Every finding on record at Medilodge of Haggerty Road

Based on observation, interview, and record review, the facility failed to complete an initial skin assessment and implement interventions in a timely manner to prevent the worsening of a pressure ulcer for one (R86) of three residents reviewed for pressure ulcers resulting in R86's Moisture Associated Skin Disorder (MASD-inflamed, irritation, erosion of the outer layer of the skin) developing into a Stage Two pressure ulcer (partial-thickness skin loss, shallow open crater with pink or red wound base). Findings include:On 8/4/26 at 10:07 AM R86 was observed seated in their bed with heels elevated on pillows. During interview R86 complained of 'butt pain'. R86 said, Yeah, I got a sore there. They look at it but they ain't doing nothing about it. It hurts. I think they put some cream on it. R86 reported that they did not have pain in that area until after they got to the facility. On 8/05/2026 at 8:53 AM R86 was observed seated in their bed. R86 said they were soiled and needed changing because their butt was hurting. At this time Licensed Practical Nurse (LPN) Q and the Director of Nursing (DON) provided incontinence care to R86. R86 was observed to be incontinent of stool with an open shallow crater on the coccyx area with an approximate size of a small almond. The wound was open to air, without a dressing on it, and directly lying in stool. A dried white cream was visible around R86's wound and surrounding area. Upon inquiry LPN Q said, Yeah, there is an order for a skin treatment, but I hadn't got to it yet today. Yesterday's dressing should still be on unless it was removed during a brief change. LPN Q and the DON acknowledged R86's wound did not have a dressing on it. According to R86's Electronic Health Record (EHR) they admitted to the facility on [DATE] with multiple diagnoses that included Chronic Obstructive Pulmonary Disease and pneumonia. A review of R86's admission orders from the hospital revealed there was no documentation regarding a skin concern or orders for skin treatments. The initial skin assessment dated [DATE] documented that R86 had MASD on the coccyx. No further description was documented. A care plan for Skin Impairment was initiated and included the following interventions: administer treatments as ordered, apply barrier cream to skin after incontinence episodes, complete weekly skin inspections, and notify nurse of new skin impairments. There were no skin treatments ordered. There was no additional documentation regarding R86's skin or any skin treatments until 7/21/26 (4 days after admission). On 7/21/26 the physician ordered the following; Clean coccyx wound with Normal Saline (NS), pat dry, apply Medi-Honey and dressing one time a day for wound. There is no additional complete skin assessment until 7/29/26. On 7/29/26 (12 days after admission) a complete skin assessment documented the following; wound measurements 1.26-centimeter (cm) Length (L) x 0.6 cm Width (W) and 0.1 Depth (D) with light amount of serosanguinous fluid (pink, blood-tinged fluid) exudate. On 7/30/26 the physician changed the pressure ulcer treatment to; Cleanse coccyx with wound care cleanser or soap and water. Pat dry. Apply Medi honey and cover with bordered gauze. Change daily and prn (as needed). A review of July 2026's Treatment Administration Record (TAR) revealed R86 missed 2 of 12 prescribed skin treatments, 7/30/26 and 7/31/26. On 7/30/26 the TAR was blank. No nurse initials were documented to indicate the treatment was administered. On 7/31/26 the TAR indicated R86 did not get the prescribed skin treatment to the coccyx because the resident was sleeping. On 8/5/26 a skin assessment documented the following; wound measurements 1.3 cm L x 0.83 cm W x 0.1 cm D and listed as stable and that the previous deteriorating wound characteristics plateaued (no changes). 08/05/2026 at 2:00 PM during an interview with the DON and the wound care nurse Registered Nurse (RN) B they acknowledged that no skin treatments were ordered or documented on until 7/21/26, four days after admission. It was confirmed that a skin assessment with measurements and complete description of R86 was not completed until 7/29/26, 12 days after admission. The DON said it is the facility's policy to complete a full skin assessment upon admission and weekly. Neither the DON or RN B could explain why R86 did not have a skin treatment to the coccyx area at the time of incontinence care on 8/5/26. The DON said, There was a prn order. The treatment should have been done after incontinence care. According to the facility's Pressure Ulcer/Skin Breakdown - Clinical Protocol last revised on 3/20/24 in part read: 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.5. Initial Screen: All Pressure Ulcers/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) .7. Continued assessment and management: Norton Plus, Braden or other standardized skin risk assessment weekly for 4 weeks uponadmission, readmission, quarterly and as needed; Weekly skin evaluation/assessment by the licensed nurse on residents who have no currentPU/PI's; Certified Nurse Aid completes a skin worksheet/point of care (POC) documentation withbath/shower; A resident with current PU/PI's is evaluated/assessed by the licensed nurse at eachtreatment and as needed.

This citation pertains to 1228847. Based on observation, interview and record review, the facility failed to prevent verbal abuse from staff for one resident (R39) of two residents reviewed for abuse resulting in the resident feeling upset and rights being violated. Findings include: On 07/29/2025 at 9:00 AM, R39 was observed sitting on the bed. R39 was interviewed and asked about their interaction with Certified Nursing Assistant (CNA C) on 5/19/25. R39 stated that CNA C told (R39) to shut up and called (R39) a (profanity word). R39 didn't want to take a shower and said that CNA C was in her business. A review of R39's electronic medical record revealed a re-admission to the facility on [DATE] with a diagnosis of Type 2 Diabetes, Hypertension, Major Depressive Disorder, Hyperlipidemia, Asthma, Neuromuscular Dysfunction of Bladder. R39 had a Brief Interview for Mental Status (BIMS) dated 4/25/25, which revealed a score of 15/15 (intact cognitive function). On 07/30/2025 at 11:25 AM, the Director of Nursing (DON) was interviewed and queried about the incident with R39 and CNA C. The DON stated that after the investigation, CNA C was terminated for Disorderly Conduct. A review of the facility's Investigation Report revealed the incident with R39 was witnessed by three facility staff. On 07/30/2025 at 1:15 PM, the Nursing Home Administrator (NHA) was interviewed and asked about the incident with R39 and CNA C. The NHA said CNA C had an inappropriate response towards a resident which led to a termination. The NHA stated, (CNA C) crossed the line and (their) behavior was against their abuse policy. On 07/30/2025 at 1:30 PM, the Minimum Data Set (MDS) Coordinator A said that on 5/19/25, loud raised voices were heard in the hallway. MDS Coordinator A reported that R39 refused a shower and both R39 and CNA C began yelling at one another. R39 told CNA C to Shut Up and CNA C responded in a loud voice saying No, You Shut Up! R39 then called CNA C a dumb bitch! and CNA C responded by telling R39 No, You are one! MDS Coordinator A stated, It's inappropriate to go back and forth with a resident like that.My mother use to be in a facility, I wouldn't want anyone talking to her like that! On 07/30/2025 at 1:45 PM, Dietician B was interviewed and said on 5/19/25, she overheard CNA C getting loud with a resident. Dietician B stated that she was sitting in her office and heard voices escalating near the elevator which is adjacent to her office. She went to assess the commotion and witnessed CNA C instructing R39 to go to the shower room. R39 responded by telling CNA C not to worry her, leave her alone and to shut up! In response, CNA C told resident to Shut Up! R39 called CNA C a Bitch to which, CNA C replied, No, you are one! She stated that CNA C responded negatively and was yelling. Dietician B stated, I was concerned because that's not how you handle residents. On 07/30/2025 at 2:09 PM, a voicemail message was left for CNA C and for CNA D. CNA C and CNA D did not return the phone call prior to survey exit. On 07/30/2025 at 3:29 PM, the DON was interviewed regarding the alleged incident. The DON stated, Staff should not speak to residents like that. DON also stated, That was not professional behavior of an employee. As per the DON and the NHA, CNA C was immediately placed on suspension pending an investigation and the allegation was reported to the State Agency. CNA C was terminated following the investigation. Review of the Abuse Policy, updated on 3/24/2023, documented, It is the policy of this facility to provide professional care and services in an environment that is free from any type of abuse . Verbal abuse includes but not limited to humiliation, harassment, threat of bodily harm, punishment, isolation or deprivation to provoke fear or shame.

Based on observation, interview, and record review, the facility failed to: 1. Ensure pans and lids were properly cleaned and allowed to air dry before stacking; 2. Ensure the ice machine and three-compartment sink were properly air gapped; 3. Effectively clean surfaces in the kitchen; 4. Ensure proper drainage of floor drains; 5. Ensure thermometers were available in all refrigerators and coolers; 6. Ensure moldy food items were not stored in the walk-in cooler; 7. Remove expired, undated, unlabeled food from the kitchen walk-in cooler and resident refrigerators; and 8. Properly seal food in the freezer to prevent freezer burn (a condition that occurs when frozen food has been damaged by dehydration and oxidation due to freezer air reaching the food. Findings include: On [DATE] at 8:50 AM, during the initial tour of the kitchen with Food Service Director (FSD) I the following was observed: 1. In the clean pot/pan area, three one-third size pans, two half-size pans, and two full-size pans, were stored wet and nestled together. Also, eight steam table lids, nestled together, and a 24-cup muffin pan were observed soiled with food debris. 2. AM [NAME] N was observed putting cleaned, but wet, cooking/serving utensils in a storage drawer with cleaned, dry cooking/serving utensils. Later during the kitchen tour, a sticky-appearing substance was observed inside the drawer. FSD I indicated the sticky substance appeared to be honey or syrup. 3. FSD I said the three-compartment sink was still being used even though the garbage disposal was under repair. The drain line from the three-compartment sink was observed to not have the required minimum one-inch air gap (an unobstructed vertical space between the end of the drain line and the flood rim of the floor drain). 4. The drain line from the ice machine was not properly air gapped. 5. Pipes attached to the wall underneath the dishmachine drain board were observed soiled with grime. FSD I said a dietary aide recently power washed this area. Dirt was visible on a wet paper towel used to wipe the pipes. FSD I stated the power wash was ineffective because it's still dirty. 6. A puddle of water, approximately two feet in diameter, was observed in the cook's prep area. The cook and dietary aides in the kitchen said the floor drain backs up. When Maintenance Director (MD) H arrived in the kitchen, he said the drain gets clogged. It was not sewage. 7. A thermometer was not available inside the reach-in cooler. 8. The following was observed inside the walk-in cooler: - A thermometer was not available. - A box contained a moldy orange and fresh strawberries inside two 16 oz. containers were moldy. - An opened one-gallon container of Caesar dressing had a use-by-date of [DATE], opened one gallon container of mayonnaise and a five-pound container of sour cream did not have a use-by-dates. - Floor tiles were missing in the threshold leading into the walk-in cooler resulting in a floor surface that was stained and not easily cleanable. 9. The following was observed inside the walk-in freezer: - Opened and undated containers of pepperoni and breadsticks - A package, container approximately twelve hotdogs, was unsealed and open to the freezer air. 10. On [DATE] beginning at 12:00 PM with FSD I, the following was observed regarding the following residents' refrigerators - A Floor resident refrigerator: a 46 oz. opened container of cranberry juice with a use-by-date of [DATE], a six-ounce container of yogurt was not labeled with a resident name, and food in a fast-food bag not labeled with a resident name or a use-by-date. - B Floor resident refrigerator: a temperature log was not available. An opened 46 oz. container of cranberry juice was not labeled with a use-by-date. The following items were not identified with a resident's name: a four-ounce container of yogurt, 16 oz. container of yogurt, and 20 oz. opened bottle of ginger flavored soda. - C Floor resident refrigerator: an opened container of thickened apple juice was not labeled with a use-by-date and ten-ounce fruit-flavored beverage pouch was not identified with a resident's name. On [DATE] at 12:49 PM, the Nursing Home Administrator (NHA) indicated he expected kitchen staff to maintain a daily cleaning schedule and weekly deep cleaning schedule because sanitation was key and essential for the well-being of the residents. A review of the following facility policies documented in part the following: 1. Sanitation, dated [DATE]. - All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners will be kept in good repair. - Food preparation equipment and utensils that are manually washed will be allowed to air dry whenever practical. - Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. 2. Food Brought by Family/Visitors, dated [DATE]. Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Containers will be labeled with the resident's name, the item and the use by date. The nursing staff is responsible for discarding perishable foods on or before the use by date. On [DATE] at 4:00 PM, the NHA and Director of Nursing were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and reported there was not. According to the following sections of the 2013 FDA Food Code: ,d+[DATE].11, entitled, Safe, Unadulterated, and Honestly Presented, was reviewed and revealed, Food shall be safe, unadulterated, and, as specified under S ,d+[DATE].12, honestly presented. ,d+[DATE].11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. ,d+[DATE].13, Nonfood-Contact Surfaces, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. ,d+[DATE].11. Storing Equipment, Utensils, Linens, and Single-Service and Single-Use Articles: (B) Clean equipment and utensils shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying. ,d+[DATE].13: An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 1 inch. ,d+[DATE].11 Floors, Walls, and Ceilings. Except as specified under S ,d+[DATE].14 and except for antislip floor coverings or applications that may be used for safety reasons, floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable.

Based on observation, interview, and record review, the facility failed to properly maintain the commercial dishmachine. Findings include: On 8/27/24 at 8:50 AM, during the initial tour of the kitchen the side panel of the dishmachine was not properly attached and was observed situated on top of a drainpipe leaving the mechanicals of the dishmachine exposed. Food Service Director I said the panel has been off the dish machine for over four months. Maintenance had reattached the panel, but it keeps falling off. On 8/29/24 at 1:28 PM, the Nursing Home Administrator (NHA) said the panel needs to be in place and maintenance needs to get it fixed properly. On 8/29/24 at 4:00 PM, the NHA and Director of Nursing was asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and reported there was not.

Based on observation, interview, and record review, the facility failed to properly dispose of rubbish and ensure proper maintenance of outside disposal containers. Findings include: On 8/27/24 at 11:50 AM, during an observation of the exterior refuse area with Food Service Director (FSD) I, three dumpsters, approximately 4 to 6 cubic yards in size, were observed. The two side doors of one of the dumpsters were observed opened. The top lid on a second dumpster was completely broken off and a side door was opened. FSD I stated the broken and opened doors leaves the garbage inside exposed to pest and rodents can be attracted to the smells. On 8/28/24 beginning at 12:49 PM, the Nursing Home Administrator (NHA) said the doors of the dumpsters should be closed to avoid wind causing the garbage to fall out and to keep out rodents and pests. NHA added that it was not effective to have half the lid gone. We want to get that taken care of to avoid garbage spilling out. On 8/29/24 at 4:00 PM, the NHA and DON was asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and reported there was not. According to the 2013 FDA Food Code, Section 5-501.110 Storing Refuse, Recyclables, and Returnables: Refuse, recyclables, and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents.

Based on interview, and record review, the facility failed to ensure the Preadmission Screening/ Annual Resident Review (PASARR) forms for Mental Illness/ Intellectual Disability/ Related Conditions Identification (DCH-3877) documents were reviewed, revised, and sent to the local state agency for annual evaluation for a Level II determination for one (R46) of three residents reviewed for PASSARs, resulting in the potential for unmet psychosocial care needs. Findings include: A review of R46's electronic medical record (EMR) did not reveal a Level ll evaluation. There was not a Mental Illness/Intellectual/Developmental Disability/Related condition exemption Criteria Certification (DCH-3878) form. (The DCH-3878 is a State of Michigan Department of Health and Human Services (MDHHS) form used to claim exemption for level ll screening). R46 was admitted to facility on 11/24/2022 with most recent readmission on 5/9/2023 with pertinent diagnoses of schizophrenia, visual hallucinations and bipolar disorder. Review of a Minimum Data Set (MDS) assessment, with a reference date of 7/10/2024, revealed R46 had moderate impaired cognition with a Brief Interview for Mental Status (BIMS) score of 8/15. On 8/28/24 at 1:27 p.m., Social Service Director F was interviewed and said the 3877 was not submitted to the Health Department timely. It should have been submitted on 11/29/23. On 8/29/24 at 11:38 AM the Director of Nursing was interviewed and agreed PASARRs should be completed thoroughly and timely. On 8/29/24 at 9:17 AM a facility Pasarr policy was requested. The facility provided material referencing the State Operating Manual.

Based on interview and record review, the facility failed to implement an individualized comprehensive seizure disorder care plan for one resident (R25) Findings include: A review of the Admission Record for Resident #25 (R25) documented an initial admitted [DATE] and readmitted [DATE]. R25's diagnoses on 2/27/2020 included unspecified convulsions. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. Current physician's orders for R25 documented Levetiracetam (medication used to treat seizure disorders) oral tablet 750 mg. Give 2 tablets by mouth two times a day for anticonvulsant. Order date 5/14/24. R25's clinical record documented in part the following: - R25 was discharged to the hospital on 5/6/24 and returned to the facility on [DATE]. - Nursing progress note dated 5/6/24 documented the following: The CENA (Certified Nurse Aids) yelled for help, when entering the room the patient was having a seizure. The seizure lasted 1 minute and 45 seconds. The patient was in his bed and safety was maintained throughout. After the seizure stopped the patient opened his eyes but did not respond to verbal or pain stimuli. NP (Nurse Practitioner) was notified and gave order to send to the hospital. VS (vital signs): 155/76, 98.8, 18, 98, 98% RA (room air). (R25's Guardian) notified via voicemail, also attempted to call patient's sister .left message for her to return phone call. The patient was transferred to (local hospital by ambulance) at 0830. On 8/29/24 at 12:30 PM, a review of R25's current care plans was conducted with the Director of Nursing (DON). R25 did not have a focused care plan related to resident's seizure disorder. Rather R25's seizure disorder was included as part of a Risk for Falls, Activities, and Nutrition care plans. The Fall, Activity, and Nutrition care plans provided the following interventions related to a seizure disorder: administer medication as directed and keep bed in lowest position. The DON indicated that R25 had a seizure disorder, was on a anti-seizure medication, and had seizure activity, he should have a seizure care plan. The DON said the care plan drives the care the resident receives. R25's care plan should include more specific interventions related to his seizure disorder and it did not. On 8/29/24 at 4:00 PM, the Nursing Home Administrator and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and reported there was not.

Based of observation, interview, and record review, the facility failed to document the application of a WHFO (wrist, hand, finger orthotic) as ordered for one resident (R44). Findings include: On 8/28/24 at 8:30 AM, R44 was observed sitting in a wheelchair. R44 did not have a splint on his right hand. A review of the Admission Record for R44 documented an original admitted [DATE] and readmitted [DATE]. R44's diagnoses included atherosclerotic heart disease, anoxic brain damage, and aphasia. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. A current physician's order documented: Splint: type R (right) WHFO location: Right wrist wear schedule patient to wear up to 4 hours daily, monitoring for skin breakdown, to position and protect R hand. Ordered 4/3/24. On 8/29/24 at 11:32 AM, Certified Nurse Aide (CNA) P said she was unaware R44 wore a splint. CNA P located R44's splint in his closet drawer. CNA P said she would chart the application of R44's splint as part of her CNA tasks. CNA P said if she attempted to apply R44's splint and he refused to wear it, she would document his refusal. CNA tasks were reviewed with CNA P and did not reveal a task related to R44's splint use. On 8/29/24 at 12:00 PM, the Director of Nursing (DON) said the Therapy Department put the order in for the splint use. Record review of R44's care plans documented in part the following: - Focus: (R44) has limited physical mobility related to weakness. I have a right resting hand splint that I wear during the day. (R44) can remove the splint and take it off. Dated 6/21/24. - Interventions included: Provide encouragement and reassurance during mobility activities. Dated 4/26/23. Nursing rehab/restorative: Restorative to continue PROM B LE (passive range of motion bilateral lower extremity) in available planes as tolerated 10-15 repetitions. Dated 5/25/23. Nursing rehab/restorative: Restorative to continue PROM B UE (passive range of motion bilateral upper extremity) in available planes as tolerated 10-15 repetitions. Dated 5/25/23. A review of R44's care plans did not list interventions related to the application of R44's wrist, hand, finger orthotic. The DON indicated when the splint application was attempted, the nurse or CNA should document it. A review of R44's CNA tasks with the DON did not reveal a task related to splint use. The DON said the system canceled the tasks on 3/27/23. The way the current order was written did not specify charting the application of R44's splint on the Medication Administration Record or Treatment Administration Record. The DON said maybe restorative was documenting the application of the hand splint. Restorative CNA R was queried and said restorative had no documentation of hand splint use for R44. The DON indicated that if the application and removal of R44's right hand splint was on the CNA tasks list, it would trigger the CNAs that it was part of his care. On 8/29/24 at 12:03 PM, the Director of Rehab (D.Rehab) Q said at one point R44 began to cradle his arm and they did not want a contracture to develop. The order for the splint was to prevent a contracture. On 8/29/24 at 4:00 PM, the Nursing Home Administrator and DON was asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and reported there was not.

