J stated she was only aware of the need to see her primary care physician.Review of R1's EMR revealed the following the following entries: New Follow Up Note on 10/6/25 at 9:32 PM by NP C: 10-2. They [family] are also concerned about post-op follow up. They did not have the information or recall that they were to make a post-up appt [appointment] (in) 10-14 days. Today is day 13. New Follow Up Note on 10/6/25 at 9:32 PM by NP C: 10/4 - Surgical site midline abdomen still has staples, with skin healing around staples and patient reports wanting to scratch. New Follow Up Note on 10/6/25 at 9:32 PM by NP C: 10/6- Discharge planned for later this afternoon.Patient still needs post-op follow up and staple removal from abdominal incision.On 10/22/25 at 1:17 PM, an interview was conducted with the Nursing Home Administrator (NHA) who stated it is expected the facility coordinates and schedules all follow-up appointments.Review of the facility policy titled, Transfer and Discharge (including AMA [against medical advice]), revised 10/30/23, read, in part: .the facility permits each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents are endangered.

This deficient practice pertains to Intakes 2646261 and 2647525.Based on interview and record review, the facility failed to coordinate post-surgical care and follow established bowel protocol for two Residents (#1 and #2) of three residents review for quality of care.Findings include:Resident #1 (R1)Review of R1's electronic medical record (EMR) revealed initial admission to the facility on 9/20/25 with diagnoses including aftercare following surgery on the digestive system, perforation of the intestine, and colostomy status (a surgical procedure that creates an opening in the abdominal wall to divert feces from the colon to the outside of the body). Review of R1's discharge Minimum Data Set (MDS) assessment, dated 10/6/25, revealed a Brief Interview for Mental Status (BIMS) score of 13, indicative of intact cognition.Review of an intake submitted by Physician Assistant (PA) A to the State Agency (SA) on 10/20/25 read, in part: I am the primary care provider for [R1]. She was hospitalized .from 9/12/2025 through 9/20/2025 and was discharged . for subacute rehab following her bowel perforation which required surgery on 9/12/2025 unfortunately with end colostomy.During the time she was there [at the facility], she had staples in place which were supposed to be removed on day 10-14 postop (post-operative), this was not done. I saw the patient 10/10/2025 and had to send her to the emergency department as she was 28 days postop with staples still in place. They [facility] also made no effort to get her a follow-up with the surgeon, she had no scheduled appointment with the surgery office after she left the facility, and [R1] is not able to do these things on her own.Review of a document titled, Hospital Summary, dated 9/20/25, read, in part: .Discharge Recommendations: Follow up in clinic in 1-2 weeks.On 10/23/25 at 10:25 AM, an interview was conducted with Scheduler F who stated the facility protocol for new admissions is to review discharge instructions from the hospital, ascertain the correct doctor to follow up with, and call and schedule the appointment. Scheduler F explained it is preferential for the facility to schedule follow-up appointments to ensure facility transportation is available. When asked, Is there any time a resident would be expected to schedule their own follow-up appointments? Scheduler F replied, No. When Scheduler F was asked if a follow-up appointment was scheduled for R1, she stated she called the surgeon's office to schedule an appointment, and they directed her to remove the staples in-house [in the facility]. Scheduler F stated she did not have documentation she made the call to the surgeon's office, but she informed former Unit Manager/Registered Nurse (UM/RN) I of the directive. Scheduler F was unsure if R1's staples ever were removed.On 10/23/25 at 10:27 AM, an interview was conducted with Registered Nurse (RN) H at R1's surgeon's office. RN H stated the office had no record of a call from the facility to schedule a follow-up appointment.On 10/23/25 at 11:30 AM, a telephone interview was conducted with former UM/RN I who stated she never received a report from Scheduler F which indicated R1's staples were to be removed in the facility.Review of R1's EMR revealed the following physician's order, initiated 10/1/25, 11 days after her initial admission: Monitor abd (abdominal) surgical site for complications every shift.On 10/23/25 at 11:43 AM, an interview was conducted with UM/RN B regarding the management of R1's abdominal staples. UM/RN B stated she never received a report to remove R1's staples but had been, watching them and they were, looking good. UM/RN B stated she was waiting for R1's follow-up appointment to be scheduled but did not indicate why she did not check-in with Scheduler F after 14 days had elapsed. UM/RN B confirmed post-operative surgical site checks should occur daily but was unsure why R1's physician order for surgical site monitoring started on 10/1/25, 11 days after her initial admission. Prior to 10/1/25, UM/RN B stated daily monitoring was completed visually and not documented unless an issue was observed.On 10/23/25 at 11:24 AM, an interview was conducted with Social Services Director (SSD) J who verified she was responsible for ensuring follow-up appointments were scheduled for residents upon discharge from the facility. When asked if all follow-up appointments were scheduled for R1, SSD J stated she was only aware of the need to see her primary care physician.Review of R1's EMR revealed the following the following entries: New Follow Up Note on 10/6/25 at 9:32 PM by Nurse Practitioner (NP) C: 10-2. They [family] are also concerned about post-op follow up. They did not have the information or recall that they were to make a post-up appt [appointment] (in) 10-14 days. Today is day 13. New Follow Up Note on 10/6/25 at 9:32 PM by NP C: 10/4 - Surgical site midline abdomen still has staples, with skin healing around staples and patient reports wanting to scratch. New Follow Up Note on 10/6/25 at 9:32 PM by NP C: 10/6- Discharge planned for later this afternoon.Patient still needs post-op follow up and staple removal from abdominal incision.On 10/22/25 at 11:01 AM, a telephone interview was conducted with PA A who verified she evaluated R1 on 10/10/25 in an outpatient clinic. PA A stated, When she [R1] came into the office, I saw she still had staples that needed to be removed because the facility hadn't scheduled a follow-up appointment with the surgeon . I ended up sending her to the ER to have them removed. PA A noted 10/10/25 was 28 days after the initial surgery while R1 was directed to follow-up with the surgeon within 10-14 days. PA A stated she wanted the ER to rule out infection at the incision because the area appeared red and inflamed.Review of an Emergency Department Triage Document, dated 10/10/25, read, in part: Chief Complaint: Sent from post op followup [sic]; sx (symptoms) to see with staple removal. On 10/22/25 at 1:17 PM, an interview was conducted with the Nursing Home Administrator (NHA) who stated it is expected the facility coordinates and schedules all follow-up appointments.Resident #2 (R2)Review of R2's EMR revealed initial admission to the facility on 7/13/20 with diagnoses including anoxic brain damage, cognitive communication deficit, and constipation.On 10/22/25 at 1:44 PM, a telephone interview was conducted with Family Member (FM) K regarding R2's care at the facility. FM K stated R2 was transferred to the hospital on [DATE] for an overall decline in health status and was informed by emergency room (ER) staff that he may have an impacted bowel (the buildup of hard, dry stool in the colon or rectum that cannot be passed normally).Review of R2's EMR revealed the following physician's orders, initiated 8/1/25:Milk of Magnesia Suspension, give 30 mL (milliliters) by mouth every 72 hours as needed for constipation if no bowel movement for 3 days. Dulcolax Suppository (Bisacodyl), insert 1 suppository rectally as needed for constipation if no result from Milk of Magnesia. Fleet enema, insert 1 unit rectally as needed for no result from Dulcolax, administer fleet enema daily PRN [as needed] for constipation.Review of R2's EMR revealed a task titled, Bowel Elimination Description which indicated R2 went without a bowel movement (BM) for seven days (from 9/29/25 at 1:59 PM to 10/6/25 at 8:44 PM).Review of R2's EMR revealed no abdominal or bowel assessment in the seven-day span. Medication Administration Records (MAR) for the months of September and October 2025 indicated R2 was not administered Milk of Magnesia, a Dulcolax Suppository, nor a Fleet enema per physician's orders in the same span. On 10/23/25 at 1:14 PM, an interview was conducted with Assistant Director of Nursing (ADON) L regarding the facility's bowel protocol. ADON L verified after three days, a resident should be administered milk of magnesia and reevaluated based on the success or failure of completing a bowel movement. ADON L stated R2 should have been administered milk of magnesia on 10/2/25 and should have been monitored until producing a bowel movement. When asked the clinical risk of going extended periods of time with no bowel movement, ADON L replied, Constipation, bowel obstruction.Review of a facility policy titled BM Protocol, undated, read: Nurse will review clinical alerts who triggered for no BM more than 3 days 2) Nurse will assess resident for abdominal pain, distention and bowel sounds 3) Check orders if resident has orders for Milk of Magnesia, Bisacodyl or Fleets 4) If no orders, call physician for orders a. Milk of magnesia 30ml PRN (as needed) for no BM x 3 days b. Bisacodyl 1 suppository PR (per rectum) PRN if Milk of magnesia is ineffective c. Fleets enema 1 application PRN if Bisacodyl is ineffective 5) Administer medication and monitor for effectiveness 6) Notify physician if bowel protocol is ineffective.

This deficiency pertains to Facility Reported Incident (FRI) #MI00144562. Based on observation, interview, and record review, the facility failed to provide adequate supervision per the plan of care for three residents (Residents #508, #509, and #510) during mealtimes. This deficient practice resulted in two choking/aspiration events for Resident #509 which resulted in hospitalization and subsequent death. Findings Include: The Immediate Jeopardy began on [DATE] at 2:40 PM when the facility failed to provide supervision during a mealtime for a resident (Resident #508) with a known history of choking/aspiration. This resulted in R508 experiencing a choking event in his room. R508 experienced a subsequent choking event on [DATE] at 6:24 PM when R508 was left unsupervised on two different occasions in the dining room during a dinner time meal and was found unresponsive. R508 required life-saving efforts and was ultimately transported to a local hospital where he later expired. The Nursing Home Administrator (NHA), Senior Regional NHA, and Director of Nursing (DON) were notified of the immediate jeopardy on [DATE] at 12:10 PM. At that time, a written removal plan was requested from the facility. This surveyor confirmed by interview and record review that the immediacy was removed on [DATE] at 3:35 PM, however, noncompliance remains at the potential for more than minimal harm due to sustained compliance which has not been verified by the State Agency (SA). Resident #508 (R508): Review of R508's electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnoses including history of traumatic brain injury (TBI), dysphagia (difficulty or inability to swallow), and chronic obstructive pulmonary disease (COPD). Review of R508's Brief Interview for Mental Status (BIMS) assessment revealed a score of 00, indicative of severe cognitive impairment. Review of R508's discharge summary from the acute care hospital revealed the following: .Dysphagia: it was noted last week that he is impulsive with eating, and this may in part cause him to choke/cough when eating . Review of R508's Speech Therapy Clinical Swallowing Evaluation at the acute care hospital on [DATE] revealed the following recommendations: .he [R508] is noted to be an impulsive/fast eater per many recent ST [speech therapy] swallowing evaluations .if speed of intake is an ongoing issue, recommend direct supervision/assist w/ [with] pacing during meals. This has been recommended during each swallow assessment in the past . Review of R508's Nursing Admission Evaluation dated [DATE], indicated the following: 1. Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. Supervision or touching assistance, was selected by the evaluator. 2. Most support needed for eating. Supervision/cueing needed, was selected by the evaluator. Review of a Nursing to Dietary diet order form dated [DATE] completed by Registered Nurse (RN) E revealed the following: .[R508] is a feed. On [DATE] at 11:25 AM, a phone interview was conducted with RN E who verified she completed R508's Nursing Admission Evaluation and Nursing to Dietary diet order form on [DATE]. RN E stated she indicated R508 required supervision and cueing with eating on the Nursing Admission Evaluation because, the hospital told me that he stuffs his mouth and doesn't swallow and just keeps putting more and more in [his mouth]. RN E stated she talked with R508's sister/guardian [Guardian F] who stated R508 needed frequent cues to slow down when eating due to his impulsivity. RN E was asked for clarification behind the meaning of, [R508] is a feed on the Nursing to Dietary diet order form. RN E said, he [R508] has to have supervision to eat, he can't eat by himself . I meant that somebody has to be in his direct presence, they can't leave him alone in the room with his tray . On [DATE] at 8:20 AM, an interview was conducted with Occupational Therapist (OT) O who verified Guardian F was present at the time of her evaluation. OT O stated Guardian F revealed R508 needed supervision whenever he was eating. OT O recalled Guardian F was feeding R508 peanuts at the time of her evaluation and continued to repeat, chew, chew, chew! to cue R508 and reduce the risk of choking. Review of OT Evaluation and Plan of Treatment signed [DATE] read, in part: .Medial hx (history): .impulsive and eats to [sic] fast . Prior Level(s) of Function: .Eating = Supervision or touching assistance (Patient is impulsive and eats very fast. 