Every finding on record at Medilodge of Montrose Inc

This citation pertains to Intake Numbers 3108936 and 3155120. Based on interview and record review, the facility failed to ensure that 2 resident's (Resident #109 and Resident #112) Power of Attorney/POA or Guardian was contacted in a timely manner after a fall and an allegation of abuse of 3 residents reviewed for representatives contacted after an incident, resulting in Resident #112's POA's verbalization of anger regarding not being informed of a fall with hospitalization, and Resident #109's guardian not being contacted after event of neglect occurred. Findings Include: Intake Number 3155120: Resident #112: Review of the facility Face Sheet, care plans, dated 2022 through current, and Incident Report dated 8/8/26, Resident #112 was [AGE] years old, alert x1 only with a Power of Attorney/POA in place, non-ambulatory and required assistance with all Activities of Daily Living (ADL). The resident's diagnosis included Dementia, chronic heart and lung disease, diabetes, chronic pain and anxiety. Review of the facility Incident Report dated 8/8/26 revealed on 8/8/26, the resident was found on the floor of her room, she had fallen with no visual injuries noted. The resident was transferred to the hospital for evaluation. At the hospital she was diagnosed with fracture of leg. Review of the facility Incident Report dated 8/8/26, revealed staff member Nurse, LPN G called and informed Family Member #2 of the fall and transfer to the hospital on 8/8/26 at 18:10 (6:10 p.m.). The report also had documentation dated 8/8/26 of the POA being called at 17:56 (7:56 p.m.), no notes or addendum was documented on the bottom of the sheet when it was given to this surveyor on 8/12/26. During a phone interview done on 8/11/26 at 3:30 p.m., Nurse G stated My DON (Director of Nursing) just asked me if I called the POC (Family Member #1) yesterday (DON asked her on 8/10/26) and asked me that. No, I did not, I looked on the face sheet, and it was confusing; I called the emergency contact (Family Member #2). During an interview done on 8/12/26 at 12:00 p.m., Nurse Unit Manager, LPN H stated I put the POA (Family Member #1) in on 8/8/26. Review of the facility Incident Report (electronic program used by facility) sheet dated 8//8/26, 8/11/26 and 8/12/26, revealed Unit Manager H revision date was 8/11/26; this was the date she had put in the system POA/Guardian had been called by the facility. During the interview done on 8/12/26 at 12:00 p.m., Nurse Unit Manager H also stated I put the addendum today (on 8/12/26), the DON asked me to put it in today. I should of put it in under the progress notes, I will never do that again. We regularly go over all the incident reports and add to them. Manager H said she knew the POA should have been contacted, not the emergency contact, that's why she was asked to correct it on the incident report dated 8/8/26. Review of a second copy of the facility Incident report regarding resident #112's fall, given to this surveyor on 8/12/26, revealed an added addendum dated 8/12/26 on the bottom of the first sheet stating, addendum and correction to POA/Guardian (Family Member #1) notification on 8/8/26 17:56; (Family Member #1) was spoken to on 8/10/2026 at 10:30 AM. During a phone interview done on 8/12/26 at 9:10 a.m., Family Member #1 stated They (facility) didn't even call me, the hospital called and told me she (Resident #112) was there, that really tore me up, I am not happy with them, that was not right. Family Member #1 was clearly listed on page 2 of the residents' face Sheet as the POA. During an interview done on 8/12/26 at 12:29 p.m., the Director of Nursing/DON stated, I questioned the fact that the POA was notified on 8/8, I told her (Nurse Unit Manager H) that if it was charted incorrectly, she should put in an addendum. There is not policy on how to do incident reports. I should have given more clear instructions; I am part of the QA team (Quality Assurance Team). Review of the facility Notification of Changes policy dated 8/29/24, stated Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the residents' physician; and notifies, consistent with his or her authority, residents' representative when there is a change requiring notification. Circumstances requiring notification include Accidents, resulting in injury. Intake Number 3108936: Resident #109: Record review of Resident #109's medical diagnosis list included: dementia, malnutrition, psychotic disorder, history of falls, hallucinations, major depressive disorder, and insomnia. Record review of Resident #109's Incident report, dated 7/13/2026 at 1:20 PM, revealed that staff made an allegation of neglect on behalf of Resident #109 against the Sunday night shift staff. Facility staff reported that the resident was still in the same clothes and seated at the dining room table when they arrived for their shift. Sunday night staff were suspended immediately pending investigation. The resident remained safe in the facility. The Power of Attorney (POA)/Guardian was notified on 7/14/2026 at 10:00AM. Observation on 8/11/2026 at 9:20AM of Resident being taken to the restroom by 2 CNAs, observed buttocks area with skin intact. Record review of Resident #109's progress notes, dated 7/13/2026 at 2:23PM, revealed a skin issue: new skin issue to buttocks generalized Moisture Associated Skin Damage (MASD) in-house acquired, painful yes. Area cleansed with soap and water and barrier cream applied. Measurements: 15.05cm length x 8.95cm width x 0.0 depth. In an interview on 8/12/2026 at 10:25AM, Registered Nurse (RN)/Wound Care Nurse F stated that on 7/13/2026 she did observe Resident #109's buttocks after being left up in a wheelchair over night with no brief changes. Resident #109's skin was fiery red, hot to touch and skin was peeling. Photographs were taken of the buttock damage. RN F staged the skin issue as Moisture Associated Skin Damage (MASD) measurements on 7/13/2026 were 15.05cm in length x 8.95cm width x 0 depth. On 7/15/2026 record review of Resident #109's buttocks photograph was still red in buttocks clevis measurements were 16.62cm in length x 4.92cm in width x 0.1 depth. She was left up in a wheelchair for extended period of time, 12 hours all night with no brief changes/peri care given. An interview on 8/12/2026 at 1;00PM with Nursing Home Administrator revealed that the Notification of the responsible party was not until 7/14/2026 at 10:00AM and documented. Record review of 'Notification of Change' policy dated 8/29/2024 revealed the purpose of the policy was to ensure that the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, resident's representative (guardian) when there is a change requiring notification. Merriam Webster dictionary definition of Promptly: with little or no delay; immediately. Cambridge dictionary definition of promptly- quickly without delay.

This citation pertains to Intake Number 3108936. Based on observation, interviews and records review, the facility failed to immediately notify the abuse coordinator of the alleged neglect of one resident (Resident #109) of 3 residents reviewed, resulting in a delay of 7 hours in staff reporting neglect to the abuse coordinator. Findings include: Resident #109:Record review of Resident #109's medical diagnoses list included: dementia, malnutrition, psychotic disorder, history of falls, hallucinations, major depressive disorder, and insomnia. Record review of Resident #109's Incident report, dated 7/13/2026 at 1:20PM, revealed that staff made an allegation of neglect on behalf of Resident #109 against the Sunday night shift staff. Facility staff reported that the resident was still in the same clothes and seated at the dining room table when they arrived for their shift. Night staff were suspended immediately pending investigation. Resident #109 remained safe in the facility. The Nursing Home Administrator/Abuse coordinator were notified on 7/13/2026 at 1:20PM. In an interview on 8/12/2026 at 9:03AM, Registered Nurse (RN) C revealed she worked a 12-hour day shift and gave shift report at 6:00 PM to the oncoming nurse and Resident #109 was seated up in her wheelchair in the common area as RN C was leaving the unit. RN C stated that she picked up an extra 8 hour shift the next day. RN C stated she came into the unit and saw Resident #109 seated up in the wheelchair in the same spot and clothes. Resident #109 was turned toward the camera all night. RN C came back to work and saw Resident #109 in the same clothes, same spot. RN C told the day shift Certified Nurse Assistant (CNA) to get Resident #109 back to her room and get her cleaned up. The resident needed her brief changed right away. No one touched Resident #109 for 12 hours, no incontinence care, did not lay her down for bed. RN C did a skin assessment on Resident #109, and her bottom was red. Staff put zinc on the buttocks, and it healed. The management took photographs and IRN C stated that she gave a statement to management. Five staff were fired. RN C stated that all staff Education on neglect- were educated on neglect and to check our residents every 2 hours, and especially Resident #109. The staff are more conscious of checking residents and their needs. It is making a big difference for the residents. An interview on 8/12/2026 at 1;00PM with Nursing Home Administrator (NHA)/Abuse coordinator revealed that she was made aware of Resident #109's alleged neglect on 7/13/2026 at 1:20 PM and not at 6 AM when the allegation was made and the facility educated all staff on 'Timely reporting of abuse allegations' on 7/13/2026 and reported to the MI-FRI agency. Date of Compliance 7/14/2026. Record review of sampled residents who had falls incident reports were reviewed for timely reporting. PNC Statement:During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included. termination of two licensed nurses and three certified nurse assistants from employment, all staff education on the immediate reporting of abuse/neglect to the abuse coordinator, posted signs with phone number and 24 hour access to call anytime. Observed posted sign reporting phone number signs in public and staff restrooms, on bulletin boards/white boards and at nursing stations and hallways. Interviewed direct care staff for reporting process/procedure and to whom. Quality Assurance and Process Improvement was involved in meeting the compliance goals. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to Intake Number 3033898. Based on observation, interview, and record review, the facility failed to 1) Consistently provide the prescribed mechanically altered diet as ordered and 2) Follow the resident's stated dining preferences for one resident (Resident #5) of three residents reviewed for nutrition maintenance and resident preferences.Findings include: Resident #5 (R5):A record review of the face sheet and Minimum Data Set (MDS) assessment indicated R5 was admitted to the facility on [DATE] with diagnoses: gastro-esophageal reflux disease (GERD/ stomach acid back up), fracture of first lumbar (back) vertebra, hyperlipidemia (high cholesterol), history of protein-calorie malnutrition, oropharyngeal dysphagia (difficulty swallowing), lung cancer stage IV, congestive heart failure (CHF / decreased ability of heart to pump blood), and hypertension (high blood pressure). The MDS assessment dated [DATE] indicated the resident had moderate cognitively impairment with a Brief Interview for Mental Status (BIMS) score of 12/15 and required assistance with care and a mechanically altered diet.06/15/2026 at 12:47PM, an observation of R5 sitting in bed with lunch tray on tray table. The meal tray had a plate with a cubed-up BBQ pork sandwich (0% consumed), mashed potatoes (100% consumed), an empty cup that held vanilla pudding (100% consumed), a bowl of sliced peaches (0% consumed), a glass of water and a glass of juice both full. When R5 was asked about her meal she said she was done eating. R5 was queried about the untouched food on her tray she said she ate as much as she could and I can't eat that and pointed to the sandwich, when asked why she responded, I can't eat tomatoes-based food and referred to the sauce and issues with her stomach.A record review of the meal ticket revealed on the resident information side: Diet order: level 3/Advanced, small portions; Alerts: provide verbal food/drink location on tray; set-up assistance; supervision; Dislikes: juice, oatmeal, raw fruits & vegetables (pineapple, broccoli, peas), eggs, coffee, milk; standing orders: 4 oz health shake, mash potatoes (with gravy), 1/2 C. pudding, 8 oz water. and on the daily lunch order side nothing was circled, the daily special was listed as BBQ pork sandwich. On 06/16/2026 at 8:26AM, during an observation of R5, her breakfast tray was sitting in front of her, she said she was full and that she had eaten all that she could. R5 said she cannot eat a lot because of her stomach issues and because she had cancer, she said she struggles with some foods. R5 continued to explain she does not tolerate tomatoes or tomato based foods or butter on her toast. She said I don't eat yogurt, milk or (points to dry bowl of corn flakes). Observed on her meal tray was an empty pudding cup, an empty 4 oz mighty shake, a full bowl of corn flakes, a full glass of milk, 2 pieces of dry toast cut in half diagonally, an unopened strawberry jelly packet, a full cup of pink yogurt, a full glass of orange juice, and a full a glass of water.A record review of the meal ticket revealed on the resident information side: Diet order: level 3/Advanced, small portions; Alerts: provide verbal food/drink location on tray; set-up assistance; supervision; Dislikes: juice, oatmeal, raw fruits & vegetables (pineapple, broccoli, peas), eggs, coffee, milk; standing orders: corn flakes , 4oz. health shake,1/2 C pudding, 1 sl (slice) of toast (with jelly ) no butter), 8 oz. water. On the daily breakfast order side nothing was circled, the daily special was listed as egg, bacon and cheese on an English muffin. On 06/16/2026 at 8:28AM, During an interview with Nurse B they said they were familiar with the resident and when asked said that R5 does not typically eat a lot. Nurse B said R5 had stomach issues and had medication scheduled and prn (as needed). According to a record review of R5's physician orders: revised 05/04/2026: Regular diet, Level 3 texture, Regular fluid, thin consistency with Directions: small portions, 5 small meals daily.According to a record review of the facilities provided National dysphasia diet level 3: advanced was defined as: The diet consists of foods of varying textures with the exception of very hard, sticky, or crunchy foods. Foods need to be served moist, ground, chopped or in bite size pieces (less than 1 inch) . with Considerations for specific food items: Bread- plain bread or rolls must be served with margarine. Sandwiches must be served with a condiment spread on the bread; Toast- restricted from the diet and noted Meals need to be modified to suit individual resident tolerance. and Individual preference needs to be considered when planning the patient meal.According to a record review of the attached food guide list reference for the National dysphasia diet level 3: advanced listed under the categorized food group-recommended-avoid: Grains: recommended- any well moisten breads, biscuits, muffins, pancakes, waffles etc.; Need to add adequate syrup, jelly, margarine, butter etc. to moisten well. All well moistened cereals. Avoid- Dry bread, toast, and crackers etc.; Course or dry cereal.According to a record review of R5's care plan: Focus: (R5) has an ADL self-care performance deficit related to decreased. functional mobility and physical limitations. with Interventions: EATING: tray setup assist, supervision/cueing as needed. And Focus: (R5) is at risk for altered nutritional status related to my appetite is poor which may be r/t pneumonia, nausea & pain from vertebra fractures. history of acid reflux. Weight loss since admission due to feeling sick to my stomach upon eating, inability to eat a full meal . Newly diagnosed with stage IV cancer. with Interventions: Provide meals/fluids based on resident food preferences and as ordered-five small meals daily-encourage food intake & fluid intake prn (as needed) -consistently eats cottage cheese 100%--sending with lunch and dinner; Let the resident know where food is located on the tray; Observe percentage of meal intake for changes in eating habits; Provide assistance with meals as needed. And Focus: Resident is at risk for malnutrition as evidenced by Mini Nutritional Assessment (MNA) score 8 (8-11 points: At risk of malnutrition) with Interventions: Provide diet as ordered. Focus: (R5) has an impaired gastrointestinal status related to gastroesophageal reflux disease. with Interventions: Diet as ordered.According to a record review of R5's recorded weights revealed: June 5 weight 99.4; May 5 weight 99.6; April 5 weight 101.6; March 23 weight 99.1; February 24 weight 100.0; January 29th weight 107.4 at admission.A record review of R5's nutrition- amount % eaten in the electronic medical record (EMR)14-day look back, dated 06/03/2026 to 06/16/2026, revealed: 3 meal percentages recorded for each of the following days: 3rd,6th,7th,8th,9th,10th,11th,12th,14th and 15th.2 meal percentages recorded for each of the following days: 5th and 13th.1 meal percentages recorded for each of the following days: 4th and 16th.For a total of 35 documented meals served of 74 ordered. At no time during the look back time were 5 meals a day documented as ordered and care planned.On 06/16/2026 at 10:00AM, during an interview, Dietary Aide F was asked about the process for meal tickets. Dietary aide F explained that on second shift, the staff go take residents' orders (he was not sure if it was weekly of nightly) and those are put into the pink binder, the kitchen staff gets the pink binder, reviewed the ticket and whatever was on the ticket was what got served to the resident. If nothing is circled on the daily side alternate menu, the resident would get the daily special. Dietary Aide F explained the standing orders were the minimum of what was placed on the resident's tray and said they have to follow the dislike and allergy instructions. Dietary Aide F was asked what a level 3 advanced diet meant and he said, 'it was thin, or small diced and not big chunks of food' and that residents on that diet would likely have a choking concern. When asked who decided what was placed on the resident's information side of the meal tickets, he said Dietetic Technician (DT) C. On 06/16/2026 at 10:23AM, during an interview with DT C she was asked if R5 who was on level 3 advanced diet and could have dry toast. She said if it was severed with something to soften it like, jelly or syrup. DT C agreed that it needed to cut into bite sized pieces. DT C was asked when the 5 small meals were served and monitored. She said the 3 main meals are the regular times of meal service and that the additional meals were a scheduled snack and were served in-between breakfast and lunch and between lunch and dinner. On 06/16 at 10:40AM, during an interview, the DON she was asked to review the Level 3 diet guidelines she provided, and she agreed that according to the guidelines that R5's toast should have been jellied and cut up prior to service to the resident. After the DON was advised on the finding of milk and juice on the resident's tray despite the dislikes present on the ticket, and in that addition on more than one occasion the resident has said she cannot tolerate tomato or tomato-based products and will not eat them, the DON said she would update the dislikes for the resident and make sure her diet is correct. On 06/16 at 11:35AM, during an interview the DON was asked if R5 should have received her 2nd meal today since it was close to lunch and she said she was not sure if she had or not. During an observation of R5 with the DON, R5 was asked if she had her meal between breakfast and lunch today and she said, she didn't think so. Observation revealed that there is no meal or snack tray in R5's room.On 06/16/2026 at 12 noon, R5 was observed resting in bed with eyes open, on her over-bed tray was a crustless peanut butter and jelly sandwich cut once in half on a plate cover in cling wrap with the resident's name and room number on it. R5 was asked why she did not eat the sandwich, and she stated it was because it was not opened. On 06/16/2026 at 12:09PM - 12:15 PM, observed lunch service for R5 by CNA H who had R5's food tray. When CNA H uncovered the plate and set up the tray, R5 said I can't eat that and R5 pointed to the goulash on the plate and said it has tomatoes and I have stomach issues and diverticulitis (although that is not a documented diagnosis currently). CNA H started to take the plate away as she stated, I can see if they have something else for you and R5 said no. She wanted to eat the potatoes and started eating. CNA G entered the room and CNA H told CNA G that R5 said she can't eat the red stuff to which CNA G replied That's ok she only eats her pudding and potatoes anyway. CNA G was queried regarding the resident's statement, that she cannot 'tolerate' the tomato base, which did not mean that she did not want to eat something else, CNA 'G looked at R5's meal ticket and said, I don't see that on there.On 06/16/2026 at 12:25PM, during a follow up interview with the DON about the peanut butter and jelly sandwich observation and interview and the lunch food tray that had goulash on it, the DON said she meant to fix the ticket to include no tomato and tomato products, but the order did not make it in time for the lunch tray. The DON was queried about the lunch observation, and she said that was not acceptable. The CNA should have offered the resident an alternative and reported the intolerance reported. On 06/16/2026 at 12:32PM, during an interview with the DT C and Dietary Director (DD) D, the DT C said that either the Regional Dietary Director (RDD) E, DD D or herself review the resident food preferences, dislikes and allergies with assessments. When she was asked how often residents had those assessments, DT C said on admission, with a significant change and quarterly. DT C said that if the staff make herself or DD D aware of an issue they would make adjustments. When DTC was advised R5 said 'that she didn't eat the peanut butter and jelly because it was not open' and that it had been placed on R5's over bed tray with the cling wrap still on it, DT C said did you ask if she wanted it then, maybe she wanted it later? DT C was advised the sandwich was cut in half and not cut into bite sized pieces, and it was not open.At 12:51 DT C asked to add RDD E to the interview via phone call. The interview continued with RRD E. The RRD E was asked about R5's ordered and care-planned 5 small meals a day and how those where documented. RRD E said the snacks are not documented and when queried that the order stated 5 small meals, and if the 3 (breakfast, lunch and dinner) meals intake was documented, then why the documentation was not there for the 2 additional in-between scheduled meals order for a resident who was at risk for malnutrition. RRD E she didn't look at snacks when she considered diet regulation. RRD E was asked if it should be tracked since it is an intervention to a health concern and is ordered as part of the resident's diet. She said yes. She could see why that was necessary. RDD E was asked if toast cut in half with no condiment on it to soften the toast could be served to a level 3 diet. She said no. It has to be served cut up and with something on it to soften it ahead of serving it to resident and agreed that the toast had to be cut up in 1-inch pieces, and the jelly could not just be added to the resident's tray to apply themselves. The same would apply to the peanut butter and jelly needed to be cut as diet level 3 guidelines. When she was asked about the intolerance and dislikes being updated for R5, RRD E suggested that DD D meet with R5 and make sure it was updated so she would not continue to receive unwanted or non-tolerated foods.At 12:58 the RRD E left the interview, and it continued with the DT C and DD D when asked they agreed that when a resident was ordered a diet for medical purposes such as dysphasia, malnutrition, weight loss etc. their intake should be monitored as ordered. When asked about R5 and why she continued to received items she had voiced concerns over several times, DT C said the CNA from earlier had been re-educated already and the DD D said she planned to meet with R5 and update her preferences, dislikes and intolerances as the RDD E suggested. A record review of the facilities policy labeled Therapeutic diet orders revealed: Policy: The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences; Definitions: Mechanically Altered Diet is one in which the texture or consistency of food is altered to facilitate oral intake. Examples include soft solids, pureed foods, ground meat, and thickened liquids; Therapeutic Diet is a diet ordered by a physician, or delegated registered or licensed dietitian, as part of treatment for a disease or clinical condition. ; 5. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed.A record review of the facilities policy labeled Nutritional Management revealed: Policy: The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition; Definitions: Acceptable parameters of nutritional status refers to factors that reflect that an individual's nutritional status is adequate, relative to his/her overall condition and prognosis, such as weight, food/fluid intake, and pertinent laboratory values; Compliance Guidelines: 1. d. Monitoring the effectiveness of interventions and revising them as necessary; 4. Care plan implementation: a. The resident's goals and preferences regarding nutrition will be reflected in the resident's plan of care; Monitoring/revision: a. Monitoring of the resident's condition and care plan interventions will occur on an ongoing basis. Examples of monitoring include: a. ii. Directly observing the resident. iii. Interviewing the direct care staff to gain information about the resident, the interventions currently in place, what their responsibilities are for reporting on these interventions, and possible suggestions for changes if necessary.

This citation pertains to intake Numbers 3009454 and 3009709. Based on observation, interview and record review, the facility failed to ensure that Restorative Therapy for range of motion ROM) and splint application were provided, as ordered, for one resident (Resident #105), of three residents reviewed for positioning. Findings include:Resident #105 (R105):On 5/26/26 at 11:00 AM, an observation was made of R105 lying in bed with a gown on. The Resident was lying on his back at this time. The Resident was clean, had no odors. The Resident did not respond to questions but made eye contact, followed with his gaze, and responded by smiling. The Residents arms and hands were placed on top of the blankets and hands were closed in a fist. The head of the bed was elevated and enteral nutrition was infusing. An observation was made of a hand splint on the top of a set of drawers, positioned under the television. On 5/27/26 at 11:05 AM, an observation was made of R105 dressed and in a reclining wheelchair in the common area where the Resident could visualize the TV. The Resident was observed without the splint on his hand. An observation was made in the Resident's room of the hand splint on the top of the chest of drawers under the TV. A review of Resident 105's medical record revealed an admission into the facility on [DATE] and readmission on [DATE] with diagnoses that included traumatic hemorrhage of right cerebrum, disorder of the autonomic nervous system, neurocognitive disorder and aphasia. A review of the Minimum Data Set assessment revealed the Resident had severely impaired cognitive skills for daily decision making and was dependent on a helper for activities of daily living, mobility, and transfers. Review of the Resident's orders revealed an order for Restorative Nursing: On 5/27/26 at 9:03 AM, an interview was conducted with Confidential Person (CP) E regarding Resident 105's care at the facility. The CP reported that they have come to visit for long hours during the day and staff have not come in to reposition the Resident while they were there and stated, We are never going to stop them from doing their job, he was to be repositioned every two hours. No one came in there while we were there, reported being there for a large portion of the day. When asked about physical therapy, the CP reported the Resident was no longer getting physical therapy and they were to be doing exercises with him. The CP reported when they questioned why he was not getting his exercises done, the staff would tell them they were short staffed and pulling staff to work the floor, Were short staffed, they would say that all the time. On 5/27/26 at 9:43 AM, an interview was conducted with Confidential Person (CP) J regarding Resident 105'2 care received at the facility. The CP reported that they are telling us they are understaffed, but they are neglecting the Resident. When asked about what they are not doing, the CP reported that among other concerns, they were not doing his therapy, ROM exercises. They don't try or if he was not trying, they don't come back. The CP stated, ROM, he is supposed to have it every day. They never do it. He is going to lose his ability if it's not done. We can't be there all the time to do it for him. He can't do it on his own. The CP reported the Resident has a hand splint but it is never on him. The CP reported that when they were there to visit, being there for a good part of the day, no none (staff) comes in to work with him (ROM exercises), the don't reposition him, they don't check him every two hours (for incontinence). The CP reported that the resident relies on the staff to keep him moving, he can't do it himself. A review of R105's order for Restorative Nursing and task for ROM included: Restorative Nursing: Range of Motion (active) To maintain functional strength, resident may complete AROM/PROM to bilateral upper and lower extremities x 10-15 reps to include all planes 5-7 days per week. A look back from 4/28/26 to 5/26/26 revealed 7 days as Tolerated well and two days the Resident ill. A review of R105's order for Restorative Nursing and task for the splint included: Restorative Nursing: Splint/Brace Assistance (12h (hour))Splint to RUE (right upper extremity) (resting hand) 2 hours on 2 hours off to resident's tolerance; ensure skin integrity and positioning 5-7 x per week, with a look back from 4/28/26 to 5/26/26 revealed 7 documented applications of the splint. A review of the Amount of minutes spent providing splint or brace assistance, with documented minutes of 10, 5, 90, 15, 15, and 15. A review of R105's Restorative Program Monthly Documentation, revealed the following:-Dated 3/29/26 to 4/26/26, Restorative note for: Range of Motion; Participation: How many times did the resident participate in the program? 3; How many times was the resident unavailable to participate in the program? 0; How many times did the resident refuse to participate in the program? 0; Goal: The resident is currently: Not meeting the goal; Explain how the resident is exceeding, maintaining or not meeting the goal: No occurring as orderedRestorative Note 2: Restorative Note For: Splint/Brace; Participation: How many times did the resident participate in the program? 3; How many times was the resident unavailable to participate in the program? 0; How many times did the resident refuse to participate in the program? 0; Goal: The resident is currently: Not meeting the goal; Explain how the resident is exceeding, maintaining or not meeting the goal: No occurring as ordered -Dated observation 2/27/26 to 3/26/26, Restorative note for: Range of Motion; Participation: How many times did the resident participate in the program? 8; How many times was the resident unavailable to participate in the program? 0; How many times did the resident refuse to participate in the program? 0.Restorative Note 2: Restorative Note For: Splint/Brace; Participation: How many times did the resident participate in the program? 10; How many times was the resident unavailable to participate in the program? 0; How many times did the resident refuse to participate in the program? 0. -Dated observation 2/10/26 to 2/26/26, Restorative note for: Range of Motion; Participation: How many times did the resident participate in the program? 6; How many times was the resident unavailable to participate in the program? 0; How many times did the resident refuse to participate in the program? 0.Restorative Note 2: Restorative Note For: Splint/Brace; Participation: How many times did the resident participate in the program? 9; How many times was the resident unavailable to participate in the program? 0; How many times did the resident refuse to participate in the program? 0. On 5/27/26 at 11:09 AM, an interview was conducted with CNA H who has had assigned care of Resident 105. When asked about Restorative Therapy program for R105, the CNA reported that the facility had a restorative program but the CNA would get pulled to the floor to take over assigned care of residents and indicated that when the CNA gets pulled to the floor, they are unable to do the therapy that needs to be done. The CNA reported that the Restorative CNA was assigned to the floor on this day. On 52726 at 12:09 AM, an interview was conducted with the MDS Nurse L who reported she was oversight for the Restorative Therapy department. The MDS Nurse reported that the Therapy department would set up a plan, she would put it in the task list for the Restorative aide or the CNAs to follow. An order would go in for the Restorative plan. The plan would populate daily for the CNA who is assigned care to be completed daily. The MDS Nurse reported she would review once a month. When asked how many Residents were on Restorative Therapy and Restorative staff to work with the Residents, the MDS Nurse reported 41 residents currently and one full time CNA and one that also did transportation with Residents to appointments with plans that included ambulation, transfers, ROM, grooming, and included splint application. When asked about the CNAs getting pulled to the floor, the MDS Nurse stated, Yes, that does occur, but was unsure how often they get pulled. The MDS Nurse reported that if the Restorative Therapy CNA can not do the plan, then it was the responsibility of the CNA assigned care to complete. When asked about the Resident's 5 to 7 days a week for ROM, the MDS Nurse indicated that yes, Resident 105 would need ROM more often if unable to do the ROM himself, with 7 days over just the 5 days. When asked why the ROM and splint application was not being completed with Resident 105, the MDS Nurse reported she was unsure why it was not getting completed. When asked if the Resident was not tolerating the splint, the MDS Nurse reviewed progress notes and was unable to find documentation of not tolerating the splint. On 5/27/26 at 12:42 PM, CNA M reported she was the Restorative CNA but had been pulled to take an assignment on the floor. When asked how often it happens, the CNA reported that it depends on the week, the CNA reported if here for 3 days in the week, she could be pulled and has been pulled to floor care two out of the three days. The CNA stated, I work today and tomorrow, so tomorrow I don't know where I will be, I could wake up tomorrow and it will say CNA if short staffed, and reported 1 to 2 days a week she would work as a CNA and the rest as a Restorative Aide, sometimes Restorative Aide all week, but that does not happen very often. When asked if able to complete Restorative Therapy for Residents, the CNA reported maybe for the ones in the hall she was working in, but there were Residents on the other side also, and you can't always get to the Restorative Plan if busy. The CNA reported that there was a Resident who was supposed to ride a bike in therapy and needed someone to be with him so that would be able to happen. The CNA stated, if have time then can do the ROM. On 5/27/26 at 12:58 PM, an interview was conducted with the Therapy Director O regarding R105's Restorative Therapy plan. The Therapy Director (TD) reported that the therapy department gives recommendations for Restorative Therapy once therapy was completed. The ROM and the Splint application for R105 was reviewed regarding the lack of follow-through with the exercises and splint application. When asked what the benefits for R105 are to participate in the ROM, the TD stated, That is to maintain ROM and positioning and to keep ROM to all extremities. When asked the consequences if the plan was not followed as ordered, the TD stated, He could have a loss of range of motion, lose degrees of motion. On 5/27/26 at 1:49 PM, an interview was conducted with the Administrator (NHA) and Corporate Nurse K regarding the lack of Restorative Therapy plan follow through with ordered ROM exercises and splint application. It was reviewed that in the last 30 days look back that the ROM exercises ordered for 5 to 7 times a week were completed 7 days and splint application for 2 hours off and 2 hours on for 5 to 7 days was completed 7 days with application for 15 to 90 minutes a day as documented. A review of facility policy titled, Activities of Daily Living (ADLs) revealed, Policy: The facility takes measures to minimize the loss of residents' functional abilities, including activities of daily living. 2. The facility provides maintenance and restorative program to assist residents in achieving and maintaining the highest practicable outcome based on their comprehensive assessment.

This citation pertains to Intake Numbers 2736807, 2736887, 2736910 and 2742953 Based on observation, interview and record review, the facility failed to ensure that one resident (Resident #2) was free from neglect when staff did not complete a skin assessment after identifying a new area of skin concern, did not ensure appropriate treatment was in place, and did not accurately monitor and document the resident's skin condition, of one resident reviewed for neglect of care, resulting in Resident #2 being admitted to the hospital for 5 days with a diagnosis of cellulitis (bacterial skin infection) and having to receive IV antibiotics.Findings include:Resident #2 (R2):A review of R2's medical record revealed an admission into the facility on [DATE] with diagnoses that included memory deficient following intracerebral hemorrhage (stroke), dysphasia (impairment of speech), hemiplegia and hemiparesis (weakness and paralysis affecting right dominant side), vascular dementia, and major depression. A review of the quarterly social services assessment on 01/02/2026 revealed a Brief Interview of Mental Status (BIMS) score of 2/15 that indicated severe problems with memory or thinking.A record review of intakes 2736807, 2736887, 2736910 and 2742953 with allegations pertaining to R2 was completed.On 03/03/2026 at 8:04AM, A phone call was made to complainant Z who said that the resident was evaluated for wavier to discharge to another facility on 02/05/2026 and was not intended to move that day but did. Complainant Z said that the facility's social workers were asked to supply appropriate discharge information including any information regarding needs of the resident and when she asked about skin issues she was told R2's chart only noted 'the use of barrier cream with no skin issues or wounds'. Complainant Z said the transfer facility requested the activities of daily living log (ADL), medication list and skin documentation for R2. Complainant Z said that no on site visual/physical skin assessment was completed by the (facility) or (evaluating agency) prior to the residents discharge that day (02/05/2026). Complainant Z (evaluating agency) asked for and reviewed R2's recent skin assessment from the resident's chart and said it did not have any documented skin issues. Complainant Z said when the resident arrived at the new facility he cried and exclaimed 'he was happy they were able to get him discharged '. Complainant Z said that shortly after his arrival at the new facility R2 was assisted to the restroom by a CNA (unknown name), that CNA alerted the family and a nurse to observe the residents' bottom and back. Complainant Z said that they reported that R2's 'lower back to his legs were bright red, his bottom had open areas and weeping bloody fluid was seen on the resident's brief'. Complainant Z said the new facility took photos and submitted them to the ombudsman. R2 was sent to the hospital within a short time of arriving at the new facility to be evaluated and treated. Complainant Z said that the hospital had reported to them and other appropriate agencies for suspicion of neglect.On 03/03/2026 at 2:33PM, During a phone call with family member N of R2 she revealed that she is also R2's guardian. Family member N said that R2 was discharged from the facility to another facility on 02/05/2026. Family member N said that she was unaware that R2 had any ongoing skin issue, she said she was aware that R2 previously had a pressure ulcer that had healed in September of 2025. Family member N said the family transported the resident to the new facility and that that once they arrived at the new facility family was with R2 as he was 'getting settled in', the resident requested to go to the restroom. Family member N said that the CNA alerted the nursing staff, herself and sister that R2 had 'a red bottom with leaking sores from the top of his back throughout his bottom down to the top of his legs. The CNA requested them to observe it. Family member N said she was shocked and vomited it was so bad, she said she had no idea about his bottom and that the paperwork from the facility did not identify any skin issues. Family member N said she felt like they left R2 in his wet briefs and neglected to care for him, that was why his bottom looked like that. Family member N was asked if R2 had made complaints to her about the facility, and she said that he had only said 'he didn't like the soft food, and his old roommate was young and loud'. Family member N was queried on the roommate's name, and she identified R8. Family member N was concerned over the care he received and stated she does not want this to happen to anyone else's loved one.A record review of R2's discharge to Home/ Community /AL (assisted living) /Equal care setting dated 02/05/2026 revealed that R2 was discharged to assisted living on 02/05/2026 at 13:00 (1PM). In section (e) the Nursing summary: Skin/wounds identified No skin issues noted and was completed by Nurse I.A record review of R2's hospital records revealed that R2's registered/arrival date and time was 02/05/2026 at 16:19PM (4:19PM) with his initial exam on 02/05/2026 at 17:06 (5:06PM) with findings noted as Redness along sacral region extending to the back; Takes up much of the entire buttocks; Excoriated hyperemic (a buildup of blood) redness on the back. A record review of R2's Hospital skin exam revealed Large amount of excoriation throughout the coccygeal . region redness that extends to the lower thoracic region hyperemia tending to palpation there is no blistering however patient does have some satellite lesions compatible with possible fungal infection. Some evidence of secondary infection. And Notes from: 02/05/2026 at 17:40 (5:40PM) R2's initial lab work revealed an elevated white blood cell count of 14.8 (high) with (normal range 4.5-11.0), indicated an infection. At 17:43 (05:46PM) R2's pain scale was noted to be reported at 10 out of 10, which indicated the worst possible pain.A review of R2's Emergency room's disposition to general admission revealed in the History and Physical (H&P) . A large area of Cellulitis on his lower back. There is also a high suspicion for elderly neglect.A review of R2's of hospital discharge date d 02/10/2026 revealed that R2 was discharged from the hospital with diagnosis of Cellulitis, he had been treated with IV Vancomycin (antibiotic) and Miconazole cream (antifungal) and Morphine 2 mg (Narcotic pain medication) during his 5 day hospital course, and upon his discharge the Infectious disease doctor recommended continued antibiotics of Clindamycin 3mg to be given four times a day for an additional five days. On 03/04/2026 at 8:42 AM, during an interview with wound care (WC) nurse G was asked what the facility used as their standard barrier cream was and she said zinc oxide and every resident that had incontinence received the barrier cream with incontinence care, applied by the CNA when briefs were changed. WC nurse G further explained that, if a resident had an area of skin that was identified as reddened, there would be a specific order that identified the area of skin that was treated and how often, and that nurses applied the treatments. It was confirmed with WC nurse G that CNAs applied the 'preventative' incontinence barrier creams and nurses applied 'treatment' creams as ordered. On 03/04/26 at 8:55AM, During an Interview with R2's ex-roommate, he was asked about R2's demeanor as a roommate, and he said he was a quiet person that rarely talked. R8 was asked if he observed or heard any of R2's care while they were roommates and R8 said yes. R8 said that at night the CNAs asked R2 if he was wet and if R2 told them no, they would not check or change him. R8 further said that the CNA's did not always come back later to check and change him, and that R2 would sit in piss. On 03/04/26 at 1:15PM, During an interview with CNA H she was asked about R2's incontinence care and if there was any issues with his skin. She said his bottom was really red and had a lot of dead skin present. When CNA H was asked if R2's skin concerns were reported to the nurses she said yes, the nurses were all aware and had treatment ordered for the (coccyx) area also. CNA H was unable to give specifics of what nurses knew or when it was reported. CNA H was asked if R2 refused incontinence care, she said he did not refuse it when she worked with him. CNA H was asked if she used barrier cream on R2, and she said yes with every brief change. CNA H was asked if the WC nurse evaluated the skin area, she said she was not present if she did. CNA H further explained that if the WC nurse evaluated it, she would have taken a picture and documented it. On 03/04/26 at 2:02PM, During an interview with CNA AA was asked about if he observed any skin issues when he provided activities of daily living (ADL) or incontinence care for R2, he said R2 had body eczema throughout and his bottom was red with dry skin, there were no broken areas of skin but it leaked fluid. CNA AA' said that R2 did not refuse incontinence care from him. CNA AA was asked if he applied barrier cream to R2 and he said yes. CNA AA said the nurses were aware of R2's skin issues and that R2 had creams he received treatment from the nurses for it. Record review of R2's orders revealed the following: Dated 01/01/2026 at 2200 (10 PM) Hydrocortisone Cream 2.5 % Apply to Left arm topically every day and night shift for Pruritus.Dated 01/04/2026 at 17:04 (5:04 PM) Verbal order. Zinc Oxide Ointment 10 % . Apply to coccyx topically every day and night shift for red area.AND apply to coccyx topically as needed for red area.Record review of R2's medical administration record (MAR) completed and documented by Nurses revealed: the following: January: Treatments started 01/04/2026 on night shift and ended on 01/31/2026 on night shift the ordered Zinc Oxide Ointment 10 % Apply to coccyx topically every day and night shift for red area was documented with a check and initials of the nurses, which indicated that medication was applied for all of day and night applications with one exception to that on 01/13/2026 night shift was no check mark or nurse initials indicated it not done. February: 02/01/2026 on day shift and ended on 02/05/2026 on day shift the ordered Zinc Oxide Ointment 10 % Apply to coccyx topically every day and night shift for red area was documented with a check and initials of the nurses, which indicated that medication was applied for all of day and night applications.The MAR documented a total of 63 times treatment to the coccyx was applied by nurses with no supplemental documentation, assessments, or progress notes that included description or status of the area related to the 'red area on the coccyx'.On 03/04/2026 at 3:14PM, During a phone call to Nurse K a female answered the phone and said that nurse K was not available, a message was left for a call back. On 03/04/2026 at 3:15PM, During a phone call interview Nurse J was queried about R2 and she said I vaguely remember the resident and that she was unsure about his skin issues from recollection and stated, nothing sticks out. On 03/04/2026 at 3:40PM, During a phone call interview Nurse L was queried about R2 skin and she said he scratched a lot and had eczema and dry skin on his trunk, legs and throughout his back. Nurse L was asked about R2's buttocks and backside, she said there was nothing but dry skin and that he would scratch at his butt cheeks, we used barrier cream treatment, and she denied that R2 had any red or open areas. Nurse L said she was off the day before R2 was discharged and that either Nurse K or Nurse I covered for her. Record review of R2's January point of care (POC) tasks completed and documented by CNA's revealed: Skin observation on 01/01/2026 at 17:27 (5:27PM) noted red area and indicated (Y,Y) which it was a new area and it was reported. A record review of progress notes revealed an Alert note from 01/02/2026 (that was triggered by the 01/01/2026 CNA's (Y,Y) MAR entry) in the POC charting revealed: NS - A new skin problem was observed. with WC nurse G's note - no areas of concern noted at this time.On 03/04/2026 at 4PM, During an interview with WC Nurse G said that on 09/27/2026 R2 came to the facility with a stage 2 pressure ulcer on his coccyx and that when she saw him on 09/30/2026 it was blanchable redness and she resolved it out. WC Nurse G said that R2 did not have any wounds after that she was aware of. WC Nurse G was queried about the alert note from 01/02/2026 that indicated NS = New skin area and she said that she gets those alerts off the clinical dashboard, it is triggered by CNA charting or the nurses skin assessment charting and that notified her as the WC nurse that she needs to go assess the residents skin. WC Nurse G said that because she does not know where the area of skin concern is located from the triggered note, she will ask the staff if she knows who triggered it and if not, she does a full skin assessment to capture it. WC Nurse G said after she had seen the resident, she completed the alert note. When WC Nurse was asked what no areas of concern noted at this time meant, and if there was skin assessment completed/documented by her that described what she assessed, and WC Nurse G said If residents have blanchable redness that she does not follow it. WC nurse G was queried on if blanchable redness was present, where and what were dimensions of that red area was and where she documented those findings. She said she did not complete an assessment because it was not a wound, she only completed the alert note. WC Nurse G was asked if she followed other rashes or skin issues besides wounds and she said yes, she followed up on them. WC Nurse G said R2's new skin area was a blanchable red spot and was not a crossed his buttocks area and that it did not appear yeasty or open and that if it got worse, she was unaware. WC Nurse G was asked if she took photos of the area or ordered treatment even though it was not a wound, she said no. WC nurse G was asked about R2's order to treat red area on coccyx on 01/04/2026, and WC nurse G said that order was put in by Nurse I and not by herself, and that if the area was worse that she was not made aware of it. A record review of R2's weekly skin assessments revealed the following:On 1/30/2026: New abnormal skin areas? No; Existing abnormal skin areas? NoOn 1/23/2026: New abnormal skin areas? No; Existing abnormal skin areas? NoOn 1/16/2026: Comments: Unable to do full skin assessment due to resident refusal several times. Unit manager made aware.On 1/9/2026: New abnormal skin areas? No; Existing abnormal skin areas? NoOn 12/31/2025: New abnormal skin areas? No; Existing abnormal skin areas? No All the above assessments have the acknowledgement box marked that indicated the nurse conducted a full skin assessment and no new abnormal skin areas were observed. Record review of R2's February (POC) tasks completed and documented by CNA's revealed: Skin observation on 02/02/2026 at 01:36 (1:36AM) noted red area and discoloration and Skin observation on 02/05/2026 at 05:44 (5:44AM) noted red area and both of February entries indicated (N) which meant it was not a new area.On 03/04/2026 at 4:30PM, During an interview with the DON she was asked to review the progress note / alert note from 01/02/2026 from the WC nurse G. After the DON reviewed the note, she agreed it was devoid of any information on the new skin problem. She said she could not identify where on the body, what the appearance or characteristic were or were not observed from the note. The DON was asked to review the order for treatment on the that was placed for R2 two days later 01/04/2026. After the DON reviewed the note, she acknowledged that a red area on the coccyx was noted in the order and that a treatment of that area was ordered. The DON was asked to review all R2's skin assessments completed from 12/31 through R2's discharge to another facility on 02/05/2026. After the DON reviewed the skin assessments, she agreed that the coccyx area (that was treated twice a day on the MAR) was not documented in skin assessments. The DON is asked to review the MAR for R2 from 01/04/206 to 02/05/2026 and she verified it was documented that R2 was treated (observed) two times a day by nursing staff, and by CNAs with incontinence care.The DON is asked if there were any progress notes that indicated the red coccyx area was being assessed, monitored and documented on, and she said there is no supplemental documentation or other documentation for the skin condition on the coccyx that had been treated for R2. The DON was asked if the skin concern was better, worse, same or resolved from the day it was identified on 01/01/2026 by the CNA triggered POC charting, and she said there is no documentation that supported an answer. The DON indicated that going forward she was going to have a stop date for treatments to ensure they are reassessed by the wound care nurse and that she would add supplemental documentation to the MAR/TAR so that nurses will have to answer basic questions about what they treated. On 03/05/2026 at 9:18 AM, During an interview with Nurse I she was asked about R2's skin and she said his coccyx was red but not open, no drainage or odor that she could decern and that she could not recall how big the area was affected. Nurse I was asked if she assessed the area where she documented it, she said we do not document progress notes or assessments on treatments, we just document on the MAR if it was done or not done. Nurse I was asked if nurses documented on skin rashes, and she said yes we do and the wound nurse also takes photos of them. Nurse I admitted that on days she worked she would have observed the area during treatments, when she was asked if R2's identified skin issue from 01/04/2026 the time the treatment order was placed until 02/05/2026 when the resident discharged if it was better, worse or the same, she replied I can't remember when she was asked how would she be able to find that out she stated if we documented on it. Nurse I said that she should have done an initial skin assessment and then it would be followed up on every 8 hours with documentation, and she admitted she did not put in a progress note nor does she recall why she placed the treatment order on 01/04/2026 now. Nurse I explained that when I treatment order is placed that the WC nurse should follow up on it to make sure it is the proper care needed, she is the certified nurse on treatment types and timing. Nurse I said that new orders also appear on the 24-hour report that is reviewed by management at morning meetings. Nurse I said the order never changed and the wound care nurse never followed up with me. Nurse I explained that she completed part of the discharge for R2 that day 02/05/2026 and that it was rushed and unexpected. Nurse I admits that no body skin assessment was done on 02/05/2026 and that she complete the discharge assessment in the nursing summary of skin/wound care needed (include location and description of any wounds): no skin issues noted, when she reviewed it. A record review of R2's Care plan revealed the following: Focus (R2) has episodes of bladder / bowel incontinence related to decreased functional mobility and physical limitations further potentiated by clinical conditions and medication adverse effects with Interventions: Observe peri/rectal-area for redness, irritation, skin excoriation/breakdown; report abnormal findings to Nurse/Physician/PA/NP; Provide peri-care after each incontinent episode; apply house barrier cream after incontinence care. Focus: (R2) s at risk for impaired skin integrity related to decreased functional mobility and physical limitations further potentiated by risk for incontinence and other clinical conditions which potentiate skin breakdown with Interventions: Administer medications as ordered; Apply protective barrier cream after incontinent episodes; Complete skin inspection weekly and as needed; Notify nurse of any new areas of skin impairment noted during bathing or daily care (e.g., redness, blisters, bruises, discoloration, impairment related to medical device/tubing); Notify Physician/NP/PA of any new areas of skin impairment. On 03/05/2026 at 11:17PM, During an Interview with Staff P she stated the facility was unaware of the resident discharge until the day it happened when he was evaluated by a community agency for wavier. Staff member P admitted the discharge was rushed by request from the family. Staff member P said that she verbally reported to the outgoing facility what was documented in R2's chart under skin assessments, and that she was not aware of anything different that what was documented about R2's skin. On 03/05/2026 at 2:35PM, During an interview with Social Worker Q said that R2's discharged was rushed due to a request by the family and evaluating agency. SW Q said that she supplied a green folder with R2's medication list, history and physical, IDT discharge summary, face sheet, advanced directives and progress note from Nurse Practitioner. SW Q said that R2 was being admitted to hospice services also. SW Q said she was unaware of any skin issues for R2 and that none are noted on the discharge summary. On 03/05/2026 at 2:35PM, During a follow up with WC Nurse G she said she was certified for wound care on 03/03/2026. WC nurse said as of today we started using an end date to trigger reassessments on skin areas that are not wounds, and that she would reassess in every 14 days or sooner until resolved. WC Nurse G said that there was now supplemental questions that the nurse will have to answer with each treatment. A review of the facilities Policy and Procedure titled Abuse, Neglect and Exploitation: 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 .Definitions: Neglect means the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distrust. Alleged Violation: is a situation or occurrence that is observed or reported by staff resident, relative. that has not been investigated and, if verified could be indication of noncompliance with the federal requirements related to mistreatment, exploitation, neglect or abuse. Serious bodily injury: means an injury involving extreme physical pain; .Requiring medical interventions such as surgery, hospitalization. Policy explanation: 1. The facility will develop and implement written policies that: a. Prohibit and prevent, abuse, neglect. 3. The facility will provide ongoing oversight and supervision of staff in order to assure its policies are implemented as written. IV. Identification of Abuse, Neglect and exploitation: B. 8. Failure to provide care needs .A record review of the facility's Licensed practical / vocational nurse (LPN) job description revealed, Summary: coordinates and provides nursing care for residents and provides supervision and guidance for clinical staff members. Essential functions: Documents the resident's condition and nursing needs; .Administers medications and performs treatments for assigned residence, and documents that treatment as required by company, and local, state and federal rules and regulations; Reports and records pertinent observations and reactions regarding residents.According to a record review of the facility's Registered nurse (RN) job description: Summary: plans, coordinates and provides total nursing care for residents and provides supervision and guidance to clinical staff members. Essential functions: assesses and documents the resident's condition and nursing needs; supervises, directs and evaluates LPN and CNAs.; Administers medications, starts IVs and performs treatments for assigned residents, and documents that treatment as required company, and local, state and federal rules and regulations.