This citation pertains to Intake MI00145543. Based on interview and record review, the facility failed to ensure staff to resident verbal abuse did not occur for one resident (R2), resulting in verbal abuse. Findings include: A review of the facility's incident reported to the State Agency documented on 6/25/24 at approximately 6:50 AM, Housekeeping Aide (HA) T heard CNA S use profane language towards R2 and told R2 that he was irritating and annoying. A review of the clinical record revealed R2 was admitted to the facility on [DATE]. R2's diagnoses included dementia with agitation and sensorineural hearing loss. A Minimum Data Set assessment dated [DATE] documented moderate cognitive impairment, minimal difficulty in ability to hear, and did not exhibit behaviors towards others. Further review of the abuse investigation documented that HA T informed Staffing Coordinator (SC) U that CNA S was yelling at R2. SC U heard CNA S say, You're going to make me clock the (expletive) out. You're getting on my (expletive) nerves. SC U reported CNA S appeared aggravated and frustrated. R2 looked a little shaken up. SC U reported the incident to the Nursing Home Administrator (NHA) and Director of Nursing (DON). The NHA and DON immediately placed CNA S on suspension pending investigation. R2 was assessed for injury and there were none. The local police were notified. The following employee interviews were conducted regarding the abuse allegation, and documented in part: - SC U: Around 6:50 AM she came up to C floor to go to the storage room and the housekeeper (HA T) told her CNA 'S' was yelling at the (R2). As (SC 'U') approached, she listened and heard CNA 'S' yelling at (R2). She said it was loud and disturbing. She heard her say, 'You're going to make me clock the (expletive) out. You're getting on my (expletive) nerves.' She appeared aggravated and frustrated and while handling (R2's) catheter bag. (R2) was looking at her while she was yelling at him and looked a little shaken up. - Staff V: Can't say verbatim what she (CNA 'S') said. In computer room charting, but heard yelling all the way down the hall from (R2's) room. She could tell it was aggressive. The housekeeper (HA 'T') said she said, 'You are (expletive) irritating, you are gonna make me punch out from this (expletive). - Housekeeping Aide T, Stated hearing yelling coming from (R2's) room and (CNA 'S') said, shut the (expletive) up, you are so irritating and annoying. I've been telling you all night, I'm not about to tell you again. I'm gonna leave you like this and leave out this room. - CNA S: Stated that she was frustrated with (R2) because he was repeatedly putting on his light and calling for help despite her every effort to assist him. She was struggling to empty his catheter bag and he was not cooperating. She said she was frustrated and raised her voice and shouldn't have but did not use profanity. She knew that (SC 'U') saw her and felt that (SC 'U') told on her to get her in trouble for some reason. The abuse investigation documented five residents in the vicinity who were cognitively able to participate in interviews reported not hearing any yelling or profanity. These residents had also been under the care of CNA S previously. None reported any mistreatment by the staff. On 6/25/24 Social Services met with R2 and no signs of symptoms of distress were noted. There were no reports of issues with mood, sleep, or appetite. He mentioned the skin assessment and the police but did not have any issues with the staff. The facility verified that verbal abuse occurred in term of yelling and profane language toward the resident. A review of CNA S employee file documented a hire date of 12/3/23, participation in abuse education, and did not have any previous disciplinary write-ups. CNA S was terminated from employment at the facility on 7/2/24. On 8/29/24 at 11:15 AM, the NHA said CNA S should have backed away and gotten some help when she became frustrated. CNA S should not have raised her voice at R2. The NHA provided in-service education on triggers to all staff. A review of the facility policy titled, Abuse and Neglect, dated 3/24/23, documented in part the following: Verbal abuse includes but not limited to the use of oral, written or gestured language. This definition includes communication that expresses disparaging and derogatory terms to residents within their hearing/seeing distance. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: identification of affected and like residents. Completed resident assessment and interviews. Provision of staff education on abuse and how to care for residents with behaviors. Wellness visits to R2 from social service staff. Termination of CNA S. Ongoing resident interviews/audits to ensure no resident concerns with abuse. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on observation, interview and record review facility failed to: 1) accurately assess, monitor and prevent the development of pressure ulcers consistent with professional standards of practice to prevent avoidable pressure ulcers; and 2) implement care-planned and non-care-planned interventions for one Resident (R15) of four reviewed for pressure ulcers, resulting in facility acquired stage 4 pressure wound and the increased likelihood for delayed wound healing and/or worsening of wounds and overall deterioration in health status. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R15 was a [AGE] year old male admitted to the facility on [DATE] with re-admission to facility on 7/13/23 after a in-patient psychiatric treatment, re-admission to hospital 7/25/23 and re-admission to the facility 8/2/23 related to altered mental status and Soft tissue injury of lower back with diagnoses that included dementia, cerebral vascular accident, chronic obstructive pulmonary disease, diabetes mellitus, left below the knew amputation, hypertension(high blood pressure), anxiety, and depression. The MDS reflected R15 had a BIM (assessment tool) score of 7 which indicated his ability to make daily decisions was severely impaired, and he required one person physical assist with transfers, bed mobility, dressing, toileting, hygiene, and bathing. During an observation on 8/7/23 at 10:55 a.m. R15 was laying on back in low bed with lights off, blinds closed and eyes closed. During an observation on 8/7/23 at 1:00 p.m. R15 was laying in same positions on back in low bed with the lights off and eyes closed. Review of the Facility Matrix, dated 8/7/23, reflected R15 had a stage 4 pressure ulcer. Review of the Nursing Progress note, dated 7/13/2023 at 4:00 p.m., for R15 reflected, Re-admit to [named facility] family with ems staff. skin assessment reveal no open area multiple bruises on upper and later extremities, foley intact draining amber urine . Review of the Physician Progress Note, dated 7/14/2023, for R15, reflected, Date of Service: 07/14/2023 .Chief Complaint / Nature of Presenting Problem: Readmission Medication review/clarification pain, anxiety-request for narcotic prescriptions gabapentin, lorazepam History Of Present Illness: Patient being seen today as he is a readmission to the facility post hospitalization request for review of medications/clarification of medications and evaluation of pain and anxiety with narcotic prescriptions gabapentin and lorazepam. Patient came back with diagnosis which is not new of MDD and urinary tract infection. Patient is easily agitated this morning but cooperative with exam .Plan: Upon readmission patient is on Levaquin to 50 mg1 p.o. daily x7 days for urinary tract infection .Patient did return on Ativan 1mg 3 times a day for anxiety send in prescription and nursing to hold for increased somnolence .Psychiatric services to follow-up as patient is also on risperidone 1 mg in the morning and 2mg at at bedtime . Review of the History and Physical, dated 7/17/2023, for R15, reflected, Date of Service: 07/17/2023 Visit Type: History and Physical .Chief Complaint / Nature of Presenting Problem .Patient was sent to the hospital for altered mental status and aggressive behavior. Patient was returned to the facility with no new diagnoses The patient is difficult to arouse. He is not offering effective communication due to his deep sleep . Review of R15 Provider Progress Notes, dated 7/19/2023, reflected, Date of Service: 07/19/2023 .Chief Complaint / Nature of Presenting Problem: Upset stomach History Of Present Illness: Patient being seen today due to complaints of upset stomach, he states he is feeling constipated Patient is to have a follow-up with urology to consult follow-up regarding urinary retention. Unable to find any urology notes in records that were available from most recent hospitalization . Will attempt to see if they can find the urology information and urologist he was seeing patient. In the mean time maintain Foley catheter accordingly . Review of the Braden Scale for Predicting Pressure Ulcers, dated 7/20/23, reflected R15 was at high risk. Review of R15 Provider Progress Note, dated 7/21/2023, reflected, Date of Service: 07/21/2023 .Chief Complaint / Nature of Presenting Problem: Evaluate tongue, white film, sore throat Evaluate diabetic medication History Of Present Illness: Patient being seen today per nursing request for evaluation of patient's tongue that has a white film on it and he is complaining of a mild sore throat. Nursing also requesting evaluation of insulin diabetic medication. Patient does appear fatigued but he is calm at this time no acute distress and no noted anxiety .Plan: Patient does have noted oral thrush .Noted that he is on Ativan 1 mg p.o. 3 times a day for anxiety and agitation will add to hold for increased somnolence and psychiatric services to follow-up .he did return also with an insulin aspart 6 units with meals will discontinue this 6 units and just continue with the sliding scale insulin due to inconsistent oral intake and risks for hypoglycemia. Will monitor vital signs every shift and as needed. Nursing to notify doctor of any acute changes and/or concerns . Review of R15 Progress notes, dated 7/24/2023 at 10:44 a.m., reflected, Significant Change Note .Resident is seeming more tired and weak since readmission from hospital. Resident is sleeping more often . During an interview on 8/8/23 at 12:02 PM, Unit Manager (UM) X, Licensed Practical Nurse(LPN) Y, R15 floor nurse, and LPN O reported assist with R15 wound treatments. LPN O reported had already completed R15 treatments that day and would inform this surveyor of any need for additional treatments needed. Review of the EMR, dated 7/13/23 through 7/25/23, reflected missing weekly skin assessments, 16 pound weight loss, decline in activities of daily living including oral intake. Review of the Skin Care Plan reflected no updates between 7/13/23 and 7/25/23. Review of the Care Plans, dated 5/26/21, for R15 reflected interventions that included, Daily skin inspection. Report abnormalities to the nurse. Date Initiated: 10/11/2022 .Encourage and assist resident to participate in mobility activities per additional plan of care. Date Initiated: 05/26/2021 .Encourage good nutrition and hydration in order to promote healthier skin. Date Initiated: 05/26/2021 .Keep skin clean and dry. Use lotion on dry skin. Date Initiated: 05/26/2021 .Observe skin daily with care activities. Report any changes in coloration, integrity, etc. to nurse. Date Initiated: 05/26/2021 . During an interview on 8/8/23 at 5:25 p.m., Director of Nursing (DON) B reported R15 transferred to the Hospital on 7/25/23 and reported R15's stage 4 pressure ulcer was not a facility acquired pressure ulcer and was present when R15 readmitted from the hospital on 8/4/23. DON B verified R15 transferred to the hospital today (8/8/23) related to altered mental status. Review of R15 Provider Progress Note, dated 7/25/2023, reflected, Date of Service: 07/25/2023 .Chief Complaint / Nature of Presenting Problem: Altered mental status Decreased oral intake Difficulty with swallowing Acute skin breakdown on his buttock coccyx area. History Of Present Illness: Patient being seen today per nursing request due to acute altered mental status, decreased oral intake, difficulty with swallowing and taking medications, and a noted acute skin breakdown impaired area on his coccyx and buttock. Patient does appear malaised and fatigued he is arousable but unable to speak. Vital signs .Skin: Significant discoloration impairment noted of patient's coccyx area bilateral gluteal folds, skin sloughing off, bleeding .Diagnosis and Assessment Assessment .Altered mental status .Cognitive decline .Impaired skin integrity Significant breakdown noted on patient's coccyx and buttock area which is new .Decreased oral intake .Difficulty swallowing Plan: Patient is currently a full code with hospitalization . Patient's sister would like him to be a DNR however he does have a guardian and will have to have agreement with guardian for him to be a DNR. Patient is having significant altered mental status and cognitive changes, decreased oral intake and difficulty swallowing. He does also have a new significant skin impairment on his coccyx and buttock area. With patient being a full code with hospitalization and current medical status we will send him to ED for evaluation and treatment regarding to rule out sepsis with current altered mental status, decreased oral intake, acute skin breakdown and overall decline . During an interview on 8/9/23 at 7:35 AM, LPN O verified she had performed R15 dressing changed just prior to conversation with this surveyor yesterday(8/8/23) and was transferred to the hospital shortly after related to change in condition. During an interview on 8/9/23 at 7:45 AM, Certified Nurse Aid(CNA) T reported often worked with R15 including on 7/25/23. CNA T reported identified R15 large open/discolored area to coccyx and buttock area and reported to floor nurse immediately on 7/25/23 during morning care. CNA T reported skin breakdown to floor nurse and reported DON B and UM E entered R15 to observe R15 skin breakdown on 7/25/23 prior to transferring R15 to the hospital. CNA T reported R15 skin was dark color and falling off sacral and buttock area and stated, how does someone not notice that? During an interview and record review on 8/09/23 at 8:05 AM, CNA U reported was responsible for collecting and shower sheets for the entire facility. CNA U provided shower sheets for R15 dated 7/15/23, 7/19/23 with no skin concerns. CNA U also provided shower sheet for R15, dated 7/22/23 that reflected R15 had bed bath with red area noted to sacral area. The shower sheet reflected nurse signature dated 7/22/23. CNA U reported R15 appeared very sedated after return from psych hospital stay(7/13/23) and needed total care with all activity of daily living. During an interview on 8/9/23 8:45 a.m., DON B reported again R15 stage 4 pressure ulcer was acquired at hospital after 7/25/23 admission. DON B verified R15 returned to the facility 7/13/23 after psych admission and transferred back to the hospital 7/25/23. Second request was made for skin assessments between that time. DON B reported facility had own wound doctor who staged wounds and documents were located in the the EMR. (unable to locate skin assessments between 7/14/23 and 7/25/23 including wound physician notes.) DON B reported would expect CNA staff to report abnormal skin changes to nurse and nurse staff to assess and document changes in skin condition. DON B verified nurse staff expected to complete weekly skin assessments. During an interview on 8/9/23 at 9:21 a.m. LPN Z reported sent R15 to the hospital on 7/25/23 because R15 was not eating that day no breakfast, so tired he could not swallow, skin on coccyx breaking down. LPN Z reported R15 top layers of skin were peeling off left side of buttock and skin color was pale and not blanchable. LPN Z reported to Nurse Practitioner AA in house immediately on 7/25/23. During a telephone interview on 8/09/23 at 10:47 a.m., R15 guardian BB reported last visited R15 5/12/23 and verified unable to find records of care conference since 2021. R15 guardian BB reported R15's sister very involved in care as well. During a telephone interview on 8/9/23 at 10:55 a.m., R15's family member CC reported unsure why he was sent to hospital on 8/8/23 because he was in the same condition as last time and was still in the emergency room . R15's family member CC reported R15 declined after 7/13/23 re-admission to the facility and was not eating or drinking and needed total assistance with care, which was a big change for him. R15's family CC reported was sent to hospital from the facility with skin breakdown on buttock area. During an interview on 8/9/23 at 11:30 a.m. Nurse Practitioner(NP) AA reported R15 had large area on both buttock area with open loose skin that was purple in color and appeared to be deep tissue injury on 7/25/23. NP AA reported was unaware of 16 pound weight loss in 12 days at that time or that he had no oral intake in 3 days. Review of the Hospital History and Physical, dated 7/25/23 at 9:23 p.m., reflected R15 chief complaint was altered mental status. The History and Physical reflected, [named R15] is a [AGE] year-old male with past medical history of CVA, HTN, CHF, HLD, anxiety, and vascular dementia due to worsening altered mental status over the past week. Patient comes from an assisted living facility [named facility]and is bed-bound with chronic urinary catheter in place. Patient is a poor historian and history was obtained from his sister, who was bedside. Patient was recently transferred from a psychiatric facility back to his assisted living facility two weeks ago. Facility and his sister reports that the patient has had decreased PO intake, more lethargic and unresponsive, and complaining of severe lower back pain. Patient's sister reports that he was at his baseline about 1-2 weeks ago, and used to talk and interact normally with other people, but has completely stopped over the past few days. Patient is unresponsive to verbal stimuli and only responds mildly to painful stimulus .In the ED, VSS. Physical exam demonstrated a decubitus ulcer in his lumbaosacral area with surrounding necrotic tissue and no overt signs of infection . Review of the Hospital Discharge Summary, dated 8/2/23, reflected R15 was admitted on [DATE] with, Presenting Chief Complaint: Altered mental Status Primary Discharge Diagnosis: Soft tissue injury of lower back .Previously he was in a psychiatric facility due to agitation and suicidal ideation but was discharged back to skilled nursing facility with home Ativan increased which could have contributed to worsening AMS .Patient also was noted to have deep tissue pressure injury in the sacral area . Review of the facility Skin Alteration Evaluation V3, dated 8/4/23, reflected R15 had a stage 4(full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed) pressure wound to coccyx that measured 5.4 cm length by 4.6 cm width by 0.5 cm depth. During an interview on 8/9/23 at 12:56 p.m., DON B reported R15 did not have wound on 7/25/23 and reported R15 had maceration to buttock area. (R15 had foley catheter in place from 7/13/23 to 7/25/23 at time of transfer to the hospital and Hospital records of deep tissue injury on admission 7/25/23).

Based on observation, interview and record review, the facility failed to ensure a clean, comfortable and homelike environment, resulting in excessively worn and soiled furniture, increased risk for infections. This deficient practice had the potential to affect the 90 residents who reside within the facility. Findings include: During a dining room observation during lunch on 8/07/23 at 12:03 PM on the C level floor, a resident was observed sitting in a chair that was not a dining chair, the table was positioned above elbow level for the resident. Two residents were observed sitting in dining chairs at the same table and at an appropriate height for eating. All residents that were served lunch were served on cafeteria type trays. The living area in the same dining room was observed with a couch and loveseat that were heavily soiled with water stains, what appeared to be milk stains, and dirt on the seat cushions and arm rests. One resident was observed sitting on the sofa eating his lunch on an over-the-bed table. Two light brown vinyl covered chairs were excessively worn through vinyl exposing the cushion and was black in color, on both arms of each chair and the headrest of both chairs. A half round side table was observed next to the television with medium-density fiberboard (MDF) exposed with water damage on the edge of the table. A dorm-sized refrigerator was observed in the cabinet area that was soiled with food/liquid spills. The cupboards were observed with dried liquid spills. Inside three cupboards were several sheets wadded up and a soiled napkin. The gold hardware on the cupboards were worn, exposing a silver color. During an interview on 8/09/23 at 8:50 AM, Housekeeping supervisor (HS) W, stated the dining rooms were cleaned every day, and sheets were removed from cupboards. HS W stated he did not know why sheets were in the cupboards. HS W stated he had reported the condition of the furniture in the dining room and that the facility had ordered new furniture but was not sure when the furniture had been ordered.

Based on observation, interview and record review, the facility failed to implement effective individualized interventions to prevent falls, in four of four residents reviewed for falls (R36, R47, R51, and R69), resulting in fractures (Resident #36) and injuries (Resident #47, #51 and #69). Findings Include: Resident #36 (R36) On 08/07/23 at approximately 10:15 AM R35 was observed lying in bed with swelling, a laceration and multiple bruised areas on her face; R35 was observed with a cast on her right wrist. R35 stated in an interview that she fell the day prior and had fallen multiple times at the facility. R36's Minimum Data Set (MDS) assessment dated [DATE] revealed she was admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS), a short cognitive screener, score of 15 (13-15 Cognitively Intact). The same MDS assessment revealed R36 had functional range of motion limitations on one side of her lower extremity (hip, knee, ankle, foot); she used a walker and a wheelchair for locomotion. R36's same MDS indicated she was occasionally incontinent of bladder and a trial of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) had not been attempted on admission/reentry or since urinary incontinence was noted in the facility. Physical Therapy Evaluation and Plan of Treatment dated 3/28/23 indicated she had the diagnoses of status post joint replacement aftercare, lung disease, Parkinson's Disease and difficulty walking. Treatment approaches included gait training and exercise four to six times a week for four weeks. R36 required partial to moderate (50 percent) assist to roll from lying on her back to her side; transfer from back to sitting on the side of the bed with feet flat on the floor; and safely and efficiently transfer from bed to a chair or wheelchair. The same evaluation revealed R36 was worried about falling, felt unsteady when walking and standing. R36 had impaired strength in both lower extremities and had poor/fair sitting balance. The same evaluation indicated R36's decision making ability was moderately impaired and she lacked insight into condition and risk factors. Occupational Therapy Evaluation and Plan of Treatment dated 3/28/23 revealed that R36 was at risk for falls, her upper extremity strength, balance, mobility, problem solving skills were impaired. Progress Note dated 3/28/23 at 5:13 PM revealed R36 planned to remain in facility until her second knee surgery was completed and would need assistance in finding housing once she recovered from surgery. In review of R36's Fall Risk Care Plan dated 3/30/23, interventions included to educate the resident/family/caregivers about safety reminders and what to do if a fall occurred and to administer medications as directed. The same care plan instructed to refer to current physician orders and/or medication administration record (MAR) and to report any abnormal signs or symptoms. Orthopedic consult letter dated 4/05/23 indicated R36 was seen for left total knee revision. The same letter indicated R36 needed to be working with a physical therapist two times a day on range of motion exercises, strengthening, and gait training. R36 should be up and ambulating, as tolerated with a walker and continuing to wean off assistive devices and was crucial for recovery from her procedure. The plan was to follow-up again in four weeks. Physical Therapy Discharge Summary dated 4/07/23 indicated R36 was discharged from physical therapy services due to exhausted benefits. R36 required supervision/touching assistance when going from lying to sitting on the edge of the bed, and with chair to bed transfers. R36 was able to ambulate 30 feet with contact guard assistance at the time of discharge. Restorative therapy for range of motion services only were planned. There was not a plan related to strengthening or gait training twice daily as recommended by her orthopedic physician on 4/05/23. Occupational Therapy (OT) Discharge Summary dated 4/07/23 indicated R32's dynamic sitting balance (able to sit unsupported and shift weight) was fair. R32 required minimum assistance with dressing and standby assist/supervision with toilet hygiene. Speech Therapy Discharge Summary dated 4/07/23 indicated R32 was discharged due to exhaustion of benefits. The same summary indicated R32 completed delayed recall with 0 percent (%) accuracy with verbal cues and instruction in use of strategies. Centers for Medicare and Medicaid Services (CMS's) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0, Version 1.17.1, October 2019, manual, indicated as inactivity increases, complications such as pressure ulcers, falls, contractures, depression, and muscle wasting may occur. A previous fall, especially a recent fall, recurrent falls, and falls with significant injury are the most important predictors of risk for future falls and injurious falls. Incident report dated 4/06/23 at 1:09 PM indicated R36 reported she had slipped out of bed a week prior; a skin tear was noted on her left shin. R36 reported she did not remember what she was trying to do, but slipped out of bed onto her bottom, then got herself back up. R36 stated she didn't report it because she was not hurt. There were no new interventions added to the report to prevent additional falls. In review of R36's fall risk care plan, interventions dated 4/06/23, included R36 was to request for help when needed; be sure call light was within reach and to provide cueing and reminders for use as appropriate due to level of cognition. Incident Report dated 4/14/23 at 10:30 AM revealed R36 slid from her wheelchair when reaching for telephone. No new interventions were documented on R36's incident report to prevent reoccurrence. In review of R36's fall risk care plan, an intervention was created on 4/14/23 included to anticipate and meet needs; the intervention was not individualized. The same fall care plan had an intervention created on 4/17/23, to ensure R36's personal items were within reach. Incident Report dated 4/25/23 at 7:30 PM revealed R36 was found on the floor in her room and stated she was trying to reach her phone when she fell , and her left leg was bleeding. R36 was educated to use the call light. R36's fall risk care plan included an intervention created on 4/26/23 to remind and cue to request for assistance when reaching for items. Incident Report dated 4/27/23 at 1:30 PM revealed R36 slid from her wheelchair when trying to pick popcorn off floor. R36 had multiple bruises on both arms. The same report indicated one of R36's left wheelchair break was not functioning correctly, and maintenance was to check her wheelchair breaks. R36 was reminded to lock her wheelchair breaks during transfers or when picking up items from the floor. R36's fall risk care plan included an intervention created on 4/27/23 for frequent checks on resident when not in sight or in common areas, laboratory work, and maintenance was to evaluate wheelchair brakes. During an interview with Registered Nurse/Unit Manager (RN/UM) E, on 8/09/23 at 2:42 PM she stated frequent checks were every two hours. When asked if all residents were checked on every two hours, RN/UM E stated all residents were checked and changed if needed every 2 hours. Incident Report dated 5/02/23 at 2:19 PM revealed R36 was sitting on floor in her room with her left leg slightly under wheelchair and her wheelchair was not locked. R36 reported she had tried to pick up something off the floor. R36's fall risk care plan included an intervention created on 5/04/23 to educate R36 on ensuring that she was sitting all the way back in her wheelchair. Incident Report dated 5/15/23 at 12:34 PM, R36 reported that she had fell in the hallway the day prior, was able to get herself off the floor, and requested pain medication due to right hip pain. R36 reported her pain was a 6 out of 10, with 0 being no pain and 10 being the worst pain imaginable. The immediate intervention to prevent reoccurrence was to educate R36 to report falls as soon as they occur to be assessed for injuries. R36's fall risk care plan included an intervention created on 5/18/23 to follow facility fall protocol; and was not an individualized intervention. R36's fall risk care plan included an intervention created on 5/19/23 to minimize risk factors in environment: areas free of spills and clutter; adequate, glare-free light; bed in low position at night; personal items within reach when in bed/chair, etc. Incident report dated 5/18/23 at 8:43 PM indicated R36 fell from her wheelchair in the hall. R36 reported she was trying to go into her room. There were no immediate interventions included in the report to prevent future falls. R36's fall risk care plan included an intervention created on 5/19/23 was for maintenance to assess her wheelchair for seat malfunctioning. R36's fall investigation did not include information regarding her wheelchair seat malfunctioning. Incident report dated 5/20/23 at 9:45 PM revealed R36 was observed on the floor in her room and reported she slipped from her bed when attempting to get something from her drawer. The same report indicated R36 had sustained a hematoma to the top of her scalp and was transferred to the emergency room for further treatment. After Visit Summary dated 5/20/23 indicated R36 was seen in the emergency room following a fall with head injury. R36 screened positive for depression on the Geriatric Depression Scale (30 item assessment for depression) and returned to the facility. R36's admission MDS assessment dated [DATE] revealed a Patent Health Questionaire-9 (PHQ-9, 9 question screen for depression) score was 00, no depression. R36's fall risk care plan included an intervention created on 5/20/23 included to position bedside nightstand so drawers are facing her. Incident report dated 5/23/23 at 3:09 PM R36 was observed falling headfirst from her wheelchair in the hallway and then proceeded to get herself back up into her wheelchair. The same incident report indicated R36 reported she did not hit her head. The same incident report indicated R36 was observed with a light pink area on her forehead and orders were received to transfer her to the emergency room for further assessment and treatment. R36's fall risk care plan included an intervention created on 5/23/23 for Benzodiazepine (Restoril) medication be discontinued. Incident Report dated 5/25/23 at 1:30 PM indicated at 2:30 PM, R36 reported to the nurse that an hour prior she had fell in her bathroom and hit her right shoulder on the toilet paper dispenser and her left arm on her wheelchair arm. R36 was observed with bruises to her right shoulder and left arm. There were no immediate interventions included on the incident report. Incident Report dated 5/26/23 at 6:56 PM indicated R36 was on the floor in her room. The same reported indicated the charge nurse asked R36 how she fell when her call light was within reach. R36's response was she did not fall but found herself on the floor. R36 was encouraged to use her call light when she needed help; despite being educated to use her call light had been unsuccessful in the past. R36's fall risk care plan included an intervention created on 5/30/23 to encourage R36 to maintain safety and use call light whenever help was needed. PT Evaluation and Plan of Treatment dated 6/02/23 revealed R36 was referred by nursing after decline in strength and frequent falls. R36 had exacerbation of decrease in strength, decreased coordination, decreased neuromotor control, decreased postural alignment, reduced static balance and reduced dynamic balance. There were no changed to R36's care plan to address her need for increased assistance in activities of daily living (ADL) care. OT Evaluation and Plan of Therapy dated 6/02/23 indicated R36 had a decline in upper extremity muscle strength, lower body dressing and dynamic sitting balance. There were no changes to R36's care plan to address her need for increased assistance in activities of daily living (ADL) care. Incident Report dated 6/03/23 at 1:50 PM indicated R36 was observed on the floor in her room attempting to get herself back up. R36 reported she did not fall; she was trying to reach her drawer for her clothes. R36 reported she did not know what happened and found herself on the floor. The same report did not include any immediate interventions to prevent reoccurrence. R36's fall risk care plan included an intervention created on 6/05/23 to continue on therapy services. Incident Report dated 6/10/23 at 5:07 PM indicated R36 reported she had fallen in the dining room and hit her head on the fish tank. A bruise was noted on R36's forehead. The same report indicated R36 stated she forgot to lock her breaks, and the wheelchair rolled away from her when she was looking at the fish. R36 was transferred to the emergency room for further assessment and treatment. R36's fall risk care plan included an intervention created on 6/16/23 for therapy to evaluate R36's wheelchair for proper seating. Incident Report dated 7/06/23 at 2:40 PM revealed R36 was observed in the hallway on her knees in front of the elevator. R36 reported she was waiting on the elevator and let herself down on her left knee. The same report did not include any immediate interventions to prevent further falls. R36's fall risk care plan included an intervention created on 7/10/23 indicated she was referred to neurology for evaluation related to dementia and falls. Incident Report dated 7/14/23 at 4:20 PM revealed R36 was observed on the floor in the hallway bleeding from her forehead. R36 reported she was reaching for the handrail on the wall, slipped out of her wheelchair and hit her head on the floor. R36 was transferred to the emergency room for further assessment and treatment. R36's fall risk care plan included an intervention created on 7/18/23 for therapy to evaluate and treat for soft helmet while up in her wheelchair. There were no instructions to don the helmet or that she recevied a helmet. Incident Report dated 7/20/23 at 1:15 PM revealed R36 was observed sliding from her wheelchair to her knees when attempting to reach for her toothbrush. R36's hand was caught in the top drawer for her three-drawer storage unit, and she was getting ready for an appointment. R36's wheelchair was unlocked. The same report indicated R36 sustained an abrasion to her left knee and was alert and orientated to person, place and time. The same report did not include an immediate intervention to prevent further occurrences or injuries. Physician Consult Visit Notes/Orders dated 7/20/23 indicated R36 was seen for follow-up for revision of left total knee arthroplasty (TKA, total knee replacement). R36 was diagnosed and treated for a right fifth metacarpal neck fracture (right hand fracture) and severe osteoarthritis in her right knee. Orders included splint to R36's right hand, follow-up with neurology as soon as possible due to balance issues, cognition and memory recall; as well as physical therapy (PT) two times a day. Incident Report dated 7/26/23 at 9:36 AM revealed R36 reported she fell in her bathroom the day prior and reported pain in her right hand, arm and shoulder. R36 requested an x-ray. The same incident report revealed R36 reported she had been rushing to get ready when she fell . The immediate intervention to prevent further occurrences was to educate R36 to take her time and report falls as soon as they occur. R36's fall risk care plan included an intervention created on 7/26/23 that R36 was educated on not rushing and reporting falls as soon as they happen. R36's fall risk care plan included an intervention created on 7/27/23 to educate R36 to lock wheelchair prior to reaching for stuff. Incident Report dated 7/31/23 at 11:34 PM revealed R36 was observed on the floor on the right side of her bed. R36 reported she had leaned on her table. The same incident report did not include any immediate interventions to prevent reoccurrence. R36's fall risk care plan included an intervention created on 8/02/23 to offer R36 a reacher to aid in obtaining items. Incident Report dated 8/06/23 at 11:41 PM revealed R36 was observed on the floor on the right side of her bed. The same report revealed R36 had a bruise above her right eyebrow. R36 reported she was trying to fix her bed. R36 was transferred to the emergency room for further assessment and treatment. After Visit Summary dated 8/06/23 indicated the reason for her visit was for a closed head injury (strong force of blow caused brain to shake in the skull; movement could cause the brain to bruise, swell or tear) due to a fall. R36 had a scalp laceration that required stitches; diagnostic reports indicated R36 had a up to 9-millimeter (mm) hematoma (injury caused blood to collect and pool under the skin) to her right scalp, right nasal bone fracture, and a suspected left sided nasal bone fracture. R36's fall risk care plan included an intervention created on 8/07/23 to complete orthostatic blood pressures for three days and to ensure her bed was made at bedtime. During an interview with RN/UM E on 8/09/23 at 2:42 PM, stated she reviewed incident reports every morning with the interdisciplinary team (IDT) and then again after 72 hours and documents effectiveness of interventions on the incident report. RN/UM E indicated if a resident fell during the weekend, she would review the incident report on Monday. RN/UM E stated some, not all nurses will implement an immediate intervention to prevent further accidents. RN/UM E stated in the same interview that anti-roll back wheelchair breaks, as well as an anti-slip pad on the wheelchair seat to prevent slipping were considered, but not implemented; RN E stated did not recall why the anti-roll back breaks weren't implemented. Resident #47 (R47) R47's MDS assessment dated [DATE] revealed she admitted to the facility on [DATE], had a BIMS score of 04 (00-07 Severe Cognitive Impairment); transferred with and walked in her room and in corridor with limited assistance. The same MDS indicated R47 was occasionally incontinent of urine and frequently incontinent of bowel; a trial of a toileting program (e.g., scheduled toileting, prompted voiding or bladder retraining) had not been attempted on admission/reentry or since urinary incontinence was noted in the facility. During an observation and interview on 8/07/23 at10:42 AM, R47's family member indicated R47 had recently fell from her bed and complained of back pain. Incident Report dated 6/12/23 at 5:02 AM, revealed R47 was observed lying on her back in front of her bed on floor. The nurse assistant (NA) noted R47's wheelchair at the time of the occurrence was across the room and out of reach. R47 had a discoloration on the lower back. R47 stated she was attempting to use the bathroom when she fell . No immediate intervention was indicated on the incident report. In review of R47's Fall Risk care plan, creation date of 6/13/23, staff was to ensure residents wheelchair was close to bed when not in use. The same care plan indicated an intervention created on 2/17/22 and resolved on 5/02/23; R47 was to be offered to use the bathroom while awake between 4 and 6 AM. The same care plan had an intervention created on 2/18/22 to reorient to own bed and ensure wheelchair was locked at bedside; this intervention was marked as resolved on 4/22/23. During an interview with RN/UM E on 08/09/23 at 3:25 PM stated placement of the wheelchair next to bed was technically a standard practice and had been used as an intervention before. RN/UM E indicated in the same interview R47 took herself to the bathroom and had urinary urgency. An incontinence assessment including bladder and bowel diary was not considered following R47's fall. Resident #51 (R51) R51 was observed on 8/09/23 at 10:37 AM wearing a pink helmet and propelling herself in a wheelchair with her feet. During an interview with Licensed Practical Nurse (LPN) P, she stated if R51 was not active, she was place in a reclined geriatric chair (large, padded chairs with wheeled bases used for those with mobility issues and for bedridden resident that have difficulty sitting upright in a conventional wheelchair). LPN P stated in the same interview R51 was active on day of interview, so she was placed in her wheelchair. R51's MDS dated [DATE] revealed she admitted to the facility on [DATE], her cognitive skills for daily decision making was severely impaired, never/rarely made decisions. R51's same MDS revealed she required extensive assistance of one person for transfers, bed mobility, and locomotion. In review of R51's Risk for Falls care plan dated 9/17/20 revealed no geriatric chair or Broada chair (specialty positioning chair) was ever care planned for positioning/locomotion. Physical Therapy Evaluation and Plan of Treatment dated 5/16/23 indicated R51 used a wheelchair for mobility. Incident Report dated 6/03/23 at 4:08 AM indicated R51 was found lying on the floor next to her bed on her right side, with her feet still up in her bed. Bruising was noted on her left hip and left elbow. The same incident report indicated R51's bruising may have not been caused from the incident and no new interventions were documented on the same incident report. In review of R51's Risk for Falls care plan, a new intervention was created on 6/05/23 to offer R51 to get up early and be common areas when agitated. The same intervention did not specify a time frame for early. Incident Report dated 6/07/23 at 8:30 AM indicated R51 was on the floor in her room. The report did not indicate if R51 was in bed or a chair prior to the fall. R51 was transported to the emergency room for further assessment and treatment. In review of R51's Risk for Falls care plan, no new interventions were added to the care plan. Incident Report dated 6/25/23 at 6:52 AM revealed R51 was observed lying on the floor mat between the wall and the bed. There were no immediate interventions included in the report to prevent further falls. In review of R51's Risk for Falls care plan, an intervention was added and resolved on 6/26/23, to provide R51 with a bigger bed. According to an incident report dated 6/03/23 at 4:08 AM, R51 had a larger mattress in place at that time. Incident Report dated 6/29/23 at 1:00 PM revealed at 12:45 PM R51 was observed on the floor beside the wall of hallway in her room. The same report indicated R51's bed was in lowest position; a floor mat was beside her bed, and she was transferred to a geriatric chair after she was dressed. Nurses progress note dated 6/30/23 at 6:43 PM revealed R51 was very agitated during the shift, she started screaming out and tried to climb out of bed since she woke up at 9:00AM. R51 was placed in a geriatric chair at 9:30 AM, but she still was very agitated, screaming, pulling and shacking her geriatric chair. Scheduled clonazepam (used for anxiety), Seroquel (anti-psychotic), Tramdol (pain medication)and extra dose of Clonazepam, and as needed Oxycodone (opioid pain medication) given without effectiveness. In review of R51's Risk for Falls care plan, revised on 7/03/23 indicated to offer to bring resident from room to hallway and monitor when agitated. This intervention was similar as the intervention on 6/05/23; offer R51 to get up early and be common areas when agitated, in which was not effective. In review of Incident Report dated 6/29/23 at 2:30 PM, R51 was observed on the floor in the hallway face down; the geriatric chair had flipped over on the floor bedside her. The same incident report revealed R51 was very agitated and kept pushing her geriatric chair. Ativan (anti-anxiety) medication was given at 1:15 PM and was not effective. The same report indicated R51 had been sitting in a geriatric chair that was lighter than the regular geriatric chair and she was placed in the regular geriatric chair after the fall. R51 was transferred into another geriatric chair and then transferred to the emergency room per the same incident report. The same incident report indicated R51 had new open areas, redness and swelling, but did not include location or extent of injuries. During an interview with RN/UM E on 8/09/23 at 2:42 PM, she stated R51 was supposed to be in a Broda chair, the nurse wrote geriatric chair by mistake. RN/UM E stated R51 was transferred to the hospital and treated for an infection. RN/UM E did not update R51's Risk for Falls care plan. Incident Report dated 7/06/23 at 4:00 PM indicated R51 was observed agitated and on the floor in her room. The same report did not include any immediate interventions implemented to prevent further occurrences. Incident Report dated 7/06/23 at 5:23 PM revealed R51 was observed on the floor in her room next to her wheelchair. The same report indicated she had a skin tear on her face and was bleeding and R51 was transferred to the hospital. Incident Report dated 7/27/23 at 6:07 PM revealed R51 climbed out of the geriatric chair at 1:40 PM in the hallway and fell to the floor, hitting the right side of her head against the crash cart. The same report indicated R51 was wearing a soft helmet at the time of the fall. Physicians progress not dated 7/28/23 at 1:00 PM indicated R51 had complained of neck and back soreness and x-rays were ordered. R51's Risk for Falls care plan indicated a specialty wheelchair was provided. During an interview with RN/UM E on 8/09/23 at 2:42 PM, she stated R51 used a Broda chair on 6/20/23 and prior to that used a geriatric chair. RN/UM E stated R51 was supposed to be in a geriatric chair at the time of the fall on 7/27/23. RN/UM E confirmed use of a Broda chair and/or geriatric chair was not on R51's ADL or Fall Risk care plan. RN/UM E stated the month prior to interview therapy had recommended a new wheelchair, in which R51 was currently using. Resident #69 (R69) R69's Admission MDS assessment dated [DATE] revealed he admitted to the facility on [DATE], had a BIMS score of 14 (13-14 Cognitively Intact), and required extensive assistance for bed mobility and transfers. The same MDS assessment revealed R69 was frequently incontinent of bladder and always incontinent of bowel and no toileting programs were implemented to improve continence. Incident Report dated 6/16/23 at 5:17 PM revealed R69 was observed on the floor in his room and stated he wanted to go to the bathroom. A raised area was observed on his forehead. R69 was transferred to the emergency room for further assessment and treatment. In review of R69's care plan, the was no toileting program implemented or other interventions implemented to prevent further occurrences. Incident Report dated 6/24/23 at 9:56 PM revealed R69 was observed on the floor in his room and complained of pain to his head, neck and back. R69 stated he did not know how he fell , that he was asleep. R69 was transferred to the emergency room for further assessment and treatment. R69's fall risk care plan dated 6/26/23 indicated frequent checks on resident while asleep. The same care plan did not indicate frequency of checks. Incident Report dated 7/17/23 at 6:55 PM indicated R69 was on the floor in his room calling for help. The same report indicated R69's call light was on at the time and R69 reported he was attempting to reach his washcloths and call light prior to the fall. The same report revealed R69 had an injury to his forehead and a dressing was applied. There were no immediate interventions documented on the incident report. In review of R69's Risk for Falls care plan, dated 7/18/23, instructed to ensure personal items and call light were kept within reach prior to leaving room. During an interview with RN/UM E on 8/09/23 at 2:42 PM, she stated R69 returned from the emergency room with a diagnosis of pneumonia and more frequent checks were effective. RN/UM E stated in the same interview she did not review staffing on 7/17/23 at 6:55 PM, because that would not change.

