Every finding on record at Medilodge of Howell

This citation pertains to Intake #2808113.Based on observation, interview and record review the facility failed to ensure they obtained and administered a physician ordered medication for one (R808) out of three residents reviewed for medication administration. Findings include: A complaint was filed with the State Agency (SA) that alleged R808 had not received the physician ordered drug Hizentra (a drug used to treat diseases that affect the immune system) for months. The complainant further alleged that the failure to receive the drug resulted in a hospitalization stay in November 2025. In addition, the failure to obtain the medication put the resident at risk for viruses like COVID 19.A review of R808's clinical record revealed the resident was initially admitted to the facility on [DATE] and the last admission was on 11/27/25 with diagnoses that included: respiratory failure, common variable immunodeficiencies and Crohn's disease. Review of the residents Minimum Data Set (MDS) noted the resident was cognitively intact. Continued review of R808's clinical noted the following:2/28/25: Order: Hizentra.10 GM (Grams) /50 ML (milliliters).Inject 10 gram subcutaneously one time a day every 7 days related to common variable immunodeficiency unspecified.located in med room fridge. *This order was discontinued on 10/22/25 but a similar order (Hizentra 10 gram .every Monday for Chron's Disease was started on 10/27/25 and continued as a Monday order through 3/2/26. A new order changed administration date to once a week on Wednesdays starting on 3/11/26. R808's Medication Administration Report (MAR) for the months 10/25- 3/26 was reviewed and documented the administration of Hizentra as follows:October 2025: Received on 10/6/25, 10/13/25 and noted as not available on 10/20/25 and not given on 10/27/25.November 2025: Noted as administered on 11/3/25, 11/10/25 and not administered on 11/17/25 based on hospitalization.December 2025: Noted as not available on 12/8/25, Noted as administered by Nurse E on 12/15/25, Noted as not available on 12/22/25 and not available on 12/29/25.January 2026: Noted as not available on 1/6/26, 1/12/26, 1/19/26 and 1/26/26.February 2026: Noted as no available on 2/2/26, 2/9/26, 2/16/26 and administered by Nurse F on 2/23/26.March 2026: Noted as not available on 3/2/26 and refused on 3/11/26 and noted as administered by Nurse F on 3/18/26.On 3/23/26 at approximately 9:43 AM, R808 was observed sitting on their bed. The resident was alert and able to answer questions asked. R808 reported that they had not received the drug Hizentra in months and was supposed to receive it one time per week. R808 noted that they have an immune compromised disease and believed the medication would have helped to prevent them from getting COVID and the Flu over the last few months. R808 reported that they had an appointment scheduled with an outside physician on 3/24/26 and was hoping to get things straightened out.On 3/23/26 at 1:00 PM, the Director of Nursing (DON) was interviewed regarding R808's order for Hizentra and why the resident was not receiving the medication. The DON noted that the medication came from a specialty pharmacy. The DON provided a copy of a letter sent to R808 from (name redacted) Infusion Pharmacy dated 3/13/26 that read: Dear (R808).Dr.referred you to.Infusion Pharmacy for your Hizentra therapy.we have not been able to reach you.we will close your case pending a return call.We look forward to helping you in any way we can. (Signed by Pharmacy Employee (PE) E).A phone interview was conducted with Pharmacy Employee (PE) E on 3/23/26 at approximately 2:15 PM. PE E reported that they were familiar with the resident but had not spoken to them since August 2025. When asked about the order for Hizentra, PE E stated the pharmacy would send a one-month supply of the medication (four doses) overnight to the facility as the medication needed to be stored in a refrigerator. PE E noted that the last monthly supply was sent to the facility on September 2, 2025, with a delivery date of September 3, 2025. PE E reported that have not received any calls from the facility after the last dose of medication was sent in September 2026.On 3/23/26 at approximately 2:30 PM, an interview was conducted with the Administrator. The Administrator was queried as to the failure to provide the physician ordered medication to the resident. The Administrator reported that they were aware of the concern, noted that medication should be provided as ordered and they were working on the problem.The facility policy titled, Medication Administration (Revised 1/17/23) was reviewed and documented, in part: .Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so.as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection .

This citation pertains to Intake 2806339 and 2808113Based on record review and interview, the facility failed to reconcile and administer prescribed medication (Amoxicillin, an antibiotic) according to professional standards for one (R803) and ensure the accuracy of the administration of the drug Hizentra (a medication admitted under the skin to treat immune deficiency) for one (R808) out of three residents reviewed for medication administration. Findings include: A complaint was filed with the State Agency (SA) that alleged R808 had not received the physician ordered drug Hizentra (a drug used to treat diseases that affect the immune system) for months. A review of R808's clinical record revealed the resident was initially admitted to the facility on [DATE] and the last admission was on 11/27/25 with diagnoses that included: respiratory failure, common variable immunodeficiencies and Crohn's disease. Review of the residents Minimum Data Set (MDS) noted the resident was cognitively intact. Continued review of R808's clinical noted the following: 2/28/25: Order: Hizentra.10 GM (Grams) /50 ML (milliliters).Inject 10 gram subcutaneously one time a day every 7 days related to common variable immunodeficiency unspecified.located in med room fridge. *This order was discontinued on 10/22/25 but a similar order (Hizentra 10 gram .every Monday for Chron's Disease was started on 10/27/25 and continued as a Monday order through 3/2/26. A new order changed administration date to once a week on Wednesdays starting on 3/11/26. R808's Medication Administration Report (MAR) for the months 10/25- 3/25 was reviewed and documented the administration of Hizentra as follows: October 2025: Received on 10/6/25, 10/13/25 and noted as not available on 10/20/25 and not given on 10/27/25. November 2025: Noted as administered on 11/3/25, 11/10/25 and not Administered on 11/17/25 based on hospitalization. December 2025: Noted as not available on 12/8/25, Noted as Administered by Nurse E on 12/15/25, Noted as not available on 12/22/25 and not available on 12/29/25. January 2026: Noted as not available on 1/6/26, 1/12/26, 1/19/26 and 1/26/26. February 2026: Noted as no available on 2/2/26, 2/9/26, 2/16/26 and administered by Nurse F on 2/23/26. March 2026: Noted as not available on 3/2/26 and refused on 3/11/26 and noted as administered by Nurse F on 3/18/26. On 3/23/26 at approximately 9:43 AM, R808 was observed sitting on their bed. The resident was alert and able to answer questions asked. R808 reported that they had not received the drug Hizentra in months and was supposed to receive it one time per week. When asked if they could recall the last time they received the medication, R808 noted that they never received the drug following their return from the hospital in November 2025. On 3/23/26 at 11:50 AM, the Director of Nursing (DON) was interviewed regarding R808's order for Hizentra and why the resident was not receiving the medication. The DON noted that the medication came from a specialty pharmacy. The DON provided a copy of a letter sent to R808 from (name redacted) Infusion Pharmacy dated 3/13/26 that read: Dear (R808).Dr.referred you to.Infusion Pharmacy for your Hizentra therapy.we have not been able to reach you.we will close your case pending a return call.We look forward to helping you in any way we can. (Signed by Pharmacy Employee (PE) E). A phone interview was conducted with Pharmacy Employee (PE) E on 3/23/26 at approximately 2:15 PM. PE E reported that they were familiar with the resident but had not spoken to them since August 2025. When asked about the order for Hizentra, PE E stated the pharmacy would send a one-month supply of the medication (four doses) overnight to the facility as the medication needed to be stored in a refrigerator. PE E noted that the last monthly supply was sent to the facility on September 2, 2025, with a delivery date of September 3, 2025. PE E reported that have not received any calls from the facility after the last dose of medication was sent in September 2026. On 3/23/26 at approximately 12:28 PM, a phone interview was conducted with Nurse E. Nurse E was queried as to the Administration of Hizentra on 12/15/25 as noted in the MAR. Nurse E noted that they got the drug from the refrigerator in the medication room and the resident's name was on the box. Nurse E was asked if they had administered the medication before and/or after 12/15/25 and reported that they had but also noted that sometimes the medication was not available. On 3/23/26 at approximately 3:54 PM, a phone interview was conducted with Nurse F. Nurse F was asked as to the administration of the medication Hizentra as noted as not available on 2/9/26 but administered on 2/23/26 and 3/18/26. Nurse F could not recall the administration of the medication on 2/23/26 but noted the medication was obtained from the storage room refrigerator and administered on 3/18/26. On 3/23/26 at approximately 4:30 PM, an interview was conducted with the Administrator. Corporate staff were present during the interview. The Administrator was asked if the facility kept a record of the medication delivered by (name redacted) specialty pharmacy. They reported that they did not. The Administrator was asked if they could confirm Nurse E and F administered the medication as noted in the MAR as it was reported by the specialty pharmacy that the last four doses were delivered in September 2025, and notes also indicated the medication was not available the entire month of January 2026 and the first three weeks of February. The Administrator could not provide a clear answer and noted they were aware of the concern. The facility policy titled, Medication Administration (Revised 1/17/23) was reviewed and documented, in part: .Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so.as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection . Clinical record review revealed R803 was a long-term resident since August 2024 with a chronic medical history of cardiac and kidney disease. The Minimum Data Set (MDS) dated [DATE] did not document a (brief Interview of Mental Status) BIMS score, but – indicated R803 had moderate impaired cognitive skills. On 3/16/26 State Agency (SA) received an anonymous complaint alleging the facility failed to administer an antibiotic medication timely. On 3/1/26, R803 was transferred to the hospital and admitted into Intensive Care Unit (ICU) for severe sepsis (life threatening condition raised from the body's response to an infection) related to cellulitis (bacterial skin infection) of their left lower extremity. Record review of the Infectious Disease consultation dated 3/6/26 at 12:32 PM recommended at discharge for R803 to start, Amoxicillin 1 gram (GM) oral three times daily for four weeks, through 3/30/26. R803 was transferred back to the facility on 3/8/26. Record review of the After Visit Summary (AVS) dated 3/8/26, documented to start Amoxicillin 1,000 mg by mouth every eight hours.Last time this was given: March 8, 2026, 6:37 AM. Record review of the Medication Administration Record (MAR) for March 2026 did not reflect Amoxicillin was given by the facility until 3/11/26 at 22:00. R803 was transferred back to the facility on 3/8/26 and admitted under the care of Licensed Practical Nurse (LPN) C who was identified as the LPN who entered the admission medication orders. On 3/23/26 at 11:01 AM, LPN C was interviewed and explained the process of admitting residents once they returned from the hospital. LPN C concurred that they review the AVS (After Visit Summary) and discharge paperwork from the hospital, enter the orders into the computer, then place paperwork into a bin at the desk, where a Unit Manger will perform a second reconciliation. LPN C recalled R803's return from the hospital because it was their first resident admission at the facility. Further record review revealed the Amoxicillin order was not placed until 3/11/26 at 17:03 by Infection Control Unit Manger Registered Nurse (RN), B. RN B was interviewed on 3/23/26 at 11:34 AM, and acknowledged they were the RN who entered the order. Unable to recall exactly how this was conveyed to place the order, the record review of the discharge paperwork and AVS identified this medication should have been ordered and started on 3/8/26. Record review of the Physical Medicine and Rehabilitation (PMR) Provider note authored by Nurse Practitioner (NP) D on 3/11/26 at 11:50 AM, was the first documentation since admission from 3/8/26 that R803 was to be on Amoxicillin. On 3/23/26 at 11:49 AM, NP D was interviewed and disclosed while reviewing R803's discharge notes and AVS from 3/8/26 they had identified an order for Amoxicillin to continue 3/8/26. NP D reviewed, saw R803 had never started the medication, and then placed the order on 3/11/26. On 3/23/26 at 2:31 PM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were interviewed. The ADON explained the facility admission order process and said Nursing orders are reconciled by two nurses, then a third reconciliation is performed by a Nursing leader. The DON reviewed the orders for R803 on 3/8/26. Further record review revealed LPN C did in fact enter the Amoxicillin but had placed a start date of 4/1/26. The DON and ADON both concurred this medication was not ordered correctly, and the multiple reconciliations process of the admission medications were not performed accurately.

Based on observation, interview, and record review, the facility failed to implement fall interventions for three residents (R2, R17, R68) of twelve residents reviewed for falls/accidents resulting in R2 sustaining bruising, swelling, and pain to mid back region of the head, and decline in previous independent ADL's (Activities of Daily Living). Findings include:R68 On 12/9/25 at approximately 11:35 AM, R68 was observed sitting in their wheelchair. The resident had swelling and bruising on their right hand. When asked as to what happened to their hand they reported that they had a fall. R68 who was alert, reported that they had pushed their call light, waited a very long time and then tried to get up on their own and fell. A review of R68's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: Congestive Heart Failure and Type II Diabetes. A review of R68's Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 (intact cognition) and was noted as their own responsible person. A request for IAs (incident/accident) reports was made. The following were provided: 11/9/25 (5:20 AM) Other: .Resident (R68).Nursing Description: resident was self-transferring and hit head on her bed.Predisposing Situational Factors:.ambulating without assistance.Recent Room Change.Notes: IDT (interdisciplinary team) reviewed.while self-transferring resident's head made contact with her bed.re-educated to use call light when needing assistance. (Authored by Nurse X). It should be noted that an attempt to contact Nurse X was made on 12/11/25 at approximately 1:25 PM, a voice message was left. No return call was received prior to the end of the Survey. 11/9/25 (1:00 PM): Unwitnessed Fall: Resident (R68).Nursing Description:. screaming help writer entered residents room and resident is sitting on the floor with one arm on the wheelchair seat and another on the bed.resident scooted to the floor and saying she does not want to get up.root cause analysis.Resident with recent room move, resident note to have an increase in negative and attention seeking behaviors since room move.Intervention: resident re-educated on using call light when needing assistance. (Authored by Nurse U ) *It should be noted that Nurse U was no longer employed by the facility at the time of Survey. An attempt to contact them was made on 12/11/25 at approximately 11:43 AM. 11/10/25 (9:50AM): Unwitnessed Fall: Resident (R68).Nursing Description: was called into residents room by CNA (certified nursing assistant) who reported resident was on the floor.resident laying on the floor oxygen tubing not in nose.Immediate Action Taken: full set of vitals taken resident has an elevated BP (blood pressure) along with hr (heart rate), resident was sent to Hospital.resident was sent to hospital for further evaluation post fall. 11/17/25: Fall Risk Evaluation: .Resident (R68).Interventions Required.Mobility: unable to transfer on and off toilet, bed, or chair safely.Unsafe behaviors: Attempts to stand, transfer and/or walk independently when they require assistance.History of falls: .Yes.comments: blank. 11/19/25 (6:00 AM): Unwitnessed Fall: Resident (R68).Nursing Description: resident found on the floor lying on her back.resident has bruising on both knees and her right hand has swollen up.resident asked what happened and she said she just rolled out of bed on to the floor. *An IDT (interdisciplinary team) note accompanied the IA that documented: .Root Cause was determined to be related to recent room move and more recent bed move.(Authored by Nurse X). It should be noted that an attempt to contact Nurse X was made on 12/11/25 at approximately 1:25 PM, a voice message was left. No return call was received prior to the end of the Survey. Fall assessments were also reviewed and revealed the following: 11/9/25: Fall-Initial: Resident (R68).Date of fall 11/9/25.what was resident doing prior to fall: Sitting in wheelchair.Plan of Care Review: New Interventions:.Other.educated on using call light for assistance. *It should be noted that the IA does not document the resident was sitting in their wheelchair prior to fall and the intervention to use a call light was documented in the care plan prior to this incident. 11/10/25: Fall-Initial: Resident (R68).Date of fall 11/10/25.what was resident doing prior to the fall: sitting in wheelchair.Describe pain: jaw and neck.Describe other interventions: Dycem (non-slip pad) to wheelchair. *It should be noted that the IA does not document the resident was sitting in their wheelchair prior to fall and the intervention for a Dycem was documented as an intervention prior to this incident. 11/11/25: Fall-Initial: Resident (68).Date of fall: 11/11/25.What was resident doing prior to fall: resident was being assisted to toilet.New Interventions: BLANK. 11/19/25: Fall-Initial: Resident (68).Date of fall: 11/19/25.What was resident doing prior to fall.What was resident doing prior to fall: Resident was in bed. Plan of Care Review: Assist bar put on bed. *It should be noted that R68's care plan noted an assist bar was in place as an intervention prior to this incident. On 12/11/25 at approximately 2:00 PM, an interview and record review were conducted with the Director of Nursing (DON). The DON reported they were new to the facility and not very familiar with R68. The DON was asked to review the falls that occurred and the interventions that were put in to reduce the numerous falls. The DON reviewed the care plan and confirmed that the Dysem and assist bars were already in place. The DON noted that they would speak with the ADON (Assistant Director of Nursing) to see if there was any additional information put into place. No additional information was provided prior to the end of the Survey. R2 Clinical record review revealed R2 was admitted to the facility on [DATE]and had a history of weakness, and chronic pain, cardiovascular disease and dementia. A Brief Interview of Mental Status (BIMS) assessed on 11/25/25 scored 13/15 indicating R2 had no cognitive impairment. Clinical record review of a progress note and investigation report authored by Licensed Practical Nurse (LPN) K documented on 11/16/25 at 11:55 PM, R2 was heard yelling for help. Upon entering their room, R2 was observed sitting on the floor next to their bed. R2 stated they reached for their rolling walker (RW), it moved, and they landed on their buttocks and hit their head. R2 initially did not remember the name of the facility, was assessed having a newly bruised bump on their mid back of head, with pain and discomfort rated three out of ten and described as .tender to touch. On 12/11/25 at 8:40 LPN L was contacted by phone for an interview, and no response was received by the close of this investigation. On 12/11/25 at 9:49 AM, a telephone interview with former Nurse Unit Manager (NUM) confirmed R2 was independent, would dress, toilet and feed themself and was compliant asking for help if needed. After R2 fell on [DATE], NUM M remarked a decline in all previous activities. R2 required staff assist with dressing, transfers, ambulating, toileting and at times feeding. NUM M said when R2 started asking for help, they knew something was not right because R2 was known to tell staff they .could do it themself. and was observed previously doing such things independently. Review of Pertinent Charting-Change in Condition from 11/18/25 at 8:32 documented: .Change identified: S/P <sic>fall resident has exhibited need for 1 person assisted d/t <sic> functional debilitation. Review of Pertinent Charting-Change in Condition from 11/19/25 at 01:20 documented: .Weakness and unsteady gait noted since fall. Review of Pertinent Charting-Change in Condition from 11/19/25 at 11:39 documented: .Resident was not able to communicate.change in condition after a fall that happened earlier in the week. Review of Pertinent Charting-Change in Condition from 11/19/25 at 14:20 documented: .Decline in transfers after fall Resident had wet bed this am which resident is usually continent.resident unable to assess pain.needed assistance with lunch. Review of Pertinent Charting-Pain from 11/20/25 at 03:07 documented: .sore at times.Lump remains back of head. Review of Pertinent Charting-Change in Condition from 11/20/25 at 03:09 documented: .Lethargic and decline in care.Continues to need increased help from staff. On 12/11/25 at 11:52 AM, a telephone interview with LPN J acknowledged prior to the fall on 11/16/25 R2 was for the most part independent with ambulating and ADL's (Activities of Daily Living) and therefore documented the following as this was a change since the fall. Record review of a Progress note dated 11/19/25 authored by LPN J documented: .Originally identified change: Weakness and unsteady gait noted since fall. Record review of the Investigation Summary post fall documented .New Intervention(s) implemented post-fall.Equipment modification.RW (Roller walker) locks not locking. and a work order was submitted for repair. On 12/11/25 at 8:58 AM, the Director of Maintenance (DOM) I confirmed their department was responsible for repairing all equipment at the facility including residents' adaptive equipment which included walkers, rolling walkers, and wheelchairs. On 12/11/25 at 9:15 AM, DOM I was asked to show what was repaired on R2's rolling walker. Upon entrance, R2 was observed asleep and unavailable for an interview. The rolling walker was next to their bed and DOM I pointed and commented the silver-colored fastener between the locks and brake cable tends to loosen after time and use. When asked if there was a schedule for preventative maintenance for the resident's equipment, DOM I replied unfortunately there was not but that is probably a good idea. DOM I provided a copy of the work order #24341 created on 11/17/25 at 3:13 AM and documented .fell because of faulty locks. R17 On 12/09/2025 at approximately 10:15 a.m., R17 was observed in the hallway dining room, sitting in an armchair with his legs up on the wheelchair seat. R17 was observed to have large facial bruising and a blood shot eye. R17 was queried how they obtained the bruising on their face and they were unable to say what happened. On 12/10/25 at approximately 9:22 a.m., R17 was observed in their room, sleeping in their bed. R17's side of the room was observed to be dark without any lighting on. R17's wheelchair was observed to not contain a cushion or any dycem (a non-slip material to prevent sliding) and was observed to be unlocked. On 12/11/25 at approximately 9:05 a.m., R17 was observed in the common area/dining room. R17 was sitting in an armchair, without any shoes on. R17 had one missing anti-rollback bar from their wheelchair and no dycem was observed in the seat. On 12/11/25 at approximately 10:20 a.m., R17 was observed with Nurse R and Nurse R was shown R17's wheelchair missing the anti-roll back bar and dycem along with R17 not having any shoes with bare feet. Nurse R was queried if R17 was at risk for falling and needed their interventions of dycem, footwear and anti-rollback bar and they reported they were and they would have to let staff know to come and give them some shoes and place some dycem on the wheelchair along with replacing the anti-rollback bar on the back of the chair. On 12/10/25 the medical record for R17 was reviewed and revealed the following: R17 was initially admitted to the facility on [DATE] and had diagnoses including Dementia, Repeated Falls and Restless and Agitation. A review of R17's comprehensive plan of care revealed the following: Focus- Resident is at risk for falls/injury related to: potential seizure activity, history of falling, takes psychotropic medication, and cognitive deficits Resident often chooses to self-transfer from bed to wheelchair, or wheelchair to bed, often being observed as plopping self onto bed or into wheelchair Date Initiated: 04/22/2024 .Interventions-Keep an over the bed light on at night. Date Initiated: 12/27/2024, Midnight staff to get resident up before end of the shift, as resident allows. Date Initiated: 06/13/2025, nonskid socks, frequent monitoring by staff. Date Initiated: 09/11/2025, Dycem to wheelchair Date Initiated: 08/16/2025, Ensure the resident's room is free from accident hazards (e.g., providing adequate lighting, ensuring there are no trip hazards, providing assistive devices) Date Initiated: 04/22/2024 . On 12/11/25 at approximately 11:00 a.m., during a conversation with Nurse Manager T (NM T), NM T was queried regarding the fall interventions that were not in place per R17's care plan and they reported that R17 was a fall risk and that the interventions noted in the care plan should be in place such as the dycem being on the wheelchair, overhead light on when in bed sleeping, the wheelchair being locked at the bedside and the anti-rollback bar being replaced.

This citation pertains to incident #2667744.Based on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident for four (R60, R74, R142 and R186) of nine residents reviewed for abuse. Findings include: R186 and R74 On 12/9/25 at approximately 10:43 AM, R186 was observed sitting in a reclining chair. R186 was alert and reported that they had been at the facility for a few weeks and this was the third or fourth room they were in. The resident had a large bruise on the left forearm along with several bloody scabs and scratches. When asked what happened, they replied that their roommate hit them. They stated that last weekend while in a different room, their bed was located near the heater. They turned the heat down and the other resident (hereinafter R74) got upset and hit them on their forearm. A review of R186's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: staphylococcus infection, mild neurocognitive disorder, dementia with mood disturbance. A review of the residents Minimum Data Set (MDS) MDS noted the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 (intact cognition). The resident also had a court appointed legal guardian. On 12/9/25 at approximately 1:44 PM, a phone interview was conducted with the resident's legal guardian. The Guardian was asked if they were aware of the alleged resident to resident incident. They reported that they did know about it via R186 and had a conversation with a Nurse, they believed it was the Assistant Administrator but could not confirm. The Guardian further reported that they asked the facility to provide photos of the injury. They stated they had not received them. A request was made for all Incident/Accident (IA) reports regarding R186. The Administrator/Abuse coordinator provided the IA and additional documentation including interviews. They also reported that the allegation was reported to the State Agency. A review of the IA revealed in part, the following: Physical Aggression Received.Resident (R186).Incident Location: Resident's Room.Nursing Description: was called into residents room by CNA (certified nursing assistant) reported that his roommate hit him and scratched him on the forearm noticed a bruise on his forearm and a 3cm (centimeter) skin tear actively bleeding.Bruise: Left forearm.Skin Tear: left forearm . Continued review of the IA documentation noted the following: Statement of Witness: .Resident Name (F186).Date of Interview (12/8/25).SW (social worker) met with resident to discuss incident over the weekend with his roommate. Resident stated the room was cold and I asked my helper to turn it to 72 degrees. My roommate did not want it at that temperature and became angry about it. He came over to me and attacked me. He hit my arm. Statement of Witness: .Resident Name (R74).Date of Interview (12/8/25).SW (Social Worker) met with resident to discuss incident over the weekend with his roommate. Resident stated, I did not hit him. I am tired of him not using his urinal. He consistently is urinating on the carpet. He is messy with his food when he is in the recliner. On 12/11/25 at approximately 9:15 AM, an interview was conducted with R74. R74 was alert and asked about the incident that occurred between him and his roommate. R74 reported that he did not care for R186 as he urinated and defecated on the floor. R74 stated on the day of the incident they got into an altercation about the temperature. R74 reported that they did hit R186, but they did not beat him up as he stated. R74 said they both hit each other. A review of R74's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: heart failure, type II diabetes and paranoid schizophrenia. A review of the resident's MDS assessment noted they had a BIMS score of 14/15 (intact cognition). Additional clinical review reported that the resident had had a prior altercation with another roommate on 9/24/25 as noted in a Charting Follow-up- Behavior: Resident (R74) became agitated and screamed at roommate. Additionally, another incident occurred on 7/27/25 between R74 and another resident that shared the bathroom. Again, it was alleged R74 was verbally aggressive and threated to go after him if he did not stop washing clothes in the shared bathroom. R74's care plan was reviewed and documented, .Focus: Resident has an impaired mood/psychiatric status related to paranoid schizophrenia.history of ramping situations up when upset over situations with other residents.history of making false allegations about incidents regarding other residents.History of making sexually inappropriate and rude comments about females related to their weight. On 12/11/25 at approximately 10:50 AM, an interview was conducted with the Administrator/Abuse coordinator. The Administrator stated that there was no skin assessment of R186's forearm prior to the incident on 12/7/25. They noted the incident had been reported to the State Agency and continued investigation was in process. R60 & R142: A review of a Facility Reported Incident (FRI) submitted to the State Agency (SA) revealed an allegation It was reported the facility failed to protect the resident from a resident-to-resident physical abuse incident which did not result in injury. Documentation in the summary of incident revealed the incident occurred on 11/3/25 but no time was included in the incident summary provided. The incident was initially reported to the SA on 11/3/25 at 8:54 PM. The facility's investigation documented: .On 11/3/2025, resident (R60) had a disagreement in the Unit 2 common area over the loudness of the television as she requested for the television to be turned down. As a result, resident (R142) intervened and contact was made by (R60's) quad point cane to (R142's) leg. Pain and skin assessment completed. There was a small bump to (R142's) leg. No pain and resident (R142) indicated that she was fine. There were no new findings as a result of the assessments provided to (R60). (R60) was re-directed to the Unit 3 common area where her room is located and there is less stimulation. Both residents remain at the facility and feel safe. 5 day investigation to follow. The facility's conclusion to the investigation revealed they did not substantiate abuse occurred because there was no intent to harm, there was no harm or injury, and there was no allegation of abuse made by either resident related to the alleged resident to resident incident. The small bruise that was identified has since been resolved. Using the reasonable person concept, it can be determined that the reasonable person would likely experience harm with the potential for more than minimal psychosocial harm (e.g. anger directed at the action or at a person) as a result of the physical abuse since there is an expectation that the resident would not have contact with another resident's cane and subsequent bruise and abrasion while in the facility. Review of R142's incident report provided by the Administrator dated 11/3/25 [which was completed by the former Director of Nursing (DON 'O')] documented: .Nursing Description: Resident was sitting in common area lounge with other residents watching TV, another female resident approached the group of people demanding the volume be turned down by a male resident who had the remote control, hitting the back of his chair with her cane when request was not obliged. (R142) interjected herself into situation resulting in female resident making contact with her LLE (Left Lower Extremity), leaving a bruise and a small bump, writer was able to redirect said female resident back to her hall. Resident Description: (R142) stated she was sitting in her wheelchair when another female resident came up and hit her with her cane when she was trying to defend herself by putting her hand up to block the cane from making further contact. Resident showed writer bump on lower extremity .Injury Type Abrasion .Left lower leg (front) .Bruise .Left lower leg (front) .Mental Status .Oriented to Person .Place .Situation .Time .Notes 11/4/2025 IDT (Interdisciplinary Team) reviewed incident from 11/3/25, guardian, provider, and management notified. Pain and skin assessment completed, bruise noted to left shin, resident denied pain. Resident was in common area when two other residents started to argue over the TV volume, this resident attempted to de-escalate the situation, during this attempt, the cane of one of the other residents made contact with this resident's leg. Residents were immediately separated. It should be noted that the facility's documentation of the investigation provided to the SA online did not identify/include the abrasion and new skin treatment orders as mentioned in the original incident report. Additionally, the above documentation was not accessible/available as part of the resident's electronic clinical record during the survey. Review of R60's clinical record revealed the resident was initially admitted into the facility on [DATE], readmitted on [DATE] with diagnoses that included: vascular dementia mild with psychotic disturbance, type 2 diabetes mellitus without complications, adjustment disorder with mixed disturbance of emotions and conduct, adjustment insomnia, and unspecified psychosis not due to a substance or known physiological condition. According to the Minimum Data Set (MDS) assessment dated [DATE], R60 had a Brief Interview for Mental Status Exam (BIMS) score of 15/15 which indicated intact cognition and was independent with walking using a cane. Review of R142's clinical record revealed the resident was admitted into the facility on 5/21/24 and readmitted on [DATE] with diagnoses that included: alcohol dependence with alcohol-induced persisting dementia, degeneration of nervous system due to alcohol, malignant neoplasm of unspecified site of right female breast, generalized anxiety disorder, major depressive disorder recurrent, mild, and cognitive communication deficit. According to the MDS assessment dated [DATE], R142 scored a 7/15 on the BIMS exam which indicated severe cognitive impairment. Further review of R60 and R142's clinical records revealed no documentation of the resident-to-resident incident from 11/3/25. Additionally, there was no identification or mention of the incident from 11/3/25 included in documentation by the Nurse Practitioner (NP 'L'), Social Work, or Psych NP following this incident for either of the residents. Additionally, R142's skin assessment dated [DATE] documented new concern for .Left lower leg (front) .one inch bump with bruise . There was no identification of the abrasion as identified by DON 'O' on 11/3/25. Review of the orders included a skin treatment order entered by Nurse 'F' on 11/3/25 to start on 11/4/25 and discontinued on 11/7/25 with a note of scabbed over that read, clean LLE with normal saline, apply A&D (topical vitamin used to protect minor cuts and scrapes) ointment, cover with dry dressing. one time a day for Treatment for 7 Days. On 12/11/25 at 7:55 AM, an interview was conducted with the Administrator (also the facility's Abuse Coordinator). When asked how it was determined they did not substantiate abuse, the Administrator reported the resident does not have the cognition to formulate intent, there were different witness statements and there were no outcomes emotionally. The Administrator confirmed the incident was not witnessed by staff, only upon hearing yelling/commotion. They further reported both residents had guardians and stated just because contact was made, doesn't mean abuse occurred, there was no intent. When asked how they determined no harm was sustained despite the injuries documented to R142 and if utilizing the reasonable person concept, the Administrator reported they did identify a bruise and offered no further clarification. According to the facility's policy titled, Abuse, Neglect and Exploitation dated 1/10/2024: .Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish .Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .Possible indicators of abuse include, but are not limited to .Physical marks such as bruises .Physical injury of a resident, of unknown source .

This citation has two Deficient Practice Statements (DPS). DPS #1This citation pertains to intake #'s 2642115 and 2661022. Based on observation, interview, and record review, the facility failed to ensure scheduled IV (intravenous) antibiotics were administered per physician's orders for two residents (R#'s 185 and 183) of two residents reviewed for IV antibiotics resulting in verbalized complaints, frustration, delayed treatment for infections, and the potential for an extended stay due to missed medication doses. Findings include: R185 On 12/9/25 at 12:17 PM, R185 was observed in their room seated in their wheelchair. An IV pump and pole were present in the room. At that time an interview was conducted with R185 regarding their stay in the facility. R185 verbalized complaints they were not receiving their IV antibiotics as scheduled. They said they were to receive the medication three times a day and felt they had missed some of their doses. On 12/10/25 at 10:30 AM, a second interview with R185 was conducted and they indicated they did not receive their 6 AM dose of their IV antibiotic. R185 appeared upset, frustrated, and verbally expressed worry about the missed doses and how it would impact their recovery. 12/10/2025 at approximately 10:35 AM, R185's Nurse, Nurse 'W' was asked if R185 received their 6 AM dose of their IV antibiotic and said they did not. They were asked if they knew why and said they did not think the pharmacy delivered the medication overnight, so it was not available for the midnight shift nurse to administer. A review of R185's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: surgical aftercare and a MSSA (Methicillin Susceptible Staphylococcus Aureus) bacterial infection in their blood. The record further revealed R185 had intact cognition and admitted for physical rehabilitation and IV antibiotic therapy for the MSSA bacterial infection. A review of R185's physician orders and medication administration record (MAR) was conducted and revealed an order dated 12/6/25 for cefazolin (IV antibiotic) 2 gram IV every 8 hours scheduled for 6 AM, 2 PM, and 10 PM for 21 days. It was noted the first dose of the medication was administered at 10 PM on 12/6/25 when they arrived at the facility. The order for the medication was discontinued on 12/8/25 after the 6 AM dose was given and re-ordered to start on 12/8/25 at 10 PM. The documentation on the MAR was blank for the 12/8/25 dose scheduled for 2 PM and it was unclear why they did not receive that scheduled dose. Further review of R185's MAR revealed the 12/10/25 6 AM dose of cefazolin was blank on the MAR in congruence with R185 saying they did not receive it as scheduled. On 12/10/2025 at 3:18 PM, an interview was conducted with Registered Nurse (RN)/Unit Manager 'S' regarding R185's missing antibiotic medication administrations. Nurse 'S' said they did not know why the medication was discontinued on 12/8/25 and re-started on 12/8/25 at 10 PM causing them to miss the 2 PM dose. They further reported the dose missed at 6 AM on 12/10/25 was because the pharmacy did not deliver any medications due to the weather. On 12/11/25 at 12:05 PM, an interview was conducted with the facility's Director of Nursing (DON) regarding R185's missed IV antibiotics. The DON acknowledged the concern and indicated the doses may have been missed but they would be added on to the end of the course of treatment to ensure R185 got 21 days of their three times a day antibiotic. At that time, it was pointed out that for every three doses R185 missed (already having missed two, with several more days to go) would equate a one extra day stay in the facility; to which the DON indicated they did not think about it in that way. R183 Clinical record review revealed R183 was admitted to the facility on [DATE] for weakness and deconditioning secondary to a stroke. R183 had a significant cardiac history for a prosthetic heart valve and was treated with intravenous (IV) antibiotics for infective endocarditis (infection and inflammation of the heart valve). R183's Brief Interview of Mental Status (BIMS) assessed on 8/13/25 scored 15/15 indicating no cognitive impairment. The State Agency received a concern identifying Nurse Practitioner (NP) L was informed that after a cardiology consult on 10/7/25, it was recommended for R183 to continue IV Vancomycin (antibiotic) until they were seen by their Infectious Disease (ID) doctor on 10/29/25. It was alleged the facility failed to order and administer the IV antibiotic. Record review of R183's Cardiology consult signed and dated on 10/7/25 recommended to continue Vancomycin IV until follow up with infectious Disease. Underneath the Cardiologists signature was an ineligible signature dated 10/8/25. Record review of a Progress note dated 10/8/25 at 8:00 AM authored by NP L read .medical history of vegetative endocarditis of prosthetic aortic valve. Pt (Patient) was on iv vancomycin, completed today. Pt had appointment with her cardiology yesterday, cardiology recommended to continue iv vancomycin until pt f/u with her infectious disease. Discussed with facility, iv vancomycin re-ordered to restart tomorrow. The Medication Administration Record (MAR) documented R183 had not received IV Vancomycin on 10/8/25 and 10/9/25. On 12/11/25 at approximately 11:00 AM the Director of Nursing (DON) confirmed that NP L was in the building and would send them down to the surveyor conference room for an interview. Approximately two hours lapsed, and Assistant Director of Nursing (ADON) B was asked if NP L was coming to the surveyor room at which time the ADON confirmed NP L had left the facility without seeing the surveyor. On 12/11/25 at 1:36 PM, NP L was contacted by telephone, was unable to access the Electronic Medical Record (EMR) and the surveyor had to read the documentation in question over the phone. NP L had recollection of R183 and history of the note from 10/8/25 and commented they collaborated with Infectious Disease RN N about reordering and did not reorder the medication. When asked why their progress note documented .iv vancomycin re-ordered to restart tomorrow. NP L did not provide an explanation and referred back that they spoke to ID RN N about it. On 12/12/25 at approximately 3:30 PM, an interview with the DON, ADON, and Infectious Disease RN N. The cardiology consult recommendation document was reviewed and the DON confirmed the ineligible signature and date of 10/8/25 was in fact that of NP L. ID RN N said they were approached by R183 on 10/9/25 asking why their antibiotic had not been given. RN N stated they had no knowledge of IV Vancomycin continuing and never collaborated with NP L about R183 and reordering the Vancomycin. ID RN N was very familiar with R183 and their diagnosis of endocarditis, immediately investigated their concern, confirmed that the antibiotic should had been ordered, was not, and had RN S obtain the order immediately. Record review of the of the medication order documented Vancomycin IV 1.25 grams (GM) for endocarditis was taken as a verbal order on 10/9/25 at 3:00 PM by RN S and was not administered to R183 until 10/10/25. A review of a facility provided policy titled, Medication Administration revised 1/2023 was conducted and read, .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. DPS #2 Based on observation, interview and record review, the facility failed to provide a comprehensive skin assessment and initiate considerations regarding treatment management for one (R91) of one reviewed for non-pressure-related skin ulcers/wounds. Findings include: Clinical record review revealed R91 was admitted to the facility on [DATE] with COPD (Chronic Obstructive Pulmonary Disease), cardiovascular failure, depressive and generalized anxiety disorders. R91's Brief Interview of Mental Status (BIMS) assessed on 11/19/25 scored 15/15 indicating no cognitive impairment. On 12/9/25 at 9:00 AM, during initial introductions, R91 voiced concern needing a dermatology consultation for a skin sore on both lower legs. R91 legs were observed with numerous rounds partially scabbed and open sores with inflamed red colored borders. R81 said they were admitted with sores appearing like insect bites, nothing has helped, and they are itching more. R91 was observed removing a medicine cup filled with an ointment off their bedside tray and said, this is what they gave me nothing is working and is told by the staff, try not to scratch them. Clinical record review revealed on 6/25/25 Nurse Practitioner (NP) L ordered a wound care consult .to follow open wounds lower extremities. Wound consult on 7/1/25 documented .Asked to see resident due to scratches and picking marks. Spoke to resident about her wounds and she told me that she has tic's under her skin that she has to pick out.This is clearly a psychiatric issue, and she should be followed by psychiatry. Record review of R91's Care Plan Initiated on 6/5/25 and revised on 8/29/25 documented .Resident has behavior(s)as evidenced by: picking at skin. Interventions include .Administer medications as ordered. Observe for effectiveness and side-effects.Encourage resident to ask questions when concerned with their medical condition to reduce anxiety. Record review of Progress Note dated 12/10/25 at 8:00 AM authored by NP L documented resident apply Triamcinolone Acetonide Ointment 0.1% to affected area topically every 8 hours as needed for rash and apply to bilateral legs. On 12/11/25 at approximately 11:00 AM the Director of Nursing (DON) confirmed that NP L was in the building and would send them down to the surveyor conference room for an interview. Approximately two hours lapsed, and Assistant Director of Nursing (ADON) B was asked if NP L was coming to the surveyor room at which time the ADON confirmed NP L had left the facility without seeing the surveyor. On 12/11/25 at 1:36 PM, NP L was contacted by telephone, was unable to access the Electronic Medical Record (EMR) and the surveyor had to read the documentation in question over the phone. NP L confirmed they did not assess R91 legs. Informed them that R91 was complaining of increased itching to them and both legs and were observed with numerous round partially scabbed and open sores with inflamed red colored borders. NP L was asked why the Triamcinolone Acetonide Ointment 0.1% to affected area topically every 8 hours as needed for rash as clearly no rash was observed and there was concern for the sores on their legs. NP L said R91 never mentioned anything to them about the sores on their legs, therefore, they did not assess. NP L then replied to the surveyor because the surveyor brought it to their attention, they would look at their legs next time. On 12/11/25 at approximately 3:30 PM, an interview with the Director of Nursing (DON) was questioned if the residents have skin assessments and how often. Per the DON every resident, regardless of their diagnosis, has a weekly skin assessment documented by Nursing. Record review with the DON revealed that R91 had not had a documented skin assessment since 10/25/25. An alert in red documented Skin Assessment 40 days overdue 11/1/2025. The DON confirmed this was not acceptable and R91 should have had up to date skin assessments.

Based on observation, interview and record review, the facility failed to ensure proper storage of medications and biologicals for four of four medication carts reviewed for medication storage.Findings include: On 12/10/2024 at 9:10 AM, An observation of the Mum Front Medication Cart was conducted with Licensed Practical Nurse (LPN) F. The following medications were observed unpackaged and without patient identifiers: Second drawer was observed with loose medications including a white oval shaped tab, white round scored tab stamped 16, tallow round tab stamped 54, white scored tab. Third drawer base was observed with moderate amounts of red and brown colored spilled dried matter where liquid stock medications are stored. A liquid stained envelope with name of a resident was observed tucked into the corner containing four size 13 Kirkland Brand hearing aid batteries. Per LPN F the resident no longer at the facility. On 12/10/2024 at 9:30 AM, an observation of the Lilly Back Medication Cart was conducted with Registered Nurse (RN) G. The following medications were observed unpackaged and without patient identifiers: Second drawer was observed with loose medications including a purple round stamped 175, green oval stamped E47, peach oval stamped D 850, yellow oval stamped H88, two yellow oval tabs stamped 152, orange colored capsule, blue white capsule stamped [NAME]/Q02, pink capsule, three green oval tabs stamped A16, two round white tabs stamped HH974, two round stamped 127c, two pink oval shaped stamped 8945, orange round stamped 022, purple round tab stamped L17, blue round stamped HH205. Third drawer base was observed with chalklike crushed debris and red and brown colored spilled dried matter where liquid stock medications are stored. Fourth drawer contained an open pack of strawberry flavored hard candies. RN G was not sure who they belonged to and acknowledged food should not be stored in the medication cart. On 12/10/2024 at 10:00 AM, an observation of the [NAME] Medication Cart was conducted with LPN H. The following medications were observed unpackaged and without patient identifiers: First drawer was observed with four individual packaged Risperidone (an antipsychotic medication) with no resident identifiers. Second drawer was observed with loose medications including a round tab stamped V/15, blue white capsule R149, two white round tabs stamped P5, white round stamped EP116, blue round tab, oval round 216, white scored tab, round yellow tab stamped T230. Third drawer was observed with a single use vial of Cyclosporine (medication to reduce inflammation and improve tear production) eye drops with no resident identifier. LPN H remarked the name of the resident and when questioned how they knew the medication with no patient identifier, LPN H said it was the only resident on the unit who uses it. Top drawer of right side of cart where insulin, syringes, and glucometer supplies are stored was observed storing a single use vial of Cyclosporine, a yellow colored lighter, and a pair of sunglasses (unknown owner). LPN H acknowledged these items should not be stored amongst medications and medication supplies. LPN H accessed the units Medication Storage unit where an opened package of Froot Loop brand cereal was stored amongst medical storage supplies. On 12/10/25 at 4:07 PM, The Director of Nursing (DON) was informed of the medication cart and room storage observations. The DON acknowledged loose unidentified medication and no resident identifiers is not safe or proper storage. The DON remarked the Staff had brought the above findings to their attention prior to this interview. On 12/10/25 at 12:47 PM, an observation of a medication cart on Unit 3, stored in the hallway outside of room [ROOM NUMBER] revealed there were two clear cups stored on top of the cart. One cup contained two lancets (needles used to monitor blood sugar levels) with two glucometer test strips and the other cup was a smaller one-ounce cup which contained a clear, thicker liquid substance. There were multiple residents and staff observed passing directly by the medication cart. Further down the hallway, another Nurse (Nurse 'P') was observed at another medication cart. At 12:50 PM, Nurse 'P' was asked about who was assigned to the medication cart outside of room [ROOM NUMBER] and they reported they were in training and the main Nurse (Nurse 'G') was with another resident. Nurse 'P' was asked about the items stored on top of the medication cart and Nurse 'P' proceeded to pick up the cup and smell the contents and reported they thought it was icy hot (a topical pain reliever containing menthol) and left it on the top of the cart. Nurse 'P' then was asked about the lancets and glucometer test strips and if those should be stored on the top of the cart and they stated those should've been locked up. Nurse 'P' proceeded to remove the lancets to place back into the cart and then removed the two glucometer strips with their bare hands and placed the strips back into the original glucometer strip container in the cart. On 12/10/25 at 1:09 PM, Nurse 'G' returned to the hallway. When informed of the storage of the biological (clear substance in cup) on the top of the medication cart, Nurse 'G' proceeded to discard the cup into the open garbage attached to the lower side of the medication cart which was full (the cup remained stored on top of the garbage). When informed of the storage of the lancets on top of the med cart and the observation of Nurse 'P', Nurse 'G' reported that should not have occurred and would follow-up with the nurse. According to the facility's policy titled, Medication Storage dated 1/30/2024: .It is the policy of this facility to ensure all medications housed on our premises will be stored according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security .All drugs and biologicals will be stored in locked compartments .

Based on observation, interview, and record review, the facility failed to implement appropriate infection control practices relating to laundry service and transmission based precautions for one resident (R185), of one resident reviewed for transmission based precautions, resulting in the spread of infection. Due to faulty infection control practices in the laundry, this his deficient practice had the potential to affect all residents residing in the facility. On 12/9/25 and 12/10/25, multiple observations of R185's room revealed a sign that indicated they were on contact isolation precautions (transmission based precaution that requires the use of an isolation gown and gloves when entering the room) as well as personal protective equipment (isolation gowns, gloves, masks, face shields) for use located in the hallway next to R185's room. On 12/11/25 at 9:20 AM, Phlebotomist 'W' was observed to enter R185's room with their phlebotomy kit (a bag with blood draw supplies). Upon entry to the room they were not observed to don an isolation gown. When they entered the room, they were further observed to place their phlebotomy kit on the floor and obtain a lab specimen from R185. After exiting the room, they were not observed to sanitize the kit that had been placed on the floor in the contact isolation room. On 12/11/25 at 9:25 AM, an interview with Phlebotomist 'W' was conducted and they were asked why they did not don an isolation gown prior to entering the room. They said they did not know R185 was on contact isolation precautions. They were then asked if they saw the sign hanging on the door that indicated the room was a contact isolation room and they offered no response. On 12/11/25 at 12:05 PM, an interview was conducted with the facility's Director of Nursing, and they indicated Phlebotomist 'W' should have donned the appropriate personal protective equipment prior to entering the room. A review of a policy titled, Transmission-Based (Isolation) Precautions revised 12/2023 was conducted and read, .'Contact Precautions' refers to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment .9. Contact Precautions- .c. Healthcare personal caring for residents on Contact Precautions wear a gown and gloves for interactions that involve contact with the resident or potentially contaminated areas in the resident's environment . On 12/11/25 at approximately 2:30 p.m., a review of the linen/personals was conducted in the laundry room with laundry aide V (LA V). In the main washing room, three bins full of clean personal clothing were located uncovered in close proximity to the washing machine. LA V was queried if they had a room for clean clothing after it has been washed and they reported they did but it was not being used for clean storage at that time. LA V was queried how they wash the soiled linen and clothing and they reported they take it to the washing machine from the dirty room and put it in. LA V was asked why the clean clothing was located close to the washing machine where they fill with soiled clothing and linen and they acknowledged they understood the risk of contamination from the soiled clothing and did not think it was being done correctly. At that time, the Middle washing machine was inspected and revealed the back right corner was leaking water and had a standing puddle of water behind it. LA V was queried regarding the leaking washing machine and the large puddle of stagnant water, and they indicated they would have to let maintenance know about the water.