This citation pertains to Intake Number 2785490.Based on interviews and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act. Findings Include:Resident #5:On 3/3/2026 at approximately 2:30 PM, Resident #5 reported he loaned CNA S $500 (cash) and they had a verbal agreement that she would pay him back every paycheck. He explained she typically worked weekends, and he gave her $300 cash on a Friday, $100 on Saturday and $100 on Sunday. Resident #5 continued he was upset, as the aide was not abiding by their verbal agreement and had only paid back $30. He stated she eventually came into the facility on a Monday (that she was not scheduled to work) and remitted the remaining $470 that she owed. On 3/3/2025 at approximately 3:45 PM, a review was conducted of Resident #5's medical record and it indicated the resident was initially admitted to the facility on [DATE] with diagnoses that included, Diabetes, Atrial Fibrillation, Hypertension, Chronic Kidney Disease, Anxiety Disorder, and Major Depressive Disorder. Resident #5 is his own person and able to clearly articulate his needs to facility staff. There was no other documentation located in the chart regarding an allegation, or any follow up regarding misappropriation of money. On 3/4/2026 at 12:38 PM, CNA T reported CNA S was in Resident #5's room with the door closed and they were screaming at one another. CNA T stated she overheard Resident #5 yelling that (CNA S) made an agreement to give him $30 every pay period and she had not remitted payment. She had until the end of the week to pay the balance owed or he was reporting the incident to the Administrator. CNA T reported upon CNA S exiting the room she was visibly crying. On 3/4/2026 at approximately 4:08 PM, the Administrator was queried if there was a FRI (Facility Reported Incident) for the allegation of misappropriation of money between Resident #5 and CNA S. The Administrator reported there was a not a FRI related to this incident. He further explained the Social Worker informed him Resident #5 had loaned a facility staff money and he wanted it back, but would not provide the name of the facility staff. At some point he provided the name of CNA S and when she was interviewed, she was in tears, denied the allegation of misappropriation and said it was against the facility's code of conduct. The Administrator followed up with Resident #5 who said nevermind and retracked his initial account. The administrator was asked wouldn't that be considered an allegation that would be investigated by their facility and he stated No, as there was no proof provided by resident. On 3/4/2026 at 5:10 PM, Social Work Director Q stated in around December 2025 she was speaking with Resident #5 and he stated he did not know what to do about a situation. He proceeded to provide a scenario that a good employee came to him and shared she did not have enough money to pay a parking or speeding ticket. The resident loaned her the money to pay the fine and there were payments arrangements made, but he is having a difficult time getting the money repaid upon their agreed upon terms. Director Q informed him she would have to report the allegation to the Administrator/Abuse Coordinator Director Q stated the resident reported misappropriation of funds and it was assumed this was reported to the State Agency. On 3/5/2026 at 10:28 AM, Staff Development Coordinator W' was queried iif it's appropriate for staff to accept money from a resident (rather the staff asked or it was offered) she reported that is not appropriate. She explained this is company policy that is reviewed in their orientation training in depth by their corporate orientation liaison. On 3/5/2026 at approximately 12:00 PM, the administrator shared Social Work Director Q, initially informed him that Resident #5 had given money to an employee but would not provide the staff name. The Administrator stated at that time the resident was not alleging anyone stole anything from him. The next day at resident council he shared with the Activities Director and Regional Director of Operations that he loaned money to an employee with payment arrangement terms. Additionally, the Administrator received a phone call from Nurse U (on a Sunday) informing him again that Resident #5 has loaned money to CNA S, during this conversation with the nurse the Administrator did not ask the nurse to expound on how she came to receive their information. The Administrator asserted Resident #5 is his own person, there was no proof of the transaction between him and CNA S and there was no allegation made by Resident #5 of misappropriation. He was queried if it was acceptable for staff to take money/borrow money from a resident and he stated, No. The administrator stated even through the Social Work Director informed him of the incident it was not an allegation of misappropriation and there not a reportable to the state agency.It can be noted the Administrator was informed of the allegation of misappropriation three times but did not report it per regulations standards.On 3/5/2026 at 2:00 PM, Resident #5 was reinterviewed regarding the incident, he reported he informed the Social Work Director regarding the incident but did not provide her a name, the Administrator, Regional Director of Operations and Nurse U may have overhead the discussion with CNA S. He further stated the Administrator and Director of Operations assured him if CNA S paid him back they would not fire her.Review was conducted of the policy entitled, Abuse, Neglect and Exploitation, reviewed 1/10/2024. The policy stated, .Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative or visitor or others, but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents who consume food from the kitchen. Findings include: On 01/27/2026 at 9:00am-9:15am during the initial kitchen tour with Kitchen Manager K observed mixer visibly soiled with accumulated debris. During this observation, Kitchen Manager K was asked how often the mixer is cleaned and stated it's cleaned after every use. On 01/27/2026 at approximately 9:15am-9:30am observed brown and pink residue on the interior walls of the ice machine located in the short-term satellite kitchen. During this observation, Kitchen Manager K was asked how often the ice machine is cleaned and she stated maintenance cleans it every three months. On 01/27/2026 at approximately 9:15am-9:30am observed the rag sanitizer bucket visibly soiled with dark discoloration, located in the short-term satellite kitchen. The rag sanitizer bucket was tested with Sunburst Chemical chlorine test strips and the result was zero. During this observation, Kitchen Manager K was asked how often the sanitizer bucket is changed out and she stated it's changed out after every meal. On 01/27/2026 at approximately 9:30am-9:40am observed the interior ceiling of the microwave visibly soiled, located in the long-term satellite kitchen. During this observation, when Kitchen Manager K was asked how often the microwave is cleaned out, she stated it's cleaned every morning. On 01/27/2026 at approximately 9:30am-9:35am observed the interior wall of the ice machine visibly soiled with brown residue, located in the long-term satellite kitchen. According to the 2022 Food Code, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, Equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations, nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.According to the facility's policy on kitchen sanitation, All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions.On 01/27/2026 at approximately 9:40am when interviewed on what the desired range is for the rag sanitizer bucket located in the short-term satellite kitchen, Kitchen Manager K stated they want it at 50. When asked what sanitizer solution is used for the rag sanitizer bucket, Kitchen Manager K stated bleach is used. According to the 2022 Food Code, 3-304.14 Wiping Cloths, Use Limitation, Cloths in-use for wiping counters and other equipment surfaces shall be .Held between uses in a chemical sanitizer solution at a concentration specified under S 4-501.114 and The sanitizing solution must be changed as needed to minimize the accumulation of organic material and sustain proper concentration. Proper sanitizer concentration should be ensured by checking the solution periodically with an appropriate chemical test kit. According to the facility's policy on kitchen sanitation, Sanitizing of environmental surfaces must be performed with one of the following solutions .50-100 ppm chlorine solution. According to the facility's policy on kitchen sanitation, Between uses, cloths and towels used to wipe kitchen surfaces will be soaked in containers filled with approved sanitizing solution. Sanitizing solution will be changed at least once per shift or if solution becomes cloudy or visibly dirty. On 01/27/2026 at approximately 11:30-noon during lunch observation in the short-term satellite kitchen, observed rag sanitizer bucket stored next to drink prep area while drinks were being poured into glassware. During this observation, this surveyor drew attention to the chemicals stored next to the drink prep area and it was removed. When interviewed on where the sanitizer bucket is usually stored at, Kitchen Manager K stated it's usually stored by the hand sink. According to the 2022 Food Code, 7-201.11 Separation, Poisonous or toxic materials shall be stored so they can not contaminate food, equipment, utensils, linens, and single-service and single-use articles by .Separating the poisonous or toxic materials by spacing or partitioning. According to the facility's policy on storage of chemicals, Only chemicals that are required to maintain kitchen sanitation shall be permitted in the pot washing and dishwashing areas but may not be stored or used in the presence of food.

This citation has 2 Deficient Practice Statements (DPS). Based on interview and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility. Based on interview and record review, the facility failed to have a comprehensive infection control program for residents residing in the facility Findings include: Resident #15 (R15): According to a review of R15's medical record, the resident was admitted to the facility on [DATE] for skilled nursing care related to cellulitis (bacterial infection) of the right lower limb, abscess of right lower limb, osteomyelitis (infection of bone),Methicillin Resistant Staphylococcus Aureus (MRSA) infection (bacteria that is resistant to many antibiotics, including methicillin) and has a peripherally inserted central catheter (PICC) and receiving IV Vancomycin (an antimicrobial medication used to treat resistant bacteria) with 6 weeks remaining on IV therapy. R15's Minimum Data Set (MDS) record revealed a Brief Interview of Mental Status (BIMS) score of 15/15 that indicated the resident was cognitively intact. Additional medical diagnoses included: Chronic Obstructive Pulmonary Disease (COPD/progressive lung disease) Muscular dystrophy, Hypokalemia (low potassium), and weakness. On 01/27/2026 at 9:46AM, During an initial walk through of the unit an observation of 5 total enhanced barrier precautions (EBP) signs and 2 total transmission-based precautions (TBP) signs were posted on residents' doors. None of the 7 residents or rooms identified included R15.On 01/27/2026 at 10:58 AM, Observation of R15 sitting in wheelchair in his room watching television. There is an IV pole in the room with no IV medication hanging. He has a PICC line in his left upper extremity dated 01/27/2026. R15 is agreeable to interview. R15 said he has been at the facility for about 6 weeks, he said he has a bone infection. And that he had been on IV and oral antibiotics to treat it. When asked if staff wear personal protective equipment (PPE) clarified as gown, gloves and masks when providing IV or wound care, R15 said they wear gloves but no gowns. R15 further explained that earlier that morning (01/27/2026) the nurse changed his PICC site dressing and she wore gloves and no other PPE. On 01/27/2026 at 11:00 AM during an interview, Nurse B she was asked if residents with indwelling lines such as PICC lines should be on EBP, she said yes, those residents required EBP. She was asked if R15 had a PICC line, she said, yes, it was in his left upper arm and he received IV antibiotics. Nurse B was asked to locate the EBP sign posted and the PPE cart for R15's room and she looked at R15's door and stated, it's not there, but should be and Nurse B indicated it would be addressed due to the interview. On 01/28/2026 at 9:20 AM, An observation was made of an EBP sign outside R15's room door and PPE cart inside R15's room. R15 was not in his room. On 01/28/2026 at 2:28 PM, Observed R15 sitting up in his wheelchair watching tv in his room. When R15 was asked if staff were wearing gowns and gloves when changing IV or dressing, he said they had brought the cart to his room this morning (R15 pointed to a cart that contained PPE located inside his bedroom door) and then explained that was after they had administered his morning IV, and that no gown was used for that. On 01/29/2026 at ~(approximately)08:40 AM, During an interview with NP A she was asked if residents with indwelling lines required precautions, she said that was up to the facilities policy and added, But, yes, it is an open line and said that EBP was indicated for R15. On 01/29/2026 at Noon, During an Interview with ICP Nurse G was asked if R15 met criteria to be in precautions, she said yes, that he had a PICC line for IV antibiotics and a wound on his right foot. She said R15 should have been on EBP since admission stated, I swear there was a sign posted when I did an audit on Monday (01/26/2026) and said, when I put them up, they disappear. A record review of R15's Orders revealed:Start Date: 12/31/2025 . End date: 02/24/2026: Contact precautions every shift related to Cellulitis A Record review of R15's care plan revealed: Date: 12/24/2025 Focus: (R15) requires enhanced barrier precautions related to impaired skin integrity and IV access. Interventions: Use gown and gloves when providing direct care. Face protection may be needed if performing activity with risk of splash or spray; Utilize Enhanced Barrier Precautions when providing high contact resident care activities (dressing, bathing, transferring, personal hygiene, changing linens, changing briefs/assisting with toileting, device care: central lines, urinary catheters, feeding tubes, tracheostomy/ventilators, wound care, dialysis); Review with visitors and family members how to follow the recommended precautions when visiting if prolonged physical contact is anticipated. Resident #7 (R7): According to a review of R7's medical record, the resident was admitted to the facility on [DATE] for skilled nursing care related to anoxic brain damage, chronic diastolic heart failure, diabetes mellitis 2 (DM), Tracheostomy (tube to facilitate breathing), Gastrostomy (tube for nutrition, hydration and medication administration). R7's Minimum Data Set (MDS) record revealed a Brief Interview of Mental Status (BIMS) score of 00/15 that indicated the resident was severely cognitively impaired. On 01/29/2026 at 10:21 AM, During tracheostomy care for R7 Nurse D was observed, Nurse D set up the bedside table with a bath towel barrier with supplies placed on top, no sterile barrier was used to drop sterile gauze and sponges onto. Nurse D then opened the sterile suction pack and placed the sterile gloves on, there was no sterile water available on the clean field, observed that Nurse D reached over the field to a plastic supply cart and grabbed a bottle of sterile water and placed it onto the field where the sterile cannula and suction equipment were open. After Nurse D hooked up the suction tube she reached a crossed the field to the suction machine both to turn it on and off and Nurse D exclaimed Oh shoot, I know I am not supposed to reach over my table. On 01/29/2026 at noon, during an interview with ICP nurse G she was queried if Trach care and suctioning was clean or sterile technique and she replied it is sterile technique; she was asked if it is appropriate to reach a crossed the sterile field and place nonsterile items within the field and she responded, No it is not. A record review of R7's orders revealed: Trach care every shift and as needed. Assess stoma site and under trach collar. Change trach ties with showers and as needed. And Suction tracheostomy as needed.Use enhanced barriers while performing high-contact activity with the resident. A record review of R7's care plan revealed: Focus: (R7) requires enhanced barrier precautions related to Tracheostomy and feeding tube.Interventions: Use gown and gloves when providing direct care. Face protection may be needed if performing activity with risk of splash or spray; Utilize Enhanced Barrier Precautions when providing high contact resident care activities (dressing, bathing, transferring, personal hygiene, changing linens, changing briefs/assisting with toileting, device care: central lines, urinary catheters, feeding tubes, tracheostomy/ventilators, wound care, dialysis); Review with visitors and family members how to follow the recommended precautions when visiting if prolonged physical contact is anticipated. According to a record review of facilities policy titled Tracheostomy care and suctioning procedure revealed:Policy: Tracheal suctioning is performed by a licensed nurse to clean the throat and upper respiratory tract of secretions that may block the airway. Guideline: .7. Using sterile technique, open the suction catheter kit and put on the sterile gloves. Consider the glove on your dominant hand sterile, and the non-dominant hand clean. 8. Using non-dominant (clean) hand, pour the normal saline solution into the disposable sterile solution container. 9. Remove the suction catheter from its wrapper with dominant (sterile) hand, coiling it to keep it from touching a non-sterile object.10. Attach the suction catheter to the tubing using non-dominant (clean) hand and turn on suction machine. According to a record review of facilities policy titled Enhanced barrier precautions revealed:Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.Definitions: Enhanced barrier precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during highcontact resident care activities.Guidelines: . Initiation of Enhanced Barrier Precautions: 2b. Even if the resident is not known to be infected or colonized with a MDRO, an order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure injuries, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers. Note: Wounds generally include chronic wounds, not shorter-lasting wounds such as skin breaks or skin tears covered with an adhesive bandage (e.g. Band-Aid ) or similar dressing. ii. Indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy / ventilator tubes). Note: A peripheral intravenous line (not a peripherally inserted central catheter) is not considered an indwelling medical device for the purposes of EBP. iii. Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply. And 3. Implementation of Enhanced Barrier Precautions may include but is not limited toa. Make gowns and gloves readily available near or outside of the resident's room. Note: Face protection may also be needed if performing activity with risk of splash or spray (i.e., wound irrigation Tracheostomy care). b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not be needed to be donned prior to entering the resident's room.4. High-contact resident care activities to consider include: . g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes h. Wound care: for chronic wounds described above.7. Examples of targeted and epidemiologically important MDROs include but are not limited to: . f. Methicillin-resistant Staphylococcus aureus (MRSA).8. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility, or at the determination by the clinical team of the decreased risk of transmission. A review of the CDC Guidance to Nursing homes on EBP reveals: Enhanced Barrier Precautions expand the use of gown and gloves beyond anticipated blood and body fluid exposures. They focus on use of gown and gloves during high-contact resident care activities that have been demonstrated to result in transfer of MDROs to hands and clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated. Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Standard Precautions still apply while using Enhanced Barrier Precautions. For example, if splashes and sprays are anticipated during the high-contact care activity, face protection should be used in addition to the gown and gloves. Enhanced Barrier Precautions are recommended for residents with indwelling medical devices or wounds, who do not otherwise meet the criteria for Contact Precautions, even if they have no history of MDRO colonization or infection and regardless of whether others in the facility are known to have MDRO colonization. This is because devices and wounds are risk factors that place these residents at higher risk for carrying or acquiring a MDRO and many residents colonized with a MDRO are asymptomatic or not presently known to be colonized. Record review of the facility 'Infection Prevention and Control Program' policy dated 12/27/2023 revealed that the 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 disease and infections as per accepted national standards and guidelines . A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections . Record review of facility 'Infection Surveillance' policy dated 10/26/2023 revealed a system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections, monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections. in an interview and record review on 01/28/2026 at 1:51 PM during the infection control task with Licensed Practical Nurse (LPN)/Infection Control Preventionist (ICP) G (2 months) in training, and Registered Nurse (RN)/Regional Director of clinicals/Infection Control Preventionist (ICP) J. The state surveyor inquired about Enhanced Barrier Precautions (EBP)- staff are given education on orientation and annually, as needed. And utilized where posted, signs on resident room entrances identify what staff are to wear (Personal Protective Equipment) when in close contact with resident. Close contact, touch, moving, emptying catheter bags, personal care all need EBP for that resident. Resident #124: Record review of Resident #124's progress notes dated 1/19/2026 at 4:06 PM noted the resident returned from hospital and assessment was completed. Record review of Resident #124 vital signs dated 1/19/2026 at 3:32PM noted forehead temperature of 101.3. Record review of Resident #124's Medication Administration Record (MAR) noted that on 1/20/2026 antibiotic Meropenem intravenous 1 gram every 8 hours for sepsis. Record review of Resident #124's readmission Minimum Data Set (MDS) dated [DATE] noted a female with Brief Interview of Mental status (BIMs) score of 13 out of 15, cognitively intact. Active medical diagnoses included: hypertension, Gastroesophageal reflux disease, renal insufficiency, diabetes, seizures, malnutrition, anxiety, depression, schizophrenia, chronic obstructive pulmonary disease and sepsis (life threatening infection). Section N: Medications identified antibiotic, antiplatelet, and antipsychotic medications. Observation and interview on 01/27/2026 at 9:49 AM of Resident #124 was lying in bed, she stated that she has a belly tube and the IV in her right arm. Resident #124 showed the state surveyor her right upper arm Peripheral Inserted Central Catheter (PICC) and abdominal gastrointestinal tube site. Observation of gastro tube had no split sponge gauze dressing noted to the site. Resident #124 was diaphoretic/sweaty in appearance, moisture noted to facial area and hair line. Observation and interview on 01/27/2026 at 11:06 AM with Licensed Practical Nurse (LPN) N Unit Manager observed Resident #124's right upper arm midline Peripheral Inserted Central Catheter (PICC), dressing dated 1/20/2026, dressing occlusive. LPN N stated Resident 124 just came back from the hospital on 1/19/2026, she went with a Urinary Tract Infection and is getting antibiotics. Resident #124 opened her eyes and shakes her head in response to questions. LPN N stated that the PICC line is due to be changed today, it should be every 7 days. During the observation LPN N only wore gloves and did not wash her hand pre or post observation. Resident 124 was on Enhanced Barrier Precautions. In an interview on 01/27/2026 at 12:44 PM with Nurse Practitioner (NP) Q revealed Resident #124 had a temperature and that he let the staff know and they got temperature of 102.6 degrees. NP Q stated that he just worries about Resident #124 because she is diabetic and has co-morbidities, complications. Resident #124 may need to get more antibiotics and needs a septic work up. She was sweaty when I was in seeing her earlier this morning. Record review of Resident #124's temperature vital sign log revealed on 1/19/2026 temperature of 101.3 degrees upon admission. Resident #124's temperature was not documented as being checked again until 1/28/2026. Record review of Resident #124's Progress notes dated 1/27/2026 at 11:40AM noted resident has a temperature of 102.6, altered mental status. Resident finished Intravenous antibiotics for sepsis. Resident was sent out to hospital. Record review of resident #124's return from leave and transfer assessment 1/27/2026 at 9:40PM no mention of PICC line dressing being occlusive and intact, no photo taken, no measurements of length or arm diameter from hospital care. In an interview and record review on 01/29/2026 at 8:20 AM with Nurse Practitioner (NP) 'A' reviewed Resident #124's admission assessment with temp of 101.3, and record review of temperature/vital task log. NP A found no temperature checks until 1/28/2026, once the surveyor identified the concern. NP A stated that Resident #124 does have PICC IV for antibiotics due to sepsis. Record review of Resident #124's progress notes revealed that there was no pertinent documentation of temperature rechecks, or skin documentation related to diaphoretic or antibiotic use. NP A stated the Nurses are to follow facility protocol On 1/28/26 at 3:30PM w an interview with Registered Nurse (RN)/Regional Clinical Director J revealed to the state surveyor that a Past Non-Compliance (PNC) for Resident #124, RN J stated that the facility just identified there was no temperatures performed a couple of hours ago and we have not written it up the Past Non-Compliance the surveyor identified the temp issue on 1/27/26 when the resident visibly diaphoretic and went out to the hospital ER with 102.6 temperature and interview the Nurse Practitioner on 1/27/2026. In an interview and record review on 01/29/2026 at 8:20 AM with Nurse Practitioner (NP) A on Resident #124 was admitted on [DATE] with temperature of 101.3, Record review of temperature/vital task/logs found no temperature checks until 1/28/2026, once the surveyor identified a concern. NP A stated that Resident #124 does have Peripheral Inserted Central Catheter (PICC) intravenous access antibiotic for sepsis. Record review of Resident #124's progress notes revealed that there was no pertinent documentation of temps or diaphoretic or antibiotic use. NP A stated that Nurses are to follow facility protocol. During initial screening of residents on the 200-Hall, complaints were received regarding the temperature of the water in their bathrooms. The following concerns were voiced: 201- Resident stated his water has to run for an extended amount of time for it to heat to a temperature of his liking. 203-Resident shared his bathroom sink does not get warm. 205- Resident reported he had not showered as the water in the shower does not get hot. 210- Resident reported her shower water temperature is rarely hot or to a temperature that is appeasing for a shower. On 1/28/26 at approximately 10:07 AM, the bathroom sink hot water was temped at 104 degrees F using a Thermapen in room [ROOM NUMBER]. On 1/28/26 at approximately 10:12 AM, the bathroom sink hot water was temped at 107 degrees F using a Thermapen in room [ROOM NUMBER]. On 1/28/26 at approximately 10:17 AM, the bathroom sink hot water was temped at 106 degrees F using a Thermapen in room [ROOM NUMBER]. On 1/28/2026, staff were unable to provide a shower to the resident in room [ROOM NUMBER]-2; as after running the hot water in the shower for an extended period, it would not warm up. On 01/27/2026 at approximately 9:45am observed an unused filter plumbed into the wall connected to a beverage machine backflow preventer and carbonator, located in the supply room in the main kitchen. During this observation, Kitchen Manager K was asked if the filter was being used and she said it hasn't been in use for a while. On 01/27/2026 at approximately 1:00pm-1:30pm during the housekeeping tour with Housekeeping Manager L observed a drinking fountain that would not turn on, located in the 700 hallways. During this observation, Housekeeping Manager L was asked how long the drinking fountains have been off, and she answered they've been off since Covid. On 01/27/2026 at 1:43pm observed two shut off drinking fountains near the entrance to the facility. According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, Eliminate dead legs, which are sections of no- or low-water flow. According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, Flush low-flow piping runs and dead legs at least weekly. Flush infrequently used fixtures (e.g., eye wash stations, emergency showers) regularly as needed to maintain water quality parameters within control limits. According to the facility's water management plan, Flush low-flow pipe runs, dead legs and infrequently used fixtures weekly. On 01/27/2026 at approximately 1:00pm-1:30pm observed a utility sink with an attached hose and a chemical feed downstream of an atmospheric vacuum breaker. During this observation, Housekeeping Manager L was asked if she was familiar with a wasting tee and she said she was familiar with them and she put in an order for one already. According to the 2008 Cross Connection Manual on atmospheric vacuum breakers, AVBs shall not be installed where they will be under continuous pressure for more than 12 hours (i.e. no downstream shutoff valve). On 01/27/2026 at approximately 2:45-2:50pm observed water flooding into office area in the 700 hallways in the Coordination Center. This surveyor was informed by the Maintenance Director M that there was a burst pipe. On 01/27/2026 at 3:00pm observed water streaming in from the light fixture above the hand sink in room [ROOM NUMBER]. On 01/28/2026 at 9:15 am when interviewed Maintenance Director M on how long the drinking fountains in the facility have been shut off, he stated they've been shut off since Covid. On 01/28/2026 at 9:20am in the supply room located in the main kitchen, the unused filter was removed from the water line, and the remaining water line was leaking. On 01/28/2026 at approximately 9:25am-9:40am hot water was temped at 103 degrees F using Thermapen from the bathroom hand sink in room [ROOM NUMBER]. During this observation, Maintenance Director M was asked what range the hot water should be kept at and he stated it should be between 105-120 degrees F On 01/28/2026 at approximately 9:25am-9:40am observed discolored water at hand sink in room [ROOM NUMBER]. Maintenance Director M stated the discolored water was a result of the water being shut off the day prior due to a burst pipe and staff was told to run some faucets after the water came back on. The hot water was temped at 106 degrees F using Thermapen at the same hand sink. On 01/28/2026 at approximately 9:25am-9:40am the hot water was temped at 103 degrees F using Thermapen at the bathroom sink in room [ROOM NUMBER]. On 01/28/2026 at approximately 9:35am the hot water was temped at 105 degrees F using Thermapen at the bathroom sink in room [ROOM NUMBER]. On 01/28/2026 at 9:45am the hot water was temped at 91 degrees F using Thermapen at the bathroom sink in room [ROOM NUMBER]. On 01/28/2026 at approximately 11:35 AM when interviewed the Administrator on the range for hot water temperatures, and he answered they aim for 105-120 degrees F, as it states on the facility's hot water temperature logs. When asked about the conflicting hot water temperature range in the water management binder where it states hot water temperatures that fall below 110 degrees F needs corrective action, he stated that it's referring to the holding tank temperatures. Record review of the facility's hot water log temperatures show 105 degrees F in room [ROOM NUMBER], 105.1 degrees F in room [ROOM NUMBER], and 105.3 degrees F in room [ROOM NUMBER] on 1/23/26. In addition, hot water temperatures are 105.1 degrees F in room [ROOM NUMBER], 105.5 degrees F in room [ROOM NUMBER], and 105.3 degrees F in room [ROOM NUMBER] on 1/19/26. According to the facility's water management plan on operation, maintenance, and control limits, Hot water temperatures that fall below 110 degrees F require corrective action. According to the facility's hot water temperature logs, the hot water temperature range is listed as 105 degrees -120 degrees for Michigan.

Based on interview and record review, the facility to ensure that monthly infection control antibiotic stewardship data collections were completed, 1) antifungal monitoring and stop dates, 2) Resident #6's prophylactic antibiotic line listing, 3) Resident #15's Vancomycin scheduling, dosing and therapeutic level monitoring, and 4) Resident #124 to receive antibiotic with no temperature monitoring, resulting in the high likelihood of increased antibiotic usage and resident infection rates with hospitalizations. Findings include: Resident #15 (R15): According to a review of R15's medical record, the resident was admitted to the facility on [DATE] for skilled nursing care related to cellulitis (bacterial infection) of the right lower limb, abscess of right lower limb, Osteomyelitis (infection in the bone), Methicillin Resistant Staphylococcus Aureus (MRSA) infection (bacteria that is resistant to many antibiotics, including methicillin) and has a peripherally inserted central catheter (PICC) and receiving IV Vancomycin (an antimicrobial medication used to treat resistant bacteria) with 6 weeks remaining on IV therapy. R15's Minimum Data Set (MDS) record revealed a Brief Interview of Mental Status (BIMS) score of 15/15 that indicated the resident was cognitively intact. Additional medical diagnoses included: Chronic Obstructive Pulmonary Disease (COPD/progressive lung disease) Muscular dystrophy, Hypokalemia (low potassium), and weakness. On 01/28/2026 at 11:34AM, During an interview with Nurse I she was asked about R15's Vancomycin IV schedule for observation, Nurse I said it is a twice a day medication and given once in am and once in the pm. Nurse I said that she had given the morning dose at 6:16AM. When asked what the scheduled times were for the Vancomycin, she stated it is scheduled at liberal time. Nurse I was asked what at liberal time meant she replied that at liberal time in the AM was from 7-10 AM and the PM was from 8-11PM. Nurse I declared I am allowed to go 1 hour before scheduled time or 1 hour after schedule time to administer medications. Nurse I said R15's Vancomycin is BID (2 times a day), every 12 hours. Nurse I was queried about the scheduled Vancomycin to be given at a 12 hour interval with the at liberal schedule, she said oh I can see how that is a problem, maybe it should be a scheduled time. Nurse I stated, I am calling the NP for my piece of mind on it. According to a record review of R15's orders revealed the following: Start date: 12/24/2025 scheduled: ordlib_HS (at liberal) time ranges: 0700-1000 and 2000-2300. Medication: Vancomycin HCl Intravenous Solution 1000MG/200ML (Vancomycin HCl) Use 1 gram intravenously two times a day for osteomyelitis for 6 weeks. Pharmacy to adjust dosage as needed . Duration 6 weeks end date: 02/04/2026. According to a review of Food and Drug administration (FDA) Vancomycin prescribing information/FDA label related that, the usual daily dose IV dosage of Vancomycin injection is 2 grams divided either as 500mg every 6 hours or 1 gram every 12 hours. 01/28/2026 at ~12:40PM, Nurse I knocked on the door of office and advised SA that she had talked to NP A about the at liberal times for the Vancomycin. Nurse I said that 'NP A had advised her to adjust the order for R15's Vancomycin to be scheduled Q(every)12 hours for consistency of administration' and that it was no longer scheduled for the at liberal time. According to a record review of R15's updated orders revealed: Revision date 01/28/2026 Start date: 12/24/2025 scheduled: two times a day times 0700 and 1900 . Medication: Vancomycin HCl Intravenous Solution 1000MG/200ML (Vancomycin HCl) Use 1 gram intravenously two times a day for osteomyelitis for 6 weeks. Pharmacy to adjust dosage as needed . end date: 03/11/2026. According to a record review of R15's lab results Vancomycin Trough levels were absent in the resident's chart. On 01/29/2026 at ~(approximately)08:40 AM, During an interview with NP A she was asked about how Vancomycin was dosed and she said R15's Vancomycin was dosed by the pharmacy. She was asked how Vancomycin for R15 was ordered and she said it was ordered Vancomycin 1000mg to be given BID. NP A was asked how Vancomycin BID should be scheduled, she said Q12 hours. NP A was asked if it was standard to schedule and administer Vancomycin as at liberal times and clarified the AM dose was scheduled as 7-10 AM with an hour administration window before or after, and the PM dose was scheduled as 2000-2300 (8-11PM) with an additional hour administration window before or after, NP A stated No, it is not. NP A said she talked to Nurse I and clarified the order after it was brought to her attention on (01/28/2026). During the continued interview with NP A was asked about monitoring the Vancomycin, she said it is per pharmacy to dose. NP A was asked about R15's last peak and trough levels, after she looked in R15's chart she said, there are no results for me to review. NP A was asked how long R15 had been on Vancomycin, she said since he was admitted , clarified as 12/24/2025. After NP A reviewed R15's orders, she confirmed that R15 had not had any peak and trough labs ordered or drawn while at the facility. When NP A was asked how the therapeutic level was monitored she deferred to the orders that stated, Pharmacy to dose. On 01/29/2026 at Noon, During an Interview with ICP Nurse G she was asked R15's admission date, she confirmed 12/24/2025. ICP Nurse G confirmed that R15 was admitted to facility on IV Vancomycin 1000mg BID. ICP Nurse G was asked about R15 peak and trough lab results, she said the infectious disease (ID) doctor ordered the medication and order stated, Pharmacy to dose. ICP Nurse G confirmed that R15 had been at the facility for greater than 30 days and that no lab for peak and trough had been done. (peak and trough testing is used to monitor therapeutic drug levels- minimizing adverse effects and optimizing therapeutic effects of medication) ICP Nurse G said they did not get a note back from the pharmacy when the order was sent to them. ICP Nurse G was asked if they received a note for dosing whether labs are needed or not, she said yes, we do, if they are not requested then it would specify you do not need to monitor or something to that effect. ICP Nurse G was queried if there was a note from the pharmacy that stated there was no need to monitor for R15, she said no, I do not have one. ICP Nurse G was asked if she had followed up with the pharmacy about peak and trough labs for R15, she said I called the pharmacy yesterday (1/28/2026) about a lab request, confirmed with ICP Nurse G call was after being interview with SA for infection control program. ICP Nurse G said she asked them (the pharmacy) what to do for R15 because no lab had been requested for peak and trough. ICP Nurse G reported the pharmacy response was 'Oh, yeah we should probably get those' and said that they gave her a verbal order to place an order for peak and trough for (01/29/2026). ICP Nurse G advised SA that once the labs were drawn it would take a day to receive results. ICP Nurse G was queried about Vancomycin 1000mg BID order and how it would be scheduled, she said it would be Q 12 hours and further said it should be scheduled at a set time for proper spacing of doses. According to a record review of R15's orders revealed the following: Date 01/29/2026: Enter Labs into [NAME] for tomorrow: Weekly Vancomycin trough draw 30 mins to 1 hr before dose, BUN, and Creatinine. According to the Infectious Disease Society of America (IDSA) Vancomycin guidelines 2020 Update, The guidelines recommend an AUC/MIC (Area Under Curve/Minimum Inhibitory Concentration) ratio (parameter to assess effectiveness of an antibiotic) of 400–600 mg*hour/L to achieve clinical efficacy and ensure safety for patients being treated for serious methicillin-resistant Staphylococcus aureus infections and according to the IDSA clinical practice guideline recommendation achieving a trough (parameter to assess effectiveness of an antibiotic) concentration of 15-20 mg/L (milligram per liter) for complicated infections. These guidelines emphasize the importance of consistent and timely administration of vancomycin to maintain therapeutic exposure and endorsed Interruptions in therapy can lead to suboptimal drug exposure and potential therapeutic failure. On 02/02/2026 at 8:52AM, During an interview with NP A she was about R15's Peak and Trough labs that were ordered on 01/29/2026 and she said they were drawn, but I have no results to review in the chart and further said she was unaware of the results verbally. NP A was queried about the Vancomycin dose that was held for the lab draw and then restarted with no results reviewed, she said I did not tell them to do that. On 02/02/2026 at 8:59AM, During an interview with ICP Nurse G was queried about R15 peak and trough lab results, she said she ordered the labs to be drawn in (name of lab contractor) system for the drawn to be done for Friday (01/29/2026) morning. ICP Nurse G was asked if R15's labs were drawn. ICP Nurse G said that on Friday (01/29/2026) afternoon she called the (contract company representative name) because she was unable to find the order in the system and R15's labs had not been drawn, ICP Nurse G further exclaimed that she had no idea what happened to the order. ICP Nurse G said she then put in a STAT (rush) order for the labs to be drawn in house and taken to (hospital lab). She said that Nurse C had drawn R15's blood and that staff member E took them to the (hospital lab) on her way home (01/29/2026). ICP Nurse G reported that there was no receipt of drop off from (hospital lab) for the specimen and that (hospital lab) said 'they have no record of it'. R15 had already had his Vancomycin on Saturday. ICP Nurse G said she had requested a new order to hold a dose to draw the lab the next morning on 02/01/2026. ICP Nurse G said a dose of R15's Vancomycin was held and blood was redrawn on Sunday (02/01/2026), and the UM N dropped them off at the hospital lab. ICP Nurse G was asked about results from the 02/01/2026 specimen and she said we do not have them. ICP Nurse G said the DON (who was not available due to illness) had access to the (hospital lab) site checked for results and it said the specimen was rejected. ICP Nurse G stated we are going to draw the labs today (02/02/2026) STAT. According to a record review of R15's orders revealed the following: Date: 01/31/2026: Extend ABX (antibiotic) Vancomycin 1 day due to missed does (dose) waiting for labs to be drawn Revision date: 01/31/2026: Start date: 12/24/2025 scheduled: two times a day times 0700 and 1900. Medication: Vancomycin HCl Intravenous Solution 1000MG/200ML (Vancomycin HCl) Use 1 gram intravenously two times a day for osteomyelitis for 6 weeks. Pharmacy to adjust dosage as needed . end date: 03/12/2026. According to a record review of R15's progress notes revealed: Late entry note created 02/02/2026 at 9:21AM with effective date 02/01/2026 at 09:18AM by the DON: Contacted lab for results of vanco trough. Notified sample was rejected. Contacted floor nurse for redraw to be collected and ran STAT. Unit manager to drop off to lab directly at [NAME] hospital. On 02/02/2026 at 9:44AM, During an interview with staff member E was queried about taking labs to (hospital lab) on Friday 01/29/2026). Staff member E said it was mentioned that we had labs that needed to be dropped off at (hospital lab), and I said I live in (town name). Staff member E said it was not confirmed that the labs were drawn or ready to be taken, she said she left work between 7:30 - 8PM on 01/29/2026 and it had slipped her mind to double check. Staff member E confirmed that she had not delivered labs to (hospital lab) on 01/29/2026. Staff member E said that R15 had already received his Vancomycin on Saturday (01/30/2026) and labs could not be drawn. Staff member E said on Sunday (01/31/2026) R15 had his blood drawn and that the UM N took them to the lab and stated I guess later on they were rejected. On 02/02/2026 at 9:47AM, During an interview with NP A she said It was up to the pharmacy to decide when to do a peak and trough and that R15 returned from his appointment this morning (02/02/2026) with an order to d/c (discontinue) the vancomycin and the PICC line. On 02/02/2026 At 9:58AM, Clinical Nurse J reported R15 will not have a peak and trough due to order to d/c Vancomycin and PICC line and stated we are not going to poke him now. According to the facilities policy titled Antibiotic stewardship program revealed: Policy: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. Guidelines: The Medical Director, Consultant Pharmacist, and Attending Physicians support the program via active participation in developing, promoting, and implementing a facility-wide system for monitoring the use of antibiotics. b. Consultant Pharmacist – reviews antibiotics prescribed to residents during their medication regimen review and serves as resource for questions related to antibiotics. c. Attending Physicians – prescribe appropriate antibiotics in accordance with standards of practice and facility protocols. 4. The program includes antibiotic use protocols and a system to monitor antibiotic usage a. Antibiotic use protocols: ii. Laboratory testing shall be in accordance with current standards of practice. and b. Monitoring antibiotic use: i. Monitor response to antibiotics, and laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made (e.g., antibiotic time-out). ii. Antibiotic orders obtained upon admission, whether new admission or readmission, to the facility shall be reviewed. According to the facilities policy titled laboratory and diagnostic guidelines revealed: Policy: This guideline is set up to track the timely completion, reporting and monitoring of laboratory and diagnostic tests, results, and notifications which are used to monitor resident status and/or therapeutic medication levels. According to the facilities policy from pharmacy titled Provider pharmacy requirements revealed: Policy: Regular and reliable pharmaceutical service is available to provide residents with prescription and nonprescription medications, services, and related equipment and supplies. Procedure: 3. The provider pharmacy is responsible for rendering the required service in accordance with local, state, and federal laws and regulations; facility policies and procedures; community standards of practice; and professional standards of practice. And 4. The provider pharmacy agrees to perform all of, but not only, the following pharmaceutical services. b. Accurately dispensing prescriptions based on authorized prescriber orders. f. Providing routine and timely pharmacy service as contracted, as well as emergency pharmacy service 24 hours per day, seven days per week. h. Screening each new medication order. iv. Appropriate drug dose, dosing interval, and route of administration. Based on resident-specific information and other pertinent variables. According to the facilities policy from pharmacy titled Consultant pharmacist services provider requirements revealed: Policy: The facility will ensure regular and reliable consultant pharmacist services are provided to residents. Procedure: 3. The consultant pharmacist agrees to render the required service in accordance with local, state, and federal laws, regulations, and guidelines; facility policies and procedures; community standards of practice, and professional standards of practice. And 6. Specific activities that the consultant pharmacist performs may include, but are not limited to: a. Reviewing the medication regimen (medication regimen review) of each resident at least monthly, or more frequently under certain conditions (e.g., upon admissions or with a significant change in condition), incorporating federally mandated standards of care in addition to other applicable professional standards. b. Communicating to the responsible prescriber and the facility leadership potential or actual problems detected and other findings related to medication therapy orders including recommendations for changes in medication therapy and monitoring of medication therapy, as well as regulatory compliance issues at least monthly. Antibiotic Stewardship Program task: Record review of the facility 'Antibiotic Stewardship Program' policy dated 12/13/2023 revealed it is the policy of the facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. Antibiotics use protocols: i.) Nursing staff shall evaluate residents who are suspected of having infection. Monitoring antibiotic use: i) Monitor response to antibiotics, and laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made. (vi) Antibiotic use shall be measured by (monthly prevalence, antibiotic starts, and/or antibiotic days of therapy). (vii) At least outcome measures associated with antibiotic use will be tracked as part of the QAPI program monthly, as prioritized Record review of facility antibiotic line listing monthly monitoring from January 2025 through January 2026 was reviewed. Interview and record review on 01/28/2026 at 1:58 PM with Licensed Practical Nurse (LPN)/Infection Control Preventionist (ICP) G and Registered Nurse (RN)/Regional Director of clinicals/Infection Control Preventionist (ICP) J stated that there was no line listing prior to October 2025 in the binder. Record review of a large white three ring binder noted: January 2025 no monthly resident documentation found related to infections/antibiotic used within the month, no mapping, a computerized line listing with no organisms listed with for the treatment with antibiotics, no monthly infection control analysis and summary. There was multiple 'Validation checklists' provided. February 2025 no line listing, no mapping surveillance, no analysis or monthly summary provided. March 2025 no line listing, no mapping surveillance, no analysis or monthly summary provided. April 2025 binder tab held a computerized mapping and 'Validation Checklists'. No monthly resident documentation found related to infections/antibiotic used within the month, no line listing with no organisms listed, no monthly infection control analysis and summary. May 2025 no line listing, no mapping surveillance, no analysis or monthly summary provided. June 2025 no line listing, no mapping surveillance, no analysis or monthly summary provided. Validation checklists were found under the June 2025 tab. Record review of Resident #6 was placed on prophylactic antibiotic Cephalexin oral capsule 250mg one time daily at bedtime indefinitely dated 6/15/2025 and there was no risk vs benefits documentation for the use of the antibiotic. July 2025 no line listing, no mapping surveillance, no analysis or monthly summary provided. August 2025 no line listing, no mapping surveillance, no analysis or monthly summary provided. September 2025 Record review of the line listing provided noted 9 residents placed on Nystatin anti-fungal medication with no stop dates and no body site/location of use to monitor. There were no infectious organisms identified on the line listing for treatments with antibiotics. There was no analysis or monthly summary provided or trends for the spread of rash. Record review of Resident #6 was placed on prophylactic antibiotic Cephalexin oral capsule 250mg one time daily at bedtime indefinitely dated 6/15/2025 was not on the line listing. October 2025 Record review of the line listing provided noted residents placed on Nystatin anti-fungal medication with no stop dates and no body site/location of use to monitor. There were no infectious organisms identified on the line listing for treatments with antibiotics. There was no analysis or monthly summary provided or trends for the spread of rash. Record review of Resident #6 was placed on prophylactic antibiotic Cephalexin oral capsule 250mg one time daily at bedtime indefinitely dated 6/15/2025 was not on the line listing. November 2025 Record review of the line listing provided noted residents placed on antibiotic medications without an organism identified on the line listing for treatments with antibiotics. There was no analysis or monthly summary provided or trends for the spread of infection. No facility November 2025 mapping/tracking provided to surveyor. There was staff training on 'Enhanced Barrier Precautions' policy with signature sheets with no dates when education was given. Record review of Resident #6 was placed on prophylactic antibiotic Cephalexin oral capsule 250mg one time daily at bedtime indefinitely dated 6/15/2025 was not on the line listing. December 2025 Record review of the line listing provided noted Resident #15 placed on Vancomycin antibiotic medication from 12/24/2025 through 2/4/2026. The State surveyor inquired to see Peak & Trough (P&T) therapeutic level monitoring of the antibiotic and was told that there were no Peak & Troughs performed. Registered Nurse (RN) J had no answer for monitoring the antibiotic therapeutic levels and was not aware that there were none done. There was no analysis or monthly summary provided. Record review of Resident #15's physician orders revealed Vancomycin 1000mg intravenously twice daily. Record review of Resident #6 was placed on prophylactic antibiotic Cephalexin oral capsule 250mg one time daily at bedtime indefinitely dated 6/15/2025 was not on the line listing. January 2026 line listing generated on 1/28/2026 did not have infectious organisms noted or Resident #6 prophylactic antibiotic Cephalexin oral capsule 250mg one time daily at bedtime indefinitely dated 6/15/2025 was not on the line listing. Resident #15 (R15): In an interview and record review on 01/29/2026 at 8:20 AM with Nurse Practitioner (NP) 'A' on Resident #15's Vancomycin antibiotic 1000mg twice daily intravenous started on 12/24/2025 through 2/4/2026. NP 'A stated that Vancomycin Peak & Trough is done to determine how much vancomycin antibiotic a resident should be receiving. The order is for pharmacy to determine dosing. There are no peak & troughs for over 30 days, record review of the labs/orders review revealed no Peak & Troughs found. Pharmacy services need to call them for answer. Vancomycin is execrated through the kidneys. We do weekly renal labs. Nurse Practitioner A was asked if there was a risk vs benefits for the prophylactic use of antibiotic for Resident #6, the NP A stated that no she did not do one because that should be hospices call. In an interview on 02/02/2026 at 9:19 AM with Registered Nurse (RN)/Regional Clinical Director J, was asked about the Vancomycin peak & trough blood work/lab that was to be drawn on Friday 1/30/26. RN J stated that it was missing and a stat draw will be done this morning, because the hospital lab rejected the sample. In an interview and record review on 02/02/2026 at 9:25 AM Licensed Practical Nurse (LPN)/Infection Preventionist G (LPN/ICP) stated that Resident #15's Vancomycin 1000mg IV and that there was no Peak & trough (P&T) for therapeutic levels for the last 37 days- started 12/24/25 and is still getting the medication. On Wednesday 1/28/26 during the IC task, surveyor asked for the P&T results, and we identified that there were none. On Thursday 1/29/26 we ordered a P&T for Friday 1/30/26 in the morning, No order in the computer lab system. Friday morning results I went to look in the afternoon and couldn't find the results or order in the [NAME] system. I emailed the [NAME] lab representative, and I have not heard back from him yet. On Friday 1/30/25 we drew blood, a nurse from 300 hall drew the blood and staff member Discharge Planner E was to drop it off on her way home to [NAME]. On Saturday 1/31/2026, I text the nurse management a group text asking if anyone got the results, no one knew where the lab went. Resident #15 missed only one dose on Friday morning and then we got no results, so we drew blood again on Sunday 2/1/26 morning and Licensed Practical Nurse (LPN/UM) the unit manager dropped off the sample at the hospital. I checked labs Monday morning 2/2/26, and it was rejected because there is no reason. In an interview on 2/2/2026 at 9:41AM with Discharge Planner staff E stated that on Friday she left at 7:30-8:00PM and was to take the blood sample to the hospital but did not take the blood because she forgot about it. On Saturday he already had his dose so they couldn't draw the blood, and they were to draw it on Sunday and drop it off. In an interview and record review on 02/02/2026 at 9:48 AM with Nurse Practitioner (NP) A stated that she was notified by state surveyors on 1/29/26 of no peak & trough, so she told facility to contact pharmacy for Vancomycin directions to dose by pharmacy. pharmacy gets the results. On Friday the pharmacy said to hold the medication just to get labs, hold temporary to get labs. Resident #15 only missed one dose Friday morning; there is no trough there are no results for me to review. The resident went on Monday 2/2/26 in the morning to Infectious disease doctor and to Discontinue the PICC line, therapeutic levels not drawn. Vancomycin antibiotic, the monitoring would be up to pharmacy's discretion. Now we are going to pull the PICC line and stop the antibiotic with no therapeutic levels monitored or checked.