'Tries to shove whole piece of toast in his mouth' per sister [Guardian F]) . Review of R508's progress notes revealed the following entry on [DATE] at 2:40 PM, written by Licensed Practical Nurse (LPN) D: Resident left unsupervised for meal. Resident observed coughing up hot dog during lunch. Checked O2 [oxygen saturation] mid 80s [percent saturation] and pulse [heart rate] in 120s .nurse called on-call provider and got [an] order for 2 liters O2 to maintain O2 sat [saturation] 92% and above . On [DATE] at 12:36 PM, a phone interview was conducted with Certified Nursing Assistant (CNA) C who verified she passed lunch trays on R508's hallway on [DATE]. CNA C stated she attempted to locate R508's diet order and level of supervision in the EMR system but was unable to find the orders. CNA C indicated she asked the floor nurse, LPN D, of R508's diet orders and eating assistance requirements. CNA C indicated LPN D stated R508 was on a regular diet, therefore she subsequently placed the meal tray, which consisted of a hot dog, in front R508 and left him unattended in his private room. CNA C stated she went on a break soon after delivering R508's lunch tray, and it wasn't until after she returned from break that she learned R508 experienced a choking event. Upon return CNA C stated CNA B informed her R508 required supervision when eating. CNA C stated, I felt like an idiot, because I didn't know that [R508 required supervision during meals]. It wasn't in his chart or in the computer . You feel dumb and helpless when things like this happen. There's a lack of communication in the facility, especially regarding newly admitted patients and their diet orders. A lot of times we're [nursing assistants] scrambling around trying to figure out what they [residents] can eat or how they transfer . On [DATE] at 10:00 AM, an interview was conducted with CNA B who verified she worked with CNA C on [DATE]. CNA B stated she passed R508's room and noticed [R508] was rigid in his chair and his whole body was shaking like he was having a seizure. CNA B stated R508 was positioned in his wheelchair with his tray table in front of him, his chin was down toward his chest, his feet were sticking straight out, and his arms were out to his sides. CNA B indicated, his jaw was open a little bit and the hot dog was partially chewed and falling out of his mouth. CNA B stated she immediately grabbed a napkin off the lunch tray and began removing partially masticated hot dog from R508's mouth. CNA B stated, I held him so he wouldn't fall out of his chair because he was rigid .I called his name, and he didn't respond. I kept trying to get food to come out of his mouth . CNA B indicated R508 snapped out of it after approximately ,d+[DATE] seconds and she then yelled for LPN D for assistance. CNA B recalled, When I first went in the room, I noticed his lips were a blue or purplish color. CNA B stated she was unsure why R508 did not receive supervision during the lunch time meal. On [DATE] at 10:20 AM, an interview was conducted with LPN D who verified he responded to R508's choking incident on [DATE] after CNA B reported R508 had food coming out of his mouth, was shaking, and his lips were turning blue. LPN D stated he entered R508's room and noticed he was shaking a bit because, he had a lot of coughs backed up and was trying to breathe. LPN D stated R508's oxygen saturation would not exceed 85% following the choking event, when previously they had been around 95% on room air. LPN D indicated he called the on-call provider for an order of supplemental oxygen and chest x-rays but did not report the seizure-like activity, the discoloration of R508's lips, nor did he request a diet texture downgrade. When LPN D was asked why the change in R508's condition was not disclosed to the on-call provider, he stated R508 did not have a history of seizures and LPN D was most concerned about his low oxygen saturation. LPN D stated no changes to R508's diet order were made following the choking incident on [DATE] and admitted , I didn't let [the DON] know [about the choking incident] which was my bad .she probably would have told me to downgrade the diet but I didn't know I could do that as a nurse . LPN D verified R508 was supposed to be supervised during meal times, but CNA C had not heard him report it. LPN D stated after he notified Guardian F of the choking event she disclosed R508 was so impulsive that he attempted to consume the plastic cracker sleeve when eating a snack on the day of his admission. On [DATE] at 12:53 PM, a telephone interview was conducted with Nurse Practitioner (NP) P who verified she was on-call on [DATE]. NP P stated she was not notified R508 experienced seizure-activity during the choking incident on [DATE]. NP P indicated based on standards of practice she would have likely sent R508 to the hospital for further evaluation if he did not have a history of seizures. Review of R508's medical history did not reveal a history of seizures. Review of the Nursing to Physician communication binder located at the nursing station revealed the following entry on [DATE]: .[R508] had aspiration on food. Diet may need to be downgraded . Review of R508's EMR revealed a diet order change on [DATE] at 9:42 AM that read, Level 3 texture, regular fluid, thin consistency. Review of R508's Plan of Care revealed a revised intervention on [DATE] that read, EATING: Supervision - offer assistance with meal setup as needed. To eat in the dining room, with staff supervision. Review of a Diet Order/Change Form signed by Unit Manager/RN H on [DATE] revealed a checked box that read Feeding Assistance needed for R508. On [DATE] at 11:02 AM, an interview was conducted with Unit Manager/RN H who stated she downgraded R508's diet due to the report of the choking incident that occurred over the weekend. RN H stated, [LPN D] is a new employee and did not know how to put a diet change order in or notify the physician of a diet change which was why the change was delayed. On [DATE] at 11:45 PM, an interview was conducted with Speech Language Pathologist (SLP), G who stated he was made aware of R508's choking incident on the morning of [DATE] during a managerial meeting. SLP G evaluated R508 after the breakfast meal on [DATE]. SLP G stated he evaluated R508 eating a cakey textured food which he was able to physically chew but, .he wanted to eat the whole thing. He had poor safety awareness. SLP G stated he then had a discussion with Unit Manager/RN H about the diet downgrade. SLP G said, I told the nurse [Unit Manager/RN H] that [R508] needed supervision . the diet downgrade was safe, but it wasn't necessarily the intervention I would have placed. [R508]'s risk of choking wasn't due to his inability to chew a regular diet; it was his impulsivity. SLP G was asked his expectation for the meaning of supervision who stated, Eyes-on the resident and being able to provide cues or assistance. SLP G was asked if R508 could safely be left alone while consuming a meal to which he replied, No. During a follow up interview on [DATE] at 2:49 PM, SLP G reiterated, Downgrading his diet was a safe option, it did not harm him in anyway. But it's the impulsivity that's the root cause [of R508's choking risk]. Review of SLP Evaluation and Plan of Treatment for R508, signed [DATE] read, in part: 1.poor carryover with swallow precautions. Benefits from close supervision with all PO [by mouth] intake to promote safety and overall tolerance . 2.Reported tolerance with Reg [regular] texture solids during hospitalization though noted to have significant impulsive behaviors and recommend supervision/assistance with meals. Patient noted to have overt difficulty with intake of hot dog over weekend and nursing staff subsequently downgrading diet to L3 [Level 3] texture solids. Continues to benefit from supervision/feeding assistance to promote swallow safety . 3.Diet downgraded to L3 following overt difficultly with reg texture hot dog. Continues to benefit from closer supervision and/or feeding asisstance [sic] given poor carryvoer [sic] with swallow safety precautions . 4.Supervision: How often does patient require supervision/assistance at mealtime d/t [due to] swallow safety = ,d+[DATE]% of the time. Review of a Therapy to Nursing Communication, dated [DATE] at 3:11 PM read: SLP notified of overt difficulty observed with intake of reg texture solids over the weekend. RN initiated diet downgrade to L3 texture solids. Patient will benefit from 1:1 or close supervision during meals to promote swallow safety and improve carryover with recommended compensatory swallow strategies. On [DATE] at 2:49 PM, a follow-up interview was conducted with SLP G who reported compensatory swallow strategies include alternating solids and liquids, taking small bites, pacing, and monitoring for choking or swallowing during meals. SLP G was asked if he provides education to direct-care staff on supervision expectations during mealtimes. SLP G stated, If there is an emergent need, I'm going to the CNA and floor nurse. On the back end, I write a communication [in the EMR system] and it goes to the nursing staff. I'm generally not providing hands-on, one-to-one education. On [DATE] at 9:02AM, a phone interview was conducted with Guardian F who stated she discussed R508's prior level of function, medical history, and rehab goals with the Interdisciplinary Team (IDT) on [DATE] around 10:30 AM for a discharge planning meeting/evaluation. Guardian F stated the team discussed the hot dog choking incident at length, and the facility reassured her they were able to provide R508 with the supervision he required to mitigate the risk of choking. Guardian F stated, .I asked if the facility was capable of handling [R508] and his diagnoses, especially the TBI which causes him to be impulsive . I asked three different nurses, I was worried about him and his well-being . they said, 'yes, yes, absolutely.' Review of the Discharge Planning Evaluation signed [DATE], did not indicate R508's history of choking secondary to his impulsivity, the choking event that occurred at the facility on [DATE], or implementation of interventions to prevent future instances of choking. Review of R508's EMR revealed the following progress notes: 1. [DATE] at 6:45 PM: Responded to code blue with crash cart and set up suction, other nurses entered to attend as well and began performing Heimlich maneuver. Left room and contacted 911 . 2. [DATE] at 7:00 PM: Notified [Guardian F] per phone that [R508] left the building per EMS [Emergency Medical Services] for [local hospital] . 3. [DATE] at 11:32 PM: .1824 [6:24 PM] CNA came out of dining room yelling code blue . I immediately ran into the dining room to assess the patient. He was unresponsive and not breathing. Heimlich attempted without success. Another nurse tried 5 Heimlich maneuvers without success. 1826 [6:26 PM] patient lowered to the ground. Patient airway suctioned. Negative pulse check, called for AED [automated external defibrillator] .CPR [cardiopulmonary resuscitation] initiated .patient mouth suctioned CPR continued . Police arrived on scene .1833 [6:33 PM] EMS arrived . Review of a Witness Statement written by RN E read, in part: .I heard her [CNA I] come out and say 'we have a code blue!' from the dining room . I went straight into assess the patient .once I got there, he was slumped over, non-responsive, not breathing . [RN J] did a sternal rub, there was no response, he was ashen, grey at that point. Still not breathing . [RN K] did suction him .she had one hand on the mask and one hand on the bag, it was a mix of spit and some tuna that was coming out of the suction . Review of a Witness Statement written by RN K read, in part: .I heard the code paged, I entered the dining room .I pulled a glob of tuna out of his mouth and suctioned some [tuna] out of his mouth . Review of a Witness Statement written by RN J read, in part: .we laid him down to attempt suction, food was noted in his mouth, resting on his tongue . On [DATE] at 3:15 PM, an interview was conducted with CNA I who stated she was present in the dining room on [DATE] and called the code blue for R508. CNA I stated R508 was seated in a high back wheelchair at a dining room table with his back facing the dining room entrance. CNA I stated, He was getting done with his tuna fish sandwich, he ran out of his drink, so I asked him if he wanted more juice. He said he did, so I stepped out of the dining room door and asked for more juice .when I came back, his head was slumped in his chair, and he did not respond to my voice or touch to the shoulder . I ran to the door and shouted, 'code blue!' . Review of a Witness Statement written by CNA I read, in part: .he ate about half if [sic] the sandwich and half his drink. [CNA L] and I went to look at the binder, he had half his sandwich left .he fed the last half sandwich to himself .not even a minute was I looking at the book with [CNA L], she showed me the bread was fine and then I returned to him . I was aware he needed supervision, the day prior when I came to work, [RN M] told me he had problems choking and needs to be watched . On [DATE] at 9:11 AM, a follow-up interview was conducted with CNA I for clarification of the events leading up to the code blue for R508. CNA I revealed she had left R508 unattended earlier during the meal to check the binder on the counter which references residents' level of required assistance and lists acceptable food options according to prescribed diet texture. CNA I stated R508's meal ticket indicated he was on a level 3 diet, and she wanted to confirm that a tuna fish sandwich was an acceptable option. CNA I stated, [R508] had his tray in front of him. He already had started eating at that point, about half his sandwich was gone. I wanted to verify it was the correct food, so I walked to the counter with [CNA L] and looked in the binder. CNA I was asked how long R508 was left attended to which she replied, Just a few minutes .I just looked and came back. CNA I was unable to recall the amount of tuna fish sandwich that remained by the time she returned to the table. Review of a Witness Statement written by CNA L read, in part: [CNA I] and I were passing trays in the dining room together, we got all the trays out . [CNA I] asked me a question about level 3 diets, she asked if they were a level 3 diet what does it consist of, I said they are allowed to have bread, we went over to the book to look at [it] . On [DATE] at 12:26 PM, an interview was conducted with CNA L who verified she helped with the dinner-time meal on [DATE]. CNA L stated CNA I asked her what a level 3 diet consisted of. CNA L stated both she and CNA I walked to the dining room counter and referenced the book together. CNA I was asked how long they referenced the book together while R508 was eating unsupervised to which she replied, probably 10 minutes. Review of a Witness Statement written by the NHA read, in part: . [The DON] and I verified the tray following the event. We noted the sandwich was gone and the 4oz (ounce) beverage had been drunk . Review of R508's hospitalization records from [DATE] to [DATE] read, in part: .Pt [patient] choked on & aspirated tuna salad during dinner, becoming unresponsive . pt arrived to [local hospital] ED [emergency department] in acute hypoxic resp [respiratory] failure and was immediately intubated .that became clogged with tuna .pt noted to have significant volume of aspirated food throughout airway .he seized after arriving to the ICU [intensive care unit] likely as a result from prolonged hypoxia [low blood oxygen levels] . .Pt is known to be impulsive secondary to TBI and reportedly eats very fast w/ [with] frequent aspiration episodes .he was eating .tuna salad for dinner when he began choking, ultimately becoming unresponsive .EMS crew removed tuna salad from his mouth . Pt hypoxic .upon arrival to [local hospital] ED and was immediately intubated .with copious amounts of tuna salad noted throughout airway. Tuna removed to the best of his [ED physician's] ability, however .became clogged w/ inability to bag patient. .I [physician] was able to .intubate the patient visualizing the glottis, as well as a very large amount of what appears to be tuna salad in the posterior pharynx and the glottis and I suspect behind .patient became hard to bag and the tube was suctioned and really revealed a large amount of .tuna fish salad .saturation dropped and the tube was removed .I suspect the ET [endotracheal] tube got clogged with tuna salad . the respiratory therapist did suction numerous and multiple bits of food from the ET tube . We [physician and R508's family] reviewed that I do not feel he will return to his functional baseline and that if he were to come out of coma, an unlikely event, he would likely need ,d+[DATE] care including feeding, mobility, and toileting. We discussed how the ongoing seizure activity supports a significant degree of brain damage from the anoxia . .REASON FOR PRESENTATION: .presents to [local hospital] ED after a choking episode