Based on interview and record review the facility failed to maintain complete and accurate electronic medical records for two (R60 and R142) of two residents reviewed for medical records. Findings include:A review of a Facility Reported Incident (FRI) submitted to the State Agency (SA) revealed an allegation It was reported the facility failed to protect the resident from a resident to resident physical abuse incident which did not result in injury. Documentation revealed the incident occurred on 11/3/25 but no time was included in the incident summary provided.The facility's investigation documented, in part: .On 11/3/2025, resident (R60) had a disagreement in the Unit 2 common area over the loudness of the television as she requested for the television to be turned down. As a result, resident (R142) intervened and contact was made by (R60's) quad point cane to (R142's) leg. Pain and skin assessment completed. There was a small bump to (R142's) leg. No pain and resident (R142) indicated that she was fine. There were no new findings as a result of the assessments provided to (R60).The facility's conclusion to the investigation revealed they did not substantiate abuse occurred because there was no intent to harm, there was no harm or injury, and there was no allegation of abuse made by either resident related to the alleged resident to resident incident. The small bruise that was identified has since been resolved.Further review of additional documentation included an incident report for R142 provided by the Administrator from 11/3/25 which was completed by the former Director of Nursing (DON 'O'). This documentation included: .Nursing Description: Resident was sitting in common area lounge with other residents watching TV, another female resident approached the group of people demanding the volume be turned down by a male resident who had the remote control, hitting the back of his chair with her cane when request was not obliged. (R142) interjected herself into situation resulting in female resident making contact with her LLE (Left Lower Extremity), leaving a bruise and a small bump, writer was able to redirect said female resident back to her hall. Resident Description: (R142) stated she was sitting in her wheelchair when another female resident came up and hit her with her cane when she was trying to defend herself by putting her hand up to block the cane from making further contact. Resident showed writer bump on lower extremity .Injury Type Abrasion .Left lower leg (front) .Bruise .Left lower leg (front) .Mental Status .Oriented to Person .Place .Situation .Time .Notes 11/4/2025 IDT (Interdisciplinary Team) reviewed incident from 11/3/25, guardian, provider, and management notified. Pain and skin assessment completed, bruise noted to left shin, resident denied pain. Resident was in common area when two other residents started to argue over the TV volume, this resident attempted to de-escalate the situation, during this attempt, the cane of one of the other residents made contact with this resident's leg. Residents were immediately separated.It should be noted that the facility's documentation of the investigation provided to the SA did not identify/include the abrasion and new skin treatment orders. The only mention of R142's abrasion was on the actual incident report completed by DON 'O' and this documentation was not accessible/available as part of the resident's electronic clinical record during the survey.Review of R60's clinical record revealed the resident was initially admitted into the facility on [DATE], readmitted on [DATE] with diagnoses that included: vascular dementia mild with psychotic disturbance, type 2 diabetes mellitus without complications, adjustment disorder with mixed disturbance of emotions and conduct, adjustment insomnia, and unspecified psychosis not due to a substance or known physiological condition.According to the Minimum Data Set (MDS) assessment dated [DATE], R60 had a Brief Interview for Mental Status Exam (BIMS) score of 15/15 which indicated intact cognition and was independent with walking using a cane.Review of R142's clinical record revealed the resident was admitted into the facility on 5/21/24 and readmitted on [DATE] with diagnoses that included: alcohol dependence with alcohol-induced persisting dementia, degeneration of nervous system due to alcohol, malignant neoplasm of unspecified site of right female breast, generalized anxiety disorder, major depressive disorder recurrent, mild, and cognitive communication deficit.According to the MDS assessment dated [DATE], R142 scored a 7/15 on the BIMS exam which indicated severe cognitive impairment.Further review of R60 and R142's clinical records revealed no documentation of the resident to resident incident from 11/3/25.Review of the skin assessments for R142 included one dated 11/3/25 at 9:44 PM documented, .Left lower leg (front) .one inch bump with bruise .Treatment initiated .Yes .Are there any existing abnormal skin areas . There was no mention of an abrasion as documented in the incident report.Review of the physician orders for R142 included a skin treatment order entered by Nurse 'F' on 11/3/25 to start on 11/4/25, and discontinued on 11/7/25 with a note of scabbed over that read, clean LLE with normal saline, apply A&D (topical vitamin used to protect minor cuts and scrapes) ointment, cover with dry dressing. one time a day for Treatment for 7 Days.Review of the interdisciplinary progress notes for both R60 and R142 since 11/3/25 revealed there no identification of the resident-to-resident incident from 11/3/25 or any details of follow-up/evaluation. The documentation as available in the clinical record would not inform the reader that any incident had occurred.Review of the provider visit by Nurse Practitioner (NP 'L') on 11/4/25 at 8:00 AM and 11/7/25 at 8:00 AM revealed there was no reference or discussion that they had assessed the resident following the resident-to-resident incident on 11/3/25. Both assessments contained the same skin notes, .Skin.Negative: Wounds, Erythema, Rash, Bruising.This evaluation conflicted with the identification of a one inch bruise and abrasion by nursing on 11/3/25 as well as treatment orders and documented treatments provided to R142 on 11/4, 11/5, and 11/6.Review of R142's provider visit on 11/12/25 at 6:51 PM by Psychiatry NP 'V' revealed their documentation did not identify if they had been notified and/or aware of the resident-to-resident incident from 11/3/25.On 12/11/25 at 7:55 AM, an interview was conducted with the Administrator (also the facility's Abuse Coordinator) to review the details of the incident between R60 and R142. At that time, the only documentation provided for review was the documentation submitted to the SA and the residents' electronic clinical records.On 12/11/25 at 10:10 AM, the Administrator was asked about the lack of documentation that any incident had occurred on 11/3/25 for both R60 and R142 and they reported that information was in an incident report. When informed that incident reports were not available to the survey team in the electronic medical records, and also requested they provide an explanation as to why the documentation from the interdisciplinary team (including social services, NP 'L' and psych consultant) did not include/identify any reference to the incident in their documentation of visits following the incident, the Administrator reported the psych consultant was aware and the notes entered on the incident report had some sections go into the record. The Administrator was requested to provide that documentation and was informed there was no documentation included currently in the medical record and they reported they would follow-up.On 12/11/25 at 10:25 AM, the Administrator reported they had R142's incident report and provided a copy. They further reported they had to create a ticket with IT (Information Technology) regarding the IDT notes at the bottom of the incident report because that information should've gone into the clinical record and they confirmed it did not.When asked what the facility's expectation was regarding documentation following incidents, especially given one that was reported to the SA, the Administrator reported when the staff completed an incident/accident report the staff notify the provider, we normally have social services do wellness checks and psych consultant (NP 'V') comes in and sees the resident. When asked why that was not reflected in any of the IDT's documentation, the Administrator offered no further explanation. On 12/11/25 at 10:33 AM, the facility's corporate clinical support provided a copy of an email request from the DON regarding an IDT note from a Risk Management record (not available to the survey team) that needed to be added to the resident's chart.On 12/11/25 at 10:51 AM, the Administrator was requested via email to provide the contact information for NP 'L' as well as a facility policy that addressed complete/accurate clinical recordsOn 12/11/25 at 10:53 AM, the Administrator was requested via email to provide an incident report for R142 (as of that time an incident report was only provided for R60 and not included in the documentation of the incident file provided during survey.On 12/11/25 at approximately 11:00 AM the DON was informed the survey team wanted to speak with NP 'L' and the DON reported NP 'L' was currently in the facility and had been notified of the request.On 12/11/25 at 11:35 AM, an interview was conducted with the Administrator and Director of Nursing (DON). When queried about the treatment order and concerns that were not identified on the facility's skin assessment, nor were mentioned in any details in the progress notes, and discrepancies and lack of identification in the practitioner's notes, or social services, the Administrator questioned why this had not come up in the past as their process had not changed. Neither the DON or the Administrator offered any further explanation.On 12/11/25 at 12:55 PM, a phone interview was conducted with Psych NP 'V'. When asked about their process for documentation of their evaluation of residents for resident-to-resident incidents and whether that should be included within their documentation, Psych NP 'V' stated they had previously spoke to the Administrator before this phone call and further reported they had been notified but couldn't recall the details exactly and not sure of the exact date, but didn't verbally think as an extreme need for psychiatry so I did a routine visit and further reported they didn't always reference that in their evaluations. When asked how that could be determined based on the lack of documentation, Psych NP 'V' offered no further explanation.On 12/11/25 at approximately 1:30 PM, the survey team was informed by the Assistant Director of Nursing (ADON) that NP 'L' was no longer at the facility, but confirmed NP 'L' had been informed of the request to meet.On 12/11/25 at 1:45 PM, a phone interview was conducted with NP 'L'. When asked if they had been notified of the survey team's request to meet while they were in the facility, NP 'L' reported they had not and was told the Administrator wanted to see them. They further reported they were unable to return, did not have access to the medical records, but agreed to the interview. When asked about their knowledge of the resident-to-resident incident between R60 and R142 on 11/3/25, NP 'L' reported they were not aware of that. When asked about their documentation including multiple visits post incident in which they documented no skin issues, despite orders in place to address the bruise and abrasion, NP 'L' reported if they documented that, then they evaluated the skin and saw no issues. When asked to explain the discrepancies, NP 'L' offered no further response. On 12/11/25 at 3:29 PM, the Administrator was requested for a facility policy for complete/accurate medical records and at 3:34 PM, they responded, We do not have a policy for complete/accurate medical records.

Based on observation, interview, and record review, the facility failed to thoroughly inventory and document personal belongings upon admission for one resident (R123), of one resident reviewed for personal belongings, resulting in the potential for denial of replacement of missing items and valuables. Findings include: On 12/9/25 at 11:56 AM, R123 was observed lying in bed in their room. They were asked about their stay at the facility and verbalized a complaint regarding the facility losing their hearing aids and their ice packs brought from home. R123's room was observed to contain many personal items of value, among them: a cell phone, electric razor, and a tablet. They were asked if the facility was aware they were missing the items and said they alerted someone but did not know who. They further said the person they alerted dismissed their concern because the items were not listed on their, inventory sheet. They were asked if staff assisted them to fill out a grievance form and said they did not. On 12/10/25 at approximately 11:00 AM, a review of R123's INVENTORY OF PERSONAL EFFECTS form scanned into their record was reviewed. The form had only one item, wheelchair catalyst written in ink pen on the form. It was noted the form had an area to inventory various electronics such as a cell phone or a tablet as well as an area to document Personal Assistive Devices, such as hearing aids. The form was dated 11/13/25 and signed by a staff member but was not signed by R123. On 12/11/15 at 9:20 AM, an interview was conducted with Nurse 'F' (assigned to R123's care) and they were asked who filled out the INVENTORY OF PERSONAL EFFECTS forms when a resident admits to the facility. They said it was usually the certified nurse aides or sometimes a nurse. On 12/11/25 at 12:05 PM, an interview was conducted with the facility's Director of Nursing (DON) regarding R123's inventory form and their missing personal items (hearing aids and ice packs). They reviewed the form at that time and said the form should have been completely filled out by staff and signed by R123. A review of R123's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: spinal fusions, spinal instabilities, falls, traumatic subarachnoid hemorrhage (brain bleed), diabetes, and heart disease. A review of R123's most recent Minimum Data Set assessment dated [DATE] indicated R123 had intact cognition. A review of a facility provided policy titled, Resident Personal Belongings revised 1/2022 was reviewed and read, It is the policy of this facility to protect the resident's right to possess personal belongings .1. All resident possessions, regardless of their apparent value to others, will be treated with respect .3. All resident personal items will be inventoried at the time of admission by the social services designee, or another designated staff member and documentation shall be retained in the record .

Based on observation, interview, and record review the facility failed to ensure the call light was in reach for one resident (R114), of one resident reviewed for accommodation of needs, resulting in verbalized frustration and the potential for a delay in staff response to resident needs. Findings include: On 12/9/25 at 11:49 an, R114 was observed in their room. They were sitting in their recliner with their legs elevated. The recliner was positioned approximately five feet away from the right side of their bed. An interview with R114 was conducted and they said they were experiencing pain. They were asked if they made the nurse aware, and said they did not. They were then asked if they could activate their call light to request their nurse and said, I can't reach it, it's way over there. R114 pointed to their call light that was observed clipped to their bed, approximately five feet away from where they were seated in their recliner. R114 was asked if they were able to ambulate from their recliner to the bed to get the call light and said they could not. R114 appeared frustrated, sighed and said, It's such a simple thing, regarding having their call light left in their reach when they were assisted to their recliner. On 12/9/25 at 11:56 AM, Nurse 'S' was asked about R114's call light being out of reach and said it should have been within reach. On 12/11/25 at 11:58 AM a review of R114's clinical record revealed they most recently readmitted to the facility on [DATE] with diagnoses that included: humerus fracture, syncope and collapse, bone cancer, breast cancer, brain cancer, pain, and muscle weakness. R114's most recent Minimum Data Set assessment dated [DATE] indicated R114 was cognitively intact. A review of a facility provided policy titled, Call Lights: Accessibility and Timely Response revised 12/28/23 was reviewed and read, .1. Staff are educated in the proper use of the resident call system, including how the system works and ensuring resident access to the call light .

Based on observation, interview, and record review, the facility failed to implement their grievance process for one resident (R185) of one resident reviewed for grievances, resulting in verbalized complaints and unresolved grievances. Findings include: On 12/9/25 at 12:17 PM, R185 was observed in their room seated in their wheelchair. An IV (intravenous) pump and pole were present in the room. At that time an interview was conducted with R185 regarding their stay in the facility. R185 verbalized complaints they were not receiving their IV antibiotics as scheduled. They said they were to receive the medication three times a day and felt they had missed some of their doses. On 12/10/25 at 10:30 AM, a second interview with R185 was conducted and they indicated they did not receive their 6 AM dose of their IV antibiotic. R185 appeared upset, frustrated, and verbally expressed worry about the missed doses and how it would impact their recovery. On 12/10/2025 at approximately 10:35 AM, R185's Nurse, Nurse 'W' was asked if R185 received their 6 AM dose of their IV antibiotic and said they did not. They were asked if they knew why and said they did not think the pharmacy delivered the medication overnight, so it was not available for the midnight shift nurse to administer. A review of R185's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: surgical aftercare and a MSSA (Methicillin Susceptible Staphylococcus Aureus) bacterial infection in their blood. The record further revealed R185 had intact cognition and admitted for physical rehabilitation and IV antibiotic therapy for the MSSA bacterial infection. R185's Medication Administration Record (MAR) was reviewed and revealed a missed dose of their intravenous antibiotic scheduled for 12/10/25 at 6 AM. Continued review of the record revealed a Pertinent Charting-Behavior note entered into the record by Registered Nurse (RN)/Unit Manager 'S' dated 12/10/25 at 8:19 AM that read, .Note Text: Event Date: 12/10/2025 Behavior Displayed: resident making accusations of staff not providing care .Accusing staff of not providing medications .verbally aggressive to staff. Precipitating factors/events: resident forgetful of care/medication administration. Intervention(s) attempted: attempted speaking with resident. He voices understanding but with next person will again be verbally aggressive Intervention results: unsuccessful .On 12/10/2025 at 3:18 PM, an interview was conducted with Registered Nurse (RN)/Unit Manager 'S' regarding their Behavior note entered into the record at 8:19 AM on 12/10/25. They said R185 received their medication but was forgetful. At that time, it was brought to their attention, R185 in fact had not received their 6 AM antibiotic medication as evidenced by the MAR and an interview with Nurse 'W' and that caused them to be upset. RN 'S' was asked if they believed R185 had a valid concern and agreed. They were asked if they assisted R185 with filling out a grievance form and said they did not. They were asked why they did not take a grievance and said they were the unit manager and they, handled it. On 12/11/25 at 12:05 PM, an interview was conducted with the facility's Director of Nursing (DON) regarding R185's concerns with not receiving their scheduled IV antibiotics. They were asked if they thought R185 should have been offered or assisted to file a grievance and said they should have; so, the root cause could be investigated and R185 could have been given a clear explanation on what happened and why their medications were not given. A review of a facility provided policy titled, Quality Assistance Procedure revised 10/2023 was conducted and read, .1. Any resident, his or her representative .may file a Quality Assistance Form concerning treatment, medical care .5. Upon receipt of a written Quality Assistance Form/request, the department manager will investigate the allegations and submit a written report of such findings to the administrator .7. The resident or person filing the Quality Assistance Form on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems .

Based on observation, interview and record review the facility failed to ensure allegations of abuse were reported to the Administrator/Abuse coordinator and to the State Agency for one R (68) of nine residents reviewed for abuse. Findings include:On 12/9/25 at approximately 9:40 AM, R68 was observed sitting in their wheelchair in their room. The resident was alert and able to answer questions asked. When asked if they felt safe in the facility, they reported that some staff are often rude, disrespectful and at times not physically careful.A review of R68's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: type II diabetes, difficulty walking and acute respiratory failure. A review of R68's Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 (intact cognitive functioning) and was their own responsible party.Continued review of R68's clinical record revealed, in part, the following:11/9/25: Pertinent Charting Behavior: .Resident screaming at staff she wants to be sent out.Resident assisted to restroom.via sit-to-stand and after toileting.stating staff pushed her into a wall. X2 persons present during patient care due to allegations. Authored by Nurse U (*It should be noted that Nurse U was no longer employed by the facility).A request was made for all Incident and Accident (IA) reports pertaining to R68. No IA's pertaining to the allegation of physical abuse provided.On 12/11/25 at approximately 11:43 PM, an attempt to contact Nurse U via phone. A voice message was left. No return call was made prior to the end of the Survey.On 12/11/25 at approximately 11:52 PM, an interview was conducted with the Administrator/Abuse Coordinator regarding the allegation made by R68. The administrator reported that they were not made aware of the allegation and noted that Nurse U was terminated from employment based on attendance. The Administrator/Abuse Coordinator confirmed that all allegation pertaining to physical abuse should be reported to them.A review of the facility policy titled, Abuse, Neglect and Exploitation (1/10/24) revealed, in part: .It is the policy of this facility to provide protections for the health, welfare and rights of each resident.Abuse: means the willful infliction of injury.punishment with resulting physical harm.which can include staff to resident abuse.Reporting/Response.Reporting of alleged violations to the Administrator.immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse.or not later than 24 hours if the allegations do not involve abuse.

Based on observation, interview, and record review, the facility failed to initiate their bowel protocol for one resident (R123) of one resident reviewed for bowel and bladder, resulting in constipation and verbalized complaints of pain and discomfort. Findings include: On 12/9/25 at 11:56 AM, R123 was observed in their bed. At that time, an interview was conducted and R123 reported they had not had a bowel movement in a week. They were asked if staff were aware of his situation and said they were, and someone told them they were going to get a suppository later on in the day. R123 expressed feelings of anxiousness, pain, and discomfort in their stomach. They further reported they had several of their thoracic vertebrae fused in their spine and at home they were on a strict bowel regimen to ensure regularity. They expressed frustration with staff not listening to them and said they had been hospitalized in the past because of constipation and feared having to be hospitalized again. A review of R123's clinical record revealed they were admitted to the facility on [DATE] with diagnoses that included: falls, spinal fusion, traumatic subarachnoid hemorrhage (brain bleed), heart disease, and diabetes. R123's Minimum Data Set assessment dated [DATE] revealed they had intact cognition. R123's Certified Nurse Aide task for bowel movements was conducted and revealed the last documented bowel movement was on 12/3/25. On 12/10/25 at approximately 3:40 PM, a nursing progress note dated 12/10/25 at 2:58 PM entered into the record by nurse 'S' read, .resident would like to have a suppository daily. states he believes that he has a neuro disorder from a mva (motor vehicle accident) years ago and that he has trouble going and that it causes pain to shoot down his legs when he cannot go NP/MD (Nurse Practitioner/Medical Doctor) notified to eval (evaluate) resident for suppository. Further review of the record revealed a physician's order dated 11/26/25 for a bisacodyl rectal suppository every 24 hours as needed if they had not had a bowel movement in two days, however; R123's December Medication Administration Record (MAR) did not reveal any administrations of the as needed suppository to treat R123's constipation. On 12/11/25 at approximately 11:50 AM, a follow-up interview was conducted with R123. They were asked if they received a suppository and had a bowel movement. They said they finally received the suppository and they had a huge bowel movement. R123 went on to describe the bowel movement as feeling like they were passing, a baseball bat. They expressed relief but wondered why they had to wait so long. On 12/11/25 at 12:05 PM, an interview was conducted with the facility's Director of Nursing (DON). They were informed R123 went several days without a bowel movement despite having an order for an as needed order for a suppository. The DON said the facility should have followed their bowel protocol and the physician's orders. A request for a policy on the facility's bowel protocol was made; however the Administrator reported via e-mail on 12/11/25 at 3:07 PM the facility did not have a policy for bowel protocol.

Based on observation, interview, and record review, the facility failed to ensure dressings were changed in a timely manner for a peripherally inserted central catheter for one resident (R185), of one resident reviewed for peripherally inserted central catheters, resulting in the potential for the development of infection. Findings include: On 12/9/25 at 12:17 PM, R185 was observed in their room seated in their wheelchair. An interview was conducted at that time and R185 expressed some concerns with their IV (intravenous) antibiotic medications. R185 was asked how they received their IV medications and said they had a PICC (peripherally inserted central catheter) line in their right arm. With their permission, an observation of the line and the insertion site was conducted and it was noted the dressing on the PICC line was dated 12/2/25. On 12/10/25 at 10:32 AM, a second observation of R185's PICC line dressing revealed it remained with the date of 12/2/25. They were asked if the dressing to their PICC line had been changed since they admitted to the facility and they said no. A review of R185's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: surgical aftercare and MSSA (Methicillin Susceptible Staphylococcus Aureus) bacterial infection. The record further revealed R185 had intact cognition and admitted for physical rehabilitation and IV antibiotic therapy for the MSSA bacterial infection. A review of R185's physician orders, medication administration record (MAR), and treatment administration records (TAR) were conducted and revealed an order for a dressing change to the PICC line site scheduled for 12/7/25 and signed out as being completed, despite the dressing being dated 12/2/25 and R185 reporting it had not been done since their admission on [DATE]. On 12/10/25 at 3:18 PM, an interview was conducted with Registered Nurse (RN)/Unit Manager 'S'. They were informed R185's PICC line dressing was observed dated 12/2/25 despite the TAR indicating the dressing was changed on 12/7/25. They said the dressing should have been changed per the schedule and they would look into the concern. A review of a facility provided policy titled Care and Maintenance of Central Venous Catheter revised 12/2023 was conducted and did not define the frequency of PICC line dressing changes, however; an article titled Peripherally Inserted Central Catheter (PICC) Line Placement - StatPearls - NCBI Bookshelf from the website for the National Institute for Health read, .The dressing and venotomy site should be inspected to check for bleeding and erythema. Dressings should be changed at least once weekly .

Based on observation, interview and record review, the facility failed to ensure adequate documentation/monitoring of suctioning administration and cleaning were followed for one resident (R46) of one resident reviewed for oral suctioning. Findings include: On 12/09/2025 at approximately 10:29 a.m., R46 was observed in their room, laying in their bed. R46 was observed to have a suctioning machine (a machine used to expel secretions) next to their bed. R46's suctioning machine was observed to have multiple tubes attached to it that were observed to have dried mucus inside. R46's suctioning container was observed to be 3/4 full of dried green mucus. No dating was observed on the tubing or the container to document the last time it had been changed and emptied. On 12/10/25 at approximately 9:42 a.m., R46 was observed in their room, laying in their bed. R46 was observed to have a suctioning machine (a machine used to expel secretions) next to their bed. R46's suctioning machine was observed to have multiple tubes attached to it that were observed to have dried mucus inside. R46's suctioning container was observed to be 3/4 full of dried green mucus. No dating was observed on the tubing or the container to document the last time it had been changed and emptied. On 12/11/25 at approximately 9:18 a.m., R46 was observed in their room, laying in their bed. R46 was observed to have a suctioning machine (a machine used to expel secretions) next to their bed. R46's suctioning machine was observed to have multiple tubes attached to it that were observed to have dried mucus inside. R46's suctioning container was observed to be 3/4 full of dried green mucus. No dating was observed on the tubing or the container to document the last time it had been changed and emptied. On 12/11/25 at approximately 10:16 a.m., R46 was observed in their room with Nurse R. Nurse R was shown R46's suction machine with the tubing not dated and they indicated that it should be dated with the last time it was changed. Nurse R indicated they would get new tubing and a dating label for them. Nurse R was queried regarding how often the container of secretions should be emptied and or replaced and they indicated they did not know. Nurse R was queried how often R46 was receiving suctioning, and they reported that they did it themselves and did not know when they last suctioned themself. Nurse R was queried how often and when R46 was performing self-suctioning and they reported they did not know On 12/10/25 the medical record for R46 was reviewed and revealed the following: R46 was initially admitted to the facility on [DATE] and had diagnoses including Interstitial emphysema. A review of R46's MDS (minimum data set) with an ARD (assessment reference date) of 12/3/25 revealed R46 needed assistance from facility staff with most of their activities of daily living. R46's BIMS score (brief interview of mental status) was seven documenting severely impaired cognition. A review of R46's care plan revealed the following: Focus-Resident has an impaired pulmonary/respiratory status related to: history of acute hypoxic respiratory failure, uses bedside suction, and emphysema Date Initiated: 09/08/2023 .Interventions-Uses bedside suction ad lib. Ensure tubing and apparatus are cleaned and dated. Date Initiated: 08/16/2024 . A Physician's order revealed the following: Bedside Suction as needed Patient does suction self as needed. -Start Date-08/31/2022 A review of R46's suctioning documentation in the December 2025 medication administration record (MAR) revealed no documentation of R46 having completed bedside suctioning. On 12/11/25 at approximately 12:40 p.m., during conversation with Respiratory Therapist Q (RT Q), RT Q was queried regarding the documentation of self -suctioning performed by R46 and they indicated they did not have a current way to track self-suctioning, but that they would have to implement a way for the Nurses to ask R46 if they had suctioned that day or shift and be able to document it in the record. RT Q was queried regarding the documentation of changing the canister and tubing for the suctioning machine, and they reported when it is changed, it should be dated on the tubing and canister and that since the facility was getting more residents with suction machines, education was going to be provided to the Nurses on the requirements.

This citation pertains to intake 2600758Based on interview and record review the facility failed to ensure timely administration of an ordered and requested pain medication (Oxycodone) for one resident (R101) of one reviewed for pain. Findings include:Findings include:Clinical record review revealed R101 sustained trauma resulting in necrotizing fasciitis (also known as flesh-eating disease, an infection that kills the body's soft tissue) of the left upper extremity and lower extremity. R101 underwent emergent debridement (surgical procedure that involves the removal of dead, damaged, or infected tissue) and fasciotomy (surgical procedure involves cutting through the tissues that surround muscles) of the left anterior (front) thigh and left forearm, underwent multiple debridement's, left femoral muscle flap graft and required a Wound VAC (vacuum-assisted closure technique that pulls tissue of a wound together and promotes healing). R101's pain regimen included Oxycodone 10 milligram (mg) every four hours as needed, and hospital discharge paperwork confirmed the last time R101 had received Oxycodone 10 mg was on 8/14/25 at 10:00 AM.On 9/10/25 around 2:30 PM, a telephone interview with the complainant confirmed their allegations and stated R101 was admitted on [DATE] around 3:30 PM for further skilled nursing care and rehabilitation. R101's pain regimen included Oxycodone 10 mg every four hours and was still requiring every four hours for pain control. On 8/14/25 R101 had requested to the admission Nurse they needed Oxycodone. The Nurse assured them Oxycodone was ordered, and until it was filled and received from the Pharmacy, they (Nursing) can pull the medication from a back up supply. On 8/14/25 at approximately 4:00 PM R101 had requested ordered Oxycodone. On 8/14/25 at 9:00 PM, R101 still had not received and requested Oxycodone. Nursing remarked everything was all set and would be provided. The complainant then received a phone call from Nursing around 11:00 PM and when they asked if R101 had received their Oxycodone, Nursing reassured pain medication was given. The complainant arrived at the facility on 8/15/25 around 2:00 PM, R101 informed me that more requests were made for Oxycodone, and no Oxycodone was administered.Record review of the Medication Administration Record (MAR) documented an order for Oxycodone 10 mg by mouth every four hours as needed for Pain. Start Date 08/14/2025 at 17:15. No Oxycodone was documented as administered on 8/14/25.Record Review of the Provider Encounter on 8/15/25 documented .Situation: Need OXY 5 mg 2 pills as a now dose-out of 10 mg tablets Treatment: ordered Oxycodone 5 mg take two pills x 1 dose .On 9/10/25 The Director of Nursing (DON) provided R101's Control Substance Record and documentation revealed R101 did not receive Oxycodone 10 mg as ordered starting on 8/14/25. Documentation revealed R101 had not received the Oxycodone ordered until 8/15/25 at 21:00. The DON acknowledged the medication was never provided to R101as ordered.

This citatoin pertains to intake #MI00152841. Based on interview, and record review, the facility failed to ensure a resident was free from significant medication errors for one (R803) of four residents reviewed for medication administration, resulting in a significant change in condition and hospitalization when R803 received R801's medications. Findings include: Review of a complaint reported to the State Agency included allegations that a male resident received a heavy dose of his roommate's medication during the midnight shift and was sent to the hospital the next morning, foaming at the mouth. Review of R803's clinical record revealed the resident was admitted into the facility on [DATE] and discharged to the hospital on 4/26/25. As of this review, R803 had not returned to the facility. Diagnoses included: ischemic cardiomyopathy, permanent atrial fibrillation, ASHD (Atheriosclerotic Heart Disease) of native coronary artery without angina pectoris, CHF(congestive heart failure) pulmonary hypertension, type 2 DM (Diabetes Mellitis) with unspecified complications, nondisplaced fracture of greater trochanter of left femur, acute kidney failure, presence of coronary angioplasty implant and graft, and bradycardia. Review of the progress notes revealed following the administration of another resident's medications, R803 had a significant change in condition and changes in vital signs in which the resident was transferred to the hospital for further treatment. The progress notes included: An entry on 4/26/25 at 12:10 AM by Licensed Practical Nurse (LPN) 'G' read, Gave res (resident) wrong medication. Realized immediately when given. Notified Dr [Name of Nurse Practitioner/NP 'D'], Nurse on call DON (Director of Nursing) with no reply .No adverse reaction at this time.No change mental status.VS (Vital Signs) within normal limits.B/p (Blood Pressure) 132/68 hr (Heart Rate) 78 resp (respirations) 18 bs (blood sugar) 172 temp (temperature) 98.4.No s/s (signs/symptoms) of distress or discomfort at this time. An entry on 4/26/25 at 6:26 AM by LPN 'H' read, Resident got wrong medication last shift. In bed very lethargic. HOB (Head of Bed) elevated. 2400 (12:00 AM) (BP) 134/ 82 (O2) 96% .(Resp) 16 (Blood Sugar Level) AC 190. 0200 (2:00 AM) .(O2)93% (Resp) 18 (BP) 110/52 (HR) 64 (Blood Sugar Level) AC 136. Remains lethargic. Breathing unlabored. 0300 (3:00 AM) .(O2) 93% (Resp) 18 (BP) 81/55 (HR) 79 (Blood Sugar Level) AC 142 Continues to open eyes and that is about it. Chat easy sent to doctor about lethargic and BP drop. No new orders. 0400 (4:00 AM) .(O2) 92% (Resp) 18 (BP) 109/47 (HR) 93 (Blood Sugar Level) AC 134. HR. ranging from 79 to 100. Continues to snore and open when touched. 0430 (4:30 AM) chat easy sent with new VS (Vital Signs) and changes. No new orders. 0600 (6:00 AM) .(O2) 93% (Resp) 18 (BP) 122/61 (HR) 82 (Blood Sugar Level) AC 151. Did open mouth for TSH RX (Thyroid Medication). Continues to bed lethargic. 0625 (6:25 AM) chat easy sent and updated doctor. Improved BP and HR more stable. An entry created on 4/26/25 at 6:55 AM by Nurse Practitioner (NP 'D') for 4/25/25 documented an asynchronous - telehealth note that read, .Nurse called and report that she gave the resident was given wrong medication. These are medication that was given to the resident that does not belong to him: Divalproex Sodium 250mg (Milligrams - an anticonvulsant medication), levetiracetam 1000mg (an anticonvulsant medication), Metformin 1500mg (a diabetic medication), Clonazepam (a benzodiazepine medication), and cloZAPine Oral Tablet 200 MG (an antipsychotic medication), Lacosamide Oral Tablet 50 MG (an anticonvulsant medication). Resident doing well and Vital signs: BP (Blood Pressure) 128/62, P (Pulse) 86, O2 sat (Oxygen Saturation) 96% RA (Room Air), BS (Blood Sugar) 123, 20. Advise nurse not to give resident his Trazodone but can give Xarelto and Atorvastatin. Advise nurse to monitor vitals q (every) 2 hours and report any medical issue. Will update rounding provider. (There was no further documentation after this entry from the rounding provider and this entry did not identify/address the significant BP results reported by nursing staff.) An entry on 4/26/25 at 9:07 AM by Registered Nurse (RN 'I') read, Resident being monitored after medication error last night. Resident unresponsive to stimuli, and has increased secretions/ gurgling in throat. On call provider notified of changes and agreed to send to ER (emergency room ) for further evaluation. A late entry on 4/28/25 at 7:49 AM for 4/28/25 at 7:40 AM by Nurse 'J' (Nurse on-call on 4/25/25) read, Late entry for 4/25/25: Contacted by floor nurse That <sic> she had given medications to this patient in error. Instructed to contact the on-call provider for further orders. This writer made DON aware and was instructed to have the floor follow up with on call provider. See floor nurse's note and on call provider's note for further information. On 5/28/25 at 11:25 AM, an interview was conducted with the Director of Nursing (DON). The DON was asked to provide any documentation and facility investigation regarding R803's medication error incident. On 5/28/25 at 11:35 AM, a phone interview was conducted with LPN 'G'. When asked to recall the events regarding R803's medication error, LPN 'G' reported they worked contingent but had been working at the facility for [AGE] years as a manager. They reported they had been assigned to the south unit, which was a memory care unit. They also had to take rooms that were on the north unit and a few rooms on the Tulip wing (outside of the secured unit). LPN 'G' recalled R803 was a newer admission to the facility and they had gone to the room with R801's (roommate of R803) medications in a cup in their hands and R801 was getting up so they tried to put him back into the bed. While doing that, R803 was also getting up and they set the medication cup down on R803's tray table and when they got both residents back into bed, LPN 'G' gave R803 his medications. I had to set the medications down to get them back in bed and accidentally gave R803 the medications for R801. As soon as they did it they knew and immediately called the physician and the Assistant Director of Nursing (ADON). LPN 'G' reported following this incident, the ADON was working with them about completing paperwork and training, but due to family emergency the ADON had been off since then. LPN 'G' reported the midnight nurse (LPN 'H') was there and reported it, the on-call said to monitor and call him back at 4:00 AM. LPN 'G' reported he seemed fine throughout the night and think when first shift came in they heard he was lethargic. LPN 'G' further reported the incident occurred on Friday and they were in the facility that Monday with the ADON. LPN 'G' also reported they were sure R803 received all of R801 they had prepared since they were all crushed in the medicine cup. On 5/28/25 at 12:35 PM, an interview was conducted with the DON. When asked about the medication error incident, the DON reported the facility had identified a Past Non-Compliance (PNC) regarding this incident and would provide documentation for review. The DON reported since the incident, the facility now looked at the 24 hour reports everyday and if the floor nurses reported medication errors, they were to report it to them directly and each medication error was looked into. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: Element 1: Resident [Name of R803] is no longer in the facility. Element 2: The Director of Nursing/designee reviewed the last 7 days of Progress Notes for changes in condition being documented appropriately and timely and with proper notification. Any concerns were immediately addressed. Completed on 5/9/2025. Element 3: The Medication Administration policy and the Provision of Quality of Care policy was reviewed by the QAPI (Quality Assurance Performance Improvement) committed and deemed appropriate on 5/2/2025. The DON/Designee has re-educated all current nursing staff on Medication Administration policy by 5/14/225. Any current nursing staff member not re-educated by 5/14/2025 will be re-educated prior to their next scheduled shift. The DON/Designee has re-educated the IDT (Interdisciplinary) team on the Provision of Quality of Care policy by 5/19/2025. Any IDT team member or rehab staff member not re-educated prior to 5/19/2025, will be re-educated prior to their next working shift. IDT team will review in clinical morning meeting daily, Monday - Friday, to review the 24 Hour Report and identify all changes in condition for timely follow up. During the day, the Unit Managers will view medication records to validate accuracy. Element 4: The DON/Designee will audit all changes in condition daily, Monday - Friday, to ensure appropriate interventions are placed timely. The DON/Designee will audit 10 medication records twice a week to ensure accuracy. Audits will continue daily x4 weeks then weekly thereafter until substantial compliance is achieved and the audits are discontinued by the QAPI committee. The Director of Nursing is responsible to maintain compliance. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to intake #MI00152565. Based on interview and record review, the facility failed to ensure sufficient Nursing staff were available to meet resident medical and supervision needs for 15 residents (R901 and R907) and 13 anonymous residents residing on Mum Unit 2, resulting in delayed medication administration and inadequate resident supervision. Findings include: On 5/1/25 a concern submitted to the State Agency was reviewed that alleged the facility was short on Nursing staff on 4/25/25 through 4/26/25 and were not able to provide adequate supervision. On 5/1/25 at approximately 11:37 a.m., Certified Nursing Assistant I (CNA I) was queried if they were one of the CNA's providing care for R901 on 4/25/25 into 4/26/25 and they reported they were. CNA I was queried regarding the incident between R901 and R907 and they reported they heard R907 yelling out for help and when they got to R901's room, they found R907 and R901 in R901's bed but there was a little space between them. CNA I explained that both residents were intoxicated and R901 had liquor in there bed. CNA I reported that R907 stated that R901 had inappropriately touched them in bed. They stated that they told the Nurse and that they did a green sheet and put it under management's door. CNA I was queried if they had informed the Administrator and they indicated they did not but that the Nurse was aware. CNA I reported that R901 is a problem and is always drinking and trying to talk to females in the building that have dementia. CNA I was queried regarding the facility staffing levels that night and they reported that there were only four Nurses in the building and that most of the residents that had Nurse J had late medications. CNA I reported the CNA's were trying to help but there were too many residents with behaviors and risk of falling to supervise them all. CNA I was queried if they were aware of R901 and R907 being intoxicated in R901's room and they indicated they were not until R907 started yelling for help. CNA I further indicated there were not enough Nurses to help with supervising the residents and that R901 needed one to one supervision to ensure the safety of the other female residents. On 5/1/25 at approximately 2:55 p.m., Nurse J was queried regarding the incident between R901 and R907 on 4/25/25 into the early morning on 4/26/25. Nurse J reported that CNA I had informed them what had transpired and they went down to the room and R907 informed them that R901 had inappropriately touched them. Nurse J indicated they had a skin assessment done on R907 because they were both intoxicated and that they had called the Administrator and told them everything that had happened. Nurse J reported that R901 needs a one to one staff member to supervise because they are always drinking and starting fights with other residents and staff. Nurse J was queried regarding the staffing levels of the night of 4/25/25 and they reported the facility had four Nurses show up for the midnight shift. Nurse J indicated almost all of their residents that they were giving medications to that night had their medications administered past the scheduled times and some were multiple hours past. Nurse J reported they were residents with high fall risks and behaviors that needed supervision so they could not get all of their medications passed due to there other Nurses not showing up. On 5/1/25 a quality assurance form dated 4/26/25 filled out by CNA I revealed the following allegations between R901 and R907: Details: I was on [Name of unit] when I heard yelling from [R901's] room about 11:55 p.m., It was [R907]. She was screaming. [R901] was touching her and asking why he was in her room. She was actually in his room. They were both intoxicated. [R901] was trying to hide the empty bottles of alcohol with his body . On 5/1/25 a review of the facility staffing for 4/25/25 night shift revealed four total Nurses were assigned and the total required by the facility was six. Further review of the calloffs for the 4/25/25 into 4/26/25 midnight shift revealed two Nurses had called off. On 5/1/25 at approximately 4:11 p.m., the staffing levels for the 4/25/25-4/26/25 midnight shift were reviewed with Staffing Scheduler N (SS N). SS N reported that two Nurses had called off for that shift and were not replaced. SS N indicated that nobody was available to mandate to stay over and that Nurse managers are supposed to come in to cover the shortage but nobody did so the Nurses were short staffed that night. On 5/1/25 at approximately 4:32 p.m., during a conversation with the Director of Nursing (DON), the DON was queried regarding the staffing levels on 4/25/25 midnight shift and the allegation that Nurse J had administered many residents with late medications due to the staffing shortage. The DON reported they had reviewed Nurse J's residents and indicated that thirteen residents on Unit 2 had their medication administered late that shift. On 5/1/25 a facility document titled Nursing Services and Sufficient Staff was reviewed and revealed the following: Policy: It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment.

This citation pertains to intake #MI00152565 Based on observation, interview and record review, the facility failed to report allegations of abuse/mistreatment to the State Agency (SA) involving two residents (R901 and R907) of three residents reviewed for abuse/neglect/mistreatment. Findings include: On 5/1/25 a complaint submitted to the State Agency was reviewed which alleged R901 touched R907 inappropriately in their room on the midnight shift between 4/25/25 and 4/26/25 and that R901 was seeking out other women in the facility for sexual activity. R901 On 5/1/25 at approximately 1:22 p.m., R901 was observed in their room, laying in their bed. R901 was queried regarding the night of 4/25/25 into the early morning of 4/26/25. R901 reported they were aware of the night and that he was drinking alcohol in their room with R907. R901 indicated he likes female companionship. R901 was queried if the staff had to come in after R907 was yelling help and he indicated they did but that they did not do anything do them. On 5/1/25 the medical record for R901 was reviewed and revealed the following: R901 was initially admitted to the facility on [DATE] and had diagnoses including Chronic obstructive pulmonary disease, Heart disease, Major Depression, Alcohol Abuse, Cannabis abuse, other psychoactive substance abuse. A review of R901's progress notes revealed the following: 4/26/2025 at 01:40-Writer heard commotion from residents room. Writer immediately entered room. Resident was observed in room with other resident [R901] was visibly intoxicated and multiple pints of liquor were observed in and next to bed. Items were confiscated . 3/24/25 at 18:38- .Resident upset throughout entire day about accusations. Would not stop talking to staff and other residents about same issue. Attempted to get nurse to leave another resident's room to talk about it further. Resident swearing throughout the day to staff and other residents. Resident making comments to other resident who he has had multiple issues with. This evening, resident went to main dining room to physically and verbally confront residents who he perceived were causing him trouble. Staff intervened and resident swore at them multiple times and then proceeded to return to room. Resident passed another resident in wheelchair and attempted to swing at him and called him a racial slur but resident in wheelchair was able to move out of the way before contact was made 3/24/2025-encounter-resident petitioned out. Attempted to make physical contact with another resident. Making verbal and physical threats to staff and residents. 3/22/2025 at 23:36-resident threatening another resident calling him profanity's and telling him he would put him in the hospital when he was done with him. 2/25/2025 at 06:49-resident went into another residents room yelling for him to wake up and then began yelling at another resident and antagonizing him cursing profanities. 1/30/20252 at 1:51-Event Date:10/02/2024 Resident had some agitation toward roommate. was telling roommate to shut up and stop talking 1/1/2025 at 13:15-Resident has been out of control arguing with resident in his room. He is yelling for his resident to shut up and he wants staff to tell him to shut up. Resident is yelling down the hall way that we are all ganging up on him . Very difficult to have a reasonable conversation with resident, any conversation at this point is just escalating his behavior. Finally managed to get resident to leave area for a few minutes and return when he has calmed down . R907 On 5/1/27 at approximately 2:49 p.m., R907 was queried pertaining to the incident with R901. They reported they were in R901's room and drinking and smoking. R907 Stated that R901 wanted them to have one more beer but R907 had wanted to leave but that R901 would not let them and blocked the way out and pinched them. R907 was queried why they had yelled out help and R907 indicated because R901 wouldn't let them leave and they had to get staff to help. On 5/1/25 the medical record for R907 was reviewed and revealed the following: R907 was initially admitted to the facility on [DATE] and had diagnoses including Alcohol dependence with alcohol-induced persisting dementia. Further review of R907's medical record revealed R907's husband was their activated power of attorney (POA). R907's BIMS score (brief interview of mental status) was six indicating they had severely impaired cognition. On 5/1/25 at approximately 11:37 a.m., Certified Nursing Assistant I (CNA I) was queried if they were one of the CNA's providing care for R901 on 4/25/25 into 4/26/25 and they reported they were. CNA I was queried regarding the incident between 901 and R907 and they reported they heard R907 yelling out for help and when they got to R901's room, they found R907 and R901 in R901's bed but there was a little space between them. CNA I stated that both residents were intoxicated and R901 had liquor in their bed. CNA I reported that R907 stated that R901 had inappropriately touched them in bed. They stated that they told the Nurse and that they did a green sheet and put it under management's door. CNA I was queried if they had informed the Administrator and they indicated they did not but that the Nurse was aware. CNA I reported that R901 is a problem and is always drinking and trying to talk to females in the building that have dementia. On 5/1/25 at approximately 2:55 p.m., Nurse J was queried regarding the incident between R901 and R907 on 4/25/25. Nurse J reported that CNA I had informed them what had transpired and they went down to the room and R907 informed them that R901 had inappropriately touched them. Nurse J indicated they had a skin assessment done on R907 because they were both intoxicated and that they had called the Administrator and told them everything that had happened. Nurse J reported that R901 needs a one to one staff member to supervise because they are always drinking and starting fights with other residents and staff. On 5/1/25 at approximately 3:19 p.m., during a conversation with the facility Administrator (abuse coordinator, the Administrator was queried regarding R901's use of profanity and threatening behaviors towards other residents and the incident in which R907's allegation that R901 had inappropriately touched them while alone in their room. The Administrator indicated that they had been away from the facility for a few days and had not been made aware of R907's allegation until they had a chance to review the staff's green sheets (quality assurance forms) that day. The Administrator indicated they would be reporting the allegation at that time, but hat the staff should have informed them of R907's allegation the night that the incident occurred so it would have been reported then. The Administrator indicated they were unaware of any other incidents in which R901 had allegations of reportable incidents. On 5/1/25 a quality assurance form dated 4/26/25 filled out by CNA I revealed the following allegations between R901 and R907: Details: I was on [Name of unit] when I heard yelling from [R901's] room about 11:55 p.m., It was [R907]. She was screaming. [R901] was touching her and asking why he was in her room. She was actually in his room. They were both intoxicated. [R901] was trying to hide the empty bottles of alcohol with his body . On 5/1/25 a facility document titled Abuse, Neglect and Exploitation was reviewed and revealed the following: Policy-It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect exploitation, and misappropriation of resident property .Reporting/Response: A. The facility will have written procedures that include: 1. Reporting of alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframe's as required by state and federal regulations: a. immediately, but not later that two hours after the allegation is made, if the events that cause the allegation involved abuse or result in serious bodily injury, or b. not later than 24 hours if the event that caused the allegation do not involve abuse and do not result in serious bodily injury .

This citation pertains to intake #MI00151369 Based on interview and record review, the facility failed to timely address a change of condition for one resident (R#904) of one resident reviewed for a change of condition, resulting in delayed treatment, and failed to ensure the necessary documentation was completed to obtain a medically necessary power tilt recline wheelchair for one Resident (R#905) of two reviewed for rehab services. Findings include: On 5/1/25 at 9:20 AM, a review of R904's closed clinical record was conducted and revealed they admitted to the facility on [DATE] and most recently discharged to the hospital on 3/23/25. A review of R904's progress notes was conducted and revealed the following: A Pertinent Charting-Change of Condition note dated 3/17/25 at 7:43 AM entered into the record by Nurse 'M' that read, .Change identified: Confusion .general weakness, Increased urinary frequency, abdominal cramping .Assessment: .Needing 2 people assist with all transfers due to weakness .Needed to use the bathroom about every hour during the night. c/o (complains of) of pain during urination .Nursing intervention: Collected urine culture to check for UTI (urinary tract infection) . A progress note from NP (Nurse Practitioner) NP 'H' entered into the record on 3/18/25 at 12 AM that read, .Per nursing pt (patient) has increased confusion for the past few days, most occurs in the evening and at night. UA (urinalysis) & c/s (culture & sensitivity, a test for appropriate antibiotic treatment) ordered, pending result .ASSESSMENTS AND PLANS .Altered mental status, unspecified: Pt (patient) also c/o (complains of) burning with urination, abdominal pain, ordered .ua & c/s to further evaluate . Three notes entered into the record by the Assistant Director of Nursing (ADON) on 3/18/25 indicated R904 was tired, weak, confused, drowsy, and experienced a change of condition. A progress note dated 3/18/25 at 8:22 AM that read, .Resident was confused and disoriented could not stand or make sense of what is around her . A progress note from NP 'H' entered into the record on 3/21/25 at 12 AM that read, .Pt is seen today for lab result. Pt?s <sic> urine culture +for uti (positive for a urinary tract infection). Pt admitted to bladder spasm, suprapubic tenderness. Per <Laboratory Name> recommended Cipro (antibiotic) for 3 days . Continued review of R904's chart included a review of orders and labs and revealed R904 was symptomatic for a urinary tract infection (mental status change, pain/burning, frequency, abdominal/suprapubic pain) on 3/17/25, NP 'H' ordered a urinalysis and culture & sensitivity lab on 3/17/25, the urine was collected on 3/18/25, the lab picked up the specimen on 3/20/25, the lab reported the results to the facility on [DATE], and R904 was started on antibiotics on 3/21/25, four days after symptom onset. Continued review of R904's chart revealed a nursing progress note dated 3/23/25 that read, .has been confused for the last couple weeks .has antibiotics .advised to send out for evaluation, as well as a second nursing progress note entered into the record on 3/23/25 that read, .Event date 03/17/2025 Originally identified change: altered mental status mental status change continues residents vs (vital signs) are residents O2 (oxygen level) was 89%, hr (heart rate) 128, bp (blood pressure) 118/81 .with the positive uti I wrote the on call provider with concerns of possible sepsis . It was revealed through an SBAR (Situation/Background/Assessment/Recommendation) assessment dated [DATE] R904 was transferred to the hospital for a change of condition including confusion, heart rate of 128 (Normal value 60-100), low oxygen level, and weakness. On 5/1/25 at 2:50 PM, a telephone interview was conducted with NP 'H' regarding R904's urinary tract infection with signs and symptoms beginning 3/17/25. They were asked if they started any antibiotic treatment based on R904's reported signs and symptoms prior to the urinalysis and culture and sensitivity reports and they said they did not. They were asked to provide their clinical rationale and explained they didn't know for sure R904 had a UTI based on the symptoms and they, have to wait until cultures come back. They were asked why they had to wait, and if they suspected a UTI could they start antibitotics and either discontinue or change them when the cultures came back. They said they could have started antibiotics if they, really suspect a UTI. They went on to say R904's vitals were stable and they didn't have a fever so they decided to wait. They further said, they didn't see any signs or symptoms of R904 going septic, despite R904 exhibiting signs and symptoms of sepsis (rapid heart rate, (pulse 128) difficulty breathing, (oxygen saturation 89%), and documented altered mental status) upon their discharge on 3/23/25. Finally, NP 'H' was asked if they were aware four days passed between symptom onset and the start of the antibiotics due to a delay in the labs and they said they were not aware of that. On 5/1/25 at 3:47 PM, an interview was conducted with the facility's Director of Nursing (DON) regarding R904. They indicated NP 'H' could have started R904 on antibiotics prior to the labs being reported and said the delay in the time of symptom onset and beginning of the antibiotics should not have occurred. They further went on to say they, (DON) and the Assistant Director of Nursing (ADON) saw R904 was declining and had numerous conversations with R904's medical providers throughout the week of 3/17/25 and 3/23/25 regarding R904's condition. They said they received push-back from the providers regarding sending R904 out for evaluation and they could not get an order to send them out. When asked why, the DON said the providers wanted to wait until after a scheduled cardiology appointment on 3/21/25 to address her becoming more edematous and the possibility of R904 signing onto hospice. The DON further went on to say R904 should have been transferred out sooner and volunteered their knowledge R904 passed away at the hospital. A request for a policy for addressing a change of condition in timely manner was requested on 5/1/25 at 4:04 PM, and a policy titled, Notfication of Changes was provided, however; it did not address the concern of timely assessment, monitoring, and treatment for a change of condition. R905 This citation pertains to Intake #MI00151296. A complaint was received by the State Agency on 3/18/25, which stated R905's additional necessary medical documentation had not been submitted timely to order a power wheelchair, and the process had been initiated five months prior. The complainant reported the provider was canceling the request on 3/18/25, as they had not received the documentation from the facility after numerous requests. The complainant stated R905 could not maneuver a manual wheelchair because three of the fingers on their hands were paralyzed, and they were struggling with coordinating their care and obtaining necessary assistance. Review of R905's Minimum Data Set (MDS) assessment, dated 4/22/25, revealed R905 was admitted to the facility on [DATE], with diagnoses including quadriplegia (partial paralysis from the neck down), traumatic brain injury, seizures, anxiety, and depression. The assessment revealed R905 required set up (with adaptive equipment) with eating and was dependent for toileting and transfers. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 15/15, which showed R905 was cognitively intact. The behavioral assessment showed no behaviors or resistance to care. The skin assessment showed R905 had a Stage 4 pressure ulcer (a deep open wound that extended beyond the skin into the tissues, tendons, and bone). On 5/01/25 at 9:25 a.m., Occupational Therapist (OT) A reported they had submitted the vendor requested documentation showing medical justification for R905 to receive a power tilt wheelchair from their insurance provider in November 2024, which they believed was denied. OT A explained they newly understood the vendor was sending over a documentation request to them to submit for reconsideration for the power chair on this date (5/01/25). OT A clarified R905 had a loaner power chair, but they were not aware how long R905 could keep the chair, and understood R905 needed their own power tilt wheelchair. OT A was asked why R905 needed a power tilt wheelchair. OT A responded R905 had weakness in both arms and could not push a manual wheelchair without marked fatigue and pain, and needed their own power wheelchair for community mobility, as they went outside the facility in their loaner power wheelchair for medical appointments. OT A confirmed R905 had quadriplegia at the cervical (neck) level, with a head injury and seizures. OT A clarified R905 could use a power wheelchair with a joystick controller safely and needed the tilt recline feature for pressure relief. OT A stated they would resubmit the paperwork on 5/01/25, during the survey. OT A was asked if R905's wheelchair medical necessity appeal paperwork had been submitted timely, and responded, Yes. Review of R905's Occupational Therapy power wheelchair evaluation, dated 11/04/24, revealed, The patient (R905) demonstrated the ability to operate a motorized wheelchair safely. Cognition is good due to a score of 28 of 30 on the Montreal Cognitive Assessment (MOCA). (R905) demonstrated adequate strength, active range of motion, gross motor coordination, and fine motor coordination in BUE (both upper extremities) to operate all the controls. Her vision with glasses is within functional limits . On 5/01/25 at 9:57 a.m., R905 was observed in their bed in their room. Their head of bed was elevated to approximately 45 degrees, and they were positioned on their back. R905 was wearing only a sheet over their chest, and blankets, which they reported was most comfortable for them, and agreed to an interview. R905 was observed pushing their call light by grasping the cord with their hand and pushing the small red button with their chin. R905 was observed with flexed distal (farthest) digits on their hands. A power wheelchair was observed outside R905's room, with a headrest, joystick control, tilted seat, swing away armrests, foot cradle, elevating footrests, and a pressure relieving gel cushion. On 5/01/25 at 10:00 a.m., R905 was asked about their power wheelchair. R905 reported the process of obtaining a power tilt in space wheelchair for them had begun in July 2025, by their outpatient therapy provider, where they continued therapy until November 2024, and then planned to see therapy in house (in the facility), as they had a therapy prescription from their rehab physician for continued therapy. R905 reported they had a cognitive test completed by OT A in November 2024 and had not seen an occupational therapist since that time. R905 stated they had been in a loaner power wheelchair since November 2024 and were concerned they would not have a power chair soon, as they did not know when the vendor would ask for the loaner power wheelchair to be returned. R905 explained they had believed the facility was completing the necessary paperwork to get them their own power wheelchair until they learned in March (2025) the facility therapy department had not followed through on the paperwork from the vendor. R905 continued they maneuvered their loaner wheelchair down to the therapy department in March (2025) and asked OT A why their wheelchair application had not been completed, and was told the paperwork had already been sent over to the vendor for the reapplication, with the necessary documents. R905 contacted the Vendor afterwards, Vendor C, who again stated they had not received the additional documentation requested and had also asked OT A in person during March 2025 for follow-up. R905 explained they received another phone call from Vendor C from April (2025) yesterday on their voicemail, and learned Vendor C had still not received their wheelchair paperwork. R905 reported this made them feel upset and frustrated. R905 was speaking in an elevated voice tone, appearing distressed and became tearful, and said she was tired of playing the [NAME] between their providers and the facility. R905 reported they had told multiple staff their concerns and nothing changed. R905 stated they wanted assistance with care coordination, as this was too much for them and they felt overwhelmed. R905 clarified they used their loaner power wheelchair for community mobility and to access community transportation regularly, as there were no other options available to them, which was confirmed in the medical record. On 5/01/25 at 10:42 a.m., Registered Nurse (RN) B confirmed R905 used their loaner power wheelchair during the week for community mobility. On 5/01/25 at 11:48 a.m., R905 initiated calling Vendor C with Surveyor present. Vendor C explained R905's initial power wheelchair paperwork was completed by therapy staff on 9/04/25, which was denied. Vendor C reported this was typical with power wheelchair applications, and often facilities had to submit additional paperwork up to several times during the application process. Vendor C confirmed R905 needed their own customized medically necessary power wheelchair, which included a tilt recline feature, elevating legs, joystick propulsion, and pressure relieving cushion due to their pressure ulcer. Vendor C reported they requested in an email to the therapy department on 2/07/25 the facility submit additional paperwork due to a second wheelchair denial they received on 2/06/25 from the 11/04/2024 submission and specified what was needed from the occupational therapist in the email. Vendor C reported they sent a second email in February 2025, with no response to either email. Vendor C reported they left a voicemail on 2/26/25 with the facility therapy department with no response. Vendor C indicated they went to the facility on [DATE], and spoke directly to OT A, who reported they would leave a message for the Interim Rehabilitation Director, Speech Language Pathologist, SLP E, about the additional documentation requested. Vendor C reported on 3/18/25 they called R905 since they had not received the necessary documentation. They reported R905 attempted to facilitate the completion of the appeal documentation themselves. Vendor C stated they heard from the current Rehabilitation Director today (5/01/25), who reported they had received an email on 5/01/25 from them and would submit the required paperwork on 5/01/25. Vendor C reported the email they sent on 5/01/25 was to the same email address where they had sent earlier documentation requests to the facility. Vendor C confirmed the delay in documentation had been from 2/07/25 until 5/01/25 and understood why R905 was frustrated and concerned, since this was an extended period. Review of an email thread dated 5/01/25 by Vendor C received from R905 at 12:14 p.m., showed Vendor C had sent the facility therapy department two emails, dated 2/07/25 and 2/13/25. The emails specified additional documentation the insurance provider requested from therapy and the facility to obtain R905's power tilt recline wheelchair. On 5/01/25 at 2:18 p.m., the Rehabilitation Director, Certified Occupational Therapist Assistant (COTA) D, reported they had been on a leave from February 3, 2025, until April 23, 2025, and confirmed the Interim Rehab Director, SLP E was covering the department during their absence. COTA D conveyed they had not made aware the additional power wheelchair documentation had not been submitted until today (5/01/25), when OT A and Vendor C made them aware. COTA D reported their emails dropped off over time, so they had no record of earlier emails received by the therapy department. COTA D shared with Surveyor an email received by Vendor C on 5/01/25, which specified additional documentation needed from the facility to reapply for R905's power wheelchair they had earlier requested, and a thread of the two February emails to the therapy department. COTA D shared there appeared to a larger gap in time where there was no follow up on the wheelchair when they were on leave, and stated they were not finding evidence of any paperwork submitted. COTA D showed Surveyor two paper packets which included letters of medical necessity completed by therapy staff during 9/2024 and 11/2024, and reported this was all they found. COTA D reported SLP E had a full-time caseload when they were working as the Interim Rehab Director, and this may have impacted the completion of R905's follow-up power wheelchair additional documentation request from their insurance provider. On 5/01/25 at approximately 2:40 p.m., SLP E, with COTA D present, reported they took full responsibility for the additional documentation not being resubmitted for another appeal, per R905's and Vendor C's request. SLP E clarified they unintentionally had not followed up, after receiving two emails from Vendor C, which they recalled receiving, and believed one was in February 2025 and the second was possibly in March 2025. SLP E stated they had a full-time resident therapy caseload while in their role as Interim Rehab Director. Both reported they understood the concern related to the nearly 3-month gap in time related to the additional appeal documentation not being resubmitted. COTA D confirmed they were submitting the documentation on this date (5/01/25) to Vendor C, since they had been made aware of the documentation omission. COTA D confirmed the recommended power wheelchair would benefit R905, and R905 had a loaner power wheelchair they were using in the interim from Vendor C. On 5/01/25 at 3:10 p.m., Vendor C clarified in a phone interview they had made multiple attempts to obtain the medically necessary documentation from the facility therapy department to submit per request from R905's insurance provider, after the insurance provider requested additional documentation on February 6, 2025. Vendor C confirmed they had reached out to the facility initially on February 7, 2025. Vendor C reported they believed R905 was advocating for themselves without assistance from the facility and was understandably frustrated. Vendor C explained applying for a power wheelchair for a resident can be a lengthy process with several denials however it was possible R905's power tilt recline wheelchair would be approved with the additional documentation requested. Vendor C stated they wanted R905 to receive the power wheelchair, if possible, as they deemed it medically necessary for R905. Vendor C confirmed they had loaned R905 a pressure-relieving cushion and power wheelchair Review of R905's, Evaluation and Medical Justification for Complex Seating Systems and Mobility Devices ., dated 11/04/25, revealed R905 required the power tilt recline wheelchair due to a cervical spinal cord injury. The form further revealed, The equipment is needed for independent mobility for lifelong use and will improve caregiver ability to manage pt (patient) care . The medical justification form revealed in summary, (R905) has demonstrated the ability to operate a power wheelchair independently and safely on several occasions in the past month utilizing a borrowed power wheelchair, including on 11/02/24. (R905) has adequate vision, active range of motion, coordination, and strength to operate the power wheelchair and good cognition. Signed by OT A. On 5/01/25 at 4:35 p.m., the Director of Nursing (DON) was asked about R905's power wheelchair additional documentation request not being completed by the facility from 2/07/25 until 5/01/25, during the survey. The DON reported they did not recall being made aware of the concern and understood R905's frustration. The DON stated if they had known about the concern, they would have followed up timely. A policy for Rehabilitation Services and/or Rehabilitation Services was requested from the facility administration on 5/01/25 at 3:30 p.m. via email. The policy was not received by survey exit.