Based on interview, observation and record review the facility failed to provide sufficient staff to meet 5 of 8 residents' needs, as voiced during a confidential Resident Council meeting, , resulting in unmet needs and frustration. Findings include: During a resident council meeting on 08/07/23 at 01:54 PM, residents voiced concerns with staffing. CNAs told us to just pee in the bed and they would have to change us. 3 out of 8 residents stated that they are neglected by staff disappearing on their shift and not providing care as needed. 5 out of 8 residents stated they were told CNA was not their aide, or that not my job. 3 out of 8 residents stated they have waited over an hour for someone to answer their call light, when the CNA comes in, if the resident fell asleep waiting, staff will turn off the call light and leave the room. 1 out of 8 residents stated the CNA will come in to see what they need and then say they cannot help the resident because they have a bad back or sore wrist. 4 out of 8 residents stated they have only had one CNA working on their floor and they are a 2 person assist, they had to go to another floor to get help. Needs not getting made, when they have 2 staff, they had to rush from one resident to another, especially when we are all 2-person assistance. During an interview and observation on 08/08/23 at12:45 PM, observation of Rm C1-was still in her pajamas in bed, lunch on her over the bed table, Rm C7 was wearing his pajamas in bed sleeping with his lunch on his over the bed table, Rm C11-was still wearing her pajamas in bed. During an interview on 08/09/23 at 08:01 AM, scheduler R stated they schedule based of the census. Also stated she leaves the schedule at front desk. Scheduler R stated everything is based off census, has had between 85-91 residents since March 2023. Writer asked if they take acuity of the resident into consideration when scheduling caregivers. Scheduler R stated she would they have to get approval from administration before she could do that. Scheduler R stated she scheduled 2 CNAs on A floor, 3 CNAs for B floor and 3 CNAs for C floor on day shift. When asked if she had residents complain about the need for more staff. Scheduler R stated she had a couple residents complain about not having enough staff to meet their needs and the CNA's they preferred. During an interview on 08/09/23 at 09:27 AM facility resident S stated some staff were good, could see they were stressed and could see it in their face and attitude. During an interview on 08/09/23 at 09:32 AM, CNA T stated they were short staffed, not uncommon to have 1 CNA and 1 nurse on A floor, added it was a hard floor and nobody wants to work it. CNA T had been left alone on this floor many times. Had to go get a CNA from other floor to help with resident care. During an interview and observation on 08/09/23 at 09:54, R72 stated he didn't get the care he needed due to staffing, the CNA would not help him get up to the bathroom, they gave him a bedpan to use. R72 stated he was supposed to get up to the bathroom with 2-person assistance, rarely had 2 CNAs to do it. During an interview on 08/09/23 at 11:30 AM, Restorative Aide (RA) U stated she was able to get her work done, even if she had to come in on Saturday, may get behind on her paperwork and needed to catch up. RA U also stated she gets pulled to other floors to help due to staffing need. During an interview on 08/09/23 at 02:30 PM, DON B stated they staff according to the budget and census. DON B stated they had a conversation with Administration daily. Also added the CNAs and Nurses have voiced the need for more help, brought up on room rounds with residents. Writer asked what their recruitment plan. DON B stated they were not doing anything, no agency staff are used, they offer no bonuses. During an interview on 08/09/23 at 04:40 PM, Administrator A stated they were not understaffed, over staffed if anything, stopped using agency staff. Staffing based off acuity and budget. Administrator A stated he spreads out the higher acuity residents throughout the building. Added if there was a reason we need more staff, they would go to corporate and would have to validate the need, they could always have that conversation.

Based on interview, observation and record review, the facility failed to ensure that resident's care plan included the collaboration of the hospice plan of care, description of the services furnished by hospice, and failed to ensure hospice orders were implemented for one of one resident (R4) who received hospice services resulting in the potential of care not being provided to resident. Findings Include: Resident #4 (R4) Review of the medical record reflected R4 was an initial admission to the facility on [DATE]. Admission to hospice program on 01/27/23. Diagnoses include Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Rheumatoid Arthritis and history of falls. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/28/2023, revealed R4 had a Brief Interview of Mental Status (BIMS) of 5 out of 15 (severely impaired cognition) and was dependent of all care. During an interview on 08/07/23 at 04:45 PM, family of R4 stated they have sat in the room for more than 4 hours and nobody came in to check on R4. R4 was not being repositioned every two hours as order by hospice on 11/16/22. Family also reported R4 had an increase of little sores on her skin from not being cleaned and dried with every brief change. Also added that the hospice team finds her saturated in urine laying in her bed. During an interview on 08/07/23 at 04:16 PM, DON B stated the hospice visit notes were in PPC (electronic medical record). DON B also stated they had a hospice binder in the nurse's station that also had visit notes, care plan, orders and calendar of scheduled upcoming visits. DON B was unable to locate any hospice documents in PCC and stated she did not know why hospice notes couldn't be found. During observation and record review the hospice binder with R4's name on it was empty. There was not a hospice plan of care, care plan, medication list, communication notes or calendar stating who would be making visits on which day. During an interview on 08/08/23 at 12:51 PM, Social Worker (SW) K stated they collaborate with hospice social worker during the quarterly case conference. SW K stated that family of R4 had voiced concerns regarding R4 skin issue, taking a long time to clear up. During an interview on 08/09/23 at 08:43 AM, Hospice Nurse M stated she was making skilled nursing visits once a week but had increased her visits to two times a week due to skin integrity, rash is not healing the way it should be. Hospice Nurse M stated even after she placed an additional order to be repositioned every two hours, at times she had a red sacral area, indication of decreased repositioning. Hospice Nurse M also stated the family of R4had reported to her that R4 was not getting turned often enough. Also stated visits were scheduled out through the month for coordination of care. During an interview and observation on 08/09/23 at 12:50 PM, Certified Nursing Assistant (CNA) N stated she didn't have a task sheet or way to document when she repositioned R4. CNA N also stated caregivers were supposed to check her brief and reposition her every 2 hours. Writer asked CNA N if she was aware of an order written on 11/16/22 from hospice Medical Director to reposition R4 every 2 hours. CNA N stated it was not added to the care plan, task sheet or Kardex. Documentation does not support that the order was initiated or followed. During an interview on 08/09/23 at 01:20 PM, DON B, stated she would expect to see the hospice order for repositioning every two hours be put on the care plan, Kardex and task sheet. Observation of DON B looking at R4's care plan for initiation of that order. DON B stated that order was not put on the care plan. DON B also stated care plans should be updated during quarterly case conferences and was not done. Record review revealed R4 was to receive bathes two times a week on Tuesdays and Fridays with skin assessments on a form called shower sheets. During a 60 day look back R4 received bathes on 07/14/23, 07/18/23, 07/21/23, 07/28/23, 08/01/12 and 08/08/23. Not on 07/18/23, 07/25/23, 08/04/23. Hospice CNA's provided bathes on Wednesdays and Fridays. Bathing schedule revealed R4 was to receive showers on Friday by the facility and hospice. Documentation did not reveal if R4 received duplicate showers on Fridays. Record review revealed that hospice notes were being scanned into the chart after requested information on R4.

Based on interview and record review, the facility failed to immediately investigate and report allegations of abuse for one resident ( R72) of 21 residents reviewed for abuse, resulting in an incomplete investigation, an unreported allegation of abuse to the State Agency timely, and the potential for further allegations of abuse to go unreported and not thoroughly investigated. Findings include: Review of the medical record reflected R72 was an initial admission to the facility on [DATE], readmission on 07/17/22. Diagnoses of Malignant Neoplasm of Oropharynx, Neurogenic Bowel, spinal cord injury, functioning quadriplegic, Neuromuscular Dysfunction of Bladder. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/12/2023, revealed R72 had a Brief Interview of Mental Status (BIMS) of 15 out of 15 (cognitively intact) and requires 2-person assistance for transfer, toileting and showers. During an interview on 08/07/23 at 03:26 PM, R72 stated he was in the shower, the CNA took a picture of him. R72 stated he told management, they fired her. During an interview on 08/09/23 at 07:57 AM, Human Resource (HR) J stated they did had a past employee by the name of I, was given personal file. During an observation on 08/09/23 at 11:46 AM, observed Licensed Practical Nurse (LPN) H working on B floor. This writer asked her if she had a minute to come to the conference room after resident care was completed. During an interview on 08/09/23 at 11:51 AM over the phone with previous employee I, she stated her employment was terminated. I stated she was called into the Director of Nursing's (DON) office. Also stated the DON B asked I about taking her phone in the shower taking pictures. I stated she did not take any picture. I stated R72 saw her phone out, R72 had accused staff of stealing money, so they would take 2 people in the shower. I stated that she took a picture R72's purse as evident of the purse and how much was in it. I stated that she was talked to by another CNA and then she went to LPN H and told her everything. LPN H told I not to take her phone in the shower. LPN H talked to R72, and he said nothing happened and he was ok. I stated that 2 days later she was called up by the DON B who told her to never take the phone in the shower. I also stated that she got a suspension from working on that floor but kept working on other floors before getting terminated. During an interview on 08/09/23 at 12:10 PM, LPN H stated R72 denied it, and CNA did not do it. LPN H also stated she did not do anything because R72 said she didn't do anything like that. On 08/09/23 at 12:45 PM, writer requested via email to DON B all incident reports, investigations and facility reported incidents (FRI's) involving R72 and previous employee I. During an interview on 08/09/23 at 01:33 PM, DON B stated she didn't recall that incident, would have to speak to Administrator A. During an interview on 08/09/23 at 03:52 PM, Administrator A stated he did not report this, read off his investigation to writer. Administrator A stated the other CNA looked through I phone pictures. Administrator A stated he educated staff regarding keeping their phones out of patient care area. Administrator A also stated he talked to R72, and he was fine with the outcome. Administrator A stated R72 didn't get hit, it was black and white so no reason to report. Administrator A again explained his process he followed, added he reported everything, and this didn't need to be reported. During the interview on 08/09/23 at 03:52 PM, Administrator A was asked to provide copies of his investigation, as previous request was not fulfilled at this time. On 08/09/23 at 05:08 PM, writer received two pages via email of his investigation. This investigation included a half page of typed notes and a Teachable Moment dated 01/09/23 and an unidentified signature on a document that was not part of the past employee's personal file. Administrator A failed to follow facilities policies and procedures- Nursing Administration. Section: Resident Rights Subject: Abuse and Neglect Policy: It is the policy of this facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, involuntary seclusion, misappropriation of property, exploitation, neglect, or mistreatment. This includes but is not limited to freedom from any physical or chemical restraint not required to treat the resident's medical symptoms. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. If abuse/neglect is suspected the facility will: 1. Take immediate steps to assure the protection of the resident(s). This may involve separation from the alleged abuser and/or provision of medical care. 2. Notify the appropriate/designated organization/authority (State Agencies) that an investigation is being initiated immediately following intervention for the resident's safety. 3. Conduct a careful and deliberate investigation centering on facts, observations and statements from the alleged victim and witnesses. 4. Conduct the investigation with clear communication processes to ensure all relevant information is reported and recorded. 5. Take actions related to resolving resident and family issues/concerns/allegations, educating staff, communicating with families and others (as relevant) and record. 6. Notify law enforcement authorities and press charges, if indicated. 7. Report the investigation findings to the appropriate State Agencies, as required by law. 1150 B Posting Any owner, operator, employee, contractor, or manager of the LTC facility has the obligation to report to the State Agency and at least one local law enforcement agency, any reasonable suspicion of a crime against an individual who is a resident of or is receiving care from the facility. The Administrator is the Abuse Coordinator. Preliminary Investigation Report: The abuse coordinator must submit a preliminary investigation report to the appropriate State Agencies immediately once assurances for the resident's or other resident's safety have been established. However, if the event that caused the allegation involved abuse or resulted in serious bodily injury, the allegation of abuse must be reported to appropriate state agencies immediately and not later than 2 hours after receiving the allegation of abuse or not later than 24 hours if the event that caused the allegation did not involve abuse and did not result in serious bodily injury. Final Investigation Report: The abuse coordinator must submit a final investigation report to the appropriate State Agencies within five (5) working days of the allegation.