while at [Facility Name] for rehab. Pt choked on & aspirated tuna salad during dinner, became unresponsive . Patient was admitted to the ICU. He was maintained on mechanical ventilation .he was started on multiple antiepileptic drugs for intractable seizures. The patient failure to improve despite our best efforts. After discussion with the family the patient became comfort measures and was eligible for organ donation. The patient had a DCD [Donation After Cardiac Death] on [DATE] at 1554 [3:54 PM] . .date of death : [DATE] CAUSE OF DEATH/DIAGNOSES AT TIME OF DEATH Acute hypoxic respiratory failure Aspiration pneumonia Cardiac arrest Anoxic brain injury with resulting seizure disorder Hyponatremia Myocardial injury . On [DATE] at 9:48 AM, an interview was conducted with the Senior Regional NHA, the NHA, the DON, and regional RN N. The DON verified that based on R508's medical history and acute care discharge summary, R508 required oversight, cueing, and supervision with eating due to his well-documented history of impulsivity which resulted in a choking/aspiration risk. The DON confirmed she was unaware of R508's initial choking event that occurred on [DATE] until she was informed during report upon arriving to work on [DATE]. The DON confirmed LPN D was unaware of the protocol following a choking incident, including downgrading the diet and notifying the DON and/or physician. The DON stated, I would have probably downgraded the diet [on [DATE]] if I would have known about the choking incident. The Senior Regional NHA, the NHA, and the DON all confirmed R508 should have been supervised during the lunch meal on [DATE]. When the DON was asked if LPN D should have reported R508's seizure-like activity and discoloration of his lips to the on-call provider she stated, He [LPN D] didn't witness any seizure activity and there was nothing to alert him [of the seizure activity]. The Senior Regional NHA added, [LPN D] didn't think he [R508] had a seizure. Both LPN D and CNA B's witness statements were reviewed which stated, .food coming out of his mouth, he was shaking, and his lips were turning blue, and, he was not talking or responding ., respectively. The Senior Regional NHA stated, It's not the CNA's place to say if he had a seizure. When asked who the appropriate person would be to make that determination, the DON stated, The physician. CNA I witness statements and interviews were reviewed with the Senior Regional NHA, the NHA, the DON, and regional RN N which confirmed CNA I left R508 unattended twice during the [DATE] dinner meal. The Senior Regional NHA stated, I don't know what to say to you, that's not what I heard . I was told he [R508] was never left unattended with his food. When CNA I's witness statement was reviewed which read, he ate about half if [sic] the sandwich and half his drink. [CNA L] and I went to look at the binder, he had half his sandwich left .he fed the last half sandwich to himself .not even a minute was I looking at the book with [CNA L] the NHA replied, She [CNA I] never told us she left [R508 unattended]. All parties confirmed R508 was care planned for direct supervision in the dining room at mealtimes at the time of the incident on [DATE]. Resident #509 (R509): Review of R509's EMR revealed admission to the facility on [DATE] with diagnoses including cerebral infarction (stroke), dysarthria (difficulty speaking), and dysphagia. Review of R509's Brief Interview for Mental Status (BIMS) assessment revealed a score of 9, indicative of moderate cognitive impairment. Review of R509's Plan of Care read, in part: .EATING: 1 person assist, 1:1 supervision, initiated [DATE]. On [DATE] at approximately 1:40 PM, R509 was observed eating lunch in the A-side dining room. Two facility staff members, Resident Voice/Staff Member Q and Registered Dietitian (RD) R were in the dining room. R509 was observed with a meal tray placed in front of her with no staff supervision. R509 was observed eating for the duration of her meal without receiving cueing or assistance from staff. On [DATE] at 1:50 PM, an interview was conducted with the DON regarding facility personnel expectations in the dining rooms during mealtimes. The DON indicated there should be two staff members in the dining room as, a rule of thumb. When asked if the staff members should be a CNA she replied, Yes. The DON was asked if a non-CNA could assist in the dining and stated, As long as they're not providing direct care or feeding. On [DATE] at 2:46 PM, a follow up interview was conducted with the DON and Resident Voice/Staff Member Q. The DON was asked her expectations for a resident who required 1 person assist or 1:1 supervision during mealtimes. The DON stated she considered 1:1 supervision to be, sitting next to the resident, providing cues and assistance, and being able to visualize the resident. Resident Voice/Staff Member Q was asked if she was aware of any residents in the dining room who required 1:1 supervision during mealtime to which she replied, No. Review of R509's meal tray card read, Alerts: 1:1 feeding assistance, supervision with meals. On [DATE] at 2:49 PM, an interview was conducted with SLP G who verified R509 required 1:1 supervision during mealtimes. When asked why R509 required 1:1 supervision, SLP G stated, Because she has zero motivation to feed herself . she's a failure to thrive. If she has one-on-one assistance, she'll accept that assistance [and eat]. When asked his definition of 1:1 assistance, SLP G replied, Eyes-on the resident, cueing, helping her feed herself. Resident #510 (R510): Review of R510's EMR revealed initial admission to the facility on [DATE] with diagnoses including dysphagia, cognitive communication deficit, and schizophrenia. Review of R510's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, indicative of moderate cognitive impairment. Review of R510's Plan of Care read, in part: .EATING: 1 person assist, initiated on [DATE]. On [DATE] at 7:35 AM, R510 was observed in the East-side dining room in a high back wheelchair in the rear left corner with his back facing the dining room entrance. At 7:39 AM, the Assistant Director of Nursing (ADON) was observed placing R510's tray in front of him then walking away and leaving him unsupervised. R510 was observed eating the entirety of his breakfast meal without assistance from staff. Review of discharge instructions from an acute care hospital, dated [DATE], read, in part: .Diet after discharge: dysphagia diet . Will need 1:1 assist. Hx [history] of choking on solids . Review of a Progress Note written by written by NP S on [DATE] read, in part: .He [R510] is on a modified diet and recommended to have one-to-one feeding assist . Dysphagia, unspecified type: history of aspiration pneumonia .recommend to have 1:1 feed assist . Review of R510's progress notes revealed the following entries: 1. [DATE]: .requires assist and supervision with meals-recent aspiration pneumonia . 2. [DATE]: .resident drinks very fast and requires staff to assist with eating and drinking . 3. [DATE]: .low safety awareness, impulsive ,d+[DATE] assist/sup [supervision] for feeding . 4. [DATE]: .recommend 1:1 feeding assistance with all intake. 5. [DATE]: .resident drinks very fast if left unattended during meals . Review of R510's most recent SLP Evaluated, dated [DATE], read, in part: .Patient referred to ST following change in payer source and continued concern with intake of modified diet texture . high risk of aspiration . .How often does patient require supervision/assistance at mealtime d/t swallow safety = ,d+[DATE]% of the time. Review of R510's most recent quarterly Nutrition Data Collection/Evaluation dated [DATE] read, in part: .Resident's ability to feed self: supervision/cueing needed . On [DATE] at 9:48 AM, an interview was conducted with the Senior Regional NHA, the NHA, the DON, and regional RN N who were made aware of the ongoing concerns regarding lack of implementation of interventions for residents care planned to receive supervision/assistance while eating as evidenced by observations of both R509 and R510 not receiving their care-planned level of supervision during mealtimes. The DON stated R509's level of assistance for eating was downgraded the morning of [DATE] to, supervision as needed for cueing and encouragement to eat, but confirmed R509 was care planned for 1:1 supervision at the time the lunch observation was made on [DATE]. The DON confirmed R510 was care-planned for 1 person assist. The NHA stated there was ongoing confusion between the nursing staff, the MDS staff, and the speech therapist regarding verbiage for level for assistance. The regional NHA admitted , We [managerial staff] need to educate all staff that someone needs to be in the dining room if a resident requires supervision . if they are 1:1 then someone has to be with them and cannot leave them. Review of facility policy, Accidents and Supervision revised [DATE] read, in part: .Each resident will be assessed for accident risk and will receive care and services in accordance with their individualized care plan . .Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) [TRUNCATED]

Based on observation, interview, and record review, the facility failed to implement and maintain interventions to prevent the development and progression of a pressure ulcer for one Resident (#46) of three residents reviewed for pressure injuries. This deficient practice resulted in the development of a stage four pressure ulcer (a wound affecting skin, fat, and muscle tissue) for a high-risk resident. Findings include: Resident #46 (R46): Review of R46's Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with diagnoses including left femur fracture, diabetes, and congestive heart failure. Review of R46's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, indicative of moderate cognitive impairment. Further review of the MDS revealed Resident #46 had an unhealed stage four pressure ulcer that was not present upon admission. Review of R46's Braden Scale admission assessment (a standardized assessment which calculates risk of pressure injury) on 10/13/23, revealed a score of 15.0, indicating R49 was at risk [for pressure ulcer]. On 3/4/24 at 10:28AM, an interview was conducted with R46. R46 stated that he was admitted to the facility after breaking his hip and soon after developed a wound on his left heel. R46 was observed sitting in a wheelchair wearing only socks, with both feet resting on the tile floor. On 3/5/24 at 9:21AM, R46 was observed laying on his back with a heel elevating cushion improperly positioned under R46's knees instead of at the calf area to float heels. R46's heels were resting flat on the surface of the bed. On 3/5/24 at 10:05AM and 11:53AM, additional observations were made of R46 sitting in his wheelchair with both heels resting on the tile floor. On 3/5/24 at 12:32PM, R46 was observed sitting in his wheelchair with both feet resting on the wheelchair footrests. R46 stated he had protective boots in his closet. When asked if nursing staff offered to put them on his feet, R46 replied, No. Review of R46's plan of care revealed the following focus: Resident has impaired skin integrity as evidenced by .stage 4 [ulcer] to left heel . Interventions were listed as: 1. Encourage resident to sit in the recliner to help with repositioning and his heels off the end of the foot rest, initiated 11/3/2023. 2. Offer and encourage resident to sit in recliner with feet dangling using blue boots when up in recliner, initiated 11/3/2023. 3. Encourage/assist as needed to elevate heels off the mattress as tolerated. Boot on bilateral [both] feet to off load heels, initiated 10/25/23. On 3/5/24, an interview was conducted with Certified Nursing Assistant (CNA) R regarding implementation of pressure reduction interventions for R46. CNA R stated she was unsure if R46 was supposed to be wearing heel protective boots during the day, but she thought they might be offered to him at night. Review of R46's Would Evaluations revealed the following data: 1. 10/25/23: a. Pressure - Deep Tissue Injury b. Body Location: Left Heel c. New - Minutes Old d. Acquired - In-House Acquired e. Dimensions/Area: 0.76cm^2 2. 10/30/23: a. Pressure - Deep Tissue Injury b. Body Location: Left Heel c. Deteriorating - 5 days old d. Acquired - In-House Acquired e. Dimensions/Area: 1.77cm^2 (+131%) [increase in area by 131% since latest assessment] 3. 11/13/23: a. Pressure - Unstageable (slough and/or eschar) [a collection of dead tissue within a wound] b. Body Location: Left Heel c. Deteriorating - 19 days old d. Acquired - In-House Acquired e. Dimensions/Area: 3.15cm^2 On 3/5/24 at 4:00PM, an interview was conducted with Registered Nurse (RN) Q' who stated R46 was admitted to the facility without a pressure ulcer and eventually developed a wound on his left heel. RN Q stated the pressure ulcer likely had gotten progressively worse due to the nursing staff not ensuring that interventions were appropriately implemented. RN Q stated, Nurses are stretched too thin, often covering two hallways. They don't have time to check to see if interventions are in place. When asked if R46 was noncompliant with interventions, RN Q stated, I've never seen him resistant to cares. Review of a Consultation Report dated 12/13/23 from an advanced Wound Care Center read, in part: Stage 4 [left] heel pressure ulcer .must offload 100% of [the] time . Review of a Consultation Report dated 1/5/24 from an advanced Wound Care Center read, in part: s/s [signs and symptoms] of cellulitis to left heel .pt [patient] must wear heel protector at all times. Review of a Progress note dated 2/16/24 from an advanced Wound Care Center read, in part: .Wound Assessment(s) .Left .Posterior [toward the back] Heel is a chronic stage 4 pressure injury pressure ulcer .necrotic [dead] tendon is exposed .the wound is deteriorating .upon assessment the wound is measuring slightly larger than last visit . General Notes: Patient is to wear a heal (sic) pillow protector on left heel at all time[s] . Review of R46's EMR did not reveal orders for left heel offloading or a left heel pillow protector per recommendations following consultations with the advanced Wound Care Center on 12/13/23, 1/5/24, or 2/16/24. On 3/6/24 at approximately 9:32AM, during an interview and observation, R46 was observed sitting in his wheelchair with heels resting on the tile floor with Unit Manager/RN H who confirmed R46 had a stage four pressure ulcer on his left heel. When asked about R46's positioning, RN H stated, He [R46] should be wearing boots. On 3/6/24 at 9:40 AM, an interview was conducted with RN H who stated it was unacceptable for a stage 4 pressure ulcer to be facility acquired. RN H verified recommendations for heel offloading and heel protectors from the advanced wound care clinic were never transcribed into R46's orders and acknowledged the miscommunication this caused to direct care staff. RN H was unable to provide documentation with dates and times from direct care staff verifying refusals to pressure ulcer interventions. RN H acknowledged there had been no updated interventions to R46's care plan for impaired skin integrity since 12/22/23 despite continued worsening progression of the pressure ulcer on R46's left heel. Review of facility policy titled, Pressure Injury Prevention and Management revised 1/1/2022 read, in part: .Interventions for Prevention and to Promote Healing .Basic or routine care interventions could include, are not limited to .redistribute pressure (such as repositioning, protecting and/or offloading heels .) .Modifications of Interventions .Interventions on a resident's plan of care will be modified as needed. Considerations for needed modifications include .lack of progression towards healing .