This citation pertains to intake #'s MI00146852 and MI00146901. Base on observation, interview and record review, the facility failed to ensure a timely investigation of a fall, complete a safe transfer, provide urinary assistance per the plan of care and provide appropriate supervision and interventions to prevent falls for two residents (R35 and R119) resulting in R119 sustaining an acute subcapital left femoral neck fracture. Findings include: On 9/16/24 a concern submitted to the State Agency was reviewed which alleged R119 had a fall with a fracture and the facility delayed in documenting and assessing R119 for injuries. On 9/17/24 the medical record for R119 was reviewed and revealed the following: R119 was initially admitted to the facility on [DATE] and had diagnoses including Difficulty in walking, Restlessness and Agitation and Chronic obstructive pulmonary disease. A review of R119's MDS (minimum data set) with an ARD (assessment reference date) of 6/9/24 revealed R119 needed assistance from facility staff with most of their activities of daily living. R119's BIMS score (brief interview for mental status) was three, indicating severely impaired cognition. A review of R119's comprehensive plan of care revealed the following: Focus-Resident is at risk for falls/injury related to: cognitive deficits, history of falling, visual deficits, takes psychotropic medications, and weakness Bed Modification: Patient prefers his bed against the wall. Date Initiated: 10/04/2023 .Interventions:-Frequent rounding while in resident room. Date Initiated: 09/09/2024 .Focus-Resident has an ADL (activity of daily living) self-care performance deficit related to: cognitive deficits, visual deficits, weakness, and difficulty in walking Date Initiated: 10/04/2023 .Interventions-TRANSFERS: 2 person assist. Date Initiated: 10/04/2023 . A review of R119's progress notes revealed the following: 9/3/2024 .Date of Service: 9/3/2024. Visit Type: Acute. Chief Complaint: Pain left hip. History of present illnesses: General: [AGE] year-old male with past medical history significant for diabetes dementia A. fib (Atrial fibrillation) pneumonia. Pt (Patient) is seen today per nursing requested for pain on the left hip. There was no reported of fall. Per nursing pt started to c/o (complained of) pain this morning. Pt alert but confuse, baseline, did not remember of fall .Assessment and Plans-Pain in left hip: Ordered X-ray left hip, right hip, lumbar, and left femur. Ordered tramadol 50 mg (milligrams) q6 hrs prn (every six hours as needed) for 1 wk (week). continue to monitor . 9/3/2024-Nurses' Notes: Writer called to resident room for evaluation related to resident indicating left leg pain and declining to get out of bed. Resident observed in bed, alert to baseline. C/O left upper leg pain and left hip pain. Resident stated to writer I fell . Resident assessed, unable to lift left leg off bed, left hip and upper leg painful to palpation, resident with facial grimacing, unable to determine any leg shortening or rotation, resident unable to lay flat due to increase in pain . A SBAR (Situation, Background, Assessment, Recommendation) Communication Form with an effective date of 9/3/24 that was completed by R119's day shift nurse on 9/3/24 at 09:34 revealed the following: Request 4. Nursing Notes: VS (vital signs) and neuros (neurocheck) unremarkable and baseline. Writer attempted medication administration, resident declined medication, which is unusual for resident. When resident asked why he declined medication, he was unable to answer. A&O (alert and orientated) to self and baseline, moments of confusion, poor historian, usually follows commands. When asked if resident has pain, he initially declined pain. When resident was asked to sit up, he verbalized 'give me a hand.' When assistance was given, resident shouted out in pain. Assessment revealed left hip and left lower back pain. Resident unable to raise left leg off bed. Any movement of hip caused pain, but resident could not quantify pain, although using Wong-Baker it was 0 at rest, and 9/10 with movement. Declined to be rolled or changed. Left hip was externally rotated, it appeared shortened compared to right leg, although resident was poorly positioned in bed during assessment, then resident declined to reposition self or allower <sic> staff to reposition, and declined further assessment. Declined breakfast, which is unusual for resident since he baseline requests more that one breakfast and eats 100% of his breakfast. No bruising at left hip site. Verbalized he did not fall, verbalized he did not hit head. Dx. (diagnosis) Dementia, Provider [name of medical provider] on unit for evaluation. Ordered STAT hip and lumbar x-ray. DPOA daughter [name of DPOA] verbalized she instead wanted resident sent to [local hospital] immediately 9/7/2024-Nursing Evaluation Summary: Resident came back from [local hospital] via EMS (ambulance) at 1600. Residents principal problem is a closed displaced fracture of left femoral neck. Incision is 20 1/2 inches long with dressing intact and dry. Follow up with ortho (orthopedic) in 1 week to have post-op incision checked. Foley catheter in place with orders for follow up with urology in two d/t (due to) failing voiding trial Resident only complains of pain upon movement. Respiration equal and unlabored 9/9/2024 .Progress Notes-Date of Service: 9/9/2024 .History of present illness-General: [AGE] year-old male with past medical history significant for diabetes dementia A. fib pneumonia. Pt is seen today for re-admission. Pt sent to hospital for left hip pain. Pt found to have subcapital left femoral neck fracture. Pt underwent left hip hemiarthroplasty .Assessment and Plans- Risk of Complications and/or Morbidity or Mortality of Patient Management: moderate .Fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing: PT/OT, monitor site for s/s of infection(drainage, edema, redness) F/u (follow-up) with orthopedic sx (surgery) as recommended . A review of the facility investigation and statements from staff pertaining to R119's fractured femur identified on 9/3/24 revealed the following: A statement from CNA (Certified Nursing Assistant) O (CNA O) on 9/5/24 who was identified as one of the CNA's who worked the midnight shift from 9/2/24 through 9/3/24 revealed the following: I worked on South. I work 11pm to 7am. I worked with [CNA S] and [Nurse R]. [R119] was sleeping when I arrived, and stayed asleep. I went on lunch around 04:10. I found him on the floor, [CNA S] was on lunch. He was behind bedroom door, hand was sticking out from the door. He was on his left side, his head was in the corner. I don't recall if he said anything to me. I called for [Nurse R] and said '[R119]'s on the floor'. We two person lifted him onto the bed, [R119] then said he was trying to go to the bathroom. He was complaining of left leg pain. The Nurse educated him, she didn't see any injury. The Nurse and I attempted to assist him to the bathroom. He couldn't stand, I couldn't find a urinal so I grabbed a cylinder. [CNA S] entered room right after he was done urinating. When he was on the floor, his bed sheet was wrapped around his feet. Until about 0600 he kept yelling for help, we kept checking on him. I texted [CNA S] at 03:40 that a resident fell . A statement from Nurse R on 9/5/24 who was identified as the Nurse assigned to R119 on the midnight shift from 9/2/24 through 9/3/24 revealed the following: I got to work around 2:30pm, I was on South. [R119] as his normal self. He gets meds early afternoon, and evening meds. I'm not sure when he went to bed. Wandered into the hall around 11pm. I redirected him back to his room. I didn't see him get up at any other point during the night. I checked on his roommate around 1am, [R119] was sleeping. I was not notified he was having any pain. When I gave report to day shift, I;I'm pretty sure he was still in his room A statement from CNA S on 9/5/24 who was identified as another CNA assigned to R119's unit on the midnight shift from 9/2/23 through 9/3/24 revealed the following: Worked on South. [R119] went to bed around 0200 on 9/3. I went to lunch around 03:15, returned to unit quarter to 4. I go outside on my lunch. [CNA O] texted me around 3:30 that he fell . I returned to the unit, [CNA O] and [Nurse R] were assisting [R119] with the urinal. He never asks for help. Kept going into his room to check on him, he was talking and wanting 'the guys' to help him fix something. I work 7pm-7am . A second statement from CNA O on 9/10/24 recorded by the Assistant Administrator during their final interviews revealed the following: During an interview with employee [CNA O] regarding a resident investigation, employee stated that when she found the resident on the floor, she immediately began texting her counterpart [CNA S] who was on break at the time. Writer asked why her immediate thought was to text her counterpart and not assist the resident, she stated that she always let's her partners know when something happens to a resident. Writer then asked what happened. [CNA O] stated she went and got her Nurse [Nurse R] in the common area to assess the fall. She stated resident was having a hard time walking to the bathroom, so they stood him to use the urinal. Writer then asked [CNA O] if the resident was showing signs of pain and distress and having a hard time sanding <sic> which she stated that she noticed, why would she make him stand to use a urinal since a urinal can be used lying or sitting. She stated, 'Oh yeah, I guess you're right.' She stated that they proceeded to help him use the bathroom in the urinal or cylinder. [CNA O] also stated that resident continued to need two people to assist him throughout the night and yelled out in pain. When asked why she didn't report it to another Nurse if she didn't feel confident that her Nurse had reported the fall or was doing the 'right thing' on behalf of the resident, she stated she didn't know she could and didn't know that CNA's did fall charting or behavioral charting. On 9/18/24 at approximately 11:05 a.m., the Director of Nursing (DON) was queried regarding their investigation of R119's fall during the early morning hours on 9/3/24. The DON stated that they were notified by the day shift Nurse T in the morning of 9/3/24 that R119 had been presenting with pain in their left leg. The DON indicated they assessed R119 at that time and then asked Nurse T to call the medical provider and get an order for an X-ray. When Nurse T notified the family of the change in condition they requested him to be sent out to hospital instead of having the in-house X-ray completed. The DON indicated that through their investigation, it was revealed that CNA O never informed Nurse R of R119's fall and had assisted R119 back into bed by themselves which was against facility policy. The DON indicated that CNA O should have had Nurse R assess R119 for any injury and then together they could have transferred them with the mechanical lift back into the bed. The DON also reported that after the fall, CNA O transferred R119 into a standing position to use a urinal without getting anyone to assist them and without Nurse R having had a chance to assess them. The DON reported that CNA O had multiple inconsistent reports of the incident and that they had filled out 15 minute check documentation for monitoring R119 that night and that no fall was indicated on the checks when CNA O had found R119 on the floor. The DON indicated that disciplinary action was issued to all three staff members including CNA O, CNA S and Nurse R and that Nurse R was disciplined for not following facility policy on providing supervision to R119 at least every two hours and checking on them. On 9/18/24 at approximately 4:10 p.m., Nurse R was queried regarding R119's fall during the midnight shift from 9/2 through 9/3/24. Nurse R reported that neither CNA O or CNA S had informed them that R119 had fallen in their room. Nurse R indicated they were never provided an opportunity to assess R119 for injury and that they were never consulted when CNA O transferred them back to bed by themselves. Nurse R was queired regarding assisting CNA O with R119 using the urinal later that night and they indicated they did not do that, and were unaware of any concerns regarding R119 that night. Nurse R reported that it was very unfortunate of what occurred, but that they knew nothing about R119 falling. On 9/18/24 a review of the disciplinary action forms titled Performance Improvement Form that were all dated for 9/9/24 for Nurse R, CNA O and CNA S revealed the following: Employee Name [Nurse R] .Reason for counseling/corrective action: Employee failed to check on resident every two hours per policy . Employee Name: [CNA S] .Reason for counseling/corrective action: Employee failed to report resident change to supervisor regarding resident complaint of extreme pain after unreported fall resulting in major injury to the resident . Employee Name: [CNA O] .Reason for counseling/corrective action: Failure to comply with 6.1 in employee handbook (1. violating resident right, failing to report to supervisor, 6. Falsifying documentation, 22. disruptive behavior) and 7.2 accidents to residents, 'if you suspect serious injury, do not move resident.' Employee failed to notify supervisor of resident change, didn't document resident experienced change in condition. Employee did not notify supervisor of resident fall that resulted in major injury, employee improperly assisted resident off the floor .Counseling sessions/corrective actions: Termination of employment . 34275 R35 On 9/16/24 at approximately 11:10 AM, R35 was observed lying in bed. The resident had bruising around their right eye as well as wraps around both their lower and upper right arm. The resident was alert but could not answer questions regarding the observation. A review of the R35's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: Epilepsy, vascular dementia, and traumatic brain injury. A review of R35's MDS noted the resident had a BIMS (8/30/24) score of 0/15 (severely impaired cognition). The resident was noted to be incompetent to make their own decisions and had a court appointed guardian. Continued review of R35's clinical record and Incident/Accident (IA) documented, in part, the following: 6/17/24 -Encounter: Nurse stated resident had an unwitnessed fall . IA report: Incident witnessed: No- Resident unable to give description . Immediate Action: ensure that matt is next to bed at all times every time staff enters rooms, resident is moving objects . 6/18/24-Nurses Notes: Nurse heard a bang and went to resident's room. Resident was ambulating unassisted and was leaning against the wall began yelling to writer 'I told you that you should take a shot gun with you' .Resident yelling out nonsense .All discussions seem to center around violence, guns, cutting off heads, stealing and being 'stuck with broken needles' Resident gets very agitated . IA report: Resident lying on floor on the left side of the bed .R (resident) had removed brief and blue jeans were half pulled up. No footwear on .Notes: Resident has history of laying on floor .unable to communicate needs .Resident did not have night ware on .care plan updated to ensure resident is wearing sleeping clothes at night . 6/20/24-Nurses Notes: .Bump and bruising to right forehead and right eye . IA report: Observed lying on floor next to bed .It was observed resident's peg tube had dislodged .resident taken to ER (emergency room ) resident experiences confusion and often unable to communicate needs .care plan undated with nonskid foot ware as resident allows. *The resident returned from the hospital on 7/4/24. 7/10/24 -Nurses Notes: Resident found on floor laying next to overturned wheelchair. Resident not able to verbalize how he got on floor .Resident had also pulled out all clothes in drawers and closets and threw them all over the room . IA report: Immediate action: Continuing to monitor resident to maintain his safety and staff safety .care plan updated to remove excess furniture . 7/11/24 - Nurses' Notes: Found resident on floor in room. Resident was laying on his back with pieces of blinds in his hand .also the bed control .Resident not able to tell how he got on the floor .Nursing management .were notified. IA report: .Immediate Action: Bed control removed from room .Called NP (nurse practitioner) on call and she suggested 1:1 sitter and maybe adding care plan .because of continuous falls .Called nursing management and notified them of NP suggestion and they stated they would bring it up in morning meeting .Notes .Care plan updated for provider to evaluate medications and add pain medication as indicated. *It should be noted there was no documentation in the resident's care plan that noted an intervention to provide a 1:1 sitter. 7/17/24- Nurses' Notes: .R35 appears as if he was eating chocolate ice cream due to residue on his hands and face and in his bed. Writer asked if he ate ice cream, and he states yes .unable to provide details .R35 is NPO (nothing by mouth) . 7/18/24 - Progress Notes: .Fall 2x this morning . IA report(s): .9:00 AM .he was sitting against bed with wheelchair in reach .Witnessed: No .Immediate Action: Maintenance added another break to wheel of bed . IA report .10:10 AM . Housekeeper director called nursing staff to back common area on hall and stated resident fell .Incident witnessed: No .Immediate Action: reminded resident to lock wheels before transferring and to ask for assistance . 7/19/24- Pertinent Charting Behavior: .Resident spending most of time in room, occasionally upset because he wants to eat food . 7/23/24- Progress Notes: .R35 seen today for fall .Pt. attempted to transfer self from wheelchair to regular chair, missed it and fell to carpet floor . *No IA was provided for this accident. 7/25/24- Nurses' Notes: .found resident walking down hall naked from waist down .Continue to monitor . 8/1/24 - Nurses' Notes: .Resident was found at the end of his bed on the floor. Mattress was halfway off bed and resident went to floor off mattress .Maintenance request sent as urgent to place foot board at the end of the bed to prevent further falls . IA report: Was this incident witnessed: No . Immediate Action: .there is no foot at the end of the bed . 8/2/24- Nurses' Notes: Resident was demanding to call kitchen to get food and became very irate that he cannot have food by mouth . 8/8/24- Nursing Evaluation: .Resident has a history of frequent agitated behavior .Resident was also evaluated by speech and started on puree diet with 1:1 supervision . 8/8/24-Nurse's Notes: Walked into resident's room and found him bleeding from penis from foley catheter. Resident stated he had stepped on the bag, and it hurts .continued to monitor . 8/21/24-Nurses Notes: .Resident very agitated . IA report: .3:06 PM .Walked into room found resident laying on floor R35 totally naked feces over lower body on legs and back Was this incident witnessed: No .Immediate Action: .managed to walk R35 to bathroom . 8/21/24-Nurses'Notes: .Found resident on floor laying on top of blue foam cushions. Resident was totally naked with feces noted all over lower extremities . IA report: .11:55 PM Was this incident witnessed: No Notes: resident experiences confusion, often doesn't ask for assistance .Resident was self-ambulating when he went to sit on the footrests of his wheelchair . 8/23/24-Pertinent Charting Behavior: Between 2 AM and 4 AM resident was seeking food. Went to all the carts, dining room, and onto unit 2 .Yelling I want food . 8/29/24-Encounter: Resident fell to floor and hit back of head on floor. 2-inch laceration noted which will most likely need sutures. Ok to send to ED (emergency department) . IA report: Resident was walking and pushing his wheelchair attempted to redirect .he began running and fell .hit his right brow and lower eye lid on either the floor or the back of the wheelchair when he fell .Resident reported that he thought the nurse was going to try to give him a bolus tube feeding and was running away .Was this incident witnessed: No Immediate Action Taken: resident would be sent to ER for assessment .d/t (due to) 2 recent falls with head involvement .skin tear flap hanging down from right lower eye lid .Staff have noted resident to be more difficult to redirect recently related to changes in tube feed administrative times .Care plan updated to staff to discourage resident from pushing wheelchair while walking as needed . 8/29/24-Progress Note: Resident returned from ER (emergency room ) at 8:40 AM. 3 staples to back of head . 8/30/24-Nurse's Notes: Found resident at end of poppy hall, eating a cookie and trying to remove puddings from med cart . 8/30/24-Progress Note: EMS (emergency medical services) here to transport resident for psych evaluation . *It should be noted that the resident remained in the hospital through 9/9/24. Hospital records pertaining to the residents' psychological concerns were not located in the resident's clinical record. A request was made to provide the documentation. 9/12/24-Progress Notes: .R35 is seen today for fall. It was unwitnessed .found next to his bed . IA report: .was this incident witnessed: No .Notes: Care plan updated for sleep diary . 9/12/24-Nurses' Notes: resident opened up the food cart and removed tray and going down hall with food tray . 9/14/24-Pertinent Charting Behavior: .Resident took a plate of food from lunch caddie .Writer approached resident and he had a fistful of French fries and actively shoving them in his mouth .Writer convinced resident to spit out what he hadn't already swallowed .Resident was continuously leaving the hall in search of food or drinks . 9/15/24: IA report .10 PM .Was this incident witnessed: No .Notes: care plan updated to encourage resident to keep wheelchair within reach. 9/16/24-Progress Notes: .seen today for Slide off wheelchair twice this weekend . IA report: .1:48 AM .Resident was with a small cup of water while wheeling himself down the hallway. When staff attempted to get the cup, the resident became upset and threw the cup .followed him .when the resident went to transfer himself from his wheelchair to a chair he missed and fell to the floor Notes: .R35 recently returned from hospital stay where a diet order was in place for 1:1 assistance with meals .resident was drinking unsupervised .care plan updated for medication review. 9/16/24: IA report: 12:10 AM Was this incident witnessed: No .Notes: resident often chooses to self-transfer and has an increase in behaviors related to receiving enteral nutrition .Care plan updated for staff to encourage resident to be in common areas while awake on night shift and to offer 1:1 activity to resident. A review of R35's care plans documented, in part, the following: Focus: Resident has an ADL (activities of daily living) self-care performance deficit .Interventions: Ambulation: walker or wheelchair (6/13/24) .Bed Mobility-1 person assist (4/22/24) .Eating -NPO at this time (4/29/24) .Transfers -1 person (4/29/24) . Focus: Resident is at risk for falls/injury related to potential seizure activity, history of falling, takes psychotropic medication and cognitive deficits .Interventions: .Discourage resident from pushing wheelchair while walking as needed (8/29/24) .Encourage resident to be in high visibility areas while awake (8/22/24) .Encourage resident to keep wheelchair within reach (9/16/24) .Encourage resident to lock wheelchair breaks before standing up (8/29/24) .Frequent rounding while resident in room (6/14/24) .Sleep Diary (9/12/24) .Staff to ensure bed height to be at residents knee level .(6/14/24) .Staff to ensure wheelchair is locked when resident not in it (7/19/24) .Encourage resident to keep needed items within reach (4/22/24) .Encourage resident to use call light (4/22/24) .Encourage the resident's room is free from accident hazards .(9/15/24) .Non-skid footwear to reduce the risk of slipping .(6/20/24) . Focus: Resident is at risk for altered nutritional status related to: Enteral nutrition via PEG .NPO .Chooses to consume orally despite NPO/pleasure feeds offered during therapeutic setting .Interventions: Keep all food off hallway and dinning room when resident is up. Resident known to get into uneaten food (8/17/24) .Resident is NPO (4/24/24) . Review of a document titled, Department of Health and Human Services - Comprehensive Level II Evaluation (8/6/24) .reported, in part, the following: .R35 .Diagnoses: Schizoaffective disorder, Bipolar type-primary .Recommendations: R35 was living in a group home .but is reportedly unable to return there due to his feeding tube. From reports, it appears R35 would be more satisfied if he were able to have small amounts of pleasure foods. This is allowed in the results of his swallow study, yet the nursing facility reported that he must be on hospice to receive this . A swallow study dated 6/19/24 noted the following: .Recommendation .Supervision Swallow Recommendations: 1:1 .Position Swallow Recommendation: Upright 90 degrees .Swallow Precautions Recommendations: Small bites of food .Discharge Recommendations: NPO with PEG as primary source of nutrition, hydration, medications. R35 may have bites of puree consistency foods for comfort . On 9/19/24 at approximately 10:36 AM an interview and record review were conducted with the DON. The DON was queried as to the multiple falls sustained by R35 and the interventions that were introduced to try to reduce them. The DON noted that the resident was very impulsive, non-compliant and had several behavior issues. The DON noted that initially they tried to remind the resident to utilize their call light, lock their wheelchair and wear proper footwear, but that did not always work. They further reported that were seeking to adjust the resident's medications to ensure they are getting a good sleep. The DON stated that R35's behaviors seem to get worse when they do not get their necessary sleep. In September 2024 they started to keep a sleep diary. The DON was asked why the facility did not follow the NP's recommendation (dated 7/12/24) that R35 receive 1:1 sitter due to excessive falls. The DON noted that they did not implement the recommendation and indicated that due to the resident's behaviors, including behaviors towards staff, that would require two staff to always assist the resident and the facility was not able to provide that care. The DON was asked about the resident's attempts to obtain food that led to falls and/or potential injury. The DON noted that they were aware the resident attempted to obtain food and on more than one occasion was able to grab and consume food. The DON was then asked if the resident required additional supervision to ensure the resident was not grabbing and consuming food on their own again. The DON noted that staff will try to redirect the resident if they are observed trying to obtain food, but again there is no direct 1:1 supervision currently being provided. The DON reported that they were trying to work with the resident's Legal Guardian to try to obtain permission to place the resident on Hospice so that they could have potential pleasure trays during meals, however the Guardian was not responsive to the request. The DON did indicate that the only person providing food was the Speech Therapist. On 9/19/24 at approximately 11:17 AM, an interview was conducted with Speech Therapist (ST) V regarding 1:1 feeding assistance for pleasure trays that may have the potential to reduce falls. ST V confirmed that they are the only person providing feeding assistance at this time and have not trained any further staff. They also noted that unless R35's Legal Guardian agrees to Hospice they do not feel comfortable allowing other staff to provide feeding assistance. On 9/19/24 at approximately 11:44 AM, an interview was conducted with the Administrator regarding R35's falls and attempts to obtain food. The Administrator reported that they were aware of the incidents and were trying to work with the Guardian as to whether they would agree to Hospice or palliative care for the resident. As to providing 1:1 supervision for R35, the Administrator noted that at this time they did not believe it was needed. On 9/19/24 at approximately 12:30 PM, an interview was conducted with the Ombudsman X. The Ombudsman reported that they were at the facility to discuss concerns brought up by R35's Legal Guardian. According to Ombudsman X, R35's Legal Guardian had reported concerns related to falls and the failure to feed the resident a pleasure tray without being a Hospice resident. Ombudsman X noted that the Legal Guardian reported that prior to admission to the facility the resident had minimal behavior issues and limited falls and felt that if the resident were to receive feeding it might limit falls and behavior issues. Review of the facility policy titled, Fall Prevention Program (10/26/23) documented, in part:; Policy: Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls .Policy Explanation and Compliance Guidelines: .Each resident's risk factors .will be evaluated when developing the residents comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed .

Based on observations, interviews, and record reviews the facility failed to ensure appropriate interventions were implemented as ordered timely and consistently to prevent the development and or worsening of pressure ulcers for three (R2, R100, and R522) of four Residents reviewed for pressure ulcers, resulting in the development of additional wounds and the likelihood of the worsening of wounds and pain. Findings include: R100 R100 was a long-term resident of the facility admitted on [DATE]. R100's admitting diagnoses included stroke, dementia, chronic left heel ulcer, seizures, peripheral vascular disease, and history of polio. R100's Brief Interview for Mental Status (BIMS) score of 3/15, indicative of significant cognitive deficits. R100's Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 8/5/23 revealed that R100 needed extensive assistance from two staff members to assist with their mobility in bed and extensive staff assistance from 1 to 2 staff members with their Activities of Daily Living (ADL). An initial observation was completed on 8/29/23 at approximately 10:35 AM. R100 was observed lying on their bed on their back. R100 bed had an alternating pressure mattress and was positioned in the low position. R100's bed was positioned against the wall on the right side. R100's heels were in direct contact with the surface of the bed. Both heels had a dressing covered with gauze. There were no pillows or offloading cushions or heel boots (pressure relieving heel protection boots). There was a Broda chair (a tilt in space reclining chair with wheels) in R100's room, next to the bed on the left side. There were two heel boots on the Broda chair together with other resident belongings. Later that day, at approximately 4 PM a second observation was completed. During this observation, R100 was observed in their bed lying on their back. R100's both heels were resting on the surface of their bed. The two heel boots were observed on the Broda chair on the same spot as before and the chair was parked next to the left side of the bed. On 8/30/23, at approximately 8:45 AM a follow up observation was completed. R100 was lying on their bed and was not dressed. R100 had a facility provided gown and had moved part of their covers/blankets. R100's heels were in direct contact with the bed. There were no pillows under their feet or near their feet. They were awake and asking for help and staff were notified. The Broda chair was parked next to the bed and two heel boots were on the chair. During this observation the surveyor asked if he could call R100's spouse and R100 replied yes. A called was placed to R100's spouse. At approximately 10:45 AM, another observation was completed. During this observation, R100 was observed in the same position on their back. The gauze covers on the heels were partially off and R100's heels were directly resting on the surface of the bed. Two heel boots were observed on the Broda chair next to the bed. Later that day (8/30/23), at approximately 1 PM another observation was completed. During this observation R100 was in their gown, lying on their back. Both heels were in direct contact with bed surface. Both heel boots were observed on the Broda chair parked next to the bed. At approximately 3 PM a follow up observation was completed. R100 was observed in bed with a gown on, with their eyes closed. R100's heel dressings were partially off on both heel with brown stains on them. Both heels were resting directly on the surface of the mattress. The two heel boots were observed on the same spot in the Broda chair next to R100's bed. On 8/30/23 at approximately 3:50 PM another observation was completed. During this observation assigned RN (Staff member S) was present in the room. R100's heels were resting on the bed surface. Staff member S checked the dressing on both heels that were stained and not properly secured. Staff member S reported that they were dated for 8/29/23. Staff member S reported that R100's dressing changes were done daily, on mid-night shift. Staff member S reported that they were going to change the soiled dressings. Staff member S was queried about the two heel boots that were on the Broda chair. Staff member S reported that they should be on while in bed and not sure why they were not on. Staff member S reported that they would change the dressings and put the heel boots on. It must be noted that a total of six observations at different times/shifts were completed between 8/29/23 and 8/30/23. R100 did not have their protective heel boots on during these observations. A review of R100's Electronic Medical Record (EMR) revealed that R100 was admitted with an unstageable left heel pressure ulcer. Admission skin assessment, section under describe other foot problems, read in part .pressure to heel, black, per hospital reports, unstageable. The preventative foot care section of the assessment read, resident arrived with heel boots. R100 had a Braden assessment (Scale for Predicting Pressure Sore Risk was developed to foster early identification of patients at risk for forming pressure sores) score of 16 (dated 2/5/23) indicative of mild risk for pressure ulcer. A review of the Braden assessment dated [DATE] revealed a score of 15, indicating a mild risk for pressure ulcer development, despite their diagnoses and comorbidities. A review of R100's hospital referral documentation also revealed a lower extremity arterial doppler (study of blood flow in legs) results. The results revealed no arterial occlusive disease (no blockage) in right lower extremity and mild arterial occlusive disease (mild blockage) in left lower extremity. Review of R100's EMR revealed a physician order that read, Bilateral heel boots to be worn at all times, dated 8/17/23. Another ordered dated 8/13/24, read wound left heel, right heel, and right ankle: cleanse with wound cleanser, pat dry. Apply honey gel and calcium alginate to wound bed. Cover with pink silicone foam. Please wrap from ankle to calf with kerlix for protection, every night shift for wound care. Another order dated 8/20/23 read, ensure air mattress is on and operational every shift. It must be noted that R100 had a recent admission to hospital on 7/27/23 and readmitted back to facility on 7/31/23. R100 was readmitted back to the facility with a chronic left heel wound and no treatments were initiated until 8/13/23 (13 days after readmission to the facility) based on the orders and review of the treatment administration record. A review of orders also revealed that preventative interventions to protect the heels (heel boots) that R100 was originally admitted with were not in place after readmission on 7/31/23. Bilateral heel boots were reordered on 8/17/23 (17 days after readmission back to the facility). Further review of R100's EMR revealed a nursing progress note dated 7/23/23 (prior to recent hospitalization ), that read in part, .apply medi honey to wound bed only. Apply alginate to wound bed place foot back in heel protector. A nursing progress note after readmission, dated 7/31/23 at 17:14, read, Also on admission skin assessment right malleolus scabbed over area and several scabbed over areas on bilateral lower extremities from flaked off skin. Wound care referral. There was no documented evidence that wound care was initiated timely. Further review of physician orders revealed an order dated 8/10/23, (10 days after readmission to facility) that read, wound care team to follow patient as warranted. A review of R100's skin assessment dated [DATE], revealed a facility acquired stage 3 pressure ulcer (pressure injuries that extend through the skin into deeper tissue and fat) on right heel with the following measurements: Length of the wound: 1.14 cm; width of the wound 0.89 cm; and depth of the wound 0.2 cm. It must be noted that were no documented skin assessments prior to 8/20/23 reflected that R100 had an acquired right heel pressure ulcer. A review of practitioner note dated 8/8/23, revealed that R100 had right heel and right ankle facility acquired pressure ulcer that were present on 8/8/23. The practitioner note read in part, Chief complaint: Evaluation of wound left heel, right heel, and right ankle. assessment and plans: Pressure ulcer of right heel, unspecified stage: cleanse with wound cleanser, pat dry,. Apply honey gel and calcium alginate. Cover with bordered foam. Pressure ulcer to left heel, unspecified stage: cleanse with wound cleanser, pat dry,. Apply honey gel and calcium alginate. Cover with bordered foam. Pressure ulcer of right ankle, unspecified stage: cleanse with wound cleanser, pat dry. Apply honey gel and calcium alginate. Cover with bordered foam. It must be noted that these wound treatment orders were initiated on 8/14/23 (7 days after the practitioner's wound consult and 13 days after readmission to the facility). A review of R100's care plan revealed the interventions that included, Encourage and assist as needed to elevate heels off of the mattress as tolerated; preventative treatment per orders, pressure redistribution mattress to bed, with an effective date of 8/15/23 (15 days after readmission to facility). An interview with R100's spouse/responsible party was completed on 8/30/23 at approximately 9:45 AM. During the interview the responsible party reported that they had not been receiving communications from the facility staff members. R100's spouse/responsible party reported that they were not aware of the pressure ulcer on the right heel. They had confirmed that no one from facility had called and notified them of the pressure ulcer on R100's right heel pressure ulcer. An interview with was completed with the unit manager (staff member O) on 8/30/23, at approximately 3:55 PM. Staff member O was queried on facility acquired stage 3 pressure ulcer on the right heel and the preventative measures that were in place for the R100. Staff member O reported that R100 was being followed by the wound team and the facility used heel boots or pillows or heel up cushions to off load and protect the heels. Staff member O was queried on why staff were not following the orders and not assisting R100 with off loading and protecting their heels. Staff member O' reported that R100 refuses at times. Staff member O was notified on the multiple observations when R100 was not offered and assisted with offloading the heels with heel boots or alternate interventions. Staff member O reported that staff should follow the orders for the wounds to heal and they would follow up with their staff. An interview was completed with the Director of Nursing (DON) on 8/30/23 at approximately 10:25 AM. The DON was queried about the facility acquired stage 3 pressure ulcer and the facility's plan. The DON reviewed R100's EMR and reported that the right heel pressure ulcer was identified on 8/20/23. The facility wound care nurse followed up on the wound treatments and obtained orders from the attending physicians and practitioners. As noted above, the skin assessment report revealed that the right heel ulcer was identified on 8/20/23. But the practitioner note dated 8/8/23, revealed that they had done a wound consult on 8/8/23 for the right heel wound. A follow up interview was completed with the DON on 8/31/23, at approximately 12:50 PM. The DON was queried on their facility policy on following preventative measures as ordered. The DON reported that expectation is treatments and other interventions should be continued as ordered. The DON reported that R100 had an order for heel boots to be on at all times and staff are expected to assist resident with heel boots. The DON reported that they would follow up with their staff and agreed with concern. A facility provide document titled Pressure injury prevention and management with a revision date of 1/1/22, read in part, The facility is committed to prevention of avoidable pressure injuries and promotion of healing of existing pressure injuries. Definitions: Pressure Ulcer/Injury refers to localized damage to skin and or underlying soft tissues usually over a bony prominence or related to a medical or other device. Avoidable means that the resident developed a pressure ulcer/injury, and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of interventions; or revise the interventions as appropriate. Policy Explanation and Compliance Guidelines: 1. There are multiple terms used to describe type of skin damage, including pressure ulcer, pressure injury, decubitus ulcer, and bed sore. For purposes of this policy, pressure injury as the current standard terminology, will be used. 2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying interventions as appropriate. 3. Assessment of Pressure Injury Risk: a. Licensed nurses will conduct a pressure injury risk assessment, using [NAME] or Braden tool on all residents upon admission/re-admission, weekly x 4 weeks, then quarterly or whenever the resident's condition changes significantly . 34208 R522 On 8/29/23 at 10:42 AM, R522 was up to their Broda Chair in the common/dining area of the memory care unit. They were observed to be seated in the chair with no specialized cushion for offloading pressure and no soft heel boots in place to protect the feet from skin breakdown. On 8/29/23 at 12:37 PM, R522 was observed eating their lunch meal in the dining room. No offloading cushion or heel boots were observed in place at that time. An observation of their room revealed soft heel boots were placed on the stripped bed. On 8/29/23 at 12:48 PM, a review of R522's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: late onset Alzheimer's disease, dementia, protein calorie malnutrition, anxiety disorder, and falls. R522's MDS assessment dated [DATE] revealed they had severely impaired cognition and required assistance from staff for activities of daily living. The MDS assessment indicated they did not admit to the facility with any pressure ulcers. A review of a Skin & Wound Evaluation Dated 8/27/23 revealed R522 developed an unstageable pressure ulcer (Full thickness tissue loss in which the base of the ulcer is covered by slough, and/or eschar in the wound) to their right heel. A review of R522's physician's orders was conducted and revealed a treatment order to the wound dated 8/27/23, an order for, Heel protectors to be worn at all times dated 8/27/23, and an order for Pressure redistribution surface while seated dated 8/27/23. On 8/29/23 at 1:53 PM and 2:10 PM, and 8/30/23 at 9:15 AM, 11:18 AM, and 12:10 PM, R522 was observed seated in their Broda chair in the dining/common area. It was not observed R522 had heel boots, or an offloading cushion in place. On 8/30/23 at 12:15 PM, an observation of R522's wound care was observed with nurse 'C', R522's assigned nurse. R522's right heel revealed a wound approximately 1.5 inches in diameter with undeterminable depth, covered in yellowish slough and blackened tissue around the perimeter of the wound. It was further observed the wound had moderate, foul smelling drainage that had seeped through the dressing and into the gripper sock. At that time, Nurse 'C' was asked if the left heel could be observed. The left lateral heel revealed a fluid filled blister approximately the size of a quarter. On 8/31/23 at 11:40 AM, R522 was observed seated in their Broda chair in the common/dining area. R522's heels were observed on the ground and no heel boots or offloading cushion were observed in place. At that time, nurse 'P' (R522's assigned nurse) was asked if R522 had any wounds. Nurse 'P' reported they had a wound on their right heel, but did not mention any concerns with the left heel. They were asked if they could remove R522's gripper sock the the left heel could be observed. When the sock was removed the left heel revealed a fluid filled blister that was approximately double in size than the previous observation on 8/30/23. On 8/31/23 1:15 PM, an interview was conducted with the facility's DON regarding the observations of the heel boots, offloading cushion, and identification of the blister on 8/30/23. They said the interventions should have been put in place when ordered and when the new blister on left heel was identified, a treatment order should have been put in place. 48680 R2 On 8/29/23 at 10:30 a.m. Resident #2 was interviewed about having heel or puffy boots or does the facility do anything special for his legs while he is in bed. Resident #2 replied, No they do not do anything for my legs while in bed. I do not have any boots, I have my shoes over there in the corner. On 8/30/23 at 09:00 a.m. Resident #2 was observed in bed with no puffy boots or heel protecters on. There was also no extra pillows or blankets (utilized to offload pressure) observed on the foot of bed where resident could have potentially been able to float his heels. There were no heel boots in the resident's room. On 8/30/23 at 09:07 a.m., Nurse K was asked how did the facility manage the wounds on Resident #2's right ankle, she stated, The wound is very small so we just use 4x4 foam border gauze. Nurse K was asked if Resident #2 wore or has heel boots/ puffy boots. Nurse K stated, No, he does not have any of those and if he did he probably would not keep them on. He self-transfers and he is in and out of his bed and chair all the time. On 8/30/23 at 09:30 a.m., CNA L was asked if Resident #2 removed any heel boots or puffy boots. CNA L stated, No he does not wear those, he doesn't even have any that I have seen. On 8/31/23 at 08:53 a.m., Resident #2 was observed with no heel boots or puffy boots on. Record review revealed the care plan of Resident #2 with an intervention to float heels when laying in bed with puffy boots or pillows per residents preference.

This citation pertains to intake #138289 Based on interview and record review the facility failed to ensure adequate supervision was provided for three cognitively impaired residents (R80, R88 and R110) of seven residents reviewed for accidents, when on 6/15/23 R80 followed by R110 and R88 wandered into another resident room, (unsupervised by staff) which resulted in R110 pushing R88 over and R88 sustaining a nondisplaced fracture of the femoral neck, hospitalization requiring surgery and pain. Findings include: Resident #110 On 8/29/23 a facility reported incident (FRI) submitted to the Stage Agency was reviewed which indicated on 6/15/23 R110 pushed R88 over which resulted in R88 falling down and receiving a fracture of their left hip. On 8/30/23 the medical record for R110 was reviewed and revealed the following: R110 was initially admitted to the facility on [DATE] and had diagnoses including Dementia with other Behavioral Disturbance. A review of R110's MDS (minimum data set) with an ARD (assessment reference date) of 7/15/23 revealed R110 was independent with ambulation. R110's BIMS score (brief interview for mental status) was three indicating severely impaired cognition. A review of R110's progress notes revealed the following: 6/12/23-Resident was following around [R80], when [R110] asked [R80] to do something and [R80] did not do it [R110] spanked [R80] on her butt. 6/15/23-Approx (approximately) 7:00pm resident had physical aggression with another resident [R88] Resident was following around [R80] when [R88] decided to intervene. Resident pushed [R88] to the ground. when asked what she was doing [R88] stated that Resident would not leave [R80] alone. A review of R110's careplan revealed the following: Focus-Resident has impaired communication related to: Alzheimer's disease, dementia, and age-related cognitive decline .Interventions-Anticipate and meet the resident's needs . Resident #88 On 8/30/23 the medical record for R88 was reviewed and revealed the following: R88 was initially admitted to the facility on [DATE] and had diagnoses including Vascular dementia with other behavioral disturbance, Muscle weakness and Delusional disorders. R88's MDS with an ARD of 3/23/23 revealed R88 needed supervision from facility staff with ambulation. R88's BIMS score (brief interview for mental status) was nine indicating moderately impaired cognition. A review of R88's progress notes revealed the following: 6/15/23- Approx 7:00pm resident had a physical interaction with another resident [R110]. Resident stated that she saw [R110] not leaving [R80] alone. [R88] said she went to [R110] and told her to leave her alone. [R110] pushed [R88] and [R88] fell to the floor. Resident was sent to the hospital approx 7:10pm due to extreme pain in the hip and unable to bear weight on the leg. POA (power of attorney) called approx 9:15pm stating that resident has broken her hip and was getting surgery tomorrow (Friday). 6/19/23-resident arrived VIA EMS (emergency medical services) approx 3:45pm after a fall at [Name of facility]. Resident had a left femoral neck fracture and received surgery for it. A Physician hospital note dated 6/15/23 revealed the following: History of present illness This patient from [Name of facility] nursing home presents after a fall. Patient was apparently pushed by another roommate. There was no loss of consciousness. Patient apparently injured her left hip and has been complaining of left hip pain since the fall. Patient is now having difficulty ambulating .Work-up .X-rays of the left hip, acute nondisplaced fracture of the left femoral neck .Assessment plan: 1. Status post fall, mechanical 2. Nondisplaced left femoral neck fracture Orthopedics consulted Surgery is planned later today . A review of the facility investigation pertaining to the altercation between R110 and R88 on 6/15/23 was reviewed and revealed the following: Investigation Summary/Actions Taken: On 6/15/2023 at approximately 7:00PM CNA (Certified Nursing Assistant) [CNA N] observed Resident [R110] (Bimms <sic> 3) (severe cognitive impairment) push Resident [R88], causing her to fall to the floor onto her left side. [CNA N] escorted [R88] <sic> what she was doing and she stated that [R110] was going after [R80]. Staff immediately separated the two residents and the nurse conducted a skin check noting extreme pain to her left hip and she was unable to put weight on her left leg. Resident, [R110] was immediately put on a 1 :1 and was referred to the providers for a medical work-up. [R88] responsible party and Physician were notified about the incident, [R110] responsible party and Physician were notified about the incident. [R88] was sent to the ER (emergency room ) per Physicians order do to possible fracture. The nurse conducted a skin check on [R110] and noted a scratch on her right wrist from [R88] reaching out trying not to fall. On 6/16/23 at 2:59AM the hospital called the facility to report that [R88] had a left femoral neck fracture. All unit staff that were working at the time of the incident and no one saw [R110] push [R88]. But they did state that throughout the day they had been redirecting [R110] away from another resident named [R80] and it seemed that [R88] had picked up on this and was trying to keep [R110] away from the other resident .[R88] returned to the facility on [DATE] after receiving surgery to her left hip. She is now using a wheelchair with minimal discomfort. Due to [R110] still trying to follow [R80] she will remain on a 1:1 until staff can get her to focus on other things. [R80] is very small and childlike. [R110] sees [R80] as her responsibility and continues to try to be near her .The IDT (interdisciplinary team) through its investigation found that [R88] was trying to keep [R110] away from [R80] causing [R110] to get upset and push [R88] making her fall to the ground. [R110] remains on a 1:1 due to her still trying to follow [R80]. Based on the interviews and the facts of the investigation the facility was able to substantiate that a physical altercation occurred but was not able to substantiate that any abuse had occurred due to the inability to form intent due to cognitive deficits for both [R110] and [R88]. At this time [R110] is at baseline and resting comfortably in the facility and states that she feels safe and secure. [R88] has to now use a wheelchair until her hip fully heals, she uses the wheelchair with minimal discomfort and state that she feel safe and secure at the facility . An incident and accident report dated 6/15/23 pertaining to the altercation between R110 and R88 revealed the following statements from staff: CNA N-[CNA N] states she was coming out of room [ROOM NUMBER], she came down the hall and saw [R110] shove [R88]. they were In the doorway of room I. [R88] lost her balance and fell sideways onto the floor, [CNA N] asked [R88] what she was doing and [R88] stated that [R110] was going after [R80] .Nurse P-[Nurse P] states that she had left prior to the incident occurring: States resident was needing to be redirected away from the resident (R80). [R88]. was telling resident to stay away from throughout the day .CNA Q-[CNA Q] states she was In another residents room at the time of the Incident .[CNA R] was not on the unit yet . On 8/31/23 at approximately 12:30 p.m., during a conversation with CNA A and Nurse P, CNA A was queried regarding the behaviors of R110 on 6/15/23 and they reported that they frequently had to redirect R110 from following R80 around. CNA A was queried regarding the supervision needed for R110 and they indicated that R80 will walk into other resident rooms all day and that they do not have enough staff on the unit to appropriately supervise the residents that that is when residents to resident altercations occur. On 8/31/23 at approximately 1:05 p.m., CNA N was queried regarding their observation of R110 pushing over R88 on 6/15/23. CNA N indicated they were coming out of a resident room down at the end of the hall and saw R80 was wandering in another resident room with R110 following them in. CNA N reported that R88 tried to get R110 to stop following R80 at the doorway to the room. R110 pushed R88 over and they fell in the hallway and were not able to get up. CNA N was queried how the staff were providing supervision for the residents in the altercation when R110 had been noted to be following around R80 and they indicated they were unable to monitor them because they had to help another resident and the Nurse had gone on break. CNA N reported no one was able to watch the residents until they saw R110 push R88 over. CNA N reported there was no Nurse on the locked unit at that time, because the Nurse assigned to the unit was on break and they had to leave the locked unit to get another Nurse after R88 had fallen. CNA N was queried if they had enough staff members to monitor the residents on the locked unit and they indicated that they did not. CNA N reported there were other residents that needed 1:1 supervision because they frequently try to stand up and are a big risk for falling, so they have to watch them and are not able to watch the other other residents who are cognitively impaired and ambulatory. On 8/31/23 at approximately 2:21 p.m., The Director of Nursing (DON) was queried regarding the lack of supervision being provided for the cognitively impaired residents on the locked unit. The DON indicated that they try to staff it with an adequate amount of staff to watch everyone but that is only when the facility has enough staff on the other units to provide care. The DON indicated the staff assigned to the locked unit should be aware of who needs to be monitored. On 8/31/23 a facility document titled Accidents and Supervision was reviewed and revealed the following: Policy .Each resident will receive adequate supervision and assistive devices to prevent accidents .5. Supervision-Supervision is an intervention and means of mitigating accident risk The facility will provide adequate supervision to prevent accidents .