Based on observation, interview, and record review, the facility was found to be in an Immediate Jeopardy (IJ) due to the facility failing to: 1. Identify, track, and test for a potential outbreak of Influenza after one Resident tested positive for Influenza; 2. Investigate and report a potential Legionella outbreak after the facility water tested positive for Legionella, 3. Track, map, and report the spread of COVID-19 among facility Residents and conduct an investigation of the outbreak; 4. Ensure staff were following transmission based precautions and utilizing personal protective equipment (PPE) for isolation rooms, in the hallways, and in the dietary and laundry areas rooms; 5. Ensure hand hygiene and infection control practices were implemented during medication pass and for medication storage, 6. Ensure proper sanitation of towels and laundry used for patient hygiene and care 7. Maintain an up-to-date infection control program including mapping and summarizing of monthly infections as well as summarizing outbreaks to prevent further spread of infection to all 91 Residents residing in the building.This resulted in the likelihood of continued transmission of Influenza A to facility residents after Resident #79 subsequently tested positive for Influenza A following Resident #139's readmission to the facility from the hospital with positive Influenza A. There was a total of nine cases of pneumonia with no organism identified from [DATE] through [DATE]. Residents #146 and #148 expiring after being diagnosed with COVID-19. There was the potential for further outbreaks and resident deaths. The IJ began on [DATE] when Resident #139 returned from the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to maintain an accurate and up to date infection surveillance program. The IJ notification was communicated verbally to the Administrator on [DATE] at 11:49 a.m. and was followed with an email copy with request for an abatement plan. The deficient practice continued at a pattern level of potential for more than minimal harm and will remain at this level until onsite review and confirmation of the completion of the full plan of correction can be performed. Findings include: A review of the [DATE] Monthly Infection Surveillance Summary Report revealed nine resident healthcare associated (HAI) respiratory infections, but no trends identified was marked. A review of the April and [DATE] surveillance logs revealed 15 residents marked as having Resp-HAI (Healthcare Associated Infections), indicating they had a facility acquired respiratory illness. All 15 Residents were marked for no cultures taken and Treatment: Oral ABX (antibiotics). Nine of the 15 Residents were listed as having pneumonia. The April summary report noted there were no trends despite 9 Residents having unidentified facility acquired respiratory infections. No mapping of the infections was provided for April or [DATE]. Resident #139 was listed on the May line listing as follows: . Type of Infection: Resp - HAI .Signs/Symptoms: cough [CONDITION(S)] . Date of onset: [DATE]. No culture taken . Precautions: Standard. Treatment: Oral ABX. Date Infection Resolved: [DATE]. A review of Resident #139's medical record revealed a progress note dated [DATE] which revealed, Per the daughter patient is to be on scheduled ATC (around the clock) Tylenol. (Name of Hospital) did not have any new orders due to patient having the flu. A review of Resident #139's provider note dated [DATE] revealed, .Spoke with patient's daughter she stated she thought they told her that she had influenza A but that they would not give her the official paperwork. Spoke with the hospital ED and requested final results of her swab. It was confirmed that she did swab positive for influenza A . Further review of the Residents marked as Resp-HAI revealed that five of them (#9, #67, #54, #24, and #79) had received [MEDICATION(S)] (an antiviral medication used to treat viruses like Influenza). On [DATE] at 5:05 p.m., an interview was conducted with the Director of Nursing (DON) and Infection Preventionist (IP) III. When asked about Resident #139 having Influenza, the DON reported the hospital had not sent any additional documentation about what type of Influenza the Resident had despite them trying to request it but did acknowledge confirmed influenza illness for Resident #139. The DON and IP III were asked why it was not documented appropriately on the line listing, and why other Residents who had presented with similar signs and symptoms were not also tested for Influenza. The DON could not explain why it was not documented as Influenza but reported that they did not have any other residents tested because there were no other signs of symptoms of influenza in the building. IP III was asked what the symptoms of Influenza were and stated, Increased temp (temperature), shortness of breath, the whole bit. The DON and IP III were then asked why the five Residents (#9, #67, #54, #24, and #79) had been given [MEDICATION(S)]. IP III reported the Nurse Practitioner had seen them for a dry cough and wanted to be on the safe side so she gave them a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked how many Residents had been tested for Influenza in April or [DATE], IC III reported that no Resident had been tested . When asked how the facility was able to determine whether there was currently an Influenza outbreak occurring, IP III stated, I don't have a good answer. When asked why the current line listing for [DATE] was not up to date, IP III reported that she, . hasn't gotten to the whole month. I'm watching them. I know who's on antibiotics and when they go on and off. IP III revealed that she was only tracking Residents who were on antibiotics on the infection line listings and maps. When asked if the local Health Department was notified of Resident #139 having Influenza, the DON reported that the hospital had already done that. On [DATE] at 9:21 a.m., CNA XX was observed taking a breakfast tray into a room for a Resident (#144) on Transmission Based Precautions (TBP) as an unvaccinated new admission. CNA XX was only wearing a standard surgical mask and eye protection. CNA XX did not don a gown, gloves, or change her surgical mask. CNA XX was observed from the hallway to set the tray down on Resident #144's bedside table, adjust the table and touch Resident #144's items and then exit the room without using hand sanitizer or washing her hands. CNA XX was then observed digging though the silverware used for all the residents and then re-enter Resident #144's room. CNA XX again exited the room without disinfecting her hands. CNA XX was then stopped and asked if she was supposed to enter Resident #144's room without donning the proper PPE. CNA XX apologized for not wearing the PPE into the room and acknowledged she should be wearing additional PPE. CNA XX then proceeded to pass more breakfast trays without washing or sanitizing her hands. On [DATE] at 3:50 p.m., Resident #79 was observed from the doorway walking around her room and talking with her roommate (Resident #54). Resident #79 was observed coughing without covering her mouth. On [DATE] at 8:59 a.m., IC III notified the survey team that four Residents had been swabbed in the evening of [DATE] (#9, #24, #54, and #79) and Resident #79 had tested positive for Influenza A. IC III reported Resident #79's roommate had been moved into a room by herself for isolation and the health department had been notified. A review of Resident #79's medical record revealed she admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of her [DATE] Minimum Data Set (MDS) assessment revealed she scored ,d+[DATE] on the Brief Interview for Mental Status (BIMS) assessment, indicating moderately impaired cognition. A review of Resident #79's [DATE] provider note revealed, .Patient being seen today due to persistent cough, congestion, mild increased shortness of breath. She is hospice and comfort care patient. Currently in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #24's provider note dated [DATE] revealed, .Patient is end-stage renal and on hemodialysis he does go to hemodialysis 3 times a week. He is currently complaining of increased cough, mild shortness of breath and chest congestion. Will order chest x-ray . Unable to test for flu as flu swabs are on order. He is on hemodialysis and at risk for exposure as he does go out 3 times a week. Will order [MEDICATION(S)] . A review of Resident #9's provider note dated [DATE] revealed, .Rapid swab patient for COVID was negative. Flu swabs not available but on order. Patient is in a room with 2 hemodialysis patients of both who have coughs. Will initiate [MEDICATION(S)] . A review of Resident #54's [DATE] provider note revealed, .Will order chest x-ray . Will initiate Z-Pak (antibiotic) as directed. Will initiate [MEDICATION(S)] . No available swabs for influenza they are on order . A review of Resident #67's provider note dated [DATE] revealed, .Patient being seen today for evaluation of persistent cough, mild shortness of breath, and malaise Patient is to complete [MEDICATION(S)] as directed for an high risk population/empiric tx, symptom precaution . Resident #67's medical record also revealed that on [DATE] the resident was found unresponsive and sent to the hospital. Resident #67 was never tested for influenza. A review of Resident #67's hospital note dated [DATE] revealed, . Cardiopulmonary Resuscitation was medically necessary due to patient pulseless and apneic (not breathing) . a geriatric patient in acute distress as well as ill-appearing . Resident was declared deceased at 6:33 AM . On [DATE] at 11:54 a.m., the provided an updated Infection Surveillance Log for [DATE]. This log now showed 14 Residents marked as having facility acquired respiratory infections (with no culture or organism noted), seven of which were marked as having pneumonia. Resident #139 was still not marked as having Influenza A. Compared with the original line listing provided on [DATE], this was an increase of eight respiratory infections and four cases of pneumonia. Further review revealed that eight of the respiratory infections occured on the B-hall (Rooms B,d+[DATE], B,d+[DATE], B,d+[DATE], B,d+[DATE], B,d+[DATE], B,d+[DATE], B,d+[DATE]). Of the cases of pneumonia, three were on B hall (Rooms B,d+[DATE], B,d+[DATE], and B,d+[DATE]) and the two cases on C hall were roommates (C,d+[DATE] and C,d+[DATE]). This is evidence that there were clusters of infections that went undetected by the facility due to a failure to map, track, and trend the infections. A review of the facility policy titled, Surveillance - Outbreak Investigation adopted [DATE] revealed, . 1. Definition. An outbreak is defined as two (2) or more cases over the usual (endemic) number of cases of health care associated infections, usually produced by the same organism Any personnel recognizing a possible epidemic will immediately report this to the Infection Preventionist (IP) through which the facility management and medical director will be notified . The IP (an others as assigned) is designated as the investigation coordinator. He or she will review the charts of the involved patients and determine that an epidemic exists . The Infection Preventionist will gather, and compile data related to the infection(s) as follows: 1. Conduct case finding (review ongoing surveillance charts of other patients at risk and microbiology reports) to determine whether there have been other cases of infection . 3. Prepare a line listing of cases to include: resident, room number, date of admission, date of infection onset, site culture results, and physician . 6. Review various infection prevention techniques (hand hygiene, use of standard precautions, etc.) . 7. Maintain surveillance for occurrence of any further infections. D. The IP will communicate with the lab regarding: 1. Any need for isolates of the involved organism(s) to be saved for further study . A final written report of the investigation, outlining findings and recommendations, is prepared by the investigation coordinator and issued to the infection prevention committee . A review of the facility policy titled, Infection Prevention and Control Program adopted [DATE] revealed, . There is on-going monitoring for infections among residents, employees, volunteers and visitors and subsequent documentation of infections that occur . Systems are in place to facilitate recognition of increases in infections as well as clusters and outbreaks. A review of the facility policy titled, Resident Care-Reportable Diseases Adopted [DATE] revealed, It is the policy of this facility to guide reporting of suspected and confirmed communicable diseases to the appropriate governmental agency or authority. 1. All reportable infectious diseases (residents' or employees') must be reported to the Infection Preventionist as soon as a definite diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Infection Preventionist or Administration is responsible for notifying the local, district, or state health department of confirmed cases of state-specific reportable diseases . A review of the facility policy titled Transmission Based Precautions (Isolation) Contact Precautions adopted [DATE] revealed, .2. Gloves and Hand Hygiene. A. Hand hygiene should be completed prior to donning gloves. B. Gloves should be worn when entering the room and while providing care for the resident . 3. Gowns. A. A gown should be donned prior to entering the room . COVID-19 The facilities COVID-19 Infection Documentation (line listings, infection maps, summaries, testing logs, vaccination logs, and outbreak investigations) was requested multiple times on the following dates and times: [DATE] at 1:45 p.m., during the entrance conference from the Administrator. On [DATE] at 9:30 a.m. from the Administrator. On [DATE] at 11:27 a.m. from IP III. On [DATE] at 8:59 a.m. from IP III. On [DATE] at 10:22 a.m. and 2:00 p.m. from the DON. On [DATE] at 8:48 a.m. via email from the DON. On [DATE] at 8:59 a.m., IP III was asked for documentation regarding the COVID-19 outbreak for [DATE]. IP III reported she did not have anything to provide. On [DATE] at 10:22 a.m., the DON was informed that there was no COVID-19 outbreak investigation or mapping provided. The DON reported she had the documentation and she would provide it. A review of the facility COVID-19 documentation provided by the DON on [DATE] at 8:50 a.m. via email revealed the following: The COVID infection documentation included only line listings for the months with a mix of Residents and staff. There were no maps of infection, no summaries, and no outbreak investigations. A review of the [DATE] COVID-19 line listing revealed 23 Residents and 17 staff tested positive for COVID-19. Of the 23 Residents who tested positive, two Residents (#148 and #146) were noted to have expired shortly after their diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident #148's medical record revealed he admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #148's [DATE] Minimum Data Set (MDS) assessment revealed he scored ,d+[DATE] on the Brief Interview for Mental Status (BIMS) assessment indicating severely impaired cognition. A review of a [DATE] provider note revealed, .being monitored for ongoing hematuria as well as being COVID +. He is currently in isolation. Patient reports he feels a little tired. He reports bring up a lot of flem (sic) . A [DATE] provider note revealed, . in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient does have mild intermittent cough per nursing. He does have noted fatigue . A review of a [DATE] provider note revealed, .Patient being seen today due to complaints of shortness of breath and feeling 'under the weather' . Resident #148 was admitted to hospice on [DATE] and expired in the facility on [DATE]. A review of Resident #146's medical record revealed she admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #146's [DATE] MDS assessment revealed she was assessed by staff to be severely impaired in cognition. A review of a [DATE] provider note revealed, .Patient being seen today due to report of decreased appetite and currently being monitored/treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a [DATE] progress note revealed, . resident has not been eating or drinking. Resident's skin is dry and pale. Resident is alert, lethargic . Resident #148 was placed on hospice services on [DATE] and expired in the facility on [DATE]. Legionella A review of the April and [DATE] surveillance logs revealed 15 residents were marked as having Resp-HAI, and for no cultures taken. Nine of the 15 Residents were listed as having pneumonia. The [DATE] summary reported there were no trends despite nine Residents having unidentified facility acquired respiratory infections. A review of documents titled, (Name of Company) Validation Test Standard ISO Report Summary for [DATE] revealed the A Shower room hot water tested positive for Viable Legionella was detected. On [DATE] at 8:48 a.m., an interview was conducted with Maintenance Director VV. When asked about any flooding that occurred in the past year, Maintenance Director VV reported, Back in November (2021) before the holiday. Around the 8th. The flood came from the backflow in the sprinkler room. Maintenance Director VV reported they had called the plumber who had snaked the pipes and found old plumbing and a collapsed line. Maintenance Director VV reported that he had been out with a COVID-19 infection around that time, but that the issue of the sprinkler room flooding from up the backflow had been an ongoing issue. When asked if he had reported the issue to IP III, the Administrator, or the health department, Maintenance Director VV reported he .Gave it (the information) to the State Rep. Maintenance Director VV could not identify who the state representative was or what agency they were from and could provide no documentation of such. When asked about the Legionella test that came back positive, Maintenance Director VV reported the lab had told him to redo the test for five days and then it came back clear. Maintenance Director VV reported he felt the positive test was due to the Certified Nurse Aides (CNA's) leaving the shower heads touching the shower room floor. On [DATE] at 8:59 a.m., IP III was asked if she had been notified the facility water had tested positive for Legionella in October of 2021 and reported that she had not been notified. IP III confirmed that to her knowledge no residents had been assessed or tested for Legionella infection. When asked if that was something she would have investigated and reported, IP III stated, Absolutely. On [DATE] at 9:15 a.m., a phone interview was conducted with the Regional Lab Manager MMM for the laboratory used by the facility to test for Legionella. When asked about the positive Legionella sample, Regional Lab Manager MMM reported that prior to the pandemic the company's staff would test but now the facility was doing its testing by themselves. When asked if there was any way to show that the sample had been taking correctly, Regional Lab Manager MMM stated, No. It's not like we're checking if it was just bottled water. That is possible. We wouldn't be able to tell . That's a good question if they are good samples. Regional Lab Manager MMM was notified of the nine Resident cases of facility acquired pneumonia and the lack of investigating to rule out that it was not Legionella and reported that he understood the potential concern. On [DATE] at 10:22 a.m., the DON was asked if she was aware of the positive Legionella test from October of 2021. The DON reported that she was on a leave of absence at that time and didn't return until mid November (2021). The DON reported she did not notify the health department but when she became aware of the issue (during the survey) she had educated IP III, Maintenance Director VV, and the Administrator on Legionella. The DON was asked if an investigation into the Legionella and 15 cases of facility acquired pneumonia/respiratory illness for April and [DATE] had been completed. The DON state she had looked at the data and didn't see any evidence to suggest it could be Legionella, but that she was not aware of any residents being tested for Legionella. On [DATE] at 3:00 p.m., the DON and Administrator were asked about why the health department was not notified about the positive test in October of 2021. The Administrator reported that he was unaware of the Infection Control aspect and the reporting requirements. The DON reported that she had educated the Administrator about Legionella reporting guidelines. A review of the facility's Water Management Program last updated [DATE] revealed, Ice Machines . Significant Risk? Yes Proper maintenance of ice machine equipment is important for safe and reliable operation. Control Measures: 1. Cleaning/Disinfection . 8. Waste . Sewage can transmit pathogens or other contaminants. However, exposure is limited and well controlled. 1. Backflow preventers . 4. Heating/Hot Water Control Measure: Heat. Control Limit: ,d+[DATE] F. Monitoring Method: Temperature monitoring via thermometer measurement at the heating element. Frequency: Monthly . Distribution (Potable) hot water. Control Measures: 1. Flushing. 2. Disinfectant . 2. If chlorine result is <0.2 ppm (parts per million), flush and retest . On [DATE] at 1:20 p.m. during a kitchen observation meal, it was observed that staff JJJ was not wearing a mask while preparing the dinner meal service. On [DATE] at 8:00 a.m., during the breakfast meal observation in the kitchen, Food Service Director/Staff II was observed not wearing a mask. On [DATE] at 3:50 p.m., during a kitchen observation, staff JJJ was observed not wearing a mask. On [DATE] at 7:50 a.m., during a tour of the laundry room, it was observed that Laundry Aide/Staff KKK was observed not wearing a mask, while Laundry Aide/Staff LLL was observed folding clean linen at a long table. Staff LLL was attempting to fold a bed sheet, which was observed touching the floor at various times while they attempted to fold it on the table. An interview was conducted with Staff KKK and Staff LLL in which they stated that the facility no longer provides colored bags to label potentially infected articles of clothing or linen, and they are not aware if there are any current infections in the facility. When asked if staff evaluate the temperature or ppm (parts per million) of solution used in the washing machine, Staff KKK stated that maintenance does, and they do not know how to evaluate the washing machines to make sure they are cleaning the linen. Staff KKK and Staff LLL confirmed they are short on linen supplies due to throwing so many products away because they are too soiled to go through the washing machines. Staff KKK stated that they were instructed to maintain standard infection control practices, and to wear PPE which included gloves, gowns, masks, and face shields while loading any dirty laundry into the washing machines. On [DATE] at 8:46 a.m., an interview was conducted with Maintenance Director/Staff VV regarding the testing of the facility's washing machines. Staff VV stated that he believed the temperature of the washing machines needed to be around 160 degrees Fahrenheit. Staff VV could not describe how long the washing machine needed to maintain that temperature or what concentration the cleaning solution needed to be to properly disinfect linen. Staff VV was asked to provide documentation of routine testing for the facility's washing machines. On [DATE] at approximately 11:45 a.m., an observation was made of Staff LLL loading soiled linen into the washing machine. Staff LLL was wearing a mask only during this observation and stated that there is no PPE in the laundry room to don prior to loading the machines. A review of the facility's 'Logbook Documentation' for the weeks of [DATE] through [DATE] were reviewed and found the following temperatures of various washing machines. [DATE] ,d+[DATE] [DATE] 160 [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] 148 [DATE] 145 [DATE] 160 [DATE] 161 Review of the '(Facility Name) Bi-Weekly Hazard Control Monitoring revealed the following temperatures and ppm of various washing machines: week of [DATE] 161 degrees Fahrenheit and .4 ppm week of [DATE] 162 degrees Fahrenheit and .7 ppm week of [DATE] 157 degrees Fahrenheit and .02 ppm week of [DATE] 46 degrees Fahrenheit and 1.7 ppm Water Pass During an observation of water pass on [DATE] at 9:20 a.m., CNA HH entered room A5 with fresh Styrofoam water cups wearing no gloves. CNA HH placed the clean water cups on the overbed tables of the residents, picked up the previously used water cups, emptied any water in the cup, and threw the old cups in the resident garbage in the room. CNA HH exited the room without the performance of hand hygiene and moved to room A1. A fresh Styrofoam water cup was delivered into room A1, placed on a resident overbed table, with the previously used cup disposed of in the resident garbage. CNA HH exited room A1 without the performance of hand hygiene. CNA HH continued to rooms A7 and A9 with the same repeated pattern of entering the rooms with fresh water cups, picking up the previously used cups with disposal of the old cup in the resident garbage. No hand hygiene was observed at any time between entering the rooms, contact with clean and dirty water mugs and moving on to another room. During an interview at this same time, CNA HH was asked about the performance of hand hygiene during water pass. CNA HH said she had washed her hands prior to starting water pass on the A Hall but confirmed she did not perform hand hygiene between entrance and exit of any of the resident rooms once water pass had begun. CNA HH said she usually had hand sanitizer in her scrub pocket but did not have any that day. CNA HH acknowledged she should have performed hand hygiene between each room. Review of the 'Hand Hygiene' policy, updated [DATE], revealed the following, in part: It is the policy of this facility that hand hygiene be regarded as the single most important means of preventing the spread of infection .Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: .Proper hand hygiene should be performed between all services to residents .After touching a resident or the resident's immediate environment, After contact with blood, body fluids, or contaminated surfaces . To cleanse hands to prevent transmission of possible infectious material. To provide clean, healthy environment for residents and staff . During a telephone interview on [DATE] at 2:17 p.m., when asked about the performance of hand hygiene during resident water pass, the DON confirmed hand sanitation should be performed after touching anything in the resident environment, including the previously used water cups. The DON stated, If you touch something dirty (potentially contaminated) you would sanitize again. Medication Administration During an observation of Resident #22's blood sugar check on [DATE] at 6:40 a.m., Licensed Practical Nurse (LPN) B, took the blood glucometer into Resident #22's room and set it directly on Resident #22's bedside table. After obtaining Resident #22's blood sugar, LPN B placed the blood glucometer back into the medication cart without disinfecting it. LPN B was asked about cross contamination when placing the glucometer onto Resident #22's nightstand and into the medication cart LPN B said she was not aware of the need for a barrier to prevent cross contamination and the glucometer should have been disinfected prior to placing it back into the medication cart. On [DATE] at 07:42 a.m. Registered Nurse (RN) A obtained a blood sugar for Resident #46. RN A did not disinfect the glucometer prior to placing the glucometer back into the medication cart. During an observation of Resident #78's insulin administration [DATE] 07:46 a.m., RN A did not wash her hands or don gloves prior to administering #78's insulin. On [DATE] at 07:50 a.m., RN A did not respond when asked if the glucometer should have been disinfected prior to placing it back into the medication cart. RN A said she should have washed her hands prior to giving Resident #78 her insulin and did not wear gloves when administering insulin because there was no risk of exposure to body fluids or cross contamination. Interview an interview with the Director of Nursing (DON) on [DATE] at 02:05 p.m., the DON reported the expectation would be to always provide a barrier when taking items into a resident room that were going to be put back into the medication cart. Glucometers were to be disinfected with a bleach wipe and allowed to dry prior to placing them back into the medication cart. The DON said handwashing should be practiced before administering medications and gloves should be worn when injecting insulin. The DON said all of these measures need to be taken to effectively prevent cross transmission of germs and potential illness. A copy of the facility's Injections Insulin policy which was most recently updated on [DATE] contained the following information in part, For a Single Injection: .2. Wash hands 3. Wash hands, apply gloves . The facility's Blood Glucose Monitoring policy with an adoption date of [DATE] did not contain information regarding disinfecting the glucometer after obtaining a resident's blood sugar. The facility Abatement plan was accepted, and facility implementation began as follows to remove immediacy: On [DATE], DON ensured the following steps were completed by the clinical staff: All residents were assessed by a Licensed Nurse for signs and symptoms of influenza or respiratory illness. Education was initiated immediately on PPE and proper use of to clinical staff, as well as resident assessments/identification of respiratory illness. Any residents with signs or symptoms of respiratory illness and/or influenza the physician will be notified and influenza test administered as ordered. Staff will follow the proper PPE and hand hygiene for any residents with positive results for influenza and/or specific respiratory illness or with TBP's. The IP will properly identify, monitor and investigate any residents with signs/symptoms of respiratory infections and timely initiate interventions per policy to prevent the spread of infection. The IP updated Line Listing to properly track residents with respiratory illnesses. Inservice: On [DATE], facility initiated education for Licensed Nurses, including Infection Preventionist. In-service focused specifically on Infection Control and Influenza: The IP will properly identify, monitor and investigate any residents with signs/symptoms of respiratory infections and timely initiate interventions per policy to prevent the spread of infection. The IP will up [TRUNCATED]