Based on interview and record review, the facility failed to ensure physician orders [REDACTED].#701) out of three residents reviewed for physician orders, in a total sample of three residents. This deficient practice resulted in the discontinuation of a physician order [REDACTED]. Findings include: A review of Resident #701's medical record revealed he was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. A review of hospital records revealed he was transferred to the hospital on [DATE] and passed away in the hospital on [DATE]. A review of the progress notes for [DATE] revealed the following: [DATE] 15:06 (3:06 p.m.) .New order given to send res(ident) (#701) to ED (emergency department) for PICC (peripherally inserted central catheter) line insertion. Pharmacy to dose IV (intraveneous) [MEDICATION NAME] x 2 weeks. [DATE] 15:30 (late entry note) Resident toileted before dinner. Medium BM (bowel movement). Vital signs stable. Resident placed back in wheelchair and taken to dining room. [DATE] 15:50 (3:50 p.m.) (late entry note) Resident states no pain . Labs back and (Physician G) notified. (Physician G) wants PICC line placed. Resident will be sent out to hospital ER due to no other ability to place PICC line at this time. (Physician G) stated no oral or IV antibiotics, only PICC line. Resident will continue to be monitored until sent out. [DATE] 16:15 (4:15 p.m.)(late entry) Resident checked for clean brief before being sent to hospital . A review of the emergency room report with an admitted [DATE] revealed, . He (Resident #701) has been in for a PICC line for ongoing IV antibiotics. He apparently was running a fever today . Dx (diagnosis): 1. Acute [MEDICAL CONDITION] (MRSA) infection, right 2nd toe. 2. Acute urinary tract infection. A review of the Hospital Summary Note dated [DATE] revealed the following, Diagnosis: [REDACTED]. Urinary Tract Infection. Bacteremia. Non-pressure chronic ulcer of right heel and midfoot with fat layer exposed. Acute [MEDICAL CONDITION] with [MEDICAL CONDITION]. Cachexia .Sepsis. Pneumonia . Patient (Resident #701) developed an infection involving his right second toe and heel. A culture of drainage from the toe [MEDICAL CONDITION]. Patient was sent to emergency for further evaluation and treatment. Patient was initially treated with a combination of intravenous fluids and intravenous [MEDICATION NAME]. Approximately 24 hours into the hospitalization , patient developed acute hypoxic [MEDICAL CONDITION] . palliative care service was asked to see the patient .the patient was made comfort care. Patient's condition continued to deteriorate . [DATE] the patient expired. A review of the (MONTH) (YEAR) Treatment Administration Record (TAR) revealed an order (with no date) of, Cleanse right foot - 2nd toe daily w/ (with) N.S (normal saline) and apply bandaid. This order was scribbled out, and there was also no date when the order was discontinued. The documentation showed the order had not been carried out after (MONTH) 5, (YEAR). A review of the Physician order [REDACTED]. Cleanse right foot - 2nd toe daily with NS (normal saline) and apply bandaid daily. Skin tear. There was no documentation to discontinue this order. On [DATE] at 4:10 p.m., an interview was conducted with the Administrator. When asked why the order had been scribbled out and was not continued after the 5th of December, the Administrator stated, Because it (#701's skin tear) healed on the 4th (of December, (YEAR)). On [DATE] at 11:40 a.m., an interview was conducted with the Administrator and the Director of Nursing (DON). When asked about the events that occurred on [DATE], the Administrator stated, He (Resident #701) was sent to (name of hospital) on [DATE]. (LPN H) is friends with the EMS people. They said that they were going to report (Physician G) for sending (Resident #701) out to the ER for a non-emergent need. When asked what she had remembered of the events, the DON stated, She (LPN H) called (Physician G). I had her call the pharmacy to see if it was ok to give vanco (an antibiotic) short term via IV. The pharmacy said yes. But when she called (Physician G) he said 'no'. The DON then stated LPN H had asked Physician G if they could do oral vanco or another antibiotic to treat [MEDICAL CONDITION] infection, but the Physician said 'no'. The DON stated, The nurse (LPN H) told me she called him (Physician G) and he said, 'I want him to have a PICC, send him out (to the hospital ER) now.' When asked how much time had lapsed between when the original order to get emergency treatment for [REDACTED].#701 to the emergency room , the DON stated, Not even an hour. On [DATE] at 2:17 p.m., an interview was conducted with Physician G who, when asked about the transfer of Resident #701 to the hospital stated, I got a second call after they called with the culture results, asking if we can give IV (intravenous) vanco. I said again, No, we need a PICC (line).' Then a few hours later I got another phone call. I got upset. The nurse told me they tried peripheral but couldn't get it (access). I asked they why did they do this, they said they thought they should try to do it peripherally before sending him to (the) ER. They also asked if they could do (give him the medication) orally. I said 'no', that oral vanco can only treat one thing,[DIAGNOSES REDACTED]icile infection. Then there was another call with some symptoms. When asked about the expectations when a physician's orders [REDACTED]. Why were they coming up with their own ideas? When asked how much time had lapsed between when he gave the order and when Resident #701 was actually sent out, Physician G stated, A big gap, a number or hours. When asked if the nursing staff had failed to follow his physician orders, Physician G stated, Yes, that was against physicians orders. On [DATE] at 2:33 p.m., a phone interview was conducted with LPN H, who reported that she was in fact the nurse that sent Resident #701 out to the hospital on [DATE]. When asked what happened on the afternoon of [DATE], LPN H stated, (Physician G) wanted a PICC placed. It was New Years Eve, and usually we have people to come to do (place) PICCs. They couldn't come until (MONTH) 2nd. So I asked if he wanted IV or oral Vanco. He said no, and to send him (Resident #701) out. When asked how long it took between the order came to send the Resident out and when he (Resident #701) actually got sent out, LPN H stated, Originally he (Physician G) wanted him sent to the ER for the PICC. I told him that you can't really do that, that it wasn't emergent. I asked for IV or oral antibiotics and he said no, and to send him anyways. It was about an hour. A review of the emergency transportation services documentation utilized for Resident #701 on [DATE] revealed, (call) received: 18:26 (6:26 p.m.) . at scene: 18:40 (6:40 p.m.) . This document indicated that the 911 call from the faciity did not occur until 6:26 p.m., more than 4 hours after the order was received to send Resident #701 to the emergency room . Per this documentation, the transportation services left the facility with Resident #107 at 6:49 p.m. On [DATE] at 3:15 p.m., a second phone interview was conducted with LPN H. When asked when Resident #701 was actually sent out to the ER, LPN 'H stated, I think between 4:30 and 5:00 p.m., around dinner time. When asked if she had tried to insert an IV, LPN H stated, No, but we did draw (blood for) labs. LPN H did not comment on why she had not sent Resident #701 to the ER when the order was received. On [DATE] at 3:25 p.m., a second interview was conducted with LPN F. When asked what time she received the order to send Resident #701 to the ER, LPN F stated, I called (Physician G) with the results (positive [MEDICAL CONDITION]) at around 2 to 2:30 p.m., and he said to send him to the ER for PICC line placement. At that point there was a discussion about the ER and (Physician G) and about residents being sent (to the ER) for the wrong reasons. At that time, I gave the keys to (LPN H) and she took it from there. A review of a Physicians Order for Resident #701 dated [DATE] at 15:00 (3:00 p.m.) revealed, 1. Pharmacy to dose [MEDICATION NAME] IV x 2 weeks. 2. PICC line placement ASAP (as soon as possible) in ER. Per Lippincott Manual of Nursing Practice, Chapter 2, Standards of Care and Ethical and Legal Issues, page 16 reads, in part: . departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders [REDACTED].

Based on interview and record review, the facility failed to correctly transcribe, then discontinued, a physicians order for significant medication for one resident (#200) out of four residents reviewed for pharmaceutical services, from a total sample of four residents. The facility was placed in Immediate Jeopardy (IJ) on 06/02/17 10:07 a.m. as a result of the facility's failure to ensure pharmaceutical services for the accurate administration of medication, when they failed to recognize a transcription error which led to the abrupt discontinuation of a medication needed by Resident #200, contributing to an acute [DIAGNOSES REDACTED] crisis and requiring emergency hospitalization , IV medication and oxygen therapy. The facility was notified of the transcription error by Physician A's office on 5/2/17, but the facility failed to take steps to prevent reoccurrence by: 1. failing to investigate the root cause of the confusion regarding an order for [REDACTED]. 3. failing to monitor the nursing staff's transcription of medications from physician order [REDACTED]. The Imediate jeopardy was removed on 6/2/17 at 12:18 p.m., when the Administrator and Director of Clinical Services/ Registered Nurse (RN) E submitted a Plan of correction and completed the following, confirmed by this Surveyor by observation and record review: 1. Nurses were re-educated on the policy and procedure for Receiving, Transcribing and discontinuation of physician orders: Completed 6/2/17. 2. Re-education of Nursing Managment, by the Director of Clinical Services, on Receiving, Transcribing and discontinuation of physician orders. Completed 6/2/17. 3. The Nursing Management were re-educated on the process of reviewing physicians daily in triage and bring forward those the need clarification to the DCR (Daily Clinical Review.) Completed on 6/2/17. 4. (Pharmacy Name) was scheduled to provide education on Physician orders [REDACTED]. Scheduled for 6/6/17. 5. A QAPI (quality assessment process improvement) meeting was conducted with Leadership Team and the Medical Director and Regional Team on 6/2/17. 6. Daily Audits began on Physicians Orders to identify unusual orders related to stop dates, quantities and number days supplied. Although the Immediate Jeopardy was removed, the facility's deficient practice continued at a pattern level with the potential for more than minimal harm to the residents until the facility has demonstrated that: 1. All current Physician order [REDACTED]. 2. All licensed nursing staff who dispense medications complete a competency review of their medication pass technique. 3. The QAPI plan is adopted for the monitoring of pharmacy services to include accurate transcription and administration of medications. Findings include: On 6/1/17 an abbreviated survey was conducted at the facility in response to a complaint filed on behalf of Resident #200. The Complaint information read as follows: (Resident #200) was admitted to (hospital name) on 4/22/17 as she was found on the floor unresponsive and in acute respiratory distress in her room at the nursing facility. It was later determined by neurology staff at (hospital name) that (Resident #200) was experiencing a [DIAGNOSES REDACTED] crisis (life-threatening muscle weakness effecting the respiratory muscles). (Physician A) wrote a prescription to increase the dose of Pyridostigmine Bromide (improves muscle strength) in January 2017. The script was written as a 90 day supply, with 3 refills however (facility name) orders did not reflect the 3 refills and stopped the medication after 90 days. According to the electronic and physical chart, Resident #200 is a [AGE] year old female, admitted originally on 10/30/15 with [DIAGNOSES REDACTED]. The most recent Minimum data set assessment (prior to discharge to hospital on [DATE]), dated 2/1/17, revealed Resident #200 scored 09/15 on her Brief Interview of Mental Status exam, revealing she had moderate cognitive impairment, and needed limited one person to total assist with all other areas of her activities of daily living. A review of the physician's orders [REDACTED]. This order was taken from a consult with Physician A on 1/20/17. The correct order read as follows: Increase Pyridostigmine Bromide: 60 MG 1/2 tablet orally 3x daily, 90 day(s){supply}, 135 (number of 60 mg pills), Refills: 3. Per review of the MAR for April 2017, the facility continued to view this order as a discontinuation in 90 days, and Resident #200 did not receive Pyridostigmine Bromide after 4/20/17. Two days later she was admitted to the hospital in acute respiratory distress. An interview was conducted with LPN G and LPN H on 6/2/17 at 2:01 p.m., LPN G was shown the original prescription and she replied, Yes, I transcribed this order, some of those numbers don't mean anything to me. LPN G was asked to clarify her statement, she replied: I read the order as Increase Pyridostigmine Bromide : 60 MG 1/2 tablet orally 3x a day for 90 days, then it was to stop that number 135 means nothing to me. When asked about the prescription stating Refills 3 LPN G replied .I don't deal with that, pharmacy does. LPN H (co-signed) the order, when asked how she read the order? she replied I guess I read it the same as (LPNG) did, the medication was for only 90 days Why didn't pharmacy call and tell us the difference? An telephone interview was conducted with the General Manager of the facility's pharmacy, RPH I on 6/2/14 at 11:34 a.m RPH I was asked to interpret Physcian As order for Pyridostigmine bromide. RPH I stated, It's a standard prescription order, she (Physician A) wrote for a year long script .she wrote 3 refills. When asked why the pharmancy printed '90 days', RPH I stated, We have to transcribe the order as written, however we knew by the language of the script it was a year long script. When asked if this order was confusing, RPH I replied No, it's standard script language RPH I was asked if any of the pharmacist called the facility to clarify the order with them, he replied, No, we didn't see a problem with the script.

Based on interview and record review, the facility failed to accurately transcribe two physician's medication orders, and failed to administer the correct dosage of medications to three Residents (#200, #201, #203) out four medication errors identified from a total sample of four residents. This failure resulted in a long standing medication (pyridostigmine [MEDICATION NAME] - muscle strengthening medication) being discontinued, a potassium supplement was not given for 3 days, and an incorrect dosage of [MEDICATION NAME] (blood thinner) was given. This deficient practice resulted in Resident #200 having severe respiratory complications, and the potential for cardiac and bleeding complications for Resident #201 and #203, respectively. Findings include: According to the electronic and physical medical record, Resident #200 is [AGE] year old woman admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The facility received a prescription from Physician A on 1/20/17 to increase 'pyridostigmine br 60 mgs (milligrams) 1/2 tab three times a day. 90 days (supply), 135 (tablets), three refills.' The facility transcribed the order as 'pyridiostigmine br 60 mgs, 1/2 tab three times a day for 90 days.' The physicians order transcribed this way led the facility to believe the medication was to be discontinued on 4/20/17, and did so on that date. Resident #200 did not receive the medication for two days (6 doses) and was transferred to the local emergency roiagnom on [DATE]. The inaccurate medication transcription contributed to an acute [DIAGNOSES REDACTED] crisis requiring emergency hospitalization , IV medication and oxygen therapy. Resident #201 is a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. [MEDICATION NAME] 40 mgs 1 po (orally) twice a day, for three days and then for [MEDICATION NAME] 40 mgs po qd (every day). 2. KCL (potassium chloride) 10 meq (milliequivelents) po every day. The order for the KCL was not transcribed to the MAR (medication acceptance record.). A review of the IDT (interdisciplinary team notes) dated 4/25/17, revealed nurse noticed a new blister pack (medication package) in the cart (medication cart) of KCL checked the orders and found the order for KCL was never transcribed as ordered. Resident #201's physician was notified and the KCL was reordered with a start date of 4/24/17 and for a lab draw for K+ (potassium) level to be drawn 4/24/17. According to the results of the lab draw on 4/27/17, Resident #201's K+ level was found to be in normal range. Resident #203 is a [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the physician orders [REDACTED].#203 at risk for bleeding, and an order for [REDACTED]. IDT notes dated 4/18/17, revealed a medication error was discovered while a nurse was completing the days orders (after her evening medication pass). This nurse gave [MEDICATION NAME] 5 mgs as previously ordered, and failed to transcribe the new order for [MEDICATION NAME] 3 mgs. The physician group (for the facility) was notified and ordered a lab draw for PT & INR to be drawn on 4/18/17. The results from the 4/18/17 lad draw revealed Resident #203's PT & INR were in therapeutic range.