Based on interview and record review, the facility failed to ensure that there were adequate staff and/or that staff were utilized appropriately to sufficiently meet the needs of facility residents resulting in increased call light response times, unmet care needs, lack of resident assessment and monitoring.Findings Include:During Resident Council on 1/28/2026, the eight attendees reported the following regarding staffing at the facility:There are not enough staff to meet their needs, and the facility terminates the good staff or forces them out.There is currently a mass exodus of nurses due to how the facility is run and the nurses left do not having enough time to ensure all their needs are met.At times they can have up to three different nurses providing care to them during one shift.Average call light wait time is about 30 minutes and that is across all shifts. On 1/29/2026 at 1:10 PM, an interview was conducted with Staffing Coordinator BB regarding facility staffing. Coordinator BB shared over the last three months approximately ten staff (nurses and aides) have resigned from their positions. When asked if they provided reasoning regarding their resignation, it was reported some would not provide a reason and others stated upper management concerns. Within the last month one nurse and two aides have put in their notice of resignation. Coordinator BB was asked how many openings they currently have, she stated the following:1 nurse on day shift4 nurses on night shift1 aide on day shift The short-term unit is split into four halls- 100, 200 and 300 halls each have an assigned nurse. The nurse for 100 and 200 halls split the 400 hall. It can be noted there are separate halls that are not connected to one another. There is one CNA assigned to each hall to care for the residents and if a resident is a two-person assist they will radio for assistance. On the long-term care unit there is one nurse assigned to 500 and 700 halls and the two nurses split 600 Hall. On 1/29/26 at 4:00 PM, the DON (Director of Nursing) was queried why a resident was unable to remain on the restorative program. The DON stated they do not have staffing to maintain the restorative program. Review was conducted of Resident Council Minutes from January 2025 to present and the resident expressed concern with staffing on multiple occasions.Resident Council Notes:2/11/2025: .Night & day shift cna staff on cell phones.nursing staffing has been challenging/short. 3/11/2025 .staffing has been challenging.4/8/2025: .Staffing has been challenging.Not seeing MOD (manger on duty) on the weekends.6/17/2025: .Call lights are not answered timely on nights and weekend.8/12/2025: .CNA call ins nights and weekends.9/24/25 .Concerned about low employee morale.long wait time for call lights. 10/28/28 (10/28/25) .Some nurses going too fast when providing med.11/18/25 .Some nurses going too fast when providing med.12/22/25 .Some nurses going too fast when providing med.delivery of medications at times late.Concern regarding nurses sharing/splitting 400 Hall. The facility was asked to provide the number of two person assist (this includes mechanical lifts) within the facility. The facility has the following:Short term unit: 12 two-person assistsLong term unit: 15 two- person assist During confidential interviews with facility staff the following was reported regarding staffing concerns:The CNA (certified nursing assistants) rarely take their breaks due to the acuity of the unit. The acuity has been increased for approximately 6-8 months, but the staffing has not increased to meet the needs. More than ten residents require assistance with feeding and the pulls the aides away from direct care during meal times. They are unable to take their time resident care as they have to rush off to the next thing. Many staff are leaving as it has become overwhelming to manage in the current environment. There are nursing tasks that are missed due to the lack of staffing.The mandation is becoming overly common and many times their evening managers are working the carts due to lack of staffing. There is poor staff morale due to concerns over capabilities of leadership. On their units they have multiple PEG (percutaneous endoscopic gastrostomy) tubes, bolus feeds, IV (intravenous) antibiotics, hospice residents, postoperative patients and residents with surgical incisions. During the four-day annual/abbreviated survey the facility was deficient in the following resident care areas that are directly related to staffing:Daily grooming provided to residentsAssessment and monitoring of newly identified skin conditions, tube feeding site and weight lossLack of resident related documentation and coordinator of care

Based on observation, interview and record review, the facility failed to operationalize policies and procedures for medication storage in one of one medication rooms and four of five medication carts, resulting in open, undated, expired, and inappropriately stored medications. Findings include:On [DATE] at 7:09 AM, an open fabric open zipper bag with visible personal items including hand lotion, hand sanitizer, and pens along with a teal-colored Yeti cup were observed sitting on the top of the 700 Hall Medication Cart. There were no staff present at the cart and/or in the hallway. RN Z was observed approaching the medication cart. When asked if the items on top of the cart were theirs, RN Z confirmed they were. RN Z was asked if they are supposed to have personal beverages/cups on top of the medication cart, RN Z did not provide a verbal response but proceeded to remove the bag and cup from the cart. A tour of the 600 Hall Medication Cart was completed on [DATE] at 8:22 AM with Licensed Practical Nurse (LPN) T. A 2.5 milliliter (mL) unopened bottle of Rhopressa 0.02% ophthalmic solution (prescription eye drop used to lower pressure in the eye) for Resident #105 was present in the medication cart. The instructions on the bottle specified the medication should be stored in the refrigerator until opened. A tour of the facility medication storage room was completed on [DATE] at 8:46 AM with LPN T. Two 12 count boxes of Hemorrhoidal Suppositories with an expiration date of [DATE] were present in the medication room. On [DATE] at 2:31 PM, a tour of the 500 Hall Medication Cart was completed with LPN T. The medication cart contained an unopened vial of Lantus 100 units/mL insulin for Resident #8. The insulin was labeled to keep refrigerated until opened. Per the medication label, it was delivered to the facility on [DATE]. A tour of the 300 Hall Medication Cart was completed on [DATE] at 10:24 AM with Registered Nurse (RN) C. The following was present in the cart: - Latanoprost 0.005% ophthalmic solution (prescription eye drop used to lower pressure in the eye) for Resident #72. The medication package was a dark colored bag was labeled Package Protect from light. The medication was on top of and not stored inside the dark colored bag.- Brimonidine 0.2% ophthalmic solution (prescription eye drop used to lower pressure in the eye) for Resident #72. The medication was opened and undated.- A vial of Lantus (insulin) 100 units/mL for Resident #128. The insulin was opened and undated.- A vial of Lispro (insulin) 100units/mL for Resident #128. The insulin was opened and undated.- A 30-count box of Duoneb (nebulizer inhalation solution used to improve airflow) 0.5 mg/ 3 mg three mL vials for Resident #95. The medication was dated as opened [DATE]. The instructions on the medication box specified, Vials should be used within 2 weeks of opening.- A 30-count box of Duoneb (nebulizer inhalation solution used to improve airflow) 0.5 mg/ 3 mg three mL vials for Resident #73. The medication was open and undated.

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5% when three medication errors were observed for three residents (Resident #56, Resident. #59, and Resident #111) for a total of 26 observations, resulting in a medication error rate of 11.5%. This deficient practice resulted in the potential for adverse medication effects and decreased medication efficacy related to medications administered late and the lack of implementation of standards of practice for medication administration. Findings include:Resident #56: A medication pass observation was completed on 1/28/26 at 2:57 PM for Resident #56 with Registered Nurse (RN) AA. RN AA prepared Mirapex (medication used to treat symptoms of Parkinson's disease including tremors and stiffness as well as Restless Legs Syndrome) 1 milligram (mg) tablet for administration to the Resident. The Medication Administration Record (MAR) specified the medication was supposed to be administered at 1:00 PM. RN AA was asked why they were not administering the medication until now when it was due at 1:00 PM and responded that they were unable to get to the Resident's room to administer the medication due to the floor being remodeled/replaced in the hallway. When queried why Resident #56 was in their room if staff were unable to get to them due to the current remodel construction occurring in the facility, RN AA did not provide an explanation.Resident #111:A medication observation for Resident #111 was completed on 1/29/26 7:11 AM with RN Z. RN Z prepared medications for the Resident at the medication cart by removing the medications from the blister packs and placing them in a medication cup including one metoprolol succinate (medication used to treat high blood pressure and heart failure) 25 milligram (mg) Extended Release (ER) tablet. RN Z proceeded to crush all the medications in the cup. Prior to administration, RN Z was stopped prior to administration and queried regarding crushing extended-release medications. RN Z stated, That is what we do. I will have to call the Doctor I guess. With further inquiry, RN Z stated, That is what we always do. RN Z proceeded to administer the crushed medications, including the crushed metoprolol succinate 25 mg ER tablet.Resident #59:On 1/29/26 at 7:28 AM, a medication observation for Resident #59 was completed with RN Z. After preparing medications at the medication cart outside of the room, including oral medications and Breo Ellipta 100/25 mcg (microgram)/inh (inhalation) inhaler (once a day inhaler to improve breathing), RN Z entered Resident #59's room. The first medication RN Z administered to Resident #59 was the Breo Ellipta inhaler. RN Z prepare the inhaler dose and handed the inhaler to the Resident. Resident #59 put the inhaler in their mouth and took two rapid breaths. RN Z did not educate the Resident on proper inhaler use. After using the inhaler, Resident #59 did not rinse their mouth with water and spit.An interview was completed with RN Z after exiting Resident #59's room on 1/29/26 at 7:40 AM. RN Z was asked about Resident #59 taking two rapid breaths when taking the medication and indicated the Resident does that but can only receive one dose due to the inhaler. When queried regarding rinsing with water and spitting after administration of a Breo Ellipta inhaler, RN Z stated, (Resident #59) usually doesn't. No further explanation was provided.An interview was completed with the Director of Nursing (DON) on 1/29/26 at 9:08 AM. When queried if extended-release medications should be crushed, the DON responded they should not. The DON was then informed of RN Z crushing and administering extended-release metoprolol succinate to Resident #111 even after being stopped by Surveyor. When queried regarding their thoughts, the DON stated, The nurse chose not to follow policy/procedure and they would provide education. The DON was then asked if residents should rinse their mouth after using a Breo Ellipta inhaler and verbalized they should. The DON was informed of Resident #59 not rinsing and spitting during medication pass observation and did not provide further explanation. When queried regarding Resident #56 receiving their Mirapex late and RN AA stating they were unable to get to the Resident in their room due to the remodel and flooring installation in the building, the DON indicated that was not an acceptable reason to administer medication late. When asked why Resident #56 was in their room if staff were unable to get to them, the DON responded that staff should be able to reach residents at all times. Review of facility policy/procedure entitled, Medication Administration (Reviewed/Revised: 1/17/23) revealed, Medications are administered by licensed nurses. as ordered by the physician and in accordance with professional standards of practice. 11. Compare medication source with MAR to verify resident name, medication name, form, dose, route, and time of administration. b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. 14. Administer medication as ordered in accordance with manufacturer specifications. c. Crush medications as ordered. Do not crush medications with 'do not crush' instruction.

Based on observation, interview and record review, the facility failed to ensure that physical restraints were not used for one resident (Resident #69) of one resident reviewed, resulting in the use of a seatbelt restraint without an assessment for its use and an evaluation of its appropriateness. Findings include:Resident #69:On 1/27/26 at 3:34 PM, Resident #69 was observed sitting in their room in an electric motorized wheelchair. A seat belt was in place across the Resident's abdomen. An interview was completed at this time. When queried if they were able to undo their seat belt by themselves, Resident #69 replied, No. With further inquiry, Resident #69 stated, I used to be able to, but I can't anymore. Record review revealed Resident #69 was most recently readmitted to the facility on [DATE] with diagnoses which included chronic pain, anxiety, and muscular dystrophy (genetic disorder with progressive weakening and wasting of the muscles). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and dependent upon staff for completion of Activities of Daily Living (ADL). The MDS specified the Resident did not have any restraints in place. A review of the CMS- 802 form revealed the Resident was not marked for having restraints. Review of Resident #69's care plans in their Electronic Medical Record (EMR) revealed the Resident did not have a care plan and/or intervention in place related to seat belt use. Further review of the EMR revealed the Resident did not have a Health Care Provider (HCP) order for seat belt and/or restraint use and no documentation of assessment for seat belt and/or any restraint use. An interview was conducted with the facility Administrator on 1/28/26 at 5:06 PM. When queried if a seat belt on a wheelchair that a resident is unable to undo/disconnect themselves is considered a restraint, the Administrator verbalized they were unsure and would need to review the facility policy. With further inquiry, the Administrator confirmed a seat belt may be considered a restraint. The Administrator stated, Yes, if you can't undo the belt. When asked why Resident #69 had a seat belt in place on their motorized wheelchair which they were unable to undo, the Administrator did not provide a response. When queried why they did not have an assessment for a restraint completed and why the Resident was not listed as having a restraint on the CMS-802 form, the Administrator stated, I will have to discuss with my team. No further explanation was provided. On 1/29/26 at 12:35 PM, an interview was completed with the Director of Nursing (DON). The DON was asked if the Administrator spoke to them regarding Resident #69's seat belt and responded, Yes and we asked the therapy OT (Occupational Therapy) manager to do an evaluation. When queried if they were saying Resident #69 did not have an assessment completed for use of the seat belt, the DON confirmed they did not. The DON was then asked if a seat belt is considered a restraint if the Resident cannot undo the belt by themselves and stated, Yes. When asked, the DON verbalized the seat belt was a restraint. On 1/29/26 at 1:51 PM, Resident #69 was observed sitting in their motorized wheelchair in their room. At interview was completed at this time. Resident #69 was asked again if they could unhook the seat belt and stated, I can't. The Resident was observed attempting to undo the seatbelt latch but was unable to depress the release button. Resident #69 then stated, I told them (staff) I can't. Resident #69 was asked when they informed staff that they could not undo the seat belt by themselves and responded they were unsure of the exact date but that it had been quite a while. Review of facility policy/procedure entitled, Restraints (Reviewed/Revised: 10/26/23) revealed, Policy: Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. 1. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). An evaluation will be completed to determine the medical symptom requiring the device and to determine the least restrictive device to treat the symptom. 2. Restraints with locking devices shall not be used. 5. Physical restraints shall be applied in such a manner that they can be speedily removed in case of fire or other emergency. 6. Physical restraints shall only be used on the signed order of a physician, except in an emergency which threatens to bring immediate injury to the resident or others. 7. Care plans which include the use of physical restraint for behavior control shall specify the behavior to be eliminated, the method to be used, and the time limit for the use of the method. 9. Residents shall be informed about the use of restraints as well as the negative outcomes of restraint use .

Based on observation, interview and record review, the facility failed to ensure the provision of services to maintain grooming and hygiene for one resident (Resident # 1) of two residents reviewed. Findings include:Resident #1: On 1/28/26 at 8:43 AM, Resident #1 was observed in their room. The Resident was in bed, positioned on their back. The Resident was unshaven and had an unkempt appearance with uncombed and chunks of unknown substances on their shirt. When spoke to, Resident #1 made eye contact and shook their head yes or no in response to questions. When asked if staff had assisted them to get cleaned up, Resident #1 shook their head no. Record review revealed Resident #1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), epilepsy, gastrostomy (surgical procedure where an opening is created through the abdominal wall to the stomach, anxiety, traumatic brain injury, and dementia. Review of the Minimum Data Set (MDS) dated [DATE] revealed the Resident was severely cognitively impaired and required supervision to moderate assistance to complete Activities of Daily Living (ADLs). Review of Resident #1's Electronic Medical Record (EMR) revealed a care plan entitled, (Resident #1) has an ADL self-care performance deficit related to decreased functional mobility and physical limitations. (Initiated: 12/26/24; Revised: 10/22/25). The care plan included the interventions:- Dressing: 1 person assist (Initiated: 12/27/24; Revised: 11/25/25)- Shower/Bath. 1 assist . Prefers no facial hair. (Initiated: 12/27/24; Revised: 11/20/25)- Transfers: one person assist (Initiated: 12/26/24; Revised: 11/25/25)- Toileting: one person assist (Initiated: 12/26/24; Revised: 11/25/25) On 1/29/26 at 2:13 PM, Resident #1 was observed laying in their room in bed. Their hair remained uncombed and they were unshaven. [NAME] colored flecks of what appeared to be dandruff were observed on the Resident's hair and shirt. Resident #1 appeared to be wearing the same maroon colored shirt they were wearing on 1/28/26. The shirt had unknown dark colored areas on it as well as chunks of unknown substances. When queried if they were wearing the same shirt, Resident #1 shook their head to indicate yes. Resident #1 proceeded to smell their shirt and indicated it smelled bad. Resident #1 then raised their arm for me to smell it. The shirt had a foul odor. Resident #1 then held up three fingers. When asked if they were saying they had been wearing the same shirt for three days, Resident #1 shook their head yes. When asked if staff had assisted them to get cleaned up, Resident #1 shook their head no. An interview was completed with Certified Nursing Assistant (CNA) DD on 1/29/26 at 2:15 PM. When queried if they were assigned to care for Resident #1, CNA DD confirmed they were. CNA DD was asked if Resident #1 had gotten cleaned up for the day and had oral care completed and stated, No, I'm going to do it later today. At 2:19 PM on 1/29/26, an observation and interview with Resident #1 was completed with the Director of Nursing (DON). Upon entering the room, Resident #1 informed the DON they had been wearing the same shirt for three days and that it smelled bad. After exiting Resident #1's room, the DON confirmed the Resident's poor hygiene/grooming and the visible substances on their hair and shirt. The DON stated Resident #1's lack of daily care was Not acceptable and they were embarrassed. The DON verbalized they would have a staff member assist the Resident. Review of facility policy/procedure entitled, Activities of Daily Living (ADLs) (Revised: 12/28/23) did not address the provision of daily ADL care.

Based on observation, interview and record review, the facility failed to operationalize policies and procedures to ensure that residents were treated in a dignified and respectful manner for two residents (Resident #32 and Resident #69) of four residents reviewed, resulting in staff not knocking prior to entering residents' rooms and a lack of timely care resulting in incontinence, and resident's verbalizations of dissatisfaction with care. Findings include:Resident #32: On 1/28/26 at 9:24 AM, Resident #32 was observed sitting in a wheelchair in their room. An interview was completed at this time. When queried regarding the food and care they receive in the facility, Resident #32 replied, The food is slop and the facility is short staffed. With further inquiry, Resident #32 stated, It makes you feel mean, you are waiting all the time for something in here. Resident #32 was asked how they are treated by staff and stated, I feel like this is the ignored room. When asked to explain, Resident #32 verbalized they have to wait for hours when they want to be transferred. When asked why they have to wait so long, Resident #32 responded that they require the Sit to stand (mechanical lift) and have to use the toilet in the shower because it wont fit in my room. With further inquiry, Resident #32 revealed they have a urostomy (surgically created opening in the abdomen to the bladder for the drainage of urine) and sometimes know when they need to have a bowel movement. Resident #32 stated, I put on my light when I think I have to go, but it takes them (staff) an hour or more (to answer light). Resident #32 continued, The one day I was sitting outside (room), not five feet from the toilet shitting myself. That is so embarrassing for an old lady. When queried if staff respect their privacy, Resident #32 replied, I have no privacy. They (staff) just walk in and not knock. At 9:43 AM on 1/28/26, while speaking with Resident #32 in their room, Certified Nursing Assistant (CNA) CC was observed entering Resident #32's room without knocking. Record review revealed Resident #32 was most recently readmitted to the facility on [DATE] with diagnoses which included diabetes mellitus, multiple sclerosis, depression, and pain. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact, was dependent upon staff for transferring, and frequently incontinent of bowels. Resident #69:On 1/27/26 at 3:34 PM, Resident #69 was observed sitting in an electric wheelchair in their room and an interview was completed. When queried how they are treated by facility staff, Resident #69 replied, It takes them forever to get to my light. When queried if the staff treat them with respect, Resident stated, Sometimes. When asked what sometimes meant, Resident #69 responded that some staff have an attitude when they come in their room. Resident #69 was asked what they meant by attitude and replied, Just treat me like I'm bothering them. When asked if there were specific staff that made them feel that way, Resident #69 revealed it was mainly night shift staff. When queried what the staff say that make them feel that way, Resident #69 revealed they say, What do you want? with a tone when they put on their call light for assistance. With further inquiry, Resident #69 stated, They are really rough when they are positioning me and indicated the staff are moving fast and not being careful. Resident #69 stated, I have two rods in my back, and the head of my femur is out and indicated the staff need to go slower so it causes them less pain. When asked if they informed the staff about this and asked them to slow down, Resident #69 responded they had but indicated it did not make a difference. Record review revealed Resident #69 was most recently readmitted to the facility on [DATE] with diagnoses which included chronic pain, anxiety, and muscular dystrophy (genetic disorder with progressive weakening and wasting of the muscles). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and dependent upon staff for completion of Activities of Daily Living (ADLs). An interview was completed with the facility Administrator on 1/28/26 at 4:45 PM. When queried if they had been made aware of any resident concerns related to long call light wait times, the Administrator responded they had a couple call light (concern) forms. When asked if it is acceptable to wait an hour for someone to answer your call light, the Administrator responded, No. The Administrator was then asked if they had received any concerns regarding related to staff treatment of residents and replied, Had some concern forms about rude staff and indicated the concerns were customer service issues. The Administrator was then informed of Resident statements related to staff not knocking, not providing timely assistance, and how staff speak to them. When asked if that was acceptable, the Administrator responded that it was not. Review of facility policy/procedure entitled, Promoting/Maintaining Resident Dignity (Reviewed/Revised: 10/26/23) revealed, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life. 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. 5. When interacting with a resident, pay attention to the resident as an individual. 6. Respond to requests for assistance in a timely manner. 10. Speak respectfully to residents.

Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures for storage and cleaning of respiratory equipment for one resident (Resident #1) of three residents reviewed, resulting in a lack of cleaning and appropriate storage of nebulizer (machine which converts liquid into fine mist for administrator of medications directly into the lungs through respiration) equipment. Findings include:Resident #1: On 1/28/26 at 8:43 AM, Resident #1 was observed in their room in bed. When spoke to, Resident #1 would make eye contact and shook their head yes or no in response to questions. A nebulizer machine was observed on the dresser beside the Resident's bed. A nebulizer administration mask was sitting next to the machine on the dresser in a clear bag. The nebulizer mask was connected in the bag and visible fluid was present in the medication administration chamber. An oxygen concentrator was present with nasal canula tubing connected. The nasal cannula tubing was uncontained and sitting on top of multiple items on the dresser. Record review revealed Resident #1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), epilepsy, gastrostomy (surgical procedure where an opening is created through the abdominal wall to the stomach, anxiety, traumatic brain injury, and dementia. Review of the Minimum Data Set (MDS) dated [DATE] revealed the Resident was severely cognitively impaired and required supervision to moderate assistance to complete Activities of Daily Living (ADL). On 1/29/26 at 7:51 AM, Resident #1's nebulizer face mask was observed sitting in the same position, in a clear bag, on top of their dresser. The nebulizer mask was connected in the bag with visible fluid present in the medication administration chamber. Unit Manager Licensed Practical Nurse (LPN) N was observed in the hallway and asked to come into Resident #1's room. LPN N was shown the medication administration mask set with the visible fluid in the medication chamber and informed the mask and fluid were observed in the same position on 1/28/26. LPN N stated, It shouldn't be left together with fluid in the chamber. When queried regarding appropriate care and storage of nebulizer equipment, LPN N replied, Should be taken apart and cleaned. Review of facility policy/procedure entitled, Nebulizer Therapy (Reviewed/Revised: 5/15/24) revealed, It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions. p. Disassemble and rinse the nebulizer water and allow to air dry. 2. Care of the Equipment a. Clean after each use. c. Disassemble parts after every treatment. d. Rinse the nebulizer cup and mouthpiece with water. e. Shake off excess water. f. Air dry on an absorbent towel. g. Once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag. h. Change nebulizer tubing weekly.

Based on observation, interview and record review, the facility failed to follow standards of practice by failing to assess and monitor the removal site of a gastrostomy tube (GT) site and monitor pain for one resident (Resident #124) of 3 residents reviewed for tube feeding in a sample of 22 residents. Finding include:Resident #124:Peg Tube Removal:In an observation and interview on 01/27/2026 at 9:49 AM, Resident #124 was lying in bed. She stated that she has a belly tube and the IV in her right arm. Resident #124 showed the state surveyor her right upper arm and abdominal gastrointestinal tube site. Observation revealed no split sponge gauze dressing noted to the site.In an interview on 01/28/2026 at 3:50 PM, Resident #124 was seated up in Wheelchair in the hallway and was so happy she got her belly tube out. She went to the doctor, and they took out her feeding/peg tube. She is so happy and tells everyone about it. Record review of the facility 'Nutritional Management' policy, dated 7/1/2025, revealed the facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. (5.) (c.) The care plan will be updated as needed, such as when a resident's condition changes . Record review of Resident #124's Care Plans, Pages 1-33 revealed that the resident was at risk for bleeding or hemorrhage related to Aspirin therapy dated 11/4/2024. Interventions included: Observed for and report to MD as needed and signs & symptoms of abnormal bleeding . Gastrointestinal care plan related to complications related to her impaired gastrointestinal status secondary to: Acid reflux, fatty liver, gastrotomy (peg tube) status. Interventions included: report abdominal cramping, nausea or vomiting, stay up right after meals, observed abdominal pain, abdominal cramping, increase in abdominal girth, hyperactive/hypoactive bowel sounds, frequency, urgency and loose stools. Tube feed: administer enteral nutritional ordered, observe for complications, treatment to tube site per order. Observed and reported to physician/NP/PA any abdominal pain, distention, tenderness at tube site, nausea/vomiting . In an observation and interview on 01/29/2026 at 1:52 PM with Licensed Practical Nurse (LPN) H (wound care nurse), the state surveyor observed Resident #124's abdomen. LPN H was not aware that the gastro/peg tube was removed yesterday on 1/28/26. Observation of a 4x4 covered with tape, no date on the dressing. Resident #124 stated that the hospital nurses put the dressing on it and no one's looked at it since. In an interview and record review on 01/29/2026 at 1:55 PM, the Director of Nursing (DON) I was not aware that Resident #124 had her peg tube removed yesterday. The DON did a record review of Resident #124's progress notes and there was a transport note at 5:55AM of a gastro appointment. The DON could not find the consultation packet that is supposed to come back with the transport staff. The DON stated, What is supposed to happen is the transport person gives the consult packet to the nurse the nurse lets the provider know and puts in the new orders. Record review of the medical record revealed no new orders were put in. Record review of the progress notes revealed no note upon return of peg tube removal. The DON stated that there should have been an abdomen assessment, drainage from dressing, pain assessment, erythremia at the site, and some sort of abdomen assessment. There were no new orders put in by the nurse, so we did not know of the tube removal. Record reviews of care plans still had tube feeding on the care plan and there was no assessment of the dressing or how long it was to be in place or when to change the dressing. Record review of Resident #124's 'Skilled Daily' document, dated 1/29/2026 at 3:41AM, noted that the PEG tube was removed. Record review of the facility 'Pain Management' Policy, dated 10/23/2023, revealed that the facility will ensure that pain management is provided to residents who require such services, consistent with professional standards of practice . Recognition: Evaluate the resident for pain upon admission, during ongoing scheduled assessments and with change in condition to status . Pain Assessment: An assessment or evaluation of pain based on professional standards of practice by appropriate members of the interdisciplinary team . Review of the resident's diagnosis or conditions and any additional factors that may be causing or contributing to pain . Duration, frequency, location, onset, pattern, radiation .Aching, burning, throbbing, tingling, stabbing .

Based on observation, interview and record review, the facility failed 1) Address a hunger strike for Resident #57, 2) Assess and monitor a new skin alteration for Resident #99, and 3) Ensure a quality of care of assessment and monitoring per professional standards for Resident #124, resulting in a lack of care coordination, documentation and assessments. Findings include: Resident #124: Record review of Resident #124's progress notes dated 1/19/2026 at 4:06 PM noted the resident returned from hospital and an assessment was completed. Record review of Resident #124's vital signs, dated 1/19/2026 at 3:32 PM, noted a forehead temperature of 101.3 degrees F. Record review of Resident #124's Medication Administration Record (MAR) noted that on 1/20/2026, an antibiotic Meropenem intravenous 1 gram every 8 hours for sepsis. Record review of Resident #124's readmission Minimum Data Set (MDS), dated [DATE], noted a female with Brief Interview of Mental Status (BIMS) score of 13 out of 15, cognitively intact. Active medical diagnoses included: hypertension, Gastroesophageal reflux disease, renal insufficiency, diabetes, seizures, malnutrition, anxiety, depression, schizophrenia, chronic obstructive pulmonary disease and sepsis (life threatening infection). Section N: Medications identified antibiotic, antiplatelet, and antipsychotic medications. In an observation and interview on 01/27/2026 at 9:49 AM, Resident #124 was lying in bed. She stated that she has a belly tube and the IV in her right arm. Resident #124 showed the state surveyor her right upper arm and abdominal gastrointestinal tube site. Observation revealed no split sponge gauze dressing noted to the site. Resident #124 was diaphoretic/sweaty in appearance and moisture noted to facial area and hair line. In an observation and interview on 01/27/2026 at 11:06 AM with Licensed Practical Nurse (LPN) N [Unit Manager], the surveyor observed Resident #124's right upper arm midline Peripheral Inserted Central Catheter (PICC), with a dressing dated 1/20/2026 and the dressing was occlusive. LPN N stated Resident 124 just came back from the hospital on 1/19/2026, she went with a Urinary Tract Infection and is getting antibiotics. Resident #124 opened her eyes and shakes her head in response to questions. LPN N stated that the PICC line is due to be changed today. It should be every 7 days. In an interview on 01/27/2026 at 12:44 PM, Nurse Practitioner (NP) Q revealed Resident #124 had a temperature and that he let the staff know and they got temperature of 102.6 degrees. NP Q stated that he just worries about Resident #124 because she is diabetic and has co-morbidities and complications. Resident #124 may need to get more antibiotics and needs a septic work up. She was sweaty when I was in seeing her earlier this morning. Record review of Resident #124's temperature vital sign log revealed on 1/19/2026 a temperature of 101.3 degrees upon admission. Resident #124's temperature was not documented as being checked again until 1/28/2026. Record review of the facility 'Abuse, Neglect and Exploitation' Policy, dated 1/10/2024, noted neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Record review of Resident #124's Progress Notes, dated 1/27/2026 at 11:40 AM, noted the resident has a temperature of 102.6, altered mental status. Resident finished Intravenous antibiotics for sepsis. Resident was sent out to hospital. Record review of Resident #124's return from leave and transfer assessment of 1/27/2026 at 9:40 PM made no mention of the PICC line dressing being occlusive and intact, no was photo taken, and there were no measurements of length or arm diameter from hospital care. Resident #57: On 1/28/2026 at approximately 3:00 PM, Resident #57 shared he has been on a hunger strike since 12 AM today due to the way facility management treats their employees and their termination. Resident #57 was asked if he informed anyone of his intentions and he reported Business Officer Manager W is aware. On 1/28/2026 at 3:30 PM, a review was conducted of Resident #57's medical records and it revealed the resident readmitted to the facility on [DATE] with diagnoses that included Diabetes, Atrial Fibrillation, Kidney Disease, Hypertension and anxiety. The resident is his own person and able to make his needs known to staff. Further review of his chart yielded the following: Care Plan: (Resident #57) is at risk for endocrine complications related to his altered metabolic status secondary to diabetes.Monitor blood glucose levels per orders. There was nothing located in his care plan regarding his hunger strike. On 1/28/2026 at 4:00 PM, an interview was conducted with Business Officer Manager W regarding Resident #57's hunger strike. Manager W reported during her rounds this morning he shared he was not happy with the Administrator because of the loss of employees. Due to this, he is now on a hunger strike and has not eaten breakfast. Manager W reported they discussed this during their morning stand-up meeting. On 1/29/2026 at 8:40 AM, Nurse Practitioner A reported she was aware on 1/27/2026 of Resident #57's hunger strike as he informed her during a visit. She educated him on the possible negative outcomes and informed the management team who stated they would provide additional support services. Practitioner A stated the resident should have monitoring in place. 01/29/2026 at 10:16 AM, an interview was conducted with Registered Dietetic Technician X. She shared she checked in with Resident #57, and he expressed he was on a hunger strike due to his favorite employees being terminated. Technician X stated she was made aware of his intentions on Tuesday and assessed him on Wednesday. She was uncertain how serious staff were taking his hunger strike as many resident's order takeout. Upon evaluation he agreed to accept mighty shakes with each meal going forward. Technician X stated prior to leaving yesterday she emailed the Nurse Manager to request an order for Accu-Cheks given that he is diabetic, being administered metformin and not currently eating. Combined with his other comorbidities could affect his health status. Review was conducted of his chart, and it was found his blood glucose levels were not being monitored and there was a practitioner note on 1/27/26 regarding the strike but no other monitoring efforts were located in his chart. Resident #57's FAR (Food Acceptance Record) was reviewed, and he did not eat on 1/27/2026 or 1/29/2026. On 1/27/2026 - dinner its documented as 240 Technician X stated it is assumed this is the amount of fluids that he drank as it does not make sense for percentage eaten. Upon review of the MAR (Medication Administration Record) it indicated he was administered both does of his Metformin on 1/27/26, 1/28/26 and the morning does on 1/29/26. On 1/29/2026 at 12:42 PM, Resident #57 stated he did not eat last night 1/28/2026 or this morning. He explained he had three mighty shakes yesterday evening after speaking with the dietitian and two this morning. Resident #57 stated he is still on his hunger strike. On 1/29/2026 at 1:00 PM, CNA (Certified Nursing Assistant) Y was asked if Resident #57 ate food during breakfast and she stated he did not. She stated he had a few might shakes but not food intake. CNA Y was asked to clarify her charting on his FAR from breakfast and she stated it was indicative the he drank 100% of the mighty shakes. Further review was completed of Resident #57's chart and it yielded the following: Progress Notes: Practitioner note -1/27/2026 at 0800: .He does report dissatisfaction with some facility issues, I am going on a hunger strike for one week because the facility has fired some of my favorite nurses and I am going to make a statement.IDT made aware and will offer additional support. It can be noted dietary evaluated Resident #57 on 1/28/2026 at 7:10 PM after he had not eaten for 48 hours. There were not any other assessments and monitoring of his hunger strike until this point. Blood Sugar Summary: Resident #57's blood sugar was last checked on 1/1/2026 and was 109. January 2026 FAR: 1/27/2026: Breakfast- refused Lunch – refused Dinner – 240 ( per Registered Dietetic Technician X believes this is fluid intake not amount eaten) 1/28/2026: Breakfast- refused Lunch – refused Dinner: 60 ( per Resident #57 he did not eat only drank mighty shakes) 1/29/2026: Breakfast- 100 Lunch – 50 Per CNA Y 1/29/26 documentation is indicative of amount of fluid intake. January 2026 MAR: Metformin HCI Tablet 500 MG – give one tablet by mouth every morning and at bedtime. Resident #57 was administered both doses on 1/27/26 and 1/28/26. On 1/29/26 he was administered his morning dose. Review was completed of the facility policy entitled, Resident Meal Service, reviewed 7/1/2025. The policy stated, .Significant variations from usual eating or intake patterns must be recorded in resident's record. The Nurse Supervisor and/or Unit Manager shall evaluate the significance of such information and report it, as indicated, to the Attending Physician and Dietitian. Resident #99: On 1/27/2026 at 11:10 AM, Resident #99 was observed in bed and reported he was awaiting his therapy session. Observed on his fitted sheet, top sheet and blanket were dark red circular spots and multiple areas of splattered red stains. Resident #99 reported it was from his bilateral legs bleeding. On his left forearm was a large bandage that was undated or initiated. The resident reported he has an area that continues to bleed and the staff have been bandaging it for the past three days. On 1/27/2026 at 12:36 PM, Nurse S stated she was unaware of any bandages on his arms. She reviewed Resident #99's progress notes and treatment orders and shared there was nothing listed regarding this. CNA (Certified Nursing Assistant) U shared on yesterday the nurse was attempting to get ahold of the Wound Nurse H to assess Resident #99's arm as it kept bleeding through the bandages. He had gone through two bandages prior to the nurses placing xeroform, folding a 4x4 gauze in half twice and securing with boarder gauze. From their understanding Wound Nurse H never came down to assess the area. On 1/27/2026 at approximately 12:55 PM, Wound Nurse H was queried if staff asked her to assess Resident #99's forearm yesterday and if she was aware of the new skin alteration. Nurse H reported she was unaware of this, and no staff asked her to assess any skin issues for him yesterday. Nurse H was asked if she would be able to assess and she reported she would go right down. On 1/27/2026 at 1:00 PM, an interview was conducted with Nurse R regarding Resident #99's forearm. She explained upon arriving for her shift the residents left forearm was already bandaged. She reviewed his chart and did not see a treatment order or any notes regarding the reasoning for the bandage or subsequent skin alteration. Nurse R reported she contacted Wound Nurse H and asked her to assess the area but she informed her to reinforce the dressings. Nurse H never came down to assess Resident #99's forearm. Review of text message exchange between Nurse R and Wound Nurse H on 1/26/2026 at 12:36 PM: Nurse R: 102 has a bunch of bandages on his arms and hands. I don't' have orders visible. Can you come down for further instruction? I never knew him to have them. Wound Nurse H: He picks at his skin. U can remove, if there is no drainage leave them off. Nurse R: He's bleeding, soaking through them to be exact. I'll change them. Wound Nurse H: Face palm emoji On 1/27/2026 at 1:20 PM, Wound Nurse H was asked if she had a text exchange with a nurse regarding Resident #99's bandages. Wound Nurse H asked which nurse and then stated, Was is (Nurse R)? Nurse H proceeded to recant her earlier account and reported she did not recall speaking to Nurse R regarding this as she receives so many text messages a day. Nurse H did not have an answer when asked why she hurriedly went to assess the resident when asked by this surveyor but did not assess the day prior when requested by nursing staff. On 1/27/2026 at approximately 3:30 PM, a review was conducted of Resident #99's medical records and it revealed he readmitted to the facility on [DATE] with diagnosis that included, Congestive Heart Failure, Diabetes, Atrial Fibrillation, Insomnia, Major Depressive Disorder and Peripheral Vascular Disease. TAR (Treatment Administration Record): January 2026: The TAR indicated treatment orders were first entered on 1/27/2026 at 1:15 PM for his left inner forearm wound. Which was after the discussion with the facility regarding this concern. Care Plan: . (Resident #99) is at risk for abnormal bleeding or hemorrhage related to anticoagulant therapy, aspirin therapy and antiplatelet therapy. On 1/29/2026 at 8:40 AM, Nurse Practitioner A reported Resident #99 does pick at his skin and a request for their psychiatric group to evaluate him will be placed. Practitioner A stated any wound care treatment should be an order and if staff observed a new skin alteration, they reach out to Wound Care Nurse H for assessment and appropriate order.