This citation refers to Intake #MI 303. Based on observation, interview and record review, the facility failed to provide necessary and adequate care as evidenced by lack of timely and appropriate incontinence care and inadequate supplies, ignored and/or delayed call light response times, and failure to complete resident scheduled shower/bed baths for five Residents (#44, #51, #60, #63, and #74), of 28 residents reviewed for abuse. This deficient practice resulted in the identification of Immediate Jeopardy (IJ) on 5/25/22 when four Residents (#60, #63, #74, and #51) reported and/or were observed having been left in urine and feces for extended periods of time with bathing washcloths, towels, and sheets used for removal of feces, resident call lights and calls for assistance unanswered, bathing not completed as scheduled, feelings of hopelessness, worthlessness, and sadness. The facility failed to meet the physical, mental, and psychosocial needs of facility residents based both on a Reasonable Person Standard for cognitively impaired residents and verbally expressed concerns by cognitively intact residents. This deficiency had the potential to affect all residents that required extensive to dependent assistance with activities of daily living (ADLs). The Nursing Home Administrator (NHA) was notified of the IJ on 5/25/22 at 11:35 a.m. The IJ was removed on 5/25/22 at 5:45 p.m., when the facility's Abatement Plan was approved, and education was provided to licensed nursing staff regarding the necessity of timely and consistent incontinence care, timely and appropriate call light response, and proper use of incontinence supplies necessary for urine and feces removal during incontinence care. The facility's non-compliance remained at a widespread level due to the potential for more than minimal harm for 89 Residents identified on the CMS-672 (Resident Census and Condition) as requiring the Assist of One or Two Staff for Toilet Use, and for 75 Residents for Bathing. Findings include: Resident #60 Review of Resident #60's Minimum Data Set (MDS) assessment, dated 4/18/22, revealed Resident #60 was admitted to the facility on [DATE], with active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #60 scored 15 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition, was able to make her needs known, required extensive assistance with bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. Resident #60 was frequently incontinent of urine, and always incontinent of bowel. During an interview on 5/23/22 at 2:39 p.m., Resident #60 was asked about care received in the facility. Resident #60 said she had only had four showers and four bed baths since her January 6th admission. Resident #60 was supposed to have a shower on Friday 5/20/22, but staff did not have an appropriate size sling for the Hoyer (mechanical) lift, so no shower was provided. Resident #60 said she has timed the call light response times, and especially on the night shift, she has had to wait up to two hours for a response. Resident #60 stated, I had the call light on for a couple hours one night. I told the nurse (Licensed Practical Nurse (LPN) CCC) that I needed to be changed. She turned the light off and it was 45 minutes before the aide came in. Resident #60 said her incontinence brief had just been changed (by Certified Nurse Aide (CNA) AA, who was observed leaving Resident #60's room at 2:32 p.m. Resident #60 said her incontinence brief had last been change at approximately 5:00 a.m., that morning (5/23/22) Resident #60 said CNA AA was coming back to change (roommate) Resident #51, because she had not had her incontinence brief changed since 5:00 a.m. either. Resident #60 stated, I have had to sit in feces while I waited for someone to change me. Resident #60 had one incontinence brief in the room, and reported previously purchasing her own incontinence briefs, but they were put in her roommates closet and used on her roommate. Resident #60 said the facility did not have any disposable wipes that could be used for incontinence care (cleaning of feces and urine from the residents). Resident #60 stated, They (facility administration) expect people (CNAs) to wipe people's butts with wash rags and towels, and then wash them, and use them on people's faces. Review of Resident #60's Skin Observation Shower Sheets and Electronic Medical Record (EMR) Task Documentation for bathing revealed one Skin Observation Shower sheet was provided by the facility, complete by CNA staff on 3/3/2022 when a shower was documented for Resident #60. Bed Bath task documentation in the EMR revealed bed baths were documented as completed, without completion of accompanying Skin Observation Shower sheets for Resident #60 for May of 2022 on 5/6/22 and 5/20/22 prior to the start of the facility recertification survey. The Resident was scheduled for bathing two days per week - Tuesday and Friday evenings. The documentation provided did not show evidence of Resident #60 receiving bed baths or showers according to the facility schedule. Review of Resident #60's May 2022 Urinary and Bowel Incontinence EMR task documentation revealed Resident #60 received incontinence care on 5/23/22 at 00:28 (12:28 a.m.), 5:01 a.m., and 9:13 p.m. During an interview on 5/23/22 at 2:59 p.m., CNA AA was asked about the urine saturation of Resident #60's incontinence brief when changed at approximately 2:30 p.m. CNA AA stated, It was pretty saturated. When asked if it brief appeared to have been changed during the day shift, CNA AA stated, No, it did not look like it was changed today. During an interview on 5/25/22 at 1:27 p.m., Resident #60 confirmed they used cloth washcloths to clean up her bowel movements. Resident #60 stated, They need wipes. I am not going to buy wipes. I used to buy myself wipes and staff would take a pack and use them on everyone else. I think it is gross that they are using the washcloths. Some of the aides do the right thing and throw them out, others put them in a bag and wash them . Yesterday I was supposed to have a shower, but I asked for a bed bath. My showers are on Tuesdays and Fridays, and they mark on the thing refused, but they never ask me about a shower. They just never give them (bed baths) to me . Resident #51 Review of Resident #51's MDS assessment, dated 4/5/22, revealed Resident #51 was admitted to the facility on [DATE], with active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #51 score 4 of 15 on the BIMS reflective of severe cognitive impairment, and required extensive to dependent assistance with bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. Resident #51 was always incontinent of urine and bowel. During an observation and interview on 5/23/22 at 3:05 p.m., CNA AA changed Resident #51's incontinence brief. Observation of the brief, inside the clear plastic disposable bag, showed the incontinence brief was yellow from urine saturation, and the bag was heavy with the weight of the saturated brief. CNA AA stated, Because it is heavy (from urine saturation) I don't think they (day shift CNAs) changed her before now. (Last change would have been by night shift before going off-duty at approximately 5:00 a.m.) Review of Resident #51's May 2022 Urinary and Bowel Incontinence EMR task documentation revealed Resident #51 received incontinence care on 5/23/22 at 00:28 (12:28 a.m.), 5:01 a.m., and 9:12 p.m. Urinary incontinence changes were documented only once daily, on 5/4/22 at 21:29 (9:29 p.m.), 5/6/22 at 02:33 (2:33 a.m.), and 5/21/22 at 20:31 (8:31 p.m.), and twice daily on the following dates: 5/7, 5/8, 5/10, 5/12, 5/15, 5/22, 5/27, 5/28, and 5/29. During an interview on 5/25/22 at 2:13 p.m., CNA DDD confirmed she had changed both Resident #51 and Resident #44 that morning. CNA DDD said both residents were soaking wet when changed this morning and both required linen (bed linen) changes with the incontinence brief change because of urine saturation. CNA DDD confirmed it appeared the residents had not been changed for the entire night shift. CNA DDD said she feared retaliation from the facility administration and staff if any concern related to lack of resident incontinence care was reported. Review of Resident #51's Skin Observation Shower sheets and EMR bathing documentation provided by the facility revealed one Skin Observation Shower sheet had been completed for a bed bath on 3/11/22, and bathing was scheduled for this Resident on Tuesday and Friday evenings. Bed baths were documented for the May 2022 in Resident #51's EMR as completed on 5/10, and 5/13, with a resident refusal documented on 5/24 prior to the start of the facility recertification survey on 5/23/22. The documentation provided by the facility did not show evidence of Resident #51 receiving bed baths or showers according to the facility schedule. Resident #74 Review of Resident #74's MDS assessment, dated 4/26/22, revealed Resident #74 was admitted to the facility on [DATE], with a re-admission on 1/19/2022. Resident #74 scored 14 of 15 on the BIMS, reflective of intact cognition, and was able to make her needs known. Resident #74 had the following active diagnoses, in part: heart failure, renal failure, wound infection, depression, complete traumatic amputation at knee level (right lower leg), and pressure ulcer of sacral region, Stage 4. Resident #74 required extensive to dependent assistance with bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing, and was always incontinent of urine and bowel. During an observation and interview on 5/23/22 at 3:31 p.m., Resident #74 was heard calling for this Surveyor's attention as this Surveyor was walking near the Resident #74's room door. Resident #74 stated, I have not been changed since about 5:30 (a.m.) this morning. I have seen [Registered Nurse (RN) R about four times, and she keeps telling me she is going to find someone, and someone never comes. Resident #74 was positioned on her left, leaning on the left mobility bar with her head in contact with the rail. Resident #74 stated, I keep pulling myself to the right, but I end up back there on the rail. My head hurts because my head is leaning against it . The bed is wet now because I have been waiting for two hours and I have had a bowel movement, and I haven't been changed since this morning. Resident #74 confirmed she did have a pressure sore on her bottom that required a physician prescribed dressing. During an observation and interview on 5/23/22 at 3:40 p.m., CNABB was observed performing incontinence care, including a change of urine saturated linen for Resident #74. CNA BB confirmed the facility did not have any disposable wipes for incontinence care. CNA BB stated, They (facility) use towels (bath towels and wash cloths). When asked about the saturation of Resident #74's incontinence brief, CNA BB said it was over-saturated, which was agreed with by Resident #74. CNA BB said she was probably going to have to change all the bed linen, as she wiped dark brown, dried-on feces from Resident #74's perineum, anus, buttocks, and sacral region with a dingy, grayish bath towel. The towel was folded and refolded, as feces was scooped off Resident #74's buttocks. The dirty incontinence brief removed from Resident #74 had a light brown, liquid saturation ring approximately 2-3 inches out from the gross feces on the brief. CNA BB asked the assisting nurse for a bag for the dirty, feces covered towels. No pressure ulcer dressing was present on Resident #74's coccyx wound. CNA BB then asked for another towel, as Resident #74 was still not clean from the incontinence brief that was overly saturated with urine and feces. When asked how long Resident #74 had sat in urine and feces, CNA BB's eyes opened wide, and her head nodded up and down as she said it appeared Resident #74 had sat in the feces for quite a while. The bowel movement needed to be cleansed from the coccyx wound which had been covered in semi-dried feces. The window blinds had not been closed during the incontinence change, and Resident #74's room was on the ground level of the building. Review of Resident #74's May 2022 Urinary and Bowel Incontinence EMR task documentation revealed Resident #74 received incontinence care on 5/23/22 at 00:30 (12:30 a.m.), 5:02 a.m., and 9:15 p.m. Urinary incontinence changes were documented only once daily, on 5/4/22 at 21:30 (9:30 p.m.), and 5/21/22 at 20:33 (8:33 p.m.), and twice daily on the following dates: 5/6, 5/7, 5/8, 5/11, 5/12, 5/15, 5/20, 5/22, 5/25, 5/28, and 5/29. During an observation and interview on 5/23/22 at 3:52, Licensed Practical Nurse (LPN) R was asked why three Residents had not received incontinence care on the day shift. LPN R raised her arms out to the side, with hands upward, as an indication she did not have an answer for the question. When asked if the three Residents should have been changed on the day shift, LPN R agreed the CNAs should have checked and changed all residents on the day shift. LPN R entered the room of Resident #74 to perform wound care. Feces was wiped from Resident #74's skin on and surrounding the wound. A brown liquid was observed running down Resident #74's left buttock, from the coccyx wound. Resident #74's coccyx and sacrum appeared redden and excoriated. Review of Resident #74's Physician Orders, as of 5/23/22, revealed the following order: Coccyx: Cleanse with NSS (Normal Sterile Saline). Pat dry. Apply silver gel to dry gauze then apply ordered gauze dressing once a shift, every shift related to PRESSURE ULCER OF SACRAL REGION every shift for wound care. Start date: 4/18/22 . During an observation and interview on 5/24/22 at 3:28 p.m., Physician/Wound Consultant CC confirmed his physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician CC confirmed if there was fecal contamination to Resident #74's the staff should use [cotton-tipped applicators] for removal of the feces from the wound bed and confirmed there should always be a dressing on Resident #74's coccyx wound. Resident #74 was observed with fecal incontinence prior to the dressing change that required another change of the incontinence brief following wound care. During an observation on 5/24/22 at 3:39 p.m., CNA OO was asked to perform a repeat change of Resident #74's incontinence brief, due to the episode of fecal incontinence. CNA OO was observed stomping down the hall, shaking her head back and forth. CNA OO appeared upset and spoke with a frustrated voice when she stated, I just changed her (Resident #74)! During an observation and interview on 5/25/22 at 1:09 p.m., Resident #74 again called to this Surveyor for assistance. Resident #74 stated, I have had my call light on three times because I wanted to wash up. Each one (staff member) came in and said they would get someone three times, and they didn't. They kept turning off the call light so nobody would come and help me, and they said they would get somebody, but they were just lying. I kept waiting for them until lunch time. [LPN T] was the fourth one to come in. By then I was trying to sleep because I thought they were not going to do anything. [LPN T] said she would get someone, and she never brought anybody either, so I never did get washed up and I wanted to get washed up . My head was starting to get itchy (because hair was dirty). When asked how she felt when nobody came to provide assistance Resident #74 stated, It makes me feel horrible . I am supposed to get a bed bath on Monday and Thursday, and they don't come in here and give it to me .I would like a shower, but they never ask if I want a shower . Review of Resident #74's Skin Observation Shower sheets, and EMR task documentation revealed Skin Observation Shower sheets were completed by CNA staff for only bed baths for Resident #74. All bathing documentation showed only bed baths were provided to Resident #74, and no showers were documented between 2/3/22 and 5/30/22. Documentation of Resident #74's hair being washed during May of 2022 was documented as Not Applicable (N/A) on 5/2 and 5/16, and Resident Refused on 5/23 and 5/30/22. Evidence provided and reviewed in Resident #74's EMS did not document that the Resident's hair was washed at all during the month of May 2022. Review of Resident #74's care plans revealed the following, in part: ADL Self care deficit related to impaired mobility . Interventions: ADL assist: 1-2 person ext (extensive) assist, Bed mobility: 2 person ext assist, Transfers: 2 person dep (dependent) assist with total mechanical lift, Toileting: 2 person extensive assist . I prefer bed baths instead of showers, if I refuse come back and offer at a later time, Date Initiated: 3/10/2020 . Total Assist to bathe/shower as 1-2 person needed on assigned shower days. Date Initiated: 6/25/2018. Review of the Policy/Procedure - Nursing Clinical Bath, Shower, adopted 7/11/2018, revealed the following, in part; It is the policy of this facility to promote cleanliness, stimulate circulation and assist in relaxation . 9. Document all appropriate information in medical record . Resident #63 Review of Resident #63's MDS assessment, dated 4/16/2022, revealed Resident #63 was admitted to the facility on [DATE], with a re-admission on 4/9/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #63 scored 13 of 15 on the BIMS, reflective of intact cognition, and was able to make her needs known. Resident #63 required extensive to dependent assistance with bed mobility, transfers, dressing, eating, toilet use, personal hygiene, and bathing. Resident #63 and was not rated for urinary continence due to the presence of a urinary catheter, and was rated as frequently incontinent of bowel. During an observation and interview on 5/23/22 at 4:08 p.m., Resident #63 agreed to be interviewed in her room with roommate Resident #39 present in the room during the interview. Resident #63 said she was changed about 5:00 a.m. in the morning, and then was not changed until 2:00 p.m. When asked about the typical time she went between incontinence changes, Resident #63 said she was not repositioned every two hours, and she does not routinely get the incontinence brief changed timely or consistently. Resident #39, stated, I am shocked sometimes that they leave her sitting in urine for so long. Resident #39 confirmed she had been in the room all that morning, and had not seen Resident #63's incontinence brief changed until approximately 2:00 p.m. When asked about call light response times, Resident #63 stated, Oh Lord! Same (expletive) one day to the next. Resident #63 said staff come when they want to. Resident #39 (roommate) confirmed she had time the call light response times for Resident #63, and Resident #63 had to wait three hours for assistance at times. During an interview on 5/25/22 at 11:44 a.m., Resident #63 confirmed they used cloth washcloths and towels to clean her up when she has a bowel movement. Resident #63 stated, I have been waiting as long as two hours for a response to a request to be changed. Roommate, Resident #39, confirmed Resident #63's statements. Resident #39 stated, When she rings around lunch, they will tell her [Resident #63] that they need to pass lunch trays first and they will be back after lunch so she will have to wait for up to 2 hours. Resident #63 said, I am a heavy wetter, and I need to be changed more often, because my catheter is not working right. When asked if she was checked and changed as needed every two hours, Resident #63 stated, No, they don't, and it has always been that way . Things are always like this. Resident #63 stated, Staff come when they want to, and it has always been that way. It makes me feel bad when they don't come to change me. They just don't come. Roommate Resident #39 confirmed Resident #63's statements regarding incontinence care for Resident #63. Review of Resident Council Minutes, December 2021 through May 2022, revealed the following concerns: 12/6/21: Old Business - Review of Previous meeting, Outstanding Issues and Resident Council Departmental Response Forms: Nursing: Call light/meds passed un-timely. 2/7/2022: New Business: Nursing: . Feel staff is slow at answering call lights . 3/7/2022: Old Business: Nursing: . Feel staff is slow to answer call lights . 5/2/2022: Old Business: Nursing: Feel staffing is short and linens are being left out. New Business: Feel night shift staff aren't timely with call lights or medication pass . Review of the facility Policy/Procedure - Nursing Clinical, Incontinent Care, Adopted 7/11/2018, revealed the following, in part: It is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition. PROCEDURE: Supplies: Disposable incontinent brief, pad or resident's own undergarments, Disposable wipes, Barrier cream, if applicable, Linen, if needed . 3. Provide Privacy. 4. Wash hands, apply gloves .7. Cleanse perineal/rectal area and apply a new brief . 8. Remove gloves, wash hands. 9. Document all appropriate information in medical record. 10. Do rounds at least every 2 hours to check for incontinence. During interviews on 5/25/22 at 9:20 a.m. and 9:25 a.m., CNA AAA confirmed disposable wipes had not been available in the facility for use during resident incontinence care. CNA AAA said the residents want the wipes, and don't want the cloth towels for wiping urine and feces from bottoms. CNA AAA agreed that the residents did not want a towel or washcloth used to remove feces from resident bottoms to be washed and then used on the resident faces. CNA AAA stated, It is hard to do your job without the supplies you need to do the job. We (CNAs) run out of linens (towels and washcloths) because they are all being used to clean up the residents (urine and feces), and sometimes they get thrown out because they are so covered in poop. CNA AA reported staff come from the other floors (B Hall and C Hall) and take the briefs from these residents (A Hall residents). They (CNAs) cut towels because there are no washcloths. When asked to count dingy, white washcloths and towels in the A Hall supply closet, CNA AAA counted 17 wash cloths and 21 towels, for approximately 26 residents on the A Hall floor. CNA AA stated, We (staff) are even using the sheets to wipe the poop off of people. During an interview on 5/25/22 at 12:04 p.m., CNA JJ confirmed usage of cloth washcloths for gross urine and feces removal during incontinence care. CNA JJ stated, It is harder, they (residents) have to use the washcloths for their face, so it is not very nice to use them on their bottom as well. Sometimes I buy my own wipes .Some residents say the washcloths are too hard on their bottoms. I (like to) use the wipes to remove most of the stool . During an interview on 5/25/22 at 12:45 p.m., CNA XX said the facility took the wipes away from the residents because people were putting them down the toilet. CNA XX stated, One day we came in and people (facility administrative staff) were taking the wipes and they were just gone, and the nursing staff told us to use the towels. During an interview on 5/25/22 at 12:57 p.m., CNA I confirmed the aides had been using the towels and washcloths for incontinence care for months. CNA I stated, The Director of Nursing (DON) and the Nursing Home Administrator (NHA) said they (disposable wipes) were blocking up the drain, so they are going back to using washcloths . We would rather use the wipes, because when you are cleaning poop you can just throw it away. You have to use two or three (towels or washcloths) depending on the load (of feces). We don't know of any wipes in the facility (at all). We the workers don't have access to it. CNA I confirmed she had been told to cut up towels when they didn't have enough washcloths to clean the residents up, and she had done that many times. During a telephone interview on 5/27/22 at 9:38 a.m., when asked if there was any difference in the care required for residents on the A Hall, CNA S stated, The care down here (in the basement level (A Hall) with ground access on one side) is more extensive with the changing and the rolling. The residents upstairs (B and C Halls) are more independent. During a telephone interview on 5/27/22 at 9:46 a.m., when asked about checking and changing of incontinent residents, CNATT stated, This is my first time at this facility . We check and change them before we leave . During a telephone interview on 5/27/22 at 9:52 a.m., CNA UU confirmed she had been working at the facility for less than one year, and said she normally worked A Hall. CNA UU stated, A floor is the most need for Hoyers (mechanical lifts) - the most people for transferring. A floor is known to be the hardest to work CNA UU said she had cut up towels when they ran out of washcloths for incontinence care, but never had to resort to a bed sheet yet. CNA UU stated, We had to have something to clean them up. Review of an email received by this Surveyor from Confidential Witness #C500 on 5/30/22 at 7:21 p.m., revealed the following, in part: [Resident #60, Resident #44, and Resident #63] have not been changed since (about) 10:30 a.m., it is now 7:15 p.m., and [they] still haven't been changed and the aide is nowhere to be found. Now [they] have to worry about UTIs and skin breakdown. I can't take this anymore! Review of EMR completed task documentation for urinary and bowel incontinence documentation for Residents #60, #44 and #51 showed the incontinence changes for the following individual Residents on 5/30/22: Resident #60: 2:32 a.m., 12:39 p.m., and 20:48 (8:48 p.m. with bowel incontinence), with greater than eight hours between each incontinence brief change. Resident #44: 2:32 a.m., 12:35 p.m., and 20:46 (8:46 p.m.) with greater than eight hours between each incontinence brief change. Resident #51: 2:32 a.m., 5:22 a.m., 12:33 p.m., and 20:44 (8:44 p.m.) with approximately 8 hours between the noon check and change and the evening incontinence brief change. Resident #44 Review of Resident #44's MDS assessment, dated 4/7/22, revealed Resident #44 was admitted to the facility on [DATE], with active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #44 required extensive to dependent assistance with be mobility, dressing, toilet use, personal hygiene, and bathing, and was always incontinent of urine and stool. Resident #44 scored 12 of 15 on the BIMS reflective of moderate cognitive impairment. Review of Resident #44's Skin Observation Shower sheets and EMR revealed bathing was scheduled for Tuesday and Friday evenings. Bed baths were completed during May 2022, on 5/10 and 5/13, with all other staff documentation as N/A or Resident Refused. The documentation provided by the facility did not show evidence of Resident #44 receiving bed baths or showers according to the facility schedule. During a telephone interview on 5/31/22 at 2:17 p.m., when asked for the facility's acceptable timeframe for incontinence checks and changes for facility residents, the DON stated, Every two hours. When asked when hand hygiene should be performed during a dressing change, the DON said hand hygiene should be performed whenever you have touched something dirty in the environment or on the resident. The DON stated, I keep clean, clean and dirty, dirty. I would absolutely wash my hands if I touched poop, and then apply fresh gloves. The DON agreed that showers should be complete based on the assigned shower schedule, unless the resident refuses. Review of the facility Policy/Procedure - Nursing Administration, Abuse and Neglect, revised 6/17/2019, revealed the following, in part: Definitions of Abuse, Neglect . Abuse (is that) willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being . Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Abuse includes .5) Neglect: Neglect is the failure to provide necessary and adequate (medical, personal or psychological) care. Neglect is the failure to care for a person in a manner, which would avoid harm and pain, or the failure to react to a situation which may be harmful. Neglect may or may not be intentional . Examples: . - Lack of bathing which leads to indignity, and poor hygiene . - Lack of toileting or changing disposable briefs which causes incontinence and results in resident sitting or lying in (sic) urine or feces. - Ignoring call light or cries for help . The deficient practice immediacy was removed on 5/25/22 at 5:45 p.m., when the accepted abatement plan had begun, including but not limited to the following: .Incontinence care was completed immediately by the CENA for .Resident #64 . Resident #74 . and Resident #51., and all residents were rounded on by the CENAs and Licensed Nurses and received timely incontinence care and to ensure resident ADL needs were met . .On May 25, 2022, facility initiated education for clinical staff on Abuse and Neglect policy and Incontinence Policy. In-service focused specifically on: - Ensuring residents receive consistent and timely incontinence care to prevent feelings of neglect, social isolation and promote dignity. - Responding to call light timely. - On May 25, 2022, Laundry staff and will be in-serviced on ensuring adequate linens are available to staff to provide adequate supply of linens for staff to complete incontinent care timely. - On May 25, 2022, Central Supply Coordinator will be in-serviced to ensure PAR levels will be maintained for incontinence care including disposable wipes.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: (1) failed to manage potentially hazards food appropriately and (2) failed to maintain food contact surfaces in a sanitary manner (ice scoop holder). Findings include: On 5/24/22 at 1:47 p.m., observations of the kitchen were made during dinner meal prepping hours. It was observed that Dietary Aide/Staff JJJ was preparing pork chops for the dinner service which started at 5:00 p.m. Staff JJJ was noted to add various spices to the pork chop while using bare hands and wiping the spices all over the pork chops. Staff JJJ was then observed to go to the hand washing station after to wash their hands but was not observed washing her hands for 20 seconds. The FDA Food Code 2013 states: 2-301.12 Cleaning Procedure (A) Except as specified in (D) of this section, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a HANDWASHING SINK that is equipped as specified under § 5-202.12 and Subpart 6-301. P On 5/24/22 at 1:20 p.m. and 5/25/22 at 8:30 a.m., the scoop holder, for the ice machine, mounted on the wall to the right side of the ice machine, was observed to be absent of any drainage holes. The holder was further observed to have standing water at the bottom where the tip of the scoop sits. The FDA Food Code 2013 states: 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. Pf (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

This deficiency pertains to Intake #MI 303. Based on observation, interview, and record review, the facility failed to ensure respectful and dignified care and services were provided for six Residents (#17, #29, #74, #2, #143, and #240) of 28 sample residents reviewed for resident rights. This deficient practice resulted in the potential for resident embarrassment, humiliation, and loss of self-worth. Findings include: Resident #17 Review of Resident #17's Minimum Data Set (MDS) assessment, dated 2/22/22, revealed Resident #17 was admitted to the facility on [DATE] with active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . It may cause difficulty with walking and balance, hand coordination, speech and swallowing, and eye movements). Resident #17 scored 15 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition, and was able to make his needs known. During an interview on 5/24/22 at 8:54 a.m., when asked if he was treated with dignity and respect in the facility. Resident #17 stated, No, I am not. When asked why he felt he was not treated with dignity and respect, Resident #17 stated, Most of the nurses ignore me. When they ask me if I am ok, they leave me (leave the room) before I can given an answer. That made me feel bad because with multiple system atrophy . most nurses know what the characteristiccs are of multiple system atrophy are (including speech difficulty). Resident #17 was observed and heard to speak with a slow, faltering voice, pronouncing each word as clearly as possible, with understanding of his speech sometimes difficult for this Surveyor. Resident #17 said there was an Agency (worked for an employment agency) nurse who was playing gospel music very loud and she had refused to turn the volume down when Resident #17 requested the volume lowered. The nurse told Resident #17 she had to be in the facility working and she had to be able to hear the music, so she would not turn the volume down. Resident #17 said he had told the Director of Nursing (DON) about the loud gospel music, and the DON said she would look into it. Resident #17 stated, I requested to speak to the DON last week, but nobody ever showed up . Resident #29 Review of Resident #29's MDS assessment, dated 3/13/22, revealed Resident #29 was admitted to the facility on [DATE], with active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #29 scored 3 of 15 on the BIMS, reflective of severe cognitive impairment. Resident #29 required extensive one-person assistance with dressing, toilet use, and personal hygiene. On 5/24/22 at 3:27 p.m., Resident #29 was observed lying in bed, with the room door open, and privacy curtain not positioned to prevent view of the resident, with no clothing on the top half of her body, and both breasts fully exposed. Resident #74 Review of Resident #74's MDS assessment, dated 4/26/22, revealed Resident #74 was admitted to the facility on [DATE], with a re-admission on 1/19/2022. Resident #74 scored 14 of 15 on the BIMS, reflective of intact cognition, and was able to make her needs known. Resident #74 had the following active diagnoses, in part: heart failure, renal failure, wound infection, depression, complete traumatic amputation at knee level (right lower leg), and pressure ulcer of the sacral region, Stage 4. During wound care to Resident #74's Stage IV coccyx pressure ulcer on 5/24/22 at approximately 3:30 p.m., Cook BBB opened the door and entered the room without knocking, while Resident #74's buttocks was uncovered and exposed. The document 'Rights of Residents in (state) Nursing Facilities', dated 11/28/16, revealed, .As a basic premise, all residents have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside of the facility .You have the right to be treated with respect and dignity . Resident #240 On 5/23/22 at 4:03 p.m., Resident #240 was observed resting in a cardiac chair in the C hall dining room with only a hospital gown on. During this observation, an interview was attempted with Resident #240, but he did not respond to questions. While attempting the interview with Resident #240, a catheter bag was observed hanging from the right side of the cardiac chair with the collecting bag contents visible. There were several other unidentified residents in the the C hall dining area during this observation. Resident #240 was positioned with his feet off to the right side of the cardiac chair foot rest, with the back and foot rest in a reclined position. An unreachable locking bar in the back of the cardiac chair was engaged so Resident #240 could not get up from a reclined position. On 5/26/22 at 11:16 a.m., Resident #240 was observed still resting in bed and had a hospital gown on. On 5/26/22 at 11:18 a.m., during an interview, Family Member (FM) EE and FM FF had just finished visiting with Resident #240. When asked if Resident #240 would want to be up and dressed this time of day, FM EE and FM FF both agreed Resident #240 would want to be up and dressed and in a chair during the day. FM EE stated she she did not understand why he was still in a hospital gown and in bed and replied, (Resident #240) would not have wanted to still be in bed. A review of the Minimum Data Set (MDS) assessment for Resident #240, dated 4/10/22 revealed the following: Section F question F0400, A. How important is it to you to choose what clothes to wear? was rated as 1. Very Important Resident #143 On 5/23/22 at 3:29 p.m., Resident #143 was observed lying in bed, with his buttocks, back, and legs exposed to the hallway via the open room door. Two roommates were observed in the room. On 5/23/22 at 4:35 p.m., Resident #143 was observed naked lying in bed with a just sheet covering his groin area. Resident #143 was half slid out of the bed with his lower extremeties resting on a fall mat on the floor. The room door was open and the Resident was visible from the hallway. On 5/23/22 at 6:30 p.m., Resident #143 was observed to be naked in his bed with the room door wide open. His buttocks was exposed to the open room door. On 5/24/22 at 7:40 a.m., Resident #143 was observed from the hallway lying in bed. Resident #143 was observed only wearing a brief that had large brown stains on it. A review of Resident #143's record revealed he admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 Resident #2's admission record contained an admitted [DATE] and medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2's MDS assessment dated [DATE] revealed a BIMS score of 15/15, indicating Resident #2 was cognitively intact. During a medication administration observation on 05/24/22 at 8:05 a.m., Registered Nurse (RN) A entered Resident #2's room to administer insulin. RN A did not knock or announce herself when entering the room. RN A notified Resident #2 that she needed to giver her insulin and asked her where she wanted it injected. Resident #2 choose her abdomen as the injection site. RN A instructed Resident #2 to lift her nightgown. Resident #2 lifted her nightgown, and was not wearing underwear. Resident #2's abdomen and peri area were exposed. RN A did not ensure the privacy curtain was pulled and Resident #2's roommate was visible from where Resident #2 sat. The door to Resident #2's room also remained open. On 05/24/22 at 8:07 a.m., RN A was asked what she did to maintain dignity and privacy when providing resident care. RN A shrugged her shoulders and said she did not see the need to pull Resident #2' privacy curtain or close the door because the room was at the end of the hall. During an interview with the Director of Nursing (DON) on 05/31/22 at 2:05 p.m., concerns around the observation made during the insulin administration were shared. The DON said staff should always knock on the door prior to entering a resident's room. The DON reported it was not appropriate to administer insulin without pulling the privacy curtain especially since Resident #2's abdomen and peri area were exposed and visible to any passerbys and her roommate. The facility's policy Resident Rights Dignity and Respect which was adopted on 7/11/18, contained the following information, in part, It is the policy of this facility that all residents be treated with kindness, dignity and respect .Residents shall be examined and treated in a manner that maintains the privacy of their bodies. A closed door or drawn curtain shields the Resident from passers- by. People not involved in the care of the Resident shall not be present without the resident's consent while they are being examined or treated. Staff members shall knock before entering the Resident's room. Privacy of a Resident's body shall be maintained during toileting, bathing and other activities of personal hygiene, except when staff assistance is needed for the Resident's safety .