Based on observation, interview, and record review, the facility failed to ensure medication administration was conducted in a safe and accurate manner for three residents (Residents #S450, #409, and #S451) of nine residents reviewed for medication administration from a total sample of 17 residents. This deficient practice resulted in significant medication errors: vasopressor (medication to maintain blood pressure) abruptly discontinued with subsequent resident psychological distress, a [MEDICATION NAME] (pain medication) patch not changed and monitored, and inappropriate administration of crushed extended/delayed release medication. The immediate jeopardy began on 9/30/16 when multiple significant medication errors were identified on 9/30/16. The Administrator was notified of the immediate jeopardy at 12:13 p.m. on 9/30/16. The immediate jeopardy was removed on 9/30/16, but noncompliance remained at the lower scope and severity at an isolated harm level. Findings include: Resident #S450 According to the Facility Admission Record, Resident #S450 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #S450 required a vasopressor (Milrinone) to be administered intravenously (IV) through a central line (intravenous line that goes into the heart) to maintain adequate blood pressure. On 9/27/16 at 2:00 p.m. an observation of Milrinone administration for Resident #S450 was made during medication pass with Registered Nurse (RN) Y. During this time Resident #S450 stated, This nurse (RN Y) saved my life. Resident #S450 continued to report that the Milrinone did not infuse one day and he felt awful. During this same conversation, Resident #S450 stated, The nurse came in, and right away said, You don't look so good and went running out to get help. They had to put me to bed, I was so weak it took two nurses to get me in bed, and they (nurses) put my oxygen on. My oxygen level was really low. I felt like I was dying .Now, I always listen to the pump to make sure it is working. During a second observation of Milrinone administration on 9/28/16 at 4:15 p.m. with RN W, Resident #S450 stated, Make sure that (IV pump) is running, that one nurse saved my life when she found it wasn't running .That was an awful day .I never want to go thru that again .I was dizzy and sweaty .The pain was horrific .I thought I was dying .Now, I always make sure I hear that thing (IV pump) running. One nurse verified pump was infusing during observations made on 9/27/16 and 9/28/16. On 9/27/16 at 2:10 p.m., during an interview RN Y stated, I found him that day when it (Milrinone) didn't infuse. He was looked gray and weak .He was a little confused. I got help to get him into bed and put his oxygen on. Review of the facility Resident Occurrence Report dated 9/29/16 reads, Resident (#S450) was noted on 9/19/16 afternoon shift nurse after she had gone down to assess time left on resident's Milrinone pump that the cartridge was full (indicating no medication had been infused since the morning medication administration) .It is determined that upon changing the cartridge from previous shift, verification that the pump was running was not confirmed .Recommendation Add to TAR (Treatment Administration Record) for 2 nurses to verify pump is running q (every) 8 hours. Add to TAR to monitor for pump function q 2 hours along with site monitoring. This Surveyor did not observe two nurses checking the pump to ensure it was running during the observations made on 9/27/16 and 9/28/16. Review of the Medication Administration Record [REDACTED]. Two nurses verified function of the pump on p.m. shift 9/23/16. There were 21 times between midnight on 9/19/16 through a.m. shift on 9/29/16 that two nurses did not verify pump function to ensure Resident #S450 was receiving medication as ordered. During an interview on 9/30/16 at 8:20 a.m. the Director of Nursing (DON) stated, At the time of cartridge change another nurse should verify (that pump is working). When asked if there was any follow up regarding the 9/19/16 incident the DON stated, I spoke with them (nurses) and they said they are doing it. There was no documentation provided by the facility demonstrating education was provided, to whom it was provided, or follow up to ensure pump was being monitored as directed. Resident #409 According to the Facility Admission Record, Resident #409 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of Interdisciplinary team (IDT) report for Resident #409 dated 6/2/16 reads, No adverse effects have been noted R/T (related to) medication patch discovered on 5/27/16 from 5/25/16. Will alert Indigo practitioners (physician team) of resident's [MEDICATION NAME] (pain medication) request. Review of Occurrence Report dated 5/27/16 for Resident #409 reads, Checked patch ([MEDICATION NAME]) placement with the north hall nurse. Verified that patch was on the resident's right back with the date 5/22/16. Dose marked for administration on 5/25/16 was not initialed and no indication as to why medication not given. This documentation indicated Resident #409 had the same [MEDICATION NAME] (pain) patch on for five days (5/22/16 to 5/27/16) which should have been changed on day three (5/25/16) per medication orders; the MAR indicated [REDACTED]. Review of the MAR indicated [REDACTED]. This MAR indicated [REDACTED] 9/23/16: no 11 p.m. to 7 a.m. check, 9/24/16, 9/25/16, 9/26/16, and 9/27/16: no 7 a.m. to 3 p.m. checks. This MAR indicated [REDACTED]. According to the Occurrence Report dated 5/27/16 the conclusion reads, Notified nurse that had made the error. MAR/TAR is heavy with discontinued orders and FYI (for your information) orders. Order was missed on MAR indicated [REDACTED]. There was no recommendation in this report for nurse education regarding the requirement for two nurses to verify placement of [MEDICATION NAME] every shift. During an interview on 9/29/16 at 11:55 a.m., RN / Unit Manager K stated, [MEDICATION NAME] ([MEDICATION NAME]es) are to be verified by two nurses. During an interview on 9/30/16 at 8:20 a.m. the DON stated, (Nurses are) supposed to have two nurses verify placement (of [MEDICATION NAME]) each shift .I checked other patches (on residents in the building) to ensure others were changed (as ordered). There was no documentation provided by the facility to support which residents had [MEDICATION NAME]es, no copies of educational materials provided to staff and no follow up documentation to ensure patches were being changed and verified as directed. Resident #S451 On 9/29/16 at 8:00 a.m. RN L was observed crushing medications, including [MEDICATION NAME] DR (delayed release medication to treat bowel disease) and [MEDICATION NAME] ER (extended release medication to control blood pressure and heart rate) to be given to Resident #S451. Manufacturer recommendations, updated 2016, for [MEDICATION NAME] DR reads, .Swallow [MEDICATION NAME] controlled-release capsules whole. Do not break, crush, or chew before swallowing . Manufacturer recommendations, updated 2016, for [MEDICATION NAME] ER reads, .should be swallowed whole, without chewing or crushing . According to Nursing Standard, reviewed September 2012, reads, .Modified release (medications) .Should not be altered because: The medicine is designed to be released over prolonged period. The mechanism for slowing release may be damaged. Patient receives full dose quicker than expected and subsequently little or no dose at all for a period of time. Review of Resident #S451 blood pressure and heart rate log revealed on: 8/11/16 blood pressure 130/76 and heart rate 104, 9/11/16 blood pressure 120/66 and heart rate 72, 9/15/16 blood pressure 120/59 and heart rate 59, 9/29/16 at 6:48 a.m. (before medication) blood pressure 136/76 and heart rate 65, and 9/29/16 at 9:59 p.m. (14 hours after medication) blood pressure 139/62 and heart rate 82. This indicates a range of 59-104 for Resident #S451's heart rate during this time frame. Normal range for blood pressure is below 120/80 and normal heart rate range is 60 to 100. During an interview on 9/29/16 at 4:08 p.m. LPN V, an afternoon nurse working that same hallway as nurse that crushed medications, stated, An extended release tablet should not be crushed. On 9/30/16 at 10:04 a.m., during an interview Director of Nursing stated, Nurses have scheduled training on the computer regarding medication administration. The educator and I have identified in the past staff that require additional education. (This education was provided) verbally. The immediate jeopardy that began on 9/30/16 was removed on 9/30/16 when the facility developed and initiated the following plan: 1. Nurses will review Relias (computer training) module on mediation pass . 2. Re-education of Nursing Management by the Director of Clinical Services on medication pass process and required oversight . 3. A list of all vasopressor medication that cannot be immediately discontinued will be obtained .and provided to all nursing staff . 4. Nurses will be required to have medication administration checklist completed . The noncompliance remained at the lower scope and severity level at an isolated harm level because the facility had not completed all education and demonstrated competency by all staff through monitoring of staff performance. ( )

Based on observation, interview and record review, the facility failed to provide necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for one Resident (#2) of 7 residents reviewed for pressure ulcers from a total of 20 sampled residents. This deficient practice resulted in Resident #2 developing an avoidable, recurrent coccyx pressure ulcer (unstageable) and a stage II pressure ulcer to the left ankle, causing pain and increased risk of mortality for this resident. Findings include: According to the admission face sheet, Resident #2 is a [AGE] year old male re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 had problems with both short term and long term memory; he needed extensive assistance from two individuals for transfers, dressing and hygiene needs; he was non-ambulatory and used a wheelchair; and was frequently incontinent of bowel and bladder. A document titled, Skin Grid-Pressure/Venous Insufficient Ulcer/Other dated 7/11/15, revealed Resident #2 had a Left Coccyx ulcer present on re-admission. The ulcer was staged as a scab and measured 0.8 cm (centimeters) in length (L), x 0.3 cm in width (W) x 0.0 depth (D). This document revealed on 07/15/15 the ulcer was healed. Documentation from the Skin Grid-Pressure/Venous Insufficient Ulcer/Other, beginning on 8/06/15 (24 days later), show the pressure ulcer for Resident #2 redeveloped on the coccyx: 8/06/15 - Un-stageable, 5.2 cm (L) x 4 cm (W) and (D) (blank). Drainage (Y)es, color (R)ed, odor none, Black center red open area surrounding area.; Allevyn (dressing) to coccyx (L) applied. 8/17/15 - Un-stageable, 7.0 cm (L) x 6.0 cm (W) x 0.2 (D). Drainage: (P)(purulent), color (B) black, odor (M) mild, no tunneling. Comments: spongy base, black, moderate drainage noted added 'calcium alginate to wound cover with Allevyn r/t drainage'. 8/31/15 - Un-stageable, 7.0 cm (L) x 6.0 cm (W) x 0.2 cm (D) with (S) scant drainage, red, mild odor and tunneling at the 9 o'clock position of the ulcer. Comments: (Blank). 9/6/15 - Unstag(eable), 5.5 cm (L) x 5.3 cm x 4.8 cm (D) with purulent drainage color is B/R (bright red) and (F) foul odor; no tunneling documented; Comments: (Blank). 