Based on observation, interview and record review, the facility failed to update care plan interventions for two residents (Resident #55, Resident #124) of 22 residents reviewed, resulting in the likelihood for missed interventions in treatment and unmet needs. Findings include:Resident #55:In an interview on 01/27/2026 at 11:17 AM, Resident #55 stated that he has had a urinary catheter for years and basically takes care of it himself. He is on antibiotic for an irritated skin at the suprapubic site. He denied Urinary Tract Infection at this time but has had them in the past. The resident could not recall the facility staff education on catheter care provided to him. Observation on 01/27/2026 at 11:21 AM of Resident #55 was seated up in a wheelchair in his room and showed the surveyor his right catheter leg bag he puts on himself. Resident #55 was observed to be moving throughout the hallways in wheelchair self-propelling, will monitor the catheter hanging on his right leg throughout survey. Observation on 01/28/2026 at 9:54 AM of Resident #55 was Observed urinary catheter leg bag observed to right lower leg. Leg strap is noted above the catheter bag and below the bag. Record review on 1/27/2026 of Resident #55's 'Activity of Daily Living (ADL)' care plan noted the resident had self-care performance deficit related to non-traumatic intracerebral hemorrhage, syncope, muscle weakness, cognitive communication deficit. Interventions dated 12/10/2023 of toileting: supervision- resident at time prefers to empty his own catheter. An interview and records review on 1/28/2026 at 1:51PM during the infection control task line listings revealed that Resident #55 was put on antibiotic Bactrim because of skin irritation at suprapubic site. Record review on 1/27/2026 of Resident #55's 'Suprapubic catheter related to presence of urogenital implant, obstructive uropathy. Resident #55 performs own Cather care; staff will assist as needed. Care plan revised 1/28/2026 Record review of Resident #55's January 2026 Medication Administration Record (MAR) revealed the resident was started on 1/7/2026 on Bactrim DS oral 800/180mg give one tablet by mouth every 12 hours for suprapubic catheter infection for 7 days. Resident #124:Record review of Resident #124's Medication Administration Record (MAR) noted that on 1/20/2026 antibiotic Meropenem intravenous 1 gram every 8 hours for sepsis. Observation and interview on 01/27/2026 at 9:49 AM of Resident #124 was lying in bed, she stated that she has a belly tube and the IV in her right arm. Resident #124 showed the state surveyor her right upper arm and abdominal gastrointestinal tube site. Observation had no split sponge gauze dressing noted to the site.Observation and interview on 01/27/2026 at 11:06 AM with Licensed Practical Nurse (LPN) N Unit Manager observed Resident #124's right upper arm midline Peripheral Inserted Central Catheter (PICC), dressing dated 1/20/2026, dressing occlusive. LPN N stated Resident 124 just came back from the hospital on 1/19/2026, she went with a Urinary Tract Infection and is getting antibiotics. Resident #124 opened her eyes and shakes her head in response to questions. LPN N stated that the PICC line is due to be changed today, it should be every 7 days. Observation and interview on 01/28/2026 at 9:04 AM Therapy staff O and P of Resident #124's right upper arm PICC line dressing is dated 1/20/2026 and is the same dressing observed previous day. Observation and interview on 01/28/2026 at 9:10 AM with Registered Nurse C (RN), came into Resident #124's room to observe the Right arm PICC line dated 1/20/2026. It should be changed every 7 days. Record review of Resident #124's Care plans pages 1-33 revealed that there was no infection, antibiotic medication or Peripheral Inserted Central Catheter (PICC) line care plan. There were no interventions for care related to monitoring of infection (temperature), PICC line site care and treatment. Peg Tube Removal:In an interview on 01/28/2026 at 3:50 PM with Resident #124 was seated up in Wheelchair in the hallway and so happy she got her belly tube out, she went to the doctor, and they took out her feeding/peg tube out. She is so happy and tells everyone about it. Record review of Resident #124's Care Plans pages 1-33 revealed that the resident was at risk for bleeding or hemorrhage related to Aspirin therapy dated 11/4/2024. Interventions included: Observed for and report to MD as needed and signs & symptoms of abnormal bleeding . Gastrointestinal care plan related to complications related to her impaired gastrointestinal status secondary to: Acid reflux, fatty liver, gastrotomy (peg tube) status. Interventions included: report abdominal cramping, nausea or vomiting, stay up right after meals, observed abdominal pain, abdominal cramping, increase in abdominal girth, hyperactive/hypoactive bowel sounds, frequency, urgency and loose stools. Tube feed: administer enteral nutritional ordered, observe for complications, treatment to tube site per order. Observed and reported to physician/NP/PA any abdominal pain, distention, tenderness at tube site, nausea/vomiting . Observation and interview on 01/29/2026 at 1:52 PM with Licensed Practical Nurse (LPN) Wound care nurse H and state surveyor observation of Resident #124's abdomen. LPN H was not aware that the gastro/peg tube was removed yesterday on 1/28/26. Observation of a 4x4 covered with tape, no date on the dressing. Resident #124 stated that the hospital nurses put the dressing on it and no one's looked at it since. In an interview and record review on 01/29/2026 at 1:55 PM with the Director of Nursing (DON) I was not aware that Resident #124 had her peg tube removed yesterday. The DON did a record reviewing the Resident #124's progress notes and there was a transport note at 5:55AM of gastro appointment. The DON could not find the consultation packet that is supposed to come back with the transport staff. The DON stated, What is supposed to happen is the transport person gives the consult packet to the nurse the nurse lets the provider know and puts in the new orders. Record review of the medical record revealed no new orders were put in, record review of progress notes revealed no note upon return of peg tube removal. The DON stated that there should have been an abdomen assessment, drainage from dressing, pain assessment, erythremia at the site, and some sort of abdomen assessment. There were no new orders put in by the nurse, so we did not know of the tube removal. Record reviews of care plans still had tube feeding on the care plan and there was no assessment of the dressing or how long it was to leave in place or change the dressing. Record review of the facility 'Comprehensive Care Plan' policy, dated 6/30/2022, revealed it is the policy of the facility to develop and implement a comprehensive person-centered car plan for each resident, consistent with resident rights, including measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The care plan will describe at a minimum the following: Any services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being

This citation pertains to Intake Numbers 2688354 and 2689940.Based on observation, interview and record review the facility failed to ensure timely reporting, notification, comprehensive assessment and continued post-fall monitoring for one resident (Resident #2) following an unwitnessed fall of one resident reviewed for safety and accidents. Findings include:Resident #2 (R2):A record review for Resident 2's (R2) quarterly Minimum Data Set (MDS) assessment revealed a Brief Interview of Mental status (BIMs) score of 99 that indicated severe cognitive impairment and indicated a need for comprehensive assistance and specialized care approaches. Further record review of R2's medical record revealed medical diagnoses that included: dysphagia following cerebral infarction (stroke), aphasia following cerebral infarction, type 2 diabetes mellitus, seizures, contracture bilateral knees, Hemiplegia (one sided paralysis or weakness) and hemiparesis (one sided muscle weakness) following cerebral infarction affecting left non-dominant side, adjustment disorder with anxiety, vascular dementia, acute kidney failure, difficulty in walking, limitation of activities due to disability, need for assistance with personal care. According to a record review of complaint 2688354, it was alleged R2 had an injury of unknown origin by family member Y who found and inquired about discoloration of area on R2's buttocks and new abrasion on right knee on 12/08/2025.On 12/10/2025 at 1:40 PM, A phone call was placed to complainant family member Y for R2, a message was left to advise state agency (SA) was on site to review the complaint received and the SA call back phone number was left.On 12/10/2025 at ~(approximately) 2:00 PM, During a brief interview NHA was asked about R2 and any known falls or incidents recently, NHA replied Yes, R2 has a history of falls. NHA further said that they have an open FRI on R2 that was filed on 12/08/2025 and they did not want to respond specifically as they were in the middle of their 5 days, and they did not want to give incomplete information yet. NHA was asked for incident reports for the falls/incident reports related to R2, for the last month. On 12/11/2025 at 10:32AM, During an interview with CNA Q it was revealed they were a first shift CNA that primarily worked on the short-term units of the facility, and they were familiar with R2. They reported that R2's shower day was changed to day shift on 12/08/2025, at the request of the nurse and family. CNA Q reported that they had made up a shower on 12/08/2025 for R2 that was not completed on the night shift 12/07/2025. When asked about the skin assessment done with showering CNA Q said, I noticed what looked like a birthmark on her tailbone but did not think it was anything but that. When CNA Q was quired about the appearance of the birthmark they reported a description of a port wine purple/red in color type birthmark. CNA Q was asked if during incontinence care for R2 they had ever noticed the birthmark and they responded they had not noticed it before and then stated, I assumed (that) I had just overlooked it before. When CNA Q was asked if she reported or documented the finding, CNA Q stated it did not look like anything new or a bruise to me. When asked about R2 right knee abrasion, CNA Q said that their attention was not called to R2's right knee abrasion until the wound care nurse asked for help with R2 when photos were taken later that day (12/08/2025) of both the right knee and tailbone. CNA Q said she was unaware of any falls for R2 prior to 12/08/2025. According to a record review of R2's point of care documentation completed by CNA's for care provided labeled TASK -skin monitoring, it was revealed that: None of the above was noted as being no: Scratched, Red Area, Discoloration, Skin Tear or Open Area none of the above was marked on each of these entries:11/28/2025 at 10:5111/29/2025 at 05:59 & 17:5911/30/2025 at 03:52,17:51 & 23:2012/1/2025 at 17:23 & 19:0212/2/2025 at 10:3012/3/2025 at 02:46 & 17:4312/4/2025 at 01:20 & 09:2312/5/2025 03:26, 17:24 & 23:1212/6/2025 at 09:26 & 21:0112/7/2025 at 07:1412/8/2025 at 08:5212/9/2025 at 00:26, 10:15 & 19:4012/10/2025 at 17:05 & 23:27 According to a record review of R2's fall assessments in the documentation of nursing staff, it was revealed: R2 had 2 initial fall assessments completed on 11/19/2025. A record review of subsequent documents labelled follow up fall assessments, there were 2 assessments completed daily for each of the following dates 11/20 through 11/25/2025. Noted with this record review that there was no fall assessment completed for 12/01/2025 fall. According to a record review of R2's skin & wound evaluation documentation of nursing staff, it was revealed:On 12/06/2025 note reported: no new abnormal skin areas, an acknowledgement that the nurse did complete an assessment and no note of existing abnormal skin areas.On 12/08/2025 note reported: Abrasion to right front knee, in house acquired, unknown age, measuring 1.2 cm, 1.8 cm length, 0.9cm width. Another note reported: Bruise on sacrum; In house acquired; unknown age; measuring 3.7 cm, 2.6 cm in length and 2.0 cm in width. According to a record review of R2's progress notes dated 12/8/2025 at 08:00, revealed: General: Patient is an [AGE] year-old female seen today after the DON reports patient with a new bruise to the sacrum area, of an unknown origin. The DON also states that the family is requesting to speak to this provider regarding the resident's plan of care. On examination, the patient's (caregiver X and family member Y) are both present at bedside and informed the writer of this new issue to the sacrum area. (family member Y) states that she arrived to the facility this past Friday, on12/5/25 and discovered the bruise to her mother's sacrum. (caregiver X) states that she was unaware of these new findings. (family member Y) mentioned that she informed the floor nurse of the new findings. (family member Y) was reminded of the patient's recent falls, which resulted in a carpet burn and superficial laceration to the right knee, which may have contributed to the bruising. Most recent x-Ray results to the right knee and hip were reviewed, which showed no evidence of dislocation or fractures. (R2) has now returned to her room from activities and was evaluated at bedside. A small ecchymotic area is observed above the right sacrum. The area is flat, blanchable, and purplish in color. No open areas. There is no pain exhibited during the examination. Will refer to the wound care team for further evaluation and treatment. (family member Y) also visualize the area, which she states has improved since Friday. On 12/11/2025 at ~ 11:30 AM, DON submitted fall reports for R2, when DON asked about the initial fall report given with the completed date 12/09/2025 AM (signed and locked on 12/11/2025) that was documented for a fall that took place on 12/01/2025, DON admitted that the facility discovered that R2 had an undocumented fall that took place on 12/01/2025. DON reports that it was not discovered until their investigation of an injury of unknown origin FRI they had submitted, and the facility completed a past non-compliance (PNC) for the deficient practice. According to a further review of R2's Initial fall assessment report dated 12/09/2025, it was revealed: Date of fall 12/01/2025; date provider was notified 12/08/2025; responsible party notified 12/08/2025 noted as (family member Y); injury or suspected injury description of abrasion to right knee and faint bruise to sacrum.; new intervention (listed) offer toileting upon waking, before meals and before bed updated 12/09/2025. On 12/11/2025 at 1:12 PM, During a phone call to CNA R, a voice message was left with a requested callback and number given. A text message was immediately received back that said Hello?, text was replied to by SA with request to talk about ongoing investigation, no reply was received back from the number.On 12/11/2025 at 1:16 PM, During a phone call to CNA S, the phone was answered and acknowledged as being CNA S, after explaining SA call for ongoing investigation the phone line went dead. A few moments later SA received call back from CNA S. CNA S was verbally aggressive in tone yelling I don't work there, and I have not worked there in 2 weeks, I am sick of people calling and harassing me. CNA S was advised she did not have to speak with SA, however if she was agreeable to be interviewed, we could proceed. CNA S agreed but exclaimed, ask me your question and don't call me no more. CNA S was quired about R2 and knowledge of a fall on 12/01/2025. CNA S reported yes R2 fell on [DATE] at shift change (approximately 6 am was clarified), me and the other CNA (did not know CNA's name) got R2 up in her chair and I let the nurse know and left because my shift was over. When queried about the nurse she reported to and she stated, I do not know the name of who I told, she had slicked back hair. When asked if the nurse she told went to assess R2, she replied I don't know; I guess so she grabbed the vitals cart; I left my shift was done. CNA S reported she did not witness R2 fall just that she was found on her knees at the edge of her bed and we (the oncoming CNA) assisted her to her chair. CNA S indicated she was done with the call and the line went dead. On 12/11/2025 at 2:09 PM, During a phone call to CNA T, a voice message was left with a requested callback and number given.On 12/11/2025 at 2:10 PM, During a phone call to CNA U, a voice message was left with a requested callback and number given.On at 2:11 PM & 2:24 PM, During a phone call to Nurse V, a voice message was left with a requested callback and number given.On 12/11/2025 at 2:19 PM, During a phone call with Nurse W revealed they were not working on unit with R2 on 12/01/2025 but she did work on 12/08/2025, and that she had a conversation with R2's family member Y, she said the conversation was more about a missing shower from the night before. Nurse W reported that family member Y did not speak to her about R2's injuries specifically and said family member Y told me they had a meeting scheduled with the DON about it today. Nurse W stated, I only have knowledge about R2 having a fall on 12/01/2025 after speaking with DON on 12/08/2025, when she was investigating an injury on R2 knee and buttocks. On 12/11/2025 at 2:51PM, During an interview with NHA when he produced FRI investigation 2689940. NHA revealed that they had spoken with family member Y on 12/5/2025 and that they had discussed areas of concern about R2's skin, specifically the knee and the sacrum. NHA reported they reviewed the falls for R2 on 11/19/2025 with family member Y. He further reports that it was after the weekend when family member Y came back to facility on 12/08/2025 and asked to speak with NHA and DON. NHA said that family member Y said 'she had thought about it, and she was convinced that the resident had to have had a new fall or injury, and that the marks present could not be from a fall on 11/19/2025', NHA reports that family member Y was concerned. NHA stated, it was at that point that I decided this needed to be a FRI. NHA said family member Y was not happy with the previous explanation, and we needed to investigate it further. NHA reported that they sent the FRI on 12/08/2025 and that the investigation started. NHA reported that during their investigation, after they talked to staff it was realized there had been a fall for R2 that went undocumented on 12/01/2025. NHA said that was when they started the assessments, PNC and education of staff. On 12/12/2025 at 10:26AM, During an interview with CNA T she reported that on 12/1/2025 at shift change (6 AM- clarified time) that she and the night shift CNA (CNA S were doing rounds and that they saw R2 on her knees by the side of the bed, R2 had her upper body on the bed and she looked like she was praying, we got her up in to her wheel chair. CNA T stated I noticed her knee looked swollen, and I told Nurse V about that. CNA T reported that R2's brief was wet and speculated that maybe she was trying to go to the bathroom. CNA T reports that she changed R2's brief. CNA T said that CNA S reported to her that 'she had last checked R2 at 5AM and that R2 was dry then.' CNA T reported I took the nurse to show her (R2's) knee. CNA T was queried how was R2 behavior the rest of that shift (12/02/2025) day and she reports that R2 was her usual self. She reported I did not see a bruise on her bottom when performing care that day.On 12/12/2025 at 10:46AM, During an interview with nurse V it is revealed that she has worked at the facility since February on night shift and just transferred to day shift. She reported, I was late to work on 12/01/2025, I got here about 6:10 AM, she further said she had gotten report from the night nurse about 2 falls that had happened on another hall during the night shift but nothing about R2. Nurse V reported that she started her follow up on the other hall due to the falls that were revealed at shift report. Nurse V added that she also completed her med pass on the other hall, and she estimated her time being about 9-930 AM before arriving on R2's hall that morning. Nurse V said that she was not aware that R2 had had a fall, she said that at about 9:30-10 AM that CNA T asked me to look at R2's knee because it was red and said she was found kneeling by the side of her bed last night. Nurse V stated, I went to (R2's) room and looked at her knee, she was sitting in her wheelchair and was dressed and content she reports her caregiver was there also. Nurse V stated, It did not look like anything new and the caregiver said R2 had fallen before. Nurse V said that she then looked in R2's chart and saw that R2 had a fall a few weeks ago on that knee. Nurse V said that she had seen NP A in the hall and asked about it. Nurse V reported that NP A said, 'she was aware of R2's knee and that the x-ray was negative; that she was seeing R2 that day for it.' Nurse V stated, There was nothing that triggered me that this was a new fall, nor was I told it was a fall; If it was I would have done a fall assessment, monitored, notified and documented for 72 hours and In hind sight I could have documented my conversation with the NP, but explained that she thought it was a known injury. Nurse W confirmed her reeducation and verbalized fall reporting process.On 12/12/2025 at 11:12AM, During an interview with NP A she was asked about R2, she states she did see R2 to assess and documented on 12/1/2025 as a follow up from previous fall and x-rays. She reported that nurse W talked to her about R2's knee that day (12/08/2025), and they both were under the impression this was not a new issue. NP A reported that if it had been conveyed to her or nurse W that there was a new fall they would have followed there fall protocol, and that she would have assessed and documented it as such. It was noted by the interviews conducted that there was a delay in reporting a fall as such to the nurse working on shift and a delay in assessments and notification occurred following the incident that happened on 12/01/2025. On 12/12/2025 at 11:23AM, During an Interview with caregiver X who was present in R2's room, she was queried about R2's knee and bottom. Caregiver X reported that she had seen R2's knee on Friday 12/05/2025 and that they (facility) addressed it with them as not a new issue but related it to an old fall. Caregiver X reported that she did not notice the area on R2's bottom until family member Y pointed it out on Monday 12/8/2025 to her. Caregiver X stated, I know her daughter was upset and thought that something must have happened, no one could tell her what the spot was from and that's when she called them in.On 12/12/2025 at 11:30AM, During a follow up Interview with CNA T, She was asked why did her and CNA S moved R2 before notifying the nurse, she said I thought it was in her care plan, that she could be on the side of the bed, CNA T was asked if that was a common care plan item and she stated, some residents have that in their care plans and I thought she had just shimmied over the edge the bed her upper body was on the bed, I did not think she fell, further adding she looked like she was praying.CNA T was asked what time she informed the nurse about R2 and she replied, right away about 6:30AM. When CNA T was queried if she did not think R2 fell, then what did she need to get the nurse about and she responded, that R2 looked like she had a rug rash on her knee and I thought the nurse should look at it. CNA T stated, I did not tell her she fell, I just told her how I found her and that she had a spot on her knee I wanted her to check out. CNA T said she was sure it was shortly after shift change that she told nurse W. CNA T confirmed her reeducation and verbalized fall reporting process. A record review of the facilities fall prevention program policy revealed:Definition of a fall: a fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force (e.g., resident pushes another resident). The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere.Policy explanation and compliance guidelines #6, reveals: When any resident experiences a fall, the facility will: A) assess the resident. B) complete a post fall assessment. C) complete an incident report. D) notify physician and family. E) review the residents' care plan and update as indicated. F) document all assessments and actions. G) obtain witness statements in the case of an injury. A Record review of the facilities PNC was reviewed and revealed:During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: Plan of Correction:In-depth analysis of how the deficiency occurred: (RCA) ELEMENT 1Upon investigation it was noted that the resident had a fall on 12/1/25 that was not reported correctly. Furthermore, the falls protocol was not initiated to include the resident being assessed by the nurse, skin assessment post fall, notification of Provider, /responsible party, neuro checks, and notification of on call manager, timely initiation of an intervention, and ongoing monitoring.First shift CNA noted that while doing walking rounds on the morning of 12/1/25, the resident was noted to be on the floor, at the side of the bed, on her knees. The CNAs transferred the resident back to bed and reported the incident to the nurse. The nurse failed to complete a risk management/report the incident further. When family came in to visit, they noted a new abrasion to the resident's right knee and a faint bruise to her sacrum. Family reported the injuries to the floor nurse, who then notified the DON of the new injury. Floor nurse interviewed and admitted being notified, during shift report, that resident had a fall. The nurse did not initiate the facility fall protocol as she was under the impression that the fall had occurred earlier on night shift; not during shift change as it occurred. How the facility identified resident(s) affected and residents with potential to be affected by the same deficient practice. ELEMENT 2(R2): NP notified 12/8/25, no new orders. The resident was assessed by licensed nurse and Provider. Incident report completed to include care plan update with new intervention. Resident's daughter notified via phone. Residents with a BIMS of 9 or lower or BIMS 10 or greater had a skin assessment or interview completed by a licensed nurse to identify any potential injuries/incidents that may not have been reported. There were no newly identified injuries noted. Completed by12/10/25.Residents with falls in the last 14 days were reviewed by a licensed nurse manager to ensure falls protocol was initiated to include the resident was assessed by the nurse, skin assessment post fall, notification of Provider/responsible party, and ongoing monitoring was initiated. Completed 12/11/25. Corrective action to be taken: ELEMENT 3Facility nursing staff will be re-educated by the Director of Nursing or designee regarding facility Falls Protocol policies to include ensuring any incidents / falls are reported to the nurse immediately and ensuring falls protocol was is initiated to include the resident being assessed by the nurse, skin assessment post fall, notification of Provider, /responsible party, neuro checks, and notification of on call manager, timely initiation of an intervention, and ongoing monitoring. Education completed by the date of compliance.CNA staff will be educated to enter a custom alert note upon receiving knowledge of a resident fall to ensure proper reporting. How facility monitors its corrective actions to ensure deficient practice was corrected and will not recur. ELEMENT 4Director of Nursing or designee will complete a skin assessment of 5 cognitively declined residents to ensure there are no unreported injuries.Director of nursing or designee will audit 5 falls weekly to ensure that fall protocol is initiated to include falls protocol was initiated to include the resident being assessed by the nurse, skin assessment post fall, notification of Provider, /responsible party, neuro checks, and notification of on call manager, timely initiation of an intervention, and ongoing monitoring. Audits will be completed weekly x 4 then monthly thereafter. Audits will be forwarded to the QAPI committee for review and discontinuation.Date of completion of plan of correction: 12/11/25 The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to Intake Number 2580183.Based on interview and record review the facility failed to have diabetic supplies available to facility staff when Resident #108 had a hypoglycemic episode, resulting in a blood sugar of 52 and being placed on ventilator upon arrival to the Emergency Room. Findings Include: Resident #108:On [DATE] at approximately 11:00 AM, a review was conducted of Resident #108'S medical record and it revealed he admitted to the facility on [DATE] with diagnoses that included, Peripheral Vascular Disease, Heart Disease, Atrial Fibrillation, Diabetes Mellitus, Chronic Kidney Disease and Hypertension. Resident #108 was his own person and able to make his needs known to staff. Further review of his chart yielded the following: Progress Notes:[DATE] at 17:01: Resident in room comfortable in bed with call light in reach. Orders placed and verified.[DATE] at 04:30: A 22-gauge IV was inserted into the right forearm.[DATE] at 04:47: Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT 2 puff inhale orally every 6 hours as needed for wheezingPRN Administration was: Effective.[DATE] at 5:23: Resident complained of SOB and wheezing earlier in the night. Resident had an order for a rescue inhaler and 2 puffs were given. Resident verbalized that it seemed to aid his breathing. No other signs of dyspnea noted during this time. A couple of hours later, nurse went in to perform wound dressings and found resident pale, frothing at the mouth with labored breathing, and had an altered level of consciousness. Resident had a blood sugar of 52. Crash cart was pulled out and resident was thrown on 3L of oxygen r/t O2 sats of 86. EMS ((Emergency Medical Services) was notified and came without a medic. On-call provider was notified of incident and well as on-call nurse. Resident had no family members listed on his profile to notify. He is his own person.Hospital Records:[DATE]- arrival time 5:23 AM .Pt (patient) arrives from (facility) after being found to have SPO2 at 70%. After calling EMS pt was also found to have glucose level of 41 by EMS and AMS (altered mental status).On arriving to ED (Emergency department), pt's HR (heart rate) of 22, afebrile, snoring and tachypenic of 26 somnolent, AxO 0, arousal to sternal rub. Given pt clinical status and inability to protect airway, was intubated.assessment/plan: Acute Respiratory Failure- GCS 6.metformin and Januvia for glycemic control. Discontinue insulin. High risk of hypoglycemia. July MAR (Medication Administration Record):Resident #108 is prescribed the current insulin regime to manage his diabetes:Lantus Solo Star 100 Unit/ML pen injector inject 17 unit subcutaneously at bedtime for diabetes.Humalog KwikPen 100 Unit/ML Solution pen-injector inject 3 unit subcutaneously with meals for diabetes.Insulin Lispro 100 Unit/ML solution Inject per sliding scale.If blood sugar is less than 70mg/dl or patient symptomatic, follow hypoglycemic protocol. There was no medications listed on the MAR as administered during the timeframe of Resident #108's critical incident. Medication Administration Audit Report:Resident #108 was administered insulin at the following times on evening of [DATE]:Insulin Lispro 100 Unit/ML per sliding scale- 1 unit at 16:29Humalog KwikPen 100 UnitML- 3 units at 16:30Lantus SoloStar 100 Unit/ML - 17 units at 19 :43Within approximately three hours Resident #108 administered 21 units of insulin. Blood Sugars:[DATE] 19:18: 332XXX[DATE] 22:03: 578XXX[DATE] 07:45: 313XXX[DATE] 12:53: 98XXX[DATE] 14:11: 188XXX[DATE]: 19:43 182.0 On [DATE] at 10:20 AM, Nurse Practitioner O stated Resident #108 was a new admission and they were not able to evaluate him prior to his readmission to the hospital. When an emergency occurs, the appropriate supplies should be available to facility staff. On [DATE] at 4:51 PM, Nurse T stated when she arrived for her shift Resident #108 had no diagnoses listed in his chart or emergency contacts. During the shift report there was nothing mentioned regarding shortness of breath or congestion. About 9:30 PM she first observed Resident #108, and he alert and oriented x4, pleasant demeanor with no complaints. A few hours later he had shortness of breath and she administered his rescue inhaler which provided him relief. At that time, he was still responding at his baseline. Some hours after administering his inhaler she found him foaming at the mouth, confused and decreased responsiveness which was a steep change in condition from a few hours prior. He would wake up to sternal rubs. His blood sugar low and they (Nurse T and two other nurses) were not able to administer medications to combat his hypoglycemia as there was no glucagon or IV dextrose on the crash carts. Nurse ‘'T stated another nurse went to the medication room as well but was unable to locate any. They started a line and ran saline until EMS arrived. Upon their arrival they did not have a medic but one did arrive about three or so minutes later and they worked on him outside of the facility. On [DATE] at 1:10 PM, Nurse N stated as she and another nurse were going into the medication room a code blue was paged from overhead on 700 unit. As she was enrolled in the unit she grabbed the crash cart from that unit. Once she arrived in the room Resident #108 was blue to color and foaming at the mouth. The resident had congestion, and it was difficult to raise his oxygen so .they switched him to the nonrebreather and checked his blood sugar which she recalls being low. She stated they needed glucagon and were unable to locate the injection form on the crash cart. One of the nurses left to go locate glucagon but was unable to find it. The two other nurses with her said it was not on the crash cart. On [DATE] at 2:10 PM, the DON reported there was not a code blue report completed as the staff did not do CPR (Cardiopulmonary Resuscitation). The DON stated the nurse went in for wound care treatment and the resident had decreased responsiveness. They were able to start a line but DON was not certain what was administered to the resident. The DON reported she was unaware (until the survey) the staff did not have the emergency supplies they needed as they never informed her. DON was asked why there were no orders for glucagon as a standard of care for diabetic residents. The DON did not have a response. It can be noted there was no facility follow up/internal investigation regarding this incident. Review was completed of [DATE] Maple (long term care) crash cart log. It indicated the last time the crash cart was opened prior to Resident #108's incident was [DATE] ( no tag). The next time the tag was changed was [DATE]. It is unclear if the crash cart was not secured (via the securement tag sent from pharmacy) after the incident on [DATE].Crash Cart Contents:Emergency Glucagon Injector PinIV dextrose is not listed ats available in the crash cart. Review was completed of Nurse N Skills Checklist, and it was not signed off by an observer nor was it dated. Nurse J competencies packet from [DATE] and it was found there were no check offs for accessing diabetic supplies in an emergency ( or other necessary supplies for a resident emergency). The DON was asked what was included in facility training and if accessing diabetic supplies in an emergency (or other necessary supplies for a resident emergency) was reviewed, she stated it is, during their orientation on the floor. When asked for documentation of this she reported there was none from their orientation completed on the floor with their preceptor. On [DATE] at 11:50 AM, Nurse J reported she was paged on their walkie to long term unit for a resident that was not responding at baseline. Upon arriving to Resident #108's room there were two nurses there and she started the line in his lower arm. There was no IV (intravenous) dextrose on the crash cart and they were only able to administer fluids to the resident. Review was completed of the email from the facility pharmacy representative, the emailed stated, .The facility was stocked with 5 Gvoke in the MedBank since 4/11. There was 5 on hand the entire month of July, with no transactions.We will be unable to advise on how many were in the crash cart, as that is stocked by the facility. The facility was unable to provide documentation that proved glucagon or IV dextrose was accessible on the crash cart during Resident #108's hypoglycemia episode. While the facility asserts diabetic supplies were available in the medication room it was not easily accessible during a resident emergency who was a known diabetic. Three nurses conformed the medication required for a hypoglycemic episode was not available to them and they were unable to appropriately treat Resident #108 during this critical incident.Review was completed of facility protocol entitled, Diabetic Protocol, the protocol stated, .Diabetic Protocol; Hypoglycemia.Hypoglycemia is a condition that is typically related to diabetes treatment. Effective management of hypoglycemia is important to ensure that the resident does not have further decline in their condition. Residents that have a diagnosis of diabetes or on medications that could lower the blood sugar should have orders for glucose monitoring and treatment of hypoglycemia, unless otherwise ordered by the practitioner.if the blood glucose reading is 70mg/dl or below, the nurse should utilize the hypoglycemic protocol as per the practitioner's orders.Blood glucose (BG) less than 70 mg/dl and resident is unable or unwilling to take nutrition orally: give glucagon 1 mg subcutaneously or 3 mg intranasal or 1mg intramuscularly. Turn resident on their side to prevent aspiration.

This citation pertains to intake 1205083 and 1205084.Based on interview and record review, the facility failed to Prevent 2 facility acquired stage II pressure ulcers/PU, for 1 resident (Resident #15) of 3 resident's reviewed for PU's, resulting in 2 facility acquired stage II pressure ulcers, pain, increased risk for infection, antibiotic usage and hospitalization.Findings Include:Review of the Face Sheet, Resident #15's facility care plans dated 3/24/25 through 4/1/25, Physician, Nurse Practitioner and nursing notes dated 3/24/25 through 3/27/25, revealed Resident #15 was [AGE] years old, unable to make own healthcare decisions, admitted to the facility on [DATE], after a severe car accident, had a tracheostomy, feeding tube (G-tube), urinary catheter, dependent on staff for all Activities of Daily Living/ADL's and was a full code. The resident's diagnosis included traumatic subdural hemorrhage, hemiplegia and hemiparesis, acute respiratory failure with hypoxia, tracheostomy status, gastrostomy status, acute kidney failure, and muscle weakness.Review of the facility Skin & Wound Evaluation for Resident #15 dated 4/4/25, stated New Stage 2 pressure (pressure ulcer/PU), in-house acquired.Review of the facility Braden Scale for Predicting Pressure Sore Risk dated 3/31/25, revealed the resident was a score of 10, at High Risk for the development of pressure ulcers upon admission.Review of the facility ADL documentation is as follows:Bed Mobility (Nursing Assistant/CNA documentation):-3/27/25: second and third shift blank (no documentation completed)-3/30/25: second and third shift blank-3/31/25: third shift blank-4/3/25: second shift blank -4/5/25: second shift blank-4/6/25: second shift blankReview of the Physician orders dated 4/4/25, stated L (left) Gluteus daily wound assessment document abnormal's in progress notes. R (right) Gluteus daily wound assessment document abnormal's in progress notes. No documentation of daily wound assessments was found in closed records, nor given to this surveyor by the Director of Nursing/DON.Review of the IDT (Interdiasplinary team) notes dated 4/7/25, stated Writer called to resident's room by floor nurse, stage II pressure ulcers noted to R (right) and L (left) gluteus.Review of the Physician orders dated 4/4/25, stated Cleanse L Gluteus with wound cleanser, pat dry, apply medihoney and cover with bordered gauze daily and PRN (as needed). Cleanse R Gluteus with wound cleanser, pat dry, apply medihoney and cover with bordered gauze daily and PRN.Review of Resident #15's electronic closed record revealed progress notes from Nurse Practitioner NP A, Physician, MD I and Nursing dated 3/24/25 through 4/4/25; no documentation was found of any pressure ulcers/PU assessments of PU's or PU monitoring.During an interview and record review done on 7/1/25 at approximately 12:15 p.m., Wound Nurse, LPN L said she had taken a picture of Resident #15's pressure ulcers on 4/4/25. She pulled up the pictures and showed this surveyor; Rt and Lt coccyx stage 2 pressure ulcers were shown.During an interview with the DON done on 7/2/25 at 11:20 a.m., no documentation of any PU assessments or monitoring (in the progress notes: nursing, nursing practitioner/NP, physician) was found by this surveyor or the DON during electronic closed record review.Review of Physician/Medical Director, MD I History and Physical and assessment dated [DATE], revealed no documentation of any PU's and stated Negative: Wounds, Erythema, Rash, Bruising.Review of the NP A progress notes dated 3/27/25 and 3/28/25, revealed no documentation of any PU's; and stated Case discussed with nursing, no acute concerns. Nurse to notify provider with any change in condition.Review of the Skilled Charting revealed the following:-On 4/1/25: Surgical wound (neck, trach wound)-On 4/2/25: Skin intact-On 4/3/25: Skin intact-On 4/4/25: Wound and Skin assessment, pressure ulcers documented, found.-On 4/4/25: Skilled, surgical wound (neck).Review of CNA task under monitor skin observation are as follows:-On 3/31/25: CNA no documentation of pressure ulcers found.-On 4/1/25: CNA no documentation of pressure ulcers found.-On 4/2/25: CNA no documentation of pressure ulcers found.-On 4/3/25: CNA no documentation of pressure ulcers found.-On 4/4/25: CNA no documentation of pressure ulcers found.Review of the resident's At Risk for Impaired Skin Integrity care plan initiated on 3/24/25, stated staff were to, complete skin inspection weekly, notify nurse of any new areas of skin impairment noted during bathing or daily care (redness, blisters, discoloration, impairment related to medical device/tubing). The care plan identified the resident's surgical: front neck trach stoma as impaired skin integrity on 3/24/25.Review of the resident's Impaired Skin Integrity care plan initiated on 3/24/25, with a revision done on 4/4/25 to include Pressure Stage II: R Gluteus, Pressure Stage II: L Gluteus. The IDT (Interdisciplinary Team) will review each pressure ulcer weekly for progress and changes. Review of the resident's Pressure Ulcer/Skin Breakdown policy dated 10/30/2022, stated Weekly skin evaluation/assessment by the licensed nurse on residents who have no current PU/PI's. Notify Physician and Resident Representative (of any skin breakdown).During a phone interview done on 7/9/25 at 9:25 a.m., Family Member #1 of Resident #15 said she was contacted by the facility one time (unable to recall date) and told he had a small rug burn on his right buttocks. No other information was given to Family Member #1 regarding any pressure ulcers or open areas. Family Member #1 stated There were no wounds present when he was admitted (to the facility). The resident went up to 8 hour stretches with no one coming in to reposition him and that if she needed help, she had to go out of the room to find help.During an interview and closed record review done on 7/2/25 at 11:20 a.m., the DON stated I found it (the 2 stage II PU's) on 4/4/25, and I gave a write-up. I just don't believe this happened. During an interview done on 7/3/25 at 11:20 a.m., the DON gave this surveyor an education done regarding his (Resident #15) PU's to Wound Nurse Q. This education was the same one identical as the one in the PNC package given to this surveyor dated 3/26/25, with the completion date of 3/31/25.During an interview done on 7/9/25 at 3:00 p.m., Nurse Manager, LPN Q stated It's not acceptable to have 2 PU's because it's harm. He should have been identified as possible unavoidable. He was on daily skilled charting while he was here; it happened because he wasn't taken care of properly.The facility handed this surveyor a Past Non-Compliance/PNC on 7/3/25 at 2:20 p.m. The date of the report was 3/26/25, prior to the identification of 2 stage II pressure ulcers and Resident #15 was not mentioned in the report. The date of completion of the plan of correction was documented as 3/31/2025.The facility PNC included:-Licensed nurses have been re-educated by staff development coordinator/Designee that a complete assessment of the resident with change of condition needs to be performed with documentation of findings in the chart.-Ongoing weekly skin assessments are being completed by nursing staff.-Licensed nurse and Nurse Aides were educated on 3/6/25, 3/7/25, 3/10/25 and 3/11/25 (all prior to Resident #15's admission to the facility).-Performance Improvement Form dated 4/4/25; Wound Nurse, Q was counseled for, all new admissions need to be looked at following day, Pictures or re-picture the wounds if needed, and make sure treatments are in the computer. Review of the facility Wound Care Nurse job description (un-dated), stated Graduate of accredited RN School of Nursing, valid RN license.

This Citation Pertains to Intake Number MI00145690. Based on observation, interview and record review, the facility is placed in Immediate Jeopardy for its failure to 1) Initiate remediation measures, per standards of practice, and as requested by the Local Health Department, after one resident (Resident #205) tested positive for Legionella (a bacteria that spreads through water systems and devices) in a urine antigen test on [DATE]; 2) Complete and submit a Legionella Environmental Assessment Form (LEAF) in a timely manner to the Health Department; 3) Provide representative environmental water samples to the Health Department (at least 20 samples) to retest for Legionella in the facility, as the facility's water had tested positive for Legionella on several occasions in the past and most recently on [DATE]; 4) Collect urine antigen and sputum samples for each resident with respiratory or pneumonia symptoms to test for the presence of Legionella; and 5) Implement infection control practices per policy and procedure and standards of practice to prevent the potential spread of Legionellosis, for 27 of 59 sampled residents (Resident #'s: 201, 202, 203, 204, 205, 207, 211, 219, 221, 222, 226, 227, 229, 231, 235, 237, 238, 239, 241, 243, 249, 251, 253, 254, 256, 257, 259), from a census of 111, who all exhibited respiratory illness signs and symptoms, resulting in an Immediate Jeopardy when on [DATE] the Health Department was notified of Resident #205 testing positive for Legionella and the facility did not initiate remediation measures, as recommended by the Health Department, to adequately aid in assessing the risk of Legionella exposure to residents of the facility, this placed all residents, staff and visitors at risk for exposure to illness. Findings Include: Immediate Jeopardy (IJ): The IJ began on [DATE]. The IJ was identified on [DATE] at 2:30 PM. The facility Administrator was notified of the IJ on [DATE] at 3:47 PM and a plan for the removal of IJ immediacy was requested. The Removal Date was [DATE]. The removal of the IJ was verified on [DATE]. Centers for Disease Control and Prevention/CDC: Legionella (Legionnaires' Disease and Pontiac Fever) Key Points: Legionella can cause Legionnaires' disease and Pontiac fever, collectively referred to as Legionellosis; Being an older adult or having certain medical conditions puts people at increased risk for these infections . Legionellosis is a bacterial disease caused by Legionella. There are at least 60 different species of Legionella, most of which are considered pathogenic (illness causing) . Clinical Features: . Legionnaires' disease is characterized by illness with pneumonia . Pontiac Fever is a milder, self-limiting illness without pneumonia .Common signs and symptoms: Legionnaires' Disease: Clinical symptoms may vary but include acute onset of lower respiratory illness with fever or cough. Additional symptoms may be present: chest discomfort, headache, malaise, myalgia (muscle aches) nausea, diarrhea, or abdominal pain, shortness of breath (it is diagnoses by a urine antigen test and sputum culture) . Pontiac Fever: Symptoms include Chills, Fatigue, Fever, Headaches, Malaise, Myalgia, Nausea or vomiting . (it is not diagnosed by the urine antigen test) . Complications: Legionnaires' Disease: hospitalization is common. The case-fatality rate is approximately 10%. For healthcare-associated infections, the case-fatality rate averages 25% . On [DATE] the facility contacted the Local Health Department and notified them that Resident #205 tested positive for Legionella in a urine antigen test on [DATE]; this was the day after the resident transferred to the hospital from the facility on [DATE] with difficulty breathing. The Local Health Department contacted the facility on the following dates while attempting to gather assessment information to investigate and assess the facility's Legionella exposure risk to the residents. On [DATE] the Health Department began their investigation and requested additional information from the facility. On [DATE] additional information was requested again from the facility by the Health Department. On [DATE], the facility was asked if they performed regular water testing for temperature, pH, or Chlorine at the facility. On [DATE], the Health Department subsequently requested additional information, as they had not received a response from the facility and the facility was asked to complete the following: Legionella Environmental Assessment Form within 48 hours, Resident testing (urine antigen and sputum cultures) for those residents with respiratory symptoms and or pneumonia and representative environmental water samples. In addition, on [DATE] the Health Department submitted a letter to the facility with detailed information to aid in identifying the presence of Legionella in the facility's water system and preventive measures for the residents, staff and visitors to the facility and included, The (Health Department) received your report of a patient at (the facility) who meets the criteria for presumptive healthcare-associated Legionnaires' disease, given that they were inpatient at the facility for multiple days during their 14-day incubation period. Most people who develop Legionnaires' disease were exposed to water containing Legionella bacteria sometime in the 14 days before illness onset. Identifying even one presumptive healthcare-associated case of Legionnaires' disease in this timeframe raises concern for ongoing transmission within your facility . In the letter, the Health Department asked the facility if they were working with an environmental/water consultant and they strongly recommended they work with the consultant to develop an environmental risk assessment and begin the environmental Legionella sampling as soon as possible, ideally within 48 hours. The document detailed specifics on where and how to perform the water sampling to best identify Legionella present in the water system. On this date [DATE] a request was made by the Health Department for the facility to complete the Legionella Environmental Assessment Form (LEAF) and send it back to the Health Department before the two met. The facility was asked to provide results of positive isolates from the water samples from the representative environmental water testing. The facility's most recent positive water sample for Legionella was on [DATE]. The Health Department strongly recommended installation of 0.3 micron filters for sinks and shower heads; remove aerators from all sink faucets; avoid using sinks in resident rooms until 0.2 micron filters could be installed on the faucets. Showering restrictions were recommended until the 0.2 micron filters were installed; restriction of jetted or hydrotherapy tubs was recommended; bottled drinking water and restrictions for use of the ice machines was recommended for all residents with swallowing difficulties The Legionella Environmental Assessment Form was completed and submitted to the Health Department on [DATE]; five weeks after being requested. The facility was requested to send a list of residents to the Health Department with pneumonia or respiratory symptoms, both current and over the past 30 days. They recommended testing of all residents and staff with urine antigen and sputum cultures for anyone symptomatic. The Health Department recommended the facility provide notification to residents, families, visitors, recently discharged residents and the public notifying them of a presumptive positive healthcare-associated case at the facility and the need for monitoring for signs and symptoms and testing if indicated. The Health Department recommended a resident review over the past 12 months to assess for signs and symptoms of Legionella and to Implement active clinical surveillance for ,d+[DATE] months following confirmation of the last possible or definite health-care associated Legionnaires disease. On [DATE] the Health Department's Medical Director, Physician J contacted the facility via email because the facility had not provided the information that had been requested over the prior 5 weeks, since the presumptive positive Legionella result for Resident #205. The facility had not submitted a completed Legionella Environmental Assessment Form, representative water samples or urine antigen and sputum cultures for residents with pneumonia or respiratory symptoms. The Health Department had requested the facility provide the above mentioned items 6 times: [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. In addition, the Health Department had repeatedly requested facility results for water temperatures and chlorine levels, of which they had not received. The Legionella Environmental Assessment Form was completed by the facility and submitted to the Health Department on Friday, [DATE]; five weeks after the Health Department requested the facility complete it within 48 hours. On Monday, [DATE] the Health Department contacted the facility again and relayed based on the data from the facility's Legionella Environmental Assessment Form it appeared the conditions exited at the facility for Legionella growth over the past year. The facility was again requested to submit the representative environmental water samples (at least 20 samples), testing of residents with respiratory symptoms or pneumonia via urine antigen and sputum cultures. The representative environmental water samples were obtained on [DATE] and sent to a laboratory for Legionella testing: 6 weeks after they were requested and two days after the surveyors entered the building. The facility assessed the residents for signs, symptoms and risk for Legionellosis on [DATE] and began testing 25 residents via urine antigen and sputum cultures on [DATE]: 6 weeks after the Health Department requested residents be screened for respiratory signs and symptoms and pneumonia and to be tested for Legionella; this was 3 days after the surveyors entered the building. The facility tested 2 more residents with respiratory symptoms on [DATE], one more on [DATE], one more on [DATE] and one resident was transferred to the emergency roiagnom on [DATE], where testing for Legionella was requested. The facility did not initiate the following recommendations by the Health Department to aid in decreased transmission of Legionella: Installation of 0.2 micron filters for sinks and shower heads while awaiting environmental testing to be performed and resulted. Remove aerators from all sinks and faucets; restrict resident showering until 0.2 micron filters were installed; bottled water should be used for all residents with swallowing difficulties; do not use ice from ice machines for residents with swallowing difficulties; there was no testing of residents or staff with signs or symptoms of pneumonia or respiratory symptoms. On [DATE] 12:15 PM, the Infection Preventionist Nurse A and Maintenance Director B were interviewed about Legionella in the facility's water and a resident testing positive for Legionella on [DATE]. The Infection Preventionist/IP A said she wasn't sure, but she thought the resident was #202, but she would check on it. During the interview on [DATE] at 12:15 PM, The Maintenance Director B said the facility had tested positive for Legionella in the water in September, October and [DATE]. He provided a timeline of retesting and interventions that were enacted at that time. The Maintenance Director provided facility water testing results for [DATE] that were negative. The next time the facility tested the water was [DATE]th, 2024, and two areas (room [ROOM NUMBER] and room [ROOM NUMBER]) grew Legionella pneumophila Serogroup ,d+[DATE] on a culture. The report included the following: Legionella Facts: 1. Testing Methodology: Culture remains the recommended method for Legionella monitoring. Standardized culture procedures include ISO 11731: 2017 Detection and Enumeration of Legionella and CDC: Procedures for the Recovery of Legionella from the Environment. Reg: BSR/ASHRAE Standard ,d+[DATE]. The Maintenance Director B said the report showed low levels of Legionella and the facility retested on [DATE]: 5 weeks later. All sampled areas were negative at that time including rooms [ROOM NUMBERS], but no other areas on the 100 or 700 halls was tested . No remediation measures were enacted. During the same interview on [DATE] at 12:15 PM, the Maintenance Director B said the facility completed water testing for room [ROOM NUMBER] on [DATE]. This was the room that the resident was in who tested positive for Legionella. It was not Resident #202's room. It was Resident #205's room, as he was the resident who tested positive for Legionella. No additional rooms were tested . The Maintenance Director did not relay that the Health Department had requested the facility provide representative environmental water samples (at least 20 samples) and the facility had not done this. The Maintenance Director was asked if the facility had installed any 0.2 micron water filters and he said they had not. He said the facility and residents were [NAME] using the water. On [DATE] at 12:25 PM, during the interview with IP A she was asked if the facility had assessed the residents for respiratory symptoms or pneumonia and she said they had been previously assessed, [DATE] to [DATE], but only one resident was determined to have respiratory symptoms (Resident #237 pneumonia), and they were not tested via urine antigen or sputum culture for Legionella. The Infection Line Listings were requested for [DATE]- [DATE] at this time. The IP A said the facility had several phone calls and emails from the Health Department related to the resident testing positive for Legionella on [DATE]. She said the facility had provided the LEAF (Legionella Environmental Assessment Form) on [DATE]. She said no resident urine antigen tests or sputum cultures had been sent to the Health Department. On [DATE] at 1:30 PM, during a tour of the facility, a Confidential Staff P was asked if anyone had been coughing or ill with a respiratory infection recently. The Confidential Person P said that some of the residents and staff had recently tested positive for Covid-19. The Confidential Person said some people were just getting over the illness. On [DATE] at 3:00 PM during a tour of the facility with IP A, she was asked if there had recently been a Covid outbreak in the facility. She said the facility had started with Covid-19 positive staff and residents in [DATE] and there were more identified in [DATE]. An Infection Line Listing with this information was requested at this time. On [DATE] at 11:00 AM, the Resident Infection Line Listings for January- [DATE] were reviewed with IP A. The [DATE] Line Listing was missing. The IP said she would provide it. It was noted all residents listed had received an antimicrobial or anti-fungal treatment. No one on the Line List had symptoms without antimicrobial treatment. There was no one listed on the June or [DATE] line listing that was identified as Covid-19 positive. The IP Nurse provided a type written list (not a Line List) of staff and resident's who had tested positive for Covid-19 beginning [DATE] through [DATE]. There were 5 residents and 5 staff who tested positive for Covid-19; they had not been tested for Legionella. After further review of the [DATE]- [DATE] Resident Infection Line Lists, it was identified that onset of symptoms of infections was not being monitored, until the resident was diagnosed with an infection and an antimicrobial treatment was ordered. Potential Legionella infection was not being monitored. On [DATE] at 1:55 PM, Epidemiologist H was interviewed about Resident #205 testing positive for Legionella. She said the Health Department was notified of the positive result on [DATE], both by the Hospital and the facility. She said the Health Department began immediate communication with the facility on [DATE] via phone and then phone and email. The Epidemiologist H said they did not receive the Leaf assessment from the facility until [DATE] and never received the representative environmental water samples. She said a representative sample would be about 20 samples. She also said the Health Department had requested assessing the residents for respiratory symptoms or pneumonia, Covid or Influenza positive and completing urine antigen tests and sputum cultures on those residents or staff. She said they had not received any test results or confirmation that testing had occurred. She said the facility had been uncooperative in participating in the investigation into the positive Legionella test identified on [DATE]. The Epidemiologist said they could not effectively assess the resident's risk of contracting Legionella within the facility without the necessary pieces of information that the facility had been asked to provide. Resident Reviews: Resident #201 A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #201 was admitted to the facility on [DATE] with diagnoses: hydrocephalus, bipolar disorder, rheumatoid arthritis, anxiety, chronic pain syndrome, history of pulmonary embolism. The resident had multiple visits to the Emergency department/ED and hospital stays related to an ongoing respiratory condition, including pneumonia, including: [DATE]-[DATE]; [DATE]-[DATE]; [DATE]-[DATE] and [DATE]-[DATE]. Resident #201 was not tested for Legionella. Resident #202 A record review of the Face sheet and Minimum Data Set assessment indicated Resident #202 was admitted to the facility on [DATE], with diagnoses: history of a stroke, diabetes, kidney failure, dysphagia, heart failure, and heart disease. The resident was discharged on [DATE] and readmitted on [DATE]. A progress note dated [DATE] at 11:02 AM provided, . Patient notably more confused . A progress note dated [DATE] at 9:50 PM, indicated Resident #202 had low oxygen saturation levels at 85% with oxygen via nasal cannula, the resident was highly anxious and the provider was contacted. The resident requested to go to the hospital. On [DATE] at 10:52 AM, a nursing progress note Legionella Monitoring, provided the following, Legionella Monitoring: Does the resident have new onset of any of the following symptoms? Headache, muscle aches, fever (>104F), cough, (shortness of breath), Chest pain, GI symptoms, confusion or mental status changes . The nurse documented No signs or symptoms. Resident #202 was discharged to the hospital on [DATE] with respiratory distress, readmitted on [DATE] with diagnoses pneumonia and sepsis and died in the facility on [DATE]. Resident #202 was not tested for Legionella. Resident #204 A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #204 was admitted to the facility on [DATE] with diagnoses: history of a stroke, diabetes, COPD, heart disease and schizoaffective disorder. In [DATE] and [DATE], Resident #204 had several instances of low oxygen saturation levels: [DATE] oxygen saturation level 83% low on room air. In [DATE] the resident had several low levels between ,d+[DATE]%. Resident #204 was not tested for Legionella. Resident #207 A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #207 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses: diabetes, bipolar disorder, schizophrenia, hypothyroidism, heart failure, chronic pain, right hip infection related to prior surgical intervention and weakness. On [DATE] the resident was vomiting. Resident #207 was not tested for Legionella. Resident #222 A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #222 was admitted to the facility on [DATE] with diagnoses: history of breast cancer, hypothyroidism, hypertension, chronic kidney disease, anemia, obesity, anxiety, depression, GERD, and Gout. A review of the progress notes [DATE] at 12:00 AM indicated Resident #222 had an upset stomach. On [DATE] at 12:31 PM, the resident complained of pain. Resident #222 was not tested for Legionella. Resident #226 A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #226 was admitted to the facility on [DATE] with diagnoses: Dementia, Asthma, arthritis, seizures, fibromyalgia, anxiety and depression. A review of the progress notes dated [DATE] indicated the resident had a cough and was treated with Tylenol and Mucinex. Resident #226 was not tested for Legionella. Resident #238 A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #238 was admitted to the facility on [DATE] with diagnoses: end stage kidney disease, dialysis, chronic pain, an autoimmune disorder, weakness, bipolar disorder and anxiety. A record review of the progress notes indicated Resident #238 had a change of condition on [DATE] and was lethargic with very low oxygen saturation at 33% and was transferred to the hospital: she was diagnosed with Covid-19 and intubated. She returned on [DATE]. On [DATE] the resident had very low oxygen saturation levels again at 77% and 78% on room air. Resident #238 was not tested for Legionella. Resident #249 A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #249 was admitted to the facility on [DATE] with diagnoses: kidney disease, diabetes, morbid obesity, heart disease, gout, weakness, pain, depression, history of strokes. A record review of the progress notes on [DATE] at 12:00 AM, revealed the resident had a cough and trouble breathing. The resident was diagnosed with bronchitis. Resident #249 had not been tested for Legionella. Resident #251 A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #251 was admitted to the facility on [DATE] with diagnoses heart failure, COPD, history of a stroke, history of respiratory failure, heart failure, weakness, depression and anxiety. A review of the progress notes revealed on [DATE] the resident had a change of condition with difficulty breathing, dry cough, and acute respiratory distress, and the resident was transferred to the hospital. The resident was readmitted on [DATE]. Resident #251 was not tested for Legionella. On [DATE] at 9:45 AM the Abatement plan was reviewed with the Director of Nursing. She said the facility began monitoring all residents for potential signs and symptoms of Legionella on the afternoon of [DATE] and had began completing urine antigen tests for Legionella for those residents with signs and symptoms and had began obtaining sputum samples for those residents with a productive cough. On [DATE] at 10:09 AM, Nurse Practitioner E was interviewed. She said she had worked at the facility for a couple of months and was out of town for training from [DATE]st, 2024-[DATE]th, 2024. She said she had heard about the positive Legionella test for Resident #205 from the IP Nurse. She said the nurses had a list of symptoms for Legionella and residents who had symptoms should have been tested . On [DATE] at 10:56 AM, the Assistant Director of Nursing/ADON K was interviewed. She said she was notified of the positive Legionella test for Resident #205 when she returned from vacation in [DATE]. She said Charting orders were placed into the computer for nurses to assess the residents. There was a list of residents with dysphagia. We were supposed to use bottled water for them. We didn't do any testing. On [DATE] at 11:45 AM, the Infection Preventionist was interviewed and she said they had begun receiving urine antigen test results. She said so far, the results were negative, but they were waiting for the remainder of the tests. She said the facility continued to obtain sputum samples. A list of those residents tested was obtained and reviewed and the results were also reviewed. The IP said the nurses were monitoring residents for all signs and symptoms of Legionella and documenting their findings. Upon record review, it was identified the nurses were assessing the residents. A review of the facility policies identified the following: Infection Prevention and Control Program, date implemented [DATE] and reviewed/revised [DATE] identified, 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 as per accepted national standards and guidelines . The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases . A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals . Water Management: A water management program has been established as part of the overall infection prevention and control program . Water Management Program, undated provided, It is the policy of this facility to establish water management plans for reducing the risk of Legionella and other opportunistic pathogens . in the facility's water systems . A water management team has been established to develop and implement the facility's water management program, including facility leadership, the Infection Preventionist, maintenance employees, safety officers, risk and quality management staff, and Director of Nursing . Immediate Jeopardy Removal: On [DATE] at 1:30 PM, during a review of the IJ Removal Plan for the facility with the Director of Nursing the following was identified as being initiated: [DATE]: The Administrator provided education to the Maintenance Director efforts after a positive Legionella water sample. [DATE]: The Director of Nursing provided education to the Infection Preventionist on checking for and documenting signs and symptoms of Legionella on the facility's Infection Line Listing and performing urine antigen and sputum cultures as indicated. [DATE]: The Infection Preventionist/Designee began education to the staff nurses on documenting signs and symptoms of Legionella and to notify the hospital on the need for testing urine antigen and sputum cultures for those residents transferred to the hospital with signs and symptoms of Legionella. [DATE]: The Medical Director was notified. [DATE]: The Director of Nursing/Designee completed chart audits for all residents to assess for signs and symptoms of Legionella. Any resident with signs and symptoms was tested via urine antigen and sputum culture if able. [DATE]: The facility held a QAPI meeting and reviewed the policies: Water Management Program, Infection Surveillance and the Infection Prevention and Control Program. The Abatement Plan was reviewed at QAPI. [DATE]: The facility alleged compliance. 37668 Resident #205 Review of intake documentation pertaining to Resident #205 detailed the facility had positive legionella in the water for about a year and were not willingly working with the Local Health Department (LHD) as required by public health code. The intake further revealed an individual (Resident #205) tested positive for Legionnaires' (serious type of pneumonia caused by the Legionella bacteria) and was at the facility within the incubation period (time between exposure/infection to symptom onset) of Legionnaires' illness onset. Record review revealed Resident #205 was admitted to the facility on [DATE] with diagnoses which included right ischium (one of three bones that form the hip bone) fracture, falls, non-insulin dependent diabetes mellitus, atrial fibrillation (irregular heart rhythm), and heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required set-up to moderate assistance to complete Activities of Daily Living (ADL). Resident #205 was transferred to the hospital on [DATE] and did not return to the facility. A review of the facility provided Resident Infection Line Listing 2024 was completed. Resident #205 was included on the line list as having a Respiratory Tract infection caused by Legionella/Influenza with an onset date for the infection listed as [DATE]. Review of Resident #205's Electronic Medical Record (EMR) revealed the following documentation: - [DATE] at 3:46 PM: SBAR Communication Form and Progress Note . 1. The change in condition, symptoms, or signs . unresponsive vitals WNL (Within Normal Limits) . 2. This started on: [DATE] . 3. Since this started has it has . Stayed the same . 4. Things that make the condition or symptom worse are: dyspnea (shortness of breath) . Vital Signs . Most Recent O2 sats . 90 (%) Date: [DATE] (at) 21:59 . Room Air . Mental Status Changes . Decreased consciousness . Most Recent Blood Glucose . 127 . Date: [DATE] (at) 10:47 AM . - [DATE] at 4:05 PM: Change of Condition . 1. List symptoms present related to the change of condition . COG (sic- unknown abbreviation) responsive with vitals WNL (Within Normal Limits), no response to pain . (Family) present in facility at time of change . - [DATE]: Health Care Provider Note: Notified by DON that patient became unresponsive, glucagon (medication used to treat low blood sugar) administered, BS (Blood Sugar) increased, and patient stabilized. New orders given for patient to be sent to the emergency department for further evaluation and treatment . Addendum Details: Patient still unresponsive, sent out . Addendum Created Date: [DATE] at 4:17 PM. Review of Resident #205's Skilled Daily-Medically Complex Nursing documentation from [DATE] to [DATE] revealed the following: - [DATE] at 3:31 AM: Resident #205 was Alert and Orientated to person, place, date, and time (A & O X 4), experiencing shortness of breath, and receiving oxygen therapy while simultaneously specifying the Resident's most recent SPO2 was 98% on room air on [DATE] at 9:59 PM. - [DATE] at 11:40 PM: Resident #205 was A & O to person, place, and time, experiencing shortness of breath, and receiving oxygen therapy via nasal cannula. Per EMR documentation, Resident #205 had a planned discharge home for the facility in place for [DATE]. Review revealed the last documented SPO2 vital sign documentation in Resident #205's EMR occurred on [DATE] at 9:59 PM and specified, 90% . Room Air. Review of Resident #205's Health Care Provider orders, Medication Administration Record (MAR) and Treatment Administration Record (TAR) for [DATE] revealed the Resident did not have a task in place for Legionella and/or respiratory infection sign/symptom monitoring. Further review of scanned documentation in Resident #205's EMR revealed a fax from the hospital to the facility dated [DATE]. The fax contained Pneumonia Panel sputum testing laboratory testing results. The laboratory test was dated [DATE] and specified Resident #205 tested positive for Legionella pneumonia, Coronavirus, Influenza A, and Klebsiella Oxytoca (bacteria commonly found in the intestinal tract, mouth, and nose which can cause opportunistic infections including pneumonia). Review of facility water testing report dated [DATE] revealed the facility tested on e source of water in the room Resident #205 resided in while at the facility following the report received from the