This deficiency pertains to Intake #MI 226 Based on observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable and homelike environment for three Residents (#17, #28, and #74) of 28 sample residents reviewed for environmental concerns. This deficient practice resulted in a hazardous environment, the potential for falls and injury, and unpleasant living conditions for all residents residing on the A Hall. Findings include: During an observation on [DATE] at 12:15 p.m., Resident #74's room floor was noted with the following garbage and debris: a plastic fork, two paper straw covers, food and food particles, a dirty washcloth, and a dirty white tissue. During an observation and interview on [DATE] at 9:12 a.m., Resident #17's room was found with the window shade pulled all the way down, completely covering the window. When Resident #17 was asked by the shade was pulled down, with no daylight coming in, Resident #17 said it was because of the broken window. Observation of the window found the left window glass pane cracked and broken. Resident #17 also said a mouse had gotten into a bag of candy over the winter, and no traps had been set in his room to catch the mouse. Resident #17 said he had smelled the mouse recently. During an interview on [DATE] at 9:50 a.m., when asked about Resident #17's broken window, Maintenance Director VV said a glass company came out and looked at it, but the facility did not have an account with them. He said the glass company didn't the glass and the depth of the glass, but they had initially been at the facility a couple of months ago. Maintenance Director VV said the facility was waiting for the price of the glass repair, but the company would need to come out to the facility again. No appointment had been scheduled with the glass company. Maintenance Director VV was unaware of a scheduled time to have Resident #17's broken window repaired. Maintenance Director VV also confirmed the tile had been off of the floor since a plumbing repair in November of 2021, and stated, It (floor) was quoted and they were waiting for information from the insurance company. They are going to do the whole complete floor because the material was hard to get. During an interview on [DATE] at 1:37 p.m., Resident #60 reported that facility staff had been talking about live mice in the maintenance room. During an interview and observation on [DATE] at 1:45 p.m., the maintenance room door was found wide open, with no staff present in or near the maintenance office. Maintenance Director (Staff) VV and Maintenance Assistant (Staff) Y were paged to the maintenance room. Both Staff VV and Staff Y confirmed the maintenance room door had been left open all day and acknowledged a dead mouse was visible, physically trapped between two pipes and a wire in the maintenance office, close to the door. Staff VV said the mouse died because it got trapped by the pipes, not by a rodent trap. Staff VV stated, I know this door should not have been open all day, but we are cleaning in here, because housekeiping has to use the room as well. During a telephone interview on [DATE] at 10:56 a.m., Family Member (FM) Z said she would like to send photos of Resident #28's room condition, and lack of cleanliness in his room and on the A Hall. FM Z reported being disappointed with the cleanliness of the facility, and confirmed the West A Hall had the floor torn up for the past six months. Review of nine photos showing unsanitary conditions in the A Hall and in Resident #28's room were emailed to this Surveyor on [DATE] at 3:02 p.m. The photos including photographs showing the following, in part: 1. Oxygen tubing on the floor, with an imprint of the oxygen tubing in dried into a yellow liquid resembling urine on the floor, mixed with other dirt and debris. (Photo taken [DATE] 8:01 p.m.) 2. What appeared to be a nebulizer face mask on the floor, face side down, an empty [Name Brand] supplement box with a straw on the floor next to Resident #28's urinal lying on the floor. A yellow-stained cloth, with what appeared to be urine appears near the blue fall mat on the floor, in contact with the nebulizer mask. (Photo taken [DATE] 5:56 p.m.) 3. Cushioned fall mat lifted up, revealing dirty, brownish liquid under the mat. Oxygen tubing and nebulizer face mask on floor, along with dirty tissues, a screw, [Name Brand] supplement box, and urinal remain on floor. (Photo taken [DATE] 6:52 p.m.) 4. Underside of fall mat with a white foamy liquid visible on the back of the mat and on the floor. (Photo taken [DATE] 6:52 p.m.) 5. Underneath bed, with dirt, debris, stains, chipped tile, dirty washcloth, dirty tissue, screw, and two vacutainers for blood collection all on the floor. Yellow stains on the floor tiles, resembling dried urine. (Photo taken [DATE] 8:03 p.m.) 6. The condition of the flooring in the hallway since [DATE] (admitted for Resident #28), but in same condition since November of 2021 with exposed concrete plumbing repair and lack of tile on West A Hall. (Photo taken [DATE] 8:31 p.m.) 7. Back delivery hall with boxes on floor and a trail of brown dried liquid stains on the floor. (Photo taken [DATE] 8:31 p.m.) 8. Plastic serving cart with two insulated beverage dispensers, a partially filled orange juice pitcher, a brown insulated cup, with brown and orange liquid spills covering the top of the tray and unto the shelf below. A dirty oranged stained washcloth sat on top of the liquid spills and a bright orange pill, appeared to have partially disintegrated on top of the serving cart. (Photo taken [DATE] 6:08 p.m.) During an interview on [DATE] at 9:35 a.m., Certified Nurse Aide (CNA) HH reported the facility primarily used one housekeeper to clean the A Hall, Housekeeper N. CNA HH stated, If [Housekeeper N] is not here, nobody cleans (A Hall). During an interview on [DATE] at 1:05 p.m., Housekeeper N confirmed she had not been in the facility for the previous five days, and stated, Nobody cleans when I am not here . I am behind (today on cleaning) because I have to get caught up again. The floors were not mopped. I am having to do every room. The bathrooms have to be done all over again, and there are no paper towels. After me saying something, it still doesn't do any good (to get others to clean) . Observation and interview on [DATE] at 1:18 p.m., found Licensed Practical Nurse (LPN) T bringing Resident #29 a fan requested by the resident. The fan was plugged into the outlet, and began blowing dust balls and debris from the fan enclosure. When the dust, dirt, and debris was pointed out to LPN T, she stated, I will bring it to [Maintenance Director VV and get a clean one. Review of the 'Rights of Residents in [State Name] Nursing Facilities', revised [DATE], revealed the following, in part: . Safe Environment: You have a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely .

This citation has two deficient practices. Deficient practice #1: This pertains to intake number MI 440. Based on interview and record review, the facility failed to ensure speech therapy evaluations were conducted to rule out dysphagia (difficulty swallowing) for one (#194) of 22 sampled residents reviewed for quality of care, resulting in development of lethargy, dehydration, mental status changes, kidney injury,[MEDICAL CONDITION] (a potentially life-threatening condition caused by the body's response to infection), aspiration pneumonia and emergency hospitalization due to delay in appropriate care and services. Findings include: The complainant reported to the State agency that resident #194 was not evaluated for problems with swallowing (dysphagia), resulting in development of aspiration pneumonia, a lung infection due to food/liquids from the mouth entering into the lungs. On 2/05/20 at 9:14 AM, the clinical record was reviewed for resident #194 and revealed, an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum (MDS) data set [DATE] noted that the resident had severe cognitive impairment, required limited assistance for eating and had no difficulty swallowing. A regular diet in regular food texture was prescribed. Per progress notes dated 10/23, 10/25, 10/29 and 11/4/19 by the Primary Care Physician (PCP) and Nurse Practitioner (NP): No wheeze, crackles, rhonchi (coarse, continuous rattling sounds) or rales (periodic rattling sounds), non-labored, lungs clear. 11/7/19 progress note: Chief complaint-Seen for cough and wheeze, slightly less responsive, has a wet cough with wet upper respiratory sounds. I will have speech therapy (ST) assess his swallow. An order was written 11/7/19 for ST evaluation and treatment. 11/8/19 progress note: Chief complaint-congestion, diminished lung sounds. 11/8/19 nursing note: Appears weak crackles heard over lungs and resident appears to be very congested; Blood oxygen level fluctuated between 88-92% on room air (normal range 95-100%); Stat (immediate) chest x-ray ordered; Placed on oxygen; Per the 11/8/19 chest x-ray results: may have pneumonia, recommend follow up to verify; [MEDICATION NAME] (antibiotic) injection now and [MEDICATION NAME] (antibiotic) tablets for 7 days. 11/11/19 progress note: Chief complaint- cough, wet upper airway cough, questionable dysphagia, ST evaluation. 11/13/19 progress note: Diminished lung sounds, pending ST screen. Per nursing notes from 11/2-11/16/19, the resident was constantly trying to walk without supervision and getting up from the wheelchair without assistance. On 11/17/19-Resident displays increased sleepiness. 11/20/19 progress note: Chief complaint-cough, fatigue. Seen per nursing request due to increased cough and fatigue, mild wet cough noted, diminished lung sounds; Plan-will request a stat chest x-ray, cough syrup every 6 hours as needed, St to screen for dysphagia. An order was written on 11/20/19 for Speech Therapy to screen to rule out dysphagia; 11/20/19 chest x-ray showed improved from the 11/8/19 chest x-ray, lungs clear. 11/21/19 progress note: Wet cough questionable dysphagia, completed antibiotics, ST evaluation. Nursing notes- 12/1 and 12/14/19: Consistently attempting self-transfers from wheelchair and walk without assistance. 12/19/19: Taking meds, refused meals, accepted sips of water, staff encouraging meals, sleeping, attempting to wake up for meals. 12/20/19: Sleeping, attempting to wake up for meds and breakfast, refusing meals, continues to sleep, lungs with audible congestion, called physician-ordered Stat chest x-ray. 12/20/19 chest x-ray showed atelectasis (partial/complete collapse of the lung or lobes of the lung) versus pneumonia. 12/20/19 progress note: Chief complaint-Increased lethargy, cough, low blood pressure, not eating or drinking much, diminished lung sounds, wet cough; Plan-Start [MEDICATION NAME] for 7 days for pneumonia; Will request that speech (therapy) screen patient for any dysphagia as patient is symptomatic for recurrent pneumonia; Will order IV, encourage fluids, ensure patient sitting up for all meals and all fluids to prevent any aspiration; 12/20/19 order written: Speech to screen for dysphagia (recurrent pneumonia). 12/21/19 nursing note: Sleeping most of the day, on IV fluids at 70 cubic centimeters (cc) per hour. [MEDICATION NAME] tablets were not given on 12/22/19 due to the resident sleeping, per the medication record. 12/23/19 nursing note: Temperature 99.7, did not wake up sufficiently to take medications. 12/23/19 progress note written by the PCP: Chief complaint-lethargy, reduced oral intake, very weak appearing, white coating on tongue, second course of [MEDICATION NAME], wet cough, question dysphagia, ST evaluation, Acute kidney injury (sudden kidney failure): Likely due to decreased oral intake and dehydration. IV fluids. The BUN level (blood urea nitrogen-an amount of waste product built up in the blood) was 65 (normal range 8-25), indicating kidney malfunction. The PCP wrote on 12/23/19: The patient was seen in the facility because leaving the facility requires considerable and taxing effort due to the patient's limited mobility putting the patient at increased risk of fall and injury. 12/24/19 progress note: Chief complaint-abnormal labs including elevated BUN, mild fever, leukocytosis (elevated white blood count, a sign of infection), diminished lung sounds, wet cough, malaise, request vital signs every 6-hours around-the-clock for 5 days; Patient is to be sitting up for all meals and eating and drinking. Speech therapy to follow-up and eval/screening ASAP to rule out possible aspiration. 12/24/19 nursing note: Sleeping throughout shift, IV 100 cc per hour, [MEDICATION NAME] (antibiotic)injection, continue [MEDICATION NAME] tablets, ate 25% of breakfast, ate 0% for lunch and dinner. 12/25/19 nursing note: Lethargic, hard to arouse, temp 99.4, BP 86/48, blood oxygen level 84% on room air, oxygen applied, refused meds and meals, paged physican, order to send resident to hospital. On 2/06/20 at 10:37 AM Therapy Manager C said about the three ST orders, No one communicated that he needed to be getting speech therapy. It wasn't communicated that he needed to have speech. Staff C said that now all referrals were placed in binders at the nursing units, which were checked daily for orders. The binders were put in place in (MONTH) to help correct the problem because orders were missed on (the resident). Staff C said staff inservice training on use of the binders was done on 12/17/19 and on 12/20/19 but, the third and final order written on 12/20/20 for a ST evaluation still didn't go into the binder. She said that before the binders were initiated, if a referrral order was written, she would be told about it by whoever wrote the order but no one told her about any of the three orders written. The resident was receiving physical and occupational therapy until 12/14/19. When asked why it stopped, staff C said the resident was doing great, walking and everything when he started rehab then became so lethargic he couldn't do anything anymore. There was no sense in keeping him on therapy if he couldn't do anything. Hospital records were requested. At 2 PM, they were reviewed and revealed: 12/25/19 per emergency room Physician: Chief complaint cough congestion and mental status changed over the past 2-3 days According to EMS, staff at his nursing home noticed that he was becoming less responsive and far below baseline of mentation his blood pressure decreased overnight (a sign/symptom [MEDICAL CONDITION]). Today he has significantly altered mental status with blood pressure 90s/50s rhonchi present white blood count 20 (normal range 4.5-11); Upon arrival to the emergency room , the resident had rhonchi and coarse breath sounds to bilateral lungs; [NAME] blood count of 20 indicative of acute kidney injury and dehydration; Chest x-ray showed right basilar infiltrate versus atelectasis which may represent aspiration pneumonia; The resident was placed on two IV antibiotics, [MEDICATION NAME] and [MEDICATION NAME] after initial suspicion [MEDICAL CONDITION] and IV fluids as he showed diagnostic signs of dehydration admission [MEDICAL CONDITION] secondary to aspiration pneumonia. 12/26/19 per Pulmonologist (lung specialist): difficult to arouse at the present time according to emergency room notes in fact not arousable from a sleep like state with vigorous stimulation for me as well radiographic study of the chest may represent an aspiration event hypoxic [MEDICAL CONDITION] aspiration pneumonia 12/26/19 per Neurologist: (Resident) presents with decreased responsiveness, leukocytosis and an abnormal chest x-ray concerning for aspiration pneumonia. He has remained poorly responsive during hospitalization On 2/06/20 at 1:00 PM, the NP was asked by phone about the three orders for speech therapy and said, There was a lapse in communication. I was new there and I assumed that when orders were written, they would be processed but they weren't. So we discussed it and came up with a log to make sure that the orders were being followed up. The NP said, Usually when you have someone elderly with chronic pneumonia, you would investigate if dysphagia was the problem. So that's why he was referred to speech (therapy) because it could have been a silent aspiration (food/fluid entering the lungs without outward signs such as coughing) and you wouldn't know and then speech would make the determination if a swallow study (visualization of the esophagus for diagnostic purposes) should be done. At 3:41 PM, when asked why the resident did not receive ST evaluations after the orders were written for them on 11/7, 11/20 and 12/20/19, the Director of Nursing (DON) said, The orders were written then confirmed. Nurses didn't know what to do with the orders. They didn't take the time to notify therapy. Policies on therapy referrals and therapy evaluations were requested from the DON and staff C but a therapy Documentation policy was provided dated 12/17/19 and noted: Initial evaluation will be performed per the physician's orders [REDACTED]. A Therapy Contracts and Services policy dated 7/11/18 dealt with ensuring that therapy services were appropriate and necessary for purposes of billing and payment. DPS#2 Based on interview and record review the facility failed to consult and inform a Physician after Resident (R#346) refused a anticoagulant(blood thinner) medication in a timely manner, effecting one resident (R#346) reviewed during medication administration, resulting in the potential for decreased therapeutic results and possible formation of blood clots. Findings Include: On 2/5/20, record review revealed R#346 had recently been readmitted into the facility on [DATE] after undergoing a craniotomy (surgical procedure involving the skull). According to the Minimum Data Set ((MDS) dated [DATE], R#346 had intact cognition and was extensive assist with Activities of Daily Living (ADLS) and transfers. On 2/5/20 at 6:06 am, during observation of a medication administration, R#346 refused anticoagulant medication offered by Nurse [NAME] Record review revealed on 1/30/20, R#346's physician had prescribed an anticoagulant (blood thinner to prevent blood clots) injection to be given every 12 hours. Review of Medication Administration Record [REDACTED]. Review of nursing progress notes revealed the Physician or Nurse Practioner had not been informed that R#346 had not received the anticoagulant medication until 2/4/20. Nurse J was questioned regarding the policy and best practice when a Resident refuses a medication or has missed a dose, Nurse J replied, The Doctor should be called and made aware. On 2/5/2020 at 8:10 am, during an interview with Director of Nursing (DON), when asked if it was best practice and the policy of the facility to consult and inform a Physician when a resident had not received a medication that had been prescribed related to refusal or a missed dose due to a leave of absence, DON stated, Yes. DON then offered to check other sources to see if any other communication had been given to the Physician related to R#346. During follow up with DON, when asked if there was any proof the Physician was made aware of R#346 refused or missed dose of anticoagulant, DON stated, No. During survey a policy had been requested and had not been provided by conclusion of survey.

Based on observation, interview and record review the facility failed to provide [MEDICAL CONDITION] (surgical incision made in abdomen to remove liquid fecal waste) care in a timely manner, affecting one resident (R#91) interviewed for [MEDICAL CONDITION] care, resulting in R#91 expressing feelings of anger and potential rejection for not having had care done by care staff in a timely manner. Findings include: On 2/4/2020 at 9:30 a.m., during interview resident was interviewed regarding [MEDICAL CONDITION] care. When asked if he received care for the [MEDICAL CONDITION], R#91 stated, Well, a few nights ago I had to lay in my bed from 8pm until 5 am with this leaking down my side, I could feel it burning and I could smell it all night long. R#91, was then asked how that made him/her feel, R#91 stated, It made me angry and no one would take care of me, the nurse just laid a towel on it and left. Resident proceeded to pull back covers and revealed a red dry excoriation on the side of abdomen. R#91 said, It had been red before, but that night made it worse. When asked if he/she could tell surveyor which nurse had refused care, R#91 stated, It was Nurse [NAME] R#91 stated, I told the nurse to use ostomy paste, but the nurse did not care, I have had this for over a year. On 2/6/2020 at 8:30 a.m., during interview with Nurse J, when asked if R#91 was left without a [MEDICAL CONDITION] (surgical opening to released formed stool) / [MEDICAL CONDITION] bag from 8pm to 5 am on your shift over the weekend, Nurse J stated, No it was from only 1am to 5am. When asked if there was a reason that R#91 did not receive care in a timely manner. Nurse J replied, I covered it with a towel it was leaking, and I couldn't get it to stick and the resident had drunk milk and it made it leak thin stool. Then, Nurse J stated, It was a waste of supplies. and then he retracted his statement. Nurse J was then asked if the facility had enough supplies to accommodate resident's needs, Nurse J stated, Yes. Nurse J was then asked if he/she had ever taken care of a [MEDICAL CONDITION]/ [MEDICAL CONDITION] patient before, he/she replied, No. When asked if he/she had requested help from other nurses in the building, Nurse J stated, No. When asked if he/she had asked the resident how they normally take care of their [MEDICAL CONDITION], Nurse J stated, No. Nurse J was then asked do you think a reasonable person would want to remain laying in stool for hours, Nurse J did not reply. Nurse J was then asked if he/she was aware that depending on the placement of a [MEDICAL CONDITION]/[MEDICAL CONDITION] that stool will not be formed and will always remain liquid, Nurse J stated, No. On 2/6/2020 at 11:00 a.m., during interview with Director of Nursing (DON), when asked if any residents should remain hours with out a device to keep their ostomy from leaking onto their skin, DON stated, No, not at all. When asked if a reasonable person would like to lay in stool leaking down their abdomen for hours, DON stated, No. On 2/6/2020, review of policy [MEDICAL CONDITION] and [MEDICAL CONDITION] Care and Appliance Change Adopted 7/11/2018, It is the policy of this facility that appliances will be applied to provide and effective seal for the stoma, to collect fecal discharge, to protect the surrounding skin and to provide for comfort of resident.

This citation pertains to intake #MI 607. Based on observation, interview and record review, the facility failed to provide timely care planning, diagnostic testing as recommended and implementation of appropriate pressure relief interventions for two (#s 700, 701) of three sampled residents reviewed for skin integrity, resulting in the development and worsening of pressure sores. Findings include: The complainant reported to the State agency that resident #700 developed a pressure sore, was not routinely turned and repositioned and that the pressure sore was not properly treated. Resident #700- On 1/2/20 at 3:50 PM, the clinical record for the resident was reviewed with the Director of Nursing (DON) and noted: an original admission into the facility on [DATE] with [DIAGNOSES REDACTED]. A minimum data set (MDS) completed 8/21/19 noted severe cognitive impairment, inability to communicate, impaired range of motion to all extremities, incontinence of bowel/bladder, total assistance required for all care, including bed mobility/repositioning and no pressure sores. A Braden (pressure sore risk) assessment dated [DATE] noted the resident was at high risk for development. Assessments dated 8/16, 8/25, 9/1 and 10/28/19 noted very high risk. The resident's Skin Integrity care plan initiated 8/9/19 noted: The resident has potential for impairment to skin integrity related to immobility, incontinence, diabetes Assist to reposition on routine schedule as resident allows The resident needs pressure reduction interventions: mattress to bed Per a skin assessment dated [DATE], there were no skin issues. The facility's contracted wound specialist noted the following: 10/9/19-The resident was in a persistent vegetative state and had an unstageable (full thickness skin loss where depth of wound is undetermined because base is covered by dead tissue) pressure sore present on the coccyx measuring 3 centimeters (cm) by 1.5 cm and a stage 2 (partial skin thickness loss) pressure area to the left buttock measuring 1.6 cm by 1.4 cm by 0.1 cm deep. Preventive care recommended: specialty low air loss pressure reduction mattress and rotate (turn and reposition) every 2 hours. 10/16/19-left buttock pressure area resolved (healed); The sore to the coccyx measured 2.5 cm by 1 cm by 0.3 cm deep at stage 3 (full thickness skin loss). 10/22/19-coccyx sore measured 2.4 cm by 1 cm by 0.3 cm. The resident was then hospitalized from [DATE] thru 10/30/19. 10/30/19-returned from the hospital with the coccyx sore measuring 3.2 cm by 2 cm by 0.4 cm at stage 3, increased in size and worsened at the hospital, odor present, appears infected and was covered 100% by eschar (leathery, dead tissue); Recommendations: rotate every 2 hours, Bactrim (antibiotic) through the feeding tube twice a day for 10 days, an antibacterial solution applied directly to the wound and an x-ray of the sacral/coccyx area to rule out an underlying condition contributing to the pressure sore. 11/12/19-coccyx sore measured 4 cm by 1.5 cm by 2 cm at stage 3. 11/19/19-3.7 cm by 1.5 cm by 2.0 cm deep at stage 3 with odor; Recommendations: repeat Bactrim for 10 days, increase wound care from once a day to twice a day and MRI to the coccyx/sacral area to rule out osteo[DIAGNOSES REDACTED] (infection down into bone underneath the pressure sore). 11/26/19-4.2 cm by 3 cm by 2 cm, odor present, undermining (the wound was larger underneath the skin surface than appeared above); Recommendations: needs MRI, start [MEDICATION NAME] (antibiotic) 3 times a day for 14 days. The resident was transported to the hospital on [DATE] for low blood pressure (was 80/40) per nursing notes. The hospital Discharge Summary noted an admission on 12/2/19 with [DIAGNOSES REDACTED]. The resident returned to the facility on [DATE], but transferred back to the hospital within a few hours due to an injury. A hospital History and Physical dated 12/14/19 noted: recently discharged yesterday after an episode of osteo[DIAGNOSES REDACTED] in addition to having [MEDICAL CONDITION] (a potentially life-threatening response to infection with symptoms, including low blood pressure) Sacral ulcer: Recently completed [MEDICATION NAME] [DIAGNOSES REDACTED]: .IV [MEDICATION NAME] (antibiotic) Infectious Disease (physician) recommends 6 weeks antibiotics There was no documented X-ray or MRI result for the sacral/coccyx area, as recommended by the wound specialist on 10/30, 11/19 and 11/26/19 to rule out osteo[DIAGNOSES REDACTED]. When asked why, the DON said, We questioned the necessity of the MRI, so it wasn't done. She did not explain why and did not respond when asked if the pressure sore, originally developed at the facility, was unavoidable in the first place. Resident #701- On 1/2/20 at 11:20 AM, the resident was observed sitting in a wheelchair with a dressing to the right foot, in the presence of nurse Unit Manager [NAME] The resident was alert, oriented and able to respond reliably to questions. The resident winced in pain when the dressing was removed. A large, red pressure sore covered the entire heel with edges of necrotic (black, dead) skin. When asked if her heels were kept elevated, she pointed to a pillow at the foot of the bed. There were no pressure relief foam boots or heel pads observed in the room. The resident complained that the pressure sore was very painful. The resident's clinical record was reviewed and revealed: an admission into the facility on [DATE] following hospital surgery for [REDACTED]. Other [DIAGNOSES REDACTED]. The MDS completed 10/12/19 noted severe cognitive impairment at that time, extensive 2-person assistance required for bed mobility and transfers, impaired range of motion to extremities on one side and no pressure sores. Braden assessments dated 10/8 and 10/15/19 noted the resident was at moderate risk for development of pressure sores. The assessment dated [DATE] noted high risk. A Skin Integrity care plan initiated 10/1/19 noted: The resident has potential impairment to skin integrity related to [MEDICAL CONDITION], diabetes, recent surgery to wrist and ankle, incontinence and the need for assist with care (MONTH) use a pillow or other device for repositioning as the resident will allow Pressure reduction mattress bed. There were no documented pressure relief interventions specifically for the heel of the right foot, that was compromised by surgery and limited mobility. There was no mention of pillows or devices to elevate or pad the right heel, or a specialty air mattress put in place instead of the standard pressure reduction mattress provided to all the residents, whether they had pressure sores or not. At 3:20 PM, the resident's clinical record was reviewed with the DON. Per a nursing note dated 10/30/19: unstageable (UTD) pressure sore to the right heel measuring 3 cm by 7 cm. The wound specialist saw the resident on 11/5/19 and the nurse noted: apply [MEDICATION NAME] (a solution used to treat infected wounds) daily and cover the heel with a foam dressing, elevate heels and apply foam pressure relief boots. On 11/5/19, a care plan was initiated and noted: The resident has unstageable pressure ulcer on right heel related to immobility Resident's pressure ulcer will show signs of healing and remain free from infection Apply foam boots and elevate feet in bed with pillow The resident was seen by the wound specialist on the following dates and the nurse noted: 11/26/2019-right heel UTD measuring 1.6 cm by 2 cm. 12/03/2019-UTD measuring 3.2 cm by 4.5 cm. 12/10/2019- UTD measuring 3.2 cm by 5.8 cm. The treatment was changed from [MEDICATION NAME] to Calcium Alginate (used to absorb wound drainage) daily. 12/17/2019-UTD measuring 3.2 cm by 5.8 cm. The treatment was changed to a gel used to debride the wound of dead tissue. When asked why there were no interventions care planned and implemented to relieve pressure to the resident's heel until 11/5/19, after development of the pressure sore, despite a known history of surgery to the foot and decreased mobility, and when asked if the development of the pressure sore was unavoidable, the DON did not respond. On 1/3/20 at 8 AM, per review of the facility's Skin Monitoring and Management-Pressure Ulcer policy dated 7/11/2018: It is the policy of this facility that: A resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individuals clinical condition or other factors demonstrate that a developed pressure ulcer was unavoidable; and A resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new, unavoidable sores from developing All risk factors identified on assessment should be documented in the resident's clinical record and, when appropriate, be addressed through a care plan designed to minimize the possibility of skin breakdown. Those risk factors which contribute to the possibility of unavoidable skin breakdown or unavoidable pressure ulcers should be documented in the resident's clinical record in order to prevent the development of skin breakdown or prevent existing pressure ulcers from worsening, nursing staff shall implement the following approaches as appropriate and consistent with the resident's care plan: Stabilize, reduce or remove any existing underlying risks Use pressure relieving/reducing and redistributing devices (including but not limited to low aid loss mattresses, wedges, pillows, etc.)