9/12/15 - Unst. 7.8 cm (L) x 6.5 cm (W) x 6.5 cm (D) with drainage (P) and (S) serosanguineous (bloody), color B/R, (F) odor and tunneling at 8 o'clock position. Comments: foul necrotic (dead) tissue 65% (percentage of ulcer surface) wound + pain to touch ATB (antibiotic) continue. (The ulcer was documented to be significantly larger on this date.) 9/19/15 - Unstag(eable) 9.0 cm (L) x 6.0 cm (W) x 6.0 cm (D), P/S drainage, R/B color, (F) odor and tunneling is measured as 1.9 cm. Comments: (Blank). According to a physician order [REDACTED].#2 was treated with [MEDICATION NAME] (antibiotic) 100 mg (milligrams) orally twice a day for 14 days beginning on 09/07/15 [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus) infected pressure ulcer to his coccyx. A physician order [REDACTED]. The culture results returned on 09/24/15 and the results showed another infection, providencea stuartii and proteus mirabilis, a physician order [REDACTED]. On 09/22/15 at 9:50 a.m., Registered Nurse (RN) A, assisted by Certified Nurse Aide (CNA) B, was observed cleaning and dressing Resident #2's existing pressure ulcer, without using adequate infection control measures. Resident #2 was placed on his right side and his adult brief was removed and rolled under his buttock. A small amount of stool was observed at the resident's anal opening and on the brief. RN A did not clean away the stool, nor did she place a protective barrier down to shield the pressure ulcer. A foul odor was detected from the wound. The pressure ulcer was irrigated with approximately 30cc's (cubic centimeter) of normal saline, patted dry with a sterile 4 x 4 gauze and then the wound was packed with 4 x 4 gauze pulled apart and soaked with Dakin's Solution. RN A gathered approximately 1/2 of the length of the 4 x 4 gauze in her hand and the remaining soaked gauze was observed lying on the bed blanket without a clean barrier in place. The wound was packed completely and covered by a large ABD pad (type of plain gauze dressing) and secured with tape. While Resident #2 was laying on his right side during the dressing change, a new Stage II ulcer located over the resident's left malleolus (ankle bone), was detected and confirmed by RN A. Resident #2 was observed wearing non-slip socks on both feet, with no pressure relief devices to float the resident's feet. Resident #2 was observed moaning and moving in pain as the dressing was being applied over the ulcer on 9/22/15 at approximately 10:00 a.m. RN A was asked if the dressing changes were painful for Resident #2 and she replied, Yes, they seem to be. RN A was asked for evidence Resident #2 had been pre-medicated prior to the dressing change. Later that same morning at 11:50 a.m., RN A stated, (Resident #2) had a [MEDICATION NAME] (narcotic like pain pill) at 6:45 a.m. and [MEDICATION NAME] at 8:00 a.m. A physician order [REDACTED].#2 had a new order initiated for [MEDICATION NAME] 0.2 mg (milligrams)(narcotic pain medicine) . pre-medicate 30-60 minutes prior to dressing change to left buttock. A review of the care plan for Resident #2 titled, Skin Integrity Assessment: Prevention and Treatment Care Plan initiated 4/13/15 read: Assessment/Problem . Braden Risk Score (skin breakdown assessment tool) Moderate Risk (13-14) Pressure-Reduction Support Surface, Maximal Remobilization and (hand written): 'Encourage position changes'. Under Interventions: .Implement an individualized turning schedule if applicable . Speciality mattress: (7/17/15) Perimeter (elevated edges to prevent rolling out of bed); Supportive devices: wheelchair cushion (Roho-air filled cushion), initiated 9/10/15 (34 days after the un-stageable coccyx pressure ulcer). The Turn and Reposition Program is left blank. There were no other revised Skin Care Interventions on this care plan following the development of the un-stageable pressure ulcer to the resident's left coccyx on 8/06/15. During an interview with the Director of Nursing on 09/24/15 at 12:00 p.m., she presented a time line of treatment for [REDACTED]. The DON stated, They (nurses) started with the Allevyn dressing, then added Calcium Alginate because of the drainage. When the odor developed they went to the Dakin's solution, but had to take a break from usage because the solution is cytotoxic. (Resident #2) was treated with [MEDICATION NAME] and [MEDICATION NAME] whirlpool baths 3 times a week, because the ulcer was infected [MEDICAL CONDITION], and now they are using the Dakin's solution again. The DON went on to say, We healed it (coccyx ulcer) in July, and it opened back up. We used a gel (wheelchair) cushion, but he has a ROHO (air filled) cushion now. The DON was asked if any other type of pressure relief mattress, such as an alternating air mattress, was tried. The DON replied, No, we have a perimeter (elevated edge) mattress on there, because he's had falls out of bed. ( ) --

Based on observation, interview and record review, the facility failed to consider all safety risk factors and implement effective interventions to reduce the risk of falls for one (Resident #101) of three residents reviewed for falls from a facility population of 101 residents. This deficient practice resulted in a Resident #101 falling and sustaining a harmful hip fracture, requiring surgical intervention and subsequent short term disability. Findings include: An abbreviated survey was conducted at the facility on 6/04/14, in response to a Facility Reported Incident (FRI) received on 5/28/14. This FRI revealed Resident #101 was found on the floor of his bedroom; he complained of right hip and knee pain. Resident #101 was sent to the local emergency room for an evaluation, and was diagnosed with [REDACTED]. Resident #101 was admitted to the hospital and underwent surgical repair of his right hip and antibiotic treatment for [REDACTED]. A review of Resident #101's medical file revealed on his face sheet (printed 5/27/14), he is a [AGE] year old man admitted to the facility on [DATE], with [DIAGNOSES REDACTED].#1 fracture with halo traction (admission diagnosis), atrial fibrillation, dual chamber pacemaker for complete heart block, history of falls with resulting fractures of left hip, ribs, and pelvis, blindness in the left eye from Macular Degeneration, and chronic urinary tract infections (UTI's). Resident #101's most recent Minimum Data Set (MDS) assessment dated [DATE], showed he scored 9/15 on his Brief Interview of Mental Status (BIMS), indicating mild cognitive impairment. According to the Social Worker's notes dated 3/18/14, Resident #101 scored a 6/15 on his initial BIMS assessment, reflecting moderate cognitive impairment. Resident #101 required extensive assistance for transfers, dressing, eating and hygiene needs. He was one/two person contact guard assist for ambulation with a walker and a gaitbelt. A care plan initiated on 3/03/14 with revisions (significant change) on 4/1/14, titled "Potential or Actual ADL (activities of daily living)/ Mobility deficit r/t (related/to)" read as follows: "C1 & C2 fracture, generalized weakness, easily fatigued, limited ROM (Range Of Motion) bilat (both) arms has HALO limiting mobility in the neck". Interventions listed were: "provide physical assist for dressing, grooming and 1-2 person contact guard assist with front wheeled walker (FWW) and gaitbelt." A care plan titled "Fall/Injury Risk related to: H/O (history of) Falls, pain, fx (fracture) C1-C2, (R) {right} intertrochanteric femur fracture, exhaustion, weakness, pulse irregularities, cardiovascular diagnosis" was initiated on 3/3/14 and revised on 6/2/14, reflecting Resident #101's fractured hip diagnosis. This care plan listed the following pharmacological factors as: "cardiovascular meds, antidepressant and narcotics". The interventions in place prior to Resident #101's fall with hip fracture were as follows: "1-2 assist with FWW and gaitbelt, general supervision, bed in high/low position, and lock the bed wheels." The section of this care plan titled "Cognitive/Sensory Impaired Interventions:" was not completed by the facility - it was left blank. The facility failed to recognize Resident #101's cognitive limitations as a fall risk factor and failed to provide direction/list interventions to meet this safety need. The IDT (interdisciplinary team) notes dated 3/4/14, revealed Resident #101 was being monitored for "(urinary catheter) patency and effectiveness of ABX (antibiotic) therapy for a UTI...." Notes dated 3/5/14, revealed "Resident is alert to self with some confusion r/t time and place...." Notes dated 4/3/14, read as follows: "IDT met to review res(ident) for sig(nificant) change. Res has experienced decreased appetite, significant weight loss, depression and increased need for ADL support....." An interview was conducted with Certified Nurse Aide (CNA) "A" on 6/04/14 at 1:00 p.m.. CNA "A" was asked to recall the events that took place on 5/28/14, when (Resident #101) fell in his room. CNA "A" stated, "I went into (Resident #101's) room about 6:25-6:30 a.m. to obtain his vital signs and found him on the floor.... I was scared because he already has a broken neck, I yelled for help and staff came right away." CNA "A" stated, "He's alert about 75-80% of the time, but then he'll ask you if you see the cows in the pasture.... that morning (5/28/14) he told me he was looking for his wife." When asked if Resident #101 was a fall risk, CNA "A" stated, "I didn't think he was a fall risk." CNA "A" was asked if she had ever known Resident #101 to get up without assistance before the incident on 5/28/14. She replied, "Yes, he's usually (thinking he's) going to the field or the barn or to see his wife." When CNA "A" was asked if she shared this information with any of the nurses, she replied "Yes, but I can't remember who." CNA "A" was asked how she obtains information regarding the residents she cares for, such as which resident's are fall risks, fluid restrictions, etc. CNA "A" stated, "We get that information in report from other CNAs or from the nurses." CNA "A" was not able to tell this Surveyor that each resident has a Care Delivery Guide on the back of their bedroom door, with specific instructions to provide care for each resident. An interview took place at 1:15 p.m. on 6/04/14 with CNA "B", who stated, "I went into (Resident #101's) room about 6:25 a.m. on 5/28/14 and asked him what he wanted for breakfast. He was laying in bed and appeared to be half awake, he told me what he wanted and I told him breakfast would be in a little while, I told him I'd be back to get him up. I left his room and went to other residents to obtain their breakfast orders. I went back down the hallway to let the nurse (Registered Nurse (RN) "C") know someone needed pain medication, and (I) found RN "C" assisting (Resident #101) after he fell ." CNA "B" was asked if she ever observed (Resident #101) self-transferring or walking in his room unassisted. CNA "B" stated "Yes, I've gone in his room and found him sitting in his wheelchair, I'll ask another co-worker if they transferred him, and I find out they didn't." CNA "B" was asked if she shared this information with the charge nurses. She replied "I think so, most of our fall risk (residents) have alarms or mats at the bedside, he (Resident #101) did not... I thought he was a fall risk." A review of Resident 101's "Care Delivery Guide (CNA care plan) dated 3/03/14, listed "Comments/Special Needs: Fall Risk (describe): increased risk for falls (2/4/14) Cervical Spine FX (fracture) w/ (with) Halo (a metal traction device affixed to the head with pins attached to the skull through the forehead and support braces sitting on top of the shoulders, both in front and back of the head)." The only "Safety Device" listed is "other: bilateral enablers (grab bars both side of the bed)." An interview was conducted with RN "C" on 6/04/14 at 11:40 a.m. RN "C" confirmed he was the nurse working the floor on the morning (5/28/14) when Resident #101 fell . He stated, "A CNA had been in his room approximately 5-10 minutes earlier and asked him what he wanted for breakfast. Then another CNA ("A") heard him yell and found him on the floor. He (Resident #101) told me he was looking for his wife. I assessed him and he complained of pain in his right hip and knee, the right leg didn't look right, so we (facility) sent him to the hospital." RN "C" was asked if staff had ever reported to him that (Resident #101) had made unsafe transfers. RN "C" replied, "Not that I can recall." An interview was conducted with an afternoon CNA ("D") on 6/04/14 at 2:55 p.m. CNA "D" stated, "Sometimes you think he (Resident #101) is coherent, but then talking to him he's asking us about the cows... I've caught him getting up out of his bed or his wheelchair and I have to run to catch him.... this usually occurs after we've (staff) have been in to see him... he always has to go somewhere.... even if he's been sleeping for several hours, he will wake up and then he has to go to the barn to check on the cows." An interview was conducted with a second afternoon CNA ("E") on 6/04/14 at 3:10 p.m. CNA "E" stated, "(Resident #101's) mind wanders at times, he has some confusion.... I've caught him getting out of bed without assistance or using his call light, he thinks he has to go to work on the farm.... I've reported it to the nurses and I know for sure I reported it to (RN "G").... the CNA's can lower the bed to the floor if needed, and the nurses can initiate alarms or fall mats.... that information will be on our Care Delivery Guides." A telephone interview was conducted with RN "G" on 6/6/14 at 11:54 a.m.. RN "G" was asked about Resident #101's cognition, fall risk and care plan needs. RN "G" stated, "When he (Resident #101) first got here he was alert with occasional confusion, but has gotten better." RN "G" stated she "did not consider him a fall risk because he could use his call light at times. (Resident #101's Fall Risk care plan classifies him at increased risk for falls)...."He's a routine guy... he's a farmer so we tried to anticipate his needs.... he's a strong man and didn't always ask for help, he would get up and get into bed before his needs were always met." RN "G" was asked if staff had notified her of Resident #101's unsafe transfers and she stated, "Yes, I guess he technically was a fall risk." RN "G" was aware of Resident #101's past history of falls and could state he had been at the facility approximately a year ago for a fractured hip due to a fall at home. When RN "G" was asked about Resident #101's arms and if he had limited range of motion, she replied, "Not at first, but he worked with therapy and he got stronger, he can self propel in his wheelchair and walk with a walker (ADL care plan states limited range of motion to both arms)". RN "G" stated she had not let the IDT know of Resident #101's unsafe transfers, nor did she initiate any safety equipment for him. RN "G" stated she "could initiate alarms or mats if needed, but must call either the DON or the Unit Manager for appropriateness of them." RN "G" recalled "initiating an alarm for another resident and leaving the DON a note, but if the IDT team didn't think the intervention was necessary, I would be reprimanded, we (staff) can't just put alarms on anyone." An interview was conducted with the Director of Nursing (DON) on 6/4/14 at 1:43 p.m.. The DON was asked how the facility assesses a resident for fall risk using their "Fall/Injury Assessment: Prevention and Management Plan of Care". The DON stated, "We review the hospital history and physical, direct report from the hospital staff, and the Resident and their Family. Factors that contribute to being a fall risk are their medications, their diagnoses, and their fall history. A positive fall history doesn't always mean alarms.... falls can be circumstantial... like if someone slipped on the ice, or if they have gait disturbances, or cognitive deficits. If a resident is so impulsive and is getting up and down even when staff is there, or (says) 'I forgot to use my call light', then we place the alarms on them." The DON was asked to explain the circumstances of Resident #101's fall with his fractured neck. The DON replied, "He tripped over clutter in his house." The DON stated the charge nurses, the unit managers and herself all can initiate alarms or mats, we tend to use visual cues, like signs posted in their rooms to remind them to use their call light." Observations were made of Resident #101 in his room lying in bed on 6/04/14 at 10:50 a.m., and again at 1:50 pWhen Resident #101 was asked if he knew how he broke his hip, he said "I fell " but couldn't remember the circumstances leading up to it. On 6/04/14 at 1:50 p.m., Resident #101 was again resting in bed. This surveyor tested his mental ability, he answered he was in "Michigan State Hospital", unsure of the month but knew Father's Day was in "June". The facility failed to take into account Resident#101's moderate cognitive ability, his significant past history of falls with fractures from previous admissions (including this admission), his blindness in his left eye and wearing a Halo traction device preventing his ability to turn his head for better vision, and failed to increase supervision when Resident #101 was experiencing an overall decline and requiring increased ADL assistance. The facility staff failed to communicate Resident #101's unsafe transfers, and intermittent confusion to the IDT team for re-evaluation of his fall risks. As a result of these failures, Resident 101's suffered additional pain and inability to progress towards discharge plan as expected. ( ) --

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE APPROPRIATE CARE AND SERVICES THAT INCLUDED THE COMPLETION OF A COMPREHENSIVE ADMISSION ASSESSMENT AND THE DEVELOPMENT OF A COMPREHENSIVE PLAN OF CARE FOR ONE (RESIDENT #10) OF THREE RESIDENTS REVIEWED FOR CARE AND SERVICES, OUT OF A TOTAL FACILITY POPULATION OF 100. RESIDENT #10 WAS KNOWN BY THE FACILITY TO HAVE A HISTORY OF POLY SUBSTANCE AND INTRAVENOUS DRUG ABUSE (IVDA) AND WAS admitted WITH A PERIPHERALLY INSERTED CENTRAL CATHETER (PICC) IN PLACE. THE FACILITY FAILED TO UTILIZE OR ACCESS AVAILABLE PERTINENT MEDICAL INFORMATION AND THEN FAILED TO DEVELOP A PLAN OF CARE TO REDUCE THE RISK OF RESIDENT #10 ACCESSING THE CENTRAL CATHETER FOR UNINTENDED PURPOSES OR ENDANGERING HIMSELF BY OTHER MEANS OF SUBSTANCE ABUSE, RESULTING IN IMMEDIATE JEOPARDY TO THE HEALTH AND SAFETY OF RESIDENT #10. ON [DATE] AT 4:40 P.M., THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY THAT WAS IDENTIFIED ON [DATE] AND BEGAN ON [DATE], WHEN THE FACILITY FAILED TO ADEQUATELY ASSESS AND CARE PLAN INTERVENTIONS TO REDUCE THE "AT RISK" FACTORS ASSOCIATED WITH THE PERIPHERALLY INSERTED CENTRAL CATHETER INTO RESIDENT #10 PRIOR TO HIS ADMISSION. RESIDENT #10 WAS FOUND UNRESPONSIVE ON [DATE] AND LATER died . DURING THE COMPLETION OF THE EXTENDED SURVEY ON [DATE], THE IMMEDIATE JEOPARDY WAS REMOVED BY THE FOLLOWING ACTIONS: 1. THE FACILITY IDENTIFIED 20 OTHER RESIDENTS WITHIN THE CENTER WHO HAVE A HISTORY OF SUBSTANCE ABUSE AND DETERMINED ONE RESIDENT HAD AN ACTIVE PROBLEM WITH SUBSTANCE ABUSE. CARE PLANS WERE REVIEWED AND REVISED APPROPRIATELY. 2. THE ADMISSION TEAM WAS EDUCATED ON [DATE] REGARDING THE ADMISSION PROCESS TO INCLUDE IDENTIFICATION OF RESIDENTS WHO HAVE AT RISK HISTORIES SUCH AS ALCOHOL, SUBSTANCE AND/OR INTRAVENOUS DRUG ABUSE. THE ADMISSION TEAM WILL RESEARCH THE "AT RISK" HISTORY AND REQUEST AN IN-PERSON VISIT TO ENSURE CENTER CAN MEET RESIDENT NEEDS PRIOR TO ADMISSION. FINDINGS WILL BE PRESENTED TO ADMITTING NURSE. 3. LICENSED NURSING STAFF WERE RE-EDUCATED ON [DATE], REGARDING THE ADMISSION PROCEDURE DOCUMENTATION TO INCLUDE A COMPREHENSIVE ASSESSMENT. 4. LICENSED NURSING STAFF WERE EDUCATED ON [DATE], REGARDING FACILITY POLICY FOR MEDICATION ADMINISTRATION, DISPOSAL OF MEDICATIONS AND ASSOCIATED EQUIPMENT, SYRINGES, ETC. 5. THE CENTER WILL COMPLETE A COMPREHENSIVE ASSESSMENT UPON ADMISSION, PER POLICY. A PLAN OF CARE WILL THEN BE DEVELOPED BASED UPON THE ASSESSMENT AND RESIDENT DIAGNOSIS/HISTORY, WHICH WILL ASSIST STAFF IN MONITORING AND IDENTIFYING POTENTIAL ISSUES. IF A POTENTIAL RISK IS SUSPECTED, MEASURES WILL BE IMPLEMENTED TO ENSURE RESIDENT'S SAFETY. PLAN OF CARE WILL THEN BE REVISED AND UPDATED AS APPROPRIATE. 6. AUDITS WILL BE COMPLETED DURING DAILY CLINICAL REVIEW, WHERE THE INTERDISCIPLINARY TEAM WILL REVIEW ALL NEW ADMISSIONS PER POLICY AND ENSURE THAT APPROPRIATE CARE PLANS ARE INITIATED. 7. THE ADMINISTRATOR WILL BRING THE RESULTS OF THOSE AUDITS TO THEIR QUALITY PERFORMANCE IMPROVEMENT TEAM FOR FURTHER REVIEW AND RECOMMENDATIONS. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE WAS NOT CORRECTED AND CONTINUES AT AN ISOLATED LEVEL WITH POTENTIAL FOR MORE THAN MINIMAL HARM PENDING: 1. VALIDATION BY THE STATE AGENCY OF THE FACILITY'S ABILITY TO MAINTAIN SUBSTANTIAL COMPLIANCE WITH CONDUCTING ACCURATE COMPREHENSIVE ASSESSMENTS, DEVELOPING INDIVIDUALIZED COMPREHENSIVE CARE PLANS TO MEET THEIR RESIDENTS' NEEDS, AND PROVIDING THE APPROPRIATE CARE AND SERVICES TO ENSURE THEIR SAFETY AND WELL-BEING. FINDINGS INCLUDE: A FACILITY REPORTED INCIDENT (FRI) DATED [DATE] INVOLVING RESIDENT #10, REVEALED ON [DATE] AT 7:10 A.M., "RESIDENT WAS A/O X3 (ALERT AND FULLY ORIENTED). AT 7:50 A.M., UNRESPONSIVE. 911 INITIATED AND RESIDENT WAS SENT TO A HOSPITAL... STAFF WERE CLEANING ROOM AFTER HEARING OF EXPIRATION... THEY FOUND PILLS AND A NEEDLE BROUGHT INTO CENTER FROM OUTSIDE. THE POLICE, ER (emergency room ) AND PHYSICIAN WERE NOTIFIED..." A REVIEW OF RESIDENT #10'S DEMOGRAPHIC INFORMATION, FOUND ON THE FACE SHEET IN HIS MEDICAL RECORD, REVEALED HE WAS A [AGE] year OLD MAN. RESIDENT #10 HAD A HOSPITAL STAY FROM [DATE] UNTIL [DATE]. HE WAS admitted INTO A PRIVATE ROOM OF THE FACILITY ON [DATE]. THE [DIAGNOSES REDACTED]. A FACILITY FORM TITLED "[DIAGNOSES REDACTED]. ALL THE LISTED [DIAGNOSES REDACTED]. A REVIEW OF A FORM TITLED "D/C (DISCHARGE) INSTRUCTIONS - ECF (EXTENDED CARE FACILITY)" DATED [DATE] AT 11:50 A.M., WITH RESIDENT #10'S NAME ON IT, REFLECTS THE ADDITIONAL Diagnoses: [REDACTED]. MEDICATIONS LISTED ON THIS D/C INSTRUCTION FORM DATED [DATE] FOR RESIDENT #10, INCLUDED IN PART THE FOLLOWING: [MEDICATION NAME] (LONG ACTING INSULIN), [MEDICATION NAME] (FAST ACTING INSULIN), [MEDICATION NAME] SR (ANTIDEPRESSANT), [MEDICATION NAME] (ANTIDEPRESSANT), [MEDICATION NAME] ([MEDICATION NAME] NARCOTIC PAIN PATCH), [MEDICATION NAME] ([MEDICAL CONDITION] MEDICATION USED TO TREAT [MEDICAL CONDITION] PAIN) AND [MEDICATION NAME] IR (INSTANT RELEASE [MEDICATION NAME] EVERY 4 HOURS AS NEEDED FOR PAIN). RESIDENT #10 WAS NOT PRESCRIBED ANY OTHER MEDICATIONS FOR PAIN CONTROL. AN ADDITIONAL FORM TITLED "PATIENT INFORMATION FOR HOME INFUSION" ATTACHED TO THE D/C INSTRUCTIONS FORM DATED [DATE] FOR RESIDENT #10, REVEALED A PICC WAS INSERTED INTO RESIDENT #10'S RIGHT BASILIC VEIN ON [DATE], AND THE TIP OF THE CATHETER WAS LOCATED AT THE CAVO-[MEDICAL CONDITION] JUNCTION. THE CAVO-[MEDICAL CONDITION] JUNCTION IS THE POINT AT WHICH THE SUPERIOR VENA CAVA MEETS AND MELDS INTO THE SUPERIOR WALL OF THE CARDIAC RIGHT ATRIUM. A REVIEW OF AN ORTHOPEDIC SURGERY "CONSULTATION NOTE" DATED [DATE] FOR RESIDENT #10 FROM THE DISCHARGING HOSPITAL, WAS PRINTED BY THE FACILITY ADMINISTRATOR ON [DATE]. THIS CONSULTATION NOTE DOCUMENTED "...THE PATIENT HAD AN EPISODE THIS MORNING APPROXIMATELY 8:00 A.M. WHERE HE HAD DECREASED RESPIRATION AND WAS HYPOXIC AT 64%. HE WAS LETHARGIC. HE WAS SEEN BY A MEDICAL RESPONSE TEAM AND EVALUATED... THE PATIENT WAS FOUND TO BE [MEDICAL CONDITION] AND HYPOTENSIVE. IT WAS THOUGHT THAT THIS MAY BE RELATED TO NARCOTIZATION... HOWEVER,[MEDICAL CONDITION] RULE OUT IS IN PROCESS... HISTORY OF MULTIPLE PSYCHIATRIC COMORBIDITIES... HISTORY OF IV DRUG ABUSE....". A REVIEW OF RESIDENT #10'S MEDICAL history and physical examination ...HE HAS SIGNIFICANT GASTROPARESIS FROM DIABETES AS WELL AS HEAVY NARCOTIC USE..." DURING THE SURVEY ON [DATE]-[DATE], A DOCUMENT WAS REVIEWED TITLED "DISCHARGE SUMMARY", DICTATED ON [DATE] BY THE DISCHARGING FACILITY REGARDING RESIDENT #10. HOWEVER, IT WAS NOT REVIEWED BY THE ADMITTING PHYSICIAN AND FACILITY UNTIL [DATE]. THIS DOCUMENT REFLECTS THE SAME [DIAGNOSES REDACTED].