This Citation pertains to Intake Number MI00142716. Based on interview and record review the facility failed to provide adequate supervision and assistance for one resident (Resident #113) of 3 residents reviewed for falls resulting in Resident #113 falling and sustaining a serious laceration requiring hospitalization . Findings include: Resident #113 (R113): Review of R113's face sheet dated 7/2/24 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: Chronic respiratory failure with hypoxia, congestive heart failure, muscle weakness, difficulty in walking, liver disease, dependent on supplemental oxygen, and dependent on other enabling machines. Review of R113's Activities of Daily Living (ADL) care plan dated 3/17/23 revealed she required the assistance of 1-2 people for bed mobility, personal hygiene, for toilet use at bed level (bed pan). Transfers required assistance of 2 with a mechanical lift. Required a sponge bath as a full bath or shower could not be tolerated. Review of R113's fall care plan, dated 3/17/23, revealed interventions that included: call light in reach, bed in low position when not providing care. Review of R113's incident and accident report, dated 5/12/23 at 9:00 PM, revealed, R113 was found in her room laying on her right side next to the bed. Predisposing Physiological Factors, the boxes were checked for confused, incontinent. Predisposing Environmental the box was checked for bed height. Witnesses listed 6 staff. None of the staff witnessed the event. No statements were made to indicate who had provided care or when care had last been provided. During an interview with the Nursing Home Administrator (NHA) on 7/2/24 at 9:00 AM, R113 incident and accident report for 5/12/23 at 9:00 PM was reviewed. The report did not have any statements related to R113's care prior to the fall and all 6 staff listed on the report indicated they did not witness the fall. The NHA said she did not investigate the fall because the resident said she was attempting to get out of bed and go to the bathroom. The resident did not return so she did not have any additional information. The NHA said she did not have any additional information related to R113's fall. The NHA said only one staff person listed in the report still worked at the facility. During an interview with the Director of Nursing (DON) on 7/2/24 at 10:27 AM the DON provided a fall assessment for R113, dated 5/13/23 at 3:14 AM, that indicated R113 had not had any care during the 3 hours prior to her fall out of bed and there was no indication what care was provided or what R113 was like 3 hours prior to the fall. The DON confirmed that the standard of care for dependent residents is to provide care every 2 hours at a minimum. The DON said she did not investigate the fall. The DON said the Registered Nurse that completed the incident report and fall assessment no longer worked for the facility. The DON said the only staff person listed on the incident and accident report still working for the facility was Certified Nurse Aide (CNA) I. Review of R113's fall assessment dated [DATE] at 3:14 AM reveal no indication of who did the assessment. The injury description was right knee r/t laceration. What was resident doing prior to the fall listed attempting to self-transfer. Last time care was provided was 1800 (3 hours prior to her fall). No information was available to determine who provided her care or what care was provided. Review of R113's progress note dated 5/12/23 at 9:45 PM revealed, Called to resident's room for reports of resident observed on floor. Upon entering the room resident was noted laying on the floor, on her right side, next to the bed. Blood noted in a puddle under her leg. VS (vital signs) obtained. Mentation check and at baseline. ROM (range of motion) checked at baseline. Resident assisted from the floor to her wheelchair by 4 staff members. Right knee noted to have a large laceration that was bleeding heavily. Pressure applied by CNA (certified nurse aide) while RN (Registered Nurse) obtained wound care supplies. Knee irrigated with normal saline. Nonstick dressing applied. Wrapped with kerlex. ABD (absorbent dressing) applied to reinforce when the bleeding was noted through the dressing. More ABD applied and secured with an ace wrap for more pressure applied. EMS (emergency medical services) called and transported resident to (name of hospital) Review of R113's progress note, dated 5/12/23 at midnight, revealed, Notified by nursing the resident was sent to the hospital due to uncontrolled bleeding from a 6-8-inch laceration to the right knee. This note was electronically signed by a nurse practitioner. During a telephone interview on 7/2/24 at 2:37 PM, CNA I recalled working the night R113 was found on the floor. He recalled assisting getting her off the floor. He could not recall who the staff were that worked that night and he did not recall who provided R113 with care that night. The only thing he recalled clearly was that her bed was all the way up and he kept asking why the bed was all the way up. CNA I said R113 did not say she put the bed up when he asked. CNA I said he was concerned that someone left her bed up when they last did care. CNA I said he remembered that resident because there was a lot of blood. Review of R113's hospital medical consult, dated 5/13/23 at 9:57 AM, revealed, Yesterday patient states she fell out of bed, however she cannot remember how or why she fell . She was brought to the ER (emergency room ) for confusion and R (right) knee laceration. In ED (emergency department) patient was found in a fib (abnormal heartbeat) with RVR rapid ventricular response. She was given a bolus of amiodarone and went into VT (ventricular tachycardia) with hypotension. Pt shocked x 1 and went into SR (sinus rhythm) and then a fib with controlled rate. Currently pt in a fib with controlled rate. Patient does have h/o (history of) a fib and Eliquis (blood thinning medication) was held during previous admission 2* (secondary to) GI (gastrointestinal) bleed, unsure when this was resumed. Pt also found to have significant electrolyte imbalance, which are being replaced. She is anemic (low blood iron) and hypotensive (low blood pressure). IVR (intravenous fluids) are being started and PRBCs (packed red blood cells) have been ordered. Her right knee is being sutured at time of evaluation. Patient currently confused on why she needed to come to the hospital for just a fall. She denies any chest pain, pressure or tightness. She denies R (right) knee pain. She does have occasional SOB (shortness of breath) that is worse when she tries to move in bed. Review of R113's hospital medical record for her emergency room admission on 5/12/23 at 9:49 PM revealed she discharged on [DATE] at 2:22 PM. Review of R113's discharge summary for this hospitalization revealed. Pt (patient) was admitted s/p (status post) fall for AMS (altered mental status), multiple medical problems, PT (patient) was intubated at one time. Pt had been transferred out of ICU (intensive care unit) but was transferred back yesterday afternoon for respiratory acidosis. She was receiving respiratory support via AVAPS (ventilator). Per the nursing pt had sudden severe bradycardia followed by PEA (Pulseless Electrical Activity) ROSC (return of spontaneous circulation) was unable to be achieved and pt passed away.

Based on observation, interview, and record review, the facility failed to prevent skin injury and pressure ulcer development for two residents (Residents #23, Resident #239), resulting in the development of new skin injuries for Resident #23, and the development of a Stage III pressure ulcer after admission to the facility and failed to use positioning devices. Findings include: Record review of facility 'Pressure Injury Prevention and Management' policy, dated 1/1/2022, revealed the facility is committed to the prevention of avoidable pressure injuries and the promotion of healing existing pressure injuries. Definitions: Pressure Ulcer/Injuries- refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence There are multiple terms used to describe this type of skin damage, including pressure ulcer, pressure injury, pressure sore, decubitus ulcer, and bed sore. For the purpose of this policy, pressure injury, as the current standard terminology, will be used. Interventions for prevention and to promote healing: 4. (a.) included to complete a thorough assessment/evaluation and to develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. #4. (c.) Evidence-based interventions for preventions will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include but are not limited to: Redistribute pressure (such as repositioning, protecting and/or off-loading heels, etc.) (f.) Interventions will be documented in the care plan and communicated to all relevant staff. Resident #23: Record review of Resident #23's electronic medical record revealed the resident was admitted on [DATE] and an admission skin assessment noted one (1) open coccyx wound with no measurements documented. Record review of Resident #23's admission Minimum Data Set (MDS) dated [DATE] section M: skin conditions- noted (1) one Stage IV pressure ulcer present upon admission. In an interview and record review on 11/08/23 at 9:50 AM, Nurse Practitioner A reviewed the electronic record revealed that Resident #23 was admitted with a trach and one pressure ulcer from a hospital. Record review of Resident #23's progress note, dated 9/8/2023 at 11:12 AM, noted while doing AM wound care two new open areas were observed Observation and interview on 11/09/23 at 08:31 AM with Licensed Practical Nurse (LPN) F of Resident #23's peg tube site dressing noted bleeding to split sponge There was no date on dressing. Observation on Bilateral feet was noted to have bilateral pressure boots in place, the skin on the feet was smooth and intact. Observation of Resident #23's sacrum and bilateral buttocks noted three (3) open wound areas with scant bleeding noted. LPN F revealed that the bilateral buttocks wounds developed from a border gauze dressing while the resident was residing at the facility. An interview and record review on 11/09/23 at 09:55 AM of Resident #23's medical record with Licensed Practical Nurse (LPN) F revealed that the resident had gotten the two (bilateral buttocks) and were in house acquired because we followed the orders from her previous facility and then the border dressings ripped the skin and created two new areas. LPN F stated that she took photos and started treatment stating that they were calling them abrasions. Record review of Resident #23's wound care assessments noted a right gluteal wound measurement: length 9.45 cm X width 3.97 cm X depth 0.1 cm, left gluteal were also noted. In an interview and record review on 11/09/23 at 10:05 AM, Licensed Practical Nurse (LPN) F stated that they had her treatment as calcium alginate (debride treatment) for granulation and recently changed it to collagen treatment. In an interview on 11/09/23 at 12:13 PM with Nurse Practitioner A, related to the development of Resident #23's new skin injuries to the bilateral buttocks, the Nurse Practitioner A revealed the facility is calling those areas abrasions to the right and left gluteal and are from the tape of the border gauze peeling the skin off. The facility is calling them abrasions. Resident #239: Record review of Resident #239's care plans noted diagnosis of dementia, cerebral infarction, dysphagia, peripheral vascular disease, transient ischemic attack, chronic obstructive pulmonary disease, difficulty walking, debility, and weakness. Record review of Resident #239's 'Admission Nursing Assessment', dated 10/24/2023 at 3:42 PM, of skin revealed right antecubital redness as the only skin condition for the resident. Record review of Resident #239's admission progress note, dated 10/24/2023 at 3:42 PM, noted skin assessment completed and there were no indications of skin concerns. Record review of Resident #239's history and physical progress note, dated 10/26/2023, noted that the resident was negative for: changes in hair or nails, changes skin color, swelling, itching, bruises, rash, mass, or open lesions. Record review of Resident #239's admission Minimum Data Set (MDS), dated [DATE], section M: skin conditions- noted no unhealed pressure ulcer/injury present upon admission. On 11/08/23 at 08:14 AM, Resident #239 was observed in bed slumped to the lower end of the bed, head of the bed is elevated slightly. Residents #239 was noted to be flat on his back at an upward angel with the knees raised up. There was only one pillow noted in the bed located under the resident's head. Observation of Resident #239's bilateral feet were resting on the mattress with no pillow or pressure relieving boots noted. An observation on 11/08/23 at 12:01 PM of Resident #239 noted that the resident was boosted higher up in bed, still flat on his back with only one pillow in the bed behind his head. Resident #239 watches the doorway to his room and smiles in response to questions or shakes his head yes/no. Resident #239 denied being out of bed the prior day. Observation and interview was conducted on 11/08/23 at 01:45 PM of Resident #239 with Licensed Practical Nurse (LPN) H of the resident's skin. Family member was visiting the resident. LPN H came into the room, did not wash her hands or glove, turned Resident #239 to his right side, and lowered the brief. Observation of Resident #239's bottom revealed an open area with scant bleeding noted to brief. Observation of the brief was wet. LPN H stated that the resident came with scarring to his bottom when he came, and that he came when his prior home was closed. LPN H resecured the brief rolled the resident back onto his back. Observation during the pressure ulcer/injury observation revealed that there was only one pillow in the bed and was located behind the resident's head. There were no extra pillows or positioning wedge noted in the bed or observed in the room. Bilateral feet were observed with no pillow to off-load or pressure relieving boots. LPN H covered Resident #239 with a sheet and left the room with the surveyor. In an observation on 11/08/23 at 03:42 PM, Resident #239 was observed in the same position that he was left in after the pressure ulcer/injury observation, there are no extra pillows or positioning devices noted in the room. An interview and observation on 11/09/23 at 08:22 AM with Licensed Practical Nurse (LPN) F, who was wound care certified, revealed that Resident #239 had a lot of scar tissue and it opened a while ago, but it looks good. Staff are to position every 2 hours usually with 2 pillows and positioning wedge. Observation was made of Resident #239 while lying in bed flat on his back with no positioning pillows or wedge devices noted. Observation with LPN F washed her hands and gloved, the resident was rolled to his right side, the brief was lowered, and the surveyor observed an estimated 3.5 cm long by 1 cm wide open wound with scant bleeding noted. Observation of bilateral heels, skin is smooth and intact. Observed pressure relieving boots on of gray in color and too small for residents' feet. LPN F removed her gloves, washed her hands, and walked out of the room and told the Certified Nurse Assistant to get another pillow for Resident #239. In an interview and record review on 11/09/23 at 08:50 AM with Licensed Practical Nurse (LPN) F Resident #239's admission skin assessment dated [DATE], and revealed that revealed no skin issue or scarring to the buttocks area. Record review of Resident #239's Admission Minimum Data Set (MDS) dated [DATE] noted no pressure ulcers/injuries. LPN F agreed with the state surveyor that skin will get red in color before opening an ulcer. LPN F revealed that the treatment of cleansing buttocks with calcium alginate (debridement) because it was red on the outside, and cover with an ABD pad. LPN F stated that if the residents does not walk or get up then we do not use duoderm boarder dressing or tape because it causes breakdown. In an interview on 11/09/23 at 09:45 AM Licensed Practical Nurse (LPN) F came to the state surveyor to notify that she had looked in the closet of Resident #239 and found a turn wedge. The state surveyor inquired why was the positioning wedge in the closet for the past three days? LPN F stated that she did not know why. LPN F stated that there was a pillow now between his legs and the positioning wedge is placed in the bed behind the resident positioned on his side. LPN F stated that Resident #239 should be repositioned frequently as needed. In an interview and record review on 11/09/23 at 11:45 AM Licensed Practical Nurse G came to the state surveyor with a late entry progress note for Resident #239. LPN G revealed that she did the admission assessment. When the resident came in, we were learning a new process on the IPAD, when he was admitted , the wound care team was not here. He was really red all over, rosacea type redness on his face, back and butt, but his skin was a little red. He did not have any open areas on his butt, just scaring. I did put in a new progress note today on his skin assessment. Record review of Late entry dated 11/9/2023 at 11:34 AM revealed: Clarification to skin assessment upon arrival. Resident noted to have generalized red skin all over body. Skin on buttocks we intact with deep red skin noted. His buttocks, back and face were deeper red, with scarring on his buttocks. There was some MASD (Moisture Associated Skin Damage) noted to buttocks on arrival as well. Attempted to document with IPAD, without success. LPN G could not give an answer to why she had not documented the subject at the time of the admission. In an interview on 11/09/23 at 03:11 PM, the Director of Nursing came to the state surveyor to speak about Resident #239 and the citation going to be a harm tag and we were using a new IPAD program at the beginning of his admission and the nurse failed to document the skin until today. Surveyor explained that during the survey observations of only one pillow in the bed behind the resident's head, no positioning wedge was used for three (3) days and was later found in the closet by Licensed Practical Nurse F on 11/9/2023. There were no position changes noted of the resident in three days or that the resident had gotten out of bed during the survey time observations.

Based on observation, interview and record review, the facility failed to prevent repeated urinary tract infections (UTI's) for one resident (Resident #78), resulting in hospitalization and a prolonged illness. Findings include: Record review of facility provided 'Infection Prevention and Control Program' policy dated 5/22/2023 revealed the facility has established and maintained as infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Record review of the Center of Disease Control and Prevention (CDC) 2023 National Healthcare Safety Network (NHSN) Patient Safety Component Manual device-associated module UTI (Urinary Tract Infection) page 7-5, Table 1. Urinary Tract Infection Criteria, #3. Patient has a urine culture with no more than two species of organisms identified, at least one of which is bacterium. Record review of the APIC Implementation Guide to Preventing Catheter-Associated Urinary Tract Infections, first edition 2014, revealed catheter-associated urinary tract infection (CAUTI) has been associated with increased morbidity, mortality, hospital coat, and length of stay. Bacteriuria also leads to unnecessary antimicrobial use, and urinary drainage systems can be reservoirs for multidrug-resistant bacteria . Resident #78: Observation was done on 11/07/23 at 11:12 AM with Resident #78. When asked the resident stated that he has a Foley catheter. Observed Foley catheter in a privacy bag facing the wall. Closer observation noted sediment in the tubing and bag. In an observation on 11/08/23 at 08:48 AM, Resident #78 was observed to be eating in bed, with no lights on and the shade closed. Resident #78 stated that he has to feel for the food items on his tray. The surveyor inquired if opening the shade would be helpful, and resident gave consent to open the shade. Observation of resident's meal tray noted hash browns and eggs, toast, yogurt, and juice. Resident was appreciative of having the shade opened and he was able to see the food items on the tray. Record review on 11/08/23 at 03:19 PM of Resident #78's electronic medical record for urinary tract infections revealed: April 2023: Record review of the facility April 2023 infection control infection line listing noted Resident #78 on 4/13/2023 was noted to have urinary tract infection and was placed on Macrobid 100 mg or from 5/8/2023 through 5/22/2023 (14 days) organism enterococcus faeccium. Record review of Resident #78's May 2023 Treatment Administration Record (TAR) revealed that on 5/8/2023 noted Foley catheter was documented as replaced. There were no other catheter changes documented in the month of August. May 2023: Record review of Resident #78's May 4,2023 urine swab lab results identified Enterococcus faecium at 99.99% and Candida parasilosis, topicalis, albicans 0.01% organisms. Record review of the May 2023 Medication Administration Record (MAR) revealed antibiotic Macrobid 100 mg oral twice daily for 14 days was given. Record review of Resident #78's May 2023 Treatment Administration Record (TAR) revealed that on 5/8/2023 noted Foley catheter was documented as replaced. There were no other catheter changes documented in the month of May. June 2023: Record review of Resident #78's progress notes dated 6/1/2023, 6/2/2023 and 6/3/2023 revealed that the resident was having visual hallucinations. Altered mental status change and was sent to the hospital. Progress notes on 3/9/2023 noted re-admission with urinary tract infection with enterococcus faecium organism. Record review of Resident #78's June 2023 Medication Administration Record (MAR) revealed antibiotic Amoxicillin 800 mg oral twice daily for 7 days was given. Record review of Resident #78's June 2023 Treatment Administration Record (TAR) revealed that on 6/27/2023 noted Foley catheter was documented as replaced. There were no other catheter changes documented in the month of August. July 2023: Record review of Resident #78's progress notes dated 7/2/2023 and 7/3/2023 revealed the resident was found on the floor with altered mental status change and was sent to the emergency room for evaluation. Progress notes on 7/11/2023 noted that Resident #78 returned to the facility. Progress notes on 7/12/2023 noted that the resident was presented to emergency room due to altered mental status change post fall. The resident was hospitalized and treated for urosepsis. The resident was stabilized and then discharged back to the nursing home. Record review of hospital urine culture dated 7/6/2023 revealed enterococcus faecium organism. Record review of Resident #78's July 2023 Treatment Administration Record (TAR) revealed to change indwelling catheter as needed as clinically indicated and that there were no Foley catheter changes/replacement documented. There were no other catheter changes documented in the month of July. Record review of Resident #78's hospital infectious disease consult, dated 7/10/2023, revealed the resident was evaluated for urinary tract infection with the urine culture growing VRE and Candida albicans. Intravenous antibiotics were started. Sediment was noted in the Foley catheter. August 2023: Record review of Resident #78's progress notes dated 8/9/2023 at 10:57 AM orders-administration note revealed: Once the catheter has been replaced, please obtain urine sample and dip sample. If sample is positive, please send to lab one time a day for abdominal pain on antibiotics for urinary tract infection. Progress notes dated 8/10/2023 at 7:03 AM orders-administration note revealed: Once the catheter has been replaced, please obtain urine sample and dip sample. If sample is positive, please send to lab one time a day for abdominal pain on antibiotics for urinary tract infection. Record review of Resident #78's August 2023 Medication Administration Record (MAR) revealed antibiotic ciprofloxacin 500 mg oral twice daily for 28 doses (14 days) was given started 8/7/2023 through 8/21/2023 for urinary tract infection (UTI), and on 8/31/2023 antibiotic Fosfomycin Tromethamine oral 3-gram packet by mouth one time every 3 days for urinary tract infection (UTI). Record review of the August 2023 Treatment Administration Record (TAR) revealed that on 8/4/2023 noted Foley catheter was documented as replaced. There were no other catheter changes documented in the month of August. September 2023: Record review of Resident #78's September 1, 2023, urine swab lab results identified four (4) organisms: Providencia stuartii 82.645%, Enterococcus faecium 8.264%, Staphylococcus aureus 8.264% and Candida parasilosis, topicalis, albicans 0.826% organisms. Record review of the September 2023 Medication Administration Record (MAR) revealed antibiotic fluconazole 20mg oral once daily for 14 days was given for urinary tract infection. Record review of Resident #78's September 2023 Treatment Administration Record (TAR) revealed that: Once the catheter has been replaced, please obtain a urine sample and dip sample, If the sample is positive send sample to lab was signed out for 17 days. October 2023: Record review of Resident #78's October 4, 2023, urine swab lab results identified five (5) organisms: Providencia stuartii 90.001%, Staphylococcus aureus 9.0%, Enterococcus faecium 0.9%, Klebsiella oxytoca pneumoniae 0.09% and Candida parasilosis, topicalis, albicans 0.009% organisms. Record review of the September 2023 Medication Administration Record (MAR) revealed on 10/5/2023 antibiotic Fosfomycin Tromethamine oral 3-gram packet by mouth one time every 3 days for urinary tract infection (UTI). Record review of Resident #78's September 2023 Treatment Administration Record (TAR) revealed that: Change indwelling catheter as needed was documented as completed on 10/21/2023. In an interview on 11/09/23 at 11:58 AM with Nurse Practitioner A regarding Resident #78's urinary tract infections revealed the resident had chronic Foley obstructive uropathy, pathogens went from 2 pathogens up to 5 pathogens with use of antibiotics. We are using (name of lab), resident has sediment in the catheter tubing, and change the catheter to a new catheter, it should be an automatic order set when a resident is admitted with a catheter, change as needed. Multiple pathogens since admission related to his care, he doesn't refuse the care its either a cleaning of catheter or it's how often he is bathed. Anytime there is a dip or UA order the catheter should be removed and sterile sample should be collected. The catheter system is to be changed and the sample sent for analysis. The lab gives the counts of organisms/pathogens. The surveyor inquired about contaminated urine sample with five or more organisms/pathogens? Record review of the electronic medical record for Resident #78 revealed that there was no urine re-sample collected. In an interview and observation on 11/09/23 at 12:37 PM with Registered Nurse/Unit Manager B related to urine sampling with a catheter. RN B stated that she dates the bag when she changes the catheter itself or the entire system. Observation of Resident #78's Foley catheter bag and hose revealed no date on system. RN B stated that each time the urine sample is collected the entire urinary catheter system should be changed before a sample is collected, it needs to be a new system. In an interview and record review on 11/09/23 at 12:46 PM of Resident #78's electronic medical record with Registered Nurse B stated that the Foley catheter was changed a couple of weeks ago. Record review of 10/4/23 urinalysis with 5 pathogens, the catheter was changed on 10/21/2023 as documented. Record review of the September Treatment Administration Record 2023 noted no catheter changed. In an interview on 11/09/23 at 01:47 PM with the Infection Control Preventionist (ICP) C revealed that she was not aware that the catheters were not changed with urine samples, record review of the residents' medical records with the unit manager was conveyed to the ICP/RN by that staff member. Record review of the facility urinary tract infection rates for a four month look back (July, August, September, October 2023) revealed that the infection rates from July increased. The ICP C who was also the staff educator presented an in-service education dated 9/20/2023 for urinary tract infections (UTI's) revealed that staff were educated in all areas and verbalized understanding. There were no return hands demonstration on catheter replacement or on how to collect a urine sample.

Based on observation, interview and record review, the facility failed to prevent significant medication errors for 1 resident (Resident #44) of 6 residents reviewed for medication errors, resulting in medications being administered to the resident's hours after they were due for Resident #44 leading to the potential for mistreatment of the resident's medical conditions, serious side effects, adverse effects and a decline in condition. Findings Include: FACILITY Medication Administration Resident #44: On 11/7/2023 at 9:25 AM during the Entrance Conference with the Director of Nursing/DON, she said the Medication Administration times for residents was divided into morning/AM (6:00 AM to 10:00 AM) and evening/HS 6:00 PM to 10:00 PM or at specific times if the medication had specific administration instructions. A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #44 was admitted to the facility on [DATE] with diagnoses: Diabetes mellitus, kidney disease, renal dialysis, bipolar depression, history of falls, neuropathy. The resident had full cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 15/15. Resident #44 received some assistance with care. On 11/8/23 at 11:30 AM during an observation of medication administration by Nurse T for Resident #44, she was observed preparing medications as indicated on the electronic Medication Administration Record/MAR. Many of the medications being removed from the medication cart and prepared for administration to Resident #44 were coded Red in the computer. Nurse T was asked why they were red and she said it was because they were Late and had not been given that morning. During the medication administration observation on 11/8/2023 at 11:45 AM, Nurse T began to remove several different insulins from her medication cart for Resident #44. She said she also needed to perform an Accucheck blood sugar test and it was supposed to be performed before meals. She said the resident had not received the Accucheck that morning or the insulins and other medications. The following medications were administered late: 1. Renvela (for chronic kidney disease) oral tablet 800 mg-Give two tablets by mouth with meals, start date 10/22/2023; 2. Novolog penfill subcutaneous solution cartridge 100 units/ml (Insulin Aspart), Inject 4 units subcutaneously before meals and at bedtime for (Diabetes Mellitus), start date 10/4/2023; 3. Januvia (diabetes medication) oral tab 25 mg -Give 1 tablet by mouth one time a day for Diabetes Mellitus- scheduled for 8:00 AM, start date 9/27/2023; 4. Lasix (a diuretic) oral tablet 40 mg-Give 1 tablet by mouth two times a day every Monday, Wednesday, Friday, Sunday for fluid overload, start date 8/9/2023; 5. Amlodipine (a cardiac medication for high blood pressure) 5 mg daily-Give 1 tablet by mouth in the morning, start date 2/14/2023; 6. Coreg (Carvedilol a heart medication) oral tablet 12.5 mg - Give 1 tablet by mouth every morning and at bedtime for beta blocker. With meals. Please hold am dose on dialysis days (Tuesday, Thursday, Saturday) Please hold if Systolic blood pressure is less than 120 per nephrology team, start date 8/23/2023; 7. Fluoxetine (antidepressant) oral capsule 40 mg, Give two capsules by mouth in the morning for depression, start date 2/14/2023; 8. Flonase/Fluticasone propionate suspension 50 mcg/ACT, 1 spray in each nostril in the morning for Nasal congestion for 14 days on order order date 11/2/2023; 9. Gabapentin/Neurontin (nerve pain medication/anticonvulsant) oral capsule 100 mg- Give 1 capsule by mouth every morning and at bedtime for pain, start date 5/3/2023. 10. Loratadine tablet 10 mg-Give 1 tablet by mouth in the morning for Nasal congestion for 14 days, start date 11/2/2023; 11. Insulin Glargine (Long -acting insulin) subcutaneous solution 100 unit/ml, Inject 18 units subcutaneously every morning and at bedtime for Diabetes Mellitus, start date 10/11/2023; 12. Accucheck before meals and at bedtime for Diabetes Mellitus: 0700, 1100, 1700 (5:00 PM) and 2100 (9:00 PM), start date 6/16/2023. On 11/8/2023 the 0700 (7:00 AM) reading was not completed. The 11/8/2023 1100 (11:00 AM) reading was documented as NA (not available) but on 11/8/2023 at 12:05 PM, Nurse T performed the blood glucose (sugar) Accucheck and the result read HI. The DON was also in the room during the Accucheck and both the DON and Resident #44 stated, It means its greater than 600. The resident's blood sugar was not checked in the morning at 7:00 AM and he did not receive his morning insulins. His 11:00 AM Accucheck was completed at 12:05 PM, and it read HI (greater than 600). This is very high. Resident #44 had not received any insulin or his oral diabetic medication as ordered that morning. The DON asked the Nurse if she had contacted the provider to let him know the resident did not receive the morning insulin; Nurse T said she had not contacted the provider. The DON told the Nurse to call the provider and let him know the resident did not receive his morning insulin and oral diabetic medication and his blood sugar reading was High. On 11/8/2023 at 12:10 PM, Resident #44 was interviewed about his medication. He said he had not received his morning medication, but he had eaten breakfast and was just coming back from lunch prior to receiving his medication. Mayo Clinic: Hyperglycemia in diabetes, dated August 20, 2022, High blood sugar, also called hyperglycemia, affects people who have diabetes . Skipping doses or not taking enough insulin or other medications to lower blood sugar also can lead to hyperglycemia. It's important to treat hyperglycemia. It it's not treated, hyperglycemia can become severe and cause serious health problems that require emergency care, including diabetic coma. Hyperglycemia that lasts, even if it's not severe, can lead to health problems that affect the eyes, kidneys, nerves and heart . To help keep your blood sugar within a healthy range: . Follow your meal plan . Monitor your blood sugar . Careful monitoring is the only way to make sure that your blood sugar level stays within your target range . Carefully follow your health care provider's directions for how to take your medication . On 11/8/2023 at 2:30 PM, during a conversation with the DON, she said the nurse had contacted the provider about the late medications for Resident #44. The DON was asked about staffing on the resident's hall (500). She said there were 2 nurses working that day for the 500, 600 and 700 halls; each nurse had 1 hall and half of another hall. Nurse T was a new nurse at the facility and had only been off orientation for a few days. The DON was asked why no one helped the nurse, as the residents were not receiving the medications. She said there were other nurses in the building who could have helped. The DON was asked how many nurses were usually scheduled to work the 3 halls and she said 2-3 nurses. A review of the facility policy titled, Medication Administration, dated 10/30/2020 and revised 1/1/2022 provided, Medications are administered by licensed nurses . as ordered by the physician and in accordance with professional standards of practice . Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician .

Based on observation, interview and record review the facility failed to complete comprehensive fall investigations for Resident #229's injuries of unknown origin and ensure that loose medications were not present in Resident #25's room, resulting in two pills being discovered on Resident #25's bedside table that were not prescribed for him and Resident #229 sustaining a left [CONDITION(S)] in July 2022 requiring surgical intervention to repair her right hip hardware (that was fractured and repaired in April 2022) in May 2022. Findings Include: Resident #25: During initial tour on 8/8/22 at approximately 3:30 PM, Resident #25 was observed sitting on the edge of his bed. He appeared to be in good spirits and did not report any concerns with the current care he is being provided. While speaking to the resident this writer observed two pills on his bedside table. Resident #25 reported he found them in his bed today and was going to throw them away. He continued he was unsure how the pills ended up in his bed, he stated he does have tremors and maybe they fell out of his mouth as the nurse was administering his medications. There were two distinct pills: -One was a pink circular pill with HP 2 on the front and was identified via Drugs.com as [MEDICATION(S)] 25 MG (milligrams). The medication is used to treat hypertension (high blood pressure). -The 2nd pill was a peach circular pill with R 129 on the front and was identified via Drugs.com as [MEDICATION(S)] [MEDICATION(S)] 0.3 MG. This medication is used to treat hypertension. On 8/8/22 at 3:45 PM, this writer alerted Nurse A to the two medications found in Resident #25's room. This writer showed Nurse A the pills and he reported he believes one is [MEDICATION(S)] and the other is [MEDICATION(S)] or [MEDICATION(S)]. Nurse A added those pills were not administered on their shift and after some thought, stated Resident #25 is not prescribed those medications and he is not sure why they were in his bed. Nurse A was queried if the resident was cognitively intact, and he stated he was. On 8/9/22 at approximately 11:15 AM, a review was completed of Resident #25's medical records and it revealed the resident was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)], [CONDITION(S)] and Disc Degeneration. Resident #25 is cognitively intact and able to make his needs known. Further review yielded the following the results: Physician Orders: Resident #25 does not have a physician order for [MEDICATION(S)] or [MEDICATION(S)] It is unknown how Resident #25 acquired the two medications in his room as they were not his medications. On 8/15/22 at 10:00 AM, a review was completed of the facility policy entitled, Medication Storage, revised 1/1/2022. The policy stated, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medications rooms according to manufacturer's recommendations .All drugs and biological's will be stored in locked compartments .Only authorized personnel will have access to keys to locked compartments. During medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. Resident #229: On 8/8/22 at 2:40 PM, Resident's #229's significant other requested to speak to the Surveyors. He reported facility staff are not timely when they respond to call lights and many times it has taken them over 30 minutes to respond. He continued their failure to respond timely to Resident #229's call light resulted in her attempting to ambulate to use the restroom, falling and leading to her 2nd fractured hip that had to be repaired. On 8/9/22 at 9:30 AM, Resident #229 was observed laying in bed as her tube feed was infusing, she admitted she was in pain and had not requested pain medications from nursing staff. This writer observed Resident #229's nurse and informed her of the resident's pain. Resident #229 offered she has only been back at the facility for a few days after having hip surgery. She reported she does not recall much from her fall at the facility but knows she got out of bed, walked into the bathroom, and fell . The resident stated she required surgery on her hip after the incident. She further reported facility staff do take a long time to answer the call lights, but she was unable to tell this worker how long they take to respond. It can be noted the fall Resident #229 was referring to was from May 2022, not her most recent falls on 7/27/22. On both occasions she did require surgical intervention at the hospital. On 8/10/22 at approximately 10:00 AM, a review was completed of Resident #229's medical records and it revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: Left Femur Fracture, Diabetes, [CONDITION(S)], [CONDITION(S)] and Chronic Kidney Disease. Resident #229 was assessed as being moderately cognitively impaired and a one person assist for toileting. Further review of her records revealed the following: Initial Hospital Discharge Paperwork 4/2022: Patient is [AGE] year-old female who sustained a ground level fall after tripping over a dog toy. She landed on her rip hip .Minimally displaced subcapital fracture of right femoral neck .Right hip arthroplasty on 4/14/2022. Progress Notes: 4/20/22 at 17:29: Resident arrived via ems upon discharge from [NAME] with dx of right [CONDITION(S)] . 4/21/22 at 00:00: .Is a new admit who fell at home and fx (fracture) her right femur neck base, which required surgical intervention. Last night pt (patient) got up on her own and fell in the bathroom. Right hip swollen and 2 view ordered .ANOx3 and encouraged to not get up without using the call light for staff assistance. Pt agree to this plan. She states she will not get up alone. 4/21/22 at 10:11: Right hip surgical incision, well approximated, no drainage, extremity normal in warmth, toes less than 3 sec cap (capillary) refill, hip is swollen. Lodger did fell in bathroom last night . On 8/10/22 at 2:00 PM, a review was completed of Resident #229's falls since her admission to the facility in April 2022. Resident #229 had five falls at the facility with three (two occurred within hours of one another) requiring surgical intervention: 4/20/2022 at 9:00 PM: Pt (patient) was in bathroom she tried to get up on her own after being advised not to she fell on her back. Interventions: Pt was educated on importance of call light, aide will con. (continue) to be a 1 assist. Encourage resident to ask for & await assistance for transferring. 5/2/2022 at 6:38 PM: Called to resident room. Aid stated when doing rounds she noticed blood on carpet leading from BR (bathroom). On investigation there was blood on the BR floor and showing on resident's brief .There was a small amount of blood on blanket .Upon assessment it was noted that resident's left hip surgical incision was opened with clotted blood in brief. No active bleeding .Resident upper forehead had swelling, bruising and serosanguineous drainage. Hip wound cleansed .Sent to (emergency room ). Resident #229's fall was unobserved, and resident was unable to explain how she fell . It was relayed to the facility she would require surgery for her hip. The facility did not complete a thorough investigation. 7/7/2022 at 2:59 PM: (Resident #229) was attempting to self-transfer from w/c (wheelchair) to chair in DR (dining room) & ended up sitting on floor staff unable to reach her in time to intervene. No injures noted . Interventions: Offer toileting assistance with waking, before and after all meals and activities, at hs (bedtime) and PRN (as needed). 7/27/2022 at 3:18 AM: Heard loud yelling went to room with c.n.a. Observed resident laying on floor next to bed. flat on back. Making loud growling/grunting noise. Skin moist, cold and clammy. Not responding to name or questions with verbal or tactile stimuli .BSG assessed, with result of 24. IM [MEDICATION(S)] given .Orange juice 8 oz given .Protein shake given after orange juice. BSG after 15 min 47. Second glass of orange juice . BSG after second dose 54, at 30 min 71. Resident responsive, open eyes and gives verbal response to nurse questions . 7/27/2022 at 5:26 AM: Called to residents' room by c.n.a. Observed resident kneeling at end of bed, on floor. Legs folded up under buttocks. Resident alert, anxious and tearful .Resident c/o (complaints of) left hip pain and will not allow ROM (range of motion) assessment .Orders to send to ER for evaluation received . Fall was unwitnessed. It can be noted one of the 7/27/22 falls resulted in a left [CONDITION(S)] that required surgery. Both of Resident #229's falls were unobserved, and resident was unable to explain how she fell . The facility did not complete a complete and thorough investigation for a injury of unknown origin. On 8/10/22 at 4:05 PM, the DON (Director of Nursing) reported she does not have an investigation for Resident #229's falls on 7/27/22 that resulted in a [CONDITION(S)]. Further review was completed of Resident #229's records: Progress Notes: 5/2/22 at 18:38: .During cena's rounds, noticed the lodger lying in the bed oddly and investigated, there they noticed blood on the BR floor and bedroom carpet. Lodger was lying on the blanket in bed and her brief had blood on it over the right trochanter area and there was a small amount on legs and blanket. Upon further inspection removing the brief and saw the right surgical wound was reopened and had clotted AEB blood clots .Further inspection revealed an noticeable trauma to her upper right forehead in the form of swelling, and bruising . 8/9/22 at 00:00: .was recently hospitalized for fall resulting in L [CONDITION(S)] requiring ORIF with cephalomedullary nail . Hospital Discharge Notes 8/5/2022: [AGE] year-old female patient admitted to the hospital following a fall at her facility in left [CONDITION(S)]. She was seen by orthopedic surgery and has undergone left intertrochanteric short femoral medullary nailing . On 8/11/22 at 9:40 AM, an interview was held with the DON regarding Resident #229's falls. The DON reported Resident #229 admitted to the facility on [DATE] post right [CONDITION(S)] and repair. Resident #229 had her first fall the evening she admitted to the facility that was witnessed by facility staff as she stood up unassisted from her wheelchair and fell . On 5/2/22, Resident #229 had an unwitnessed fall. The aide was walking past the room and noticed blood on the floor and went to investigation. The DON stated it was obvious the resident had been in the bathroom and gotten back in bed. There was blood on the bathroom floor and staff could see the pathway of blood from the bathroom to the resident's bed. Resident #229 was lying in bed and once the nurse assessed, they saw blood on the right side of her brief. Once they removed the brief her surgical wound (from her hip surgery in April) was open but not actively bleeding but there were blood clots. She also had a bruise on her forehead that was swollen and draining clear fluid. Facility staff dressed the hip wound and sent her to the emergency room for evaluation. The DON called the hospital the next morning and was informed they were going to wash out and close the wound. A few days later when the resident had not returned, her daughter informed them the broken the repair on her hip and that had to be corrected. The DON was queried if she obtained witness statements, completed a timeline of events leading up to the fall, watched the cameras etc. The DON reported she did interview facility staff but did not complete written statements or any other elements listed above. The DON reported on 7/7/22, Resident #229 had a witnessed fall in the dining room as she was trying to self-transfer to the chair and fell to the floor on her bottom. There were no injuries from the fall. On 7/27/22 at 3:18 AM, the DON received a phone call from facility staff stating they heard a loud noise and went to check on Resident #229. They observed she had rolled off and the bed, was speaking nonsensical and her blood sugar was 24. The nurse went through the process to increase the resident's blood sugar. Once the resident was stable. they assisted her back to bed and at 5:26 AM she was found kneeling on the floor at the end of her bed. Resident #229 was sent out to the emergency room for evaluation, and it was discovered she fractured her left hip and required surgery. The DON was queried if after being informed of Resident #229's [CONDITION(S)] did the facility complete an investigation. The DON reported they did not complete an investigation regarding the [CONDITION(S)]. A discussion was held regarding the falls and the need for a comprehensive investigation to ensure proper interventions can be put in place, that there were no systematic failures and verifying the timeline of events as reported by facility staff. It was added now the resident had broken the repair on her right hip and fractured her left hip all in a matter of three months at the facility. The DON expressed understanding. It can be noted an investigation was not completed into the two falls that resulted in a right [CONDITION(S)] on 7/27/22. Resident #229's fall on 5/2/22 that resulted in a surgical intervention on her left hip, was not investigated thoroughly after staff observed a pathway of blood from the bathroom to the resident's bed On 8/15/22 at 2:00 PM, a review was completed of the facility policy entitled, Falls- Clinical Protocol, revised 1/1/2022. The policy stated, .For an individual who has fallen, staff should attempt to define possible causes within 24 hours of the fall .Residents who have fallen and have been witnessed to hit their head, suspected to have hit their head, and all un-witnessed falls regardless of the residents' cognitive status should have neurochecks per MD orders or protocol .Post fall analysis items to be considered: the A/I, the nurses notes, review staff and witness statements (to include last time resident seen, provided care and what type of care), Review of care plan and CNA assignments/Kardex that were in place at the time of the fall .Reenactment . Analysis of the causative factors and rationale for interventions developed and implemented should be documented in the Standards of Care notes .