This citation pertains to intake #MI000134909 and MI00135251 Based on observation, interview and record review the facility failed to protect R701's right to be free from sexual abuse. This deficient practice resulted in Immediate Jeopardy to the health and safety of R701 (a cognitively impaired female) when R702, a male resident with a long history of inappropriate sexual behaviors was observed by a visitor in R701's room with his penis exposed and R701 performed non-consensual manual stimulation to his genitals. Using the reasonable person concept the sexual abuse resulted in the potential for serious psychosocial harm and/or injury to R701 and placed other female residents at risk. Immediate Jeopardy: The Immediate Jeopardy began 2/23/2023. The Immediate Jeopardy was identified on 3/22/2023. The Administrator was notified of the Immediate Jeopardy on 3/23/23 at 4:58 PM, and a plan to remove the immediacy was requested. The Immediacy was removed on 3/23/23 at 2:42 PM based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the immediacy was removed, the deficient practice was not corrected and remained patterned with potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency. A Complaint was filed with the SA that alleged a family member entered R701's room and observed R702 sexually assaulting R701. A Facility Reported Incident (FRI) was reported to the State Agency (SA) that alleged R702 was found in R701's room. R701 was performing oral sex on R702. The facility policy titled, Abuse, Neglect and Exploitation (revised 10/24/22) was reviewed and documented, in part: It is the policy of this facility to provide protections from health, welfare, an rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse .Abuse means the willful infliction of infliction of injury .intimidation .which can include .certain resident to resident altercations .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish .it includes .sexual abuse .Sexual Abuse is non-consensual sexual contact of any type with a resident .III. Prevention of Abuse .Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how and by who determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded . A review of the facility Incident Summary revealed in part, the following: Date Incident Discovered: 02/23/2023 7:20 PM .Date/Time Incident Occurred 02/23/2023 -07:10 PM .On 2/23/2023 at approximately 7:20 PM R701's daughter-in-law called the Administrator and reported that her husband's daughter and her husband walked into R701's room and saw her laying in bed with R702 and was giving oral sex. R702 exited the room and went to his room. DON (Director of Nursing) was in the building at the time, so she went with the facility social worker (hereinafter SW A) to interview both residents. The DON met with R702 and asked him if he was in a woman's room, he stated yes. He was asked what he was doing in there and he stated that she was playing with him. DON asked if she was using her hand or mouth and R702 said that she was using her mouth. He was questioned whether he asked for it and he stated he did not, he was then asked if R701 asked for it and he stated yes. R702 was asked if he took his pants down or did R701 take his pants down, he stated that she took his pants down .SW A interviewed R701 while her son and granddaughter were in the room. R701 was asked what happened, she stated she was watching TV and R702 came into her room and laid on her bed. He unzipped his pants and pilled<sic> out his (motioned to the genital area). R701 stated she told him she did not think it was okay and R702 stated, no it's okay. R701 stated that R702 was attempting to zip his pants up when her family walked in. At this point in the interview R701's son (name redacted) interrupted and stated no, .granddaughter saw what happened, he had his penis out .There was no facility staff that witnessed this incident the .Police were called in regards to the accident .Investigation Conclusion: Based on the interviews and the facts of the investigation the facility was able to substantiate that there was sexual touching that occurred, but was not able to substantiate that any abuse or non-consensual sexual activity had occurred due to the inability to form intent due to cognitive deficits and due to the fact that R701 stated that she must have wanted it to happen at first . A review of the Police Department Incident/Investigation (authored by Police Officer C) report documented, in part, the following: .Date/Time Reported .02/23/2023 .7:42 PM Victim (R701) .Additional Name List .SW A .R701's Granddaughter .R701's Son .DON .Criminal Sexual Conduct .Date & Time .Reported on Thursday, February 23, 2023 at approximately 07:42 hours .Venue: Facility .Offender R702 .On the date and time, I was dispatched to the listed venue for a .report that had just occurred. Central dispatch advised that the incident was between two residents and it was unknown at the time if the contact was consensual .Reporting Officer Narrative .Upon my arrival I made contact with staff on scene .I made contact with SW A, who advised that the incident occurred in the locked memory care unit between two patients within the unit .SW A noted R701 is in the locked memory unit for diminished mental capacity due to a medical condition (dementia/Alzheimer`s). SW A stated that R701 described a sexual incident that occurred between R701 and another male resident, R702. SW A advised that R701 had informed her that R702 had come into her room and sat down next to her on the bed. SW A advised R701 went on to describe the incident and that R702 asked R701 to pleasure him and he pulled his pants down, exposing his penis. SW A stated that R701 told her she advised R701 that her family was on the way to see her, and that it was not a good time for the two to have sexual relations. SW A advised that R701 admitted to stroking R702's penis with her hand, but the two were interrupted when R701's granddaughter and son entered the room. SW A advised that when she initially asked R701 if the incident was consensual .The DON advised . that she had already spoken to R702 and received a partial statement from him. The DON advised that R702 had admitted going into R701's room. DON advised when she asked R702 about the incident, he stated that R701 had pulled down R702's pants and insisted that she stroke his penis .I then made contact R701's granddaughter and R701's Son outside of R701's room. R701's Son advised that R701 was deemed incompetent by a psychologist / medical doctor .I asked R701's Son what had happened, and R701's Son advised that he was walking down the hall to see his mother and R701's Granddaughter walked into R701's room before he had. R701's Son advised that R701's Granddaughter came rushing back out of the room, startled and in a panic. R701's Son advised R701's Granddaughter stated something along the lines of not wanting to see what she had just seen, and he entered further into the room to observed R701 stroking R702's penis. R701's Son advised that he began to rush out into the hallway and wave his arms to alert the attention of staff members assigned to the locked memory unit. I then made contact with R701's Granddaughter who provided the same series of events as R701's son. R701's Granddaughter advised that she could not believe what she had seen upon entering the room and tried to leave as quickly as possible without focusing on the details I then made contact with R701 in her room . I asked R701 if she could concentrate on what had occurred since she had been served dinner and asked if she remembered another patient coming into her room. R701 advised that she did and that it was a male patient who she believed was named name redacted and different name than R702). I asked R701 to describe name redacted and she advised that he was a (description redacted) .it should be noted that R701 provided the matching physical description for R702 but was simply unaware of R702's real name.R701 stated that the door to her room was open and R702 walked in. R701 advised that R702 sat down next to her on the bed and began asking her for sexual favors. R701 stated that she told R702 it was a bad time because her family was coming to visit. R701 stated that R702 was aggressive with his advances. I asked R701 to describe what she meant by aggressive and R701 advised that R702 was being quite persistent. R701 stated that R702 pulled down his pants and she began to stroke R702's penis with her hands because he had asked her to. R701 advised that she continued to do so until R701's Son and Granddaughter walked in on them. I asked R701 if R702 had made any kind of threats to harm her or coerced her in anyway. R701 advised these actions are not like her and she stated that if she could do things over, she would not have touched R702s` penis. R701 advised she felt coerced and did not want to do it but was unable to explain further as she was becoming emotional.I then made contact with R702; it should be noted that the facility`s DON was present during this interview. It should also be noted that R702 had been placed in the locked memory care unit due to brain damage caused by a severe TBI (Traumatic Brain Injury). R702 was unable to answer any basic questions at this time. I asked R702 if he remembered R701 or remembered walking into a female`s room and he advised he did not .he did not remember anyone touching his penis and denied that he had a girlfriend in the facility . On 3/22/23 at approximately 10:38 AM, R702 was observed in sitting in a chair in front of the television on the locked dementia unit. There were approximately six to eight other residents also watching the TV. One Certified Nursing Assistant (CNA) D was in the TV room as well. CNA D was asked if they had been assigned to R702 and they reported that they were not but were just with all the residents. R702 was asked if they could step out of the TV area so that they could be interviewed. R702 agreed and was able to ambulate on their own to a private room for interview. During the interview R702 was alert, spoke in a very soft voice and was not able to answer most questions asked with respect to the incident involving R701 on 2/23/23. The resident did shake his head Yes when asked if he recalled a police officer talking to him in the building. Other than the Yes response regarding the police the resident did not answer any further questions. A review of R702's clinical record revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cerebral infarction, eplileptic syndrome, dementia and anxiety disorder. A review of R702's Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status score of 10/15 (moderately cognitively impaired) and required limited assistance for ambulation. Continued review of R702's clinical record documented, in part, the following: 12/27/2021: Pertinent Charting Behavior: .Resident came out of his room and raised his fist at the housekeeper .The housekeeper moved out of the way. The resident then went up behind the CNA and punched her in the back of the head . 2/17/2022: Pertinent Charting Behavior: .Resident wondering in and out of rooms .sleeping in (name redacted) bed .hitting (name redacted) CNA in the back of head for no reason .female CNAs are nervous with resident . 2/18/2022: .Resident was going through his roommate's belongings .lying in bed that belonged to roommate .Resident reminded that he is to only utilize his personal belongings .Resident needs to be monitored .his attention span is not long enough for the redirection to work long term . 2/18/2022: Progress Note: .denies hitting staff .care plan reviewed and updated to reflect resident requiring two persons for care due to safety concerns . 2/21/2022: Progress Note: .Pt is seen today for behavior evaluation .Pt has been wandering into other resident's room . 2/21/2022: Pertinent Charting Behavior: .resident wandering in the hall and going into women's rooms . 3/3/2022: Nurse's Notes: .Resident identified as an elopement risk .sister agreed that resident is appropriate for memory care unit .Resident to move . 3/30/2022: Pertinent Charting-Behavior: .wondering in the hall and common area. Wouldn't stay in room . 4/13/2022: Social Service Progress: .Resident had female friend visiting in room .female resident was redirected out of room . 4/22/2022: Nurse's Notes: .Resident was walking down towards his room and female resident was walking up the hall to common area. They met in the middle: hugged, kissed on the lips, and then hugged again . 4/25/2022: Nurse's Notes: .Resident caught hugging female resident in her doorway . 5/1/2022: Nurse's Notes: .Resident was sitting by a female resident with his arm around her shoulders. Aide slid in between the two on couch. R702 grabbed aid's butt while on the couch . 5/12/2022: encounter: .Nursing reports that resident is having behavioral episodes that are out of normal. Per nursing, resident is asking staff to join him in bed, trying to pull a resident out of their seat, stating his groin size is a problem . 5/30/2022: Pertinent Charting Behavior: .following another female resident around closely for a couple of hours . 6/6/2022: Pertinent Charting Behavior: .Aides expressed that he was inappropriate during shower. He asked aide if he had a big penis . 7/8/2022: Nurses' Notes: .Resident pretends like he is hitting other residents .Resident did get repeatedly re-directed and did not stop . 2/18/2022: Pertinent Charting Behavior: .when aide was giving shower resident became sexually inappropriate towards staff .grabbed staff multiple times inappropriately . 2/23/2022 (5:09 PM): Pertinent Charting Behavior: .Resident was in room naked. Aide went in to get him dressed and he asked if she would take a shower with him . 2/23/2022 (8:00 PM): Pertinent Charting Behavior: .Sexually inappropriate behavior with another resident . R702's care plan: Focus: The resident exhibits behavior of being affectionate towards others r/t (due to) dementia (4/25/22) .Resident has potential to participate in sexual interactions with others (Date initiated 1/2/2023 .Revision on 2/24/2023 .Interventions: Administer medication as ordered (1/2/2023) .Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by .Explain all procedures to the resident before starting and allow the resident to adjust to changes (1/2/2023) .If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident (1/2/2023) .Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm matter. Divert attention. Remove from situation and take to alternate location as needed (1/2/2023) .Monitor behavior episodes and attempt to determine underlying cause (1/2/2023) .Observe for environmental stressors such as excessive heat, noise and overcrowding . R701 A review of R701's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included, in part: type II diabetes, chronic kidney disease, and rheumatoid arthritis. A review of the residents MDS noted a Brief Interview for Mental Status (BIMS) score of 6/15 (cognitively impaired). Continued review of R701's clinical record documented the following: 2/7/2023: Nursing Evaluation Summary: Resident admitted on [DATE]. Resident noted to have confusion and restlessness. Resident continuously standing then sitting. Poor safety awareness noted. 2/9/2023: Pertinent Charting Behavior: Resident awake and walking around. After exiting building yesterday resident now has an aide sitting with her and walking with her to ensure no other falls or exits . Census: On 2/10/23, R701 was transferred to the locked memory unit where R702 resided. Decision Making Determination Form: I have evaluated this resident (R701) and have made the following determinations regarding decision making abilities. The resident (X) Incapable of making decisions regarding medical treatment Signed (name redacted) physician 2/17/23 and Psychiatrist (name redacted) 2/16/23. 2/23/2023: Social Services Progress Notes: .notified of sexual interaction between this resident and another .family observed this resident with a male resident in her bedroom touching the genitals of male resident .Writer provided support to resident who was distressed r/t (related to) family having witnessed interaction. Resident verbalized fear that son was upset with her .Family reports that sexual behavior is uncommon for this resident . On 3/22/23 at approximately 12:50 PM, an interview was conducted with Police Officer (PO) C. PO C was queried as to the investigation pertaining to the reported sexual assault against R701. PO C reported that they were dispatched to the facility on [DATE] around 7:40 PM and was told that a female resident (R701) was sexually assaulted. The resident's family was coming to visit the resident and when the granddaughter entered the room, she witnessed R702 with his pants down, penis exposed and R702 holding the R701's penis. PO C interviewed R701 who stated that a male resident entered into her room uninvited and took his pants down and asked for manual stimulation to his penis. R701 further stated that she did not want to comply but felt the resident was getting aggressive. PO C reported that R701 started to get very emotional during the interview and he did not proceed any further with questioning. PO C further reported that they tried to interview R702, but the resident was not able to answer many questions asked. PO C reported that they interviewed facility staff that noted R702 had a past history of inappropriate sexual behaviors with staff. On 3/22/23 at approximately 2:39 PM an interview was conducted with Social Worker (SW) B and the DON. SW B reported that they were familiar with the incident involving R701 and R702 but noted that they were not present on the date it occurred (2/23/23). They indicated that SW A was at the facility that evening. The DON was also present. It should be noted that SW A was on vacation and could not be interviewed during the survey. SW B stated that both R701 and R702 had been deemed incompetent and there was no documentation that either resident had the capacity to consent to sexual encounters. When asked if they were aware that R702 had a history of inappropriate sexual behaviors, SW B noted that they were and indicated that most of the behaviors stopped in the summer of 2022 following an increase in the medication Paxil. When asked if they were aware that some inappropriate sexual behaviors started again on or about February 18, 2023, SW B noted that they believed it to be a one-time event and no interventions were implemented. When asked if they were made aware of the incident involving inappropriate behavior with Staff during a shower on 2/23/22, they noted that they were not made aware of the behavior on that day and if they had known they might have initiated frequent checks on R702. On 3/23/23 at approximately 11:48 AM, a phone interview was conducted with CNA E. CNA E was asked about both R701 and R702 and the incident that occurred on 2/23/23. They reported that they had worked the day shift that day from 7 AM to 7 PM. CNA E reported that in the AM around breakfast time on 2/23/23 they observed R701 hanging all over R702 in the common area. CNA E stated that they redirected both of the residents. When asked if they had reported the incident, they noted that they did not. CNA E then reported as they were giving a daily report to the oncoming CNA, R701's Son came down the hall and stated that there was a man in his mother's (R701) room with his dick out and their mom was touching it. CNA 'E reported that they told Nurse F and left the facility. When asked if they ever witnessed any inappropriate sexual behavior prior to that day, CNA E stated that R702 would state that he wanted to kiss her and would touch me inappropriately around my waste. An attempt to contact Nurse F was made on 3/22/23 at 2:48 PM and 3/23/23 at 11:46 AM. No return call was made prior to the end of the survey. On 3/23/23 at approximately 2:24 PM, an interview was conducted with the Administrator/Abuse Coordinator. The Administrator reported that they started their employment at the facility about two months ago. When asked about the incident involving R701 and R702 that noted that they were not at the facility at the time of the incident but were familiar with what occurred. When asked if they were familiar with R702 past history of inappropriate sexual behavior and whether they had any IA (incidents/accidents)pertaining to prior incidents, the Administrator noted that they could not locate any prior IAs. When asked if they were aware that R702 exhibited signs of inappropriate sexual behavior starting the morning of 2/23/23, they reported that they did not and if they would have know they might have initiated additional interventions. When asked if the residents were competent to consent to sexual activity, they indicated both residents had been deemed incompetent. Removal plan for IJ of Abuse (3/23/23) As a result of the finding of immediate jeopardy by the survey team on 3/22/2023 related to resident 702 the facility has reviewed the below to determine causation. Findings include: Resident 702 was admitted to facility on 12/20/2021 from Home with diagnosis of Cerebral Infarction, Localized-Related Symptomatic Epilepsy and Epileptic Syndromes, Unspecified Dementia, Hyperlipidemia, Anxiety Disorder, Gastro-Esophageal Reflux Disease, Essential Hypertension, Muscle Weakness, Dysphagia, Major Depressive Disorder, Vitamin B12 Deficiency, Hip-Osmolality and Hyponatremia, Deviated Nasal Septum, Diaphragmatic Hernia, Hypothyroidism, Adjustment Disorder, Difficulty in Walking, and Cognitive Communication Deficit. Due to the states findings from the incident that occurred on 2/23/2023 that the facility should have acted upon the first encounter of resident 702 becoming sexually inappropriate with staff and noted earlier in the day on 2/23/2023 that resident was in his room naked. The facility is re-educating staff on the potential for abuse involving sexual behaviors. Resident 702 was immediately relocated away from unit. Resident 702 remains in the facility and remains on 1:1 supervision as of 2/24/2023. No inappropriate sexual behavior noted. Resident 701 discharged home per resident and family request with home health services. Total of 124 residents, 59 out of the 59 residents that are capable of making their own decisions have been interviewed by the IDT (interdisciplinary team) regarding sexual behaviors from other residents on 3/22/2023. Do you feel adequately supported by staff? Do you have any concerns with other residents that have not already been addressed? Do you feel safe in the facility? Of the 59 residents' questioned, there were no sexual inappropriate events voiced by these residents. If a resident voices any events of sexual inappropriateness, the Administrator will immediately interview the resident, ensure their safety, notify the police and the State of Michigan. The Administrator will notify Psych services for assistance with psychological harm and provide emotional support. The Administrator will notify the resident's responsible party of the event immediately. Remaining 65 Residents that are cognitively impaired have been assessed by Unit managers/DON for s/s (signs and symptoms) of sexual inappropriateness using a skin assessment on 3/22/2023. Any signs of physical abuse? Any signs of psychosocial distress? Any bruising, skin tears? 65 out of 65 residents had no findings of physical sexual abuse noted on their skin assessments. The administrator has reviewed the last 6 months of behavior documentation to ensure no other inappropriate sexual abuse has occurred. Residents with a history have been reviewed to ensure proper interventions in place. No other issues identified. Systemic changes include: When behaviors of a sexual nature occurs between residents the facility staff will: Immediately separate the residents Ensure residents safety by providing 1:1 supervision for residents as needed Notify Administrator Nurse will complete a physical assessment to ensure no harm Social services will complete an assessment to ensure psychological stability. Psych-services will be notified for additional support if needed. Administrator will ensure other residents safety by interviewing other like residents for identification of previous events. Administrator will interview staff witnessing the event for prior history of non-consensual sexual behavior. The Administrator will screen grievances as well as Incident Reports daily Monday-Friday for possible events that involve resident to resident contact that are sexual in nature. The QAPI (quality improvement process improvement) committee has reviewed the Abuse policy and has deemed it appropriate. The facility had an Adhoc QAPI meeting including the Medical Director on 3/22/2023 and deemed this abatement plan appropriate. Current staff will be re-educated on the Abuse policy regarding sexual behavior, reporting guidelines and investigation by the DON/designee on 3/22/2023, any staff not currently working will be re-educated prior to their next scheduled day to work. During this education, staff will be questioned about other potential residents whose behaviors indicate sexual behaviors. The administrator will audit incident reports for possible sexual abuse daily M-F (Monday-Friday) and via phone on the weekends. Social services will complete random interviews of residents for verbalization of feeling safe in their environment. The Administrator is responsible for continued compliance.

This citation pertains to intakes MI 980 and MI 982 and has two deficient practices. Deficient Practice #1 Based on interview and record review, the facility failed to follow their policy and Centers for Disease Prevention and Control (CDC) guidance to administer pneumococcal vaccinations to residents who consented for immunization, screen and assess residents for eligibility of receiving pneumococcal vaccinations, offer pneumococcal vaccinations to residents who were eligible to receive it, and educate residents on risks versus benefits of the vaccination for eight (R814, R815, R816, R817, R818, R819, R821, and R822) of nine residents reviewed for pneumococcal vaccinations resulting in facility acquired pneumonia, [CONDITION(S)], and hospitalization . The failure to implement policies following current recommendations for pneumococcal immunizations resulted in an Immediate Jeopardy (IJ) to the health and safety of R819 and R821 who developed pneumonia in the facility and resided on the same floor of the facility, and residents who were not fully immunized against pneumonia. Facility residents, many of whom were at high risk due to age and co-morbidities, had the likelihood of developing pneumonia resulting in serious health complications from the disease including the risk of death. Findings include: The IJ began 6/1/21. The IJ was identified on 11/23/21. The Administrator was notified of the IJ on 11/23/21 at 12:25 PM and a plan to remove the immediacy was requested. The immediacy was removed on 11/23/21 based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the immediacy was removed the facility's deficient practice was not corrected and remained at a pattern with potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency. Review of a facility policy titled, Pneumococcal Vaccine (Series) revised 8/13/21 read in part, It is our policy to offer our residents immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations .Each resident will be assessed for pneumococcal immunization upon admission .Each resident will be offered a pneumococcal immunization unless it is medically contraindicated, or the resident has already been immunized. Following assessment for any medical contraindications, the immunization may be administered in accordance with physician-approved 'standing orders' .Prior to offering the pneumococcal immunization, each resident or the resident's representative will receive education regarding the benefits and potential side effects of the immunization .The individual receiving the immunization, or the resident representative, will be provided with a copy of CDC's current vaccine information statement relative to that vaccine .The resident/representative retains the right to refuse the immunization. A consent form shall be signed prior to the administration of the vaccine and filed in the individual's medical record. The type of pneumococcal vaccine (PCV13 - pneumococcal conjugate vaccine, PPSV23/PPSV - pneumococcal [MEDICATION(S)] vaccine) offered will depend upon the recipient's age and susceptibility to pneumonia, in accordance with current CDC guidelines and recommendations .The resident's medical record shall include documentation that indicates at a minimum, the following: .The resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization .The resident received the pneumococcal immunization or did not receive due to medical contraindication or refusal. Review of the CDC publication titled, Adults Protect Yourself with Pneumococcal Vaccines revealed in part: Many adults may be at increased risk for pneumococcal disease and not know it. Two vaccines provide protection against this serious and sometimes deadly disease . Each year in the United States, pneumococcal disease kills thousands of adults. Thousands more end up in the hospital because of pneumococcal disease. It can cause severe infections of the lungs (pneumonia), bloodstream (bacteremia), and lining of the brain and spinal cord (meningitis). Vaccines are the best way to prevent pneumococcal disease. Two vaccines help prevent pneumococcal disease: PCV13 PPSV23 . CDC recommends PCV13 for: All adults [AGE] years or older; Adults [AGE] years or older with certain health conditions. CDC recommends PPSV23 for: All adults [AGE] years or older; Adults 19 through [AGE] years old with certain health conditions or who smoke cigarettes . Most pneumococcal infections are mild. However, some can be deadly, especially for adults [AGE] years or older: Pneumococcal pneumonia kills about 1 in 20 older adults who get it; Pneumococcal bacteremia kills about 1 in 6 older adults who get it; Pneumococcal meningitis kills about 1 in 6 older adults who get it . Pneumococcal Disease Is Contagious: Pneumococcal bacteria spread from person to person through coughing, sneezing, and close contact. People can carry the bacteria in their nose and throat without being sick and spread the bacteria to others . Review of the CDC publication titled, Pneumococcal Vaccination revealed the following: .Vaccines help prevent pneumococcal disease, which is any type of illness caused by Streptococcus pneumoniae bacteria . On 11/18/21 at 2:52 PM, as part of a review of the facility's infection control program, the facility's Infection Control Preventionist (ICP), Infection Control Nurse (ICN) A was interviewed. When queried about the facility's policies and procedures for offering, educating, assessing, and screening for eligibility, and administering the pneumococcal vaccination, ICN A stated, I was not here when they offered it at the beginning of the year. When queried about whether residents were assessed for eligibility on an ongoing basis and/or on admission into the facility, ICN A stated, I'm not sure what they do about that. ICN A reported that she had not assessed or screened any residents in the facility for eligibility for the pneumococcal vaccination and had not offered or administered the pneumococcal vaccination since she started in the ICP position in June 2021. At 3:00 PM, five residents (R814, R815, R816, R817, and R818) were selected to review for screening and assessment for eligibility to receive the pneumococcal vaccination, education about risks and benefits of receiving the pneumococcal vaccination, and evidence of administration of the vaccination, if eligible and consent was given to be immunized. On 11/18/21 at 4:00 PM, ICN A provided MCIR (Michigan Care Improvement Registry - vaccine registry database) reports for R814, R815, R816, R817, and R818. When queried about how ICN A educated residents about the risks versus benefits of the pneumococcal vaccinations, ICN A reported she only educated residents and their representatives about side effects if they wanted the vaccinations. ICN A reported they were asked if they wanted the pneumococcal vaccination on admission and then someone would let ICN A know if the residents wanted the vaccination and then she would educate them. When queried about why education about risks versus benefits of the vaccination was not provided to all residents in order for them to make an informed decision, the ICP reported if the resident signed the consent, the form had education on it. ICN A reported consent forms for pneumococcal vaccinations were scanned into the residents' electronic medical records (EMR) but that they are probably not in there (the EMR). ICN A reported R818 was a new admission, and she did not offer any vaccinations to him because he was admitted to the facility on a short-term basis. Review of R814's MCIR report documented no administration of the pneumococcal vaccination. In the Status section, the following was documented Pneumococcal PCV13 DUE NOW. Review of R814's clinical record revealed R814 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R815's MCIR report documented no administration of the pneumococcal vaccination. In the Status section, the following was documented Pneumococcal PCV13 DUE NOW. Review of R815's clinical record revealed R815 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R816's MCIR report documented they received the PPSV23 vaccination on 9/20/17. In the Status section, the following was documented Pneumococcal PCV13 DUE NOW. Review of R816's clinical record revealed R816 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R817's MCIR report documented no administration of the pneumococcal vaccination. In the Status section, the following was documented Pneumococcal PCV13 DUE NOW. Review of R817's clinical record revealed R817 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R818's MCIR report documented no administration of the pneumococcal vaccination. Review of R818's clinical record revealed R818 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] No evidence of screening for eligibility, education provided, or consent obtained for pneumococcal vaccinations was provided for R814, R815, R816, R817, and R818. On 11/19/21 at 1:00 PM, the Regional Director of Infection Control (ICN B) was interviewed. When queried about the facility's protocols for offering the pneumococcal vaccination to residents, ICN B reported all residents were offered the vaccination upon admission, their history of the pneumococcal vaccination was researched through MCIR and hospital records and by asking residents or their responsible parties. It was further reported all residents and their representatives were educated on the risks versus benefits of receiving the pneumococcal vaccination, and then they were offered an opportunity to consent or decline immunization. ICN B reported the facility following CDC guidance for pneumococcal vaccinations and that it was an ongoing process to screen and offer the vaccination based on eligibility and consent. When queried about who was responsible to offer, educate, obtain consent, and administer pneumococcal vaccinations, ICN B reported the facility's ICP (ICN A). ICN B was not aware that pneumococcal vaccinations were not offered to residents since June 2021 and reported she would look into it. On 11/19/21 at 2:45 PM, documentation of all residents who received the pneumococcal vaccinations in the facility since June 2021 and any residents who were diagnosed with facility acquired pneumonia since June 2021 was requested from ICN B. On 11/23/21 at 9:10 AM, ICN B reported she was unable to find any consents for R814, R815, R816, R817, or R818 or any evidence that any residents in the facility were offered the pneumococcal vaccination in the facility since June 2021. ICN B provided a list of residents who were diagnosed with pneumonia since June 2021 which revealed three residents (R819, R821, and R822) who did not receive the pneumococcal vaccination and were diagnosed with facility acquired pneumonia. R819 On 11/23/21 at approximately 9:09 AM., R819 was observed in their room lying in their bed. R819 was queried about whether the facility had ever offered them the pneumococcal vaccination. R819 reported they did not. R819 reported they did not think they ever received the pneumococcal vaccination. When queried about having pneumonia, R819 reported they had pneumonia and went out to the hospital for it. R819 reported that if they were offered the pneumococcal vaccination they would have consented to the immunization. On 11/23/21 the medical record for R819 was reviewed and revealed the following: R819 was initially admitted to the facility on [DATE] and last readmitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of R819's Immunization consents in the electronic medical record did not reveal any informed consent documentation for the pneumococcal vaccination. A progress note dated 8/6/21 written by the Nurse Practitioner revealed the following: CHIEF COMPLAINT- Shortness of breath, low oxygenation, exacerbation of [CONDITION(S)] (Chronic Obstructive Pulmonary Disease) .HISTORY OF PRESENT ILLNESSES- [R819 demographics redacted] She has history of [CONDITION(S)] and uses [MEDICATION(S)] for nebulizing treatments. Patient states that she has been short of breath x3 weeks. She notified staff today because it is not getting any better and it made <sic> even be worse per patient. She was satting (oxygen saturation) at 82% on 5 L (liters) nasal cannula. [MEDICATION(S)] treatment x2 patient continues to sat around 84 to 85% at 5 L nasal cannula post a butyryl <sic> treatments. Patient states that she does not feel well and she is also very wheezy even post breathing treatments. EMS (emergency medical staff) activated patient taken to [Name of local hospital] .Notes: Spent 35 minutes with patient helping with her [MEDICATION(S)] nebulizer treatment. Discussed with patient about her oxygen needs. Patient is needing 5 L of oxygen and so did not maintain oxygen saturation above 85% today. This was true even after 2 [MEDICATION(S)] treatments. Patient is seated upright in position of comfort to facilitate breathing . A hospital document titled ED (emergency department to Hosp (hospital)-admitted d 8/6/21 revealed the following: Diagnoses-Shortness of breath - Primary .Pneumonia of left lower lobe due to Streptococcus pneumonia .Acute on chronic respiratory failure with [CONDITION(S)] . An Emergency Department Evaluation dated 8/6/21 revealed the following: History of present illness-Patient presents today for shortness of breath. Patient comes from [facility name redacted] and has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient had Covid in April .XR (X-ray) Chest 1 View-Final Result Borderline enlarged cardiomediastinal silhouette. Peripheral right upper lobe and lower lobe patchy opacities and left lower lobe opacities are concerning for multifocal pneumonia in the appropriate clinical setting .Patient had a fever per EMS but not here. Number of diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .Shortness of breath .diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Recent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Fever per EMS in route. Patient was extremely short of breath but doing much better after [MEDICATION(S)] treatment and EMS and oxygen is now 5 L. She is not ambulatory .Patient remains on 5 L of oxygen. Patient on 2 liters for baseline. Patient sent here for hypoxic episode at [facility name redacted]. Patient has pneumonia on x-ray. Blood cultures have been drawn. Patient will require admission. Patient will be put on [MEDICATION(S)] and [MEDICATION(S)] (antibiotic medications) . A hospital Physician evaluation dated 8/11/21 revealed the following: [R819 demographics] .with PMH (previous medical history) of .[CONDITION(S)] with [CONDITION(S)] on continuous supplemental oxygen of 2 L, .presenting with progressive shortness of breath and cough of 3 weeks duration. She is admitted and managed for acute respiratory failure secondary to Pneumonia and acute exacerbation of [CONDITION(S)] A MICR (Vaccine history report) document dated 8/12/21 revealed the following: Pneumococcal-Adult-Pneumococcal .PCV13 DUE NOW . There was no documentation in R819's medical record that indicated she ever received a Pneumococcal vaccination. R821 Review of R821's clinical record revealed R822 was initially admitted into the facility on [DATE] and readmitted on [DATE] and 7/28/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a progress note written by the Nurse Practitioner on 7/26/21 revealed the following documentation: I am seeing (R821) today on an urgent basis related to decreased LOC (level of consciousness), skin cold and clammy. On exam (R821) is in bed with head of bed slightly elevated, nonresponsive to verbal or tactile stimuli. She begins vomiting yellow fluid without warning, she is immediately turned down to the right side and help is called. Instructed primary nurse to call 911 emergent transport to ER .General: Lying in bed; nonresponsive to verbal or tactile stimuli or to sternal rub .Neck: Range of motion decreased. Pt vomits without turning head .Respirations shallow Cardiovascular: Apical and radial pulse irregular, faint. Abdominal: Bilious vomiting, grainy yellow . Gray skintones. Cold, clammy to touch .Neurological: Unresponsive. Psychological: Nonverbal, which is a new decline for this patient .ASSESSMENTS AND PLANS .Unspecified abnormalities of heart beat: Apical and radial pulses faint, irregular. Treatment pending; awaiting EMS personnel .Altered mental status, unspecified: Unresponsive to verbal or tactile stimuli or to sternal rub. Skin cold and clammy. Nurse instructed to call 911 .Bilious vomiting: Patient immediately turned onto side. Vomitus was thin, grainy, yellow. No foreign objects/matter observed in mouth .Muscle weakness (generalized): Patient needed assist to transfer from wheelchair to bed earlier this morning . Review of a Nurses' Note dated 7/26/21 revealed the following documentation: Pt observed vomiting, skin clammy, cold, non-alert, unaware. Pt experienced extreme generalized weakness .Pt was sent to hospital for further eval (evaluation) . Review of a progress notes written by the Nurse Practitioner on 7/28/21 revealed the following documentation: .Readmission. Pt went to hospital tx (treatment) for [CONDITION(S)] .ASSESSMENTS AND PLANS .[CONDITION(S)] DUE TO STREPTOCOCCUS PNEUMONIAE: Pt is on [MEDICATION(S)] and oxycycline (antibiotic medications). Respiratory checks . Review of a Discharge Summary from the hospital dated 7/28/21 revealed the following documentation: .Discharge Diagnosis .Pneumonia of right lower lobe due to Streptococcus pneumoniae . R822 On 11/23/21 at 12:12 PM, R822 was observed dressed and sitting on their bed. R822 was asked if they had ever been offered a pneumococcal vaccination since they had been admitted into the facility. R822 explained no one at the facility had ever said anything or offered a pneumococcal vaccination. Review of the clinical record revealed R822 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS assessment dated [DATE], R822 had moderately impaired cognition, and required the limited assistance of staff for ADL's. Review of R822's immunizations revealed No immunizations found. Review of R822's consents revealed no signed consent or refusal for a pneumococcal vaccine Review of R822's October MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R822's progress notes revealed: On 10/23/21 at 3:18 PM, a nursing note read in part, resident has productive cough w/ (with) yellow [MEDICATION(S)] resident unable to get good lung sounds with auscultation resident states she hears a wheeze when laying down . On 10/25/21 untimed, a progress note read in part, .Pneumonia, unspecified organism: New issue [NAME] [sic] criteria met: Chest x-ray demonstrating pneumonia, probable pneumonia or new infiltrate. New or increased cough New pleuritic chest pain fever ? 100 ?F (Fahrenheit) New or increased sputum production changed lung exam abnormalities Increased respiratory rate (>25/minute) (greater than 25 per minute) Decreased in ADL Mental changes . On 10/29/21 untimed, a progress note read in part, .Pneumonia, unspecified organism: Pt (patient) is on zpak ([MEDICATION(S)]). Improving. Finish course . The immediacy was removed on 11/23/21 based on the facility's implementation of the follweing as verified on-site by the survey team: -Resident 819 will be educated on 11/23/21 regarding pneumococcal immunizations and offered vaccination. -Resident 821 Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -Current resident were reviewed for pneumococcal vaccination status by a licensed nurse on 11/23/2021. -Residents were educated and offer the pneumococcal vaccination by a licensed nurse on 11/23/2021. Deficient Practice #2 Based on interview and record review the facility failed to offer influenza vaccinations to two (R818 and R817) of eight residents reviewed for influenza vaccinations. Findings include: Review of a facility policy titled, Influenza Vaccination, revised 8/2/20, revealed the following: .Influenza vaccinations will be routinely offered annually from October 1st through March 31st unless such immunization is medically contraindicated, the individual has already been immunized during this time period, or refuses to receive the vaccine .Prior to the administration of the influenza vaccine, the person receiving the immunization, or his/her legal representative, will be provided with a copy of CDC's current vaccine information statement relative to the influenza vaccination .Individuals receiving the influenza vaccine, or their legal representative, will be required to sign a consent form prior to administration of the vaccine. The completed, signed, and dated record will be filled in the individual's medical record .The resident's medical record will include documentation that there resident and/or the resident's representative was provided education regarding the benefits and potential side effects of immunization, and that the resident received or did not receive the immunization due to medical contraindication or refusal . On 11/18/21 at 2:52 PM, an interview with conducted with the facility's Infection Control Preventionist, Infection Control Nurse (ICN) A. When queried about the facility's protocol for offering and administering influenza vaccinations, ICN A reported she called all of the resident's responsible parties for consent or if the resident made their own decisions they were asked directly. ICN A reported that if residents or their representatives consented to the influenza vaccination, they would be educated on the risks versus benefits of being immunized. A consent form would be signed and then the vaccination was administered. - called everyone unless own person went directly, educated guardians over the phone about the flu vaccine, if they did we double signed consent forms, then offer the vaccine. At that time, a list of residents was provided to ICN A, and all education provided, completed consent forms, and proof of administration of the influenza vaccination was requested for those residents. On 11/18/21 at 4:00 PM, ICN A reported she did not offer the influenza vaccination to R818 because he was brand new and short term. ICN A was not sure about the other residents. On 11/19/21 at 1:00 PM, the Regional Director of Infection Control (ICN B) was interviewed. The list of residents provided to ICN A was given to ICN B and any education, consents, or proof of administration of the influenza vaccination were requested. ICN B explained that all residents or their legal representatives were to be educated about the benefits versus the risks of being immunized against influenza, offered the vaccination, and if consented, the vaccination should be administered. On 11/19/21 at 2:45 PM, ICN B provided information about influenza vaccinations. It was revealed that R817 and R818 were not offered the influenza vaccination as there was no consent form found. ICN B reported that the influenza vaccinations should have been offered to those residents on admission into the facility. Review of R817's clinical record revealed R817 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of R817's clinical record revealed no consent form, documentation that the resident or their representative was educated regarding benefits and potential side effects of immunization, or documentation about whether they received or did not receive the influenza vaccination. Review of R818's clinical record revealed R818 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .

This citation pertains to intake #MI 100. Based on observation, interview and record review the facility failed to ensure appropriate supervision was provided for two residents (R809 and R810) of six residents reviewed for abuse, resulting in R810 walking into R809's room unsupervised and striking R810 in the face resulting in jaw pain and bruising of the left eye. Findings include: On 11/18/21 a facility reported incident submitted to the state agency for review alleged [R810] entered [R809]'s room believing that it was his room. [R810] told [R809] to get out of his bed and [R809] refused and then [R810] struck [R809] about the body and head . Resident# 809 On 11/18/21 at approximately 1:00 p.m., R809 was observed in their room, lying in their bed. R809 was queried if they had any concerns regarding any altercations with any other residents in the facility and they indicated that they did. R809 reported a resident (R810) who was living across the hall kept walking into their room multiple times a day. R809 indicated on one of days, R810 walked into their room and sat down in the chair across from their bed and told them to get out of the bed because it was their bed. R809 indicated they told R810 that they needed to get out of their room and to stop walking into the wrong room. R809 reported the other resident told them if they didn't get out of their bed, they were going to beat them to death. At that point, R809 indicated they told R810 to get out and R810 walked over to their bed and started punching them in the face. R809 reported they started screaming and the Nurse came in and had to get R810 off of them and remove them out of the room. R809 indicated their jaw still has not felt right since the incident and they had a black eye for a week and that they (the facility) should have been watching R810. On 11/18/21 the medical record for R809 was reviewed and revealed the following: R809 was admitted to the facility on [DATE] and had diagnoses including Anxiety, Muscle weakness and Pain. A review of R809's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 9/19/21 revealed R809 needed extensive assistance from facility staff with most of their activities of daily living. R809's BIMS score (brief interview of mental status) was 15 indicating intact cognition. A progress note dated 9/11/21 at 7:40 p.m., revealed the following: Made [Director of Nursing] aware of incident between the 2 residents .interventions given .to provide safety for residents and staff. A progress note dated 9/11/21 at 9:27 p.m., revealed the following: after incident resident alert and oriented, complains of left side facial pain,mrdicated <sic> with Tylenol 325 2 tablers <sic> po (by mouth) resident in without bruising or swelling at this time .monitored throughout shift. A Physician's progress note dated 9/13/21 revealed the following: Patient had an altercation on September 11, 2021, with another resident. Other resident had entered his room unprovoked, and patient had ignored him. Other resident approached patient and told to get out of his bed. It was not other residents bed. When patient refused to leave his bed, other resident proceeded to punch patient in face. I examined his face tenderness on left side of jaw and around left eye. Slight bruising on outer portion of left eye. Patient had complained of missing teeth. Patient will follow up with dentist .ASSESSMENTS AND PLANS--Jaw pain: Secondary to altercation with another resident. Continue Tylenol for pain ice pack if any swelling develops .Pt (patient) to follow up with dentist a pt states he is missing teeth. Difficult to assess as pt has partial dentures. Tylenol for pain. Monitor for any swelling . An interdisciplinary progress note dated 9/13/21 revealed the following: On 9/11/21 Resident reports he was laying in his bed at approximately 19:35 when another resident [R810] entered his room from across the hall where he had been staying. Resident reported [R810] approached his roommate and sat on the edge of his bed, then got up and sat in a chair in the room. He then stood up and told resident to get out of his bed, resident refused and resident [R810] struck resident on the left side of his face with his hands. The nurse entered the room and stopped [R810], removed him from the room and provided care. On call provider, DON (Director of Nursing), Administrator and family notified. Pain and skin assessment provided. Pain medication provided for complaint of pain to the left side of his face. Monitoring in place for pain. Resident# 810 On 11/18/21 the medical record for R810 was reviewed and revealed the following: R810 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's Disease. A progress note dated 9/9/21 revealed the following Patient admitted to [NAME] (Medilodge of [NAME]) at 1315, arrived by family, Vital signs stable, no complaints of pain or nonverbal indications of pain. Patient A&O (alert and orientated) X (times) 1-2 person and place, . able to ambulate with assistance- gait unsteady . A Nursing note dated 9/10/21 at 6:21 a.m., revealed the following: resident was observed walking in hallway, pleasantly confused, stated that he wants to go to toilet, redirected him to toilet but he went out the room , and entered the room next door, confused , redirected him again to toilet but went straight to his roommate's side and was going to pee in the trash can , no facial grimace noted. A Nursing evaluation summary note dated 9/10/21 at 12:15 p.m., revealed the following: resident continues to wander in and out of other resident rooms agitating other residents. Social work notified. redirected with snacks. will cont (continue) to monitor. An Order Administration Note dated 9/10/21 at 9:29 p.m., revealed the following: Resident on Transmission-Based Precautions for 14 days - if no symptoms may discontinue after 14 days every shift for Admission/Readmission Observation for COVID for 14 Days resident continually comes out of his room and goes into other patients rooms as well. A Nursing note dated 9/11/2021 at 1:30 p.m., revealed the following: Resident observed wandering in and out of other resident's rooms. Resident was able to be redirected without issue. An interdisciplinary progress note dated 9/13/21 revealed the following: On 9/11/21 at approximately 19:30, resident was observed by nurse standing over another resident and striking the resident with his fists. The nurse intervened and escorted the resident back to his room, had the staff stay with him until he was transferred out of the building by EMS (emergency medical staff personnel . A facility investigation pertaining to the incident between R809 and R810 on 9/11/21 was reviewed and revealed the following: On Saturday, 9/11/21 at approximately 7:35 PM, nursing staff heard yelling coming from [R809's] room. The nurse and Aid responded to the room where they witnessed [R809] laying in his bed and [R810] standing over him striking him. The Nurse and Aid intervened, removed [R810] from the room and took him back to his room across the hall. [R810] was attempting to strike the Nurse and Aid but he was redirected and went to his bed willingly. The Aid assisted [R810] to lay down in his bed where he went to sleep and did not wake until EMS arrived and woke him for transport to the hospital. The Nurse returned to [R809] to provide aid and support. [R809]stated he was sitting in his bed watching TV when [R810] came in and sat on his roommates bed for a moment, then moved to a chair for a moment, put his head in his hands then stood up walked over to the side of his bed told him to get out of his bed. [R809] told him No and [R810] struck him in the face and back with his fist several times until the Nurse and Aid intervened. [R809] was assessed by the nurse for pain and skin impairment/injury. Ice and pain medication were offered and administered to the resident. Monitoring of skin and pain continues . On 11/19/21 at approximately 3:47 p.m., The facility Administrator was queried regarding the incident between R809 and R810 on 9/11/21. The Administrator indicated that R810 went into R809's room and started hitting him and the Nurse came in and got R810 out of the room. The Administrator was queried regarding how supervision is provided in the facility for residents, and they indicated the staff on the floor provide it. The Administrator was queried regarding R810's recent history of wandering into other residents rooms previous to the incident and they indicated they were unaware of any previous behaviors prior to the altercation. On 11/23/21 at approximately 8:25 a.m., Nurse U was queried regarding the incident between R809 and R810 on 9/11/21. Nurse U indicated they were working on the floor and heard R809 start screaming and went into the room and saw R810 punching R809 in the face. On 11/19/21 a facility document titled Accidents and Supervision was reviewed and revealed the following: Policy: The resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary .Policy Explanation and Compliance Guidelines: The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. 1. Identification of Hazards and Risks- the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. a. Observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. b. Attempt to identify the hazards and risk factors for each resident. c. Various sources provide information about hazards and risks in the resident environment. d. These sources may include, but are not limited to: i. quality assessment and assurance (QAA) activities ii. environmental rounds iii. MDS/CAA data iv. medical history v. physical exam vi. facility assessment. vii. individual observation .e. This information is to be documented and communicated across all disciplines. 2. Evaluation and Analysis- the process of examining data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents. Interdisciplinary involvement is a critical component of this process. 3. Implementation of Interventions- using specific interventions to try to reduce a resident ' s risks from hazards in the environment. 4. Monitoring and Modification- Monitoring is the process of evaluating the effectiveness of care plan interventions. Modification is the process of adjusting interventions as needed to make them more effective in addressing hazards and risks. 5. Supervision- Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents .

This citation has two deficient practice statements (DPS). DPS #1 Based on observation, interview and record review, the facility failed to develop and implement interventions to prevent falls, ensure residents were transferred according to their plan of care and properly utilize necessary equipment during transfer for three (R42, R103 and R83) out of six residents reviewed for falls/accidents, resulting in pain from a fractured rib (R42), laceration to forehead (R103) and a fractured arm (R83) all requiring emergency hospital care. Findings include: Resident #42 On 5/12/21 at approximately 10:20 AM, R42 was observed sitting in a wheelchair in her room. The resident was alert and able to answer some questions. The resident stated that she was tired and was having some pain. R42 pointed to her left upper side. When asked if she had ever sustained a fall, R42 reported that she had fallen in the bathroom, but could not recall the date or the exact details of what occurred. A review of the resident's clinical record documented that the resident was admitted to the facility on [DATE] with diagnoses that included: type II diabetes, [CONDITION(S)], and Alzheimer's. A review of the resident Minimum Data Set (MDS) dated [DATE] indicated the resident was severely cognitively impaired and required two-person assistance for transfers. A care plan for Activities of Daily Living (ADLs) (initiated 6/3/2020) documented, in part: Interventions: Toileting x 2 assist (date initiated 6/4/2020) .Transfer x2 assist (date initiated 6/3/2020). Continued review of R42's clinical record documented, in part, the following: 4/11/2021 (Nurses' Notes) authored by Nurse O: Resident during transfer from toilet to WC (wheelchair), became weak. Assisted resident gently to floor to be able to assist resident better. No injury It should be noted that there was no documentation in the resident's clinical record that indicated that an assessment was completed following the incident as noted above. 4/12/2021 (Nurses' Notes): At 1845 (6:45 PM) resident complained of chest pain .Called DR (doctor), he ordered nitro .no relief after 15 min to send resident to hospital . 4/12/2021: (After Visit Summary from (name redacted) Hospital): You have been evaluated in the Emergency Department today for fall and chest pains. Your evaluation suggests that your symptoms are due to rib fracture on the left side. You should use the incentive spirometer to prevent the development of pneumonia from her rib fracture . A request for R42's Investigation and Accident (I/A) report was made. Review of the IA for 4/11/21 documented, in part, the following: .R42 .Date of Incident: 4/11/21. Time of Incident: 6:57 PM . Location: Bathroom .Witness: Certified Nursing Assistant (CNA) P. Brief Description: Resident became weak during transfers, assisted to floor. No injury observed .Was a mobility device used: Yes .Type WC .Person preparing report: Nurse O 8. Select appropriate investigation type .Fall/Accident .Resident's explanation of incident: Legs became weak . STATEMENT OF WITNESS: CNA P On 4/11/21 at approximately 8:50 PM I entered the bathroom of room (R42's) to get nurse O. I needed Nurse O .to provide care to a resident that did not want to be cared for by a male. Nurse O left the bathroom where she had assisted R42 to the toilet. When R42 was ready, I assisted her to the standing position and attempted to assist her with a pivot to her wheelchair. R42's legs became weak, and I lowered her to the floor . STATEMENT OF WITNESS: R42's Roommate: .Roommate did state she witnessed part of the residents fall- she rolled over to the bathroom and saw the resident (R42) being held up by the CNA, resting while he lowered her to the floor. Roommate stated she lent him her gait belt to assist him in standing her up- which he did with assistance . On 05/12/21 at approximately 3:52 PM a phone interview was conducted with CNA P regarding the incident that occurred on 4/11/21. CNA P reported that he was currently employed by a sister facility as an uncertified CNA but was asked to work at the facility where R42 resided for about one month. When queried as the incident, CNA P stated that on 4/11/21 he was trying to help a resident that did not want a male CNA to assist, so he went to ask Nurse O if she could help that resident and he would take care of R42. CNA P then helped R42 onto the toilet by placing the gait belt behind the resident, asked her to hold the rails and counted 1, 2, 3. When R42 needed to be taken off the toilet, CNA P indicated that he again put the belt around the resident, counted 1, 2, 3 and lifted her off the toilet, but indicated that her knees gave out and he lowered her to the ground. When queried if there was another staff in the room that provided assistance, CNA P stated No. When queried if the R42 required a two person assist for toileting and transfers, CNA P indicated that he was not aware and was not informed by any staff. When further queried as to whether he received any in-service training following the incident, CNA P reported that he received training on transfers including gait belts. On 05/13/21 at approximately 9:29 AM a phone interview was conducted with Nurse O regarding the incident involving R42. Nurse O reported that they worked as a contingent nurse at the facility one to two days per week. Nurse O recalled that on 4/11/21, R42's roommate was yelling for help. Nurse O indicated that the resident was on the floor and CNA P got her off the floor and she assessed the resident. When queried if she knew R42 was a two person assist for transfers/toileting, Nurse O stated that she did not and indicated that as a contingent nurse she often works on different units with different residents and is not always aware of a resident's transfer status. When queried as to the resident's broken rib, Nurse O stated I'm sure he probably grabbed to tightly around the waist when trying to lower her or get her off the floor. On 5/13/21 at approximately 10:34 AM an interview and record review were conducted with the Director of Nursing (DON). When queried as to the incident pertaining to R42 on 4/11/21, the DON, after reviewing the residents care plan, agreed that the resident was a two person assist for toileting/transfers and should have been transferred as such. With respect to CNA P lifting the resident from the floor with a gait belt, the DON reported that CNA P was in-serviced on the use of a gait belt and should never have used the belt to lift the resident from the floor. With respect to the lack of documented assessments following the fall and prior to the resident being sent to the Hospital, the DON indicated that Nurse O did not consider the incident a fall, as the resident was lowered to the floor. A review of the Performance Improvement Form documented, in part, the following: CNA P and Nurse O lifted R42 off the floor following a fall, with a gait belt and under the arms instead of using a mechanical lift. It is the policy of (name redacted) to lift residents from the floor with a mechanical lift to prevent possibly injuring the resident. Resident #103 On 5/12/21 at approximately 11:51 a.m., R103 was observed in the hallway self ambulating in their wheelchair. R103 was observed to have sutures above their eyes on their forehead. On 5/12/21 the medical record for R103 was reviewed and revealed the following: R103 was initially admitted on [DATE] and had diagnoses including Dementia, Anxiety and Muscle Weakness. A review of R#103's MDS (Minimum Data Set) with an ARD (Assessment Reference date) of 4/14/21 indicated R#103 needed assistance from facility staff with most of their activities of daily living. R103's BIMS score (Brief interview of mental status) was 5 indicating severely impaired cognition. A Pertinent Charting-Falls note dated 5/4/21 revealed the following: Date of Fall: 05/03/2021 Situation Details: Witnessed roll to floor from bed .Assessment: sent to ER (emergency room ) for evaluation and treatment-Laceration to forehead .Mitigating Factors: Dementia . A progress note dated 5/4/2021 revealed the following: Resident returned from ER this shift after being sent out for a fall with a forehead laceration. Resident has a dressing to forehead covering sutures along with facial bruising on left side of face. Resident also noted to have a bruise on the left knee .Per hospital paperwork the sutures are to be assessed and removed if applicable on 5/11/21 . An IDT-Interdisciplinary Progress Note dated 5/4/21 revealed the following: Resident with fall on 5/3/21. Resident rolled over for check and change and rolled out of the bed. Root cause is that when rolling resident is to close to the edge of the bed. Intervention is for resident to be provided a bariatric bed . A progress note dated 5/3/2021 revealed the following: Aide was changing resident, aide asked resident to roll over, resident grabbed roll bar and rolled over. Resident rolled too far and rolled out of bed. Resident has large laceration on forehead. First aid performed and sent resident to ER for additional first aid . A hospital emergency department evaluation dated 5/3/21 revealed the following: .Patient is a [R103's demographics] with a significant fall and is on an anticoagulant .She will also require plastic surgery consultation for the large facial laceration due to the depth of the wound . A review of R#103's careplan revealed the following: Focus-The resident needs activities of daily living assistance related to: covid (COVID-19) related weakness .Interventions-BED MOBILITY: extensive two person .Date Initiated: 04/12/2021 . On 5/12/21 at approximately 2:39 p.m., CNA (certified nursing assistant) U (CNA U) was interviewed regarding R#103's fall on 5/3/21. CNA U indicated R#103's bed was soaked with urine and they were trying to change her sheets and was assisting R103 in rolling over to change the sheet. CNA U indicated that R103 rolled over onto the floor and the momentum took them off the side of the bed and they hit their head on the garbage can. CNA U was queried if anyone else was in the room when they were assisting R103 in rolling over and changing the sheet and they indicated they were the only one in the room. CNA U was queried regarding the level of assistance R#103 required when completing bed mobility tasks and toileting and indicated they thought R#103 was a one person assistance but now uses two people sometimes because of the fall. On 5/13/21 at approximately 9:58 a.m., Nurse Manager H (NM H) was queried regarding R#103's fall on 5/3/21. NM H indicated they were working the floor during that shift and was R#103's Nurse when R#103 fell . NM H indicated that CNA U was changing R#103 and when they were being rolled over, they rolled off the other side of the bed. NM H was queried if CNA U was the only person in the room providing care to R103 when they fell and they reported CNA U was the only one staff member in the room. NM H was queried if R103 required one or two people to assist with bed mobility and they indicated R103 needed two staff during bed mobility. NM H indicated that CNA U was a new CNA but that there was no excuse for them to be the only staff person performing the care. NM H was queried if CNA U was provided any education on how to perform bed mobility and the importance of reviewing the resident careplan for levels of required assistance and she indicated they were. R83 On 5/11/21 at 11:17 am, R83 was observed sitting in a chair in their room. Their left arm was wrapped in a bandage and hung in an elevated position against their chest supported by a blue sling. When asked about their arm the resident stated they fell and broke it. A review of the clinical record revealed the following: R83 was admitted into the facility on [DATE] with a readmitted [DATE] and diagnoses that included: dementia, cerebral atherosclerosis, [CONDITION(S)] with heart failure and [CONDITION(S)] and required staff assistance for all Activities of Daily Living (ADLs). A review of the resident Incident and Accident report for falls revealed the following: On 12/29/20 at 8:15, the form documented in part, .Resident, physically impaired .skin injury .Resident observed lying on the floor in her room at the foot of her bed. She was on her back . On 12/31/20 at 4:40 pm, the form documented in part, .Resident, Memory impaired, physically impaired .Confused/Disoriented, Skin injury .Resident was observed on floor next to bed with head against magazine stand. Stated she was getting up to go to bathroom. Skin tears to R (right) hand + bruising to R hand + R wrist .Treatment- First Aid .Action Taken- Therapy Screen . R83 care plans were reviewed and revealed no new and/or modified interventions implemented to prevent further falls. An Incident and Accident report dated 4/26/21 at 10:20 pm, documented in part the following, .Staff heard noise from residents room entered room observed resident sitting on floor beside bed states, I had to go to bathroom Abrasions on back large laceration on left upper arm Telemed visit. Resident transferred to (hospital name redacted) .Treatment- 911, sent to hospital . A hospital operative note dated 4/27/21 at 11:38 am, documented in part .Procedures- Irrigation and debridement of left extremity upper wound closure .Orthopedic resident attempted a I&D (Irrigation and debridement) washout and wound closure in the emergency room , the patient did not tolerate the procedure. Recommended the above procedure in the operating room for better sedation and anesthetics . The resident was readmitted back to the facility on [DATE]. Further review of the care plans revealed the facility failed to implement and/or modify the resident's fall care plan and interventions. Further review of the clinical record revealed the interdisciplinary team failed to review and/or implement additional interventions to reduce and/or prevent further falls. On 5/13/21 at 11:36 am, the Director of Nursing (DON) was queried regarding the resident falls and the plan of care to prevent further falls. At 2:19 pm, the DON acknowledged that somehow the resident's fall care plan had been resolved but was reimplemented on 5/13/21. A facility policy titled Falls (date implemented 1/1/21) documented in part, .As part of an in initial and ongoing resident assessment, the staff will help identify individuals with a history of falls and risk factors for subsequent falling .Based on the assessment an initial plan of care will developed and implemented to address identified risk. This will be revised as necessary .Goals of the plan of care may include the interdisciplinary team .Interventions should be developed and implemented per the assessed needs .Analysis of the causative factors and rationale for interventions developed and implemented should be documented in the Standards of Care notes .Update the plan of care with the new or revised interventions .The staff will monitor and document the individual's response to interventions intended to reduce falling or the consequences of failing .If the individual continues to fall, the interdisciplinary team should re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions.

This citation has two deficient practices. Deficient Practice #1 Based on observation, interview, and record review, the facility failed provide approprite medications for one (Resident #89) and notify the physician when a high risk antipsychotic medication that required routine laboratory monitoring and dose titration was not administered for 15 days and restarted at the original dose for one (R78) of two residents reviewed for medication administration, resulting in an emergency hospital transfer when the resident was found unresponsive and limp, became hypothermic (dangerously low body temperature), and was admitted to the hospital for acute toxic metabolic [CONDITION(S)]. Findings include: According to the Nursing 2020 Drug Handbook (2020, p. 377), there is a Safety Alert for the drug [MEDICATION(S)] which has a therapeutic class of antipsychotic. The Indications & Dosages for [MEDICATION(S)] documented, .When restarting drug in those who have discontinued [MEDICATION(S)] for 2 days or more, re-initiate at 12.5 mg (milligrams) once daily or b.i.d. (twice a day) to minimize the risk of [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)]. If that dose is well tolerated, the dose may be increased to the previously therapeutic dose more quickly than recommended for initial treatment . CONTRAINDICATIONS & CAUTIONS: Black Box Warning: Because of risk of severe [CONDITION(S)], which can lead to fatal infections, drug is available only through the [MEDICATION(S)] REMS (Risk Evaluation and Mitigation Strategy) Program. Prescribers, patients, and dispensing pharmacists must enroll in the program and be certified .Obtain CBC (Complete Blood Count) with differential before initiating treatment .Monitor ANC (Absolute [CONDITION(S)] Count) regularly during treatment . On 5/11/21 at 11:30 AM and 5/12/21 at 8:45 AM and 2:24 PM, R78 was observed sleeping. A review of R78's clinical record was conducted and revealed the following: R78 was admitted into the facility on [DATE] and most recently readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) assessment dated [DATE] documented R78 had intact cognition, no behaviors, and required supervision to limited assistance with bed mobility, transfer, and most activities of daily living. A Nurse's Note dated 3/26/21 at 7:48 PM written by Licensed Practical Nurse (LPN) N documented, Resident transferred to [hospital name redacted] via ambulance at 1910 (7:10 PM) due to unresponsiveness and irregular breathing. Resident's VSS (vital signs stable) at the time of transfer but still unresponsive and limp . A Hospital H&P (history and physical) Note dated 3/26/21 at 10:14 PM documented, Chief Complaint: acute [CONDITION(S)] .(R78) is a transfer from [facility name redacted]. Story is limited due to altered mentation .but protecting her airways. Per notes, she was found walking around earlier today, asked an aide for water about 50 minutes prior to the acute change in mentation. When the aide came back with water, found her slumped in the chair. No apparent trauma or seizures. [MEDICATION(S)] 100 mg po (by mouth) was given about 1 hour prior to the abrupt change in mental status. Apparently, no vomiting or diarrhea, no evidence of pain. Per EMS run sheet, blood sugars were 104, patient had pinpoint pupils, received [MEDICATION(S)] (medication used for the emergency treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Blood pressures were soft on the mid to high 80s systolic, and patient received 1 L (liter) IV (intravenous) fluids enroute .In the ED, she was hypothermic to 94.6 (degrees) F (Fahrenheit) .EKG (electrocardiogram) revealed NSR (normal [MEDICATION(S)] rhythm) and QTc (QT interval corrected) 486ms (millisecond) (QTc is prolonged if greater than 460 ms in women. A prolonged QT interval can increase the risk of sudden death due to abnormal heartbeat) .She was admitted for further assessment and management. Of note, she had a very similar admitted <sic> on 2/06-2/08/21 with acute [CONDITION(S)] which was thought to be due to a UTI (urinary tract infection) .By the bedside, she has pinpoint 1 mm pupils bilaterally, does not respond to voice but wakes up to sternal rub only to fall asleep again .Vital Signs in Last 24 Hours .BP (blood pressure) .148/111 .Temp (temperature) 34.8 °C (94.6 °F) (Rectal) .Assessment/Plan .coming in for acute [CONDITION(S)] likely due to [MEDICATION(S)] intoxication Acute Toxic Metabolic [CONDITION(S)] DDx (diagnoses): [MEDICATION(S)] induced vs (versus) UTI. Called poison control, they stated that [MEDICATION(S)] can increase QTc and cause miosis (excessive [MEDICATION(S)] of the pupil of the eye) .Plan -Holding [MEDICATION(S)] .EKG every 6 hours per poison control to eval QTc interval prolongation .Continue telemetry .-Monitor closely her airways, if deteriorating call DPOA (durable power of attorney) before any aggressive measures such as intubation .Call Poison Control .to report on her status, they are monitoring her case .QTc prolongation [MEDICATION(S)] toxicity may increase QTc. EKG x2 in ED shows up trending QTc 473ms (to) 486ms .Plan - EKG q6h per poison control as above .Telemetry .Hypothermia .Apply warming blankets until temp is normalized .Holding [MEDICATION(S)] as above . A hospital physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Since [MEDICATION(S)] can have a long half-life, it remains likely that her presentation was due to resumption of [MEDICATION(S)] at 100 mg after an approximate month long hiatus. Though son is eager to have his mother on [MEDICATION(S)], restarting the drug will be dependent on a [MEDICATION(S)] REMS certified prescriber being able to do so at the SNF (skilled nursing facility) on her return. We will be recommending that if [MEDICATION(S)] is restarted that it be at a greatly reduced dose and titrated as needed over time . Further review of R78's clinical record revealed the following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Tablet 100 MG ([MEDICATION(S)]) Give 1 tablet by mouth at bedtime for [CONDITION(S)] disorder was ordered on 1/13/21 by Psychiatrist M. It was documented that the order was discontinued by Physician L (R78's former attending physician) on 3/9/21 with a note that read, needed to reenter due to recent readmission. (Note that R78 was transferred to the hospital on 2/5/21 and was readmitted on [DATE]). [MEDICATION(S)] Tablet 100 MG ([MEDICATION(S)]) Give 1 tablet by mouth at bedtime was ordered on 3/9/21 by Physician L and discontinued by Physician L on 3/15/21 with a note that read, incorrect doctor chosen. [MEDICATION(S)] Tablet 100 MG ([MEDICATION(S)]) Give 1 tablet by mouth at bedtime was ordered on 3/15/21 by Psychiatrist M and discontinued on 3/28/21. A review of R78's Medication Administration Record (MAR) for March 2021 revealed R78 did not receive [MEDICATION(S)] 100mg at bedtime from 3/11/21 through 3/25/21 according to the above physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . It was documented R78 received 100mg of [MEDICATION(S)] on 3/26/21 according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Orders - Administration Note progress notes for R78 were reviewed for March 2021 and revealed the following documentation for why [MEDICATION(S)] 100 mg at bedtime was not administered: 3/11/21 awaiting pharmacy 3/12/21 on order 3/13/21 med (medication) not yet received from pharmacy 3/14/21 Med not available. On order. 3/16/21 Med out. On order. 3/17/21 Med out. On order. 3/18/21 Med not available, on order. 3/19/21 Med not available. On order. 3/20/21 Med not available. On order. 3/21/21 Med not available. On order. 3/22/21 Med not available. On order. 3/23/21 Med out. On order. 3/24/21 otu <sic> of stock 3/25/21 Med not available. On order. On 5/12/21 at 2:30 PM, LPN N was interviewed via the telephone. LPN N was queried about why R78 was sent to the hospital on 3/26/21. LPN N stated, (R78) was actually sent out for the exact same reason another time. LPN N explained that R78 used to be prescribed [MEDICATION(S)] and did not take it any longer. LPN N reported after being out on medical leave for two weeks, when she returned, she noticed R78 did not have [MEDICATION(S)] in the medication cart. LPN N stated, Something that I learned about this particular medication is that it requires labs (laboratory tests) once in a while. I'm not sure how often labs needed to be done but I know the pharmacy would only send 14 pills and needed labs in order to fill the order. LPN N further reported that when she returned from medical leave, she ensured laboratory tests were ordered for R78 and once the results were received the pharmacy sent the medication. LPN N reported once she received the medication, the first dose was administered to R78 (100 mg of [MEDICATION(S)]). LPN N stated, (R78) was fine and talking. Then the CNA (certified nursing assistant) was called in by (R78) and said, 'Can I get some water?' It was around supper time and when the CNA came back, (R78) was unresponsive. LPN N reported she was unsure how long R78 was unresponsive, reported the resident was breathing, but not responding to stimuli, had a change in pupil size, and was slumped over and drooling. LPN N stated, This had happened before. She presented in the same way. I knew I had just given her the meds ([MEDICATION(S)] 100 mg), so I called 911 and let the doctor know. LPN N further reported that while in the ambulance, R78 received [MEDICATION(S)] two times, and her temperature was dropping. (Note: there was no documentation in the progress notes other than R78 being found unresponsive). LPN N was further interviewed at that time. When queried about the facility's procedures for ensuring medications were available to administer according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN N explained that for [MEDICATION(S)], the pharmacy could not send the medication without laboratory results. LPN stated, Staff members are in and out and inconsistent, it seems like labs should be prescheduled. It is concerning if the other nurses don't know anything about this medication and that labs were needed. When queried about whether a physician was notified that [MEDICATION(S)] not being available and if a physician was notified prior to administering the [MEDICATION(S)] (100 mg) after not receiving it for 15 days, LPN N said she contacted the physician. There was no indication in the clinical record that the physician or psychiatrist was notified when R78 did not receive [MEDICATION(S)] according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A one-time physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] <sic> was ordered on 7/31/20 and discontinued on 3/28/21. A review of laboratory results revealed R78 had a CBC with differential drawn on 3/24/21 (R78 had not received [MEDICATION(S)] for 14 days at that time). On 5/13/21 at 9:34 AM, a phone interview was attempted with Psychiatrist M (who no longer saw residents at the facility). A message was left. Psychiatrist M was not available for an interview prior to the end of the survey. On 5/13/21 at approximately 9:45 AM, a phone interview was conducted with the Medical Director (Physician K) who was also R78's current attending physician. Physician K reported R78's previous attending physician (Physician L) no longer saw residents at the facility. Physician K was queried about monitoring required for residents who were prescribed [MEDICATION(S)]. Physician K reported that [MEDICATION(S)] could only be prescribed by a REMS certified provider due to the high risk of [CONDITION(S)]. It was further reported that due to that risk, CBC with differential laboratory tests were required at regular intervals. When queried about what should be done if a medication like [MEDICATION(S)] was not available for administer to the resident, Physician K reported that a physician should be notified. When queried about any notification received regarding R78 not receiving [MEDICATION(S)] for 15 days, Physician K reported they were not made aware by the facility. Physician K further reported that whoever the prescriber was would be the person who also ordered any laboratory tests and the prescriber for [MEDICATION(S)] must be REMS certified or else the order would be denied by the pharmacy. On 5/13/21 at 10:01 AM, the Director of Nursing (DON) was interviewed. When queried about the facility's protocol for reordering medications, the DON reported the nurse could pull the tag off the sheet or reorder via the electronic medical record. The DON further reported that it should be done by the reorder date, but that medications could not be reordered before that. The DON stated, It would be prudent to do three days prior in order to ensure the medication was available to administer to the resident. When queried about who was responsible for monitoring residents on [CONDITION(S)] medications for required laboratory tests, the DON reported psychiatric services were required since they were the Prescribers of the medications. The DON was queried about what occurred with R78 and why she did not receive the physician ordered [MEDICATION(S)] for 15 days. The DON reported R78 went out to the hospital and came back and when she was readmitted the [MEDICATION(S)] was ordered under the incorrect physician. The physician that the medication was reordered under did not have REMS certification and that delayed the receipt of R78's [MEDICATION(S)]. When queried about when the facility became aware of the need for a REMS certified provider to order the [MEDICATION(S)], the DON stated, I can't recall of when we were notified of the hold up. When queried about what should occur if a reordered medication was not available, the DON reported a call would be made to the pharmacy and they would let the facility know the reason for the delay. The DON further reported the physician should be contacted to receive an order to either hold the medication or replace it with another medication. When queried about when the DON became aware that R78's [MEDICATION(S)] needed to be ordered by a provider with REMS certification, the DON stated, I was not aware of it until after she went to the hospital. When queried about any interventions implemented to prevent future incidents, the DON reported R78 was no longer on [MEDICATION(S)] and no education was provided as a result of the incident. When queried about whether the Medical Director was contacted, the DON stated, I do not think that the medical director was contacted. On 5/13/21 at 10:43 AM, the Administrator and Regional Director of Operations (RDO) were interviewed. When queried about whether they were made aware of the reason R78 was hospitalized on [DATE], the Administrator reported she was not aware until that day (5/13/21). The RDO stated, I think I remember hearing something about it. The RDO reported the facility had a change in contracted psychiatric providers and provided the date when Psychiatrist M stopped seeing residents in the facility, which was 3/31/21 (after the incident with R78's [MEDICATION(S)]). When queried about whether incidents such as the one documented above would be discussed through the facility's quality assurance process, the RDO reported he would expect it to be discussed with the clinical team, which would include the Medical Director and proper education should be provided to prevent reoccurrence. On 5/13/21 at 1:30 PM, the DON was asked if she had any additional information to provide. The DON reported she contacted the pharmacy to get any information about communication between the facility and the pharmacy regarding R78's [MEDICATION(S)] but had not heard back yet. The DON reported she reviewed R78's MAR and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . It was reordered on 3/15/21 under Psychiatrist K who was a REMS certified. When queried about why R78 did not receive the [MEDICATION(S)] until 3/26/21, 11 days later, the DON stated, Because we did not know labs were needed and pharmacy was denying the request because of that. When queried about whether the DON was notified about the delay in receiving R78's [MEDICATION(S)], the DON reported it was reviewed in daily morning meetings. When queried about whether there was any notification to the attending physician or psychiatrist to inform them that R78 had not received [MEDICATION(S)] for 15 days, the DON reported she did not see any documentation that a physician was notified and reported they should have been. Further review of R78's clinical record revealed the following: A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .returns to us for AMS (altered mental status) and severe psychiatric symptoms which include confusion. Patient was returned after some medications were changed (Note: there was no prior documented discussion with a physician or psychiatrist about the continuation of the 100mg dose of [MEDICATION(S)] after R78 had not received it in 15 days. There was no documented directed change of medications for R78). Had discussed with hospitalist about psychiatric services taking intervention in order to change some medications around. Patient was deemed to have toxic metabolic [CONDITION(S)] due to [MEDICATION(S)] (Note: R78 was not prescribed [MEDICATION(S)], an anti-anxiety medication. R78 was prescribed [MEDICATION(S)], a high risk antipsychotic medication) and UTI. Patient did well and was went <sic> back here .1) Acute [CONDITION(S)] - due to [MEDICATION(S)] (Note: [MEDICATION(S)] was the medication that contributed to R78's acute [CONDITION(S)] according to the hospital records. R78 was not prescribed [MEDICATION(S)]) .was weaned .2) [CONDITION(S)] disorder continue 100mg [MEDICATION(S)] (Note: R78 was not prescribed [MEDICATION(S)]. According to the Nursing 2020 Drug Handbook, the maximum daily dose of [MEDICATION(S)] to treat panic disorder is 4 mg). Psych (psychiatry) consulted . Further review of the clinical chart revealed that R78 did not receive [MEDICATION(S)], due to the medication not being available, between 1/10/21 and 1/27/21. A facility policy titled, Medication Administration implemented on 1/1/21 documented, .Medications are administered .as ordered by the physician . Resident #89 On 5/11/21 the medical record for R89 was reviewed and revealed the following: R89 was initially admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R89's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/31/21 revealed R89 needed assistance from facility staff with most of their activities of daily living. R89's BIMS score (brief interview of mental status) was eight indicating severely impaired cognition. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] *Controlled Drug* Give 1 tablet by mouth at bedtime for agitation. A review of R89's careplan revealed the following: Focus-The resident has impaired cognitive function/dementia. Per wife, resident displays changes in behavior/cognition with room changes (i.e., eyes appear glassy or blank stare, disoriented to place/time/situation, does not recognize/remember wife or children); resident has a hx (history) of calling out/yelling when sleeping and has the potential to become physically aggressive if woken .Interventions-Administer medications as ordered. Monitor/document for side effects and effectiveness . A review of R89's April 2021 (Medication Administration Record) was reviewed and revealed R#89's Physician ordered [MEDICATION(S)] was not available for administration on April 17, 18, 19, 20, 21, 22, 23. A review of R89's EMAR (electronic medication administration record) progress notes for the administration of R89's [MEDICATION(S)] revealed the following: 4/22/2021-awaiting Pharmacy to deliver .4/21/2021-Awaiting pharmacy to deliver .4/20/2021-Awaiting Pharm (pharmacy) to deliver .4/19/2021-awaiting Pharmacy to deliver .4/18/2021-on order from Pharmacy . On 5/13/21 at approximately 10:50 a.m., during a conversation with Nurse Manager H (NM H), NM H was queried regarding R#89's Clonezepam not being available for administration as ordered by the Physician on 4/17-4/23. R89's April MAR was reviewed with NM H and they indicated the facility Nurse who works on the midnight shift is responsible for checking the medication carts to see if medications need to be re-ordered. NM H indicated that no resident should go without their medications and that every Nurse who documented that the medication was unavailable for administration should have been calling the pharmacy to see why they did not have it and get it taken care of. NM H indicated there was no excuse and that it should have been followed up on by the floor Nurses and R89 should have been able to get their medication on the next scheduled dose after it ran out because the pharmacy would be able to drop ship it or get it on the next day's delivery. On 5/13/21 a facility document titled Medications-Unavailable was reviewed and revealed the following: This facility shall use uniform guidelines for unavailable medications .Policy Explanation and Compliance Guidelines: 1. The facility maintains a contract with a pharmacy provider to supply the facility with routine, prn (as needed), and emergency medications. 2. A STAT (emergency) supply of commonly used medications is maintained in-house for timely initiation of medications. 3. The facility shall follow established procedures for ensuring residents have a sufficient supply of medications. 4. Medications may be unavailable for a number of reasons. Staff shall take immediate action when it is known that the medication is unavailable: a. Determine reason for unavailability, length of time medication is unavailable, and what efforts have been attempted by the facility or pharmacy provider to obtain the medication. b. Notify physician of inability to obtain medication upon notification or awareness that medication is not available. Obtain alternative treatment orders and/or specific orders for monitoring resident while medication is on hold. 5. If a resident misses a scheduled dose of the medication, staff shall follow procedures for medication errors, including physician/family notification, completion of a medication error report, and monitoring the resident for adverse reactions to omission of the medication .

This citation pertains to intake #MI 486. Based on interview and record review, the facility failed to ensure feeding assistance and accurate meal intake percentages for one resident (R807), of two residents reviewed for nutrition, resulting in significant weight loss. Findings include: A complaint was received by the State Agency that alleged the resident was not being assisted to eat and had sustained significant weight loss. A review of R807's census information was conducted and revealed R807 signed onto Hospice services on 7/2/2019, had a payer source change and was discharged from Hospice services on 1/10/20, and then on 5/1/21 had another payer source change that indicated they had been re-signed onto Hospice. A review of R807's clinical record revealed an admitted [DATE] and a re-admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R807's care plans were reviewed, and an ADL (activities of daily living) care plan included an intervention dated 4/2/19 that read, .Eating: dependent for all feeding/drinking needs: x1 assist . R807's care plans also included a focus for nutritional deficits with an intervention dated 3/29/19 that read, .PROVIDE TOTAL MEAL ASSISTANCE .Provide, serve diet as ordered. monitor intake and record q (every) meal . A review of R807's documented weights was conducted and revealed the following: 1/2/21 93.3 lbs. 2/8/21 90.5 lbs. 2/18/21 85.0 lbs. 2/22/21 88.7 lbs. 3/10/21 86.6 lbs. 3/18/21 85.1 lbs. 3/23/21 86.2 lbs. 4/1/21 78.6 lbs. 4/6/21 80.5 lbs. A review of Dietary progress notes, SOC (Standard of Care)-Nutrition/Hydration progress notes, the Certified Nursing Assistant (CNA) task for percentage of meal eaten, and the CNA task for the ADL-Eating was conducted and revealed the following: A dietary progress note dated 2/10/21 that read, .significant weight loss of 11.3# (pounds) over 180 days .She requires total meal assistance . It was noted this progress note did not address R807's food acceptance or percentages of meals eaten. An SOC-Nutrition/Hydration note dated 2/12/21 that read, .Resident reviewed for weight decline .Resident discharged from hospice services .requires total meal assistance . The CNA task for ADL-Eating for February 2020 was reviewed and revealed no documentation R807 had been assisted with eating for any meals (42 meals total) from 2/1/20 until 2/15/21. The CNA task for Percentage of meal eaten was also reviewed and had no documentation of any percentage of meals eaten (42 meals total) from 2/2/21 until 2/15/21. An SOC-Nutrition/Hydration note dated 3/11/21 that read, .Resident reviewed with IDT (Interdisciplinary Team) d/t (due to) weight decline .Resident's current weight = 86.6# .Documented intake over the past week averaged 55% . An SOC-Nutrition/Hydration note dated 3/18/21 that read, .Resident reviewed with IDT. Resident's current weight = 85.1# .Documented intake over the past week averaged 55% . The CNA task for percentage of meal eaten was reviewed and revealed that in the week referenced in the SOC-Nutrition/Hydration note on 3/18/21, seven meals did not have documentation to indicate how much R807 had eaten. An SOC-Nutrition/Hydration note dated 3/26/21 that read, .Resident reviewed with IDT d/t weight decline .Documented intake over the past week averaged 70% . A review of R807's CNA task for percentage of meal eaten was reviewed and revealed that in the week referenced in the SOC-Nutrition/Hydration note on 3/26/21, eight meals did not have documentation to indicate how much R807 had eaten. A review of the complete CNA task for amount eaten for the month of March was conducted and revealed that of 93 meals, 31 meals did not document the amount eaten and that of the 93 times CNA's were to document the resident had been assisted with eating, 29 times the task had been left blank. An SOC-Nutrition/Hydration note dated 4/8/21 that read, .Resident reviewed for continued weight decline. Weekly weight 82.5# .CBW (current body weight) is down 10.8# (11.5%) over 90 days and down 17.5# (17%) over 180 days, both significant .requires total meal assistance . An SOC-Nutrition/Hydration note dated 4/13/21 that read, .Resident reviewed .d/t weight decline .Weekly weight 83# .Meal intake averaged 53% A review of R807's CNA task for percentage of meal eaten and the ADL-Eating task was reviewed and revealed that from 4/1/21 to 4/12/21 out of a total of 36 meals, 27 had been left blank and did not indicate a percentage of the meal eaten, or that R807 had been assisted with eating. A review of the complete CNA task for ADL-Eating for the month of April was conducted and revealed that of 90 times the CNA's were to document the resident had been assisted with eating, 57 times the task had been left blank, and of the 90 meals, 58 had no documentation on how much R807 had eaten. On 5/5/21 at 9:00 AM, a telephone interview was conducted with Registered Dietician (RD) 'B' regarding R807's weight loss. During the interview, RD 'B' was asked how they calculated the weekly percentages of R807's meal intake. RD 'B' said they looked back at the CNA tasks for the percentage of meal eaten and they talked to the staff for information. When queried how they calculated accurate percentages of meals eaten when there were many meals that did not have documentation of amount eaten, the RD said they could not speak to it, because at the time of the interview they were not able to review the CNA task for themselves. On 5/5/21 at 10:30 AM, an interview with the facility's Director of Nursing (DON) was conducted regarding R807's weight loss, calculated intake percentages, and assistance with eating. The DON said the CNA's should be documenting they are assisting the resident with eating and documenting accurate amounts of intake. The DON further indicated the RD should, probably not be using absolute values because of the missing documentation on the CNA task of amount eaten. A review of a facility policy titled, Weight Monitoring with a revised date of 10/30/20 was conducted and read, Policy: Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status .7. Documentation .Meal consumption information should be recorded . A review of a second facility provided policy titled, Activities of Daily Living (ADL's) with a revision date of 10/30/20 was conducted and read, .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .

This citation pertains to intake #s: MI 417, MI 477, MI 510, and MI 541. Based on observation, interview and record review, the facility failed to ensure adequate infection control practices in accordance with the Centers for Disease Control (CDC) protocol for COVID-19 including: appropriate screening of staff, contracted employees, and visitors upon arrival to the facility which included temperatures, whether symptoms consistent with COVID-19 were present or not and ensure staff with symptoms consistent with COVID-19 did not proceed into the facility. This deficient practice resulted in an Immediate Jeopardy (IJ) to the health and safety of all residents, many of whom were at high risk due to age and co-morbidities, which has likely caused transmission of COVID-19 from the community into the facility which could result in serious health complications, hospitalization or death for residents who reside at the facility. Since 1/14/21, the facility has had 52 COVID-19 positive residents, 5 COVID-19 related hospitalization s, and 2 COVID-19 related deaths. Findings include: The IJ began on 1/14/21 and was identified on 2/12/21. The Administrator was notified of the IJ on 2/12/21 at 3:51 PM and a plan to remove the immediacy was requested. The IJ was removed on 2/12/21, based on the facility's implementation of the removal plan as accepted and verified onsite on 2/12/21. Although the immediacy was removed, the facility's deficient practice remained out of compliance at a scope of widespread and a severity of potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance that has not been verified by the State Agency. Review of the CDC guidelines for Infection Control for Nursing Homes, updated 11/20/20 included: Screen all HCP (Health Care Professionals) at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19 (i.e., Fever or chills, cough, shortness of breath or difficulty breathing, muscle or body aches, headache, sore throat, congestion, or runny nose .). If they are ill, have them keep their cloth face covering or facemask on and leave the workplace . Review of the facility's Coronavirus Surveillance policy dated Revised: 1/1/2021 documented in part, .Heightened surveillance activities will be implemented to limit the transmission of COVID-19. These included, but are not limited to .Screening for visitors and staff .Signs or symptoms of a respiratory infection, such as a fever, cough, shortness of breath, or sore throat or other symptoms of coronavirus (i.e. chills, muscle pain, headache, new loss of taste or smell, fatigue, congestion or runny nose .In the last 14 days, has had contact with someone with a confirmed [DIAGNOSES REDACTED].Visitors will be denied entry into the facility if they exhibit any of the criteria listed above .Staff who have signs and symptoms of a respiratory infection shall not report to work .The facility will refer to current CDC guidance for exposures that might warrant restricting asymptomatic staff from reporting to work . On 2/9/21 at approximately 8:45 AM, upon entering the facility, Surveyors were screened by facility staff, but staff failed to ask whether there had been contact with someone confirmed or suspected to have COVID-19 in the past 14 days. On 2/9/21 at approximately 1:25 PM, the Director of Nursing (DON) who also acted as the facility's Infection Control Preventionist was informed of the lack of screening upon entry into the facility about whether there was exposure to a confirmed or suspected person in the past 14 days. At that time, the DON reported that should have been asked as part of the facility's screening process and would follow-up. The DON confirmed that following discussion with the staff that screened the Surveyors, that had not been asked and education had been provided to that employee. On 2/9/21 at approximately 2:30 PM, review of documentation provided by the facility included Housekeeper (Staff 'I') which was identified as positive for COVID-19 on 1/14/21. At 2:49 PM, Administration was requested to provide employee punch detail reports since 1/14/21 for the staff reviewed as part of the infection control pathway, which included Staff 'I'. There was no documentation of what time the positive test had been conducted and/or what time the results had been received. Review of the facility's employee/visitor surveillance screening log documentation included the following instructions: .Do you have any of the following: Fever, new onset cough, new onset shortness of breath or difficulty breathing, Chills, muscle or body aches, headache sore throat Y/N (Yes or No) If yes to any of the above explain below. If yes within 3 days post vaccine use new screening addendum. All Yes's - contact nurse in charge. ANY YES Must Have Supervisor Review .Note - If symptoms can be explained by seasonal allergies [REDACTED]. or a physician [DIAGNOSES REDACTED].* who will document justification of decision on the opposite side of this form OR POST VACCINE FORM. Symptomatic employees should put on a mask, clock out and contact Infection Preventionist / DON / RDC immediately . There was no additional documentation provided by the facility to include additional supervisor review, clinician assessment noted on the back of these logs (blank on back of surveillance logs), new screening addendum within 3 days post vaccine, or Post Vaccine Forms as identified in the instructions noted above. Review of the screening log documentation for Staff 'I' dated 1/14/21 revealed, in part, the following: Per the vaccine column it was noted as Staff 'I' had the first COVID-19 vaccine on 1/6/21 and the symptoms column on the form was documented as body aches +. (These positive symptoms were beyond the 3 day post vaccine screening.) Review of Staff 'I's time punch details for 1/14/21 revealed the employee had punched in at 6:15 AM and had punched out at 8:30 AM. On 2/10/21 at 9:50 AM, an interview was conducted with the Environmental Services (ES Manager) who reported was contracted and responsible for oversight of the facility's housekeeping and laundry staff. When queried about the facility's process for screening and testing for COVID-19, the ES Manager reported all employees entered through the back hallway, get screened, then proceed to the salon to get tested every Monday and Thursday. When asked if the facility had informed him of Staff 'I' being symptomatic on 1/14/21 for body aches and later tested positive for COVID-19 on 1/14/21, the ES Manager denied being aware of Staff 'I' being symptomatic. When asked about Staff 'I's work assignment on 1/14/21 from 6:15 AM to 8:30 AM, the ES Manager was unable to recall any specific details and reported, Facility handles testing information. They'll tell me if staff test positive. I don't have that information. On 2/10/21 at 11:50 AM, when queried about the facility's process for screening/identifying employees/visitors, and review of Staff 'I's screening log from 1/14/21, the DON and Administrator reported that if employees were symptomatic, either the DON or Administrator should be notified and those employees that were symptomatic should've been turned away at that time. The DON further reported, Should've never been allowed through facility based on active symptoms. I have a concern with that as well. At that time, a request was made to provide Staff 'I's assignment from 1/14/21. On 2/11/21 at 2:25 PM, the DON was asked about any additional documentation about Staff 'I's work assignment from 1/14/21 as there was no follow up from the previous request to the ES Manager on 2/10/21 at 9:50 AM and reported he would follow up. On 2/11/21 at approximately 3:00 PM, the interim Administrator/Regional Director of Operations reported, (Staff 'I') worked about two hours. Got screened, tested and went to cart on Lilley unit. (Staff 'I' should not have passed through the screening based on positive symptoms and positive testing on 1/14/21.) Review of the additional employee/visitor surveillance screening documentation since 1/14/21 revealed multiple concerns with the screening process in regard to lack of documented temperatures, whether or not there were symptoms consistent with COVID-19, and/or symptomatic staff/visitors being allowed to pass through the screening to work and/or obtain COVID-19 testing within the facility, some of which tested positive. The following additional concerns were identified: 1/15/21: Registered Dietician (RD) 'E': Review of screening log documentation for RD 'E' dated 1/15/21 revealed, in part, the following: The only documentation present on the screening log for this employee was a temperature upon exit. No presence or absence of symptoms or temperature on entrance to the facility had been documented. Certified Nursing Assistant (CNA) 'O': Review of screening log documentation for CNA 'O' dated 1/15/21 revealed, in part, the following: Per the column on the form to document symptoms, it was noted a y had been marked in the symptom column of the form. Next to the documentation of y it was documented cold symptoms. No explanation was provided to determine which specific symptoms CNA 'O' had been experiencing. Review of time punch details for CNA 'O' for the date of 1/15/21 revealed the employee had punched in at 9:51 AM and had punched out at 6:01 PM. Housekeeping Staff 'P': Review of screening log documentation for Housekeeping Staff 'P' dated 1/15/21 revealed, in part, the following: Per the column on the form to document symptoms, it appeared that a y had been written over previous documentation. Next to this documentation it was documented cold symptoms. No explanation was provided to determine which specific symptoms Housekeeping Staff 'P' had been experiencing. Review of the attendance report for this staff member documented the employee had clocked in at 7:01 AM, clocked out at 10:54 AM, clocked in again at 11:31 AM, and clocked out at 3:09 PM. Housekeeping Staff 'Q': Review of screening log documentation for Housekeeping Staff 'Q' dated 1/15/21 revealed, in part, the following: Per the column on the form to document symptoms, it was noted a y had been marked in the symptom column of the form. Next to the documentation of y it was documented sore throat. Review of the attendance report for this staff member documented the employee had clocked in at 6:07 AM and clocked out at 3:05 PM. 2/1/21: CNA 'F': Review of screening log documentation for Certified Nursing Assistant (CNA) 'F' dated 2/1/21 revealed, in part, the following: Per the symptom's column on the form, it was documented no to symptoms. However, next to the documentation which indicated no symptoms was (cold sympt). No explanation was provided to determine which specific symptoms CNA 'F' had been experiencing. Review of time punch details for CNA 'F' for the date of 2/1/21 revealed the employee had punched in at 7:00 AM and had punched out at 3:20 PM. CNA 'T': Review of a screening log documentation for CNA 'T' dated 2/1/21 revealed, in part, the following: Per the column on the form to document symptoms, it was noted SOB (shortness of breath), stuffyness <sic> had been documented. Review of time punch details for CNA 'T' for the date of 2/1/21 revealed the employee had punched in at 2:58 PM and had punched out at 11:15 PM. 2/3/21: Registered Nurse (RN) 'H': Review of screening log documentation for RN 'H' dated 2/3/21 revealed, in part, the following: RN 'H' had a temperature documented on entrance, however per the section of the form where the presence or absence of symptoms was to be documented vaccine had been documented. It was not indicated whether or not the employee was displaying any symptoms on entry to the facility. CNA 'U': Review of screening log documentation for CNA 'U' dated 2/3/21 revealed, in part, the following: CNA 'U' had no temperature documented upon entrance to the facility per review of the screening form. Per the section of the form where the presence or absence of symptoms was to be documented, vaccine had been documented. It was not indicated whether or not the employee was displaying any symptoms on entry to the facility, whether the employee had community or travel exposure in the last 14 days, and the screener signature section for this employee's screen had been left blank. Review of time punches for CNA 'U' for 2/3/21 documented the employee had clocked in at 12:30 PM and had clocked out at 1:10 PM. 2/4/21: RN 'Z': Review of screening log documentation for RN 'Z' dated 2/4/21 revealed, in part, the following: A negative sign was documented and circled per the section of the form to document employee symptoms. However, next to this documentation was the following: vaccine side effects earlier. Per the screening log it was indicated if the employee answered yes to symptoms within three days post vaccine then a new screening addendum would be used. The following was also documented on the form: Note-If symptoms can be explained by seasonal allergies [REDACTED]. or a physician [DIAGNOSES REDACTED].* who will document justification of decision on the opposite side of this form OR POST VACCINE FORM . 2/5/21: CNA 'V': Review of screening log documentation for CNA 'V' dated 2/5/21 revealed, in part, the following: Per the column on the form to document symptoms, it was noted aches, fever, chills - vaccine eff <sic> (effects) had been documented. Review of time punch details for CNA 'V' for the date of 2/5/21 revealed the employee had punched in at 10:38 PM and had punched out at 7:28 AM on 2/6/21. Per the screening log it was indicated if the employee answered yes to symptoms within three days post vaccine then a new screening addendum would be used. The following was also documented on the form: Note-If symptoms can be explained by seasonal allergies [REDACTED]. or a physician [DIAGNOSES REDACTED].* who will document justification of decision on the opposite side of this form OR POST VACCINE FORM. On 2/12/21 at 12:00 PM, the DON was queried about the screening process for all staff, including contracted staff and visitors and reported everyone follows the same process. When asked if any employee or visitor had symptoms, what was the facility's process, the DON reported, If any employee with any symptom, they should be stopped at the door and not go any further. A POC (Point of Care - Rapid) test would be done at the back door. When queried about the lack of documented screening entries for multiple staff including the section for temperatures and symptoms, the DON reported, The directive is to put symptoms on there (screening log). The top line says, 'Do you have any symptoms.' Any symptom is one. At that time, upon reviewing the screening logs since 1/14/21, the DON acknowledged the blank and missing documentation. When queried about who was responsible for oversight of the screening logs and employee/visitor surveillance, the DON reported himself or the Administrator and was unable to offer any further explanation as to the facility's lack of identification of the above concerns until now. On 2/12/21 at 1:15 PM, when queried about the lack of additional screening documentation as identified on the surveillance logs, the DON reported the facility used the questions prompted on the screening/surveillance logs and had not used any other forms of documentation such as a post vaccine form or other clinician assessment. When queried about the multiple employees that were symptomatic for COVID-19 symptoms but allowed to continue through the facility to work and/or obtain testing, the DON reported being unaware of those employees being symptomatic and reported those employees should have not been allowed to continue past the screening into the facility.