This citation pertains to intake #MI 607. Based on observation, interview and record review, the facility failed to implement fall safety devices and ensure proper supervision for three (#s 700, 702, 704) of three sampled residents reviewed for accident hazards, resulting in falls, a hematoma, emergency hospital treatment and the potential for further falls. Findings include: The complainant reported to the State agency that the facility failed to provide proper supervision and fall safety measures for resident #700 resulting in a fall and hospitalization . Resident #700- On 1/2/20 at 3:50 PM, the clinical record and an incident report for the resident were reviewed with the Director of Nursing (DON) and noted: an original admission into the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum data sets (MDS) completed 8/21/19 and 11/12/19 noted severe cognitive impairment, inability to communicate, impaired range of motion to all extremities, total assistance required for all care including bed mobility and no falls. According to notes dated 10/23/19, the resident was in a persistent vegetative state. A Fall Risk assessment dated [DATE] noted the resident was at high risk for falls. The resident's Risk for Falls care plan initiated 8/9/19 noted: The resident is at risk for falls related to history of falls, [MEDICAL CONDITION] with balance deficits observe for safe positioning when in bed and chair. Per notes and the Incident report dated 12/13/19: The resident had just returned to the facility that day at 7:15 PM following a hospital stay since 12/2/19 (for conditions including pneumonia, low blood pressure and infected pressure sore) and placed in bed by EMS staff. The nurse noted: I came in and looked to make sure everything was in place, he was propped up on his left side by pillows and was on a air mattress. I signed for the resident I left his room at 7:40 ish the (nurse aide) came in and told us that the resident was on the floor .he was observed face down on the floor next to the bed he had a knot on his head on the right side. The Incident report noted: The resident was placed close to the edge of the mattress by EMS personnel. After the fall, the nurse saw a hematoma above right eye and eye was not reacting as fast as the left (eye), which was a sign of possible acute neurological trauma from the fall. The physician was notified and ordered the resident transported back to the hospital for a CAT scan of the head. When queried about the fall, the DON said, He was on an air mattress and was too close to the edge and the edges gave out. The DON said that EMS staff put the resident in that position. When asked why the nurse, who had looked at the resident and had signed for his return, did not ensure the resident was positioned properly in the center of the bed, the DON said, It was the change of shift. She was helping the (on-coming shift) nurse out and I guess, didn't process that he was too close to the edge of the bed. Resident #702- On 1/2/20 at 11 AM, the resident's clinical record was reviewed and noted: an admission on 1/29/19 with [DIAGNOSES REDACTED]. Fall Risk Assessments dated 8/11, 8/12, 9/29, 10/23, 12/19 and 12/23/19/19 noted the resident was at high risk for falls. A Risk for Falls care plan initiated 1/29/19 noted: The resident is at risk for falls related to Gait/balance problems. Secondary to [MEDICAL CONDITION] weakness Cervical vertebra Fractures, balance deficits, amputation of right toes. Patient is impulsive and self transfers, and self ambulates Ambulate resident with walker and gait belt to dining room for meals apply anti-roll back device to wheelchair (w/c) to prevent w/c from moving backward during transfers Follow facility fall protocol Provide a wedged cushion (for support and better sitting balance) for resident's wheelchair scoop mattress (a mattress with raised edges to prevent falls out of bed) At 11:45 AM, the resident was observed alert, confused and sitting in a wheelchair in the hallway, in the presence of nurse Unit Manager [NAME] There were no anti-rollback devices on the back of the wheelchair. Nurse A looked and said, They should be here. The resident's room was observed. There was no scoop mattress the bed. Nurse A reported back several minutes later and said, It's still in his old room before he was transferred here. The clinical record noted the resident was transferred to the current room on 12/21/19. There was no wedge cushion observed in the wheelchair. At 3:35 PM, notes and incident reports for the resident were reviewed with the DON and revealed the following: 9/29/19-observed on the floor in his room; no noted injury. 10/23/19-fall while being assisted by a nurse aide, who said that the resident lost his balance after having an incontinence brief applied and standing for a few seconds. The resident sustained [REDACTED]. After the fall on 10/24/19, the intervention: Use gait belt with transfers and toileting, was added to the Risk for Falls care plan. 12/19/19-observed on the floor in his room; no noted injury. There were no corrective post-fall interventions to prevent reoccurrence. The DON said there should have been interventions noted. 12/23/19-was observed falling to the floor in his room and eased resident to the floor; No noted injury. When asked why there were no anti-rollback devices, scoop mattress and wedge cushion in place, the DON said that staff probably removed the anti-rollback devices and did not respond further. Resident #704- On 1/2/20 at 10 AM, the resident's clinical record was reviewed and noted: an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS completed 9/27/19 noted severe cognitive impairment, limited assistance required for transfers, supervision for ambulation and one fall with minor injury. A Fall Risk assessment dated [DATE] noted moderate risk for falls. Fall safety interventions included skid strips (to provide a rough surface to help prevent slips and falls) on the floor. On 10/11/19 at 2:40 AM, the resident was observed face down bleeding profusely from a right leg laceration, a 1-2-inch laceration near the left eyebrow and guarding of the right upper arm. The resident was transported to the hospital and returned on 10/15/19 with a left eye hematoma, four sutures to the right lower leg and a sling on the right arm due to a fractured humerus. Fall Risk Assessments dated 10/11 and 10/15/19 noted high risk for falls. Two days after readmission on 10/17/19: Resident had a fall while she was being assisted by (nurse aide) to transfer from wheelchair to toilet. There were no new injuries noted. There were no documented actions taken to prevent reoccurrence and no documented fall safety care plan revisions until 10/21/19. On that date, an intervention was added: Use a gait belt for transfers and toileting for safety. A MDS completed 10/28/19 noted extensive 2-person assistance required for mobility and transfers. At 11:40 AM, the resident was observed asleep in bed in the presence of nurse [NAME] There were no skid strips on the floor. When asked why, nurse A said that when the resident was transferred to the current room, the strips were left in her previous room. The resident was transferred to the current room on 12/11/19. The strips were observed on the floor in the previous room. At 3 PM, the Incident report for the 10/17/19 fall was reviewed with the DON. The report noted: A nurse aide was toileting the resident in the bathroom and at that time legs gave out and patient fell did not have gait belt on Resident fell when trying to transfer to toilet. She stood up and dropped. When asked why there were no skid strips in the resident's room, the DON said, It was an oversight. When asked if a gait belt should have been used after the resident returned from the hospital with the fracture and multiple injuries, the DON said, She was wearing a sling and was weaker on return. If it was me, I would have. If you don't know, you should use a gait belt. The DON said the nurse aide involved was educated, but did not respond when asked why this measure was not documented and why the gait belt was not added to the care plan until 10/21/19. On 1/3/20 at 8 AM, per review of the facility's Fall Prevention policy dated 7/11/2018: It is the policy of this facility that the Fall Prevention Program is designed to ensure a safe environment for all residents The Interdisciplinary Team will be responsible for reviewing the Fall Risk Assessments, if assessed to be a high risk and/or is appropriate they will initiate fall prevention interventions The DON/designee will be responsible for ensuring that residents who have been identified at risk or who have experienced a recent fall have all recommended interventions in place

This citation pertains to intake #MI 3 Based on observation, interview and record review, the facility failed to ensure adequate assistance during a transfer for one (R#806) of three sampled Residents reviewed for supervision and safety resulting in severe pain and a preventable major injury during a mechanical lift (a device most commonly used to move those who are unable to stand on their own making it unsafe to move or lift manually) requiring a two person transfer that was performed by one person instead of two persons, subsequently sustaining a minimally displaced obliquely oriented [MEDICAL CONDITION] distal femoral metadiaphysis (fracture to the right thigh bone) which required hospitalization and a right lower extremity (right leg) knee immobilizer (a brace that prevents the knee joint from moving) Findings include: On 3/15/19 at 9:30 a.m., review of the facility investigation and other pertinent documentation regarding a facility reported incident (FRI) that occurred on 3/3/19 approximately 2:30 p.m., documented, During a Hoyer Lift (mechanical lift), the Resident complained of pain to the right knee. The nurse assessed the right knee and noted redness and swelling. The physician was notified, and an X-ray was ordered. The Resident was transferred to the hospital and diagnosed with [REDACTED]. The Resident returned to the facility on [DATE] with treatment recommendations in place. The facility's investigation concluded the Resident did sustain a fracture. The CENA E (Certified Nurse Assistant), that performed the one-person transfer was terminated on 3/14/19. On 3/15/19 at 2:54 p.m., the Resident was observed resting in bed with visitors present at the bed side. R806 was alert, oriented to person, place, and situation, very engaging, and pleasant. The Resident also had a long brace applied to the right leg which was also propped on a pillow. The Resident was asked to recall the incident that lead to the fracturing of the leg. The Resident stated, The girl got me in the lift to put me in the chair. She thought she had sat me down flat, but both legs got stuck under me. She then took my right leg and tried to straighten it, but my legs don't bend. Suddenly, I heard and felt a pop then horrible pain. I started to scream, 'STOP! STOP! YOU BROKE MY LEG!', but she didn't stop. That's when the other girl came in to help the one girl get me back in bed. I didn't want anyone to touch my leg because it was hurting so bad that I kept it hanging off the side of the bed. R806 confirmed the aid was someone that has taken care of her regularly. The Resident was asked if the aid ever transferred her alone before this incident occurred. The Resident stated, No, never. I don't know why she didn't wait for the other girl to come help her. The Resident was then asked if other staff ever tried to transfer without assistance. The Resident stated, No. They always use two people. On 3/15/19 at 10:37 a.m., the witness statement from CENA E was reviewed. CENA E stated, I was assigned to the Resident, she wanted to go to bingo. I changed and dressed her for bingo. I then put the sling under her and connected her to the Hoyer. I lifted her up, when I was ready to lower her to the chair, I touched her leg to reposition her, that is when she yelled, I broke her leg. She would not allow me to continue. CENA A ran into the room and helped with the transfer. CENA E was terminated on 3/14/19 and unavailable for interviewing. On 3/15/19 at 2:46 p.m., CENA A was interviewed. CENA A confirmed being a witness to the incident and has taken care of the Resident regularly before this incident. CENA A was asked to recall the incident that took place on 3/3/19. CENA A stated, At the beginning of the shift (day), I gave (CENA E) report that the Resident wanted to go to bingo at 3:00 p.m. I told (CENA E) that I would help her put the Resident in her chair when she was ready. I reminded (CENA E) the Resident wanted to get up for bingo, that was around lunch time. I reminded her again after lunch too. I was taking care of something else when I heard the Resident yell. I ran to the room and saw the Resident being transferred to the wheelchair. The Resident was yelling, You broke my leg. I helped (CENA E) with the transfer. The Resident did not want us to touch her leg. I then told the nurse. CENA A was then asked had she ever attempted to transfer the resident alone before. CENA A stated, The Resident is a Hoyer Lift with transfers and that always take two people. Sometimes it takes two to three of us to even reposition the Resident in bed. On 3/15/19 at 3:36 p.m., the Director of Nursing (DON) was interviewed. The DON confirmed CENA E had worked at the facility for quit a while (date of hire 10/5/17). The DON also confirmed CENA E had received Mechanical Lift in-servicing upon hire and with Annual Competency Skills Check Off on 1/31/18. The DON stated during the investigation, the CENA stated when asked why you attempted to transfer the Resident by yourself. CENA E stated, I probably should have asked. I didn't even think to ask another CENA. The DON was asked how staff know residents transfer status. The DON stated, They are to look at the Kardex (electronic charting system) or nursing will give an update. Residents that require two-person assist should never be assisted with one person. On 3/15/19 at 11:53 a.m., review of the clinical record revealed R806 was initially admitted into the facility on [DATE] following a hospitalization with [DIAGNOSES REDACTED]. Upon readmission into the facility on [DATE], the Resident's [DIAGNOSES REDACTED]. According to the initial and quarterly Minimum Data Set (MDS) assessments dated 8/25/18 and 2/17/19, R806 was cognitively intact, required extensive assistance of two persons for transfers, and had range of motion impairment to bilateral lower extremities (both sides) with activities of daily living (ADLs). According to the Resident's ADL care plan initiated 8/23/18, identified The resident has limited physical mobility related to weakness, secondary to diabetes mellitus, end stage [MEDICAL CONDITION], bilateral left extremity fracture. Interventions included, Transfers: 2 extensive assistance mechanical Hoyer lift. On 3/15/19 at 4:04 p.m., review of the facility's policy titled Mechanical Lifts dated 7/11/18 documented: There will always be 2 staff to assist resident. 1 staff will control the lift as the other will guide resident and support back and neck to transfer surface.

This citation pertains to Intake #MI 726. Based on interview and record review the facility failed to provide adequate staff support and supervision to prevent a fall for one sampled resident (#502) out of two residents reviewed for falls from a total sample of four, resulting in an acute fracture involving the right proximal tibia (leg bone) with modest displacement. Findings include: On [DATE] at 9:20 a.m., review of a facility provided document titled, Investigation Report dated [DATE] documented, Summary of Alleged Incident: Certified Nurse Assistant (CNA-A) failed to follow plan of care by not using two people during a left transfer. Patient (R#502) was left on the side of the bed unattended and fell resulting in a tibia/fibula fracture. On [DATE] at 9:30 a.m., record review revealed that R#502 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set Assessment ((MDS) dated [DATE] indicated the residents cognition was intact and required extensive, two person physical assistance with transfers. A radiology report dated [DATE] documented, Acute fracture involving right proximal tibia with modest displacement. Review of the Kardex form (a form that guides the CNA on a residents individual care tasks) undated documented, Activities of Daily Living (ADL's)-Usually 2 person total assist and use of (brand name of sit to stand lift-mechanical lift used to stand and lift a patient from a sit to stand position). The At risk for falls due to history of falls, weakness surgical wound, history of seizure disorder, morbid obesity, and potential medication side effects care plan dated [DATE] had an intervention on Provide 2 person assist to transfer . Review of an Incident Report dated [DATE] documented, Heard resident (#502) yellling from hallway. Resident observed on floor, lying on right side with head near wheel on wheelchair. Resident claims she was sitting on edge of bed waiting to be transferred and fell . Active Range of Motion (AROM) x 4 (extremities) .Description of cause of incident: CNA left resident unattended on bed while waiting to be transferred . Review of an investigation by Unit Manager Nurse B documented, Per resident (#502) she stated that aide (CNA A) came in with sit to stand (mechanical lift) to get her out of bed. She was by herself. She positioned me in the sit to stand, but when she was attempting to raise me it (the lift) was jerky. She thought the battery died , so she went to go get another. She (CNA A) left me sitting on the edge of the bed. The (lift) machine began to roll away (because the brakes were not on) and me with it. It fell over with me in it landing on my right side. On [DATE] at 12:49 p.m., during a phone interview with CNA A she was asked about the incident with R#502. CNA A said that she was getting the resident up on [DATE] around 11:00 a.m. with the sit to stand lift. The CNA said the the battery on the lift was dying, so she exited the room to go four doors down (approximately 20 feet) to obtain a second lift. CNA A said that she had left the resident unattended sitting on the edge of the bed, and when she returned (to R#502's room) the resident was on the floor being attended to by the Nurse. CNA A was asked why she did not have a second staff member in the room for the lift transfer process (per her Kardex guide) to which she responded, I have lifted her with the sit to stand lift by myself many times before and never had a problem. The CNA said she could not recall if she locked the brakes on the sit to stand lift prior to exiting the resident's room. CNA A was asked why she would leave a resident (who was an extensive two person assistance) unattended sitting on the edge of the bed to which she responded, I asked (R#502) if she would be OK if I went and got another lift and she (R#502) said 'yes' .I apologized to her when I saw her on the floor. I didn't think she would fall. On [DATE] at 2:00 p.m., during an interview with the facility's Administrator he indicated that he investigated R#504's fall. The Administrator said that initially after the fall the resident had no complaints of pain. The Administrator indicated that in the days following the fall, the resident complained of increased pain and bruising, that is when additional x-rays were taken and the fractured tibia was discovered. On [DATE] at 2:30 p.m., review of the facility's Transfer: Bed-Chair/Wheelchair dated ,[DATE] documented, Position chair or wheelchair adjacent to and near head of bed. Verify bed locks are secure. Lock wheel of wheelchair and remove or swing footrests out . Along with the facility's Director of Nursing (DON) the Employee Warning Notice (for CNA A) dated [DATE] was reviewed and it documented, Violation of Work Rule Commitment: On [DATE] you attempted to transfer a patient leaving her alone and a fall occurred which could have resulted in serious injury. It is important to follow the Kardex pan of care in order to care for out residents. This is where you will find information to care for the resident's the best way. The DON said that the write up was issued before the fracture results were obtained and refected concerns discussed with CNA A.

Based on observation, interview, and record review, the facility failed to assess timely, care plan and implement adequate, appropriate interventions for one (#505) of five sampled residents reviewed for pressure sores from a total of 19, resulting in the development of an avoidable pressure sore. Findings include: On 3/29/16 at 4:15 PM, resident #505's skin was observed with nurse 'C' and nurse unit manager 'D'. A black pressure relief boot and a gauze wrap were removed to reveal the resident's right heel covered with a necrotic (black, dead tissue), open pressure sore. The resident had a heel protector sock (thick padding built into the heel of the sock) on the left foot. The resident winced in pain when the sore was touched. The previous dressing had a large amount of beige-colored drainage, bright blood and dark staining from the wound treatment ([MEDICATION NAME]). Nurse 'D' said that the resident was being followed by a wound specialist who came to the facility on ce a week and saw the resident once on 3/24/16. When asked what would have made the pressure sore unavoidable, nurse 'D' said, She always had a problem with PAD (peripheral artery disease). When asked if extra attention and interventions were provided for the heels in lieu of this known condition (PAD) to prevent the sore, the nurse did not respond. At 4:30 PM, the clinical record for resident #505 was reviewed with the Director of Nursing (DON) and nurse 'D'. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Minimum data sets dated 12/14/15 and 3/17/16 noted that the resident had severe cognitive impairment, required extensive assistance for repositioning, had impaired range of motion to all extremities, and had no pressure sores. A Braden (pressure sore risk) Scale dated 12/8/15 noted that resident #505 was at moderate risk for development and that friction and shear was a potential problem. Nurse 'D' was queried as to when the pressure sore was first discovered. She said, I started down here (on the nursing unit) in February (2016) and I decided to do a skin sweep (look at every resident's skin) for the first and only time on 3/17/16. She said, When I saw her (resident #505's) foot, she already had a wrap (dressing) on it that drew my attention and I saw it (pressure sore). She and the DON said that they could not determine who had put a dressing on it and not report its' presence and they did not know when it was applied. Per review of the resident's 3/2016 wound treatment record, there was no documentation that a dressing had been applied by anyone before the skin sweep. Per a Pressure Ulcer Healing Chart and a Skin Worksheet dated 3/17/16 for resident #505's right heel written by nurse 'D': Unstageable pressure sore measuring 5.5 centimeters (cm) by 4.0 cm with an odor. Nurse 'D' said that the sore was already infected when she first saw it. When asked if this was an indication that the wound was possibly present for some time before 3/17/16, the DON and nurse 'D' did not respond. Per a progress note by nurse 'D' dated 3/17/16: Patient has a unstageable pressure ulcer to the right heel measuring 5.5 cm by 4.5 cm with black tissue, malodorous, moderate serosanguinous drainage, area to be treated with (an antibacterial wound solution) Resident started on Bactrim DS (antibiotic) twice a day for 14 days. Patient shows signs of pain when area touched. Resident #505's At Risk for Alteration in Skin Integrity care plans, with interventions initiated and dated 11/5/2013, noted one intervention specific to the heels prior to 3/17/16: Float heels while in bed. The care plan noted that the resident slides down in bed. An Infection of Wound to Right Heel Pressure Sore care plan initiated and dated 3/18/16 noted the pressure sore was associated with: rubbing of feet together and against sheets/mattress. A Pressure Associated Skin Alteration to Right Heel care plan and further Skin Integrity care plans initiated, dated and revised on 3/18/16 for resident #505, continued to note one intervention specific for the heels: Float heels while in bed. There was no mention of other interventions such as: velcro heel protectors, heel protector socks, pressure relief boots, or foam/padded dressings for the heels. The resident's Braden Scale dated 3/19/16 noted that the resident was at high risk for development of pressure sores and the presence of a problem with friction and shearing. When asked what interventions were implemented for the heels to prevent pressure sores, the DON said, The heels were floated. When asked what would have made the right heel pressure sore unavoidable, the DON did not respond. The DON provided a Wound Care: History and Physical form dated 3/24/16 by the wound specialist. He noted: Right heel 'arterial' ulcer 4.5 cm by 4.0 cm odor The specialist placed a check mark by history of dementia, but not by history of PAD or [MEDICAL CONDITIONS]. Foam (pressure relief) boots were recommended by the specialist. Resident #505's 3/2016 treatment record noted: Heel protector boot to right heel at all times and heel protector sock to left heel at all times. The record indicated that these interventions were implemented for the first time on 3/25/16 and still were not care planned by the end of the survey. (On 3/29/16 at 8:50 AM however, the resident was observed in bed with gauze wraps on both feet, a pillow underneath the calves with her heels touching the mattress, but no boot or heel protector sock in place.) On 3/30/16 at 1:35 PM, the wound specialist and the DON approached to discuss resident #505's pressure sore. The specialist immediately asked in a defensive, angry tone: What makes you think this is a pressure sore? and What else do you think could have been done? When asked if the facility implemented every intervention to try to prevent a sore on the resident's heel, the specialist looked at the DON and did not respond. The DON said, The heels were floated. We told you all the interventions. When it was mentioned that resident #505's sore was already infected when observed on 3/17/16, the specialist said, What makes you think it is infected? This wound is not infected. Just because it has an odor does not mean it's infected. I put her on antibiotics. He did not explain why he prescribed antibiotics for this resident if she did not have an infection. On 3/30/16 per review of the facility's Skin Practice Guide dated 1/2013: Pressure ulcers may be the result of immobility, friction and shearing forces Identification of risk factors and potential pressure points for a particular patient is important in developing a skin prevention care plan Patient positioning and other interventions can assist with reducing the risk of breakdown Skin observations are performed daily by nursing assistants during provision of routine patient care The guide did not mention or include use of special pads, socks or boots, such as those recommended by the wound specialist, as examples of possible pressure, friction and shear reduction devices. ( )

Based on observation, interview and record review, the facility failed to ensure a staff member who was accused of mistreatment and removed from all responsibility to care for the resident, did not intimidate one (#801) of three sampled residents reviewed for abuse from a total of 3 sampled residents resulting in anxiety, fear, emotional distress and the potential for distruption of sleep at night because the staff member entered her room after being told not to do so. Findings include: On 12/10/14 at 9:35 a.m., Resident #801 was observed in bed watching television in her room. During an interview with Resident #801, she stated that "the certified nursing assistant (CNA "H") is mean, nasty, and always very rough with me during care. She slammed my legs and arms all around--and is not being careful with my sensitive skin due to melanoma ([MEDICAL CONDITION]). I am frightened of her--She scares me. She should never have got a job taking care of people. I woke up and there she was--she was here last week talking to some girl. Since I reported the incident, I was informed that she shouldn't come inside my room or come near me--but she has been inside my room talking to people. She (CNA "H") walks into my room, looks around, and walks out making me so frightened that I can not sleep all through the night for fear of her. During her shift whenever I have an accident and wet myself, she will come into my room and will forcefully fling and throw my right leg sideways and in an authoritative voice will state I am not coming back to this room tonight. I have tried to be kind to her. Whenever, I had an accident in my pants she got very upset--she is upset about everything. I am frightened and afraid whenever she comes into my room. I am not well and can't do for myself. She doesn't speak--even ask you how you are doing. She is the only one I have ever had trouble with. Everyone else has been kind, did their job. I do not understand why she has this kind of job. I do not want her in my room. I am not afraid of other aides and staff that takes care of me." Resident #801 was asked if she reported this incident to anyone and stated " I reported all my concerns to the nurse's on my floor (Nurse "B"), staff and my aide (NAME) CNA "A" . Resident #801 indicated the most recent incident she reported occurred on 12/10/14 and she reported it to her CNA (CNA "A") and Nurse B. On 12/10/14 at 1:45 p.m., during an interview with Resident #801's nurse, Nurse (B), who was the supervisor on the unit, he stated, "This is the third time (NAME) Resident #801 has complained to me about this CNA (H)...CNA "H" already knows that she is not suppose to go into the patient's room but she goes in anyways". When asked whether Resident #801's concerns were reported to abuse coordinator, Nurse B stated, "Yes" and indicated the resident's concern was reported on 11/07/14 and most recently "today" 12/10/14. On 12/10/14 at 12:25 p.m., CNA "H", the person identified as the CNA who was intimidating Resident #801, was interviewed. CNA "H" was asked about her how she provided care to residents in general and to Resident #801 specifically. CNA "H" stated, "I have been taking care of her (Resident #801) since I came here. I never understood what happened because everytime she sees me she calls me a "little angel." When asked about the allegation of rough care provided on 11/07/14 (midnight shift), CNA "H" denied being "rough" with the resident. CNA "H" was asked if she was told that she would not be providing care to Resident #801 and to stay out of her room, CNA "H" stated, "After the incident, I was put on west side (of the building) on the same floor...and sometimes my assignment takes me to the east side. Her room (Resident #801) is directly in the middle of the hallway, and I pass it when I come off the elevator, when I go to the bathroom, she is going to see me anyways." On 12/10/14 at 1:55 p.m., an interview was conducted with Resident #801 nursing assistant, CNA "A" who reported that Resident #801 had "complained to her some months back that CNA "H" was rough and rude to her--and that she is scared of her..." CNA "A" added, "This morning (day shift) Resident #801 told me that CNA "H" came into her room last night (12/10/14--midnight shift) and that she was very frightened and scared of her ." When asked whether Resident #801's concern was reported to abuse coordinator, CNA "A" stated, "Yes" and indicated that she reported it to the nurse this morning. In an interview with the DON and Administrator on 12/10/14 at 12:45 p.m., and at 2:05 p.m., the DON was asked if the facility investigated the incident of CNA "H" being rough while "changing" Resident #801. The DON reported Resident #801 was interviewed and the resident reported she was "frightened and afraid of CNA "H" and that she has been going into her room". During this interview, the Administrator revealed that Resident #801 verbalized that she did not want CNA "H" taking care of her and was told by the DON that CNA "H" would be reassigned. A review of the clinical record on 12/10/14 at 1:30 p.m. revealed that Resident #801 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] revealed that Resident #801 required extensive physical assistance from staff with all Activities of Daily Living (ADLS) including bed mobility, transfers, and toileting. Resident #801's Brief Interview for Mental Status (BIMS) score of 10 (A score of 10 indicates long and short term memory loss). The Care Area Assessment worksheet on Care plan considerations indicated that Resident #801 was alert and able to communicate her needs, was incontinent of urine and stool and required prompts toileting/pericare and assistance with ADL's. No mental health issues were identified. Resident #801 was on steroid therapy for inflammation of her skin and experienced pain from the [MEDICAL CONDITION]. Review of the Care Plan initiated 10/18/14, on 12/10/14 at 2:58 p.m., indicated Resident #801 had "sleep cycle issues" as evidenced by verbalizations related to difficulty falling asleep and medications. On 11/19/14, Resident #801 was prescribed [MEDICATION NAME] (a drug used for panic and anxiety disorder) at bedtime for anxiety (12 days after the incident). The facility's Abuse Prevention Policy was requested from the administrator on 12/11/14 at 11:59 a.m.; however, the administrator provided a policy "Incident Prevent Process Flow Chart that documented the following: "when an incident occurs, complete and document patient evaluation/assessment, preliminary investigation and electronic report with notification to family and physician. Investigate problem identification, report, establish facts, validate, evaluate, and expand..." ( )