Based on observation, interview and record review, the facility failed to implement timely interventions to prevent the development of an Unstageable Pressure Ulcer (full thickness tissue loss in which the base is covered by eschar/black dead tissue) to the right heel and a Stage III (full-thickness skin loss) left heel Pressure Ulcer for one resident (Resident #58) of two residents reviewed for pressure ulcers, resulting in a left heel Stage III pressure ulcer, Unstageable right heel pressure ulcer and pain. Findings include. Resident #58: On 8/17/21, at 10:46 AM, Resident #58 was lying in bed on their back with bilateral heel boots on. Resident #58 stated, my foot hurts so bad. I could cry. On 8/18/21, at 8:24 AM, Resident #58 was lying in their bed on their back with bilateral heel boots on. On 8/18/21, at 1:00 PM, a record review of Resident #58's electronic medical record reviewed and admission on 6/3/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #58 required extensive assistance with bed mobility and had impaired cognition. Resident #58 was discharged on [DATE] for facial droop and readmitted on [DATE]. A review of the Nursing Admission Evaluation Date: 6/3/2021 revealed no pressure ulcers on admission. A review of Braden Scale For Predicting Pressure Sore Risk Date: 06/03/2021 revealed Score 14 . Moderate Risk . A review Section M - Skin Conditions Date 2021-06-09 revealed M0100 A. Resident has a pressure ulcer . The box for NO was checked. M0150 Is the resident at risk for developing pressure ulcers/injuries? . The box for YES was checked. A review of the Skin & Wound Evaluation Effective Date: 06/15/2021 revealed Type . Blister . Right Heel . In-house Acquired . Length 7.9 cm (centimeters) Width 3.9 cm Depth Not-Applicable . A review of the Skin & Wound Evaluation Effective Date: 06/29/2021 revealed Type . Blister . Left Heel . In-House Acquired . New . Length 3.5 cm Width 1.9 cm Depth [MEDICATION(S)] . A review of the Treatment Administration Record 6/1/2021 - 6/30/2021 revealed Heel boots on at all times while in bed. Six times a day for Bilateral heel boots on at all times when in bed -Start Date- 06/25/2021. The intervention was not implemented until after the right heel pressure ulcer developed. A review of Focus (the resident) has and is at risk for pressure ulcer development to all bony prominence's, left heel, right heel . (the resident) was readmitted with actual impaired skin integrity of the left and right heel. Right heel Unstageable Left heel Stage 3 . Date Initiated 07/14/2021 . skin care plan appeared Resident #58 was readmitted with the bilateral pressure ulcers although did have both pressure ulcers prior to discharge on 6/29/21. A review of the Nurse Practitioner L visit note Signed Date 6/25/2021 revealed . Pressure-induced deep tissue damage of right heel: Continue daily wound care weekly wound assessments. Keep heel boots on at all times while in bed . Pressure-induced deep tissue damage of left heel. Keep the boot on at all times while in bed . Vascular Dementia without behavioral disturbance . Patient is confused at her baseline . On 8/18/21, at 2:32 PM, Unit Manager (UM) X was asked why Resident #58's pain medication was not scheduled routinely and UM X stated that they will ensure Resident #58 has pain medication prior to the wound care on their bilateral heels and that she doesn't always complain of pain. On 8/18/21, at 3:38 PM, an observation along with Nurse I and UM X of Resident #58's bilateral wound care was conducted. Resident #58 was lying on her back with bilateral heel boots on prior to wound care. Resident's entire left heel was black in color and measured approximately 3 inches by 3 inches. The pressure ulcer on the left heel was approximately 1 inch by 1 inch and had yellow slough. On 8/19/21, at 10:28 AM, Resident #58 was lying on their back in bed with bilateral heel boots on. On 8/19/21, at 1:52 PM, the Director of Nursing (DON) was interviewed regarding Resident #58's bilateral heel pressure ulcers. The DON was asked if the pressure ulcers were facility acquired and the DON stated, they are facility acquired and that the resident had orders for the boots but she will take them off at times. On 8/19/2021, at 4:00 PM, a record review of the facility provided Pressure Injury Prevention and Management Date Implemented: 1/1/2021 policy revealed The facility is committed to the prevention of avoidable pressure injuries . Avoidable means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following . define and implement interventions that are consistent with resident needs, residents goals, and professional standards of practice . Interventions for Prevention . Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk . basic or routine care interventions could include, but are not limited to: Redistribute pressure (such as repositioning, protecting and/or offloading heels . Provide appropriate, pressure-redistributing, support surfaces .

This Citation refers to Intake Numbers MI 737 and MI 5574. Based on observation, interview, and record review, the facility failed to ensure that weights were obtained and monitored timely and accurately for four residents (Resident #12, Resident #16, Resident #21, and Resident #22 ) and failed to monitor and implement interventions to prevent dehydration for one resident (Resident #12) out of five reviewed for Nutrition and Hydration. This deficient practice resulted in a significant weight loss and hospitalization for dehydration for Resident #12, and the potential for further weight loss, skin breakdown, and dehydration. Findings include: Resident #12: A review of Resident #12's closed medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed he was transferred to the hospital on [DATE] with the physician's order stating, .for orthostasis with near [MEDICAL CONDITION], dysphagia and coughing up undigested foods . A review of Resident #12's 9/23/20 Admission Minimum Data Set (MDS) assessment revealed he scored 15/15 on the Brief Interview of Mental Status (BIMS) assessment indicating intact cognition, and required the supervision of one staff member for eating. A review of Resident #12's Hydration Risk Evaluation, dated 9/18/20, revealed, .H. measure systolic blood pressure while sitting and 1 and 3 minutes after standing: No drop in pressure noted . K. Lab Values (no labs were abnormal) .k1. medications: [REDACTED] Further review of Resident #12's record revealed that he had not been weighed for the entirety of his stay at the facility. A progress note, dated 9/28/20, revealed, RD (Registered Dietitian) requesting admit (admission) wt (weight). Review of a Nutrition Data Collection/Evaluation assessment dated [DATE] revealed, .RD requesting admit ht (height)/wt. Per hospital docs (documents): ht 70 (inches), wt 242# (pounds). A review of a 10/7/20 Nurse Practitioner (NP) K note revealed, .Patient was provided subcutaneous fluids earlier this week and per patient his dizziness was improved significantly . A review of a 10/16/20 Physician L note revealed, .I have also evaluated the patient's weight and vital signs and they have been stable . A review of a 10/22/20 Nurse Practitioner (NP) K note revealed, .Apparently patient is coughing at times and coughing up undigested food . Patient has been encouraged to increase his fluid intake however due to some intermittent nausea and dysphagia he has not been very compliant . A review of Resident #12's care plans revealed no dehydration risk care plan, nor any individualized approaches to prevent dehydration. A review of Resident #12's Medication Administration Record [REDACTED]. A review of the hospital records for Resident #12 where he transferred from to the facility on [DATE] and was transferred back to on 10/22/20 revealed the following weight log: 9/12/20 108.4 kg (238.4 pounds) 9/13/20 108.4 kg (238.4 pounds) 10/22/20 90.9 kg (199.9 pounds) (-38.5 pounds in approximately one month/ -16% body weight) A review of his hospital labs prior to his admission to the facility on [DATE] revealed, . BUN (blood urea nitrogen) 24 mg/dL (normal range 6-20 mg/dL) . Creat (Creatinine) 1.1 mg/dL (normal) . A review of his labs when he returned to the hospital on [DATE] revealed, .BUN 142 *H (critical High) . Creat 7.9* H . A review of the hospital History and Physical, dated 10/22/20, revealed, .the patient explains that he rolled over in bed and began to experience a sudden onset of chest pain. Following this, the patient states that the nurses at the facility measured low blood pressures on multiple occasions . potassium level is 5.9. Due to this patient's elevated potassium initiate this patient IV [MEDICATION NAME] and insulin along with IV calcium [MEDICATION NAME] . admitted to the telemetry floor for [MEDICAL CONDITIONS] and acute kidney injury . On 2/23/21 at 4:25 p.m., an interview was conducted with RD F. When asked about Resident #12 not having any weights in the record, RD F stated, There's a total lack of getting weights. Its been a problem since Day 1. When asked about Resident #12's status during his stay, RD F reported that she had used his hospital weight in his assessment, but could provide no further information re: his nutritional or hydration status. On 2/24/21 at 1:14 a.m., NP K was asked if she had ordered any labs for Resident #22 during his stay to rule out dehydration. NP K verified that he had not had any lab work done while a Resident at the facility. On 2/24/21 at 3:19 p.m., an interview was conducted with NP K via telephone. When asked why the Resident received IV hydration on 10/6/21, NP K stated, For orthostatic [MEDICAL CONDITION]. When asked if that could be an indicator of dehydration, NP K stated, Yes, it could be. But his was related to a recent subdural hemorrhage. When asked if she had ever had any concerns that Resident #12 was dehydrated, NP K stated, No, When asked if the dizziness and nausea (that Resident #12 had experienced per the progress notes) could indicate possible dehydration, NP K stated, Yes it (dizziness/nausea) can be but his was associated with position changes. When asked why she had ordered the second round of IV hydration on 10/22/20, NP K stated, For orthostatic [MEDICAL CONDITION]. NP K was informed of Resident #12's lab results upon his transfer to the hospital on [DATE] upon which she stated, Obviously if his labs were that elevated he obviously had some dehydration. A review of the policy titled Hydration revised 10/30/2020 with a Date Implemented of 1/1/21 revealed, .1. As part of the initial assessment, the physician and staff will help define the individual's current hydration status (fluid and electrolyte balance or imbalances). a. The physician will distinguish various types of fluid and electrolyte imbalance (for example, [MEDICAL CONDITIONS], pre-renal azotemia, etc.) from true dehydration (clinically significant loss of total body water). 2. The staff, with the physician's input, will identify individuals with signs and symptoms (for example, [MEDICAL CONDITION], lethargy, increased thirst, etc.) or lab test results . 3. The physician and staff will identify individuals with a significant risk for subsequent fluid and electrolyte imbalance . 5. The physician will manage significant fluid and electrolyte imbalance, and associated risks, appropriately and in a timely manner . 8. The physician will adjust treatments based on specific information (lab results, level of consciousness, etc) relevant to that individual. Resident #21: A review of Resident #21's medical record revealed he admitted to the facility on [DATE] and was readmitted [DATE] after an eight day stay in the hospital, with [DIAGNOSES REDACTED]. A review of Resident #21's hospital History and Physical, dated 2/2/21, revealed that while in the hospital between 2/1/21 and 2/9/21 he had a PEG tube placed for decreased oral intake and failure to thrive. A review of Resident #21's 2/15/21 MDS assessment revealed he was assessed by staff to have severely impaired cognition, required total assistance of one staff member for eating, and had significant weight changes. A review of Resident #21's weight record revealed only two weights had been taken as follows: 1/28/21 88 pounds (taken 7 days after he admitted ) 2/20/21 108.8 pounds (taken 11 days after he readmitted ). On 2/23/21 at 4:25 p.m., an interview was conducted with RD F. When asked about Resident #21's weight record, RD F stated it was very difficult to get the weights for Residents on tube feeding. When asked about his high tube feeding rate, RD F stated, He's tolerating it ok as far as I know. I check the NP notes (to see if he's tolerating the formula). When asked how she could make recommendations for the tube feeding formula and rate if she doesn't have a recent weight, RD F stated, I can't really. I did increase his flushes though. When asked how often Residents were supposed to be weighed, RD F stated, On admission or readmission, weekly for four weeks, and then monthly unless we request weekly. RD F reported that due to Resident #22's poor nutritional status she had requested weekly weights but they had not been obtained. Resident #22: A review of Resident #22's medical record revealed she had admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #22's 2/1/21 MDS revealed she was assessed by staff to be severely cognitively impaired and relied on tube feeding for 100% of her needs and had experienced significant weight loss. A review of Resident #22's weight log revealed the following: 9/4/20 138.6 pounds 9/14/20 136.4 pounds 10/4/20 134.8 pounds 11/15/20 135.1 pounds 12/9/20 130.0 pounds 1/21/21 124.7 pounds 1/28/21 124.5 pounds 2/1/21 124.0 pounds 2/6/21 124.0 pounds 2/8/21 124.0 pounds 2/18/21 127.1 pounds 2/23/21 119.3 pounds On 2/23/21 at 4:25 p.m., an interview was conducted with RD F. When asked about Resident #22's bolus tube feeding RD F stated, She was on a continuous but she had issues with aspiration pneumonia so I switched her to a bolus. The nurses are not happy and want me to change it back. RD F reported that Resident #22 was on weekly weights, but that they weren't being done consistently. When asked how Resident #22 was losing weight despite being on a calorie controlled tube feeding, RD F reported that she felt that Resident #22 was not getting the correct number and schedule or bolus feedings. On 2/24/21 at 8:19 a.m., an interview was conducted with the DON who when asked about Resident #22's weight loss and her tube feeding, the DON stated, We had noticed a little while ago, after we'd watched the weight for a little that she had a loss. So we implemented an audit to make sure that the correct number of boluses were given. The DON was asked to provide the audits. On 2/24/21 at 1:05 p.m., the DON was asked for the tube feeding audits for Resident #22 and stated, I thought they were happening but they weren't. A review of the facility policy titled, Weight Assessment and Intervention with no date of review or publication revealed, The nursing staff and the Dietitian will collaborate to prevent, monitor, and intervene for undesirable weight loss for our residents. The nursing staff will measure resident weights on admission (and re-admission) and weekly for four weeks thereafter . Weights will be recorded in the individual's medical record. Any weight change of greater than or less than 5 pounds since the prior weight will be retaken within 24 hours for confirmation with licensed nurse confirming the reweigh . Resident #16: Resident #16 was admitted on [DATE] and had [DIAGNOSES REDACTED]. A review of Resident #16's most recent MDS assessment, dated 11/27/2020, revealed Resident #16 was cognitively intact, needed a one-person assistance with eating and was at risk for pressure injuries. A review of Resident #16's weight measurements documented in the electronic health record (EHR), revealed an initial weight of 170 pounds was recorded on 9/8/20 at 10:44 p.m. The next documented weight was 134.1 pounds. recorded on 11/19/20 at 1:10 p.m. The difference between the initial weight recorded on 9/8/20 and the next weight recorded on 11/19/20 showed a weight loss of 35.9 pounds. which was a 21% loss over the period of 10.5 weeks. Further review of the weight record revealed the DON struck out (crossed out) the recorded weight of 170 pounds on 11/20/20 at 8:53 a.m., and documented, Incorrect Documentation. A review of Resident #16's EHR revealed the resident had been transferred to the hospital on [DATE]. A review of the hospital, History & Physical, signed 9/28/20 at 5:01 p.m., revealed the following, in part: Current weight: 81.64 kg (179.9 pounds), Date/Time: 9/28/20 11:45 a.m. The resident was readmitted to the facility on [DATE]. Further review of Resident #16's EHR revealed no weight measurement had been conducted upon the Resident's return from the hospital on [DATE]. In an interview on 2/24/21 at 4:21 p.m., the DON reported weights were at times struck out of the record as incorrect when the weight seemed disproportionate with subsequent weight measurements. The DON reported weights were only documented as incorrect after a follow-up weight was taken the same day or soon after, to confirm the first weight was incorrect. When asked if it was appropriate for weights to be documented as incorrect when more than 10 weeks had passed between weight measurements, the DON reported it would not be acceptable to cross off the weight without a follow-up weight measured at the time the weight was crossed out and documented as incorrect.

Based on observation, interview, and record review, the facility failed to provide quality care related to hospice services, change of condition, assessment, and skin care for nine residents (#88, #1, #387, #28, #17, #14, #52, #59 and #51) of 19 residents reviewed for quality of care and services resulting in unmet care needs, a lack of coordination of hospice care, prevention and appropriate wound assessment/care. Resident #1: According to the Admission Record, printed on [DATE], Resident #1 was a [AGE] year old male re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 08:51 AM during the medication administration task, in the presence of Registered Nurse (RN) L, Resident #1 asked if he could remove the bandaid on the back of his left hand and did so without waiting for a reponse. The bandaid had no date on it. The skin under the bandaid had no open or scabbed area. Within a few minutes, RN L turned her attention to a foam dressing on Resident #1's upper left chest. The foam dressing was loose on the outer edge and had dry brownish-red drainage on it. The date was not clearly visible, and RN L said she thought the date was ,[DATE] and stated, it is from the hospital. The split gauze dressing around the percutaneous gastrostomy tube (PEG) had no date on it. It was stuck to the skin of Resident #1's abdomen and when removed, it had dry brownish colored drainage. None of these areas or the presence of the bandaid or dressings were noted on the Admission Skin Assessment, dated [DATE]. According to the facility policy for Pressure Ulcers/Pressure Injury Prevention and Treatment-Clinical Protocol, dated (MONTH) 28, (YEAR), the initial screen would be completed with the admission skin assessment and all skin related issues are measured and documented. Resident #1 had no treatment orders for any skin conditions until [DATE] when an order was initiated to cleanse the area around the PEG tube with soap and water, rinse and pat dry then apply a split 4 by 4. Change daily and as needed. Resident #17: According to the Admission Record, printed on [DATE], Resident #17 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Record, printed on [DATE], indicated that Resident #17 received hospice services. Resident #17 had a care plan in place for assistance with activities of daily living and mobility related to weakness and end stage disease process for which he was receiving hospice services, initiated on [DATE]. The goal was for Resident #17 to be clean, dry and dressed appropriately daily thru next review. The intervention included visits two times a week by the Hospice aids for personal care and companionship. The care plan did not specify which two days the hospice aide would visit and provide care and companionship. The care plan did not include visits by the hospice nurse or social worker. None of the interventions for the care plan designated for pain, skin integrity, falls, or communication involved any interventions by the hospice staff. On [DATE] at 08:24 AM the hospice nurse, staff T stated that she came two times a week and the aid from hospice came two times a week. On [DATE] at 08:11 AM the unit manager , Registered Nurse (RN) G, stated the hospice communication was in a separate book at the end of the hall, off the dining room. She stated the hospice care plan was in the binder. She also said doesn't know the hospice schedule, they just pop in. Inside the binder was a separate care plan for hospice services, dated as starting [DATE]. There was no indication of how often or on what days the hospice staff would visit. The hospice care plan was last updated on [DATE]. One of the interventions listed was for Foley Catheter Management. Resident #17 had no indwelling Foley catheter on the dates of the survey. During an interview with the RN unit manager G on [DATE] at 08:11 AM, she stated that the indwelling catheter had been removed quite some time ago. During an interview with the Social Worker, Staff M on [DATE] at 02:28 PM, she stated that the hospice staff did not attend the care conference for Resident #17. The facility policy for Hospice Program, dated [DATE], included a directive for a coordinated plan of care between the facility, hospice agency and resident/family to be developed and updated as necessary to reflect the resident's current status. Resident #28: Resident #28 was interviewed on [DATE] at 10:40 AM and stated, I have sores on my butt. I have to turn and twist a lot to remove the pressure. I have one right at my anus and one where my leg begins. I have sores on my feet too. The left foot was observed to have multiple elevated, dried scabbed areas on top, sides and bottom. The resident said, The Podiatrist wants me to have a boot on each foot. Both have Velcro and they stick together and then I can't move my feet. They don't change my dressings every day. They are supposed to. They say I didn't ask. The resident was observed to have a rash on his chest, arms and legs that itched. He said his back itched also. An interview with Resident #28 on [DATE] at 9:53 AM provided, About 3:00 AM they come in and clean it (wound on coccyx) and put Dermaseptin on (an ointment containing menthol). It hurts and I want to ask the NP (Nurse Practitioner) about a different treatment. The last skin assessment was dated [DATE] and does not mention a wound on the coccyx or buttocks. The resident was asked if the nurses performed weekly skin checks and stated, No they are not done weekly. Unless I tell them, I need them because it hurts, they don't look at it. On [DATE] at 12:25 PM, during an interview with NP I, she was asked about the resident's rash, I sent him to dermatology. They have been treating it. His legs looked really good and then they went right back to being swollen, discolored and he is digging at them. The NP was asked about the pressure ulcer on Resident #28's coccyx and complaints of pain, I want to send him to the wound clinic. The NP was further asked about the treatment of [REDACTED]. That is not appropriate. He needs something different. On [DATE] at 1:50 PM, the resident's wounds were observed with Assistant Director of Nursing H and Nurse L; wounds were observed on the buttocks, groin, coccyx and feet. Red, raw open areas were present on the inner buttocks, near the anus, scrotum and coccyx. The surrounding areas were bright red and inflamed. The nurses said the resident was receiving a treatment of [REDACTED]. A review of the orders and Treatment Administration Record (TAR) for (MONTH) 2019 for Resident #387 revealed an order dated [DATE] for Dermaseptin Apply every shift and prn (as needed) to Coccyx . A dressing to the right lower leg ([DATE]-[DATE]) and Right heel ([DATE]-[DATE]) were discontinued. an order for [REDACTED]. One time only for appointment in 30 days. Dated [DATE]. The TAR was signed as initiated on [DATE] with no further documentation. The (MONTH) 2019 TAR contained no documentation that the Unna Boot was removed or discontinued. An order dated [DATE] for Dermaseptin to the coccyx continued. A treatment dated [DATE]-[DATE] for a [MEDICATION NAME] dressing to the coccyx every 3 days for a skin tear, was applied twice with no additional documentation. A treatment for [REDACTED]. A review of a Skin progress note for Resident #387 dated [DATE] at 11:55 AM, mentioned bilateral vascular heel wounds. There was no mention of open areas on the coccyx, buttocks and scrotum or a rash. A progress note dated [DATE] and written by NP I said the resident had blisters on the right lower leg and a weeping rash. A review of the resident's Skin Care Plan titled At risk for pressure ulcer development and skin breakdown . date initiated [DATE] and revision [DATE] dated with Interventions last updated on [DATE]. There was no mention of open areas present on multiple areas, treatment or measures to prevent further breakdown. Another Skin Care Plan titled, The resident is being treated for [REDACTED]. There were 3 interventions Administer antibiotics; Maintain universal precautions when providing resident care; Monitor temperature/pulse BID (twice day), all dated [DATE]. There was no mention of a rash on other areas of the body. On [DATE] at 1:00 PM, the Director of Nursing (DON) was interviewed and provided team notes for the resident dated [DATE] related to wounds on the bilateral heels. There was no mention of coccyx wounds. She provided wound reports for other residents, but this resident did not have a report related to the open areas on the coccyx, buttocks and scrotum. Resident #88: A record review of the Face Sheet and electronic medical record (EMR) indicated Resident #88 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS assessment dated [DATE] revealed the resident had a BIMS score of ,[DATE] with moderate cognitive decline and needed assistance with all care including eating and needed a mechanically altered diet. The resident died on [DATE]. A review of a Late Entry progress note dated [DATE] at 8:54 AM, written by NP I provided, . had left [MEDICAL CONDITION] and repair, his staples the other day were noted to be mildly red . Did follow up today the patient is in his room laying in bed . Did assess the wound area and it does look more [MEDICAL CONDITION] .It does appear that he may have removed a staple . or possibly these fell out on their own. But 2 staples are missing .the area itself is [DIAGNOSES REDACTED]tous (red), [MEDICAL CONDITION] and it is warm . A review of a progress note written by the NP on [DATE] at 7:57 AM, . he does have staples noted to the left hip. There is some mild redness around the staples. The patient does have [MEDICAL CONDITION] . he does have a couple temperatures that were 99 . A review of a nurses admission progress note dated [DATE] revealed the resident had 23 staples in the left hip surgical wound. This was the only documentation of how many staples were in the wound. A review of Resident #88's medical record revealed there were no Skin assessments and the Treatment Administration Record (TAR) for (MONTH) 2019 was blank. The nursing Skilled Assessments did not address the resident's hip incision or how many staples were present daily. There was no documentation of nursing assessment or monitoring of the resident's surgical incision. A review of the physician orders indicated there was no order to assess and monitor the resident's surgical wound. A review of Resident #88's Care Plan for Skin titled, At risk for pressure ulcer development and skin breakdown related to decreased mobility status secondary to recent fall and fracture left femur . dated [DATE] and revised [DATE] (the resident died [DATE]). With Intervention Weekly skin assessment by licensed nurse, date initiated [DATE]. There was no mention of the incision or how many staples were present. Another Skin Care Plan titled, Actual impairment to skin integrity . dated [DATE] does not mention observing for missing staples, how many staples were present or when they would be removed. Resident #387: A record review of the Face Sheet indicated Resident #387 was initially admitted to the facility on admitted on [DATE] with Diagnoses: [REDACTED]. On [DATE] at 9:45 AM, an interview with the resident provided, They found an area. It hurts. They haven't done much more than that with it. They might have put a bandage on it. The bed sore hurts. That is the only thing wrong right now. On [DATE] at 12:27 PM, an interview with NP I related to Resident #387's newly identified wound on [DATE] revealed, I didn't know that. No one told me. A review of the Skin Notes revealed there were 2: [DATE] and [DATE]. The note on [DATE] identified 2 wounds (skin tears) on the resident's hands. There was no mention of the coccyx/sacral area being assessed. The note dated [DATE] said, Sacrum, 1.8 x 1.2 x0.5 cm. There was no further description of the wound. A review of the facility Wound Care notes (Gentell) received from the Director of Nursing, did not identify any additional documentation for Resident #387's wound. A review of the physician orders indicated an order for [REDACTED]. On [DATE] at 1:30 PM, during a wound observation with Nurse MM and Certified Nursing Assistant CNA NN, there was a dressing dated [DATE] on the sacrum with an open area, stage 2, Nurse MM said, I think the dressing is as needed. I didn't have it on my assignment sheet. The dressing order was reviewed with the nurse and it said to administer every 3 days and prn (as needed). The resident said, It gets to be awfully painful at night. The Resident asked his wife to bring him Boost (nutritional supplement) because he didn't get anything but plain broth for lunch. The resident said he requested Chicken Noodle Soup for lunch, but the facility told him they didn't have any, so he ordered the Chicken Chili that was on the menu and was told they were out of it. The resident received only broth for lunch. He did not receive any nutrients to aid in wound healing with his meal. The resident said, She'll have to buy me lunch it was pathetic. A review of the Skin Care Plan for Resident #387 revealed, At risk for pressure ulcer development . dated [DATE]. There was no mention of the identified pressure ulcer on the coccyx. Weekly skin assessments were not added until [DATE] during the survey. On [DATE] at 1:05 PM, during an interview with the DON related to the lack of documentation of the resident's sacral wound, the DON provided a copy of a skin assessment dated [DATE] that showed measurements but no description of the wound 1.8x 1.2x 0.5 cm (sacrum). A review of the facility policy for Skin Care, titled Pressure Ulcers/Pressure Injury Prevention and Treatment-Clinical Protocol, dated (MONTH) 28, (YEAR) provided, Based on the comprehensive assessment of a resident, a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers . and a resident with pressure ulcers receives necessary care and services . The plan of care for prevention and/or treatment of [REDACTED]. management . With each dressing change, or at least weekly .At a minimum, documentation should include the date observed, location, staging, size (perpendicular measurements of the greatest extent of length and width of the PU/PI), depth; and the presence, location and extent of any undermining or tunneling/sinus tract; exudate, if present; type (such as purulent/serous), color, odor, and approximate amount; Pain, if present: nature and frequency (e.g., whether episodic or continuous); Wound bed: Color and type of tissue/character including evidence of healing (e.g., granulation tissue), or necrosis (slough or eschar); and description of the wound edges and surrounding tissue (e.g., rolled edges, redness, hardness/induration, maceration) as appropriate . Resident #14: During initial tour on [DATE] at approximately 10:45 AM, Resident #14 was observed sleeping in her room. She appeared peacefully and without any distress. During record review on [DATE] at 2:32 PM, it was found Resident #14 was transferred to the emergency roiagnom on [DATE] due to her being Unresponsive, as listed on the Transfer Form-Unplanned. There was no other documentation located regarding the resident's unresponsiveness on this day. On [DATE] at 9:30 AM, a review was completed of Resident #14's medical record and it revealed the resident was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review was completed of Resident #14's medical records and it revealed the following: History and Physical (Physician) from Acute Care Hospital Dated [DATE] Problem 1:[MEDICAL CONDITION]ly ,[DATE] UTI (Urinary Tract Infection) . Admit to MICU under (Physician) .UA (urinalysis): large leukocytosis and bacteria .Problem 2: acute [MEDICAL CONDITION]ly ,[DATE] meds vs hypoperfusion [MEDICAL CONDITION] vs other .Problem 3: VDRF (Ventilator-Dependent [MEDICAL CONDITION]) ,[DATE] acute [MEDICAL CONDITION] .Plan 3: VDRF for airway protection .intubated on mechanical ventilation . Discharge Summary Dated [DATE] .initially presented to the ED (Emergency Department) on ,[DATE] from (Nursing Home) with a chief complaint of AMS and [MEDICAL CONDITION]. Patient was found unresponsive in the ER and intubated subsequently. While in the field, patient was given 3 doses of [MEDICATION NAME] without effect before transfer changes pacing was started. Patient was admitted to the ICU for AMS, VDRF, likely secondary to urosepsis .Patient was intubated for approximately 6 days before she was successfully weaned off on ,[DATE] . On [DATE] at 3:20 PM, NP (Nurse Practitioner) I reported Resident #14 is fragile and on the day in question it was a quick decline and added there was no time to complete labs and other consults to figure out what was ailing the resident. The concern about the lack of documentation related to this incident was explained and she expressed understanding of this. On [DATE] at 3:48 PM, an interview was conducted with the DON (Director of Nursing). The DON explained the Nurse Practitioner saw the resident the day previous and her leg was [MEDICAL CONDITION] but Resident #14 did have any other complaints. The next day staff walked in and found her unresponsive. It was explained to the DON there was no further documentation, other than the transfer summary that had one word for an explanation. The DON expressed understanding and the need for more documentation for incidents of this nature. On [DATE] at 11:15 AM, the DON reported both nurses that were involved in this incident are no longer employed at the facility. On [DATE] at 11:20 am, Unit Manager D reported on the day Resident #14 was sent out to the emergency room she was in the building. The resident's nurse reported to her Resident #14 was lethargic, unresponsive, her tongue was extended outside her mouth and she was drooling. Unit Manager D reported she went into Resident #14's room and observed the same thing as reported by the nurse. The Physician was contacted, and the resident was sent to the emergency room . Unit Manager D was queried if she interviewed the nursing staff on when the last time, they saw the resident and if she completed a timeline of the events that lead up to Resident #14's decline. The manager reported she did not interview staff or complete a timeline as she trust her staff will alert her when there is decline with a resident. She was further queried on why the nurse did not document properly on the incident. Unit Manager D explained she assumed since it was around shift change that there was confusion on who was responsible for the documentation. The Unit Manager was asked who would be responsible for documentation in these situations. She reported it would be the nurse assigned to care for the resident when the incident occurred. The Unit Manager was asked when she found out the documentation was not in place. She reported when this writer initially alerted her to their being no documentation, is when she became aware. Resident #52: During initial tour on [DATE] at 10:54 AM, Resident #52 was observed resting in bed. The resident reported she has calcium [MEDICAL CONDITION] on her right fingers, lower right abdomen, underneath her right breast, on the left upper abdomen and some larger ones that are busted open and have dressings on them. On the bottom of Resident #52's feet, back of her calf's, right knee and her right hip area there is a yellow/brownish, raised, flaky and rough areas on her skin. On [DATE] at approximately 11:15 AM, a review was completed of Resident #52's medical record and it revealed the resident is a [AGE] year old Caucasian female, whom was most recently admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review was completed of the resident's medical records and it revealed the following: Care Plan Focus: (Resident #52) has chronic wounds s/[MEDICAL CONDITION] infection, infected hip with hx of joint removal, debridement, and multiple areas of skin calcinosis cutis. Interventions: .weekly skin assessments . Focus: The resident has potential for impairment to skin integrity r/t immobility. Interventions: .Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Skin Assessments [DATE] - List the following for existing abnormal skin areas: o .right upper and lower abdomen calcification o calcification of left upper back calcification of left flank. o surgical wound . [DATE] - List the following for existing abnormal skin areas: o .Left trochanter (hip) wound o abdomen calcification o Other (specify) left upper back calcification o Other (specify) flank calcification wound . [DATE] - List the following for existing abnormal skin areas: o .Abdomen calcifications. o Left trochanter .wound o .flank calcification o .left upper back calcification . [DATE] - List the following for existing abnormal skin areas: o . Right trochanter (hip) .2cm diameter open area with .5 cm depth. o Abdomen multiple open areas on abdomen. [DATE] - List the following for existing abnormal skin areas: o .Right scapula-open o Right trochanter (hip)-open o Other (specify)- LUQ open o Other (specify)- RUQ open o Left toe (s)- L top foot - redness o Left lower leg (front)- redness [DATE] - List the following for existing abnormal skin areas: o .Left trochanter (hip) 1cm x1cm with .5cm depth. o Abdomen abdonin llq open areas o Abdomen below abdominal apron reddened [DATE] - List the following for existing abnormal skin areas: o .Right trochanter (hip) open areas o Abdomen redness under abdominal fold [MEDICATION NAME] applied per ordr [DATE] - List the following for existing abnormal skin areas: o .Vertebrae (upper-mid) calcinosis cutis wounds, treatment in place, dressing intact. o Abdomen RLQ (right lower quadrant) and RUQ (right upper quadrant) calcinosis cutis wounds, treatment in place, dressing intact. o Right trochanter (hip) small wound, treatment in place, dressing intact. [DATE] - List the following for existing abnormal skin areas: o .Right trochanter (hip) small open areas o Abdomen RLQ and RUQ calcinosis cutis wounds, treatment in place, dressing intact. o Vertebrae (upper-mid) Calcinosis cutis wound, treatment in place, dressing intact. [DATE] - List the following for existing abnormal skin areas: o .Right trochanter (hip) Healing surgical wound, treatment in place. o Abdomen RLQ and RUQ calcinosis cutis wounds, treatment in place. o Vertebrae (upper-mid) Calcinosis cutis wound, treatment in place. [DATE] - List the following for existing abnormal skin areas: o .Left trochanter (hip)-healing surgical wound, treatment in place. o Abdomen- RUQ & RLQ abdomen, calcinosis cutis wounds; treatment in place. o Vertebrae (upper-mid)-Left mid back, calcinosis cutis wounds, treatment in place. o Other (specify)-Left flank near groin fold; calcinosis cutis wounds; treatment in place. [DATE] - List the following for existing abnormal skin areas: o Other (specify)- right upper abdomen fold treatment in place. o Other (specify)- left and right flank treatment in place. From review of Resident #52's skin assessments from (MONTH) 2019- (MONTH) 2019, it was found there was no skin conditions listed regarding the discolored, raised and rough skin areas on the resident's feet, calf's, knees and hip/leg area. On [DATE] at 4:50 PM, this writer and Unit Manager D observed the discoloration on Resident #14's body. The Manager reported she tried to wash it off but it would not come off. The Unit Manager could not provide a [DIAGNOSES REDACTED]. The Unit Manager was made aware there was no documentation located regarding this being apart of Resident #52's disease process. Documentation was requested regarding this. On [DATE] at 10:20 AM, CNA (Certified Nursing Assistant) X reported Resident #52 is provided a bed bath due to her increased anxiety regarding showering. The CNA reported the resident has had the raised chestnut colored skin issues for at least a year. She reported she has alerted the nurses on many occasions, but they do not have a consistent nurse on their unit and is not aware if it was ever addressed. On [DATE] at 12:08 PM, an interview was conducted with NP I who reported the resident has had this skin condition for a long time and it has been addressed at the wound clinic. She continued the wound clinic is not concerned about it and explained it is the thickening and dryness of her skin. It was explained to the NP that the nursing staff has no documentation and/or assessments of this. The NP expressed understanding of the need for documentation. Resident #51: On [DATE] at 10:20 AM, Resident #51 was observed sitting at a table in the Dining Room and had a large bandage on the top of her left hand that was dated for [DATE]. The Resident was asked why she had on the bandage and reported she hit it on a piece of metal while she was out in her yard. A large amount blood was observed polling underneath the bandage. Nurse AA reported the resident self-propels herself around the facility and does not give herself enough room to get through the doorways and continues to bruise that same hand. Nurse AA was asked if there were any interventions in place to protect Resident #51's hands given she self-propels all day. The nurse stated, there are no interventions in place for this. On [DATE] at approximately 2:00 PM, review was completed of Resident #51's medical record and it revealed the resident was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the residents revealed the following: Care Plan: Focus: The resident has potential impairment to skin integrity due to Fragile skin. Goal: The resident will be free from injury to skin. Interventions: .W/C (wheelchair)gloves on (Resident #51) when she is in chair propelling herself about the facility to ensure palmar skin integrity. Revision on [DATE]. On [DATE] at 8:20 AM, Resident #51 was observed in the common area self-propelling herself around the facility. The bandage was still in place on her left hand and the palm of both of her hands were encrusted with a black substance and what appeared to be abrasions (where her palms meet the wheelchair wheels). The resident did not have on geri-sleeves for protection. On [DATE] at 4:52 PM, an interview was conducted with Nurse Z and the nurse reported the resident self-propels herself around the facility and she frequently hits her hand on the edge of the wall as she does not provide herself with enough room to maneuver. Nurse Z assessed Resident #51's hands and there was still an imbedded black, matted substance to both of her palms that was according to Nurse Z possibly callous. Nurse Z was asked if there were any interventions in place to protect the resident's hands from skin tares, wheel dirtiness and abrasions/callouses and the nurse reported stated no. Nurse Z took the resident and washed her hands and reported they located geri-sleeves to protect the resident's hand and would contact the Physician and the resident's daughter for an order and consent. On [DATE] at 9:56 AM, Resident #51 was in her room and her palms were once again observed to be free from any protective sleeve and both palms had the same black, matted substance on them with abrasions/callouses. Review was then completed of the Resident's Physician's orders and the following order was located, w/c gloves on while res in rolling self in w/c, start date pf [DATE] at 22:00. On [DATE] at 11:58 AM, an interview was conducted with CNA X regarding care planned interventions for geri-sleeves for Resident #51. The CNA reported they were not aware of any intervention of this nature. This writer and the CNA reviewed Resident #51's Kardex on the Kiosk and it revealed that on [DATE] an item was added that stated, (Resident #51) is able to propel herself about the facility in her w/c. Utilize and encourage w/c gloves when self-propelling to ensure palmar skin integrity. Lodger often refuses to wear gloves. states they get in my way. The CNA reported this was a new intervention that was not previously in place. On [DATE] at 11:00 AM, a review was completed of the facility policy entitled, Charting and Documentation, revised ,[DATE], the policy revealed, .All incidents, accidents, or changes in the resident conditions must be recorded .Documentation of procedures and treatment shall include care-specific details and shall include as a minimum: .the assessment date and/or any unusual findings obtained during the procedure/treatment . Pertinent Charting may be completed for ease of tracking specific events/monitoring. Pertinent Charting categories include but are not limited to; New or changes to behaviors a Falls/accidents b New or change in incontinence c Infection signs/symptoms / antibiotic use d Nutrition/hydration e Pain f Restraints g New or change in skin areas . On [DATE] at 11:10 AM, a review was completed of the facility policy entitled, Pressure Ulcers/Pressure Injury Prevention and Treatment-Clinical Protocol revised (MONTH) 28, (YEAR). The policy revealed the following, .complete head to toe skin assessment, document in the medical record b. Notify Physician; g. update plan of care to reflect any new risks, goals and interventions . Resident #59: According to Admission Record printed [DATE], Resident #59 (TRUNCATED)