This citation pertains to intake #MI 190. Based on observation, interview and record review, the facility failed to ensure ongoing assessment, monitoring, and implementation of nutritional interventions for two (R911 and R914) of two sampled residents reviewed for nutrition/food, resulting in delayed identification of a severe weight loss (16.76 % in 72 days for R914) and the increased likelihood for further unidentified weight loss, poor nutritional intake, and the development of/worsening of skin breakdown. Findings include: Resident #914: On 2/10/21 at 12:25 PM, R914 was observed to be very thin in appearance and was lying in bed with the head of the bed slightly elevated. A lunch tray was positioned on the overbed table which consisted of a (untouched and not cut up) spaghetti with meat sauce, (untouched and not cut up) broccoli florets, a piece of pound cake with small pieces removed, and an empty container that had pink food remnants. When queried about the lunch meal, R914 stated, I can't eat it. Too tough, I don't have teeth. At that time, the roommate of R914 stated, I gave him one of my ice creams. Review of the meal ticket on the food tray noted R914 was to receive a Level 3/Advanced diet. R914 further reported that his dentures had been lost while at another facility just before coming to this facility. When asked about whether staff provided any feeding assistance, R914's roommate stated, Oh he can do it. Continued observations of staff revealed no one offered R914 any assistance to cut up the meal, offer an alternate, or monitor food intake. R914's roommate then proceeded to remove R914's meal tray and take down to the food cart in the hallway. Review of the clinical record revealed R914 was admitted into the facility on [DATE] with contracted hospice services. [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed R914 had moderately impaired cognition, had no behavior concerns, required one person physical assistance with eating, required extensive assistance of two or more people for bed mobility, transfers, dressing, toilet use and personal hygiene, was incontinent of bowel and had an indwelling catheter (currently discontinued), had no unhealed pressure ulcers but was at risk for developing, had no natural teeth or tooth fragments, weighed 165 pounds, and had no weight loss or gain. This assessment did not identify that R914 was receiving hospice services, despite being admitted and currently receiving contracted hospice services. Review of the admission nutritional assessment completed by Registered Dietitian (RD 'D') dated 12/2/20, documented that R914 had no change in weight, was not on a physician-prescribed weight-loss regimen, had an ideal body weight range of + or - 10% of 166 and that his usual body weight was approximately 167# (pounds). This assessment further noted R914 was able to chew his own food and swallow adequately. The nutrition summary portion documented, .Resident is receiving a mechanical soft diet with thin liquids d/t (due to) edentulous status. He feeds himself. Resident reports his appetite is okay. He states he is getting enough to eat. Admission weight pending. Estimated nutritional needs based on hospital weight of 163#. Resident denies recent weight change. Skin is intact .Recommend continue current diet. Goal to maintain comfort with hospice care. Review of R914's care plans included: An activities of daily living care plan initiated 11/30/20, last revised 12/9/20 documented interventions which included: EATING: Resident is independent after set up assist. (May require occasional assist). A potential or actual impairment to skin integrity care plan initiated 11/30/20, last revised 12/9/20 documented interventions which included: Encourage good nutrition and hydration in order to promote healthier skin. A nutritional deficit care plan initiated 12/2/20, last revised 12/18/20 documented interventions which included: Monitor/record/report to MD PRN (as needed) s/sx (signs/symptoms) of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: >5% in 1 month, >7.5% in 3 months, >10% in 6 months. Provide, serve diet as ordered. Monitor intake and record q (every) meal. RD to evaluate and make diet change recommendations PRN. Review of R914's weights since admission revealed there were only three which were documented as: 12/7/20 = 163.5#, 1/29/21 = 139.5#, and 2/10/21 = 139.0#. Each of these weights did not identify the type of scale the weight was obtained from. Further review of the nutritional progress notes for R914 which read, Weight gain/loss; Hydration concern included: On 12/18/20, .Resident has a stage 3 pressure wound to coccyx measuring 1.0 x 1.0 x 0.3 cm (centimeters). Intervention: Resident is receiving a mechanical soft diet with thin liquids d/t edentulous status. Resident is eating well with documented intake over the past week averaging 84% .Recommend offer 4 oz (ounces) Med Pass 2.0 qd (every day) .for extra kcals/pro . On 12/31/20, .Resident has a stage 3 pressure wound to coccyx .0.5 x 0.6 x 0.5 cm. Resident also noted to have MASD (Moisture Associated Skin Damage - caused by prolonged exposure to various sources of moisture including urine, stool, perspiration, wound exudate) with small open areas .Resident is eating well with documented intake over the past week averaging 64% .Recommend increase Med Pass to 4 oz BID (twice daily) . On 1/21/21 (next assessment since 12/31/20), .Weekly measurements - 0.6 x 0.4 x 06 cm . Resident is eating well. Resident is receiving 4 oz Med Pass 2.0 BID .Per MAR, resident accepting 100%. On 1/29/21, .Resident has a stage 3 pressure wound to coccyx. Weekly measurements - 0.9 x 0.4 x 0.4 cm . Documented intake over the past week average 82% On 2/5/21, .Resident has a stage 3 pressure wound to coccyx. Weekly measurements pending .Documented intake over the past week averaged 75% with one meal refused. Resident is receiving 4 oz Med Pass 2.0 BID .Per MAR (Medication Administration Record), acceptance over the past week averaged 89%. Current weight = 139.5# (1/29), reweight pending . There was no further documented evidence that the facility had identified any attempt or concern with ability to obtain a re-weight for R914 following the weight on 1/29/21 which was a loss of 27.5# (16.26% weight loss since 11/30/20). The re-weight was not obtained until 2/10/21 which was 139.0#. Review of R914's food acceptance records from 12/1/20 - 2/10/21 revealed a total of 127 missing/blank entries out of a total of 213 opportunities to document the resident's food intake. On 2/11/21 at 9:55 AM, an interview was conducted with RD 'D' who confirmed had been following R914 since admission on 11/30/20. When asked what had been done to address R914's nutritional needs given the development of the stage III pressure ulcer after admission, RD 'D' reported R914 had a decline in weight which was probably a combination of multiple co-morbidities, had tested positive for COVID-19 in the past month and moved around the facility. RD 'D' was asked about the lack of re-weight for identified weight loss and what the facility's policy was and reported she had recently saw the re-weight had not been done, so the weight on 2/10 was the re-weight for 1/29. When asked when re-weights should be done, RD 'D' reported those should be done after a five pound change within 24 hours. RD 'D' reported the electronic medical record has a system that once changes are entered in, they flag and reported herself and nursing were responsible for monitoring those changes. RD 'D' was asked about the current diet of mechanically soft with thin liquids and reported the spaghetti with meat sauce and broccoli would be appropriate for R914. When informed of the observation of the food items from 2/10/21 that were not cut up once given to the resident, RD 'D' reported R914 was independent once set up which would have included staff assisting with cutting up the food. When asked about how it could be determined what R914 averaged on the food acceptance record, given the multiple blank/missing entries, RD 'D' reported that information should be documented at each meal and was unable to offer any further explanation. When asked about whether the physician had been notified of the severe weight loss, RD 'D' reported that she had left a note in the physician's communication book after yesterday's weight. RD 'D' confirmed that the physician had not been notified of the weight obtained on 1/29/21. When asked about the lack of updated nutritional care plan since 12/18/20, RD 'D' acknowledged the concern and reported there was a delay in the re-weight which was done yesterday and would follow up. On 2/11/21 at 11:04 AM, Certified Nursing Assistant (CNA 'F') was asked about R914's ability to feed self and whether there were any refusals, CNA 'F' reported R914 was able to feed himself and was not aware of any refusals. On 2/11/21 at 12:20 PM, an interview was conducted with the Director of Nursing (DON). When queried about the facility's process for obtaining weights and if discrepancies were identified, what the process was, the DON reported challenges with obtaining weights since some residents require pre-medication due to pain when moved and that the monthly weights were done the first week of the month. The DON was asked about the process for documenting food acceptance and upon review of R914's confirmed the multiple missing/blank entries and reported the nursing assistant should notify the nurse if change in food acceptance and document. Resident #911: Review of a complaint received by the State Agency alleged, in part, concerns with the facility not providing a R#911 with appropriate assistance for eating. Review of the clinical record for R#911 revealed the resident was admitted to the facility on [DATE] and was discharged [DATE] with [DIAGNOSES REDACTED]. Review of R#911's admission minimum data set (MDS) assessment dated [DATE] documented the resident scored 12 out of 15 on a brief interview for mental status (BIMS) exam, which indicated the resident was moderately cognitively impaired. Per this assessment R#911 required the extensive assistance of one person for eating. Review of a physician order [REDACTED]. Review of R#911''s *Nursing Admission Evaluation-Part 1 dated 12/4/20 and locked on 12/5/20 documented the resident's most recent height as 69.0 inches (documented as date 12/4/20 at 4:06PM, method: standing), and most recent weight as 172.0 pounds (lbs), (documented as date 12/4/20 at 4:06PM, method: mechanical lift). Review of a Nutrition Data Collection/Evaluation-V 2 for R#911 dated 12/7/20 documented, in part, the resident's most recent weight as 172.0 pounds on 12/4/20. It was documented the resident was unsure of their usual body weight, the question about change in weight had been left blank, and it was documented the resident was not on a physician-prescribed weight loss regimen nor on a fluid restriction. Per section 5. Total % of meals it was documented, Documented intake since admit averages 47% with 240-480 ml (milliliters)/meal. Per the Resident status section of the form it was documented R#913 was alert with memory problems, was able to make themselves understood/understand others, had severely impaired vision, and required assistance with eating. Review of the Section II. Evaluation, Nutrition Summary part of the form for R#911 documented, in part, .Resident is receiving a regular diet with thin liquids. He requires meal assistance. Documented meal intake has varied since admit, poor overall. He reports his appetite is okay. He is unsure of weight hx (history). He reports no difficulty chewing or swallowing. Writer discussed poor intake and importance of nutritional intake for healing. Resident agreed to try supplement . Per the Recommendations section of the form it was documented, Recommend continue current diet. Provide meal assist as needed. Offer 4oz (ounces) (Supplement Name) BID (twice a day) .Observe weekly weights per order. Review of the Weights & Vitals section in R#911's electronic medical record revealed the following weight documentation: -12/4/20: 172.0 Lbs -12/11/20: 169.4 Lbs -12/22/20: 161.0 Lbs -12/31/20: 154.4 Lbs Per this documentation, R#911 had lost 17.6 pounds between 12/4/20 and 12/31/20. Re-weights were not observed to have been taken per review of documented weights for R#911. Review of R#911's Food Acceptance Record (FAR) for December 2021 revealed six documented incidents of resident refusal of meals in the month of December. Meal acceptance had not been documented for any shift, as documentation was observed to have been left blank, for the following dates: 12/8/20, 12/20/20, 12/25/20, 12/29/20, 12/30/20, and 12/31/30. Outside of these dates, there were 15 additional days of the month where meal acceptance had not been documented three times per day, as only one or two meals had been documented. It was noted per the key on the form that there was a code that could be input to indicate the resident was not available, as well as a code to indicate not applicable. Neither of these choices was observed to have been entered on the FAR for December 2020 for the resident. Review of R#911's FAR for January 2021 revealed no documentation was present for the dates of 1/1/21 or 1/2/21. Review of a plan of care for R#911 dated 12/5/20 documented, in part, The resident has potential for nutritional deficits r/t (related to): -new admit s/p (status [REDACTED]. Review of interventions per the plan of care revealed the most recent updated intervention date of 12/7/20 (related to supplement use). Interventions dated 12/5/20 included, in part, .Provide, serve diet as ordered. Monitor intake and record q (every) meal and . RD (Registered Dietician) to evaluate and make diet change recommendations PRN (as needed). On 2/11/21 at 10:21AM RD 'D' was queried in regard to R#911. RD 'D' explained that she had not seen the resident's weight loss until the resident had been discharged . RD 'D' explained it had been recognized the resident was at risk for weight loss, and the resident was on a supplement (noted to be included in nutritional evaluation dated 12/7/20). RD 'D' was queried as to whether she had been made aware of the resident's weight loss prior to discharge, and RD 'D' explained she did not recall. When queried as to whether the resident required dining assistance, RD 'D' confirmed the resident required one person assistance. During an interview on 2/11/21 at 12:31PM the facility's Director of Nursing (DON) acknowledged concerns with re-weights at the facility. Review of a facility policy titled, Weight Monitoring with a revised/revision date of 10/30/20 and implementation date of 1/1/21 documented, in part, Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise .1. The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes: a. Identifying and assessing each resident's nutritional status and risk factors b. Evaluating/analyzing the assessment information c. Developing and consistently implementing pertinent approaches d. Monitoring the effectiveness of interventions and revising them as necessary .3. Information gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan to address the resident's specific nutritional concerns and preferences .7. Documentation: 1. The physician should be informed of a significant change in weight and may order nutritional interventions . Review of a facility's policy titled, Standards of Care (SOC) Meeting with a revised/revision date of 10/2/20 and implementation date of 1/1/21 documented, in part: .Multidisciplinary meeting held per established facility schedule .Review resident's medical record and other supporting data to be considered in the following areas .Nutrition/Hydration Risks (New or changed) .Participants: Director of Nursing, Designated Members of nursing staff, Wound nurse as applicable, MDS Coordinator .Social Services, Dietitian as applicable .Documentation should be placed in the resident's medical record indicating SOC review and actions or resolution .Updates to the plan of care and applicable interventions placed on the KARDEX .

This citation pertains to intake #MI 190. Based on observation, interview and record review, the facility failed to provide adequate and appropriate care to prevent and treat pressure ulcers for one (R914) of three sampled residents reviewed for wound care, resulting in R914 developing a facility acquired stage 3 pressure ulcer (full-thickness skin loss, in which subcutaneous fat may be visible in the ulcer) and the increased likelihood for delayed healing/worsening of existing pressure ulcer and the development of new wounds. Findings include: Review of a complaint reported to the State Agency on 1/15/21 included an allegation that facility staff failed to provide adequate and appropriate care to prevent and/or treat pressure sores. On 2/10/21 at 10:25 AM, R914's bare feet were observed directly touching the mattress and footboard, despite being propped up on a pillow under the ankles. There were no preventative measures observed in place such as soft heel boots or a specialty mattress (such as a low air loss). Further observations were made on 2/10/21 at 12:25 PM, 2:15 PM, 3:08 PM, and on 2/11/21 at 8:53 AM, 11:04 AM. At each of these observations, R914 was observed lying in bed in the same position at each observation (on the back with the head of the bed in a slightly elevated position and feet propped up by a pillow without soft heel boots or specialty mattress). There were no wedge/positioning pillows observed in use at each of these observations. R914 responded appropriately and consistently to questions asked, but did speak in a very low, muffled voice. During an interview on 2/11/21 at 11:17 AM, R914 was asked about whether he utilized a chair to be able to get out of bed and stated, I'm supposed to have a chair to get up. There was no chair observed in the room or nearby hallway. On 2/10/21 at 2:15 PM, Registered Nurse (RN 'G') was asked to observe R914's wound care treatment and reported that the wound care treatment was already done for today but would be back tomorrow. RN 'G' was requested to observe wound care at that time. On 2/11/21 at 8:52 AM, RN 'G' was asked about when R914's wound care would be completed and reported, I did his this morning. It was very painful. The coccyx and around is red. RN 'G' was queried about why the wound care had been completed given the discussion on 2/10/21 and offered no response. When asked about preventative interventions such as soft heel boots or a specialty mattress, RN 'G' reported He does not have that but might be a good idea for him. On 2/11/21 at 11:04 AM, Certified Nursing Assistant (CNA 'F') was asked about R914's transfer and mobility status and reported, Never told me his official transfer status. When asked how that information was shared to direct care staff, CNA 'F' reported, Should be in the care plan on the Kardex. I was told he doesn't get out of bed. I'm not aware of him having a chair. (R914) Only been over here for a few weeks. When asked if there were any special boots such as soft heel boots, CNA 'F stated, I'm not aware of any boots for the feet. When asked about the frequency of repositioning R914, CNA 'F' stated, Hurts him to reposition. Tried to put pillows but he says it hurts, so I take it off. When asked if anyone had been notified of that concern, CNA 'F' reported, I let nurse know. CNA 'F' was asked about R914's toileting status and reported the resident was incontinent of bowel and bladder and did not currently have an indwelling catheter. CNA 'F' further reported it was painful to change due to the fracture to the right hip area. When asked how often the incontinence care was provided, CNA 'F' reported, I'll be honest, there are times I only change him once a shift due to not having enough staff. Review of the clinical record revealed R914 was admitted into the facility on [DATE] with contracted hospice services. [DIAGNOSES REDACTED]. According to the admission Minimum Data Set (MDS) assessment dated [DATE], R914 had moderately impaired cognition, had no behavior concerns, required one person physical assistance with eating, required extensive assistance of two or more people for bed mobility, transfers, dressing, toilet use and personal hygiene, was incontinent of bowel and had an indwelling catheter (currently discontinued), had no unhealed pressure ulcers but was at risk for developing, had no natural teeth or tooth fragments, weighed 165 pounds, and had no weight loss or gain. This assessment did not identify that R914 was receiving hospice services, despite being admitted and currently receiving contracted hospice services. Review of R914's progress notes since admission included the following wound consultant documentation: Date of service: 12/15/2020 .Hospice nurse is present at bedside .We are asked to evaluate coccyx wound .Coccyx pressure injury stage III: Measures 1.0 x 1.0 x 0.3 cm (centimeters) .Moisture associated skin damage to surrounding sacrococcygeal area .Plan: Coccyx wound apply bordered foam daily. Moisture associated skin damage: peri-wound apply barrier cream daily and as needed. Date of service: 12/22/2020 .Coccyx pressure injury stage III: Measures 0.5 x 0.6 x 0.4 cm .2 viscible <sic> open areas on right. measures 5.0 x 0.5 cm. Wound base is red and moist .Coccyx wound apply bordered foam daily . Date of service: 12/29/2020 .Coccyx pressure injury stage III: Measures 0.5 x 0.6 x 0.5 .Moisture associated skin damage to surrounding sacrococcygeal skin .2 visible open areas on right and left side. Measures 0.5 x 0.5 cm on right and 0.4 x 0.6 on left .Coccyx wound apply bordered foam daily . Date of service: 1/19/2021 (21 days since last wound consultation) .Coccyx pressure injury stage III: Measures 0.6 x 0.4 x 0.6 cm .Adipose tissue is visible .Moisture .Scattered open areas on right and left side. Right is more irritated than left .Coccyx wound change treatment to collagen pad and bordered foam daily. Moisture .peri-wound apply barrier cream daily and as needed. Date of service: 1/28/2021 .Coccyx pressure injury stage III: Measures 0.9 x 0.4 x 0.4 cm. Wound is full-thickness skin loss. Adipose tissue is visible. Wound bed with pink granulation .Moisture associated skin damage to surrounding sacrococcygeal area .Scattered open areas on right and left side. Right is more irritated than left. Wound base is red and moist .coccyx wound change treatment to collagen and bordered foam daily (not a change as this was the same as noted on 1/18/21) .Moisture .apply barrier cream daily and as needed . .Date of service: 2/2/2021 .follow-up for coccyx wound .Patient currently enrolled in hospice. Patient is mildly confused but cooperative .Negative for agitation .Weight 139.5 pounds .Behavior is calm .Coccyx pressure injury stage III: Measures 0.7 x 0.4 x 0.3 cm. Wound is full-thickness skin loss. Wound bed with pink granulation, no slough or eschar .Light serosanguinous drainage. Moisture associated skin damage to surrounding sacrococcygeal area .Periwound skin is dry, flaky and thin/fragile .Coccyx wound change treatment to collagen pad and bordered foam daily (not a change as this was the same as noted on 1/18/221) .continue preventative measures and pressure relief. Frequent repositioning, elevate bilateral lower extremities, float heels, apply soft heel lift boots. Date of service: 2/9/2021 .Coccyx pressure injury stage III: Measures 1.1 x 0.4 x 0.2 cm. Wound bed with moist pink granular tissue .Light serosanguineous drainage. Moisture associated skin damage to surrounding sacrococcygeal area .Coccyx wound: change treatment to honey gel and and <sic> bordered foam daily. Moisture associated skin damage: peri-wound apply barrier cream daily and as needed .Continue preventative measures and pressure relief. Frequent repositioning, elevate bilateral lower extremities, float heels, apply soft heel lift boots . Review of R914's physician orders [REDACTED]., cover with border foam daily and PRN (as needed) if soiled or compromised every day shift. Additionally, there were multiple blank entries and refused entries documented by nursing staff which had no supporting documentation of whether treatments were reapproached with the resident, or whether the physician had been notified. TAR documentation included: December 2020: There were 3 blank entries on: 12/16, 12/24, and 12/25. There were 7 entries coded 2 (according to chart codes a 2 = Drug Refused) on: 12/18, 12/19, 12/21, 12/23, 12/26, 12/27, and 12/31. January 2021: There were 10 blank entries on: 1/4, 1/6, 1/7, 1/11, 1/12, 1/13, 1/16, 1/18, 1/19, and 1/22. There were 4 entries coded 2 on: 1/1, 1/2, 1/10, and 1/15. February 2021: There were 3 blank entries on: 2/1, 2/4, and 2/5. There were no entries coded 2. Review of R914's nursing admission assessment dated [DATE] only identified bruising to the resident's right shoulder, chest, groin, and right thigh. Review of the weekly skin assessments revealed concerns with lack of identification of changes in the resident's skin condition as compared to the wound consultant's documentation. The skin assessment on 12/7/20 documented, unable to complete full skin assessment as today is not this resident's shower day. Redness on buttocks remains, barrier cream applied. All other areas assessed were free from new skin issues. The next skin assessment on 12/16/20 documented, No new skin areas - Dressing to left buttock .Are there any existing abnormal skin areas? b. No. The skin assessment on 1/2/21 documented, Are there any new abnormal skin areas .Yes - Coccyx open area just smaller than the size of a penny .Are there any existing abnormal skin areas? b. No . The skin assessments from 1/9/21, 1/21/21, 1/25/21 and 2/3/21 all documented, coccyx, open area, tx (treatment) applied. The sections for comments were left blank as well. Review of the most recent skin observation available in the clinical record as documented by direct care staff was on 2/1/21 at 12:37 PM and noted as None of the above observed (scratches, red area, discoloration, skin tear, open area). Review of the weekly documentation from Registered Dietician (RD 'D') included a recap of the wound consultant's wound description and recommendation for a nutritional supplement on 12/18/20. There was no documented evidence that these reviews had included nursing or other members of the interdisciplinary team. R914's weight upon admission was 165.3 pounds (on 12/7/20) and was 139.0 (on 2/10/21). On 2/11/21 at 9:55 AM, an interview was conducted with RD 'D' who confirmed had been following R914 since admission on 11/30/20. When asked what had been done to address R914's nutritional needs given the development of the stage III pressure ulcer after admission, RD 'D' reported R914 had a decline in weight which was probably a combination of multiple co-morbidities, had tested positive for COVID-19 in the past month and moved around the facility. RD 'D' confirmed concerns with the lack of obtaining consistent weight and re-weights as well as lack of consistent documentation of food acceptance as a possible contributing factor. RD 'D' reported R914 was started on a (nutritional supplement administered by nurse's) and was not aware of any refusals. When asked if nursing had been included in the weekly SOC documentation as this documentation each week was from RD 'D', RD 'D' declined to offer a response. Further review of the clinical record and observation of the facility's centralized nurse desk area for the unit R914 resided revealed binders for other residents receiving hospice services, but there was none for R914. There was no access to the hospice documentation regarding what was being done to address R914's pressure ulcers. There was no further documentation that identified whether the interdisciplinary team (IDT) characterized the likelihood of wound healing. Review of the IDT care plans included 2 wound care plans that had last been reviewed/revised on 12/9/20 and neither identified R914's actual development of the stage III pressure ulcer. Review of the interventions revealed there were no new interventions added since 11/30/20 and included: Monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size (length x width x depth), stage. Skin inspections by CNA during care and shower/baths. Report changes to licensed Nurse immediately. Encourage good nutrition and hydration in order to promote healthier skin. Keep skin clean and dry. Use lotion on dry shin. Do not apply on skin impairment area (s). Review of the most recent CNA documentation for shower/baths as of 2/10/21 at 3:43 PM revealed this was last documented as completed on 2/2/21. On 2/11/21 at 12:20 PM, an interview was conducted with the Director of Nursing (DON). When queried about the facility's process for managing pressure ulcers/wound care, the DON reported the nurses provided the daily wound care to the residents but they did not stage the wounds. The facility's wound consultant would stage and assess the residents weekly. When asked about the documentation of treatments provided and if they had been refused or missed would there be any other location to review such as the reason for missed treatments, other attempts tried, whether physician had been notified, etc., the DON reported, Treatments should be documented, if done on the TAR. At that time, the DON was informed of the concerns with observations of lack of repositioning and recommended interventions, as well as treatment recommendations and multiple missed or refused treatments. The DON reported, I'm surprised. (R914) should have an air mattress. The DON was queried about who was responsible for providing oversight for the facility's skin management program, and reported it was the DON. The DON further reported that although not an excuse, the facility's focus had recently been on the recent survey (exited 1/14/21), management of the spread of COVID-19, and that there had been many staff challenges such as those willing to work and/or those that have resigned. The DON was informed that R914's pressure ulcer and skin concerns were identified prior to the last survey and COVID-19 outbreak and when queried about the lack of coordination, and identification, the DON was unable to offer any further response. The DON was unable to offer any further explanation regarding the discrepancies with nursing skin assessments, care planning, lack of coordination of preventative wound interventions, and treatment change recommendations as documented by the wound consultant. Review of the facility's policy documentation provided included: A Pressure Injury Prevention Guidelines policy dated reviewed/revised 10/30/2020 documented, in part: .Individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment, and any pressure injury assessment .In the absence of prevention orders, the licensed nurse will utilize nursing judgment in accordance with pressure injury prevention guidelines to provide care, and will notify physician to obtain orders .Prevention devices will be utilized in accordance with manufacturer recommendations (e.g., heel flotation devices, cushions, mattresses) .Interventions will be documented in the care plan and communicated to all relevant staff .The effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound. Considerations for needed modifications include .Development of a new pressure injury .Lack of progression towards healing or changes in wound characteristics . A Pressure Ulcer/Skin Breakdown - Clinical Protocol policy dated reviewed/revised 10/30/2020 documented, in part: .The plan of care for prevention and/or treatment of [REDACTED].support surfaces .Turning schedule/off-loading .Moisture Management .Incontinence Management .Nutritional Management .Disease effects on perfusion and/or healing .Certified Nurse Aid completes a skin worksheet/point of care (POC) documentation with bath/shower .A resident with current PU/PI's is evaluated/assessed by the licensed nurse at each treatment and as needed .The physician will authorize pertinent orders related to wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings .and application of topical agents .Although poor nutritional status is associated with increased risk of pressure ulcer development, no specific nutritional interventions have been proven conclusively to prevent or heal pressure ulcers .The physician will help identify medical interventions related to wound management .The IDT will characterize the likelihood of wound healing, based on a review of pertinent factors .Healing or Prevention Likely .Healing or Prevention Possible .Healing or Prevention Unlikely .

This citation pertains to intakes MI 188 and MI 147. Based on observation, interview and record review, the facility failed to ensure physical abuse did not occur between four residents (R901 & R910) and (R904 & R909) of eight sampled residents reviewed for abuse, resulting in R909 hitting R904 with their walker and R901 and R910 striking each other with a metal personal grabber tool with both sustaining abrasions, bruising, and skin tears that required first-aid care. Findings include: Resident #901 and Resident #910: Review of a Facility Reported Incident (FRI) involving R901 and R910 documented, in part: .On December 29, 2020 approximately at 8:45 p.m. staff Nurse ('EE'), became aware of two male residents having an altercation between (name of R901) and (name of R910). (R901) reported that he asked (R910) to lower the volume of his radio, and he refused. The two continued to disagree with both utilizing their personal grabber tool to strike each other. The nurse reported both male residents have skin abrasions that required first aid care. At approximately 8:54 pm the nurse ('EE') reported the incident to (name of Administrator). Residents were separated with (R901) being relocated to another room for safety .Further follow-up of the situation: Accordingly, to (Nurse 'EE') .(R901) states that his roommate (R910) unplugged his radio different times. (R901) states at that time, his roommate (R910) struck him with his grabber stick because resident was going to plug his radio back in back in <sic> causing a skin tear to his right forearm and small abrasion to left cheek. (R901) stated he then hit his roommate (R910) with his own grabber stick causing injury to his roommate .I assessed the wounds of each resident and treated. Both residents reported both residents state <sic> that the other struck first .(R901) assessed for injury and noted he had right forearm skin tear, L(left)-hand bruise, and L-facial abrasion. (R910) assessed for injury and noted he had Skin tear to left forearm and contusion/scratches to top of head . Further review of additional documentation from the Administrator's interviews with R901 and R910 on 1/6/20 documented, in part: .(R901) explained that on that night (R910) was playing country music loud and had his television on too. He had his head phones for his television, but not his radio. (R901) was listening to Rock and Roll music. When one of the staff members came in to bring him some water, they commented on they liked the song. After the staff member left, (R910), he reached down and unplugged his radio. Then (R901) stated he attempted to plug in his radio utilizing his grabber stick, while bending over (R910) took his grabber stick. (R910) started hitting him causing injury to eye, cheek and top of his head. (R901) stated he utilized his hand to protect himself and (R910) had took his grabber stick too. (R901) then put on his call light to get assistance from the staff . .(R910) stated he got into a squabble with him over playing his music too loud. He attempted to shut the radio off with his grabber stick, when (R901) took his stick and hit him. (R910) stated he was trying to protect himself with his grabbe <sic> stick and he was hit on the arm and head. (R910) stated he has been in the current room for 2 years and never had any problems. He knows the incident was reported to the police and they took his grabber stick. Resident #901: A interview was conducted with R901 on 2/5/21 at 3:05 PM. When asked about general life in the facility, R901 reported multiple concerns, including ongoing issues with the former roommate (R910), and stated, I got beat up and spoke to the police. On 2/10/21 at 12:40 PM, R901 was observed lying in bed, waiting for assistance with changing of bed linens from a bowel incontinence episode. R901 reported being much happier with current living situation and reported he was still following up with the police following pressing charges against R910. Review of the clinical record revealed R901 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment dated [DATE], R901 was cognitively intact and had no behavior concerns. Further review of the progress notes included: An entry on 12/30/20 which documented, in part: .Bruising to left arm, hand and left face .I am seeing for apparent altercation between (R901) and his roommate (R910). (R901) has bruising on his left forearm, left hand, and a small laceration to his left cheek .He reports being hit in the head with a metal grabber .He does try to avoid his roommate frequently by sitting in the cafeteria alone every day. He states his roommate makes the room smell and is loud and picks on him . Resident #910: On 2/9/21 at 10:05 AM, R910 was observed seated in wheelchair next to the bed knitting. When asked about the incident from 12/29/20 with R901, R910 pointed to the healed scars on the left forearm and top of head and reported, He had his radio up loud and wouldn't turn it down. I was trying to hit his radio, not him. He doesn't like my music. Review of the clinical record revealed R910 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the MDS assessment dated [DATE], R910 was cognitively intact (although had a legal guardian) and had no behavior concerns. Further review of the progress notes included: An entry on 12/29/20 which documented, in part: .Today I am asked to see him by the director of nursing due to an altercation between him and his roommate upon evaluation he has multiple cuts on the top of his head and an apparent defensive wound on his left forearm .He is on blood thinner and his scalp wounds are closed and appear to be healing already .He has in the past stated that he likes to pick on his roommate but today states that he was meaning that he likes to joke with him .Multiple small lacerations on his scalp and one on the left forearm .Reports HA (headache) ongoing refused skull x-ray . On 2/11/21 at 9:11 AM, an interview was conducted with Administrator 2 who reported the Administrator (also the Abuse Coordinator) that conducted the investigation between R901 and R910 would not be returning to the facility for the remainder of the week and would attempt to answer any questions. When asked about any precipitating factors such as previous arguments, Administrator 2 reported she had been transferred to this facility on August 17th, 2020 and had not been aware of any other incidents since being at the facility. On 2/11/20 at approximately 11:00 AM, an interview was conducted with the Director of Nursing (DON). Upon review of the incident between R901 and R910 on 12/29/20, the DON was asked to review a portion of the investigation documentation on the incident report which prompted staff as part of the investigation to identify Any precipitating event in which Nurse 'EE' documented, residents have not gotten along for a period of time . The DON reported he was unaware that was documented and was unable to offer any further explanation. Resident #909 and Resident #904: On 2/10/21 a facility reported incident submitted to the Stage Agency involving R#909 and R#904 was reviewed that indicated R#909 hit R#904 with their walker. On 2/9/21 the medical record for R#909 was reviewed and revealed the following: R#909 was initially admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of R#909's Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/1/20 revealed R#909 had a brief interview of mental status (BIMS) score which indicated severely impaired cognition. A nursing progress note dated 12/29/20 at 5:00 PM revealed the following: Writer observed resident sitting in dining area, peer (R#904) across table said hello. Resident stood and charged peer (R#904) with RW (rolling walker). Began yelling. Immediately separated walked with resident to room, said she would like to sit in there. Shortly after another nurse came to writer stating she hit peer (R#904) and the nurse with RW (rolling walker). Resident asked to talk to my boss about going home. While talking to administrator she swung her fist toward her and pushed into her with RW. Threatening. Yelling . A nursing progress note dated 12/29/20 at 4:18 PM revealed the following: Behavior Displayed: Resident walking down the hall toward this writer, asked if she was feeling ok, and resident stated no, I want out of this whore house. Attempted redirection. Resident proceeded to ram this writer with a 4WW (four wheeled walker) in the doorway of a tulip hall room. Resident turned to follow maintenance crew moving down the hall. Resident states He hit me! maintenance staff was not moving at the time of accusation, and had both hands on the cart he was pushing. monitored resident from a distance as she entered her room and came back to North hallway. Resident approached a resident standing in her own room's doorway (R#904) and proceeded to ram her several times with walker. stepped in between residents encouraging the other resident to go to the dining room to give this resident some space. This resident laughing and saying I know she's scared. I want her to be scared as she attempted to ram the other resident several more times . A behavior note dated 12/31/20 revealed the following: .Behavior displayed: yelling, combative, ramming walker into people History of behaviors: resident has history of cycling behaviors . A petition for mental health treatment signed by Nurse BB on 12/29/20 revealed the following: .4.The conclusions stated above are based on: A. my personal observation of the person doing the following acts and saying the following things: Willfully and intentionally hurting staff and other residents by ramming them with her walker. A review of R#909's care plan revealed the following: BEHAVIOR: Resident has history of refusing medications. Resident perceives to be confused of why she is at (name of facility) and will say, I'm not sure how long I'll be staying here. Delusions, angry with daughter for being here, hx (history) of accusing daughter of stealing her money. Resident will say that people are stealing her things .Resident has hx of exhibiting increased anxiety and paranoia when people talk with her about her daughter. Resident will cycle with behaviors for a few days at a time. Multiple attempts are encouraged to ease anxiety, but resident continues to focus on her anger directed at her daughter. Resident will go into multiple offices/departments and vent frustrations and inquire why she is here. Per daughter, resident has history of hoarding things, such as, food, pop and snacks from the dining rooms. Resident will pace the hall when agitated . On 2/10/21 the medical record for R#904 was reviewed and revealed the following: R#904 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A progress note dated 12/29/20 revealed the following: Late Entry: Note Text: SW (social worker) met with resident on today's date. Resident was involved in a resident to resident on today's date. Another resident came into resident's room, uninvited, and shoved her walker into resident. This happened twice within a short time period. Resident was not injured, just upset . On 2/11/21 at approximately 10:20 a.m., Nurse AA was queried regarding the resident to resident altercation between R#909 and R#904 on 12/29/20. Nurse AA indicated the facility has not had enough staff to appropriately monitor R#909's behaviors as well as the other residents that have behaviors in the same hallway as R#909. Nurse AA indicated they had to split the hallway with another nurse and were down a nurse on the day R#909 hit R#904 and they could not keep watching R#909. Nurse AA indicated that R#909 cycles with their mood and that that when they become agitated they need additional staff to watch them. Nurse AA was queried if the facility had sufficient staffing to appropriately supervise the residents with behaviors and thy indicated they did not. On 2/11/21 at approximately 2:33 p.m., Nurse BB was queried regarding the facility supervision and altercation that occurred with R#904 and R#909 on 12/29/20 and Nurse BB indicated they witnessed R#909 come out of their room and go down the hallway and ram R#904 with their walker multiple times. Nurse BB indicated the facility did not have enough staff to supervise R#909. Review of the facility's Abuse, Neglect and Exploitation policy dated 01/01/2021 documented, in part: .'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .'Willful' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .Prevention of Abuse .Identifying, correcting, and intervening in situations in which abuse .is more likely to occur .

Based on observation, interview, and record review, the facility failed to follow the Center for Disease Control (CDC) protocol for COVID-19 including: encouraging social distancing and mask use for residents, and following current infection control principles/CDC protocol regarding the following: environmental cleaning, appropriate personal protective equipment (PPE) use, availability of sanitizing supplies, appropriate areas for doffing PPE used on the COVID-19 designated unit, ensure staff knowledge of isolation equipment (plastic partitions), isolate residents after exposure to COVID-19 (R#'s 927 and 928), ensure staff were educated on the facility's COVID-19 outbreak, proper placement of garbage cans in transmission based precaution rooms, increased respiratory monitoring for one COVID-19 positive resident (R912), and appropriate room assignments and cohorting (R#'s 925 and 926) resulting in Immediate jeopardy (IJ). This deficient practice caused the spread of COVID-19, the need to transfer residents to acute care settings, and the likelihood for serious harm, injury, and or death. The IJ began on 1/6/21, it was identified by the survey team on 1/13/21 and the facility was notified on 1/13/21 at approximately 2:35 PM. On 1/14/2021, the facility Plan of Removal was accepted by the State Agency. A completed verification to ensure the Immediate Jeopardy was removed was conducted on 1/14/2021, however the facility remained out of compliance at a scope of pattern and severity of potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance that has not yet been verified by the State Agency. On 1/5/21 at approximately 8:45 AM, the facility reported they had no positive resident COVID-19 cases. It was reported the Daisy unit (Rooms 200-215) was their designated unit for re-admissions, new admissions, and other residents who may require a 14-day observation period for signs and symptoms of COVID-19. On 1/5/21 at 5:54 PM, an e-mail from the facility's Director of Nursing (DON) was received. The e-mail indicated the facility had completed their scheduled COVID-19 testing and seven residents tested positive for COVID-19 after the completion of their testing. On 1/6/2021 at approximately 9:00 AM, the Facility provided a list of seven residents, along with their room numbers, who were COVID-19 positive as of 1/5/21. Two of the residents resided in private rooms on the Daisy unit (the 14-day observation unit), and five resided on the Lily unit (Rooms 220-237), two resided in room [ROOM NUMBER], two in room [ROOM NUMBER] and one in room [ROOM NUMBER]. The Facility informed the Surveyors that six out of seven residents were transferred to different rooms on the Rose unit (Rooms 240-257), and a COVID-19 unit was established. On 1/6/21 at approximately 9:26 AM, the dining room in the facility's locked unit (were a significant number of cognitively impaired residents resided) was observed to have one table with three residents seated closer than six feet of each other without wearing any facial coverings. A second table in the dining room was observed to have three more residents seated within six feet from one another and without any facial coverings. Two tables in the dining room were observed to have no residents seated at them. No staff members were observed attempting to safely separate the residents; nor were any of the staff encouraging or attempting to encourage residents to wear facial coverings. A sign in the dining room was observed to indicate residents should be kept at least six feet away from one another. On 1/6/21 at approximately 9:15 AM an observation on the Lily unit was conducted. There was no indication on the double doors entering into the unit regarding what, if any PPE (personal protective equipment) should be worn. The doors to room [ROOM NUMBER], 227, and 229 were slightly ajar. No residents resided in these rooms as the residents from those room that tested positive for COVID-19 were transferred to the Rose unit and/or hospital. Housekeeper I was observed entering into room [ROOM NUMBER] wearing a surgical mask, eye protection and gloves. Upon entry the door was left open and several items, including PPE, food and wrappers, were observed on various surfaces in the room. Housekeeper I was observed filling a clear trash bag with the garbage observed in the room including PPE. Housekeeper I exited the room with the single bag of trash, left the door ajar, walked down the hall and placed the garbage bag into another bag that was attached to a housekeeping cart located in the hallway. Housekeeper I then traveled down the hall from where the cart was placed and entered into room [ROOM NUMBER]. It was noted that Housekeeper I was still wearing the same surgical mask that was observed upon entry into the previous room. Housekeeper I was observed picking up trash, including PPE from the room, placed it in a single clear bag, exited the room leaving the door ajar, again taking the clear bag of garbage out of the room and placing it in the same bag that was attached to the cart. Housekeeper I then was asked by a staff member to assist in room [ROOM NUMBER]. room [ROOM NUMBER] was occupied by two residents. Housekeeper I assisted the staff person, left the room, returned to the housekeeping cart, with the bag of garbage attached and left the unit with the housekeeping cart. A phone conversation with Housekeeping Supervisor (HS) J was conducted on 1/7/21 at approximately 9:20 AM. HS J was queried as to how resident rooms for those diagnosed with [REDACTED]. HS J reported that housekeeping staff were to wear N95 Masks, shields and gowns when entering the rooms and upon exit the staff were to dispose of all PPE, trash and rags in a double bag and then immediately take the bags to the soiled utility room. On 1/6/21 at 10:00 AM, an interview with the facility's DON was conducted regarding the facility's unit layout as it related to COVID-19. The DON explained the Daisy unit (Rooms 200-215) continued to be used as their 14-day COVID-19 observation unit, and on 1/5/20 the Rose unit (Rooms 240-257) had been converted over to a unit for COVID-19 positive residents. At that time, The DON was asked about PPE usage on the units and indicated that on the Daisy unit an N95 mask and face shield were required in the hallway, and when entering a resident room, individuals should don an isolation gown and gloves. He further explained on the Rose unit an N95 mask, face shield, and isolation gown were worn in the hallway and gloves were to be donned upon entering resident rooms and doffed upon exiting the room. On 1/6/21 at 10:20 AM, an observation of the Daisy unit (14-day observation unit) was conducted. At 10:25 AM, Registered Nurse (RN) 'B' was observed to enter room [ROOM NUMBER]. RN 'B' had on an N95 mask, face shield, and isolation gown. RN 'B' was not observed to don gloves upon entering the room. At 10:28 AM, after exiting the room; RN 'B' was queried about the use of gloves in an isolation room and said they only had to put gloves on if they were touching the resident. On 1/6/21 at approximately 10:30 AM, an interview with the Certified Nursing Aide (CNA) 'C' was conducted. CNA 'C' was asked about their assignment and said they were assigned to work on the Daisy unit, and they were also going over the Rose unit (COVID-19 positive unit) to assist the CNA over there. When preparing to exit the unit, no wipes for cleaning equipment could be located on the hall. CNA 'C' and RN 'B' were asked about where cleansing wipes were stored. CNA 'C' and RN 'B' checked the carts in the hallway, the medication cart, and the vestibule area. They were not able to locate any cleaning wipes. RN 'B' left the unit to retrieve some wipes and CNA 'C' said there were wipes on the unit earlier in the morning but thought a staff member from another unit came and took them. On 1/6/21 at approximately 10:30 AM, an observation was made of the Poppy unit. Prior to entry, residents were observed in the open area near the television. None of the residents were wearing masks. Upon entry to the Poppy unit, additional residents were observed, some had on masks, others did not. Nurse P was observed wearing a surgical mask that did not cover her nose. On 1/6/21 at approximately 11:30 AM, Nurse P was again observed not wearing a surgical mask that covered her nose. Nurse P was asked as to the protocol regarding PPE in the facility. Nurse P reported personal issues intervened with wearing the mask properly and covering their nose. On 1/6/21 at 10:55 AM, a cart of PPE was observed outside of the double doors leading into the Rose unit, the COVID-19 positive unit. It was also noted a large round trash can was observed next to the clean PPE cart. An observation down the Rose unit hallway was conducted through the window of the closed double doors. At that time, Activity Staff 'D' and Social Worker 'E' were observed in the hallway of the unit. It was observed neither staff member's gown was securely tied around the waist and the gowns were flapping as they walked down the hallway. The staff were observed to enter and exit resident rooms on the hallway. At approximately 11:05 AM, Activity Staff 'D' and Social Worker 'E' exited the double doors from the unit, doffed their isolation PPE that had been worn on COVID-19 unit and disposed of it in the large trash can next to the clean PPE cart. On 1/6/21 at approximately 11:10 AM, an observation on the Rose unit was conducted. It was noted the first door on the left inside the unit's double doors was a soiled utility room. During the observation of the unit, Maintenance Staff 'F' was observed in the hallway. Maintenance Staff 'F' was observed to be entering and exiting several rooms (occupied and unoccupied) with a toilet plunger in their hands. Staff member 'F' was noted to be wearing an N95 mask, face shield, isolation gown, and gloves. Staff member 'F' was not observed to be changing their gloves or performing hand hygiene between entry and exit of the various rooms. At approximately 11:20 AM, Staff member 'F' was asked about what was going on in the unit and they indicated there were some plumbing issues, so they were going into every room and flushing the toilets. During the observation of the Rose unit on 1/6/21, a portable, clear, plastic partition device was observed to be cordoning off the last couple rooms and an access hall to the medication room, nursing station, and hallway to the main lobby. RN 'G' (the nurse assigned to the Rose unit) was queried about why the partition was in place and they indicated they did not know why it was there. At approximately 11:25 AM, RN 'G' was observed preparing to enter a resident room on the unit. RN 'G' had on an N95 mask, a face shield, and a disposable isolation gown. RN 'G' was observed to don a second disposable isolation gown prior to entering the resident ' s room. When RN 'G' exited the room, they were queried about donning a second gown and they said it was just what they did, and they weren't sure. RN 'G' was asked about what kind of education they received on PPE use on the COVID-19 positive unit and RN 'G' stated, This just happened (the COVID-19 outbreak), I don't know it changes daily. On 1/6/21 at approximately 4:00 PM, a review of a facility provided document that listed the facility's residents who tested positive for COVID-19 was reviewed and revealed R927 tested positive for COVID-19 and had been transferred to the hospital for COVID-19 symptoms earlier in the day on 1/6/21. A review of the facility census indicated R927 resided on the Lily unit (Rooms 220-237) and had a roommate (R928) at the time of their positive diagnosis. On 1/6/21 at 4:25 PM, R928 was observed in their room, sitting on their bed. There was no evidence (signs, isolation cart, or PPE) R928 had been placed in transmission-based precautions, despite their exposure to their roommate (R927) who tested positive for COVID-19 earlier in the day on 1/6/20. On 1/6/21 at approximately 4:25 PM, an observation was made on the Lily unit. Again, the doors to rooms 223, 227 and 229 were observed ajar. All other rooms on the unit were observed with doors open. Residents were seen in the hallways, some were wearing masks, others were not. One resident expressed feelings of nausea. There were no staff observed on the unit. At approximately 4:38 PM, CNA K was observed on the hall wearing a surgical mask and eye protection. CNA K reported that they were the only CNA assigned to the hall as the other CNA assigned had tested positive for COVID-19. When queried as to whether CNA K had received any training pertaining to the new outbreak of COVID-19 and was advised that at least five residents who formally resided on Lily had tested positive, CNA K reported that he had not received any training/education following the outbreak. When queried as to the location of the Nurse assigned to the unit, CNA K reported that they believed the nurse was trying to locate medication. On 1/6/21 at 5:05 PM, an interview with the facility's DON was conducted regarding R927 and R928. The DON said R928 was cognitively intact and had been made aware of his roommate's positive COVID-19 diagnosis. The DON continued to explain R928 was asymptomatic, was being monitored for signs and symptoms, and had agreed to stay in their room in quarantine. The DON was asked about implementing transmission-based precautions and indicated they did not put R928 on transmission-based precautions. On 1/7/21 at 8:45 AM, the DON said the facility had decided to put the entire Lily unit on transmission-based precautions. On 1/7/21 at approximately 9:00 AM, a tour of the Lily unit was conducted, and it was observed the entire unit had been placed on transmission-based precautions. On 1/7/21 at approximately 12:00 PM, a review of the facility's updated resident positive COVID-19 list was conducted, and one additional resident who resided on the Daisy unit (the 14-day observation unit) had tested positive. On 1/12/21 at approximately 9:00 AM, a review of the facility's updated resident positive COVID-19 list was conducted and revealed that on 1/9/21, 14 additional residents who resided on the Lily unit tested positive for [MEDICAL CONDITION]. R928, (who was not placed on transmission-based precautions after their exposure to R927 on 1/6/21) was among the residents who tested positive. On 1/12/21 at 10:20 AM, an observation of the Lily unit was conducted. It was observed that at the end of the hall, a temporary, translucent, plastic, zippered wall was cordoning off the last few rooms. At that time, an interview with RN 'R' was conducted regarding the zipper wall divider, and its purpose. RN 'R' did not know the purpose of the temporary wall. On 1/12/21 at 1:50 PM, an interview was conducted with R912 in their room on the Lily unit. R912 was in transmission-based precautions for testing positive for COVID-19 on 1/9/21. In preparing to exit the isolation room, it was observed the garbage can was at the foot of R912's bed, bed #2, furthest from the door towards the window, approximately 15-20 feet away from the door. The garbage can was observed to have used PPE such as gowns and gloves contained in it. At that time, R912 asked, Shouldn't that garbage be closer to the door, not over here by me? On 1/12/21 at approximately 1:55 PM, other rooms on the Lily unit were observed from the hallway for placement of the trash cans used for disposal of PPE and the following was observed: no garbage can observed in room [ROOM NUMBER] or room [ROOM NUMBER], the garbage can in room [ROOM NUMBER] was over at the foot of bed #2, and the garbage can in room [ROOM NUMBER] (containing discarded PPE) was right at the bedside of bed #1. On 1/12/21 at 2:50 PM, an interview with the facility's DON was conducted. The DON was asked about the plastic partition on the Lily unit since RN 'R' did not know. The DON indicated the residents beyond the partition were COVID-19 negative on 1/9/20 but were considered exposed and were under a 14-day observation. The DON was also asked where in a transmission-based precaution room the garbage cans should be located for the disposal of used PPE when exiting a room. The DON indicated the trash bin should be near the door. On 1/13/21 at approximately 9:30 AM an interview was conducted with Nurse L. Nurse L was assigned on the North Unit. Nurse L reported concerns regarding staffing in the Facility. Nurse L was queried as to whether any COVID-19 residents resided on the unit, the Nurse indicated that Male R925 had been transferred from the Daisy Observation unit to the North Hall Unit and was placed in a private room but shared a bathroom with two female residents. R925 was attempting to utilize the shared bathroom and was transferred to the Mum unit on 1/12/21 and was sharing the room with R926. Nurse L reported that at no time on the North unit was R925 was on transmission-based precautions. On 1/13/21 at approximately 10:30 AM, a review of R925's clinical record was conducted and revealed they were admitted to the facility on [DATE] to the Daisy unit for a 14-day observation. R925's clinical record, Medication Administration Record, [REDACTED]. R925's orders were reviewed, and it was discovered R925 had a physician's orders [REDACTED]. Further review of the record included a note dated 1/12/21 that read, .resident tested COVID positive today .resident will be moving to an isolation unit. A review of R925's census information was conducted and revealed on 1/11/21 they were transferred from the Daisy unit (14-day observation unit) to the private room on the North unit, then on 1/12/21 was transferred to the room on the Mum unit with a roommate, R926. On 1/13/21 at approximately 10:40 AM, a review of R926's physician's orders [REDACTED]. An interview regarding R925 and R926 was conducted with the facility's DON on 1/13/20 at approximately 1:30 PM. The DON was queried about R925's COVID-19 status and why they had been moved from the Daisy unit (14-day observation unit) to two different rooms on the other side of the building (The North unit and the Mum unit). Additionally, the DON was queried why R925 had been placed in a room with R926 when R925 had orders for transmission-based precautions and R926's orders for transmission-based precautions were first placed on 1/13/20. The DON had no explanation for why R926 had been placed in the same room as R925. On 1/13/21 at approximately 10:30 AM, an interview was conducted with the Assistant Administrator regarding the names of the Infection Preventionists employed by the Facility. The Assistant Administrator reported that the facility currently had two (the DON and Nurse Q) acting as Infection Preventionists. It was reported that Nurse Q was not at the Facility at the time of the interview. On 1/13/21 at approximately 10:40 AM, a phone interview was conducted with Nurse/Infection Preventionist/Staff Development Q. Nurse Q was queried as to her role at the Facility and reported that she had completed her Infection Prevention training in November 2020 but was not able to work as a Preventionist/Staff Developer as the Facility was so short staffed. Nurse Q indicated that she never had a chance to utilize her skills as a Preventionist/Staff developer and had been working mainly on the units caring for residents in the Facility. A review of a facility provided policy titled, Infection Prevention and Control Program with a revision date of 8/20/20 was conducted and read, Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .

This citation pertains to Intakes #MI 087, MI 143, MI 727 and has two deficient practice statements. DPS #1 Based on interview and record review the facility failed to ensure interventions, including monitoring were in place to prevent falls for one (R#907) of two residents reviewed for falls, resulting in R#907 sustaining multiple falls, a hospital stay and a fractured right femur. Findings include: A Facility Reported Incident was reported to the State Agency that indicated a family member accused the facility of neglecting R907's care following a transfer from the memory care unit (South) to an observation unit (Daisy) following a hospitalization and failure to communicate changes to R907's daughter. Review of the Hospital records (date of service 10/20/20) documented, in part, that R#907, .Patient is alert and oriented x1 therefore details obtained from chart review. Patient presenting from (Facility name) secondary to unwitnessed fall and subsequent right [MEDICAL CONDITION]. Attempted to contact (Facility name) for additional details without success. Per chart review patient reportedly had 3 falls yesterday with the last one occurring at approximately 2330 .Right hip x-ray was completed and demonstrated fracture, so she was sent to emergency room for further treatment Per patients daughter patient has had multiple falls since returning to Medilodge on 10/14 . A review of R#907's clinical record documented that the resident was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R#907's Minimum Data Set (MDS) indicated that the resident was severely cognitively impaired and had a history of [REDACTED]. Continued review of the resident's record documented, in part, the following: 10/4/20: Resident observed attempting to sit on a chair and landing on her bottom on the floor . 10/8/20: Resident was hypertensive .departed on route to (name redacted) hospital . 10/14/20: Resident arrived to facility via EMS (emergency medical services) .attempting to enter other resident's rooms .will continue to monitor . It should be noted R#907 was admitted to the Daisy unit on 10/14/20. 10/15/20 (8:17 PM) (authored by Nurse S): Resident observed laying on floor of hallway near double doors .No injuries noted . 10/15/20 (8:22 PM) .Date of fall 10/15/20 .Interventions: BLANK . 10/19/20 (6:30 PM) (authored by Nurse S) .Resident observed falling on floor at the end of hall near exit door. Assisted resident to bed . 10/19/20 (7:00 PM) .Date of fall: 10/19/20 .Interventions: BLANK . 10/19/20 (8:08 PM) (authored by Nurse S) .Resident observed falling to floor after attempting to push CNA .Resident was complaining of some pain in right hip .physician stated to monitor resident for continued hip pain. If pain continue, physician stated to order x-ray. 10/19/20 (8:15 PM) .Date of Fall: 10/19/20 .Resident observed falling to floor after attempting to push CNA way .Resident stated her right hip was sore after she landed on it .Interventions: BLANK . 10/20/20 (2:07 AM) Observed resident on her knees next to her bed .C/O (complained of) right hip and needed 2A (two person assist to stand) .Interventions: Low bed . 10/20/20 (3:00 AM): Had 3 falls today . Further review of R#907's record documented: Pertinent Charting Initial- Falls: Date 10/18/2020 .Date of Fall .2. Is this a new event YES .Nurse came out of a patient room and observed the patient falling in the hallway patient did not hit her head .Injury .No new interventions, trying to anticipate needs as much as possible . Nursing notes pertaining to this fall were not noted. The Fall Risk assessment dated [DATE] indicated a Fall Risk score of 10.0 the Assessment increased to 15.0 following the fall noted 10/4/20 (above) and increased to 20.0 following fall noted 10/19/20. A request was for R#907's Incident and Accident (I/A) reports was made. A review of the I/A reports provided during the residents stay on the Daisy unit documented, in part the following: 10/15/20: R#907 .time of incident (8:00 PM) .Memory impaired .Decision making impaired .Was incident witnessed (NO) .Resident observed laying on floor at end of hallway next to hoyer lift .Results of Investigation: Continue current plan . 10/19/20: R#907 .time of incident: (11:52 PM) .Resident Memory impaired .Decision making impaired .physically impaired .Was incident witnessed (NO) CNA was doing round observed resident .next to bed .C/O right hip pain .3rd fall in 24 .no redness or injury noted .Results of Investigation: Will review on return for needs . *It should be noted that R#907's progress notes/ indicated that the resident had a fall on 10/18/20 and three falls (two on 10/19/20 and one on 10/20/20) as shown above only one I/A for the 10/19/20 fall was provided prior to the end of the survey. A review of the R#907's care plan documented the following: At risk for falls d/t dx DM, potential med, and cognitive deficits resulting in difficulty identifying safety risks and making safe choices (Date Initiated 1/21/2020- Revision on 1/21/20 .Interventions: Anticipate and meet the resident's needs based on nursing assessments (date initiated 1/21/20), Determine causative factors of fall and resolve or minimize (date initiated 1/21/20), Encourage resident to wear non-skid socks or non-skid shoes; note resident prefers to walk in bare feet and will become agitated with staff attempts to apply footwear (date initiated 7/9/20), Encourage rest periods as needed to avoid overtiring (date initiated 1/21/20), Monitor tiredness after dinner (date initiated 10/4/20), Physical .therapy to evaluate and treat as ordered or as needed (date initiated 1/21/20), Provide for activities of daily living .(date initiated 1/21/20), Refer to Physical Therapy/Occupational Therapy as indicated (date initiated 1/21/20), Remind the resident to do the following (walk slowly through crowded resident areas). Assist resident to toilet after all meals (7/7/20). It should be noted that the last intervention initiated into the resident's care plan was 10/4/20. Hospital record (date of service 10/8/20-10/13/20) documented, in part, the following: Patient was transferred to (Facility name) on 10/8/20 for hypoxic [MEDICAL CONDITION] as well as obstruction of left .stone Family has requested to speak with social work/case manager regarding logistics of patients discharge. Unfortunately, per protocol, it seems with every medical visit patient will require up to 14 days quarantine at her facility which will be further detrimental to her mental state and orientation. On 1/12/21 at approximately 12:30 PM a phone interview was conducted with Nurse S. Nurse S was queried as to R#907's care pertaining to her falls while on the Daisy unit. Nurse S indicated that she no longer was employed by the Facility but recalled the resident and noted that resident had formerly resided on the South memory hall and following hospitalization she was transferred to the Daisy unit. Nurse S reported that it was difficult to provide continuous care to the resident as the facility was very short staffed and often there was only one CNA on the unit to assist with care. When queried as to why interventions/I/A's were not completed for the falls occurring on the Daisy unit, Nurse S again reported that due to the lack of staff, it was difficult to complete the I/As and other documentation. On 1/13/21 at approximately 10:00 AM, an interview was conducted with the Assistant Administrator pertaining to R#907. When queried as to the Facility's policy regarding falls and fall intervention, she indicated that I/As should be completed after each falls and interventions should be put into the resident's care plan to prevent future falls. The Facility's Policy titled Fall Prevention Program (Date revised 10/20/20) was reviewed and documented in part, the following: Policy: Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls.5. Each resident's risk factors, and environmental hazards will be evaluated when developing the residents comprehensive plan of care. Interventions will be monitored for effectiveness .the plan of care will be revised as needed 6. When any resident experiences a fall, the facility will .c. complete an incident report .obtain witness statements in the case of injury .and personal and oral hygiene . Deficient practice #2 Based on observation, interview and record review the facility failed to ensure safe operation of resident equipment for one resident (R#906) of three residents reviewed for accidents/hazards, resulting in the potential for injury to occur. Findings include: On 1/7/2021 at approximately 2:53 p.m., R#906 was observed in the common area sitting in a Broda chair (tilt-in-space positioning chair) with R#906's feet resting in the footrest. On 1/5/2021 the medical record for R#906 was reviewed and revealed the following: R#906 was initially admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of R#906's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/22/20 revealed R#906 needed extensive assistance from facility staff with most of their activities of daily living. R#906's cognition was documented as severely impaired. A nurses skin note dated 12/24/2020 revealed the following: Location of skin area being documented: Right foot. Description: Large purple / red bruising to right great toe and across the top of foot. Interventions: Switched out (R#906) broad chair for one with footrest so that her feet are up off the floor. Comments: Another resident had been observed earlier pushing on (R#906) chair towards the table, when CNA (certified nursing assistant) was fixing (R#906) sock a bruise was observed on her right foot. An incident report dated 12/24/2020 was reviewed and revealed the following: Date of Incident: 12/24/2020 .Brief description: Writer had noted another resident push (R#906)'s chair towards table, CNA was fixing (R#906)'s sock and bruise (red/purple) was resent to top of R (right) food from great toe across the top of foot .Injury type: Hematoma/Bruise .Equipment: Broda with no footrest .Action taken: New chair with footrest. An investigation report dated 12/24/20 revealed the following: Results of investigation: Resident feet with new bruisings near toes, new Broda chair provided to protect feet . On 1/7/21 at approximately 2:37 p.m., during a conversation with the Director of Nursing (DON), the DON was queried regarding R#906's incident on 12/24/20. The DON indicated that R#906's footrest was missing from their chair. The DON was queried if R#906 should have had the footrest on their chair prior to being moved and they indicated that they should have. The DON indicated that they were aware of the bruise on the foot when it was found and that they had to get a new chair for R#906 with a footrest on it to protect their feet. The DON was queried regarding the incident report that indicated R#906 had been pushed in the chair by another resident on the unit and the DON indicated that R#906's unit has a lot of cognitively impaired residents. The DON was queried if other residents could be pushing R#906 and they indicated that they shouldn't. The DON was queried if they had been aware of R#906 not having the footrest attached to their chair and they indicated that they weren't until the incident of the bruise occurred. On 1/12/21 at approximately 2:53 p.m., Nurse A was queried regarding R#906's bruise on 12/24/20. Nurse A indicated that one of the aides had notified them that R#906 had a bruise on their foot. Nurse A further reported that they had been informed that another resident on the unit had been observed pushing R#906 in their Broda chair. Nurse A was queried if R#906 had the footrest on the chair to protect their feet and they indicated that they didn't. Nurse A was queried if R#906 should have had the footrest attached to the chair to protect their feet and they indicated that they should have. Nurse A reported that it was difficult to get equipment. Nurse A indicated that the DON had to be notified so a new chair could be found for R#906. Nurse A was queried regarding supervision on the unit and why another resident was pushing R#906 and they indicated that R#906's unit has many residents that have behaviors and that due to their short staffing they can't always watch them. Nurse A was queried if R#906's foot bruise could potentially have been avoided if R#906 had their footrest attached to their chair and staff had intervened when R#906 was observed being pushed by another resident and they indicated that it could have. A facility document titled Accidents and Supervision (10/30/2020) was reviewed and revealed the following: The resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. This includes l. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3.Implementing interventions to reduce hazard(s) and risk(s). 4.Monitoring for effectiveness and modifying interventions when necessity .