#10'S HOSPITAL STAY AND COURSE OF TREATMENT. IN ADDITION, THE FOLLOWING WAS DOCUMENTED: "....ALL OF THE CLINICIANS INVOLVED ARE SUSPICIOUS THAT THE PATIENT IS STILL INJECTING DRUGS. HE ADAMANTLY DENIES THIS AND GETS DEFENSIVE WHEN THIS TOPIC IS BROUGHT UP... HE WAS admitted on [MEDICATION NAME] 50 MICROGRAMS ALONG WITH [MEDICATION NAME] 60 MG Q (EVERY) 4 HOURS. EARLY IN THE hospitalization WHEN HE WAS GIVEN THESE MEDICATIONS, IT CAUSED OVERSEDATION WHICH MAKES ME WONDER WHETHER HE WAS REALLY TAKING THESE FULL DOSES AT HOME. AGAIN, IT IS PURE SPECULATION, BUT THERE IS POSSIBILITY THAT HE HAS BEEN DIVERTING MEDICATIONS... BECAUSE OF HIS LONG HISTORY OF DRUG ABUSE, HE SHOULD, UNDER NO CIRCUMSTANCE, LEAVE A HEALTH CARE FACILITY WITH A PICC LINE IN PLACE..." A REVIEW OF THE PHYSICIAN ADMISSION PROGRESS NOTE DATED [DATE] FOR RESIDENT #10, DOCUMENTS THE REASONS FOR ADMISSION TO THE HOSPITAL ON [DATE], WAS DUE TO ABDOMINAL PAIN, HISTORY OF CHRONIC ABDOMINAL PAIN WHICH RECENTLY BECAME WORSE AND UNRELIEVED WITH HIS HOME MEDICATION AND AN ABSCESS ON THE MEDIAL ASPECT HIS RIGHT ANKLE. THE PHYSICIAN ALSO DOCUMENTED RESIDENT HAS RECURRENT PANCREATITIS WITH HISTORY OF IV DRUG AND PRESCRIPTION ABUSE. A REVIEW OF PHYSICIAN ADMITTING ORDERS FOR RESIDENT #10, REVEALED NO DIRECTION OR PROVISIONS TO ENSURE THE PICC LINE WOULD NOT BE ACCESSED FOR ANY REASON OTHER THEN PHYSICIAN PRESCRIBED THERAPY. A REVIEW OF A FACILITY DOCUMENT TITLED "RESIDENT SIGN-OUT WAIVER" REFLECTS ON [DATE] AT 1:45 P.M., RESIDENT #10 SIGNED HIMSELF OUT OF THE FACILITY ON LEAVE OF ABSENCE. THE FORM WAS LEFT BLANK IN THE AREAS TO DOCUMENT THE DESTINATION AND THE TIME WHEN RESIDENT #10 RETURNED TO THE FACILITY. THERE IS NO DOCUMENTATION IN THE NURSES NOTES REFLECTING WHEN RESIDENT #10 RETURNED TO THE FACILITY OR AN ASSESSMENT/EVALUATION OF ANY KIND, I.E. PAIN ASSESSMENT, LEVEL OF CONSCIOUSNESS, OBSERVED BEHAVIOR, CONDITION OF ANKLE WOUND, HUNGER LEVEL, OR INTEGRITY OF THE PICC LINE. A TELEPHONE INTERVIEW WITH REGISTERED NURSE (RN) "E" WAS CONDUCTED ON [DATE] AT 3:00 P.M., REGARDING RESIDENT #10'S LEAVE OF ABSENCE ON [DATE]. RN "E" STATED: "I CALLED THE DIRECTOR OF NURSING (DON) AND ASKED IF IT WAS OKAY FOR HIM TO LEAVE. SHE (DON) STATED HE WAS HIS OWN PERSON... I KNEW ABOUT HIS PAST HISTORY OF SUBSTANCE ABUSE... MY THOUGHT WAS 'IF HE LEAVES HERE HOW CAN WE (FACILITY) ASSURE HE'S NOT ACCESSING THE PICC LINE', THAT'S WHY I CALLED THE DON." RN "E" WAS ASKED IF SHE HAD ANY DIFFICULTIES ACCESSING THE PICC LINE. RN "E" REPLIED, "I'D SEEN IT (PICC) UN-CLIPPED (UNCLAMPED) A FEW TIMES, BUT NO OTHER PROBLEMS." RESIDENT #10'S ADMISSION MINIMUM DATA (MDS) assessment dated [DATE], REFLECTED HE WAS COGNITIVELY INTACT AND HIS MOOD SCORE REFLECTED MILD DEPRESSION. THE PAIN ASSESSMENT INTERVIEW PORTION OF THIS ASSESSMENT REFLECTED PAIN WAS FREQUENTLY PRESENT. THIS MDS ALSO DOCUMENTS A CARE PLANNING DECISION WAS MADE FOR THE CARE AREA ASSESSMENT (CAA) FOR PAIN AND [MEDICAL CONDITION] DRUG USE . A REVIEW OF RESIDENT #10'S PLAN OF CARE TITLED "PAIN MANAGEMENT" DATED [DATE], FAILED TO LIST THE PERTINENT PAST medical history of [REDACTED].#10'S PATTERN OF PAIN MEDICATION USAGE. A REVIEW OF RESIDENT #10'S PLAN OF CARE TITLED "MOOD AND BEHAVIOR SYMPTOM ASSESSMENT..." DATED [DATE], LISTS THE ANTI-DEPRESSANTS, [MEDICATION NAME] AND [MEDICATION NAME], AS [MEDICAL CONDITION]. THE FACILITY FAILED TO IDENTIFY THE BEHAVIOR THESE DRUGS WERE INTENDED TO TREAT. FURTHERMORE, THE FACILITY FAILED TO ASSESS RESIDENT #10'S SUBSTANCE ABUSE HISTORY, SPECIFICALLY HIS DRUG(S) OF CHOICE AND FAILED TO IDENTIFY POTENTIAL INDICATORS OF DRUG INTERACTIONS FOR MONITORING PURPOSES, OR SUPPORTS AND INTERVENTIONS TO ASSIST THE RESIDENT TO MINIMIZE RISKS. A REVIEW OF RESIDENT #10'S PLAN OF CARE TITLED "SKIN INTEGRITY ASSESSMENT: PREVENTION AND TREATMENT" DATED [DATE], REVEALED THE PRESENCE OF A PICC LINE TO RESIDENT #10 RIGHT ARM. THE SINGLE INTERVENTION IDENTIFIED FOR THIS PICC LINE WAS "PROVIDE IV LINE AND SITE CARE PER PROTOCOL". A REVIEW OF THE PROTOCOL TITLED "MIDLINE CATHETER FLUSHING" WITH REVISION DATE OF [DATE], DIRECTS STAFF TO UNCLAMP THE PICC LINE FOR MEDICATION INSERTION AND TO RECLAMP AFTER PROCEDURE COMPLETED. THIS PROTOCOL REVEALED NO INSTRUCTIONS REGARDING MONITORING FOR POSSIBLE TAMPERING. THE FACILITY FAILED TO UTILIZE THE MULTIPLE AVAILABLE RECORDS REFLECTING RESIDENT #10'S PERTINENT AND SIGNIFICANT RISK FACTORS ASSOCIATED WITH HIS HEALTH HISTORY, AND TAKE APPROPRIATE ACTIONS TO ENSURE RESIDENT #10'S SAFETY WHILE A PERIPHERALLY INSERTED CENTRAL CATHETER THAT LED TO HIS HEART, REMAINED A PART OF HIS MEDICAL TREATMENT PLAN. ON [DATE] AT 2:45 P.M., AN INTERVIEW WAS CONDUCTED WITH REGISTERED NURSE (RN) "F" WHO admitted RESIDENT #10 to the facility on [DATE]. RN "F" STATED RESIDENT #10 SHOWED UP TO THE FACILITY BY A CAB. "HE (RESIDENT #10) HAD A WHITE PLASTIC BAG OF BELONGINGS AND ALLOWED ME TO LOOK THROUGH TO SEE IF HE HAD ANY PAPERWORK". HE DIDN'T HAVE ANY, SO SHE (RN "F") CALLED THE TRANSFERRING FACILITY AND A NURSE (FROM TRANSFERRING FACILITY) DROPPED OFF THE PAPERWORK ON HER WAY HOME. RN "F" VERIFIED SHE RECEIVED THE DOCUMENT TITLED 'D/C INSTRUCTIONS - ECF' WITH RESIDENT #10'S NAME ON IT, AND THE [DIAGNOSES REDACTED]. WHEN REVIEWING THE [DIAGNOSES REDACTED]. RN "F" REPLIED: "HE WAS A NICE GUY, VERY POLITE, CALLED ME MA'AM. HE DID NOT SHOW ANY SIGNS OF BEING A DRUG USER." WHEN ASKED WHAT THOSE SIGNS WOULD BE, SHE (RN "F") REPLIED "SHAKING, ACTING INAPPROPRIATE". WHEN REVIEWED WITH HER THAT THOSE SIGNS ARE NOT ALWAYS APPARENT, SHE AGREED. WHEN ASKED AGAIN WHY SHE DID NOT DISCUSS THE DRUG ABUSE HISTORY, SHE SAID, "HE WAS A NICE GUY, I DIDN'T WANT TO EMBARRASS HIM OR MAKE HIM FEEL SINGLED OUT." THE FACILITY ADMISSION NURSE FAILED TO FULLY ASSESS RESIDENT #10'S PERTINENT MEDICAL HISTORY IN ORDER TO DEVELOP A COMPREHENSIVE PLAN OF CARE. ( ) AN INTERVIEW WAS CONDUCTED WITH REGISTERED NURSE (RN) "I" ON [DATE] AT 9:53 A.M. RN "I" STATED: "...ABOUT ,[DATE] DAYS INTO HIS (RESIDENT #10) CARE, I FOUND OUT HE HAD A DRUG ABUSE HISTORY... AND THE ULCER ON HIS ANKLE WAS SUSPECTED TO HAVE DEVELOPED FROM HIM INJECTING HIMSELF... I HAD A SUSPICION A DAY OR TWO BEFORE HE EXPIRED, THE RESIDENT (#10) WAS TAMPERING WITH HIS PICC LINE... I WAS HAVING DIFFICULTY WITH THE PICC LINE. I WAS GETTING IMMEDIATE 'FLASHBACK' (BLOOD RETURN). I SHOULD NOT HAVE GOT A BLOOD RETURN IMMEDIATELY... I WAS FINDING THE PICC LINE UNCLIPPED AS WELL. I SHARED THIS INFORMATION WITH UNIT MANAGER (RN "L"), AND HE (RN "L") TOLD ME TO MONITOR IT (PICC LINE)." AN INTERVIEW WAS CONDUCTED WITH UNIT MANAGER RN "L" ON [DATE] AT 9:00 A.M. RN "L" CONFIRMED HE WAS INFORMED ABOUT STAFF NURSE RN "I" FINDING RESIDENT #10'S PICC LINE UNCLAMPED WHEN IT SHOULD NOT HAVE BEEN. THERE WAS NO DOCUMENTATION PROVIDED DEMONSTRATING THE FACILITY ATTEMPTED TO FIND WHY THE LINE WAS UNCLIPPED/UNCLAMPED OR THAT RESIDENT #10'S PLAN OF CARE WAS REVISED ACCORDINGLY. RN "L" WAS ASKED IF HE SHARED THIS INFORMATION WITH ANY OF THE ADMINISTRATIVE TEAM, AND RN "L" STATED "NO". RN "L" COULDN'T REMEMBER IF RN "I" SHARED ANY CONCERNS WITH 'FLASHBACK' FROM THE PICC LINE, NOR COULD HE PRODUCE ANY DOCUMENTATION REGARDING ANY CONVERSATIONS HELD WITH RN "I". RN "L" DID NOT STATE HE NOTIFIED RESIDENT #10'S PHYSICIAN OF THE UNUSUAL PICC LINE FINDING. A REVIEW OF THE FACILITY'S "MIDLINE CATHETER TREATMENT RECORD AND MEDICATION ADMINISTRATION RECORD" (UNDATED) AND THE NURSES NOTES DATED [DATE] THROUGH [DATE] FOR RESIDENT #10, REVEALS NO DOCUMENTATION OF FINDING THE PICC LINE UNCLIPPED NOR STAFF GETTING "FLASHBACK" UPON ACCESSING THE DEVICE. AN INTERVIEW WAS CONDUCTED WITH REGISTERED NURSE (RN) "I" ON [DATE] AT 9:53 A.M. RN "I" STATED: "I FIRST SAW (RESIDENT #10) AT 7:10 A.M. ([DATE]) WHEN I ADMINISTERED [MEDICATION NAME] SULFATE IR (INSTANT RELEASE NARCOTIC) 30 MILLIGRAMS (MG) PER HIS REQUEST. (RESIDENT #10) WAS SITTING IN HIS BED AND APPEARED TO BE RELAXED... THEN AT 7:50 A.M., I HEARD HIM HOLLER OUT... I ENTERED THE ROOM TO FIND HIM HANGING ONTO THE BEDSIDE TABLE. I ROLLED HIM OVER AND LOWERED HIM TO THE FLOOR... HIS ENTIRE BODY WAS 'TIGHT'. HE (RESIDENT #10) RESPONDED TO PAINFUL STIMULI AND WAS STILL BREATHING AND STILL HAD A HEARTBEAT... HIS BREATHING CHANGED TO AGONAL (DIFFICULT, GASPING) RESPIRATIONS... I CALLED OUT TO STAFF TO CALL A CODE AND TO CALL 911... HE (RESIDENT #10) WAS HOOKED UP TO THE AED (AUTOMATED EXTERNAL DEFIBRILLATOR). THE AED INDICATED HE WAS IN A 'NON-SHOCKABLE- RHYTHM'. THE POLICE AND EMS (EMERGENCY MEDICAL SERVICES) WERE HERE... THEY (EMS) TOOK OVER IMMEDIATELY... IT WAS ONLY ABOUT 9 MINUTES AND THEY (EMS) WERE OUT THE DOOR WITH HIM... I CALLED THE ER, HIS PHYSICIAN, THE ADMINISTRATOR AND HIS FAMILY... I WAS TOLD BY THE ER THAT (RESIDENT #10) HAD IN FACT EXPIRED IN THEIR ER... I GAVE HOUSEKEEPING THE OKAY TO START CLEANING THE ROOM... A LITTLE WHILE LATER, (HOUSEKEEPER "K") BROUGHT ME A BOTTLE OF PILLS SHE FOUND WHILE PACKING UP (RESIDENT #10)'S BELONGINGS. THE BOTTLE HAD A LABEL FROM... (A LOCAL) PHARMACY AND THE FILLED DATE WAS [DATE]. THE PRESCRIPTION WAS FOR [MEDICATION NAME] SULFATE IR (SIR) 30 MG. THE QUANTITY READ 180 PILLS... I NOTIFIED THE UNIT MANAGER (RN "L") AND WE EXAMINED THE CONTENTS... WE (RNS "I" AND "L") FOUND THERE WERE 58 PILLS IN THE BOTTLE, 2 OF THE PILLS APPEARED TO BE [MEDICATION NAME] (NARCOTIC PAIN MEDICATION) AND THE REST APPEARED TO BE THE [MEDICATION NAME] LATER ON IN THE MORNING, (HOUSEKEEPER "K") FOUND 3 SYRINGES AND A MEDICATION CUP WITH A WHITE POWDER AND WATER RESIDUE IN IT... WE (RN "I" AND RN "L") TOLD HOUSEKEEPING TO STOP CLEANING IN THE ROOM... ONE OF THE SYRINGES FOUND IN (RESIDENT #10)'S ROOM WAS FROM THE PICC LINE FLUSHES (NEEDLELESS SYRINGE USED TO FLUSH THE PICC LINE WITH SALINE TO ENSURE PATENCY)... I NEVER THOUGHT NOT TO THROW THEM IN THE GARBAGE. THE OTHER SYRINGE WAS AN INSULIN SYRINGE, BUT IT WASN'T ONE OF OURS... IT WAS AN OLD ONE..." AN INTERVIEW WAS CONDUCTED WITH HOUSEKEEPER "K" ON [DATE] AT 10:20 A.M. STAFF "K" STATED: "...IN THE 10 DAYS (RESIDENT #10) LIVED HERE, I MIGHT HAVE BEEN IN AND OUT OF HIS ROOM FOUR TIMES... HE SEEMED JITTERY, AND WHEN I'D GO TO EMPTY THE TRASH, HE (RESIDENT #10) WOULD GET UP AND GATHER THE BAG SHUT FOR ME." A REVIEW OF A DOCUMENT TITLED "emergency room REPORT" DATED [DATE] WITH RESIDENT #10'S NAME ON IT, REFLECTS "...BROUGHT TO THE EMERGENCY DEPARTMENT BY EMS... DX: (DIAGNOSIS) 1. CARDIOPULMONARY ARREST. TIME OF DEATH 08:55 HOURS (8:55 A.M.) 2. HISTORY OF CHRONIC DRUG ABUSE...." ACCORDING TO THE WEBSITE DRUGS.WEBMD.BOOTS.COM, [MEDICATION NAME] SHOULD BE USED WITH CAUTION IN PEOPLE WITH AN ADDICTION, OR HISTORY OF DRUG ABUSE AND/OR [MEDICAL CONDITION]. [MEDICATION NAME] GIVEN BY INJECTION SHOULD NOT BE USED IN PEOPLE WITH PANCREATITIS. [MEDICATION NAME] SHOULD NOT BE USED IN PEOPLE WITH A PARALYTIC ILEUS (INACTIVITY OF INTESTINE WHICH RESULTS IN DELAYED EMPTYING AND MOVEMENT THROUGH THE GUT). ( ) ( )