Based on observation, interview, and record review the facility failed to ensure/maintain the safety of 4 residents (#8, #59, #78 and #387) out of 7 residents reviewed for accidents resulting in serious injuries (re-fractured humerus, [MEDICAL CONDITION] and pain post fall for Resident #8), bruising and skin tears (#387), injury post fall (#78) and the potential [MEDICAL CONDITION] elopement (#58). Findings include: Resident #8 According to Admission Record printed [DATE], Resident #8 was a [AGE] year-old female admitted to the facility on [DATE] (initial admission date of [DATE]) with [DIAGNOSES REDACTED]. According to Minimum Data Set ((MDS) dated [DATE], Resident #8's cognition assessment was scored a zero indicating severe cognitive impairment and required assistance with Activities of Daily Living (ADL) care to include transfers. During an interview with Resident #8's daughter on [DATE] at 1:00 PM she stated My only concern is with my mother's falls. The last one she split her head open. Resident #8's daughter stated that resident went to the hospital and had stitches. According to Fall Investigation Report dated [DATE], Resident #8 fell in the dining room at 3:15 PM on [DATE]. A brief description of the fall concluded that Resident #8 was lying on her side (left) side with open laceration to (left) forehead 2 (centimeters) x 1 (centimeters) open area . Under the section titled Injury Type, head injury and laceration were checked. Under the section titled Action Taken, sent to the hospital was checked. The report explained that Resident #8 was propelling self wildly backwards in (wheelchair). Very agitated with staff - very non-compliant with care. The report said that Resident #8 was alone and unattended at the time of the fall. The report said the last time Resident #8 was toileted was 3:30 PM, 15 minutes after the fall and she was wet The report concluded that the root cause appeared to be '(Resident) frequently attempts to get up and attempt to walk and with poor balance, (resident) frequently will fall. The initial intervention to prevent future falls included was continually encouraging and reminding to stay seated in her (wheelchair). The report described Resident #8's usual mental status and mental status prior to the fall as confused-disoriented and her usual psychological status and mental status prior to the fall as agitated and not listening to any staff members. According to Statement of Witness included within the Fall Investigation Report dated [DATE], CNA wrote, (Resident #8) was sitting in her wheelchair at the end of the counter in the dining hall. Just a few minutes before the incident I noticed (Resident #8) pushing herself backwards into the walking area. I went to her and locked her wheelchair so she couldn't push backwards into other residents I did this twice, both times she unlocked the chair (on one side) then started tipping herself backwards in the chair. After she started doing that I reached down to make sure her wheels were unlocked and she grabbed onto my wrist angrily so I got my arm back and walked away to find another resident who was out in the hallway .I brought that resident back into the dining area and that is when I was told (Resident #8) was on the floor . According to another Statement of Witness included within the Fall Investigation Report dated [DATE], Resident #53 wrote, she was standing up across the room and she looked like she tripped and I saw her head go down and her feet went up . According to Pertinent Charting- Falls progress note dated [DATE] at 03:28 AM, Resident returned from the hospital at 2200. Has an area with three sutures and approximately 2 X 3 (centimeter) on left side of forehead.Per hospital report she has re fractured her left arm. Placed in sling provided by the hospital . According to (Emergency Department) Discharge Summary dated [DATE], Resident #8 was diagnosed with [REDACTED]. The chief complaint for Resident #8's visit to the emergency department on [DATE] was (left) forehead puncture wound, fall from standing . Additional history of present illness stated that Resident #8 was also complaining of pain to the left arm and shoulder region. The physical exam documented, patient has a wound to the left lateral mid forehead. It starts more like a centralized puncture with loss of skin, with stellate splits in the skin outward. You can see down to the bone in the center portion which is approximately 4 millimeters in diameter. The stellate legs of the laceration are maybe 8 (millimeter) in length. The summary explained that Resident #8's daughter wanted the emergency department to attempt to close the wound, explained to her that there were no edges to bring together, she had loss of skin, and we would be approximating areas of the skin that normally would not be put together. The discharge summary also included x-ray results of the left shoulder/humerus results that found old fracture deformity of the left humeral head with findings suspicious for superimposed acute refracture [MEDICATION NAME] through the region of the surgical neck. According to Resident #8's fall risk assessment history, she fell [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE], a total of seven times in the past one year. Review was done of Fall Risk assessment for Resident #8 dated [DATE], documented under History of Falls as ''1 to 2 falls'' during the last 90 days and checked ''Yes'' to question of: ''periods of altered perception, episodes of disorganized speech, periods of restlessness, mental function varies over the day, and wanders, abusive and resists care.''' Under ''Mobility'' documented confined to chair. Review of Resident #8''s care plan revealed Resident #8 The resident needs activities of daily living and mobility assistance related to impaired cognition, recent falls, weakness and pain (initiated [DATE], revised [DATE]). Resident #8's fall care plan focus read, (Resident #8) is at risk for falls related to: Confusion, unable to make needs known, impulsive, discomfort, history of falls, she likes to sit/lay on the floor with her feet elevated, and will hug side of the bed (initiated [DATE], revised [DATE]). Interventions for Resident #8's fall care plan included, Activities and CNA to provide floor time as resident becomes restless and/or attempting to get out of bed (initiated [DATE], revised [DATE]), Determine causative factors of fall and resolve or minimize (initiated [DATE]), Provide for activities of interest (initiated [DATE]), Provide for activities of daily living such as incontinence care, transfers, ambulation, as written in the activities of daily living care plan (initiated [DATE]) and Staff to ambulate (Resident #8) when (resident) appears anxious/fidgety (initiated [DATE]). Review of Resident #8's care plan also revealed a care plan focus that read, The resident has/is at risk for acute pain r/t history of fractures of (left) humerus and pain in left shoulder, left hip and right knee (initiated [DATE], revised [DATE]). Resident #8's ambulation care plan focus states, (Resident #8) would benefit from restorative ambulation . The goal for this care plan was minimize anticipated decline in ambulation, and identify new goals and interventions as decline occurs (initiated [DATE], revised [DATE]). An intervention included in Resident #8's ambulation care plan was to Ambulate up to 100 ft with hand held assistance up to 3 times daily as tolerated. Review of ''Falls-Clinical Protocol'' dated ,[DATE], documented ''As part of initial and ongoing assessment, the staff will help identify individuals with a history of falls and risk factors for subsequent falling. This will be accomplished by the following task: The Fall Risk Assessment is completed upon admission, quarterly, and with significant change in status. Interventions should be developed and implemented per assessed needs. Interventions for direct care givers should be placed on the Kardex (CNA Care guide), or similar format and updated with changes. If the individual continues to fall, the Interdisciplinary Team should re-evaluate the situation and consider other possible reasons for the resident falling besides those that have already been identified and reevaluate the continued relevance of current interventions.'' An interview was conducted with Certified Nursing Assistant ''FF'' on [DATE] at 2:36 PM, related to the incident on [DATE]. CNA ''FF'' was asked if she was familiar with Resident #8 she stated Yes. CNA FF was asked what interventions she follows to prevent Resident #8 from falling, CNA FF explained that Resident #8 stays in bed a lot so low bed and call light and floor mat. When asked if Resident #8 receives floor time according to her care plan CNA FF stated I have never done the floor time with her. The floor is gross, she spills a lot. When asked about interventions followed on [DATE] when Resident #8 fell and injured her head and shoulder, CNA FF stated, When you put her to a counter she pushes back. The first shift CNA put her at the counter. An interview was conducted with Certified Nursing Assistant ''HH'' on [DATE] at 1:24 PM, related to the incident on [DATE]. CNA ''HH'' was asked if she was familiar with Resident #8. CNA HH stated that she is regularly assigned to care for Resident #8 on day shift. CNA HH explained that Resident #8 does not like to be left alone in her room. CNA HH denied ever using care planned intervention of planned floor time and explained that she did not believe that Resident #8 liked to be on the floor. CNA HH stated she likes to be out of her room and kept busy and I try to walk with her if I can. An interview was conducted with The Director of Nursing (DON) on [DATE], related to Resident #8''s fall on [DATE]. The DON explained that Resident #8's daughter and the management team initiated the intervention for floor time after Resident #8's daughter told them that Resident #8 like to lay on the floor with her feet up or on the couch when she was younger at home. When asked if staff implemented that intervention the DON was unsure. Resident #59 According to Admission Record printed [DATE], Resident #59 was a [AGE] year-old female readmitted to the facility [DATE] with [DIAGNOSES REDACTED]. Resident #59 was recently hospitalized for [REDACTED]. Risk for Hot Liquid Injury During an observation on [DATE] at 2:30 PM and [DATE] at 09:22 AM and [DATE] at 1:51 PM Resident #59 was observed wandering on the short-term side of the building with liquids spilled on her shirt and pants. Review of Resident #59's medical record revealed she was last assessed for the use of hot liquids on [DATE], over one year ago. Review of progress note dated [DATE] revealed Resident noted to have cold coffee spilled on her shirt and top of pants No other progress notes related to hot liquids, spills or skin conditions were in Resident #59's medical record at the time of survey. Review of Resident #59's care plan focus area of At risk for injury (related to) hot liquids secondary to decreased cognition (Initiated: [DATE], Revised [DATE]). The goal for the hot liquids focus area for Resident #59 was to Reduce risk of serious injury in the event of accidental spillage (Revised [DATE]). [DATE] 02:38 PM during an interview with the Director of Nursing (DON), she explained she thought that hot liquid assessments should be done quarterly but she would check the policy. According to facility policy Hot Liquids/Foods (reviewed ,[DATE]), Hot liquid assessments will be completed on admission, quarterly and with acute change of condition. Risk for Elopement Resident #59 was observed on three consecutive days ([DATE] at 2:30 PM, [DATE] 01:51 PM and [DATE]) of survey wandering from the long-term side of the building where her room was located to the short-term side of the building. Review of Resident #59's most recent MDS Resident Assessment and Care Screening, dated [DATE], revealed Resident #59 wandered ,[DATE] days during the time the assessment took place. A care plan for Resident #59's assessed behavior was not implemented to reflect this most recent assessment. Review of Resident #59's care plan revealed a care planned focus area that detailed, (Resident #59) is an elopement risk/a wanderer/wants to go home r/t dementia dx, history of attempts to leave facility unattended, impaired safety awareness & (Resident #59) wanders aimlessly. (Resident #59) also pushes the handicap button at the front door to get the door open (initiated [DATE], resolved [DATE]). This focus area and the interventions associated with it were resolved on [DATE] indicating the Resident #59 is no longer an elopement risk/a wanderer. On [DATE] at 01:52 PM during an interview with Assistant Director of Nursing (ADON) D she stated, Yes, she (Resident #59) wanders down to (the café) or short term, everyone knows where she belongs. If we are doing an activity or something, they will bring her back. On [DATE] at 01:53 PM during an interview with Certified Nursing Assistant (CNA) V she stated, (Resident#59) wanders sometimes and sometimes she doesn't. It depends on the day. It's not a new behavior. She has always wandered. When I have her, I try to redirect her. She has a one-track mind so it can be hard. we try to give her something to keep her busy and comfortable. On [DATE] at 02:38 PM during an interview with DON, she confirmed she was aware of Resident #59's wandering behavior. The DON stated she was unaware of Resident #59's history of elopement attempts outlined in the resolved care plan. The DON said she is unsure why Resident #59's elopement care plan was resolved. According to facility policy titled, Unsafe Wandering & Elopement Prevention Protocol . (revised ,[DATE]), stated, Every effort will be made to prevent unsafe wandering and elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement .1. All residents who are at risk for harm because of unsafe wandering will be assessed by the interdisciplinary care planning team. 2. The resident's current MDS will be reviewed to determine what changes have occurred that would trigger elopement episodes. 3. The resident's care plan will be modified to indicate the resident is at risk for elopement episodes. Staff will be informed at shift change of the modifications to the resident's care plan. 4. Interventions for unsafe wandering and elopement attempts will be entered onto the resident's care plan and medical record . Resident #78 A review of the Face Sheet and MDS assessment indicated the resident was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS dated [DATE] indicated the Resident had full cognitive abilities with a BIMS score of ,[DATE], had unsteady balance and needed 2-person assistance with bed mobility, transfers, toileting, hygiene and bathing. On [DATE] at 3:22 PM, Resident #78 was observed lying in bed with a neck brace on and was asked if he had fallen at the facility and stated, They put me in a room, that looked like a storage room (bathroom). I went, but then had to go again, put my call light on and he (nurse aide) didn't come back. I had no alternative and had to go. I didn't want to wet myself. I waited and waited and waited. I was going to poop my pants. I decided to slide out of bed to go to the bathroom. I got my walker and should have had my wheelchair. I went about 3 steps and my left side went to mush. My ankle collapsed. I had no power and slid down the wall and hit my head on the wall. I'm lying on the floor and about 4 guys came in. They stood and looked at me. I don't know if they were trying to figure out a way to pick me up. I had just got there from the hospital and was woozy and dizzy. I should have been watched. Then I went down to the hospital in Detroit for a CT; they told me to go down there for a CAT scan. I was in the back of the ambulance for a 2- hour trip down there. All I found out was, it was a 4-hour trip. I think the doctor said he was worried the screws came loose in my neck. I guess it was ok. I've never been in a place like this before, no one tells me what they want me to do. The last couple days, they were hardly ever here. I wet my pants. What I'm supposed to do is push the button, but they don't come sometimes for quite a bit of time. It starts the timer and I'm sitting here waiting for them to help me. No floor mats. A review of an Incident and Accident report dated [DATE] at 2:07 AM revealed, Call heard from room upon arrival resident lying next to bed on right side . unwitnessed. The question When was resident last seen, was answered <30 minutes before fall-resting. A question Location of injury on body: Resident stated he hit head. No injury noted. There was no mention if the resident had the neck brace on, or if the neck was assessed. A review of the Fall Investigation Report, dated [DATE] with Additional Care Plan/Nurse Aide Assignment Updates: Bilateral floormats. Move lodger to room closer to front of hallway . A witness statement dated [DATE] by Nurse OO revealed, I was the 2nd shift nurse .the lodger was alert but very confused and paranoid. Because of this we had a CNA (certified nursing assistant) to sit in the room with the lodger for his needs assessment adl (activities of daily living) and safety. This was discussed with the lodgers wife that the CNA was going to remain in the room with the lodger for the remainder fo second shift. Also that hourly rounds were being performed. The resident did not have anyone sitting with him on the 3rd shift at 2:50 AM when he fell . A review of the CT scan of the Head and Neck and Cervical Spine provided, Order states: .fell , headache, recent neck surgery. Patient States: . Patient fell last night having confusion since, headaches . Conclusion . There is posterior C4 facet frature on the right which is likely subacute . A summary note said, Care Plans in place. A review of the Care Plans indicated the Fall care plan was not created until [DATE] after the resident fell . An intervention was added [DATE] The resident utilizes fall mats on the following side of the bed to minimize injury should the resident attempt transfers without assistance or roll out of bed, date initiated [DATE]. There was no specification to which side of the bed the fall mat should be on. During the observation of Resident #78 lying in bed on [DATE] at 3:22 PM, there were no fall mats on the floor on either side of the resident's bed. An ADL care plan titled, Needs activities of daily living and mobility assistance, date initiated [DATE] with Intervention: Neck collar on at all times may remove for adl care and evaluation of skin, date initiated [DATE]. There was no intervention upon admission addressing the resident's neck surgery or the need to wear a c-collar (a neck brace), until the day after he fell . A review of the physician orders revealed an order dated [DATE] at 4:30 PM, Neck immobilizer on at all times may remove for adl care and to check skin for integrity. There were no orders for fall prevention measures. A review of the progress notes, revealed a provider note written by Physician Assistant PP, dated [DATE] at 8:41 AM, . recently hospitalized . debulking surgery for [REDACTED]. Patient to wear c-collar when out of bed (not initially wearing this when found sitting in the dining room awaiting breakfast . A review of the nurses Skilled Daily assessment revealed assessment documented for [DATE], [DATE], [DATE] and [DATE]. The assessment of the resident's condition following spine surgery was not completed daily. A review of the resident's Fall Risk Evaluation, dated [DATE] at 3:06 PM revealed No Falls (history during last 90 days), No change in cognitive status. Under the section titled, Vitals, it was blank. Under the section titled, Health Conditions/Health Risks, there was no mention of the resident's recent neck/spinal surgery, incision, need to wear a c-collar and intermittent confusion. The assessment did provide a score of 18- Interventions Required. No care plan interventions were initiated until after the resident fell on [DATE]. Resident #88 Falls A record review of the Face Sheet and electronic medical record (EMR) indicated Resident #88 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS assessment dated [DATE] revealed the resident had a BIMS score of ,[DATE] with moderate cognitive decline and needed assistance with all care including eating. The resident fell in the facility on [DATE] and died on [DATE]. A review of the resident's progress notes, revealed a physician progress notes [REDACTED].Pt was on hospice but had [MEDICAL CONDITION] so he was treated in hospital .closed left [MEDICAL CONDITION] repair . screened for future hall risk during the last 12 months. The screening was Positive (the patient had 2 or more falls, or one fall with injury, within the prior year) . A review of the resident's Care Plans indicated a Fall Care Plan date initiated [DATE]. After the resident fell on [DATE] there was 1 intervention added. Refer lodger to Activities to re-assess likes and preferences and to establish a daily routine for dining room and out of room activities, date initiated [DATE]. A review of the Activities Care Plan initiated on [DATE] had no updated interventions after the resident fell on [DATE]. An intervention dated [DATE] said, Offer independent activity supplies; TV, dated [DATE] and Provide with an activity calendar, dated [DATE]. Further review of the progress notes and assessments indicated there were 3 Skilled daily, nursing assessments completed between [DATE] and [DATE]: [DATE], [DATE] and [DATE]. A review of the progress notes did not identify nurses notes on the missing assessment dates. The admission progress note dated [DATE] at 11:28 PM did not mention the resident's history of falls. Resident #387 Accidents A record review of the Face Sheet indicated Resident #387 was initially admitted to the facility on admitted on [DATE] with Diagnoses: [REDACTED]. The MDS was not yet completed. On [DATE] at 9:42 AM, Resident #387 was observed with large bruises and [MEDICATION NAME] clear bandages on each hand. The resident said a few days prior, he fell in the bathroom, onto the bench; his walker took off on him after he was left alone in the bathroom and his call light was on. A review of an Incident and Accident Report dated [DATE] at 8:00 PM provided, Resident observed on floor in bathroom by CNA (certified nursing assistant). He stated he was standing, trying to pull his briefs un and he fell over . Injury: skin tear . When was he last seen: 5:00 PM taking meds . Care Plan updated to remind lodger to use call light. A review of the Fall Investigation Report, dated [DATE], Statement of Witness, by Nurse W, At 8:00 PM, my pager alerted me of a bath call going off .I walked into the bathroom and observed the resident on his knees with head in hands leaning onto shower bench with his pants down . A review of the The ADL care plan, dated [DATE] o TOILET USE: 2p transfer with gait belt to toilet and offer in am, before and after meals, hs (at bedtime) and prn (as needed) upon request, date Initiated: [DATE] and revised [DATE]. The resident was not assisted with toileting prior to bedtime. A review of the Fall Care Plan, date initiated [DATE] indicated the resident had 2 interventions added after the fall on [DATE], 1.) said to ensure the call light was in reach and remind the resident to use it (this intervention was already in place on [DATE]) and Observe for potential adverse drug reaction . The resident already had drug monitoring in place for pain and anti-hypertensive medications. No additional interventions were provided. Preventative measures related to the resident's recent [MEDICAL CONDITION] were not identified. The care plans do not mention using a walker, the resident said he used it on his own until he fell and they took it away and he can only use it in therapy with assistance. A review of the nursing Skilled Daily charting indicated it was not completed daily including the date of the residents fall on [DATE]; and [DATE]. A review of the progress notes revealed a note by Physician QQ, The patient has been screened for future fall risk during the last 12 months. The screening was Positive (the patient had two or more falls, or one fall with injury, within the prior 12 months . On [DATE] at 1:20 PM, the Director of Nursing was interviewed about the resident's falls with lack of monitoring and interventions to aide in prevention of falls and stated, We are looking into that. A review of the facility policy titled, Falls-Clinical Protocol, date reviewed/revised ,[DATE] provided, .Based on the assessment (Fall Risk Evaluation) a care plan will be developed and implemented to address identified risk .the staff will monitor and document the individuals response to interventions intended to reduce falling .

This Citation pertains to Intake #'s MI 502, MI 112, Based on interview and record review, the facility failed to ensure wound care was completed per physician's orders for 2 Residents (#'s 102, 105) and that 2 Residents received routine wound assessment and monitoring (#'s 102, 106) of 3 residents reviewed for wound care assessment and monitoring from a total sample of seven residents, resulting in Resident's #'s 102 and 106 experiencing a decline in wound healing with #106 developing [MEDICAL CONDITION] and both #102 and 106 developing an infection at the wound site and Resident #105 becoming frustrated and worried about the lack of wound care to promote healing. Findings Include: Resident #102: A review of the Face Sheet and Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS revealed the resident was confused and needed 2-person assistance with transfers and toileting and 1-2 person assistance with bed mobility. The resident was discharged to the hospital on [DATE] due to a worsening wound. A review of the Care Plan At Risk for further areas of skin breakdown related to decreased mobility status, Date initiated 1/12/19, revision 1/13/19 with Interventions: Follow facility protocols for treatment of [REDACTED].developed bilateral heel blisters related to decreased mobility status, Date initiated 1/12/19, revision 1/13/19 with Interventions: Administer treatments as ordered and evaluate for effectiveness .Date initiated 1/24/19, Float heels with heels up cushion when in bed, date initiated 1/24/19, Skin inspections by CNA (certified nursing assistant) . date initiated 1/24/19, Provide incontinence care and brief change . date initiated 1/24/19. A review of the physician orders revealed: 1/13/19-Cleanse with wound cleanser. Pat Dry. Apply [MEDICATION NAME] Gel as directed to buttock. Skin barrier wipe to peri wound Cover with ABD (padded gauze dressing). There was no clarification if this treatment was for both buttocks (stated buttock). There was no order for a treatment for [REDACTED]. 1/22/19 - Cleanse with wound cleanser. Pat dry. Apply skin prep to right and left heel if blister intact. Leave open to air. If blister ruptures notify wound nurse. The bilateral heel ulcers were identified on admission (1/12/19) with no treatment until 1/22/19. 1/28/19- X-ray right ischium, one time only for ruling out osteo[DIAGNOSES REDACTED]. 1/28/19- Consult with wound care ASAP (as soon as possible) for evaluation of right ischium wound. 1/28/19- Transfer out to hospital (related to buttock (ischial wounds). A review of the nurse's notes indicated the last nurse's note was written on the day of admission 1/12/19. A Nursing/Admission/Readmission Evaluation, dated 1/12/19 identified the following wounds: Right and Left buttocks (open skin wounds), Right and Left inner thighs (blisters), Right rear thigh (blister) and also bruising on both arms and the right eye. There were no measurements or further description for any of the wounds. On 1/17/19 there were documented Wound notes with the first measurements for the following: Left buttock: Pressure, Unstageable ulcer,18.5 centimeters (CM) length x 0.8 cm width x 0.10 cm, depth, with granulation tissue, serosanguinous (clear/yellow/red) drainage, and no description or reason for the indication of an Unstageable Ulcer. Right buttock: Pressure, Unstageable, Necrotic/Eschar 50% (black, dead tissue), 18.5 cm x 3.8 x 0.10, serosanguinous drainage. Left thigh: Skin tear, partial thickness, [MEDICATION NAME] tissue, 1.9 cm x 4.6 cm x 0.10 cm serosanguinous drainage. Right thigh: Pressure Stage II, [MEDICATION NAME] tissue, 7.4 cm x 7.7 cm x unable to determine. Right heel: Pressure, Stage II, [MEDICATION NAME], 7.4 cm x 7.7 cm x unable to determine. On 1/23/19 there was 1 wound note: Right thigh, Pressure, unstageable, Slough (yellowish/gray stringy dead tissue) 4.0 cm x 2.9 cm x unable to determine with serosanguinous drainage. There was no assessment/documentation or measurement for the Right and Left buttocks, Right heel or the Left thigh. The wounds were not assessed or measured weekly. A Nurse Practitioner note dated 1/28/19, written by Nurse Practitioner O Asked to evaluate patient wound to right ischium (buttock) .eschar has sloughed off to reveal necrotic skin to wound bed. Light brown tannish in color, with foul odor .very concerning [MEDICAL CONDITION] (bloodstream infection throughout the body) versus osteo[DIAGNOSES REDACTED] (bone infection) . patient does need surgical consultation for debridement (removal of dead tissue) and antibiotics . A review of the Treatment Administration Records (TAR's) for (MONTH) 2019 revealed the treatment to the buttock wound was not documented as completed on multiple days: 1/14/19, 1/20/19, 1/22-1/23/19, 1/25/19, 1/28/19. On 1/17/19 and 1/24/19 the documentation said see progress note, but there was no note. The treatment to the right and left heels was not completed on 1/22-1/23/19, 1/25/19 and 1/28/19. On 1/24/19 there was documentation to see the progress note, but there was no note. An interview with Wound Care Nurse C on 3/21/19 at 12:30 PM revealed, I don't have any other documentation for her. I don't know why. It doesn't make sense. The Wound Care Nurse said she was the person who assessed and documented the resident's wounds weekly. Resident #105: A record review of the Face Sheet and MDS assessment dated [DATE] indicated Resident #105 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The resident had full cognitive abilities and needed 1- person assistance with transfers, positioning and toileting. On 3/20/19 at 10:15 AM, an interview with Resident #105 revealed, I laid in that bed and they did not change my bandages. I kept asking the nurses about it and one nurse even said, It's not my job. I went out to an appointment with the surgeon (for the follow-up to the left foot toe amputation) and he said he could see that my bandages weren't being changed. It was the same bandage that they put on in the hospital. They were always complaining about the tape, 'It would cost too much,' I talked to the Director of Nursing (DON) many times. After the surgeon's appointment (Nurse C) would come in and measure my wounds. A review of the Care Plans At risk for pressure areas and further areas of skin breakdown related to diabetic [MEDICAL CONDITION] and decreased mobility, Date initiated 1/16/19 with Interventions: Monitor/document location, size and treatment of [REDACTED]. date initiated 1/29/19 and The resident was admitted with osteo[DIAGNOSES REDACTED] and left second toe amputation, Date initiated 1/16/19 with Interventions: Administer antibiotic as per doctor's orders, date initiated 1/16/19, Dressing changes as ordered, date initiated 1/16/19. A review of the physician orders revealed the following: The left foot had 2 orders- Cleanse with wound cleanser. Pat dry. Place 4 x 4 gauze at site of amputation. Wrap with kerlix. Change daily. Left foot, dated 1/21/19 -1/25/19 and Left foot-clean wound with wound cleanser, cover wound with xeroform gauze and wrap with kerlix, dated 1/26/19-2/14/19. The right foot had 1 order-Clean area with wound cleanser on right third toe then cover with hydrogel gauze and then dry gauze then wrap with kerlix, dated 1/26/19-2/14/19. A review of the TAR's for (MONTH) 2019 indicated while Resident #105 was admitted to the facility on [DATE], there were no wound orders until 1/21/19 for the left foot and 1/26/19 for the right foot. The left foot treatment was not documented as completed 1/22/19, 1/24/19, 1/28/19 and 1/30/19. The right foot treatment was missing 1/26/19, 1/28/19, 1/30/19. A review of the (MONTH) 2019 TAR's wound care for the right foot was not completed on 2/1/19, 2/4/19, 2/7-2/9/19, 2/13-2/14/19. The left foot wound care was missing on 2/1/19, 2/4/19, 2/7-2/9/19 and 2/13-2/14/19. There was no nursing documentation to explain why the wound care was not completed. An interview with the Director of Nursing on 3/22/19 at 1:20 PM, related to Resident's 102 and 105's missing wound care and assessments revealed, We have not been staffed to budget. We are trying to hire more nurses. A review of the facility guideline titled, Wound and skin care Guidelines, dated revised 1/2017 revealed Care is based upon individual needs and physician orders .Pressure ulcers-Cleanse-Protect-Dress . and the facility policy titled, Dressing, Dry/clean, dated 3/23/2011 Verify that there is a physician's order .Review the resident's car plan, current orders and [DIAGNOSES REDACTED].The following information should be recorded in the resident's medical record: 1. The date and time the dressing was changed, 2. Wound appearance .4. All assessment data .7. Any problems or complaints 8. If the resident refused the treatment and why .Notify the supervisor if the resident refuses the dressing change .Report other information in accordance with facility policy and professional standards of practice and the facility policy titled, Pressure Ulcers/Pressure Injury Prevention and Treatment-Clinical Protocol, dated (MONTH) 28, (YEAR) Based on the comprehensive assessment of a resident, a resident receives care, consistent with professional standards of practice to prevent pressure ulcers .and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards .All pressure ulcer/pressure injury or other skin related issues are measured and documented .Weekly skin evaluation/assessment by the licensed nurse on resident's .complete head to toe skin assessment, document in the medical record .update plan of care to reflect any new risks, goals and interventions .the facility is expected to address the resident's concerns . This citation pertains to MI 785. Resident #106: According to admission face sheet, Resident #106 was a [AGE] year old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to Minimum Data Set ((MDS) dated [DATE], Resident #106 cognition assessment was scored a 15 indicating no cognitive impairment and required assistance with Activities of Daily (ADL) care to include transfers. Review of Resident #106's facility Care Plans documented a Problem Open Non-healing area to left lower leg from squamous [MEDICAL CONDITION] removed; [MEDICAL CONDITION] bilateral lower legs with initiated date of 2/14/19. Under goal documented Open area will show healing without S & S (signs and symptoms) of infection thru next review. Under Interventions Monitor/document location, size, and treatment of [REDACTED]. Another Care Plan documented The resident has [MEDICAL CONDITION] with an initiated date 2/28/19. On the Non healing skin Care Plan documented Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudates and any other notable changes or observations, with an initiation date of 2/26/19. On Pressure Ulcer Care plan documented Skin inspections by CNA (Certified Nursing Assistant) during cares and showers/baths. Report changes to licensed nurses immediately with an initiation 2/26/19. Review of active Physician orders for time period of 1/1/19 through 3/31/19, documented an order for [REDACTED].#106 had an order for [REDACTED]. Apply Dermseptin every shift and PRN (as needed) to coccyx until healed and every day shift and evening shift for redness, with an initiation date of 2/26/19. The Wound order was Left lower leg, Cleanse w NS (normal saline), pat dry, apply skin prep to peri wound, cover with border foam, every day shift for Wound Care, initiated 2/15/19, and discontinued 2/28/19. Further review of the orders documented Wound Care left lower leg, Cleanse with NS (normal saline), pat dry, apply ABD pad and cover with Kerlix. Wound needs to be kept dry initiated 2/28/19. Review of Nursing Admission Evaluation dated 2/14/19, documented Resident #106 skin as 'Yes' to identified skin conditions/wounds and documented bruising to abdomen and right iliac crest (front of pelvis), left iliac crest, and Surgical incision to Left Lower leg (front), and other as multiple bruising to both arms. Also documented that the resident is Diabetic. On the Admission Assessment area 'Skin related Care Plans' with Focus box checked and goal is: Resident will be free from injury. The box for 'Resident will have no complications related to skin impairment was left blank/unchecked'. Under Interventions, the box was checked for: Monitor/document location, size and treatment of [REDACTED]. The next section check applicable goals had a box checked for: 'Resident is at risk for pressure ulcer development to the following areas and nothing documented in the area provided. The next Goal checked was Resident's risk of significant injury will be reduced or minimized. The Intervention below the Goal box was left unchecked/blank for Administer treatments as ordered an evaluate for effectiveness and also unchecked was Evaluate dressing to ensure it is intact and adhering. The next Intervention boxed checked was Daily skin evaluations by licensed nurse if current Pressure Ulcer. The next Intervention box was left blank/unchecked for Evaluate/record/monitor wound healing (SPECIFY FREQ.) frequency measure length, width, depth. Evaluate and document status of wound perimeter, wound bed and healing process. Report improvements/declines to MD (Medical Director). An interview was conducted on 3/20/19, with Registered Nurse/ Unit Manager/Wound Nurse C related to Resident #106's wounds. RN C indicated that Resident #106 entered the facility on 2/14/19, with a surgical incision from removal [MEDICAL CONDITION] on the leg and at some point the wound became infected and turned into [MEDICAL CONDITION] and resident received antibiotics for the infection. RN C also verbalized that Resident #106 did not have an open wound on her coccyx that she recalled, but there was an order for [REDACTED]. RN C was unable to provide the documentation and indicated she had not been monitoring or measuring the area. RN C indicated her focus was primarily on Pressure Ulcers. RN C was asked to provided skin assessments and documentation completed weekly for Resident #106, or daily notes by the nurses indicating they were following the interventions listed above for Resident #106 and evaluating the wound and effectiveness of the treatments. RN C provided one skin assessment dated [DATE]. (Resident was in the facility 2/14/19 thru 3/5/19). RN C indicated there was not any another assessments between 2/14/19 through 2/28/19 or after 2/28/19. RN C was unable to provide any clinical documentation by licensed nurses for daily or weekly monitoring of the wound. RN C indicated Resident #106 was sent out of the facility on 3/5/19, for treatment of [REDACTED]. Review of Progress notes revealed no clinical documentation completed by nursing staff. Review of the Treatment Acceptance Record (TAR) had treatment in place to Monitor JP (Jackson Pratt, type of wound drain) drain site for S/S (signs/symptoms) of infection, monitor drainage amount, every shift for JP drain. The TAR was left blank with no documentation of the site being monitored for (MONTH) and March, 2019. There were no entries made on the TAR for monitoring of the site of the wound.

Based on observation, interview, and record review, the facility failed to ensure/maintain the safety of 1 Resident (#107) out of 3 residents reviewed for safety/accidents, resulting in Resident #107 sustaining serious injuries of fractured humerus, brain bleed, and pain, post fall and the potential for more falls with serious injuries. Findings include: According to admission face sheet, Resident #107 was a [AGE] year old female admitted to the facility on [DATE], readmitted [DATE], with [DIAGNOSES REDACTED]. According to Minimum Data Set ((MDS) dated [DATE], Resident #107's cognition assessment was scored a zero indicating severe cognitive impairment and required assistance with Activities of Daily (ADL) care to include transfers. Review of Incident/Accident report, dated 3/15/19, documented at 17:15 (5:15 PM) an unwitnessed fall 'Resident observed on floor lying on left arm.' Under section for injuries documented 'Painful, Limp, Deformed left arm.' Under action taken 'Hospital' was checked. The Incident report also had documentation of Physician, family, notified of date and time. The report was signed by the Administrator and Director of Nursing as reviewed, dated 3/18/19. On the report, under describe interventions to prevent future falls documented Lodger is not to be left alone in room while eating. Under the heading of factors observed at the time of fall documented Left alone in room to eat. Under the heading what type of assistance was resident receiving at the time of fall documented Alone and unattended. The incident report was signed by Registered Nurse L on 3/15/19. An interview was conducted with RN L on 3/20/19, who indicated she had stayed over to work on the floor from 6 PM until 10 PM, on 3/15/19, filling a four hour whole in staffing for nurses. RN L indicated she was new to the facility and was not familiar with the residents, and was shadowing another RN K who was on break at the time of the fall and had just returned to the unit. RN L indicated she had never worked the floor at the facility until that time. RN L indicated she was standing at her medication cart when she heard another Lodger yelling She is on the Floor and went to investigate with RN K who had just returned to the unit. RN L and K went to see what had happened and entered Resident #107's room and observed Resident #107 on the floor, near the bed, with her feet pointing towards the bed, and her left arm behind Resident #107's back. RN L indicated they attempted to get Resident #107 up off the floor, and noted the left arm was Floppy and felt like Rice Crispy's upon further assessment. RN L indicated Neurological assessment was started at that time. RN L indicated she asked why this Resident was not in the dinning room for meals and verbalized the Certified Nursing Assistant who was caring for Resident #107 had set her up in her room for her evening meal. RN L indicated the Resident should have been out in the dining room for closer supervision due to the history of Resident #107 having repeated falls from what was shared with her by RN K, who was the nurse that frequently cared for Resident #107. An interview was conducted on 3/20/19, with RN K who was precepting RN L on 3/15/19, at the time of the Incident. RN K indicated she heard a resident yelling, and walked to the hallway to see what was happening, and indicated she had been standing at the medication cart on the 700 hall. Resident #107 resided in room [ROOM NUMBER]-1. RN K indicated she and RN L entered Resident #107's room and observed her on the floor, feet towards the bed, and said I did not move resident at that point, and her left arm was positioned behind her back and she was laying on it. She said resident indicated pain at 6 to 7 level when asked. RN K indicated she assessed range of motion and moved Resident #107's arm from behind her back and felt/heard crepitus (grating sound/sensation between bone and cartilage, or fractured parts) and noted the arm was limp. RN K indicated the staff got the mechanical lift and assisted Resident #107 into bed. RN K indicated it was her, and RN L and CNA M who was caring for Resident #107 that day and assisted post fall. RN K indicated they were short of nurses that day and RN L stayed over to assist, but did not know the residents as she had never worked the floor before and was new. RN K indicated Neurochecks were instituted and the physician was contacted and Resident #107 was immediately sent out to the hospital with in 15 to 20 minutes. RN K was asked what happened and indicated CNA M had set up Resident #107 in her room to eat and left her alone. RN K was asked if Resident #107 was supposed to be left alone in her room unattended due to multiple falls. RN K said, No, I was surprised to find her alone in her room, and mad at the same time because this resident is very confused and impulsive, and has had numerous falls. She needed close supervision, and was to be laid down in bed immediately after her meal because she tries to ambulate to bed and cannot walk. That was the last intervention put in place after one of her recent falls in February. RN K was asked if any environmental factors were associated with the incident and indicated Resident was left alone and unattended in her room, and should not have been, because of so many falls. She is my highest fall risk on the unit. That is my baby. I wanted/expected her to be watched closely. Like I said, I was mad when this happened. An interview was conducted with Certified Nursing Assistant M on 3/22/19, related to the incident on 3/15/19. CNA M was asked if she was familiar with Resident #107 and indicated she was. CNA M indicated she (Resident #107) tries to walk and falls a lot. CNA M was asked about incident on 3/15/19, and said she asked Resident where she wanted to eat and let her choose the dining room or her room, and she chose her room. CNA M was asked if Resident was Alert and Oriented and indicated Resident #107 was confused most of the time. CNA M indicated We try to keep her under supervision for breakfast and lunch, but I thought I could get to her quickly after her meal to lay her down if I set her up in her room. The resident eats her meals very quickly usually about 15 minutes. On that day she ate in 10 minutes or less. CNA M indicated the nurse came to her and asked why Resident #107 was set up for meal in her room and not the dining room and explained the resident chose to stay in her room. CNA M was asked for those residents that are high risk for falls, should they be left unattended in there rooms and said, No, I thought I could get back to her soon and get her in bed. That day she ate faster than usual. CNA M was asked if she checks the CNA care guide to help her with changes and new interventions for residents and indicated she does not always look at the care guides. CNA M was asked if the nurses tell her in report who is a high fall risk and needs close supervision and indicated No and that she does not always get report from the nurses they are too busy to give report, and recently the overlap for oncoming shifts and the off going shifts were cut out because of the budget. The 30 minute over lap to get report was done away with by the Administrator 3 or 4 months ago, so I don't get report from the other Certified Nursing Assistants. They are usually gone when I start my shift. I don't always get told when things change by some of the nurses, or there is a change in residents. We have complained about it, but it is still happening. It makes it hard to do a good job, especially if there are residents left soiled and no one is doing shift to shift report and we are not told certain things about certain residents. I have to work fast because of all the residents I have to take care of. If I don't things just don't get done. So, I thought if I set Resident #107 up in her room, I could get back quickly and get her in bed. I know now, I should not have done that. Review was done of Fall Risk assessment for Resident #107 dated 1/6/19, documented under History of Falls as '3 or more falls' and checked 'Yes' to question of: periods of altered perception, episodes of disorganized speech, periods of restlessness, mental function varies over the day, and wanders, abusive and resists care. Under 'Mobility' documented Ambulates with problems and with devices (gait is unsteady, slow, and lurching). Under 'balance' documented Not steady, but able to stabilize without physical assistance. The Fall risk assessment documented resident: 'At risk for falls, related to balance problems, confusion, Gait/balance problems, History of Falls, and blood pressure fluctuations.' Review was done of Fall Risk Assessment for Resident #107 dated 1/10/19, (4 days later) which documented only 1-2 falls (versus 3 or more as above), and checked 'Yes' to question of: periods of altered perception, episodes of disorganized speech, periods of restlessness, mental function varies over the day, and wanders, abusive and resists care. Under 'Mobility' documented Ambulates with problems and with devices (gait is unsteady, slow, and lurching). Under 'balance' documented Not steady, only able to stabilize with physical assistance. The Fall risk assessment documented resident: 'At risk for falls, related to balance problems, confusion, Gait/balance problems, History of Falls, and blood pressure fluctuations.' Review of Resident #107's Fall/safety Care plans documented fall on 9/17/18, and an intervention to Assist Pt (patient) to bed after meals. Also Lodger moved to room closer to to beginning of hall for monitoring due to fall 6/12/18, and intervention documented to Stay with Lodger while in the bathroom. Listed also on the Falls care plan was Be sure Resident's call is in reach. Does not use it due to Dementia. On a Pain care plan documented Resident is at risk for pain related to [MEDICAL CONDITION] from Fall 5/16/18. An interview was conducted with a Family member on 3/22/19, who asked to speak to State Agency related to the latest Fall in the facility, who was very upset/crying. The family member indicated that she was not sure exactly what had happened and was in the facility for a meeting to get the details of this last fall. This family member indicated that her loved one had many falls while in the facility and this one was the worst. She indicated Mom has Dementia, and fell here few yrs ago and fractured her hip, and has fallen many times since then. That is why she is here, I can't take care of her anymore, and I trusted that the facility was going to keep her safe and not hurt. Mom is in bad shape now, her pain is bad this time. I had to get on the nurses to ensure they are giving Mom her pain med's regularly because they are not monitoring Mom's pain. Mom is confused and in a lot of pain right now due to this last fall with broken arm and cannot ask for pain meds. Mom also had a bleed in her brain from this last fall. She is also bruised pretty bad. Mom had to stay in Intensive Care for 4 days because of the bleed in her brain, but it is improving now, and they sent Mom back to the facility yesterday or day before. I am here to see what the facility is going to do to keep her from getting hurt again. I am very angry now. They have given me very few details as to what happened. Mom has had 5 or 6 falls this past year that I can recall, there may be more. They told me on the last one, that Mom needs to be watched closer, and that they would supervise her. Mom is very impulsive and wants to get into bed immediately after eating and they told me they would lay her down after the last one. I am very angry. This should not have happened. While Mom was in the Hospital, she had a sitter. The facility should be able to get someone to watch her closer, and definitely never leave her unattended in her room for any reason what so ever. Like I said, this should never have happened. Review of 'Falls-Clinical Protocol' dated 6/2018, documented As part of initial and ongoing assessment, the staff will help identify individuals with a history of falls and risk factors for subsequent falling. This will be accomplished by the following task: The Fall Risk Assessment is completed upon admission, quarterly, and with significant change in status. Interventions should be developed and implemented per assessed needs. Interventions for direct care givers should be placed on the Kardex (CNA Care guide), or similar format and updated with changes. If the individual continues to fall, the Interdisciplinary Team should re-evaluate the situation and consider other possible reasons for the resident falling besides those that have already been identified and re-evaluate the continued relevance of current interventions. An interview was conducted with The Director of Nursing on 3/22/19, related to Resident #107's most recent fall. DON indicated that her follow up on the fall for Resident #107 was due to the CNA setting Resident up for her meal in her room. DON was asked if Resident #107 should have been set up alone in her room, and left unattended. DON indicated the resident chose to be in her room. DON was asked if Resident #107 should have been closely supervised due to all the recent falls and indicated the Resident had the right to be in her room. Review was done Discharge Instructions from Hospital dated 3/20/19, documented 'Discharge Diagnosis' as Subdural Hematoma (a pool of blood between the brain and outermost covering, also know as brain hemorrhage). Further review of discharge papers indicated a CT (computerized axial tomography, shows internal organ details that an x-ray can not show) dated 3/17/19, documented Follow-up hemorrhage. fell out of bed 2 days ago. High Blood Pressure. Comparison-Most recent is from 3/16/19. Impression-unchanged Subdural Hemorrhage. On 3/15/19, documented XR (x-ray) Shoulder left complete as Complete horizontal fracture through the humeral neck is appreciated. Distal fracture fragment is displaced laterally. Impression-[MEDICAL CONDITION] neck with displacement of the distal fracture fragment and trauma secondary to to fall. (The Humerus is the bone of the upper arm and forming joints at the shoulder and elbow. Distal Humerus is part near the elbow). Resident #107 sustained fracture of her left arm, and brain bleed as result of the last fall. On 3/20/19 at 10:45 AM, Resident #107 was observed sitting in a wheelchair in the middle of her room facing away from the doorway. The call light was not in reach. Dried food was observed on the carpet of the room. On 3/20/19 at 1:24 PM, during an interview with Confidential Person P they revealed, On another day, we went down to get something to eat and when we got back, her roommate (Resident #107) was on the floor. We went to find someone, and an aide came back to help her. She came in and shut the door. I knocked and asked if I could come in? She left and the lady was still on the floor. Two to three minutes later she came back with another aide. On 3/21/19 at 9:30 AM, Resident #107 was observed sitting at a small table next to the wall near the 500 Hall, with her breakfast on a plate in front of her. There were no staff in sight. A nurse was observed passing medications near the 700 Hall. There was a half wall between the nurse and Resident #107 and the nurse could not view the resident from there. An interview with Certified Nursing Assistant M, on 3/22/19 at 9:45 AM revealed, When we put her in the open area for the resident's who need assistance, someone always stays with her.

This Citation pertains to Intake #'s: MI 956, MI 502, Based on interview and record review, the facility failed to assess, monitor, ensure availability of pain medications and provide pain management for 3 (#'s 101, 105, 107 ) of 4 residents reviewed for pain management from a total sample of 7, resulting in the resident's verbalizations of unrelieved pain, frustration and helplessness. Findings Include: Resident #101: A review of the Face Sheet and Minimum Data Set (MDS) assessment for Resident #101 indicated the resident was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The resident had full cognitive abilities and needed 1-person assistance with transfers and toileting. On 3/20/19 at 2:30 PM, during an interview Resident #101 stated, I was there because I broke my hip and I needed therapy. I had a lot of pain. They gave me one pain pill when I got there 1/19/19 and then said they were out of them until the morning that I left 1/21/19. They kept saying they were out of them and pharmacy hadn't sent any. I could have it 4 times a day and I got it twice during my stay. I left there as soon as I could. A review of the orders for Resident #101 revealed the following pain medication: [MEDICATION NAME] tablet 7.5/325 mg ([MEDICATION NAME]/Tylenol) Give 1 tablet by mouth every 4 hours as needed for pain, Start Date 1/19/19 7:30 PM and Discontinue Date 2/13/19. A review of the Medication Administration Records (MARS) for (MONTH) 2019 indicated documentation [MEDICATION NAME] was administered to the resident twice: Once on 1/19/19 at 10:11 PM for a pain level of 6/10 (with 10 being the worst pain possible) and once on 1/21/19 at 9:44 AM for a pain level of 5/10. No pain medication was provided on 2/20/19. There was no assessment of the resident's pain level documented at any other time, including on 2/20/19, to determine if the resident was experiencing pain and needed pain medication. A review of the Care Plan The resident has/is at risk for (acute/chronic) pain related to (there was nothing documented to clarify the cause of the pain), Date Initiated 1/20/19, Interventions: Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment, Date Initiated 1/20/19. There were no other interventions. A review of the Hospital discharge instruction and prescriptions for Resident #101 revealed: [MEDICATION NAME] 7.5/325 mg per tablet, take 1 tablet by mouth every 4 hours as needed for moderate pain or severe pain for up to 3 days, Quantity= 10 tablets. A Nurse Practitioner's progress note dated 1/21/19 at 1:34 PM, written by Nurse Practitioner O said Resident #101 had requested to be discharged from the facility because she was not receiving medications, including pain medication as ordered. The Nurse Practitioner noted the resident had a fall with left femur/[MEDICAL CONDITION] prior to admission and was experiencing pain. An interview with the Director of Nursing (DON) on 3/22/19 at 2:15 PM related to Resident #101 not receiving pain medication as ordered provided, It's PRN (as needed) right? It was given twice. How would I know if she wanted it more than that? The DON was asked if there was any nursing documentation related to the resident's pain and could not find any documentation. Resident #105: A record review of the Face Sheet and MDS assessment dated [DATE] indicated Resident #105 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The resident had full cognitive abilities and needed 1- person assistance with transfers and toileting. A review of the physician orders dated 2/4/19, [MEDICATION NAME] tablet 7.5/325 mg, Give 1 tablet by mouth every 8 hours for pain. The MAR for (MONTH) 2019 showed the pain medication [MEDICATION NAME] was ordered to be given at 7:00 AM, 3:00 PM and 11:00 PM each day. During an interview with Nurse E on 3/19/19 at 2:18 PM, the nurse stated I did lose the narcotic key from the key ring (for the 200 Hall). I looked in (Resident #105's) room and couldn't find it. The 3rd shift nurse (D) found it. I can't remember where they found it. I left. I had already worked 16 hours and was about to pass out and die. Nurse E was asked how she counted the narcotics, to ensure a correct accounting of the medications with the oncoming 3rd shift nurse (D) at the end of Nurse E's shift and stated, We didn't count. When asked how the residents would receive their pain medications, when the narcotic key was missing Nurse E stated, That's a good question. On 3/19/19 at 2:56 PM, Nurse D was interviewed about the missing narcotics key and stated, (Nurse E) lost it from the key ring. I don't know why but she kept it separate. We pass it to each other. Lately there is only 1 nurse for the 100 hall and 1 for the 300 Hall and each splits the 200 halls. There was a key that a patient found on the floor. (Nurse E) said (Resident #105) was scheduled for an 11:00 PM pain medication, but the key was lost. The nurse said she was tired and wanted to leave. We called the DON and she said, You guys have to find that key. When asked if the nurses obtained the pain medication for Resident #105 from the back-up supply, Nurse D said they did not. Nurse D was asked if the DON or a Nurse Manager came in to assist them with the missing key, she said no one came in. On 3/20/19 at 10:15 AM, during an interview with Resident #105, she stated A few days before I left the facility, on 2/21/19 a Thursday, I didn't get my pain pill. I was supposed to have it at 11:00 PM, but they lost the narcotics key and said they couldn't give it to me. (Nurse D) said (Nurse E) had lost the key and they couldn't open the narcotics drawer. Then, I was on my way to the bathroom and when I came out, I saw a shiny thing on the floor. I picked it up. It was a key. I found it about 2:00 AM - 3:00 AM. I gave it to (Nurse D) and she said, That is the key I'm looking for. It was by the dresser drawer. Then she gave me my pain pill. A review of the Care Plan The resident has (acute/chronic) pain related to diabetic [MEDICAL CONDITIONS], Date Initiated 1/16/19, with Interventions: Anticipate the resident's need for pain relief and respond immediately to any complaint of pain, Date Initiated 1/29/19 and Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment, Date Initiated 1/29/19. A review of the (MONTH) 16-February 24, 2019 Medication Admin Audit Report, revealed on 2/21/19, Nurse D documented at 2:19 AM on 2/22/19, that Resident #105 received [MEDICATION NAME] pain medication at 11:18 PM on 2/21/19: She documented 3 hours after the dose was due. This entry was in contrast to all other documented entries for [MEDICATION NAME] given at 11:00 PM from 2/16/19-2/24/19. None were documented 3 hours late. The resident had no other medications during that time-frame that were documented 3 hours late. On 3/20/19 at 11:20 AM, during an interview with the DON about the missing narcotics key for the 200 Hall, she stated The narcotic key was found on the bathroom floor in (Resident #105's) room. The nurse apparently went in to wash her hands and must have dropped it. (The resident) told me about it. I didn't talk to (Nurse E) for maybe a few days. When asked if the nurses would be able to get in the narcotics box to give pain medication, the DON replied, No, I don't know what time they found it. When the DON was queried if an investigation was initiated to find out how this happened and to try to prevent it from happening in the future, the DON stated, Why would there be? I think they tried to contact me, but I didn't get their messages. A review of the facility policy titled, Controlled Substances, revised 3/2019 The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal and documentation of Schedule II, III, IV and other controlled substances .All keys to controlled substance containers shall be on a single key ring that is different from any other keys. The Charge Nurse on duty will maintain the keys to controlled substance containers. The keys to this container should not be share with other staff, including licensed staff without first conducting a complete controlled substance count .Nursing staff must count controlled drugs at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. The must document and report any discrepancies to the Director of Nursing Services or His/her designee immediately .The Director of Nursing Services shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsible parties and shall give the Administrator a written report . Resident #107: According to admission face sheet, Resident #107 was a [AGE] year old female admitted to the facility on [DATE], readmitted [DATE], with [DIAGNOSES REDACTED]. According to Minimum Data Set ((MDS) dated [DATE], Resident #107 cognition assessment was scored a zero indicating severe cognitive impairment and required assistance with Activities of Daily (ADL) care to include transfers. Review of Incident/Accident report dated 3/15/19, documented at 17:15 (5:15 PM) an unwitnessed fall 'Resident observed on floor lying on left arm.' Under section for injuries documented 'Painful, Limp, Deformed left arm.' Under action taken 'Hospital' was checked. The Incident report also had documentation of Physician, family, notified of date and time. The report was signed by The Administrator and Director of Nursing dated 3/18/19. On the report, under 'describe interventions to prevent future falls documented Lodger is not to be left alone in room while eating. Under the heading of 'factors observed at the time of fall documented Left alone in room to eat. Under the heading 'what type of assistance was resident receiving at the time of fall' documented Alone and unattended. The incident report was signed by Registered Nurse L on 3/15/19. An interview was conducted with a Family member on 3/22/19, who asked to speak to State Agency related to the latest Fall in the facility, who was very upset/crying. The family member indicated that she was not sure exactly what had happened and was in the facility for a meeting to get the details of this last fall. This family member indicated that her loved one had many falls while in the facility and this one was the worst. She indicated Mom has Dementia, and fell here few yrs ago and fractured her hip, and has fallen many times since then. That is why she is here, I can't take care of her anymore, and I trusted that the facility was going to keep her safe and not hurt. Mom is in bad shape now, her pain is bad this time. I had to get on the nurses to ensure they are giving Mom the pain med's regularly, because Mom is confused and in a lot of pain right now due to this last fall with broken arm and cannot ask for pain meds and the nurses are not monitoring my Mom for her pain management. I asked the nurse to ensure that they are giving the pain meds regularly. Mom can't ask for pain pills. Mom also had a bleed in her brain from this last fall. She is also bruised pretty bad. Mom had to stay in Intensive Care for 4 days because of the bleed in her brain, but it is improving now, and they sent Mom back to the facility yesterday or day before. I am here to see what the facility is going to do to keep her from getting hurt again. I am very angry now. They have given me very few details as to what happened. Mom has had 5 or 6 falls this past year that I can recall, there may be more. They told me on the last one, that Mom needs to be watched closer, and that they would supervise her. Mom is very impulsive and wants to get into bed immediately after eating and they told me they would lay her down after the last one. I am very angry. This should not have happened. While Mom was in the Hospital, she had a sitter. The facility should be able to get someone to watch her closer, and definitely never leave her unattended in her room for any reason what so ever. Like I said, this should never have happened. Review was done Discharge Instructions from Hospital dated 3/20/19, documented Discharge [DIAGNOSES REDACTED]. Further review of discharge papers indicated a CT (computerized axial tomography, shows internal organ details that an x-ray can not show) dated 3/17/19, documented Follow-up hemorrhage. fell out of bed 2 days ago. High Blood Pressure. Comparison-Most recent is from 3/16/19. Impression-unchanged Subdural Hemorrhage. On 3/15/19, documented XR (x-ray) Shoulder left complete as Complete horizontal fracture through the humeral neck is appreciated. Distal fracture fragment is displaced laterally. Impression-[MEDICAL CONDITION] neck with displacement of the distal fracture fragment. (The Humerus is the bone of the upper arm and forming joints at the shoulder and elbow. Distal Humerus is part near the elbow). Resident #107 sustained fracture of her arm and bleed in her brain as result of the last fall, and increase in pain as a result.