Based on interview and record review, the facility failed to administer two significant medications ([MEDICATION NAME] and Eliquis) to one resident (R1) after admission to the facility resulting in R1 being admitted to a local hospital and being diagnosed with [REDACTED]. Resident #1 (R1) was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. R1 was admitted from her home with documentation from the home care company who provided care to her in (YEAR). On 6/25/19 at 12;40 PM, a phone interview with the complainant revealed that the complainant had provided the admitting nurse with a current list of medications for R1. A record review of the medication list provided by the complainant noted that [MEDICATION NAME] ([MEDICATION NAME]) and Eliquis were on the medication list. [MEDICATION NAME] ([MEDICATION NAME]) is a heart medication used to treat high blood pressure, chest pain and [MEDICAL CONDITION] (a condition where the heart muscle does not contract totally leaving blood pooling in the heart chamber and causing that blood to clot). Eliquis is an anticoagulant used to reduce the risk of stroke and blood clots in people who have [MEDICAL CONDITION]. The home care facility faxed the facility a 58 page document which detailed R1's care in (YEAR). On page 4 of the document, a list of medications from a local physician was found. The list did not include [MEDICATION NAME] and Eliquis but the list was from (MONTH) (YEAR). Further in the packet of information was detailed information from the last home care visit dated 5/18/2019. On page 18 of 23, a question asked Is the client taking an anticoagulant? The response was Yes. On page 22 of 23, under the topic Goals Met, Item #2 states Patient/Caregiver demonstrates safe, appropriate initial use of medication. Further down the page was a list of medications including [MEDICATION NAME] ([MEDICATION NAME]) and Eliquis. On page 23 of 23, which listed [DIAGNOSES REDACTED]. On 6/27/19 at 9:05 AM, Nurse Practitioner (NP) J was interviewed. NP J stated she approved the admission orders [REDACTED]. NP J stated she did not see an order for [REDACTED]. NP J was asked what would happen if someone was on an anticoagulant for awhile and then did not get it for approximately 2 weeks and NP J stated that person would be at greater risk of stroke or [MEDICAL CONDITION]. NP J said she asked a nurse to check with R1's daughters and was not told R1 was to have [MEDICATION NAME] and Eliquis. When asked, NP J admitted she did not speak with the daughters directly. On 6/27/19 at 10:30 AM, former Unit Manager (UM) M was interviewed. UM N was asked who was responsible for reviewing any documentation related to a new resident. UM N said, the day after the admission, the clinical team comprised of the Director of Nursing, Assistant Director of Nursing and nurse managers meet to review the information provided from the hospital or other entity. The team does not skim through the form but review the document page by page. On 6/27/19 at 10:50 AM, an interview with Unit Manager (UM) N occurred. According to UM N, the staff saw the medication list on page 4 of the faxed document and thought that was a list of R1's current medications. UM N was shown the documentation on page 22 of 23 where both [MEDICATION NAME] and Eliquis were listed and UM N said he was very upset about the situation and stated he felt the (list) meds should have been located immediately on the initial pages and not buried in the middle of the document. On 6/27/19 at 11:30 AM Registered Nurse (RN) G was interviewed. When asked about the admission process she said she did an assessment and checked R1's vital signs and then review the information from the home health care company. She stated she saw a list of medications in the first few pages of the information packet and did not see any type of anticoagulant listed. On 6/27/19 at noon, a telephone interview was done with physician (MD) [NAME] who was assigned to R1's care. According to MD E, when a person is admitted to the facility, the admitting nurse would call him and review all the medications that the newly admitted resident took prior to the admission. When MD [NAME] was queried about R1's Eliquis order, MD [NAME] stated I would have ordered it because she had [MEDICAL CONDITION]. On 6/27/19 at 1:00 PM, a record review of the admission notes from a local hospital were reviewed. Under the title Final report the physician from the local hospital documented: CT scan of the head without contrast showed a moderate sized localized left posterior lateral cerebral (brain) acute/subacute transcortical ischemic infarction within the posterior partial division of the left MCA (middle cerebral artery). In reviewing her medication list from (name of facility), it appears that she is no longer on the Eliquis that she was discharged on in (MONTH) 2019. Under the title Impression and Plan, a physician documented the following: Left middle cerebral artery ischemic infarct, cardioembolic (blood clot from the heart) in etiology. Imaging suggests that this infarct was embolic in nature in etiology and likely due to [MEDICAL CONDITION]. She has not been on anticoagulation. Diagnosis: [REDACTED].

This citation pertains to MI 318, MI 373 and MI 718. Based on observation, interview and record review, the facility neglected to provide residents with the necessary treatment and in accordance with professional standards of practice for 4 of 6 residents reviewed (Residents #4, #2, #6 and #1), resulting in residents experiencing physical deterioration, needs not being met and hospitalization . Findings include: Resident (R) #4 Review of R4's Minimum Data Set (MDS), dated [DATE], revealed R4 was severely cognitively impaired, needed extensive assistance for transfers, toileting, and hygiene, was frequently incontinent of urine, and [DIAGNOSES REDACTED]. According to the Face Sheet, R4 had full code status. According to the Intake Information, dated [DATE], an anonymous complainant reported, (R4) was catheterized by staff, he began bleeding and was not treated in a timely manner. The resident was sent to the hospital where he died . In an interview/observation, on [DATE] at 3:30 PM, Resident #1 (R1) was lying in bed and reported an event with his previous roommate (R4) being catheterized. R1 stated he saw R4's bed linens and briefs lying on the floor and they were soaked with blood. R1 said R4 had moaned in pain throughout and during the night after he was catheterized. R1 also said the nurse aides refused to take R4 to the bathroom. Resident #1 reported he had complained for weeks to nursing staff about the terrible amonia smell of (R4's) urine . It was so bad, I couldn't stay in my room. Review of R4's Care Plan, dated [DATE], revealed, At risk for UTI (urinary tract infection) . Asess/document for s/sx (signs and symptoms) UTI: . blood tinged urine . no output . foul smelling urine . Review of R4's Medical Record revealed he had been treated with antibiotics for a urinary tract infection in February, (YEAR). Review of R4's Medical Record revealed no Nursing documentation about a strong urine smell, swollen testicles, not voiding, being catheterized, bleeding or being sent to the hospital. In an interview, on [DATE] at 4:20 PM, Nurse Aide (CNA) F reported an observation of gross hematuria (when a person can see blood in the urine with the naked eye) with R4. CNA F stated she was R4's regular second shift CNA. CNA F said R4 was both continent and incontinent of urine and she was assigned to him on [DATE] between 3:00 PM - 11:00 PM. CNA F said, A lot of blood started around 10:00 PM when the nurse (LPN D) took the catheter out. When I left at 11:00 PM, blood was flowing out of his penis and we couldn't get it to stop. (R4) said he was tired and weak. He couldn't get up. Urine wasn't coming into the foley (catheter), so (LPN D) pulled it out. The blood was pouring out of him. It clotted once, but when I went to change his brief, it started again . Urine smelled a little strong . CNA F said R4 was a quiet man who rarely spoke or complained. In an interview, on [DATE] at 12:00 PM, LPN (Licensed Practical Nurse) D reported she received an order at 2:30 PM on [DATE] for a foley catheter to be placed and she inserted the catheter just before dinner (around 4:30 PM) it went in perfectly. A little urine, just a few drops came back. LPN D said at around 10:00 PM, she removed the catheter because there had been no urine output. LPN D said when she removed the catheter, It was frank (bright red) blood . a lot. The brief was soaked with blood and the bed sheets . Complete bed change . I passed everything off to oncoming nurse (RNE). We took vitals and they were normal. LPN D was interviewed as to whether she notified the physician, the Director of Nursing, or the family and she stated, I don't remember why I didn't call the doctor. I did not call the family. I did not call the DON. LPN D estimated the blood loss to be approximately a couple hundred cc's of blood with clots in it. LPN D stated she knew R4 had full code status but wasn't alarmed about the blood because, He had [MEDICAL CONDITION], it had been irritated from the catheterization, and he had a TURP (surgical procedure) recently. Review of a Consultation, dated [DATE], regarding R4 revealed a bladder procedure was attempted, cysto (cystoscopy - examination of the bladder) attempted, severe phimosis (tightening), not possible. And Hospital Discharge Instructions, dated [DATE], revealed an attempted TURP (failed procedure to correct the urinary system). Attempts to contact the CNA L assigned to R4 on the midnight shift [DATE]- [DATE] on [DATE] at 10:29 AM were unsuccessful; a message was left to return the call but no call was returned. In an interview, on [DATE] at 9:12 AM, RN/Registered Nurse E reported she was the midnight nurse for R4 on [DATE]- [DATE]. RN E said, I think (LPN D) said they had an order for [REDACTED]. I think she said she got a little blood when she pulled it out. Thought it was irritation. He slept most of the night. No issues with him. No vital signs during the night until issues started. Just before shift change the aide was getting him dressed an cleaned up for the day shift. The Aide (CNA L) came to me; she had changed (R4) and noticed a little blood in the diaper and his scrotum was swollen when they set him up in the chair. I came in and assessed (R4), got vitals, got him back into bed. We tried to notify the physician, left a message for his son. His (R4's) blood pressure was low, he was lethargic, complaints of scrotum being tender to the touch. It looked bruised and the size of a large orange. (R4) obviously needed to be looked at. No issues during report from (LPN D). She didn't say he had any problem passing urine during the day. (LPN D) didn't know why there was an order for [REDACTED]. Pale. When interviewed as to why she had not documented her findings, she said, Because it was shift change. Review of R4's Medical Record revealed there were no vital signs documented on 2nd or 3rd shift on [DATE] or [DATE]; the last vital signs were taken by 1st shift CNA Q prior to the insertion of the catheter: [DATE] 15:41 (3:41 PM) 140 / 80 mmHg [DATE] 15:41 (3:41 PM) 64 beats per minute Regular (temperature, respiratory rate, and Oxygen saturation were not taken) In an interview, on [DATE] at 2:27 PM, CNA V reported she was R4's Aide was assigned to R4 ,[DATE] times a week and was assigned to R4 on the day shift on [DATE]. CNA V reported R4's scrotum was abnormally swollen that day. CNA V said, (R4's scrotum) was red, very large, larger than a softball, huge, it was a change from normal and he had no (urine) output for 2 days. I reported it numerous times to (Weekend Manager Nurse W). (Nurse W) did nothing, (Nurse W) didn't look at (R4's scrotum) or have me get vital signs. (R4) needed to go in (to the hospital) because they couldn't get urine out. In an interview, on [DATE] at 2:35 PM, RN (Registered Nurse) K reported she Walked onto the hall at 6:30 AM (on [DATE]) and there was a CNA (L), the midnight Aide, in there cleaning (R4) up; she showed me wash clothes that had been placed on (R4's ) penis and scrotum soaked in blood. (CNA L) said the bleeding had slowed down; said it had been bleeding throughout the night. I got vital signs and made phone calls to get him transferred to the hospital. (R4) was lethargic. According to the SBAR (Situation, Background, Assessment, Recommendation) form, dated [DATE] at 6:30 PM (later in the day), RN K documented, Notified of frank red blood coming form penis by CNAS when arrived on floor at approx. 0630 (AM), res (R4) lethargic. o2 (oxygen) sat (saturation) 80 (%) on RA (room air). Res (R4) placed on 5L (liters) per NC (nose), oxygen sat 86%. On call service called x2, on call (Physician R) did not return call. Called (Responsible Party S) and gave ok to sent res to (hospital). EMS (ambulance) called and left facility with res (R4) at approx. 0855 (AM). R4's BP (blood pressure) was ,[DATE], Pulse, 50, Respiration - 20, temp 98.2, Oxygen saturation was 80% on room air with decreased consciousness, labored breathing, and blood in urine (at 7:20 AM on [DATE]) and (R4) left the facility at approximately 8:55 AM. (sic) In an interview, on [DATE] at 2:44 PM, Nurse Practitioner (NP) J stated LPN D was interviewed as to whether she had been informed that R4 had had recent procedures and she indicated she was not sure if she was aware. NP J said LPN D should first have used nursing judgement and called the physician on call when she inserted the foley at 4:30 PM and got no urine return. NP J said, That's a problem right there. NP J said she ordered the foley be placed because of [MEDICAL CONDITION] and swollen testicles (which NP J said could be caused by urine back-up), and if no urine returned, the physician on call should have been contacted regarding what to do. NP J also said, a physician should have been contacted rather than pull the foley catheter out and about the bleeding also. NP J said, There is a physician available at all times, 24 hours a day, 7 days a week. According to MedicineNet, [DATE], Testicular swelling . can arise from several different causes, some of which constitute a medical emergency . Inflammation of the testicle . due to any cause can also lead to testicular swelling . Testicular torsion (twisiting) is a medical emergency . Other causes include . infections . (https://www.medicinenet.com> According to the Hospital Final Report, dated [DATE], . the patient (R4) was brought to ED (Emergency Department). Here, it was noted that he had marked abnormal labs . White count of 20.7 (indicating infection) .Urinalysis was grossly bloody . was noted to be afebrile and eventually hypotensive at ,[DATE] . Date and Time of Death: [DATE] 1:50 PM. Resident #2 Review of R2's Minimum Data Set, dated dated [DATE], revealed she had resided in the facility since [DATE], scored 7 out of 10 on the Brief Interview for Mental Status, indicating she was severely cognitively impaired, and had [DIAGNOSES REDACTED]. Review of R2's Face Sheet, dated [DATE], revealed R2 had Full Code status. According to Intake Information, dated [DATE], Complainant (O) states that . (R2) suffers from [DIAGNOSES REDACTED], which prevents her from producing Cortisone (steroid hormone). As a result, the resident requires a daily dose of Cortisone. (R2) has a standing order that indicates she can be administered a 100 unit injection of steroids at the request of family or a nurse as needed. On [DATE], the complainant (O) states that she noticed (R2) appeared to be very lethargic and non-responsive. She requested the nursing staff to administer the 100 unit steroid injection. On [DATE], the complainant's brother (R2's son P) received a call from the facility telling him that (R2) was refusing to get out of bed or eat. They informed him that they were going to do some blood draws and wanted to make sure (R2's) DNR (Do Not Resuscitate) paperwork was in order. The complainant (O) states that they determined at this time that the 100 units of Steroids were never administered. On [DATE], the complainant (O) states that the Steroid injection had still not been administered as requested . asked to speak with a nurse and refused to hang up the phone until after the injection was given. On [DATE], (R2) was still not completely better so the complainant (O) asked the (NHA A) about her daily steroid dose administration . (NHA A) contacted the doctor who confirmed that this order is supposed to be in the resident's chart and should be administered every day. At 4 PM on [DATE], the doctor immediately ordered another steroid injection and instructed staff to start the daily dose of steroids again . The facility staff told the complainant (O) that (the medication) would be delivered within a couple of hours . it still had not arrived by (10:00 am) on [DATE] so the family had the resident sent (to the hospital) via ambulance. (R2) was very lethargic, non-responsive, catatonic and could not be aroused. The complainant (O) states that the order for daily steroids should never have been removed from (R2's) chart . should not have had to call 3 times to have the standing order of steroid injection administered . the doctor does not share (R2's) medication changes with the family and if someone would have contacted them to let them know the daily steroids were being discontinued, they would have stopped this change before it required hospitalization . [DIAGNOSES REDACTED] is a rare disorder in which your pituitary gland either fails to produce one or more of its hormones or doesn't produce enough of them. Hormone replacement medications may include corticosteroids. According to Mayo Clinic, (MONTH) 28, (YEAR), If you abruptly stop taking [MEDICATION NAME] or taper off too quickly, you might experience [MEDICATION NAME] withdrawal symptoms: · Severe fatigue · Weakness · Body aches · Joint pain · Nausea · Loss of appetite · Lightheadedness [MEDICATION NAME] is similar to [MEDICATION NAME], a hormone naturally made by your adrenal glands. If you take [MEDICATION NAME] for more than a few weeks, your adrenal glands decrease [MEDICATION NAME] production. A gradual reduction in [MEDICATION NAME] dosage gives your adrenal glands time to resume their normal function. The amount of time it takes to taper off [MEDICATION NAME] depends on the disease being treated, the dose and duration of use, and other medical considerations. A full recovery can take anywhere from a week to several months. Contact your doctor if you experience [MEDICATION NAME] withdrawal symptoms as you are tapering off the drug. <https://www.mayoclinic.org/[MEDICATION NAME]-withdrawal/expert-answers/faq- 923> Review of R2's Care Plan, dated [DATE], revealed, At risk for return to hospital . Reduce the risk of return to hospital through hospital related disease process and symptom management . Medications as ordered . Observe for changes in (R2's) mental status and/or behavior . Review of a Nursing Progress Note, dated [DATE] at 2:14 PM revealed, (R2) lethargic this shift and slept most of shift. had small amount for dinner. fluids encouraged . NP notified per day shift about lethargy and urine output . Review of a Nursing Progress Note, dated [DATE] at 9:10 PM revealed, (R2) lethargic this shift . Review of a Nursing Progress Note, dated [DATE], revealed, (R2) noted to (be) lethargic this shift. Decreased appetite and decreased fluid intake noted. (R2) having difficulty using straw with assistance . Son (P) notified of resident lethargy [DATE] . Note placed in physician log regarding appetite decline and fluid intake decline. Review of R2's Medical Record revealed R2 received [MEDICATION NAME] 10 mg every day for at least 2 years ([DATE] - [DATE]). Review of R2's Medication Administration Records (MARs), revealed R2's [MEDICATION NAME] had been tapered. R2 received: [MEDICATION NAME] 5 mg on [DATE] - [DATE], [MEDICATION NAME] 3 mg on [DATE] - [DATE], [MEDICATION NAME] 2 mg on [DATE] - [DATE], [MEDICATION NAME] 1 mg on [DATE] - [DATE] and No [MEDICATION NAME] tablets between [DATE] - [DATE]. Review of Nursing Progress Notes and physician progress notes [REDACTED]. According to R2's MAR, the injectable Cortisone [MEDICATION NAME] Sodium [MEDICATION NAME] 100 mg was to be given as needed before resident is sent out to the hospital related to adverse effects of her [DIAGNOSES REDACTED]. Further review of R2's MARs revealed, the injectable Cortisone was not administered on [DATE] (as requested by family); it was only administered once in (MONTH) (YEAR) (on [DATE] at 4:37 PM) and it was not administered on [DATE], [DATE] or [DATE]. In an interview, on [DATE] at 11:30 AM, Nurse Practitioner (NP) I reported, A nurse approached me and said it (the steroid) was started at the hospital and could we taper it. So, I wrote an order to have it tapered. I don't remember the nurse. When interviewed as to whether anyone had brought it to her attention that R2 had been taking 10 mg of [MEDICATION NAME] for years due to a medical condition, initially, NP I said No. When further interviewed about R2's condition, NP I reported the Medical Director (MD) M had spoken to her. NP I said, We (MD M and NP I) did have a conversation about (R2) last week. (MD M) told me (R2) needed to stay on her steroid for her condition. He said, the next time, I should look things over, don't just take the nurses' word for it. In an interview, on [DATE] at 1:26 PM, Director of Nursing (DON) B reported there was no Medication Error Reports regarding R2's [MEDICATION NAME] and said she was not sure why it was tapered. On [DATE] at 12:46 PM, DON B stated she was not aware there was no injectable steroid available for R2 when the family requested it and there had been no investigation regarding that. In an interview, on [DATE] at 1:05 PM, Medical Director (MD) M was interviewed about the taper of R2's [MEDICATION NAME]. MD M conveyed that the Nurse Practitioner I may have missed why the resident was on [MEDICATION NAME]. MD M stated, It's kind of unique to have her condition and to be on a daily dose of [MEDICATION NAME]. In an interview, on [DATE] at 1:50 PM, DON B was asked if the omission of the medication was investigated. DON B stated, How is it that a med(ication) error that they didn't give the injectable (to R2)? In an interview, on [DATE] at 2:35 PM, Administrator A said she spoke with R2's Daughter (O) the beginning of (MONTH) about a medication concern and I told her to set up another meeting to discuss. In an interview, on [DATE] at 2:45 PM, Unit Manager G reported she spoke with daughter O and did the follow-up with her complaint about R2's [MEDICATION NAME]. UM G said, I spoke with (MD M) . He (MD M) was very much surprised (R2) wasn't on it ([MEDICATION NAME]) and ordered for her to have the injection (of cortisone) for 4 days . In an interview, on [DATE] at 3:25 PM, Registered Nurse (RN) T reported, (R2's) family wanted (R2) to have a cortisone injection; she had one the day before. I didn't have any . the pharmacy was supposed to drop ship. I sent a fax and called them but there was a conflict with the order. I said I needed it now . In an interview, on [DATE] at 9:54 AM, RN U reported, I gave the IM (in the muscle) injection of the steroid to (R2) (on [DATE] at 4:37 PM). (R2) was lethargic, not responding. (R2's) son (P) was there and told me what was going on (regarding the need for the injection). It (the injection) didn't work . I went through the orders and there was no order to taper it from her last hospitalization discharge instructions. I called the doctor and he ordered an amonia level. According to a Complaint/Grievance Report, Administrator A documented on [DATE], she spoke with Daughter O via phone regarding, (R2) is supposed to be on a daily steroid . 10 mg [MEDICATION NAME] d/c (discontinued) [DATE]. Please investigate. The Report revealed UM G documented on [DATE], .started back on injections every day x 4 days and low dose [MEDICATION NAME] 10 mg q (every) day . Resident then taken to hosp (hospital) per family. Review of a Nursing Progress Note, dated [DATE] at 11:05 AM, revealed, Family called this writer at 10:15 am and wanted (R2) to be sent out to (hospital) for injection of steroids .left building at 10:45 (AM) . Review of Physician order [REDACTED]. According to the Hospital History and Physical for R2, dated [DATE] at 5:24 PM, .(R2) was difficult to arouse . but was eventually able to open her eyes and answer .The staff at her nursing facility gave her one dose of [MEDICATION NAME] 100 mg IM (injection) on Saturday, (MONTH) 30 (2018) . Given continued altered mental status, EMS (emergency medical) was called. EMS noted somnolence (drowsiness) and found the patient to be hyperglycemic (high blood sugar) . The record indicated that R2 was treated and returned to the facility the following day. Resident #6 Review of R6's Minimum Data Set, dated dated [DATE], revealed she was cognitively intact, and had [DIAGNOSES REDACTED]. In an interview/observation on [DATE] at 10:45 AM, R6 was sitting on her bed and reported she was having oral pain. R6 said she had gone to the dentist a few months ago, he had prescribed an antibiotic for an infection in her mouth. R6 said the facility physician never prescribed an antibiotic for her, and that is why she was having so much pain now. According to a Dental Consult for R6, dated [DATE], . infection on #25 (tooth). Satff (sic) Physician to prescribe antibiotic, due to patient allergies [REDACTED]. Review of R6's medical record revealed no order for antibiotics related to the above Dental visit and no documentation from R6's facility Physician M about antibiotic therapy for the infection. An Oral Surgery Report, dated [DATE], revealed R6's was seen for Extraction and 11 teeth were circled, including tooth #25. In an interview with Director of Nursing (DON B and Assistant Director of Nursing (ADON) N, on [DATE] at 12:00 PM, DON B stated she assumed Physician M did not see in the Consultation that R6 had an infection and that Physician M was to prescribe an antibiotic because no antibiotic had been ordered. Resident #1 According to the MDS and Face Sheet, dated [DATE], R1 was cognitively intact with a Brief Interview of Mental Status score of 15 out of 15, and had [DIAGNOSES REDACTED]. According to Intake Information, dated [DATE], (R1) states he felt the symptoms [MEDICAL CONDITION] (antibiotic resistant bacteria) were coming back. The facility left (R1) in bed for 30 days in pain and crying all night until he demanded to be taken to the hospital . In an interview/observation, on [DATE] at 3:30 PM, Resident #1 (R1) was lying in bed and reported he had strength in his legs and lost time in therapy due to the facility not taking his complaints of pain seriously, ignoring his concern [MEDICAL CONDITION] returning, and not detecting an infection in his right knee. R1 stated he had a fever and severe pain for a month and had been asking to go to the hospital but nothing was done until he insisted he be taken after crying in pain all night for a week. R1 stated he was sent to the hospital where they found he had an infection and he was there for weeks due [MEDICAL CONDITION] in his right knee. According to a physician progress notes [REDACTED]. According to a NP Progress Note, dated [DATE] at 7:28 PM, NP J documented, . seen for increased . pain . R (right) knee and ankle swelling . Will get CBC and BMP (complete blood count and basic metabolic profile labs) given fever yesterday and today . Review of Resident #1's Medical Record revealed no evidence nursing staff were monitoring R1's vital signs; there was only one documented temperature found in (MONTH) (YEAR) on [DATE] (102.5 degrees Fahrenheit) and only one documented temperature in March, (YEAR) on [DATE] (98.2 degrees Fahrenheit - normal). (According to a timeline of R1's pain, presented by Administrator A on [DATE] at 1:12 PM, R1's temperature (102.9) was documented on [DATE] also.) According to Nursing Progress Notes, dated [DATE] at 11:09 PM, writer called into (R1) room on am shift for uncontrolled pain to rt. (right) knee *ongoing pain (R1) recently had pain medication regime change *see mar (Medication Administration Record). (R1) stated changes are not sufficient and has been up all-night crying w (with) ,[DATE] (10 out of 10) pain every night this week. (R1) requested to be sent to (hospital for uncontrolled pain to rt. knee. Writer observed res. transported of unit via ems . approx. (approximately) (11:00 AM) . According to a Transfer Form, dated [DATE] at 10:09 AM, R1 was transferred to the hospital due to uncontrolled pain in his right knee. According to the Transfer Form, (R1) has extreme uncontrolled pain, new medication regime add(ed) w/in (within) the last 2 weeks . According to R1's Care Plan initiated after R1 returned from the hospital, dated [DATE], (R1) [MEDICAL CONDITION] . in right knee s/p (status [REDACTED]. According to Healthline.com, (MONTH) 25, (YEAR), Bacterial joint inflammation is a serious and painful infection in a joint. It's also known as bacterial or septic arthritis. Bacteria can get into your joint and cause rapid cartilage deterioration and bone damage. This can lead to significant pain, swelling, redness, and loss of movement. You can usually make a full recovery with early medical intervention. However, any delay of treatment could lead to permanent joint disability and even septic shock . General symptoms of bacterial joint inflammation . may include: elevated body temperature, pain in a joint, swelling and redness, warm skin over the joint . elevated heart rate . <https://www.healthline.com/health/bacterial-joint-inflammation> In an interview, on [DATE] at 10:54 AM, Director of Nursing (DON) B reported there were no blood (cultures) screens done at the facility for R1. When interviewed about the signs and symptoms of infection, DON B said, Yes, swelling and pain are signs and symptoms of infection . I don't know (why vital signs were not monitored). I would have.

This citation pertains to MI 269: Based on observation, interview, and record review the facility failed to thoroughly assess and monitor a resident for a change in condition following a fall for one (#505) of two residents reviewed for falls from a total sample of six, resulting in a resident being sent to the hospital for emergency treatment approximately 10 hours after sustaining a spinal fracture, a contusion of the brain, pain on movement, and loss of appetite. Findings include: On 4/11/17 at 11:00am Resident #505 was observed to be seated in a reclined position in a geriatric chair (a padded chair which has the ability to recline) in the hallway. At this time, Resident #505 was observed to be wearing a cervical collar. On 4/11/17 at 12:26pm review of Resident #505's clinical record was performed and revealed the resident had been admitted into the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Per review of the resident's admission minimum data set (MDS) assessment dated [DATE] the resident scored 11/15 on a brief interview for mental status exam, which indicated that the resident had moderate cognitive impairment. Per this MDS assessment the resident had a fall in the last month prior to admission, entry, or re-entry into the facility, and had sustained a fracture related to a fall in the last six months prior to admission. Review of an Incident/Accident (I/A) report dated 3/26/17 at 4:34am for Resident #505 revealed the resident had sustained an unwitnessed fall in the resident room. Per this I/A report it was documented that the resident was observed at foot of bed on floor-sitting. had abrasion L-forehead,nose, over R (right) eyebrow. Bruised area under R (right) eye. Pointed to heater set on 71 (degrees)- Communication poor-deaf. Board used.-I fell . Per the Injury Type section of the report it was documented that the resident had sustained a skin tear, hemotoma/bruise, and abrasion from the fall. Per the Treatment section of the form it was noted that boxes had been checked which indicated that the resident had received an assessment, neuro(logical) checks, and first aid (ice to forehead and cleaned abrasion). Per review of an Investigation Report, undated, which pertained to Resident #505's fall the following had been documented in the Comments section: Deaf-Hard to Understand.-won't use word board. Asked if fell -nodded yes. Per a Statement of Witness report (dated 3/28/17, untimed) which was included in the investigation of the incident, the following statement had been given by CNA 'C', who had worked with the resident for the day shift following the resident's 4:30am fall: Resident was not herself. She's normally a very active woman shes always doing something. But when I came in at 6:30 (am) she was sleeping. She refused all day to get out of bed which is unusual. I was asked to wash her up, got ready to wash her and she was asleep x (times) 3. (Family member) said nevermind. She was complaining of her back hurting when repositioning. She slept most of the day. She ate 50% of breakfast but refused to eat lunch. Check and changes were necessary as resident did not want to get up. Another thing I thought was strange, She slept until 11am on Saturday morning which is not like her. On 4/11/17 at 1:11pm CNA 'C' was queried in regards to Resident #505's presentation following the resident's fall on 3/26/17. CNA 'C' stated, I know she was really tired and stated, She was not herself. CNA 'C' responded that all day long the resident would not go to the bathroom. CNA 'C' stated, I know she was complaining of back pain every time you moved her or repositioned her. When queried as to whether she communicated this information to anyone else, CNA 'C' stated that she had told the nurse on the hall, Nurse 'D'. CNA 'C' also stated that she had completed a Look at Me ticket for Resident #505. Per CNA 'C', a Look at Me ticket was a system where a ticket would be completed if something different or unusual was noted. CNA 'C' stated that this ticket would then be given to the nurse. CNA 'C' stated that she had given the Look at Me ticket to the nurse before she had left for the day on 3/26/17. An attempt to contact Nurse 'D' was made on 4/11/17 at 3:27pm, and a voicemail message was left at this time. Nurse 'D' did not return the telephone call prior to the exit of the survey. On 4/12/17 at 3:30pm review of a Trauma Service note from the hopsital for a visit which occurred on 3/26/17 at 4:30pm was reviewed and revealed, in part, the following: (Resident name) is a (age)-year-old woman with a history of dementia and recent [MEDICAL CONDITION] after a fall in December 2016, who presented to the Emergency Department for evaluation of injuries sustained in another fall. She sustained a C2 (second cervical vertebrae) fracture and was admitted for evaluation. Neurosurgery has evaluated her with plan for nonoperative management of this fracture. Per the Physical Exam section of the report the following was documented: 1. Bilateral raccoon eyes. 2. Left forehead abrasion 3. Right eyebrow abrasion 4. C2 vertebral body teardrop fracture with posterior displacement 5. Right frontal intraparenchymal brain contusion. On 4/11/17 at 12:37pm progress notes for Resident #505 were reviewed, and revealed, in part, the following: Per a progress note dated 3/26/17 at 7:05am the following was documented: Doctor was called and returned call 0657 (6:57am) aware of bruised face and no new orders, no x-ray orders monitor mental status and for any changes. Day shift aware . Per a progress note dated 3/26/17 at 10:45am, the following was documented: Day one post change in elevation. Resident's pupils are equal, round, and reactive. Resident has equal strengths with both upper and lower extremities. Resident is laying in bed, she is arousable and answers questions appropriately using white board at bedside. Vital signs are stable, will continue to monitor. Review of a progress note dated 3/26/17 at 2:41pm revealed that the physician had been notified of the fact that the resident's family is concerned about the bruising and swelling on her face from change of elevation at 0430 this am. Next, this note documented that the resident would be discharged to the hospital. On 4/11/17 at approximately 3:00pm the Director of Nursing (DON) was queried in regards to the expectation for communication between staff members if a CNA was to notice a change in resident condition. The DON responded that if a CNA were to notice such a change it would then be communicated to the nurse, who would then perform an assessment. The DON stated that the nurse should chart the assessment. At this time, a pain assessment was reviewed with the DON for Resident #505. Review of a pain assessment dated [DATE] at 2:58pm, after the time of the resident's having left the facility to go to the hospital, was reviewed and revealed that the resident had been experiencing back pain at a pain level of 3 (noted as moderate) which impacted day to day activities. Per this assessment the resident's back pain was described as aching. Movement (at times) was documented as having made the resident's pain worse. Review of the resident's progress notes from 7:05am to 2:41pm, at the time the resident was sent out of the facility, did not reveal any documentation of communication of the observations made of Resident #505 by CNA 'C', or the actions taken related to this information. The DON was queried in regards to a Look at me ticket for Resident #505, and responded that the CNA had stated she had filled out at Look at Me ticket for Saturday and Sunday (3/25/17 and 3/26/17), but such a ticket was never found for the resident. On 4/12/17 at 4:00pm review of a facility policy titled Falls-Clinical Protocol dated April 2016 was reviewed and revealed, in part, the following: c. Once a fall occurs it is important to gather as much information as possible; i. Observe for evident trauma ii. Observe to determine what the resident was attempting to do if possible iii.Observe for enviornmental hasards which may have contributed iv. If the resident is able, what does he/she state happened v. Staff present and respondedrs, what did they see/hear d. Provide emergency care and assessment/s as indicated.

This citation pertains to MI 000 and MI 269: Based on observation, interview, and record review the facility failed to ensure that two (#502, #505) residents with a history of falls with injury of 2 residents reviewed for falls from a total of six residents were appropriately monitored based on assessed needs, resulting in falls with a laceration, fracture, and hemotoma, and the temporary loss of vision from a resident's eye becoming swollen shut. Findings include: Resident #502: On 4/12/17 at 10:28am Resident #502 was observed sitting up in a reclining broda chair in the North Unit dining room. The resident was observed to be positioned in a reclining position, and the resident's feet were observed to be elevated and positioned underneath a table in the dining room. The resident was noted to not respond to questions at this time. On 4/11/17 at approximately 9:00am the clinical record for Resident #502 was reviewed and revealed the resident had been admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Per review of a quarterly minimum data set (MDS) assessment dated [DATE] Resident #502 was rarely to never understood, rarely to never understood others, and had severely impaired cognition. Also per this MDS assessment it was noted that the resident had highly impaired vision, short and long term memory problems, and inattention at times. On 4/11/17 at 9:00am through 4/12/17 at 5:00pm the clinical record for Resident #502 was reviewed and revealed the following: Per review of an Incident/Accident Report dated 2/5/17 at 8:30pm it was noted that the resident had sustained an unobserved fall in the dining room on 2/5/17 at 8:30pm. Per the Brief Description section of the form the following was documented: Resident observed lying on floor of dining room with wheelchair tipped up. Per this form the resident's condition prior to the incident was noted to have been confused/disoriented. Per the Injury Type section of the form the boxes had been checked which indicated that the resident had a hemotoma/bruise and a head injury. Per the Investigation Report associated with the resident's fall on 2/5/17 it was noted that the resident's explanation of the incident was documented as having been incoherent. It was documented that the resident had last received a meal at 6:30pm and had been last seen in the dining room eating. The section of the Investigation Report which would be utilized to list staff, visitors, and other residents who were interviewed in regards to Resident #502's fall was noted to be blank. Review of a progress note dated 2/5/17 at 22:25 (10:25pm) was reviewed. Per the Situation, Assessment and Injury sections of the report, the following was documented: Can (CNA) went to find resident in north dining room and saw her on the floor on her side and blood was on the floor Pt ( patient) awake with no LOC (loss of consciousness). VS (vital signs) stable. Bleeding from ride side of head. Pressure applied and stopped per RN Pt noted to be bleeding from hemotoma to left forehead and hemotoma noted to left eye. The Mitigating Factors and Environmental Factors section of the progress note were noted to have been left blank. Per the Interventions section of the note, it was documented that Pressure applied to bleeding on pt's head and stopped. VS taken pt placed back into chair and taken to bed. EMS (Emergency Medical Services) called and pt transported to (Hospital Name). Review of a hospital ED (Emergency Department) Physician Note dated 2/5/17 at 21:22 (9:22pm) for Resident #502 revealed, in part, that the resident had a fall. Per the History of Present Illness section of the report it was documented,This (age)-year-old female with extensive past medical history including dementia, and a chronic fractured left hip secondary to her not being a surgical candidate presents to the emergency department via EMS from her nursing care facility with complaints of a left head injuy. EMS states that the nursing care facility found her on the floor. Her only complaints are of left head pain and laceration to her face. Per review of the hospital ED Physician Note dated 2/5/17 at 9:58pm the following findings were documented from a CT scan of the resident's head: Orbits are normal. The left maxillary sinus is opacified. There is left periorbital soft tissue swelling and likely a partially visualized minimally impacted fracture of the left-sided traumatic arch. The zygomatic arch at a normal convex contour on the prior CT of the head. Per the Impression section of the report the following was documented: No acute intracranial hemmorhage or major vessel territory infarct. Minimally impacted left side of back arch fracture with overlying soft tissue swelling. As was not seen on the prior study, and is most likely acute. Per the notes section of the report the following, in part, was documented: Workup in the emergency department is consistent with a left orbital fracture with opacification of the left sinus. We laceration was corrected with glue and she'll be placed on Keflex (antibiotic). The report also noted that discharge instructions had been given to the resident's family and nursing facility to check in (on) her multiple times nights and give her the antibiotics as prescribed. Per the Impression and Plan [DIAGNOSES REDACTED]. Review of a progress note dated 2/6/17 at 12:16am was reviewed and revealed, in part, the following: pt returned via ambulance from (Hospital name) alert to verbal, visual stimuli. resistive to assessment by this writer. left eye swollen shut, gray bluish in color right pupil is responsive Review of a NP/PA (Nurse Practitioner/Physician Assistant) Note dated 2/6/17 at 12:10pm was reviewed and revealed, in part, the following: Resident seen s/p (status [REDACTED]. She had conservative care there and laceration closed with skin glue .She has significant ecchymosis L side of face and L eye is swollen shut. She was placed on 7d (seven days) of keflex prophylctically for facial laceration . Review of a careplan dated 3/29/16 with a revision date of 5/9/16, prior to the resident's fall, revealed the following: Risk continues for fall and injury r/t (related to) hx (history) of falls, weakness with recent hip fx (fracture), vision deficits d/t (due to) macular degeneration, resistive/agitated behaviors during care, profound cognitive deficits with impaired safety and potential med side effects receiving hospice managed care with goal of comfort . On 4/12/17 at 10:30am Unit Manager (UM) 'U' was queried in regards to Resident #502. UM 'U' stated that she was not at the facility at the time of the resident's fall. When queried in regards to the mannerisms of Resident #502, UM 'U' said that the resident had always been fidgety and stated that the resident does not speak. When queried in regards to supervision of the resident, UM 'U' responded that the resident had always been someone who needed to be watched. When queried if the resident had safety awareness, UM 'U' acknowledged that the resident did not have safety awareness. On 4/12/17 the daily schedule per unit for 2/5/17 was reviewed and revealed that Nurse 'H', Nurse 'O',CNA 'K', CNA 'L', CNA 'M', and CNA 'N' were assigned to the unit where Resident #502 resided on the afternoon shift (3pm-11pm) on the shift and date when the resident's fall occurred. Per review of this daily schedule it was revealed that CNA 'K' and CNA 'N' were scheduled to work until 7:00pm on the evening of 2/5/17. Nurses 'H' and 'O' were both assigned to come into the facility in the middle of the afternoon shift, and were both assigned to the unit where Resident #502 resided. On 4/12/17 at 12:12pm CNA 'K' was queried via telephone in regards to Resident #502's fall on 2/5/17, and responded that she was not working on the night that the resident fell . Review of time clock punches for the date of the resident's fall revealed that CNA 'K' had clocked out of the facility at 7:02pm on 2/5/17 (prior to the time of the resident's fall). On 4/12/17 at 12:12pm CNA 'L' was queried via telephone in regards to Resident #502's fall on 2/5/17. CNA 'L' stated that she had been on a break during the time of the resident's fall. Review of the time clock punches for the date of 2/5/17 did not reveal break times taken by CNA staff. On 4/12/17 at 12:15pm a voicemail message was left with CNA 'M'. CNA 'M' returned the telephone call on 4/12/17 at 2:16pm. CNA 'M' stated that she very rarely worked the section of the unit where Resident #502 resided. CNA 'M' confirmed that she did work the day of the resident's fall, and stated that she was in another room with a resident and heard someone calling for help. On 4/12/17 at 12:21pm CNA 'N' was queried via telephone in regards to Resident #502's fall on 2/5/17. CNA 'N' responded that she had worked dayshift on 2/5/17 and had worked over until 7:00pm. CNA 'N' stated that the resident had been in her assignment group, and stated that she had assisted the resident in getting into her pajamas, put the resident into her chair, and said that the resident had still been eating at 7:00pm (when CNA 'N' left the facility.) On 4/12/17 at 3:05pm Nurse 'H' was queried in regards to Resident #502's fall on 2/5/17. Nurse 'H' confirmed that she had been working on the night the resident fell . When queried about the resident's cognition, Nurse 'H' responded that the resident was alert, not oriented, and had garbled speech. When queried about the incident, Nurse 'H' responded that the resident had been found on the floor by an aide. When queried as to who had first found the resident on the floor, Nurse 'H' was unable to identify the staff member. Nurse 'H' responded that Nurse 'O' had already responded to the situation when Nurse 'H' arrived to the incident. Nurse 'H' said that the North Dining Room was not visible from the unit (where the nurse was assigned.) When queried as to when she had last seen Resident #502, Nurse 'H' responded that she had last seen the resident sometime after 6:30pm. Nurse 'H' was queried as to why the resident had been in the dining room at 8:30pm. Nurse 'H' was unable to state why the resident remained in the dining room, and stated that normally the only residents who were left in the dining room were those that could move themselves around. Nurse 'H' said that once the residents were done eating, the normal process was to take residents out of the dining room one at a time. On 4/12/17 at 3:27pm Nurse 'O' was queried in regards to Resident #502's fall on 2/5/17. Nurse 'O' stated that she had come into work at approximately 7:15pm or 7:20pm on the date of the resident's fall. Nurse 'O' said that she had come in, received report from the outgoing nurse, and had counted medications with the outgoing nurse. Nurse 'O' noted that the window to the North Dining Room was near where the medication cart was located, but stated that a staff member could not visibly see where the resident was in the dining room from the view of the medication cart. Nurse 'O' stated that a staff would have to look into the doorway to see that part of the dining room. Nurse 'O' was queried as to the last time that she had seen Resident #502, and responded that it may have been around 7:50pm. When queried in regards to the resident's fall, Nurse 'O' said that an aide had stated that the resident was on the floor. Nurse 'O' was unable to definitively identify which aide had first noticed the resident on the floor. Review of time clock punches for Nurse 'O' for 2/5/17 revealed the nurse had clocked in to work at 7:09pm. On 4/12/17 at 3:49pm the facility Administrator was queried as to who had found the resident on the floor of the dining room on 2/5/17, and was unable to answer who had found the resident. On 4/12/17 at 4:00pm review of a facility policy titled Falls-Clinical Protocol dated April 2016 was reviewed and revealed, in part, the following: 4. Interventions should be developed and implemented per the assessed needs. Additional items to remember when developing the plan of care include a. Resident's abilities and deficits . Resident #505: On 4/3/17 a complaint was received by the State Agency pertaining to Resident #505. On 4/7/17 at 4:41pm during an interview with the complaintant via telephone it was revealed that the resident had fallen at the facility on 3/26/17 as well as on 4/7/17. The complaintant stated that the resident had been reamitted to the facility on [DATE], and had fallen on that date. On 4/11/17 at 11:00am Resident #505 was observed to be seated in a reclined geriatric chair (a padded chair which has the ability to recline) in the hallway. At this time, Resident #505 was observed to be wearing a cervical collar. On 4/11/17 at 12:26pm a review of Resident #505's clinical record was performed and revealed the resident had been admitted into the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Per review of the resident's admission minimum data set (MDS) assessment dated [DATE] the resident scored 11/15 on a brief interview for mental status exam, which indicated that the resident had moderate cognitive impairment. Per this MDS assessment the resident had a fall in the last month prior to admission, entry, or re-entry into the facility, and had had a fracture related to a fall in the last six months prior to admission. Continued review of the resident's clinical record revealed a falls progress note dated 3/26/17 at 4:34am which documented the following: Called to room and observed resident sitting on floor at foot of bed, blanket was on floor .2A (assist) back to feet and to bed. Skin checked and abrasion on left forehead and left nose. Mark over right eyebrow and bruised area under right eye. c/o (complained of) pain 2 under eye. On 4/11/17 at 3:45pm review of a progress note dated 4/7/17 at 8:10pm revealed, in part, the following: resident assisted into recliner at 3:45pm. Called to room at 4pm by hospice nurse. Resident observed lying on left side on floor in front of bathroom door in room. Resident with 0.5cm (centimeter) cut to left eyebrow with mild bleeding observed . Review of the resident's falls careplan on 4/11/17 at 3:00pm revealed the resident had a falls careplan which documented that the resident was at risk for falls r/t (related to) Balance deficits, Gait/balance problems, History of falls, Pain, Vision/hearing problems. Review of this careplan revealed that the last date when a fall intervention had been added to the careplan had been 3/26/17. On 4/11/17 at approximately 3:10pm the resident's falls careplan was reviewed with the Director of Nursing (DON). At this time the DON was queried as to where new interventions were to be documented for a resident. The DON responded that new interventions should be in the careplan. At this time, no new interventions were observed to have been added to the resident's careplan following Resident #505's fall on 4/7/17. On 4/12/17 at 4:00pm review of a facility policy titled Falls-Clinical Protocol dated April 2016 was reviewed and revealed, in part, the following: 1. Post fall analysis items to be considered (not all inclusive); a. The A/I (accident/incident) b. The nurses notes c. Review for med changes in the last 30-90 days d. Review previous lab findings e. Review for other acute clinical changes f. Review staff statements (to include last time resident seen, provided care, and what type of care) g. Review of care plan and CNA assignments/Kardex that were in place at time of fall h. Observe any equipement involved (i.e wheelchair, bed, commode, shower chair, etc) i. Observations of the resident's room or area of fall j. Reenactment 2. Analysis of the causative factors and rationale for interventions developed and implemented should be documented in the Standards of Care notes. 3. Update the plan of care with the new or revised interventions.