This citation pertains to intake number M 4407. Based on observation, interview, and record review, the facility failed to ensure an indwelling urinary catheter was properly inserted for one (#101) of three sampled residents reviewed for indwelling catheters of a total sample of four, resulting in the resident being hospitalized in the Medical Intensive Care Unit (MICU) of a local hospital for urinary tract infection, hematuria, and septic shock. Findings include: A complaint on file alleged, "...staff failed to assess/monitor the resident who was delirious, had a fever of 104 and was transported to the hospital where it was determined that he had a bladder infection..." On 1/28/13, it was determined during a tour of the facility that resident #101 no longer resided in the facility. Hospital records for resident #101 were reviewed on 1/28/13 at 10:15 A.M. and revealed the following: The emergency room History and Physical revealed that resident #101 was transferred to the hospital on [DATE] due to hematuria (blood in the urine), and admitted into the hospital with the [DIAGNOSES REDACTED]. Other symptoms that were present on admission included [MEDICAL CONDITION] (insufficient oxygen) and [MEDICAL CONDITION] (low blood pressure), and a temperature of 105.2 degrees Farenheit. Resident #101's blood pressure was 69/50, and heart rate was 142 beats per minutes. Resident #101 had an indwelling urinary (Foley) catheter which was replaced after an emergency urology consultation had revealed possible "traumatic catheterization." Resident #101 was transferred to the Intensive Care Unit (ICU) and started on antibiotic treatment. "Impression: Septic shock, most likely from urinary tract infection [MEDICAL CONDITION]" A urology consultation dated 12/3/13 revealed, "...Impression: Foley catheter is within the penis. I cannot confirm with certainty that the Foley is within the urethra, and I cannot exclude a urethral injury...Diagnostics...Hematuria from probable urethral trauma due to malpositioned (improper placement) Foley..." A "MICU History and Physical (H&P), dated 12/3/13 revealed the following: "...(resident #101) was brought into the ER because of hematuria and admitted to the ICU because of septic shock secondary to UTI...Three days before the admission, the patient was having inability to urinate so he had a Foley placed. The patient stated that he was having a lot of pain from the Foley and requested that it be removed. He was having gross hematuria and had the Foley 'tugged out'...had another Foley inserted, which was productive of gross hematuria (blood) so he was brought into the ER..." The MICU H&P also documented that resident #101 was febrile (fever), [MEDICAL CONDITION] (heart rate that exceeded a normal range), and hypotensive (low blood pressure). Resident #101 required oxygen and breathing treatments due to shortness of breath and wheezing. MICU records revealed Resident #101 required 2 units of blood to be transfused due to loss of blood. The facility's clinical record for resident #101 was reviewed on 1/28/13 at 10:30 A.M. and revealed that resident #101 was readmitted into the facility on [DATE] and had [DIAGNOSES REDACTED]. The minimum data set assessment ((MDS) dated [DATE] revealed that resident #101 had moderately impaired cognition, requires extensive assistance with activities of daily living, and had a catheter. The previous MDS from 9/2013 documented that resident #101 did not have a catheter. Nursing progress notes were reviewed from 11/3/13 through 12/3/13 and documented the following: 11/17/13...continent of b&b (bowel and bladder)...The next documented nursing progress note was dated 12/3/13 at 10:00. It documented, "Pt c/o pain in ABD (abdomen) upon start of writer shift...nightshift nurse stated in report pt had also been complaining through the night and she irrigated Foley (catheter) and did not get much return...pt was saying he felt pressure in stomach and that he could not urinate...Foley bag had around 100 ml of dark cloudy blood tinged urine...writer changed Foley cath..urine return was also blood tinged but catheter was flowing..." The following nursing progress note from 12/3/13 at 14:33 revealed, "...Told staff couldn't breathe, wheezing, coughing, pulse ox 84%, Pulse 128, grayish in color, placed on O2 (oxygen) 8 L (liters), Dr notified, sent to hospital..." The director of nursing (DON) was interviewed on 1/28/13 at 11:35 A.M. and was unable to explain when or why resident #101's indwelling Foley catheter was inserted prior to the hospital transfer on 12/3/13. At 12:16 P.M. the DON reported that she spoke with the physician and he remembered giving a verbal order to insert an indwelling catheter to the night shift nurse (LPN A) after resident #101 was complaining of abdominal pain, however, there was no supporting documentation that the physician was contacted, no written physician's order, and no nursing progress note regarding the insertion of the indwelling catheter in the clinical record. When queried about why there were no nursing progress notes between the dates of 11/17/13 and 12/3/13, the DON did not have an explanation. Licensed Practical Nurse (LPN) A was interviewed via the telephone on 1/28/13 at 1:06 P.M. LPN A was no longer an employee of the facility. LPN A reported that she remembered resident #101 having abdominal pain on the evening of 12/2/13 and that she replaced the Foley catheter at that time. When queried about whether or not resident #101 had already had an indwelling Foley catheter on 12/2/13, LPN A reported that resident #101 had the catheter placed "at least a couple weeks ago" after he had retained urine for about two or three days. When asked if LPN A was the nurse who inserted the Foley catheter, LPN A stated, "I did not place the Foley the night of 12/2/13. It was already there." Further review of the clinical record on 1/28/13 at 1:30 P.M. revealed a physician's order for a bladder scan, one time only for unable to urinate, dated 11/28/13. The DON was interviewed regarding the results of the bladder scan for resident #101 and stated, "The results are charted by exception, unless there is a specific order from the physician." The Treatment Administration Record (TAR) documented that the bladder scan was done on 11/29/13, but there was no documentation of the results. There was no documentation in the clinical record regarding the reason or date that the catheter was inserted, no physician's order, no care plan, and no documented monitoring in place. The DON was further interviewed on 1/28/13 at 1:30 P.M. regarding monitoring of residents who have an indwelling catheter and reported that the staff will check the urine output bag, but it was only documented if there was a physician's order that stated to document the results of the monitoring. When queried about the facility's expectations if they discover anything abnormal when checking residents with indwelling catheters, the DON stated, "If anything abnormal, such as no (urine) output or bloody tinged urine, it would be expected to be documented in the nursing notes and the doctor would be notified." The facility's policy titled "Bladder Scan (Ultrasonic Measurement of Bladder Volume) dated 12/2009 was reviewed on 1/28/13 at 2:00 P.M. and documented, "Suggested Documentation...Record procedure on TAR...Record how patient tolerated procedure, any abnormalities noted and subsequent interventions including communications with physician in progress notes...Place computerized read (printout) in chart..." The facility's policy titled "Catheter Care: Indwelling Catheter" dated 11/2011 was reviewed on 1/28/13 at 2:10 P.M. and documented, "Suggested Documentation...Care provided and reaction to procedure, size of catheter and balloon...Unusual observations, color and amount of urine and/or complaints and subsequent interventions including communications with physicians." ( )

THIS CITATION PERTAINS TO INTAKE NUMBERS MI 946 AND MI 030 BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY STAFF FAILED TO ENSURE THAT A SKIN ASSESSMENT TO IDENTIFY PRESSURE ULCER AND TREATMENT ORDERS WERE OBTAINED AND PROVIDED IN A TIMELY MANNER FOR 1 (#103) OF 5 SAMPLED RESIDENTS REVIEWED FOR RISK OF SKIN BREAKDOWN AND PRESSURE ULCERS, FROM A TOTAL SAMPLE OF 9, RESULTING IN A PRESSURE ULCER FOR RESIDENT #103 AND PLACING 7 ADDITIONAL RESIDENTS IDENTIFIED BY THE FACILITY WITH PRESSURE ULCERS OR AT HIGH RISK FOR DEVELOPING PRESSURE ULCERS, AT RISK OF DELAYED TREATMENT, INFECTION OR DEVELOPMENT OF NEW PRESSURE ULCERS. FINDINGS INCLUDE: RESIDENT #103, AN [AGE] year OLD MALE, WAS admitted to the facility on [DATE] AND discharged TO AN ACUTE CARE hospital on [DATE]. HE WAS NOT RESIDING AT THE FACILITY AT THE TIME OF THE ABBREVIATED SURVEY. PER HIS ADMISSION MINIMUM DATA SET (MDS) assessment dated [DATE], RESIDENT #103 WAS COGNITIVELY INTACT, BUT REQUIRED EXTENSIVE TO TOTAL ASSISTANCE OF 1OR 2 PERSONS FOR ALL ACTIVITIES OF DAILY LIVING. RESIDENT #103'S [DIAGNOSES REDACTED]. ACCORDING TO THE ATTENDING PHYSICIAN'S (#17) NOTE DATED 3/19/13, METASTATIC [MEDICAL CONDITION] [DIAGNOSES REDACTED]. THE NURSING ADMISSION ASSESSMENT FOR RESIDENT #103 DATED 3/4/13 DOCUMENTED THAT RESIDENT #103'S SKIN WAS INTACT ON ADMISSION, BUT WITH UNOPENED REDNESS TO HIS COCCYX AREA. THE RESIDENT #103 WAS ASSESSED TO BE LOW RISK (SCORE OF 17 ON THE BRADEN SCALE) FOR PRESSURE ULCER DEVELOPMENT. WEEKLY SKIN ASSESSMENTS FOR RESIDENT #103 WERE SIGNED BY FACILITY NURSES ON THE TREATMENT RECORD SHEET FOR DATES 3/11/13, 3/18/13 AND 3/25/13 AND DID NOT DOCUMENT ABNORMAL FINDINGS. ACCORDING TO THE PROGRESS NOTE DATED 3/25/13, ATTENDING PHYSICIAN #17 EXAMINED RESIDENT #103 AND NOTED "PAIN AT THE COCCYX AREA WITH A STAGE II-III DECUBITI (ULCER), WITH AREAS OF SKIN NECROSIS, TOTAL SIZE OF WOUND IS 1/2 X 1 ULCER IN SIZE ...THE DRESSING MATERIAL IS APPROPRIATE." THE CLOSED CLINICAL RECORD DID NOT CONTAIN WOUND TREATMENT ORDERS FOR RESIDENT #103'S COCCYX AREA UNTIL 3/28/13. ACCORDING TO TREATMENT ADMINISTRATION RECORDS (TARS), NO TREATMENTS WERE PROVIDED TO RESIDENT #103'S COCCYX ULCER UNTIL 3/28/13. A REVIEW OF CERTIFIED NURSING ASSISTANT (CNA) "SHOWER SHEETS" WITH BODY DIAGRAM FOR RESIDENT #103 DOCUMENTED THAT HIS COCCYX AREA HAD "REDNESS/BRUISE" DOCUMENTED ON DATES 3/9/13, 3/20/13 AND 3/23/13. ON 3/26/13, CNA #13 DOCUMENTED THAT RESIDENT #103 HAD "SKIN BREAKDOWN" AND ON 3/27/13, CNA #14 DOCUMENTED THAT RESIDENT #103 HAD REDNESS TO THE COCCYX AREA. ON 4/16/13 AT 2:15 PM, DURING AN INTERVIEW, CNA #13 SAID SHE PROVIDED CARE FOR RESIDENT #103 OFTEN. SHE SAID THAT ON 3/26/13, WHEN SHE PROVIDED A BED BATH FOR RESIDENT #103, SHE OBSERVED 2 SMALL OPEN AREAS WITH BLACKNESS SLIGHTLY LEFT OF HIS TAILBONE. SHE STATED THAT THE OPENED AREAS DID NOT HAVE A DRESSING IN PLACE. CNA #13 DOCUMENTED THE OPENED AREAS ON THE SHOWER SHEET AND INFORMED REGISTERED NURSE (RN) #21, WHO WAS THE DIRECTOR OF CARE DELIVERY (DCD). CNA #13 SAID SHE DID NOT SEE DCD #21 LOOK AT RESIDENT #103'S SKIN. ON 4/16/13 AT 2:45 PM, DURING AN INTERVIEW, CNA #14, SAID SHE PROVIDED CARE FOR RESIDENT #103 OFTEN. CNA #14 SAID THAT RESIDENT #103 HAD A RED AREA ON HIS TAILBONE FROM THE TIME OF ADMISSION AND THAT HE COMPLAINED OF PAIN IN THE AREA. SHE SAID THAT ON 3/27/13 SHE SAW AN OPEN AREA ON HIS TAILBONE AND DOCUMENTED IT. CNA #14 STATED THAT SHE INFORMED DCD #21, BUT DID NOT SEE HER ASSESS RESIDENT #103. CNA #14 SAID SHE NEVER OBSERVED A DRESSING ON RESIDENT #103'S COCCYX AREA. ON 4/17/12 AT 2:50 PM, DURING A PHONE INTERVIEW, CNA #20 SAID THAT SHE WORKED FULL TIME AND PROVIDED CARE FOR RESIDENT #103 MOST DAYS SHE WORKED. SHE SAID THAT ON 3/22/13 SHE OBSERVED RESIDENT #103 WITH A RED BUMP ON HIS TAILBONE THAT LOOKED DIFFERENT THAN IT HAD, "LIKE IT WAS GETTING READY TO BE SOMETHING." CNA #20 SAID SHE INFORMED DCD #21, WHO TOLD HER THAT SHE (DCD #21) WOULD TAKE CARE OF IT (THE RED AREA ON RESIDENT #103'S TAILBONE). ON 4/17/13 AT 2:35 PM, CNA # 19 STATED SHE CARED FOR RESIDENT #103 ON 3/24/13, 3/26/13 AND 3/27/13 AND HE HAD A DRESSING IN PLACE ON THE COCCYX AREA, BUT SHE COULD NOT RECALL WHEN SHE FIRST SAW IT. SHE SAID ON ONE OF THE DAYS THE DRESSING WAS SOILED AND SHE INFORMED RN, DCD #21 THAT IT NEEDED TO BE CHANGED. . ON 4/17/13 AT 8:30 AM, DURING AN INTERVIEW, PHYSICIAN #17 SAID THAT HE HAD BEEN RESIDENT #103'S PHYSICIAN DURING THE RESIDENT'S HOSPITAL STAY AND THEN AT THE FACILITY AFTER RESIDENT #103'S 3/4/13 ADMISSION. PHYSICIAN #17 STATED THAT HE SAW RESIDENT #103'S WOUND ON 3/25/13 AND IT HAD A DRESSING IN PLACE. PHYSICIAN #17 SAID HE REMOVED THE DRESSING, ASSESSED AND MEASURED THE WOUND, AND REPLACED THE DRESSING WHICH HE STATED WAS "APPROPRIATE." HE COULD NOT SAY WHY HE DID NOT WRITE TREATMENT ORDERS AT THE TIME. ON 4/17/13 AT 2:00 PM, DURING A PHONE INTERVIEW, RN #22 SAID THAT HE PROVIDED CARE FOR RESIDENT #103 OFTEN. HE SAID IN THE EARLY MORNING ON 3/26/13, HE DID A SKIN ASSESSMENT ON RESIDENT #103 AND FOUND AN OPENED AREA ON RESIDENT #103'S COCCYX. RN #22 SAID THE OPENED AREA DID NOT HAVE A DRESSING IN PLACE. RN #22 SAID, "I BELIEVE I WAS THE FIRST TO REPORT IT." RN #22 SAID HE DID NOT CALL THE PHYSICIAN FOR TREATMENT ORDERS, BUT HE DOCUMENTED THE FINDINGS AND REPORTED THE OPENED AREA TO DCD #21, BECAUSE IT WAS THE END OF HIS SHIFT. FURTHER REVIEW OF THE CLOSED CLINICAL RECORD REVEALED A NURSE'S NOTE DATED 3/26/13, WRITTEN BY RN #22 THAT DOCUMENTED, "COCCYX AREA WITH SMALL OPEN AREA ..." ON 4/16/13 AT 4:00 PM, DURING AN INTERVIEW, LICENSED PRACTICAL NURSE (LPN) #15 SAID THAT SHE WAS ASSIGNED TO RESIDENT #103 ON 3/27/13. SHE SAID THE MIDNIGHT-SHIFT NURSE, RN #22 HAD INFORMED HER AND DCD #21 THAT RESIDENT #103 HAD "SOMETHING ON HIS BOTTOM." LPN #15 SAID, "WE WERE VERY BUSY. I (#15) DIDN'T CHECK HIS (#103) BOTTOM. IT WAS A MISTAKE. WE WERE VERY BUSY ...I DON'T KNOW IF (DCD #21) LOOKED (AT RESIDENT #103) OR NOT." LPN #15 SAID THAT DCD #21WAS AWARE AND THAT "THEY (DCD'S) CHECK, MEASURE AND CALL PHYSICIAN AND PUT TREATMENTS IN PLACE FOR WOUNDS." ON 4/17/13 AT 2:20 PM, DURING A PHONE INTERVIEW, DCD #21SAID SHE WAS WORKING ON 3/22/13 (A FRIDAY) AND A CNA INFORMED HER THAT RESIDENT #103 HAD REDNESS ON HIS COCCYX AREA THAT WAS GETTING DARKER. DCD #21 SAID IT WAS THE END OF THE SHIFT AND SHE TOLD THE CNA TO CONTINUE WITH THE PREVENTATIVE MEASURES THAT WERE IN PLACE. DCD #21SAID SHE WAS OFF ON THE WEEKEND AND HAD IT ON HER NOTES TO CHECK IT ON 3/25/13. SHE SAID THAT ON 3/25/13, RN #22 TOLD HER AND LPN #15 IN PASSING THAT RESIDENT #103'S SKIN WAS BREAKING DOWN. SHE SAID SHE DID NOT ASSESS RESIDENT #103'S SKIN, BECAUSE LPN #15 WAS ASSIGNED TO HIM. ACCORDING TO DCD #21, SEVERAL NURSES ON EACH SHIFT FROM 3/25/13 TO 3/28/13 FAILED TO MEASURE OR INITIATE TREATMENTS PER PROTOCOL. ON 4/17/13 AT 9:12 AM, DURING A PHONE INTERVIEW, LPN # 24 SAID THAT ON 3/27/13, A CNA CAME TO HER AND ASKED HER TO CHANGE THE DRESSING ON RESIDENT #103'S COCCYX AREA BECAUSE IT WAS SOILED. LPN #24 SAID SHE WAS NOT AWARE THAT RESIDENT #103 HAD A WOUND, CHECKED THE CLINICAL RECORD AND FOUND NO ORDERS FOR TREATMENTS. LPN #24 SAID SHE INFORMED DCD #21, WHO SAID SHE WAS AWARE AND IT WAS ON HER LIST OF THINGS TO DO THAT DAY (3/27/13). LPN #24 SAID SHE DID NOT LOOK AT THE OPENED AREA BECAUSE IT WAS THE END OF THE SHIFT AND DCD #21 HAD SAID SHE (#21) WOULD LOOK AT IT. LPN #24 SAID SHE REPORTED THE SITUATION TO THE ONCOMING NURSE, LPN #8. ON 4/15/13 AT 3:10 PM, DURING AN INTERVIEW, LPN #8 SAID, THAT HE WAS APPROACHED BY RESIDENT #103'S FAMILY MEMBER ON THE MORNING OF 3/28/13 WHO ASKED IF HE WAS AWARE RESIDENT #103 HAD A PRESSURE SORE. LPN #8 SAID HE TOLD THE FAMILY MEMBER THAT HE (#8) WAS NOT BECAUSE HE HAD BEEN OFF WORK FOR A WEEK. LPN #8 SAID HE DID NOT SEE THE AREA ON THAT DAY BECAUSE RESIDENT #103 WAS SENT TO THE HOSPITAL. DURING THE 4/14/13 INTERVIEW, DCD #21 SAID SHE DID NOT ASSESS THE WOUND ON 3/27/13, BECAUSE SHE WAS IN MEETINGS AND THEN LEFT THE FACILITY ILL. SHE SAID ON 3/28/13, CNA #23 INFORMED HER RESIDENT #103'S FAMILY MEMBER WAS IN THE ROOM AND UPSET ABOUT THE WOUND. DCD #21 SAID THAT AT THAT TIME SHE MEASURED THE WOUND, RATED IT WITH THE PUSH TOOL, CALLED THE PHYSICIAN FOR TREATMENT ORDERS AND INITIATED TREATMENTS. SHE SAID SHE WAS GIVEN AN EMPLOYEE WARNING NOTICE ON 4/3/13 FOR FAILING TO FOLLOW UP TIMELY AND APPROPRIATELY ON A RESIDENT'S (#103) SKIN CONDITION. THE WRITTEN WARNING WAS VERIFIED BY A REVIEW OF DCD #21'S EMPLOYEE FILE. ON 4/16/13 AT 11:40 AM, FACILITY DIRECTOR OF NURSING (DON) #3 SAID SHE WAS NOT AWARE OF THE AREA ON RESIDENT #103'S COCCYX AREA UNTIL 3/28/13. AFTER THE INVESTIGATION WAS BEGUN, SHE (DON #3) INTERVIEWED FACILITY STAFF INCLUDING DCD #21, WHO TOLD DON #3 THAT SHE (#21) WAS NOT AWARE OF THE AREA, AND admitted SHE (#21) NEVER CHECKED RESIDENT #103 OR PUT TREATMENTS IN PLACE UNTIL 3/28/13. DON #3 SAID THAT THE CNAS HAD DOCUMENTED THE AREA ON THE SHOWER SHEETS AND DCD #21 HAD THE SHOWER SHEETS IN HER POSSESSION. THE SURVEYOR QUERIED DON #3, REGARDING THE PHYSICIAN NOTE ON 3/25/13 WITH NO ORDERS OR TREATMENTS DOCUMENTED FOR THE OPEN AREA ON RESIDENT #103'S COCCYX AREA FROM 3/25/13 TO 3/28/13. DON #3 STATED THAT WAS CORRECT AND THAT SHE (#3) HAD NOT BEEN INFORMED BY DCD #21 UNTIL 3/28/13. ACCORDING TO ATTENDING PHYSICIAN #17'S PROGRESS NOTE, DATED 3/28/13, HE EXAMINED RESIDENT #103 WITH DCD #21. THE PROGRESS NOTE FURTHER OUTLINED THAT THE DIRECTOR OF NURSING AND ADMINISTRATOR WERE AWARE TO ENSURE ADEQUATE RESOURCES ARE PUT IN PLACE TO KEEP THE WOUND FROM GETTING ANY BIGGER AND TO HELP HEAL. PHYSICIAN #17 GAVE TREATMENT ORDERS ON 3/28/13. A CARE PLAN TO ADDRESS PRESSURE ULCER ON COCCYX WAS INITIATED ON 3/28/13. ON 4/15/13 AT 1:15 PM THE FORMER FACILITY ADMINISTRATOR (#1) SAID HE BECAME AWARE OF RESIDENT #103'S PRESSURE ULCER ON 3/28/13 WHEN THE PHYSICIAN #17 INFORMED HIM. HE WAS TOLD THAT RESIDENT #103'S FAMILY MEMBER WAS UPSET. THE PHYSICIAN ASKED ADMINISTRATOR #1 AND THE DIRECTOR OF NURSING (DON) #3 SPEAK WITH RESIDENT #103'S FAMILY MEMBER. ADMINISTRATOR #1 SAID THE FAMILY MEMBER REQUESTED RESIDENT #103 BE TRANSFERRED TO AN ACUTE CARE HOSPITAL. ADMINISTRATOR #1 SAID THE FAMILY MEMBER VERBALIZED NEGLECT, AND THE FACILITY REPORTED THE INCIDENT TO THE STATE AGENCY AND BEGAN AN INVESTIGATION. PER THE FACILITY "SKIN PRACTICE GUIDE PROCESS FLOWCHART," IF A RESIDENT HAS A SKIN ALTERATION, THE WOUND TEAM AND PHYSICIAN ARE NOTIFIED. PHYSICIAN ORDERS [REDACTED]. RESIDENTS ARE RE-EVALUATED AND ORDERS AND CARE PLANS ARE UPDATED ON AN ONGOING BASIS. THE FACILITY POLICY TITLED "DRESSING CHANGE" DOCUMENTED THAT "DRESSINGS ARE PREFORMED ACCORDING TO physician's orders [REDACTED]. A REVIEW OF THE HOSPITAL RECORDS FOR RESIDENT #103'S 3/28/13 ADMISSION TO THE ACUTE CARE FACILITY REVEALED A PHYSICIAN HISTORY AND PHYSICAL EXAM THAT DOCUMENTED RESIDENT #103 HAD "A STAGE III PRESSURE ULCER WITH ESCHAR ON HIS BACKSIDE." ( )