This citation pertains to Intake #MI 136. Based on observation, interview and record review, the facility failed to provide immediate first aid to one (#1) sampled resident who spilled hot coffee in his lap out of 2 sampled residents out of a total sample of two residents resulting in pain, anguish and a second degree burn with blisters to both thighs and the potential for infection to the burned areas. Findings include: Resident #1 was a ninety-eight year old male who was admitted to the facility on [DATE], according to the face sheet dated [DATE], and his [DIAGNOSES REDACTED]. Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible score of 15 which indicated Resident #1 had no short or long term memory issues. Resident #1 died on [DATE]. On [DATE] at 8:15 AM, a record review of the Past Non Compliance document, presented upon entrance to the facility, revealed the following information Residents re-assessed. 100 remain at risk related to hot liquid spills. 110 residents that remain at risk have had their care plans updated with interventions to reduce the risks of serious injury related to hot liquids. On [DATE] at 8:30 AM, a record review of the contents of the investigation binder, which contained documentation of the results of the investigation into Resident #1's burn, revealed the following information: On [DATE] at 6:30 AM, Resident #1 was observed spilling a cup of coffee in his lap. Blisters were noted to resident's (#1) bi-lateral medial thighs, without hospitalization required. On [DATE] at 10:30 AM, an observation of a re-enactment of the event which occurred on [DATE] was done in the Courtside dining room, used by residents who are able to feed themselves. In attendance during the re-enactment were the facility Administrator A and Director of Nursing (DON) B. DON B pointed out the table which Resident #1 used on the day of the incident. An observation of the dining room indicated a sink with hot and cold running water and an Absopure water dispenser were located perpendicular to the table which Resident #1 used the day of the incident. According to DON #2, Resident #1 was admitted to the Courtside dining room at approximately 6:30 AM by DA H who was the only staff member in the dining room. Resident #1 was in a wheelchair which he used to propel himself from his room to the dining room. While Resident #1 propelled himself to his table, Dietary Aid (DA) H prepared coffee for Resident #1 and placed the coffee on Resident #1's table. The coffee was provided in a plastic mug with a lid. DA H went to the steam table and began to prepare for breakfast and heard Resident #1 yell out Dammit. DA H saw the mug and the lid were separated and were lying in Resident #1's lap. Coffee was noted to have spilled in Resident #1's lap. Resident #1 yelled to DA H: Get me a towel. DA H ran out into the hall to notify the nursing staff about Resident #1 spilling coffee on himself and grabbed a towel for Resident #1. DA H returned to the dining room and noticed Certified Nursing Assistant (CNA) E in the dining room, asked her to return Resident #1 to his room. As CNA E pushed Resident #1 towards his room, CNA F, who was Resident #1's caregiver that day, stopped CNA E and took Resident #1 back to his room. According to DON B, CNA F took Resident #1 to his room, removed his clothes, saw the burn and notified Registered Nurse (RN) G. During the re-enactment, DA I entered the dining room and began to prepare the steam table for lunch. In a brief interview with DA I, she indicated, if a resident dropped a cup of coffee in his lap, she would douse the area with a cold liquid such as apple juice or water. She stated she was aware of this first aid treatment of [REDACTED]. DON B was asked if there was an alarm system in the dining room and she stated there was a telephone on the wall that could be used to page for assistance. On [DATE] at 11:00 AM, a record review of the incident and accident report, dated [DATE], initiated by RN G, stated observed resident (#1) in bed with skin burns to BLE (bilateral lower extremities) to the inner thigh area; cleaned with N/S (normal saline), applied wound gel - covered with ABD pads. Under the box labeled Details of Injury, RN G noted Redness w (with) some purple color areas - BLE. RLE (right lower extremity) open blister. On [DATE] at 11:10 AM, a record review of the Hot Liquid Safety Evaluation, dated [DATE], noted the following information: Resident #1 was noted to have, according to the assessment, weakness/paresis in upper extremities and a loss of mobility and reduced movement in upper extremities. Interventions indicated Resident #1 was to use a cup with lid and was to be supervised with meals. DON B was asked for any previous hot liquid safety evaluations for Resident #1 and she stated there were no other hot liquid evaluations for this resident. On [DATE] at 11:15 AM, a record review of the Look At Me form, which was completed by DA H on [DATE], documented in the area labeled Observation resident (Resident #1) keeps spilling hot coffee on himself. Even with a lid he is still dropping the mug on himself. Under the area labeled Action Taken, there was nothing written. On [DATE] at 11:20 AM, a record review of an undated document titled Burn Prevention listed the following information: What do I do if a resident drops a hot beverage/gets a burn? IMMEDIATELY pour any type of cold liquid on the burned area. On [DATE] at 1:30 PM, an interview with Nurse Practitioner (NP) C was conducted. NP C was asked what the usual treatment was for an observed hot liquid spill and she responded remove the hot stuff by using cold water. NP C was asked to describe Resident #1. She stated that Resident #1 had been a resident in the facility for a long time. She stated he took himself around the building in his wheelchair and had been gradually declining. NP C stated the resident's mind was very good and that he had a BIMS score of fifteen out of a possible score of fifteen. According to NP C, on the day of the burn, she saw Resident #1 when he was in his room after the injury. Resident #1 was resting in bed, in pain, not talking, which was not like him. NP C observed second degree burns to both inner thighs, blisters were observed and broken open. NP C ordered Silvadene ointment covered by dry dressings. NP C saw Resident #1 the next day (the day of his death) in the morning. At that time, his vital signs were OK. Later that day, Resident #1 became unresponsive with a low blood pressure and died . NP C stated she conferred with Attending Physician J and their impression was that the burn did not cause the resident to go downhill. On [DATE] at 2:30 PM, CNA E was interviewed. When she was asked what she would do if she observed a hot liquid spill by a resident, she stated she would pour cold liquid on the spill to stop any blistering.She said, on [DATE], she went into the Courtside dining room and observed DA H behind the steam table. DA H told CNA E: she had looked for other staff to come and get Resident #1 and no one had come yet. DA H asked CNA E to take Resident #1 back to his room as he spilled coffee on his lap. When CNA E observed Resident #1, he was quiet and had a couple of towels over his lap. When CNA E was asked if Resident #1 had spilled coffee on himself before the incident on [DATE], she stated she had observed Resident #1 on previous occasions (dates unknown) with coffee stains on his shirt. On [DATE] at 3:00 PM, an interview was conducted with CNA F. She stated, on [DATE], she was making rounds with the midnight staff when she was informed that Resident #1 had spilled coffee on himself and he needed to be brought to his room. On the way to get Resident #1, she ran into CNA E at the nurse's station with Resident #1. CNA F then took Resident #1 to his room and waited for another CNA to help transfer Resident #1 to his bed (Resident #1 was a 2 assist transfer). While waiting for the second CNA to join her, CNA F took off Resident #1's shirt and his undershirt. Both clothing items had spots of coffee on them. After Resident #1 was transferred to his bed and had his pants removed, CNA F saw redness and what looked like blisters on the inside of both thighs. CNA F notified RN G of her findings. RN G assessed Resident #1 and asked CNA F: to place a cool, wet washcloth to his burns. After CNA F placed the washcloth to the burned areas, she left the room. On [DATE] at 3:30 PM, an interview was conducted with RN G. When asked what the treatment was for an observed hot liquid burn, she said she would throw cold liquid on the burned area. On [DATE], she was making rounds when she was asked to assess Resident #1 in his room because he had a hot liquid spilled on him. When RN G looked at the burned area, she noted redness to the bilateral inner thighs. In addition, she saw a popped blister on the right thigh area. She immediately asked CNA F to put a cool, wet washcloth to the burned area and notified NP C and Attending Physician (AP) J of her findings. On [DATE] at 4:30 PM, an interview was conducted with DA H. According to DA H, she was alone in the Courtyard dining room on the morning of [DATE] preparing the room for breakfast. At 6:30 AM, she unlocked the dining room doors and six residents entered the dining room, including Resident #1 who wheeled himself to his regular table. DA H prepared coffee for Resident #1 and began taking breakfast orders from other residents. When she heard Resident #1 yell she noted he had coffee all over him. DA H ran out of the dining room (leaving the residents in the dining room unsupervised) to Daisy Hall, where Resident #1 lived and told the staff (didn't know who she spoke with) what had happened and said someone needed to get him. DA H grabbed a towel, returned to the dining room, gave Resident #1 a towel and sent him back to his unit with CNA E. When asked, DA H said she was told (educated) prior to the incident that you should pour cold water over a burn but in the excitement during the incident she forgot to do so. DA H was asked if Resident #1 had ever spilled coffee on himself before and DA H said that on the previous Friday ([DATE]) she was dropping something off in the Courtside Dining Room and observed Resident #1 had spilled coffee on his lower stomach and legs. That was why she filled out the Look At Me form as she had witnessed two incidents of spilled coffee. Avoidable Accident means that an accident occurred because the facility failed to: o Identify environmental hazards and individual resident risk of an accident, including the need for supervision; and/or o Evaluate/analyze the hazards and risks; and/or o Implement interventions, including adequate supervision, consistent with a resident's needs, goals, plan of care, and current standards of practice in order to reduce the risk of an accident; and/or o Monitor the effectiveness of the interventions and modify the interventions as necessary, in accordance with current standards of practice. Many residents in long-term care facilities have conditions that may put them at increased risk for burns caused by scalding. These conditions include: decreased skin thickness, decreased skin sensitivity, peripheral neuropathy, decreased agility (reduced reaction time), decreased cognition or dementia, decreased mobility, and decreased ability to communicate. ( )

This citation pertains to intake MI 709. Based on observation, interview and record review, the facility failed to maintain one resident's (#5 ) safety while preparing her for a shower out of six residents (#1 - #6) monitored for showers out of a total sample of six residents resulting in an avoidable fall with fracture injury. Findings include: Resident #5 was a [AGE] year old female who was admitted to the facility, according to her electronic medical record, on 5/10/2015 with the following Diagnoses: [REDACTED]. On 10/27/2015 at 11:00 AM, a record review of the five day report submitted to the State Agency revealed Resident #5 was taken to the shower room on 9/30/2015 at 10:50 PM by Certified Nursing Assistant (CNA) H and CNA L in a shower chair. Once in the shower room, CNA L left the shower room and CNA H left Resident #5 and went around the corner to grab supplies and then heard the resident fall. CNA H called Registered Nurse (RN) M for assistance. The initial assessment indicated Resident #5 was found lying on her left side. On 10/1/2015, Resident #5 indicated non-verbally that she was experiencing pain in her left leg. Resident #5 was sent to a local hospital for evaluation. The resident was returned to the facility and no abnormalities were detected. On 10/5/2015, Resident #5 was evaluated by a Physician's Assistant for continued pain in her left leg. X-rays indicated a fracture of the left trochanter. On 10/28/2015 at 11:00 AM, a record review of the accident and incident report, describing the fall by Resident #5 which occurred on 9/30/2015, was reviewed. According to the documentation, CNA H reported resident (Resident #5) lifted the latch bar and fell forward. Under the question Were planned interventions in place? The response was no shower chair 0 (not) latched. In addition, under the topic Results of investigation documentation noted unable to determine if shower chair latch completely closed. Resident did sustain hematoma on forehead and later determined a hip fracture. On 10/28/2015 at 11:30 AM, a record review of the guidelines for a Shower/Tub Bath revealed under the topic General Guidelines staff should Never leave the resident unattended in the shower or bath. On 10/28/2015 at 1:30 PM, a reenactment of Resident #5's fall in the shower room was done using the same shower chair Resident #5 used when she fell . When the shower chair was examined, it was noted there was an arm on the front of the chair that was pulled down in front of the resident to maintain resident safety while waiting for the shower to begin. At the end of the arm, it was noted , was a metal snap. The snap closure was located on the side of the shower chair and was located on the end of a strong piece of heavy plastic. when the snap was closed, it would not be possible for Resident #5 to lift the arm and fall out of the shower chair. This surveyor pulled on the safety arm while the snap was locked and could not budge the arm open. At the end of the reenactment, the Administrator A was asked to have maintenance measure the distance from the shower area where Resident #5 was sitting to the area in the shower room where supplies were kept. That distance was twelve feet. On 10/29/2015 at 10:30 AM, CNA H was interviewed. She stated, on the day of the incident, she took Resident #5 into the shower room and, with the help of CNA L, transferred Resident #5 into the shower chair. CNA H said she pushed the safety bar down but did not recall if she latched the bar to protect Resident #5 from opening the bar and falling out of the shower chair. After she pushed Resident #5 into the shower area, CNA H realized she forgot the shower boots so she stepped around the corner to a supply area and then heard a scream and a crash. CNA H returned to the shower area and found Resident #5 lying on her left side on the floor. She said she could not see the resident when she went to get the shower boots because the supply area was behind 2 walls. CNA H said she had been terminated from her position at the facility after this incident occurred. On 10/29/2015 at 3:00 PM, in an interview with CNA L, she described Resident #5 as being unable to sit still and was considered a high fall risk. Resident #5 had a habit of leaning out of her chair and reaching down to the floor as if to pick up items off the floor. CNA L stated she would not have left Resident #5 out of her sight. In addition, CNA L said if the bar on the shower chair had been latched, Resident #5 would not have been able to open the bar and fall. On 10/29/2015 at 3:30 PM in an interview with RN M, she stated Resident #5 was always bending over picking up things off the floor, always reaching and grabbing at things. RN M stated she would not have left Resident #5 alone in the shower chair, she would have looked for additional assistance to care for Resident #5 and would have turned the call light on to signal help was needed. The CNA needed to have all her supplies assembled before entering the shower room. ( )

This citation pertains to M 1054 Based on interview and record review, the facility failed to transfer a resident with a two person assist for one (#702) of three sampled Residents reviewed for Activities of Daily Living (ADL) care from a total sample of three 3 resulting in sharp pains from a injured swollen right shoulder, a decrease in range of motion (ROM.) and a decline in physical therapy treatment and a decline in ambulation. Findings include: On 3/3/15 at 10:00 a.m., during an initial tour of the facility, Resident #702 was lying in bed, her granddaughter and great granddaughter were in the room with her. Resident #702 stated that she had been in the facility for over a month and stated that things were not going well for her. Resident #702 stated that she was admitted into the facility for physical therapy to increase her strength with the hopes of returning home. She expressed concern that the facility would be better if it had more staff. She further stated, I now have an injured right shoulder. A few weeks ago I needed to go to the bathroom. An Aide came in to help me. I have very weak bones because of my cancer. She took me into the bathroom. I think I'm supposed to have two people help. I'm not sure she even used my belt to help me. I was off balance and felt like I was going to fall and she grabbed at my shoulder. They are supposed to be careful with me. I had x-rays here. I have had to wear a sling. I have not gotten as much physical therapy as I would have liked, because of the pain in my shoulder. On 3/3/15 at approximately 11:00 a.m. the clinical record for Resident #702 was reviewed and revealed an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. Per the Minimum Data Set assessment ((MDS) dated [DATE] Resident #702 was cognitively intact and able to make herself understood and understand others, required extensive two person assist for toileting and transferring. A Care Plan for toileting dated 2/1/15, documented Extensive two person assist for all toileting and transfers Physical Therapy (PT) assessment dated [DATE] documented, the patient is at risk for falls and increased dependency upon caregivers. Initial PT records indicated that Resident #702 initially required a hoyer lift and then was reduced to a two person assist. A Nurse Practitioner note dated 2/12/15 documented, writer notified by Certified Nursing Assistant (CNA) at 8:15 a.m. that Resident was transferring to toilet and reached for a grab bar on toilet and heard a pop in the right upper extremity (RUE) and is now feeling pain. Writer assessed resident and right clavicle is swollen. Physician ordered x-ray of right clavicle STAT at 8:27. Nurse note dated 2/13/15 documented, CNA transferring and heard a pop in the left shoulder. Sharp pain 8 out of 10. Movement makes it worse. Decrease in range of motion (ROM.). On 3/3/15 at 12:30 p.m., the Facility was asked to provide an accident and incident report ( I&A) for Resident #702. On 3/3/15 at 2:30 p.m., an interview was conducted with CNA A regarding the incident that occurred on 2/12/15. CNA A stated, I took her to the bathroom myself. I used a gait belt. She reached out for a grab bar and then I heard a pop in her shoulder. She immediately complained of pain. I told my supervisor. When queried as to whether she was aware that the resident's care plan required a two person assist with tolieting, CNA A stated, I didn't think at the time she was still a two person assist. On 3/3/15 at 3:15 a.m, an interview was conducted with the treating physical therapist. When queried as to Resident #702's PT treatment with respect to her shoulder injury, PT B stated she did have a decline in her therapy due to the injury to her shoulder. She was in pain and missed a few treatments. PT B notes revealed the following, Resident #702 had been compliant with Plan Of Care and had been progressing well up until 2/13/15 when she injured her R shoulder during a a bathroom transfer with CNA staff (no fracture, potential RTC (rotator cuff) involvement). PT has since required use R UE (upper extremity) to be in a sling. Functional limitation current status dated 2/18/15 documented the following, Recent R shoulder injury has caused a decline in ambulation due to pain (7-9/10). Pain was assessed at a level of 7-9 on a 10 point scale. On 3/3/15 at 3:00 p.m., an interview was conducted with the Director of Nursing (DON). The DON was asked to provide a report of the incident that occurred. The DON stated, we did not do an Incident and Accident Report (I & A). We only do those if there is evidence of a fracture and I do not believe Resident #702 had a fracture and the injury was not of an unknown origin. I think it was just a pop to her shoulder. When further queried as to her care plan that documented Resident #702 required an extensive two person assist with transfers and tolieting, the DON stated, I think maybe PT had reduced her to a one person assist, but it is not in her careplan.

This citation pertains to MI 692 and MI 672. Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices for the prevention of falls in 2 of 4 residents reviewed for falls (Resident #101 and Resident #102), from a total of 4 sampled residents, resulting in a fall with serious injury for both Resident #101 and Resident #102. Findings include: Resident #101 Review of the Face Sheet dated 12/21/12 and the most recent Minimum Data Set ((MDS) dated [DATE], revealed Resident #101 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #101 had clear speech, usually understood/understands others, had moderately impaired cognition and was inattentive. The MDS revealed Resident #101 required the assistance of 2 people for transfers. During an interview on 7/15/13 at 3:00 PM, Nursing Home Administrator (NHA) #1 stated that upon admission "all new residents are a fall risk". Review of the "Incident/Accident Report" dated 12/21/12 at 8:20 PM, revealed Resident #101 was "heard screaming...observed (Resident #101) lying on left side on floor...R (right) leg slightly rotated outward (and) shorter". The report revealed alarms were routinely required, and at the time of the incident "did not sound". The report revealed Resident #101 was last seen, before her fall, in her room sitting in her wheelchair at 8:00 PM. The report revealed "(Resident #101) in w/c (wheelchair), attempted to stand and fell to the floor. Alarm attached to w/c not sounding..." Review of the facility physician's "Activities Order List" dated 12/21/12 - 12/22/12, revealed Resident #101 required 1-2 staff members assist with ADLs (activities of daily living), was not to ambulate in the room of the hall, and required assistance of 2 staff members for transfers. Review of the "Plan of Care" for Safety related to history of multiple falls dated 12/21/12, revealed bed and chair sensor alarms were to be on at all times. Review of the hospital "Physical Therapy" report dated 12/20/12, revealed Resident #101 had "decrease ROM (range of motion) in both knees and stiffness...stand balance: poor...Pt (patient) very weak, having difficulty (with) transfers/gait and is functioning way below her baseline". Review of the "Progress Notes" dated 12/21/12 at 6:16 PM, revealed that Resident #101 "attempted several self t/f (transfers)...Sensor alarm to bed and chair for self t/f attempts". During an interview on 7/17/13 at 11:10 AM, Registered Nurse (RN) #13 stated that Resident #101 was admitted to the facility on [DATE] at 2:30 PM. RN #13 stated Resident #101 was observed up out of her wheelchair, by herself, "multiple times". RN #13 stated that Resident #101 was not to get out of the wheelchair without the assistance of staff. RN #13 stated Resident #101 was a fall risk. RN #13 stated all the staff that was working that floor was made aware of Resident #101 being a fall risk. RN #13 stated because Resident #101 was observed multiple times trying to stand up from her wheelchair, a pressure sensor alarm was placed on her wheelchair. The floor nurse that took care of Resident #101 the night of the fall no longer works at the facility. This surveyor attempted to contact the nurse at the last known phone number without success. During an interview on 7/18/13 at 9:55 AM, Nursing Supervisor, Licensed Practical Nurse (LPN) #17 stated she was notified by the staff nurse of Resident #101 being found on the floor. LPN #17 stated the alarm was not sounding after Resident #101 was found on the floor. LPN #17 stated that Resident #101 was barefoot at the time of the fall, and was supposed to be wearing non-slid socks. LPN #17 stated, "would have liked to have seen the resident (#101) out in the hall for closer observation". LPN #17 stated she has witnessed alarms not working properly, "feels guilty when a resident falls and the alarms were not working properly". During an interview on 7/17/13 at 2:06 PM, Certified Nursing Assistant (CNA) #19 stated she remembered Resident #101's roommate using the call light system, multiple times, to inform staff that Resident #101 was trying to stand up from her wheelchair without assistance. CNA #19 stated she did not check the functionality of the pressure sensor alarm at any point. CNA #19 stated she has witnessed alarms not functioning properly, "usually the batteries are dead, or the switch on the top of the (alarm) box was not in the on position". Review of the hospital "ED (emergency department) Physician Notes" dated 12/22/12 at 12:59 AM, revealed, "exam confirms that there is clinical finding of the distal femur (thigh bone) fracture (break). X-rays confirm these findings". Resident #102 Review of the Face Sheet dated 5/17/13 and the most recent Minimum Data Set ((MDS) dated [DATE], revealed Resident #102 was a [AGE] year old female originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #102 had clear speech, usually understood, usually understands, had moderately impaired cognition and required extensive assistance with transfers. Review of the "Incident/Accident Report Investigation" dated 5/12/13 at 3:30 AM, revealed "...heard someone yell help went into the (Resident #102's) room and observed res (Resident #102) laying on her stomach between her closet (and) end of bed...c/o (complaint of right) hip/femur pain. The report revealed that "bed sensor in place, (not) sounding". The report revealed that Resident #102 was last toileted at 2:00 AM. The report revealed, "pajama pants & brief was down just above the knees, both were not wet, however the carpet was reported to be wet". Review of the "Physician order [REDACTED].#102 was to have a bed sensor alarm on her bed continuously. Review of the "Plan of Care" dated 4/1/13, revealed Resident #102 required assistance of 1 staff member for toileting, and was to be waken at 1:00 AM and 3:00 AM to toilet. The "Plan of Care" revealed alarms were to be on at all times, and Resident #102 required extensive assistance of 1 person to ambulate in room/hall. The "Plan of Care" revealed that Resident #102 had a low air loss mattress in place. During an interview on 7/16/13 at 9:00 AM, LPN #3 stated CNA #4 reported that Resident #102 fell . LPN #3 stated the last time Resident #102 was checked was 2:00 AM. LPN #3 stated that the bed sensor alarm was turned on at the time of the fall, but was not sounding, "if the alarm was working we would have heard it". During an interview on 7/16/13 at 9:30 AM, CNA #4 stated Resident #102 was last checked and changed at 2:00 AM and everything was ok. CNA #4 stated that CNA #5 heard Resident #102 yelling "help", both CNA #4 and CNA #5 went into Resident #102's room and found Resident #102 lying on the floor complaining of hip and leg pain. CNA #4 stated that the bed sensor alarm was turned on and in place, but was not sounding, "we found that these alarms don't always work on the air mattresses". CNA #4 stated, "when we hear an alarm, we double time it to the room, a lot of times we are in the room before the resident actually stands up from the bed". During an interview on 7/16/13 at 10:25 AM, CNA #5 stated Resident #102 was heard yelling "help", CNA #5 and CNA #4 went into Resident #102's room and found Resident #102 on the floor. CNA #5 stated the bed sensor alarm was plugged in but was not sounding. CNA #5 stated that sometimes the bed sensor alarms don't work because there are too many blankets on top of the sensor, "almost every time a resident has fallen and the alarms are not going off, it is because there are too many blankets on the alarms, as soon as you pull the blankets of the sensors, the alarm starts to sound". During an observation on 7/16/13 at 11:00 AM, with CNA #6 present, this surveyor pressed down onto a bed sensor alarm and released pressure, and the alarm did not sound. CNA #6 stated "sometimes the blankets weigh it down, and the alarms do not go off" CNA #6 removed the blankets from the sensor, pressed down on the sensor, and then released the pressure and the alarm sounded. During an interview on 7/17/13 at 11:34 AM, CNA #15 stated, "Sometimes with air mattresses the sensor wont sense a decrease in pressure and wont alarm". During an observation on 7/17/13 at 14:35, with CNA #18 present, Resident #102's pressure sensor alarm was on the bed, with the bed wedge on top of the sensor. CNA #18 stated the sensor should not be under the bed wedge, as this could cause the sensor to not sense a decrease in pressure, and therefore the alarm would not sound properly. During an interview on 7/18/13 at 9:55 AM, LPN #17 stated "...yes have witnessed alarms not sounding when they should have...if a resident is already on the floor and the alarm is not sounding, they are not very effective...alarms do prevent falls, feel guilty when a resident falls and the alarms are not working properly". Review of the hospital "History & Physical" report dated 5/12/13 revealed, "(Resident #102) presenting from (the facility) after a...fall...suffering a right femoral neck fracture...rib fracture". Review of the facility "Progress Note" dated 5/20/13 revealed, "(Resident #102) was transferred to the hospital...found to have a right femoral neck fracture...underwent right hemiarthroplasty (hip replacement surgery)". ( )

This citation pertains to MI 692. Based on interview and record review, the facility failed to provide adequate assessment and care after a fall in 1 of 4 sampled residents (Resident #101) reviewed for falls, from a total of 4 sampled residents, resulting in a delay in treatment for [REDACTED]. Findings include: The Professional Standards of Quality for Staff Roles and Responsibilities in Monitoring Patients with Acute Changes of Condition for the nurse includes recognizing condition change early and assessing the patient's symptoms and physical function...(Process Guidelines for Acute Change of Condition, AMDA Clinical Process Guidelines, 2003). Review of the Face Sheet dated 12/21/12 and the most recent Minimum Data Set ((MDS) dated [DATE], revealed Resident #101 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #101 had clear speech, usually understood/usually understands others, had moderately impaired cognition and was inattentive. The MDS revealed Resident #101 required the assistance of 2 people for transfers. Review of the "Incident/Accident Report" dated 12/21/12 at 8:20 PM, revealed "observed resident (#101) lying on left side on floor...confused @ (at) baseline, no (changes) in mentation, cannot follow directions...R (right) leg slightly rotated outward (and) shorter". The report revealed that Doctor of Osteopathic Medicine (DO) #20 wasn't notified of Resident #101's medical condition until 10:00 PM. In an interview on 7/18/13 at 2:20 PM, DO #20 stated that he did not remember being contacted about Resident #101's fall and change of condition. DO #20 stated that if he was notified of a resident sustaining a fall, and being found to have one leg rotated outward and shorter than the other leg, he "would presume a broken hip until proven otherwise, and would have the resident transferred to the hospital immediately". Review of the "Progress Notes" dated 12/21/12 at 6:16 PM, Resident #101 was assessed to have no complaints of pain. Review of the "Progress Notes" dated 12/21/12 at 9:53 PM, (after Resident #101 sustained fall) revealed Resident #101 "cries out with any movement of extremities or touch...Obvious discomfort with attempted ROM (range of motion), but unable to acertain (sic) if this is new pain or existing. The floor nurse that took care of Resident #101 the night of the fall no longer works at the facility. This surveyor attempted to contact the nurse at the last known telephone number without success. During an interview on 7/18/13 at 9:55 AM, Nursing Supervisor, Licensed Practical Nurse (LPN) #17 stated she was notified by the floor nurse of Resident #101 being found on the floor. LPN #17 stated that Resident #101's right leg was rotated outward and shorter than the left leg, typical sign of a [MEDICAL CONDITION]. LPN #17 stated usually residents with an apparent [MEDICAL CONDITION] would be sent to the hospital immediately, "I don't know why she wasn't (sent immediately to the hospital)". When asked, LPN #17 stated, "yes" Resident #101 should have been sent to the hospital sooner. Review of the "Progress Note" dated 12/22/12 at 12:14 AM revealed, "family members...arrived at approx (approximately) 12:05am...daughter demands resident to 'get medical care now!' Writer attempted to explain what care resident has received and what care are attempting, but daughter not willing to listen. Sending resident to ER at this time per family request." Review of the "Progress Note" dated 12/22/12 at 1:30 AM, revealed, "911 called by writer @ 12:15 AM" . Review of the "Progress Note" dated 12/22/12 at 1:06 AM, revealed Resident #101 was transported to the hospital at 12:35 AM, 4 hours after sustaining a fall that resulted in a fractured femur (thigh bone). Review of the hospital "ED (emergency department) Physician Notes" dated 12/22/12 at 12:59 AM, revealed, "exam confirms that there is clinical finding of the distal femur (thigh bone) fracture (break). X-rays confirm these findings". ( )

REFER TO INTAKE #MI 096 BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED PREVENT A SIGNIFICANT MEDICATION ERROR FOR ONE (RESIDENT #101) OF 8 SAMPLED RESIDENTS REVIEWED FOR MEDICATION ERRORS, FROM A TOTAL SAMPLE OF 8, RESULTING IN IMMEDIATE JEOPARDY WHEN RESIDENT #101 RECEIVED AN OVERDOSE OF [MEDICATION NAME], WHICH REQUIRED THE IMMEDIATE TRANSFER OF THE RESIDENT TO THE HOSPITAL. RESIDENT #101 SUBSEQUENTLY died THE SAME DAY. FINDINGS INCLUDE: RESIDENT #101, A [AGE] year OLD FEMALE WITH ADVANCED DEMENTIA, WAS admitted to the facility on [DATE] AND WAS UNDER HOSPICE CARE FOR DEMENTIA BEGINNING ON [DATE]. AT THE TIME RESIDENT #101 WAS admitted TO HOSPICE CARE, A physician's orders [REDACTED].#101. ACCORDING TO THE ELECTRONIC Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. RESIDENT #101 WAS ALERT AND ORIENTED TO SELF ONLY, PRIOR TO THE MEDICATION ERROR ON [DATE]. ACCORDING TO THE FACILITY INCIDENT REPORT, DATED [DATE], LICENSED PRACTICAL NURSE (LPN) #3 ENTERED INTO THE EMAR A MEDICATION ORDER FOR [MEDICATION NAME] SULFATE, 0.75 ML (100 MG/5 ML) EVERY 4 HOURS AROUND THE CLOCK (ATC) SUBLINGUALLY (UNDER THE TONGUE), FOR PAIN FOR THE WRONG RESIDENT (RESIDENT #101 INSTEAD OF RESIDENT #102). AS A RESULT, RESIDENT #101 RECEIVED 4 DOSES OF [MEDICATION NAME] SULFATE (TOTAL OF 60 MG) ON [DATE] AT 12:00 PM, 4:00 PM, 8:00 PM AND AT 12:00 AM ON [DATE]. THE MIDNIGHT SHIFT NURSE HELD BACK THE 4:00 AM DOSAGE ON [DATE], BECAUSE RESIDENT #101 WAS NOT AWAKE TO TAKE THE MEDICATION. REVIEW OF THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M.), AND AT 20:00 (8 P.M.) ON [DATE] AND AT 00:00 (MIDNIGHT) ON [DATE]. RESIDENT #101 WAS SCHEDULED TO RECEIVE THE [MEDICATION NAME] SULFATE AGAIN AT 4:00 (4 A.M.) ON [DATE], BUT, ACCORDING TO THE Medication Administration Record, [REDACTED] LPN #3 WAS INTERVIEWED ON [DATE] AT 2:05 PM, AND admitted THAT ON [DATE], AT 10:12 A.M., SHE ENTERED THE MEDICATION OF [MEDICATION NAME] SULFATE 0.75 ML (100 MG/5 ML) EVERY 4 HOURS ATC SUBLINGUALLY INTO THE EMAR FOR RESIDENT #101 BY MISTAKE. THE ORDER WAS FOR RESIDENT #102. BOTH RESIDENT #101 AND RESIDENT #102 WERE HOSPICE RESIDENTS, BUT ON [DATE], RESIDENT #102'S HOSPICE STATUS CHANGED TO "ACTIVE" DYING STATUS. LPN #3 WAS UNAWARE OF THE MEDICATION ERROR UNTIL AFTER RESIDENT #101 WAS SENT TO THE HOSPITAL AND died . IN AN INTERVIEW ON [DATE] AT 1:45 PM, LPN #4 STATED THAT SHE WAS THE INCOMING MORNING SHIFT NURSE ON [DATE] AND, AT AROUND 7:00 AM, HOSPICE NURSE AIDE #6 APPROACHED LPN #4 AND TOLD HER THAT RESIDENT #101 COULD NOT BE AROUSED. HOSPICE NURSE AIDE #6 DESCRIBED TO LPN #4 THAT "SHE IS TOO OUT OF IT, SO I GAVE HER A BED BATH." LPN #4 STATED THAT SHE WENT TO THE ROOM OCCUPIED BY RESIDENT #101 AT APPROXIMATELY 7:30 AM AND NOTICED THAT RESIDENT #101 WAS UNRESPONSIVE AND APPEARED TO HAVE LABORED BREATHING WITH "LOW" VITAL SIGNS. LPN #4 REVIEWED THE DOCTOR'S ORDER AND FOUND THAT THERE WAS A CHANGE OF ORDER FOR [MEDICATION NAME] SULFATE FROM 0.25 ML PRN TO 0.75 ML EVERY 4 HOURS ATC. LPN #4 NOTIFIED HOSPICE NURSE #5, WHO CAME IMMEDIATELY AND HELPED ASSESS RESIDENT #101. LPN #4 QUESTIONED HOSPICE NURSE #5 REGARDING THE NEW ORDER FROM [DATE]. HOSPICE NURSE #5 TOLD LPN #4 THAT RESIDENT #101 DID NOT HAVE A NEW ORDER ON [DATE] BUT RESIDENT #102 DID. WHEN THE HOSPICE DOCTOR WAS NOTIFIED OF THE ERROR, HE SENT RESIDENT #101 TO THE HOSPITAL FOR INTRAVENOUS (IV) SUPPORT AND [MEDICATION NAME] (ANTI-NARCOTIC) ADMINISTRATION. HOSPICE NURSE AIDE #6 WAS INTERVIEWED ON THE TELEPHONE ON [DATE] AT 12:35 PM. HOSPICE NURSE AIDE #6 STATED THAT RESIDENT #101 WAS DUE FOR A SHOWER THAT MORNING ([DATE]). AT 6:00 AM, NURSE AIDE #6 NOTICED THAT RESIDENT #101 WAS UNRESPONSIVE, HER BREATHING WAS SHALLOW WITH EPISODES OF APNEA AND HER FINGERS WERE BLUISH IN COLOR. HOSPICE NURSE AIDE # 6 STATED THAT RESIDENT #101 DID NOT LOOK GOOD. HOSPICE NURSE AIDE #6 STATED RESIDENT #101 NORMALLY WAS ALERT AND WAS ABLE TO GET UP AND WALK TO THE BATHROOM WITH ASSISTANCE. WHEN HOSPICE NURSE AIDE #6 SAW RESIDENT #101 AT AROUND 6:00 AM ON [DATE], SHE RECALLED THAT RESIDENT #101 WAS NOT ALERT ENOUGH TO GET UP AND TAKE A SHOWER LIKE SHE NORMALLY WOULD. AT THAT POINT, HOSPICE NURSE AIDE #6 DECIDED TO GIVE RESIDENT #101 A BED BATH . HOSPICE NURSE AIDE #6 STATED THAT HOSPICE NURSE #5 WAS NOTIFIED BETWEEN 6:00 AM AND 6:30 AM OF RESIDENT #101'S CONDITION. THE FLOOR MIDNIGHT NURSE WAS ALSO NOTIFIED. HOSPICE NURSE AIDE #6 FURTHER DESCRIBED THAT "RESIDENT #101 LOOKED LIKE SHE WAS ABOUT TO CROSS OVER." IN AN INTERVIEW ON [DATE] AT 2:25 PM, HOSPICE NURSE #5 STATED THAT LPN #3 MADE AN ERROR IN ENTERING THE MEDICATION ORDER IN THE COMPUTER. LPN #3 ENTERED A NEW ORDER OF [MEDICATION NAME] SULFATE, 0.75 ML (100 MG/5 ML) EVERY 4 HOURS ATC INTO THE EMAR OF RESIDENT #101 INSTEAD OF RESIDENT #102. RESIDENT #101 WAS A HOSPICE PATIENT BUT DID NOT HAVE NEW DOCTOR'S ORDERS ON [DATE]. RESIDENT #101 HAD A PRN ORDER FOR [MEDICATION NAME] SULFATE OF .25 ML. HOSPICE NURSE #5 RECALLED THAT ON [DATE], SHE WAS MAKING HER ROUTINE ROUNDS AT AROUND 7:45 AM WHEN SHE GOT A CALL FROM LPN #4 TO SEE RESIDENT #101 RIGHT AWAY. LPN #4 ALSO INQUIRED ABOUT THE NEW [MEDICATION NAME] SULFATE ORDER. ACCORDING TO HOSPICE NURSE #5, SHE (#5) TOLD AM LPN #4 THAT RESIDENT #101 DID NOT HAVE ANY NEW ORDERS. HOSPICE NURSE #5 FOUND RESIDENT #101 NON-RESPONSIVE IN BED, SNORING, WITH SHALLOW RESPIRATIONS AND 5 TO 10 SECOND PERIODS OF APNEA. RESIDENT #101'S SKIN COLOR WAS GRAY AND HER LIPS AND NAILBEDS APPEARED DUSKY. THERE WAS DIFFICULTY OBTAINING RESIDENT #101'S PULSE OXIMETRY AND HER BLOOD PRESSURE WAS 60 SYSTOLIC. HOSPICE NURSE #5 CALLED THE HOSPICE PHYSICIAN TO REPORT THE MEDICATION ERROR AND THE HOSPICE DOCTOR SENT RESIDENT #101 TO THE HOSPITAL FOR INTRAVENOUS (IV) SUPPORT AND [MEDICATION NAME] ADMINISTRATION. RESIDENT #101 SUBSEQUENTLY died AT THE HOSPITAL DUE TO [MEDICAL CONDITION]. THE AMBULANCE 911 "RUN SHEET", DATED [DATE], DOCUMENTED THAT THE 911 CENTER RECEIVED A CALL FROM THE FACILITY ON [DATE] AT 8:21 AM AND ARRIVED ON SCENE AT 8:28 AM. HOSPITAL RECORDS, DATED [DATE], NOTED THAT A REPORT WAS RECEIVED FROM HOSPICE NURSE #5 REGARDING RESIDENT #101 GETTING 4 DOSES OF [MEDICATION NAME] SULFATE BY MISTAKE AT NIGHT. RESIDENT #101 ARRIVED AT THE HOSPITAL AT 9:22 AM ON [DATE]. RESIDENT #101 WAS treated for [REDACTED]. ACCORDING TO THE EMERGENCY DEPARTMENT PHYSICIAN NOTES, DATED [DATE], THE RESIDENT'S "ASSOCIATED Diagnoses: [REDACTED]. THE POLICE INVESTIGATION REPORT (CASE # 12:0056), DATED [DATE], WAS REVIEWED. AN INTERVIEW WITH THE POLICE DEPARTMENT (PD) DETECTIVE #7 WAS CONDUCTED ON [DATE] AT 1:15 PM. PD DETECTIVE # 7 STATED THAT HE RESPONDED TO THE SCENE ON [DATE] AND SAW THAT RESIDENT #101 WAS UNRESPONSIVE. AN AMBULANCE TOOK RESIDENT #101 TO THE HOSPITAL. HE FURTHER STATED THAT RESIDENT #101 "RECEIVED 4 DOSAGES OF [MEDICATION NAME] SULFATE THAT WAS FOR A DIFFERENT PATIENT." ON [DATE] AT 4:45 PM, THE ADMINISTRATOR AND THE DIRECTOR OF NURSING WERE INFORMED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON [DATE] AS A RESULT OF THE FACILITY'S FAILURE TO PREVENT A SIGNIFICANT MEDICATION ERROR FROM OCCURRING TO RESIDENT #101, RESULTING IN HOSPITAL TRANSFER FOR A [MEDICATION NAME] SULFATE OVERDOSE. THIS DEFICIENT PRACTICE HAD THE POTENTIAL TO EFFECT 3 ADDITIONAL RESIDENTS ON HOSPICE CARE WHO HAD PHYSICIAN ORDERS [REDACTED]. RESIDENT #101 SUBSEQUENTLY died THE SAME DAY. ON [DATE], THE SURVEYOR CONFIRMED THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. ON [DATE] AND [DATE], ALL RESIDENTS' NEW AND OLD MEDICATIONS, WHICH WERE ON THE MAR, WAS REVIEWED BY UNIT NURSE MANAGERS. THERE WERE NO MEDICATION ERRORS FOUND. 2. ON [DATE], 64 OF 69 NURSES WERE EDUCATED OF THE FIVE RIGHTS TO MEDICATION PASS, AS THEY PERTAIN TO THE ORDER ENTRY PROCESS. ON [DATE], THE 5 REMAINING NURSES WERE CALLED TO COMPLETE THEIR EDUCATION ON THE FIVE RIGHTS TO MEDICATION PASS AS THEY PERTAIN TO THE ORDER ENTRY PROCESS. 3. NURSES, WHO WERE IDENTIFIED IN THE MEDICATION ERROR, WERE INSERVICED ON [DATE] (ON FIVE RIGHTS AND QUESTIONING THE DOSAGE) , [DATE] (FIVE RIGHTS PERTAINING TO COMPUTER ENTRY) AND [DATE] (ON FIVE RIGHTS AND QUESTIONING THE DOSAGE). 4. AS OF [DATE], NURSE MANAGERS WERE EDUCATED BY THE DIRECTOR OF NURSING (DON) ON THE PROCESS OF VERIFYING THAT NEW ORDERS HAVE BEEN ENTERED INTO THE RIGHT RESIDENT'S ELECTRONIC MAR indicated [REDACTED]'S EMAR. THIS SYSTEM WILL CONTINUE UNTIL ALL NURSES ARE EDUCATED ON THIS PROCESS. NEW NURSES WILL BE EDUCATED DURING THEIR ORIENTATION PROCESS. THIS VERIFICATION PROCESS INVOLVES ENTERING THE INFORMATION INTO THE NEW ORDER SECTION OF THE COMPUTER SOFTWARE, THEN VERIFYING THAT THE ORDERS MATCH THE RESIDENT'S NAME AND PHOTO WITH THEIR [DIAGNOSES REDACTED]. IF THERE IS A NOTED DISCREPANCY, THE DON IS TO BE NOTIFIED IMMEDIATELY. 5. THE DIRECTOR OF NURSING AND ADMINISTRATOR ARE RESPONSIBLE FOR COMPLIANCE. WHILE THE IMMEDIATE JEOPARDY (IJ) WAS REMOVED ON [DATE], THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF "WIDE SPREAD" AND A SEVERITY OF "NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY" UNTIL SUSTAINED COMPLIANCE CAN BE VERIFIED BY STATE AGENCY. ( )

BASED ON INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO IMPLEMENT INTERVENTIONS TO PREVENT FALLS FOR 1 RESIDENT (#4) OF 8 RESIDENTS REVIEWED FOR FALLS FROM A TOTAL SAMPLE OF 30 RESIDENTS RESULTING IN RESIDENT #4 SUSTAINING A FRACTURED LEFT HIP, SUBARACHNOID HEMORRHAGE AND A DECLINE IN HER AMBULATORY STATUS. FINDINGS INCLUDE: ACCORDING TO THE FACILITY FACE SHEET DATED 4/28/11 RESIDENT #4 WAS AN [AGE] year OLD FEMALE WITH DIAGNOSES THAT INCLUDED, CLOSED FRACTURE FEMUR, ALZHEIMER'S DISEASE, PERSONAL HISTORY OF FALLS AND HYPERTENSION. A REVIEW OF THE FACILITY INCIDENT AND ACCIDENT REPORT FOR RESIDENT #4 DATED 1/13/11 REFLECTED THAT THE RESIDENT WAS OBSERVED ON THE FLOOR, SECTION 4 OF THE INCIDENT AND ACCIDENT REPORT TITLED "OVERALL CONCLUSION" REFLECTED, "P.M. SHIFT REPORTS OBSERVING RESIDENT ON THE FLOOR IN FRONT OF THE COUCH IN SITTING ROOM. NO INJURIES NOTED." ON THE SAME FORM UNDER THE SECTION TITLED "PLAN OF ACTION" REFLECTED, "FALL INTERVENTION CURRENTLY IN PLACE...CARE PLAN REVIEWED. WILL CONTINUE WITH CURRENT PLAN OF CARE". THE INCIDENT AND ACCIDENT REPORT DATED 1/26/11 REFLECTED THAT THE INVESTIGATION SECTION OF THE FORM WAS LEFT BLANK, SECTION 4 TITLED "OVERALL CONCLUSION" REFLECTED, 'P.M. SHIFT REPORTS OBSERVING RES (SIC) SITTING ON FLOOR WITH BACK AGAINST WALL. NO REPORTED INJURIES, RES (SIC) KNOWN TO AMB (SIC) INDEP (SIC) ON UNIT OFTEN VISITS OTHER ROOMS." THE PLAN OF ACTION FOR THE FALL WAS THE RESIDENT HAD HIPSTERS IN PLACE, CARE PLAN REVIEWED, CONTACT HUSBAND AND ADDRESS WITH INTERDISCIPLINARY TEAM. THE INCIDENT AND ACCIDENT REPORT DATED 1/31/2011 REFLECTED THAT RESIDENT #4 LOST HER BALANCE AND fell LEAVING THE DINING ROOM. SECTION 2 AND 3 OF THE FALL INVESTIGATION HAD BEEN LEFT BLANK. SECTION 2 PERTAINS TO INFORMATION REGARDING MEDICATIONS AND SECTION 3 PERTAINS TO PSYCHOSOCIAL FACTORS. SECTION 4 TITLED "OVERALL CONCLUSION" REFLECTED, "AM STAFF REPORTS RESIDENT WALKING LOST HER BALANCE AND fell . BRUISE TO RIGHT ELBOW HISTORY OF MULTIPLE FALLS, WEARS HIPSTERS, SEVERAL INTERVENTIONS IN PLACE".THE PLAN OF ACTION FOR THE FALL WAS TO ADMINISTER TYLENOL. THE INCIDENT AND ACCIDENT REPORT DATED 3/5/11 REFLECTED THE RESIDENT WAS LYING IN THE HALLWAY CRYING. SECTION 4 TITLED "OVERALL CONCLUSION" REFLECTED THAT THE RESIDENT WAS IN ANOTHER RESIDENTS ROOM ON THE FLOOR CRYING AND STAFF OBSERVED HER ON THE FLOOR, THE RESIDENT HAD A 1 CENTIMETER RED AREA TO THE RIGHT SIDE OF NOSE AND A RAISED AREA ON THE RIGHT SIDE OF HER FOREHEAD. "CARE PLAN READS STANDBY." ON THE SAME FORM UNDER THE SECTION TITLED "PLAN OF ACTION" REFLECTED, "CARE PLAN ADJUSTED TO REFLECT RESIDENTS AMB (SIC) STATUS." THE INCIDENT AND ACCIDENT REPORT DATED 4/12/11 REFLECTED THE RESIDENT WAS "OBSERVED LYING ON THE FLOOR ON HER LEFT SIDE". SECTION 4 TITLED "OVERALL CONCLUSION" REFLECTED THAT THE RESIDENT PRESENTED WITH CLINICAL SIGNS OF A SEIZURE. ON THE SAME FORM UNDER THE SECTION TITLED "PLAN OF ACTION" REFLECTED A REVIEW OF THE CARE PLAN AND MONITOR FOR ANY SIGNS OF SEIZURE LIKE ACTIVITY. AS A RESULT OF THE FALL THE RESIDENT WAS TRANSFERRED TO THE HOSPITAL. THERE WAS NO DIAGNOSES OF SEIZURE DISORDER FOUND IN THE CLINICAL RECORD AND HOSPITAL RECORDS. THERE WAS NO PAST HISTORY OF SEIZURE DISORDER AND NO DOCUMENTED SIGNS OR SYMPTOMS OF SEIZURE DISORDER. ACCORDING TO THE CLINICAL RECORD, THE HOSPITAL OPERATIVE REPORT DATED 4/15/2011 REFLECTED THAT THE resident underwent [REDACTED]. THE FACILITY HISTORY AND PHYSICAL DATED 4/28/11 REFLECTED THE ..."AFTER FALLING WAS TRANSFERRED TO HOSPITAL AND FOUND TO HAVE A CLOSED FRACTURED LEFT HIP AND UNDERWENT PERCUTANEOUS PINNING AS WELL AS A SUBARACHNOID HEMORRHAGE..." THE FALL CARE PLAN DATED 10/18/10 IDENTIFIED THE RESIDENT AT BEING AT RISK FOR FALLS WITH THE FOLLOWING INTERVENTIONS: ASSIST TO TOILET, ENCOURAGE RESIDENT TO EXPRESS FEARS, FEELINGS, EXPLAIN PROCEDURES AND PROVIDE ACCURATE DESCRIPTIONS OF TASKS THAT RESIDENT IS TO PERFORM, ASSESS FOR DIZZINESS, IF FALL OCCURS ASSESS FOR CIRCUMSTANCES OF FALL, KEEP ROOM WELL LIT AND FREE OF CLUTTER, HIPSTERS ON WHILE UP AND DRESSED, CONFER WITH RESTORATIVE DEPARTMENT REGARDING FOR SAFETY EQUIPMENT. ON 10/13/11 AT 10:30 A.M., DURING AN INTERVIEW WITH THE UNIT MANAGER STAFF MEMBER "A" SHE REPORTED THAT PRIOR TO THE RESIDENT SUSTAINING THE FRACTURE THE RESIDENT REQUIRED SUPERVISION, BUT THE RESIDENT WAS INDEPENDENT AND DID NOT REQUIRE THE ASSISTANCE OF A WALKER, OR GAIT BELT AND HAD A BED ALARM SO THAT STAFF WOULD KNOW WHEN SHE GOT UP SO THAT THEY COULD SUPERVISE HER. ON 10/13/11 DURING AN INTERVIEW WITH THE PHYSICAL THERAPIST ("H"), WHO TREATED RESIDENT #4'S POST FRACTURE, HE REPORTED THAT DUE TO THE RESIDENTS ANXIETY SHE NEVER REGAINED HER PREVIOUS AMBULATORY STATUS. DESPITE HIS EFFORTS AND THAT OF THE RESIDENTS HUSBAND WHO ATTENDED THE THERAPY SESSIONS DAILY, RESIDENT #4 DID NOT RETURN TO HER PREVIOUS AMBULATORY FUNCTIONING LEVEL. ON 10/14/11 AT APPROXIMATELY 10:00 A.M. DURING AN INTERVIEW AND CHART REVIEW WITH THE DIRECTOR OF NURSING, THE RESTORATIVE NURSE STAFF "D" AND THE PHYSICAL THERAPIST STAFF "G" WHO BOTH HAD WORKED WITH RESIDENT #4 PRIOR TO THE LEFT HIP FRACTURE IT WAS REVEALED THAT AFTER EACH ONE OF RESIDENT'S PAST FALLS SINCE JANUARY 2011, THE CARE PLAN HAD NOTATIONS OF DATES AND INITIALS OF STAFF STATING, "REVIEWED". BUT NOWHERE DID IT REFLECT ANY REVISIONS OR MODIFICATIONS TO PREVENT FURTHER FALLS. A physician's orders [REDACTED]. STAFF "G" CONFERRED THAT ORDER WAS NOT DISCONTINUED AT ANY TIME AND THE RESIDENT REQUIRED THE ASSISTANCE. THIS WAS NOT INTEGRATED INTO THE CARE PLAN. THE DIRECTOR OF NURSING AND STAFF "D" WERE UNABLE TO STATE WHY THE RESIDENT HAD MULTIPLE FALLS WITHOUT THE NECESSARY SUPERVISION REQUIRED. EACH OF THE INCIDENT AND ACCIDENT REPORTS WERE REVIEWED, THE DIRECTOR OF NURSING WAS UNABLE TO STATE OR PROVIDE DOCUMENTATION AS TO WHAT INTERVENTION WAS PUT IN PLACE OR WHAT WAS MODIFIED TO PREVENT FURTHER FALLS. STAFF "D" STATED THEY HAD DISCUSSED THIS AT INTERDISCIPLINARY TEAM MEETINGS, DOCUMENTATION OF THE MEETINGS WERE REQUESTED BUT NOT PROVIDED DURING THE SURVEY. ( )