This citation pertains to intake #MI 137. Based on interview and record review, the facility failed to report acute changes to the Physician/Nurse Practitioner of the results of a chest x-ray and assessment of the lungs, after a fall occurred with an injury of fractured ribs, for one Resident (#907) of four residents reviewed for assessing and monitoring, resulting in a delay of treatment, hospitalization , shortness of breath, pain and pneumonia and the potential for an overall decline in health. Findings include: A review, of Resident #907's medical record, revealed an admission into the facility on [DATE] and a discharge on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set assessment revealed the Resident needed extensive assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. A progress note, dated [DATE] at 17:45 (5:45 PM), revealed the patient is AO (alert and oriented) x (times) 3 but during night patient becomes more confused . On [DATE] at 10:24 AM, an interview was conducted with Confidential Person L, regarding Resident #907. The Confidential Person said the Resident had been admitted into the facility on (MONTH) 27th in the afternoon. On the morning of (MONTH) 28th about 3:00 AM, the Resident had fallen out of bed. The facility had X-rays done on the 28th that showed fractures of the 10, 11, and 12th ribs. The Confidential Person stated, more x-rays were done on the 1st and we were not made aware of the results until the next morning when the PA (Physicians Assistant, the confidential person called the person that evaluated Resident #907 a PA, a review of the medical records revealed the person as a FNP, Family Nurse Practitioner) came in to check on (Resident #907) then sent her out to the hospital. She had gotten worse over the couple days. The PA didn't go in and see her until about 5:30 in the morning on Friday ([DATE]) after the second x-rays were done on Thursday ([DATE]). The Confidential Person then stated, They (the hospital) put in a tube into her chest to drain it and said there was nothing more they could do for her. They put her on Hospice, we got her home on Hospice on (MONTH) 6th and she died on (MONTH) 7th. The cause of death on her death certificate said [MEDICATION NAME] force injury. A review, of Resident #907's investigation report provided by the facility, revealed an incident report that indicated the date of the incident on [DATE] at 3:00 AM, with a brief description that revealed, Resident fond (found) face down near bed. Resident states she was going to the bathroom and can not breath O2 sat 89%. A further review, of Resident #907's medical record, revealed the following: A Progress Note dated [DATE] at 5:58 AM, author Nurse N, revealed, Situation: Observed on floor facing dorn (down) by the bottom of the bad (bed) Assessment: unwitnessed fall, neuros started, Injury/No Injury: abrasion on lt (left) back shoulder region and pain . Interventions: assessed and put back in bed . A Transcribed physician progress notes [REDACTED]. She had a fall this morning. She is complaining of right sided pain as well as mid to lower back pain . Lungs: normal effort, clear to auscultation bilaterally, good air movement, no wheezes, rales, rhonchi . Treatment. 1. Right-sided back pain Notes: Right sided pain after fall. Concern for rib fractures/flail chest. No s/s of respiratory compromise currently. No increased O2 requirement. Check rib series XR (x-ray), CXR (chest x-ray) . A Transcribed NP/PA progress Note, dated [DATE] at 13:48 (1:48 PM), author Nurse Practitioner E, revealed, Asked to evaluate pt (patient) regarding rib deformity noted after a fall . rib x rays demonstrated multiple rib fractures at #10, 11, and 12 with 10 th moderately displaced, flail chest. Pt is sitting up in bed, sob. O2 tubing on floor Lungs: slight increase in normal effort, clear to auscultation bilaterally, good air movement, no wheezes, rales, rhonchi . Treatment: 1. Right-sided back pain Notes: Right sided pain after fall. Rib x ray positive for multiple rib fractures + flail chest to right posterior aspect. Slight SOB this am, however O2 was off and replaced. Pt able to talk without difficulty. No s/s of respiratory compromise currently . Check rib serial XR (x-ray), CXR (chest x-ray) today and in am . Others. Notes: Plan of care discussed with daughter per phone, spoke with her regarding positive rib fracture high risk for pneumothorax and respiratory distress. Will complete serial x rays to evaluate for pneumothorax/high risk for respiratory decline, pneumonia . A Transcribed NP/PA progress Note, dated [DATE] at 11:26 AM, author Nurse Practitioner E, revealed, Late entry . Evaluating pt regarding flail chest after sustaining multiple right sided rib fractures. Serial x ray completed due to high risk for pneumothorax. Chest x ray from ,[DATE] with acute changes- right mid and lower lung infiltrates and moderate effusion- which was not present on ,[DATE] xray. Pt also with acute leukocytosis of 18.9 (elevated white blood cell count). Pt is lying in bed, + sob (positive shortness of breath), rhonchi noted to right mid and lower lobe. Bruising extended to right flank area . General Examination: Chest: flail chest to right posterior, ecchymosis (bruising) noted to right flank area extending Lungs: slight increase in normal effort, + rhonchi to right mid and lower lung Treatment 1. Pleural effusion. Notes: Pt with moderate effusion- new findings. In setting of multiple rib fracture and 10 th moderately displaced, VERY high risk for hemothorax. Daughter in room, updated on plan of care. Will send to ER for evaluation, high risk of respiratory distress/failure . 2. Leukocytosis Notes: WBC 18.9. 3. Pneumonia Notes: New pneumonia to right mid and lower lobe . A review of Resident #907's x-rays revealed the following: Date of service: [DATE], Ribs Bi-Lat (bilateral) and Chest Min 4V (four view). Results: There is a fracture involving the posterior portion of the right 10th, 11th, and 12th ribs. There is moderate displacement of the 10th rib fracture . Date of service [DATE], XRay Chest 2 view. Results: There is worsening of the right lower lung compared to [DATE]. There is no radiographic evidence of a pneumothorax. If a small pneumothorax is clinically suspected, a repeat study at full expiration is recommended. The heart size appears normal. There is a right mid and lower lung infiltrate and a right pleural effusion . Conclusion: A right lung infiltrate and moderate right pleural effusion. On [DATE] at 12:34 PM, an interview was conducted with Family Nurse Practitioner (NP) E, regarding Resident #907's fall and serial x-ray results. The NP stated, The Resident was admitted on (MONTH) 27th and had a fall that night ([DATE]). A chest x-ray on the 28th was done. I came to see her on (MONTH) 1st in the morning. She was a little short of breath but her O2 (oxygen) was on the ground. I transferred her to the Hospital on (MONTH) 2nd. When queried if abnormal findings on x-rays should be relayed to her, the NP stated, If there's abnormals, they are suppose to call us. Often they just fax it. When queried why the Resident was not transferred out of the facility when the rib fracture was confirmed, the NP stated, She didn't appear with resp distress, she was high risk for a pneumothorax. Serial x-rays were to be repeated on (MONTH) 1st. When queried regarding the worsening of the x-ray and when the results were reported to her, the NP stated, I am assuming I got the results when I came to work that day ([DATE]). When queried if she should have been notified of the results when the facility got them, the NP stated, For the 2nd one (x ray completed on [DATE]), we should have been notified because of the worsening. I got there about 5:,[DATE]:45 in the morning ([DATE]). I seen (Resident #907) then. She had changes, shortness of breath and rhonchi noted. The lungs had changed and she had bruising to the right flank area. I told the nurses to send her out as soon as I seen her. When queried if the nursing staff had contacted her regarding changes of the Resident's lung assessment and worsening of the x-ray, the NP stated, I don't recall getting a call about any changes. When queried if these changes nursing staff should have monitored and reported to her, the NP stated, I would assume so, yes. Any acute respiratory changes especially in that matter, they should notify us (physician staff). There was definitely a change from the day before and her WBCs (white blood cell count) was up also. The Nursing Progress Notes and the NP's documentation did not reveal that the Nursing staff had contacted the Physician/ NP regarding a change in an assessment of the lungs or the worsening chest x-ray results. On [DATE] at 12:54 PM, an interview, on the phone, was conducted with X-Ray Company Supervisor F, regarding the notification to the facility of X-ray results, for Resident #907's chest x-ray done on [DATE]. The Supervisor stated, The results were faxed on [DATE]. When queried why the results, of a worsening x-ray, were not called to the facility, the Supervisor responded, The facility is set up for fax only per the contract. Fax only facility. That is what the facility is requesting. The Supervisor stated, The order came in on ,[DATE] ([DATE]) at 3 PM for the chest x-ray 2 view to be done on ,[DATE]. Done on ,[DATE] ([DATE]) at 1:50 PM. The results were faxed to the facility at 3:03 PM on ,[DATE]. On [DATE] at 1:32 PM, an interview was conducted, with the Director of Nursing (DON), regarding the results of Resident #907's chest x-ray completed on [DATE] with a report of worsening, results faxed to the facility on [DATE] at 3:03 PM and the NP not informed of the results until she arrived in the morning on [DATE] to do rounds. The DON was unaware that the x-ray company was set up for fax only and stated, The x-ray results should have been given to the (Nurse Practitioner). The DON reviewed the medical record and revealed Nurse I was assigned care of Resident #907 on [DATE] when the faxed x-ray had arrived at the facility. On [DATE] at 1:35 PM, an interview was conducted, with Nurse I, regarding Resident #907's chest x-ray results completed on [DATE] that showed worsening. Nurse I indicated she did not remember getting a report from the day shift of pending x-ray results or receiving the x-ray from the fax machine and did not remember the Resident's lung or respiratory status. When queried regarding actions taken when abnormal results are received, the Nurse stated, I would assess them and call the doctor. When queried regarding documentation of assessment and contacting the doctor, the Nurse stated, I would chart it in the progress notes, nursing notes. A review of the medical record revealed no documentation of the Physician or NP having been contacted regarding the results of the worsening chest x-ray or the worsening of the Resident's respiratory status. A review of the facility policy entitled, Lab and Diagnostic Test Results-Clinical Protocol, revealed, A nurse will review all results. If the staff member who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility (Supervisor, Charge Nurse, etc.) should follow or coordinate the procedure . Identifying Situations that Warrant Immediate Notification: Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: 2. The result is something that should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors). 3. The resident's clinical status is unclear or worsening .

Based on observation, interview and record review the facility failed to abide by care planned fall interventions for one Resident (#47) of 4 reviewed for falls, resulting in Resident #47 having an unwitnessed fall and sustaining an abrasion on her knee, bruise on her coccyx, carpet burn on her forehead, and bruised eyes and bruised nose bridge. Findings include: On 9/10/18 during initial tour Resident #47 was observed in the dining room eating lunch. The resident was well dressed and appeared to be comfortable in their setting. On 9/11/18 at approximately 10:00 AM, a review was completed of Resident #47's medical records and it revealed the following, Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/11/18 at 10:30, a review was completed of Resident #47's fall care plan it showed the following interventions: Focus: The resident is at risk for falls r/t (related to) gait/balance problems, history of falls, actual falls and change in elevation revised on 2/18/18 Interventions: Wheelchair near bedside when in bed - initiated on 5/19/17 Bed at transfer height when not providing care for safety and against wall per her request. -revised on 5/19/17 On 9/12/18 at 9:15 AM, a review was completed of a fall that occurred on 11/16/17 at approximately 2:00 AM, the fall was unwitnessed, it was unknown what time the fall occurred, unknown who found the resident after the fall, unknown how the residents' multiple injuries occurred and there was no assessment completed on the resident immediately following the fall. Resident #47 sustained the following injuries: carpet burn on her forehead, abrasion on her right knee, bruises on her buttock and bruising around both eyes and the bridge of her nose. The Investigation included 3 separate statements (all on 11/16/18 at unknown times) from CNA E (Certified Nursing Assistant), who was assigned to care for Resident #47 that night (11/15/17-11/16/17). Statement #1, via phone with CNA E: .She was dry around 2 AM. I had the lights on then I checked her I saw a bump on her head, she was incontinent at this time .Around 4 AM I did another check I was talking to her .her wheelchair was no next to her bed she turned her back to me and never got out of bed. Statement #2: Sometime during the month of November/end of (MONTH) there was a mention of Resident #47 being on her knees and crawling into her wheelchair (back into) a sitting position. Conversation taking place near end of 600 hall between 2nd shift aides. Statement #3: .Then around 2 AM I noticed she had a bump on her head. I said to Nurse W do I need to report because it not new . The report further revealed Resident #47 continually reported that two girls picked her up. Her cognition at the time of the incident is indicated as confused. Her wheelchair was not by her bedside as she was care planned to have. The section designated for Injury of Unknown Origin was not completed. Per the facility's Fall Policy revised on 6/18 it stated, Analysis of the causative factors and rationale for interventions developed and implemented should be documented . Current facility nursing administration were unable to provide further information regarding this investigation as they were not at the facility during this time. Following this fall, Resident #47 had seven subsequent falls in her room and all unwitnessed. On 9/13/18 at 10:43 AM, an interview was conducted with CNA SS regarding the fall that occurred on 11/16/17 with Resident #47. CNA SS reported she worked 1st shift after the Resident had fallen. The CNA went into Resident #47's room to check and change her and saw that she was facing the wall which was not normal for this resident. When she was changing her, she saw the bruise on her coccyx and she immediately alerted Unit Manager F. The Unit Manager then noticed the rug burn on the Resident's forehead and the resident's eye was puffy as the day progressed her eyes bruised. CNA SS reported she was not originally assigned Resident #47, so she did not receive report from anyone. CNA reported there was no documentation that the Resident had fallen and sustained injuries. CNA SS asked Resident #47 what happened, and the Resident reported she fell and two people helped her up. On 9/13/18 at 10:57 AM, Phone contact was attempted with Nurse T whom worked until 6 PM on 11/15/17. There was no answer. On 9/13/18 at 11:01 AM, an interview was conducted with Nurse W whom stated there was no fall that occurred on their shift that was brought to their attention. She reported CNA E noticed the bump on Resident #47's forehead and stated that it was not anything new or concerning. Nurse W denied observing any discoloration around the resident's eyes. On 9/13/18 at 11:10 AM, an interview was conducted with CNA E regarding the fall that Resident #47 had in November. CNA E reported she worked 3rd shift (11/15/17-11/16/17) and provided report to 1st shift once they arrived. The CNA stated they checked everyone and there were no concerns with Resident #47. She explained the resident did not get up that morning and when she saw her last the resident was sleeping in bed and she was not facing the wall. CNA E reported when she arrived at work that evening there were staff holding a conversation and they stated Resident #47 had fallen in their bedroom and crawled to the wheelchair. CNA E was could not recall the name of the staff she heard talking. The CNA further denied an incident and accident report being completed and denied alerting a nurse to the bump on Resident #47's head. CNA E provided two variations of the incident and her statements differed between the three interviews that were conducted with her at the time of the incident. On 9/13/18 at 12:08 PM, an interview was conducted with former Unit Manager F regarding her investigation. Unit Manager F reported CNA SS called her into the room during their morning rounds and alerted her to the injuries Resident #47 had. Unit Manager F reported these injuries were never reported to her during report when she arrived at work. She reported this resident had a history of [REDACTED]. Unit Manager F explained she believes the Resident fell out of bed and crawled into the wheelchair. Unit Manager F stated there was not an assessment completed immediately following the fall as it was not reported until CNA SS noticed the Residents bruises the morning of 11/16/17. On 9/13/18 at 1:07 PM, phone contact was attempted with Nurse G who worked until 6:00 PM on 11/15/17, there was no answer. On 9/13/18 at 1:10 PM, phone contact was attempted with CNA RR, whom worked 2nd shift on 11/15/17. There was no answer. On 9/13/18 at 1:12 PM, phone contact was attempted with CNA H, who worked 2nd shift. There was no answer. On 9/13/18 at 1:14 the PM, an interview was conducted with former DON (Director of Nursing) D. DON D reported a portion of the investigation she completed is missing and explained her conclusion was Resident #47 crawled to the bottom of her bed, hit her eye on the footboard, fell and then crawled to her wheelchair. The wheelchair was not by her bed and was turned around facing the opposite direction of the bed. Former DON D explained the cameras were reviewed and the intervention following the fall was removing Resident #47's footboard. On 9/13/18 at 1:30 PM, an interview was conducted with CNA J regarding Resident #47's fall. She reported his Resident had fallen a few times and she was not a part of this incident that occurred and stated maybe it occurred on 3rd shift. CNA J stated she came in the next day and Resident #47 informed her she had fallen out of bed and then crawled to her wheelchair. On 9/13/18 at 1:35 PM, phone call was attempted with Nurse I, the number provided was no longer in service. On 9/13/18 at approximately 2:00 PM, the camera footage from the day of this incident and the remainder of the investigation was requested from the facility. The above items were not produced prior to the exit from the facility. On 9/13/18 at 2:15 PM, a record review of the progress notes from 11/15/17-11/20/17 and there was no further supporting documentation found relating to this incident. Review was completed of the facility policy entitled, Falls-Clinical Protocol, revised 6/2018, the policy revealed the following: .Provide emergency care and assessment/s as indicated .provide ongoing report at shift charge regarding updates to the plan/s of care .make referral to therapy or restorative nursing as needed .

This Citation pertains to Intake #MI 879 Based on interview and record review, the facility failed to ensure an intravenous (IV) antibiotic and wound treatment were administered, as ordered for 1 (#300 ) of 1 resident reviewed for antibiotic therapy and wound care or complete an assessment with vital signs and obtain physician's orders [REDACTED].# 305) of 2 newly admitted residents, resulting in Resident #300 experiencing a decline in condition and readmission to the hospital 2 days after admission to the facility and Resident #305 not receiving nutrition and oxygen as needed for necessary care, from the time of admission to the time of death, approximately 9 hours later. Findings Include: Review of the Admissions to the facility Policy dated 7/2017, revealed, The facility will admit only those residents whose medical and nursing care needs can be met .Admit residents who can be adequately cared for by the facility . Review of the Administering Medications Policy dated 11/28/16, revealed, Medications will be administered in a safe and timely manner and as prescribed .medications must be administered in accordance with the orders, including any required time frame . Review of the Pressure Ulcers/skin breakdown-Clinical Protocol dated 11/28/2017 revealed, .a resident with pressure ulcers receives necessary treatment and services .The plan of care for prevention and/or treatment will be developed .the physician will authorize pertinent orders related to wound treatments . Resident #300 The Centers for Disease Control (CDC), (MONTH) (YEAR) update, CRE Toolkit, Facility Guidance for Control of Carbapenem-resistant [MEDICATION NAME] (CRE), provided the following: Control of resistant organisms is a national problem and requires that facilities that share patients work together to prevent transmission .The emergence and dissemination of carbapenem resistance among [MEDICATION NAME] in the United States represents a serious threat to public health. These organisms cause infections that are associated with high mortality (death) rates and they have the potential to spread widely .Invasive infections (e.g., bloodstream infections) caused by CRE have been associated with high mortality rates (up to 40 to 50% in some studies) .facilities should work to ensure that antimicrobials are used for appropriate indications and duration . CDC, 1/23/2018, What [MEDICAL CONDITION], 'Sepsis is the body's extreme response to an infection. It is life-threatening, and without timely treatment,[MEDICAL CONDITION] can rapidly cause tissue damage, organ failure, and death.[MEDICAL CONDITION] happens when an infection you already have - in your skin, lungs, urinary tract or somewhere else - triggers a chain reaction throughout your body .Symptoms [MEDICAL CONDITION] can include a combination of any of the following: Confusion or disorientation, Shortness of breath, High heart rate, Fever, or shivering, or feeling very cold, Extreme pain or discomfort, Clammy or sweaty skin . Research shows that rapid, [MEDICAL CONDITION] treatment, which includes giving antibiotics, maintaining blood flow to organs, and treating the source of infection, can save lives. Review of the face sheet and Minimum Data Set (MDS) assessment, revealed Resident #300 was initially admitted to the facility on [DATE] and discharged to the hospital on [DATE], with readmission to the facility on [DATE]. Resident #300's [DIAGNOSES REDACTED]., including the blood stream). Resident #300 was transferred back to the hospital on [DATE] for a change of condition with increased confusion. Review of the hospital discharge instructions dated 4/17/18, indicated the resident was to receive an IV antibiotic (Avycaz ([MEDICATION NAME]/avibactam)) for the infections, for 8 more days, from 4/17/18 through 4/24/18. The physician's History and Physical (H&P), dated 4/18/18 at 9:16 am, completed by Doctor X revealed, Patient is being assessed for his readmission H&P after a hospital stay for [MEDICAL CONDITION], wound infection and UTI .ID (Infectious Disease Doctor Y) evaluated patient for wound infection of the hip and UTI. He was sent back here with plans for 8 more days of IV antibiotics .He (Resident #300) is alert but not speaking to me much . Review of a Nurses note, dated 4/17/18 at 3:40 p.m., To (facility via ambulance) place in bed .oriented to room call light .history [MEDICAL CONDITION] .resting in bed quietly . Review of the physician order [REDACTED].#300 was ordered IV [MEDICATION NAME]-avibactam (Avycaz) 1.25 grams every 8 hours, everyday for 8 days at 7:00 am, 3:00 p.m. and 11:00 p.m The order was discontinued on 4/18/18 and re-ordered on [DATE] for a scheduled start on 4/19/18. A review of the Medication Administration Record [REDACTED]. The nurses documented, Code 9- other see progress note. Further review revealed that Resident #300 had missed at least 4 doses of the prescribed antibiotic. Review of the Nurses Progress note written by Nurse Z, dated 4/17/18 at 11:50 p.m. revealed, [MEDICATION NAME]-Avibactam Solution .awaiting pharmacy. Review of the Nurses Progress note written by Nurse K, dated 4/18/18 at 1:17 p.m. revealed, [MEDICATION NAME]-Avibactam Solution .medication on order. Review of the Nurses Progress note written by Nurse U, dated 4/18/18 at 4:10 p.m. revealed, Order update due to ABT (antibiotic) processing. During an interview on 5/17/18 a 12:20 p.m., when asked about the missing antibiotic for Resident #300, Nurse U stated, I was helping to put the orders in the computer on (4/17/18), because we were overloaded and needed help. I called the pharmacy on 4/18/18 on 3rd shift, because I had (Resident #300) it (IV antibiotic Avycaz) still wasn't here. Pharmacy said it was a special order. I talked to the (Resident #300's family) and they didn't understand how (Resident #300) could come here and not get his antibiotic. During an interview on 5/17/18 at 11:45 a.m., Director of Nursing B (DON) revealed, The antibiotic (IV antibiotic Avycaz), I believe the pharmacy had to get it from somewhere else. I believe the day after he got here that I found out about it. I believe the nurse is supposed to contact the physician. That did not happen. During an interview on 5/17/18 at 1:55 p.m., Confidential Person BB stated, The resident (Resident #300) did not receive the IV antibiotic as ordered between (4/17/18) and (4/19/18). He is still in the hospital. He has been there for 28 days. During an interview on 5/17/18 at 12:00 p.m. when asked how IV antibiotics are ordered, Nurse V stated, We have a whole back up system. We don't have everything. We have stuff to mix IV's. We can call pharmacy, and have it drop shipped, for example unusual meds. On the weekends and evenings its pretty much the same thing. For orders, the nurse calls the physician once they (the resident) gets here. Review of Resident #300's Nursing Evaluation Data (assessment), dated 4/17/18 at 3:40 p.m., indicated Yes, Drug resistant infection present, and a Left trochanter (hip/thigh) Pressure Ulcer Stage IV (4). Review of Resident #300's Care Plans failed to reveal a care plan to address the resident's infections. Further review of the care plans revealed there was no urinary care plan in place. Further review of Resident #300's medical chart revealed there was also an order [REDACTED]. Review of the Treatment Administration Record (TAR) for (MONTH) (YEAR), indicated the wound treatment was not applied on 4/17/18-4/19/18. Review of the nurse notes dated 4/18/18 at 12:52 p.m. and 1:18 p.m. revealed, Orders-Administration Note, Santyl ointment, medication on order. Review of Resident #300's Care Plans revealed the wound care plan had not been updated since 3/19/18. Further review of the progress notes from 4/17/18-4/19/18 did not indicate Resident #300's physician had been notified that the IV antibiotic or wound treatment were not available for the resident's care. A progress note, by Nurse Practitioner AA, dated 4/19/18 at 4:10 am, .aggressive and combative when interaction attempted .Patient is having increased confusion with behavior. Non-verbal-refusing to eat/drink per family .Patient has had an acute change-non-verbal and combative. Will send to (hospital) . Hip wound infection, on 8 more days of [MEDICATION NAME]-avibactam via PICC (peripherally inserted central catheter) line, to receive first dose today .Per (family) patient was talking and feeding himself prior to readmission to facility . Resident #305 Review of the Hospital Discharge Instructions, revealed Resident #305 was to receive Oxygen 2 liters/minute via nasal cannula and a continuous tube feeding of Glucerna 1.5 at 45 milliliters (ml) an hour via an electronic pump. Resident #305 was to have nothing by mouth (NPO). Review of Resident #305's medical record failed to reveal an order for [REDACTED]. During an interview on 5/17/18 at 3:30 p.m. when asked what time Resident #305 was admitted to the facility, Admission's Director (AD) P stated, (Resident #305) had to come after I left. It would be documented in the admission book at the front desk. AD P provided a copy of the front desk admission book page, dated (MONTH) 16th, (YEAR) and it indicated Resident #305 entered the facility via emergency medical services at 6:55 p.m The AD added, We had 7 admissions yesterday (5/16/18) between 12:00 p.m. and 7:00 p.m That is normal. We are supposed to have an Admissions Nurse, be we don't. During this same interview, AD P stated The (hospital Social Worker) initially called us on Monday (5/14/18). Yesterday (Wednesday, 5/16/18) I got the call (Resident #305) would be coming. He had a Peg tube (feeding tube), Tube feeding (continuous over 24 hours on a pump), oxygen and wounds. They were listed in the clinical documents provided by the hospital. An interview with Nurse W on 5/17/18 at 3:00 p.m. revealed, I had a resident (Resident #305) die last night. I didn't have the resident when he was admitted . I was assigned because we didn't have enough staff. There were 7 new admissions yesterday. I was not able to do much with him because I had to deal with a resident who fell and had an injury. The aide came and got me and said he wasn't breathing. During an interview on 5/17/18 at 3:15 p.m., Resident #305's medical record was reviewed with Nurse W. Review of the medical record failed to reveal that vital signs were documented. Further review of the medical record revealed there were no assessments, progress notes or care plans in the medical record. The Nursing Evaluation Data (assessment), dated 5/16/18 at 11:41 p.m., was opened, but without any assessment information. During the interview, Nurse W confirmed the documents were not present. During this same interview Nurse W stated she gave Resident #305 2 medications, the breathing treatment and Insulin. When asked why there was no assessment documented of vital signs or lung sounds, including the resident's response to the breathing treatment, Nurse W indicated she was busy with the other resident who fell and stated, I didn't have an order for [REDACTED]. 4:00 p.m., the DON stated, We needed at least 1 more nurse yesterday. There are no vital signs or progress notes on admission (for Resident #305). There aren't any Tasks (to guide nurse aide care) or care plans. They weren't triggered yet. The nursing assessment was not completed and the orders were not completed either. During the interview, the DON was queried about how many admissions the nurse for Resident #305 had during her 8-hour shift and stated, She's new (Nurse M). It's her first week off orientation. She had 3 admissions yesterday. When queried why there were no vital signs taken or additional assessment data documented, the DON replied, The CNA (certified nursing assistant) usually takes the vital signs on admission. It wasn't documented. When further queried about the lack of documentation that the physician was contacted, for admission orders [REDACTED]. The DON was queried who the CNA was for Resident #305 and stated, I'd have to check. During an interview on 5/17/18 at 4:00 p.m., when asked about the lack of physician orders, resident assessments, and documentation for Resident #305, Director of Nursing (DON) B stated, We needed at least 1 more nurse yesterday. There are no vital signs or progress notes on admission (for Resident #305). There aren't any Tasks (to guide nurse aide care) or care plans. They weren't triggered yet. The nursing assessment was not completed and the orders were not completed either. DON B went on to state, She's new (Nurse M). It's her first week off orientation. She had 3 admissions yesterday. When asked why there were no vital signs taken or additional assessment data documented, DON Breplied, The CNA (certified nursing assistant) usually takes the vital signs on admission. It wasn't documented. When asked about the lack of documentation that the physician was contacted for admission orders [REDACTED]. During an interview on 5/17/18 at 5:08 p.m., when asked why there was no clinical documentation of vital signs, assessments, progress notes or physician notification for orders, from the time Resident #305 was admitted to the facility at 6:55 p.m., until death at approximately 4:00 am Nursing Home Administrator (NHA) A stated, I spoke with the Nurse (Nurse M) she is going to come in and document her charting (late entries). She is a new nurse. She just came off orientation. When asked how a Nurse could write late entries for everything in the medical record, the Administrator did not respond. On 5/17/18 at 6:18 p.m., contact with Doctor X was attempted via phone. A message was left. On 5/17/18 at 4:30 p.m., contact with Nurse M was attempted via phone. A message was left.

Based on observation, interview and record review, the facility failed to operationalize assessment data and implement a plan of care to prevent falls with fracture and hospitalization for 1 (#205) of 3 residents reviewed for falls, from a total sample of 6 residents, resulting in Resident # 205 falling repeatedly while attempting to transfer and toilet herself, until she fell and fractured her hip. Findings Include: On 3/22/18 at 1:45 pm, a review of the face sheet, progress notes, care plans, physician orders, Minimum Data Set (MDS) assessment, therapy notes and physician notes for Resident #205, revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with Diagnoses: [REDACTED]. The MDS dated [DATE], indicated the resident had severe cognitive impairment and needed 1-person assistance with all care, including, transfers, toileting and walking. Review of the Incident and Accident Report dated 3/20/18 at 4:10 pm revealed that Resident #205 fell in her room while trying to toilet herself. The resident complained of severe right hip pain. X-rays were positive for a right femur fracture and the resident was transferred to the hospital on [DATE] at 7:45 am. Review of the Provider Notes written by the Nurse Practitioner, dated 3/21/18 at 8:28 am, revealed that the resident was crying after being told of the new [MEDICAL CONDITION], prior to transfer to the hospital. Review of the medical record revealed that Resident #205 had previously fallen on 1/8/18, and twice on 3/9/18. After the two falls on 3/9/18 a therapy evaluation was ordered. A review of the Occupational Therapy Evaluation, dated 3/13/18, revealed that Resident #205 had fallen twice on 3/9/18 and needed moderate assistance with toileting. This assessment was inline with Resident #205's MDS assessment dated [DATE] that revealed Resident #205 required 1-person assistance with toileting . There was only one Incident and Accident Report dated 3/9/18, review of the report revealed, The resident suffered a laceration above her eye and proceeded to experience shoulder and clavicle pain. A review of Resident #205's care plans failed to reveal that the intervention of, moderate assistance with toileting was added to any care plan. Neither the Safety care plan, ADL care plan nor Mobility care plan addresses the resident needing 1 person assistance with toileting, as assessed in the most recent MDS. There was no toileting care plan. A review of the medical record revealed the following care plans and interventions: Mobility: Impaired mobility status, dated 11/10/16, Transfers: 1-person assist with gait belt with verbal and physical direction due to significant visual impairment. ADL's (activities of daily living), the resident has an ADL self-care performance deficit related to visual impairment and chronic pain, 8/9/17, Transfers: The resident uses a walker to maximize independence with transferring, dated 10/25/17. Blind: legally blind in both eyes, dated 11/10/16. Safety: at risk for falls related to limited mobility and visually impaired, dated 7/24/17, offer to toilet upon rising between meals, prior to laying down and as needed, dated 8/9/17, give verbal step by step instruction for walking past bathroom door and turning around to get into bathroom, dated 8/9/17, assess commode and handles to provide more stable commode on re-admit, dated 3/21/18. On 3/22/18 at 2:05 pm, Resident #205's room was observed to have a bedside commode directly next to the bed. A rocking chair was next to the head of the bed and a rolling walker and wheelchair were also in the room. The resident shared a room and both residents also shared a bathroom. On 3/22/18 at 2:10 pm, CNA's T and U were asked what measures staff was using to prevent Resident #205 from falling, Certified Nursing Assistant (CNA) T stated, Mostly cueing, assistance with toileting to the commode chair. When asked about the commode chair being at the foot of the resident's bed, CNA T stated, It was easier for her to make it (to the toilet). CNA U stated, She normally does it herself. She's been needing more and more help. The day we had 2 fires in the building (3/9/18) she fell twice. Smoke started pouring out of the ceiling near the 100 -hall and the 700-hall shower room smelled like burning wires. We got everyone out of here. I noticed she had been wetting herself more and more. She's usually pretty continent. On 3/22/18 at 2:20 pm, an interview with Nurse R provided, I was here when we sent her out (3/21/18). She had 2 falls too, I think on the 9th (March 9th). Her commode goes at the foot of the bed. The Care Plan should say she transfers herself. We put the commode at the foot of the bed, because she cannot see her way to the bathroom. Nurse R seemed to not be aware of the MDS assessment nor the Occupational Therapy assessment stating Resident #205 required assistance of 1 for toileting. An interview with Nurse S, on 3/22/18 at 2:30 pm revealed, I worked on the day of the fall. The girls called me. They wanted me to come ASAP and I did. I was assigned to the 700 hall, with 3 rooms on the 600 hall. When queried what fall prevention measures were in place for Resident #205, Nurse S stated, Call light next to her. She has a visual impairment and has to be reminded to use the call light and needed assistance to get on the commode. She would attempt to get up on her own. She would reach out and feel for the commode. When Nurse S was asked if the commode chair next to the bed encouraged the resident to try to get up on her own, she stated, The commode chair was always there. An interview with the Administrator on 3/22/18 at 5:20 pm revealed, The care plans were updated after the falls. When asked about the resident's repeated falls, with 2 on 3/9/18, prior to the final fall with [MEDICAL CONDITION], the Administrator had no response except to say the resident had been evaluated by therapy. The Administrator did not address why there was no toileting care plan or why staff did not know both therapy and the MDS assessed the resident to need assistance with toileting and was not able to transfer herself to the bedside commode safely On 3/22/18 at 5:30 pm, a review of the facility policy titled, Accidents and Incidents-Investigating and Reporting, dated 12/1/17 revealed, Regardless of how minor an accident or incident may be .it must be reported to the department supervisor .a Report of Incident/Accident must be completed for all accidents or incidents .The following data, as it may apply, must be included .date and time of incident, circumstances, where it took place .notification of physician and family .corrective action .follow-up information. A policy for Fall Prevention was requested at 2:00 pm and not received prior to exit.

Based on interview and record review, the facility failed to ensure that a staff member did not give crackers to 1 (#701) of 3 residents with dietary restrictions, from a total sample of 3, resulting in Resident #701 choking, falling, dislodging his feeding tube and hitting his head, suffering from a hematoma and hospitalization . Findings include: On [DATE] at 3:45 p.m., an interview was completed with Family Member A. According to Family Member A, she received a call that resident #701 had been given crackers, choked and had fallen and had to be sent to the hospital to replace his tube feeding. Family Member A stated, I asked them (the facility) to put up a sign so everyone knew that he (resident #701) was not to receive anything by mouth, but they refused. I had witnessed them (facility staff) several times offer him food and I would have to remind them that he could not have food. Family Member A stated, When they gave him (resident #701) crackers, the lady across the hall from him seen that he was choking and called for help. He ended up falling and had to go to the hospital. The day after he got back from the hospital he died . I feel like if he wouldn't have been given those crackers and choked, he wouldn't have fallen and possibly would not have died . On [DATE] at 8:00 a.m., a record review of the face sheet and Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed that the resident had mild cognitive impairment and had a tube feeding (an artificial tube surgically inserted in the stomach to provide nutrition). On [DATE] at 8:55 a.m., a review of a physician orders revealed the following: NPO diet (nothing by mouth), dated [DATE]. Osmolite 1.5 80 ml (milliliters) per hour via J-tube (feeding tube), dated [DATE]. Chest X-Ray (to rule out aspiration pneumonia). Ordered [DATE]. On [DATE] at 9:00 a.m., a review of nurse practitioner/physician assistant (NP/PA) note dated [DATE]: (Resident #701) is being seen for pain assessment and new admission assessment. Resident was admitted to this facility status [REDACTED].after his most recent hospitalization he was discharged and returned again due to a sensation of choking this lead to placement of (tube feeding) . Treatment: 1. Dysphagia Nothing by mouth. On [DATE] at 9:05 a.m., a review of Speech therapy notes revealed: Speech therapy evaluation dated [DATE]: Precautions: Aspiration. Recommendations: Intake-Diet recs (recommendations)-solids=NPO. On [DATE] at 2:45 p.m., an interview with Registered Nurse (RN B) who was in charge of Resident #701 at the time of the fall on [DATE] was completed. RN B stated, Another resident was screaming for help (for resident #701). I went into his (resident #701's) room and he was lying on the ground moaning. He had a bump and an abrasion on his head. There was orange stuff (food) coming out of his mouth and I looked and seen a wrapper (crackers) on the floor. He (resident #701) said he was scared because he was choking. (Dietary Aide C) did not know he couldn't have anything by mouth and asked him (resident #701) if he wanted anything (from the snack cart) and of course he wanted crackers so she gave him some. RN B was queried in regards if she witnessed resident #701 choking and stated, No, I didn't even have to do a finger sweep or anything. On [DATE] at 3:15 p.m., an interview with Dietary Aide C who was passing out snacks on [DATE] was completed. Dietary Aide C stated, I didn't have the book that normally would tell me what everyone's diet is and if they (the residents) are NPO or not. Someone was working on the pages in the book. I asked (Resident #701) if he wanted anything, he wanted crackers so I gave him some. He opened the package and then I left the room. A few hours later I was told he choked and he wasn't supposed to eat anything by mouth. On [DATE] at 3:30 p.m., an interview with the Director of Nursing (DON) was completed. The DON stated, They (the facility) called me and told me that a dietary staff gave (Resident #701) crackers. We reviewed the policy and procedure. She (Dietary aide C) said she didn't check the ticket (diet order). She was very upset, so much that she was going to resign. She was crying and everything and had only been employed here for a few months. I know that when he (Resident #701) fell his tube feeding became dislodged. On [DATE] at 3:40 p.m., a review of the incident report completed by RN B for Resident #701 dated [DATE] revealed the following: (Resident #701) was given food, he is NPO. (Resident #701) ate crackers and started to cough. States he stood up and then fell forward. He has a goose egg bump x 2 on right side of head and temporal area. Also removed (feeding tube). On [DATE] at 3:45 p.m., a review of the statement written by Dietary Aide C stated, I did not check his (Resident #701's) order prior to giving him the crackers . Review of a Nurses note dated [DATE]: (Resident #701) Sent to hospital secondary from fall and dislodgment of feeding tube. Review of a Physician note dated [DATE]: Possible aspiration-(Resident #701) had a persistent cough which has now improved. Lungs: Coarse to auscultation bilateral (abnormal breath sounds). Treatment: Cough suspect for aspiration pneumonia (a type of pneumonia from choking or food entering the lungs). Repeat chest X-Ray for comparison to rule out aspiration pneumonia On [DATE] at 3:55 p.m., a review of the hospital discharge notes for Resident #701 dated [DATE] revealed: Per report patient was given crackers by staff (facility) and due to his (Resident #701's) history of dysphagia was unable to swallow started to choke and fell out of his chair during this episode he hit the right side of his forehead. Cat Scan of brain results: Small right parietal scalp hematoma without underlying fracture, or intracranial hemorrhage. On [DATE] a review of the resident's care plan titled, The resident requires J-tube feeding r/t (related to) Dysphagia, dated [DATE] revealed the following: Goal-The resident will be free of aspiration . Interventions-The resident is dependent with tube feeding and water flushes. See MD (medical doctor) orders for current feeding order. Monitor/document/report to Nurse/MD PRN (as needed) any s/sx (signs and symptoms) of aspiration (food contents in lungs from choking) . On [DATE] at 3:20 p.m., the Administrator was interviewed regarding the facility's NPO policy and stated, that she was aware of resident #701 receiving food when he was NPO. The Administrator stated, We re-educated the dietary aide. On [DATE] at 4:00 p.m., a review of the facility policy titled, Enteral Nutrition revised [DATE] stated, 8. The nurse will confirm that there are appropriate by mouth (PO) or nothing by mouth (NPO) orders for all residents with tube feedings. 9. The decision to allow or disallow PO will be made in conjunction with the physician, Registered Dietician, and the Speech Therapist, as appropriate given resident [DIAGNOSES REDACTED].

Based on observation, interview and record review, the facility failed to complete Norton assessments (a tool used to identify the risk for developing pressure ulcers), perform routine/scheduled skin assessments, provide resident education for the prevention of pressure ulcers (PU), and implement interventions for the prevention of pressure ulcers for two (#s 707 and 714) of six sampled residents reviewed for pressure ulcers, out of a total of 23, resulting in facility acquired pressure ulcers with the potential for the delay in healing, worsening and the development of new pressure ulcers. Findings include: On 6/7/16 at 7:10 p.m., Resident #714 was observed lying in bed on her left side asleep. On 6/8/16 at 9:30 a.m., Resident #714 was observed lying flat on her back asleep resting on a pressure reduction mattress. A neck cushion/pillow was noted around her neck as she slept. On 6/8/16 at 10:10 a.m., a wound observation was conducted on Resident #714's facility acquired pressure ulcer (PU) located on her left lower posterior (back) scalp with the Unit Manager (UM F). The UM F used Resident #714's neck pillow to help position her for the treatment. UM F then removed the existed dressing. Yellowish/beige drainage was noted on the dressing. It was a moderate amount of slough (A layer or mass of dead tissue separated from surrounding living tissue) noted. When asked what stage it was, UM F stated, It is a stage III (full layer of skin is destroyed. A stage III PU extends into the underlying subcutaneous tissue layer). The UM went on to cleanse the wound the wound with normal saline, dried it with a gauze, and recovered the wound with an occlusive dressing. On 6/8/16 at 1:40 p.m., UM F, the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Administrator were interviewed regarding Resident #714's facility acquired pressure ulcer. The ADON stated, We discovered this wound after she complained of discomfort in that area. We talked to the doctor and [MEDICATION NAME] (antibiotic ointment) was ordered to the scalp area. When queried about when the PU was first noted, the ADON reported that there was documentation in the nurses' notes that indicated the wound was noted on 5/9/16 and the area was treated with [MEDICATION NAME] for the time period of 5/5/16 - 5/14/16. Resident #714's Norton assessments (tool/assessment used to identify the risk of developing PU) were requested. The DON and the Administrator stated, We are not able to find any since her re-admission into the facility on [DATE]. Resident #714's skin assessments were then requested for the time period surrounding the development of the facility acquire PU. The Administrator and the DON were unable to locate skin assessments in Resident #714's electronic medical record. The Administrator stated, We will look for her shower sheets. Review of Resident #714's shower sheets for the month of May 2016 revealed a total of three. The shower sheets were dated for 5/2, 5/5, and 5/30. The documentation of the PU was noted only on the 5/30 shower sheet. There were no shower sheets for the time period of 5/5 - 5/29/16. Resident #714's physician's orders [REDACTED]. Resident #714's Skin Care Plan was then reviewed with DON, ADON, Administrator, and UM F. The skin care plan titled Skin: Impaired skin integrity R/T (related to) multiple open areas bilateral legs due to [MEDICAL CONDITION]/[MEDICAL CONDITION]/[MEDICAL CONDITION], also related to head, dated 4/21/16, was reviewed. When queried regarding the date that included the area of the head on 4/21/16, the DON reported that the computer's program would not allow them to alter the care plans date to indicate the PU to the scalp developed on date later/after 4/21/16. The DON stated, May 25 th was the last time the care plan was updated. The Skin care plan revealed the following interventions related to the prevention of the scalp PU: - Monitor for signs of discomfort with dressing changes .(dated 4/21/16) - Monitor for signs of infection .(dated 4/21/16) - Turn, reposition and provide incontinent care every 2 hours attempting to keep off affected area (dated 4/21/16). - Monitor effectiveness of treatment and make changes as needed (dated 4/21/16). - Treat affected area as prescribed by MD. - Try to avoid use of cervical neck pillow (dated 5/9/16). Review of Resident #714's Nurse Practitioner's progress note, dated 5/9/16 at 12:24 p.m., revealed the following documentation related to the pressure ulcer: Continues to have open area to back of head, spends a lot of time in bed .Previous incisional line has small wound with yellow base .Small wound with yellow base, will have nursing to apply [MEDICATION NAME] ointment daily to area. May be related to use of neck pillow and previous incisional line .At risk for worsening, infection. Encourage pt (patient) to lie on side, spend more time out of bed due to pressure that is applied once lying down. On 6/8/16 at 2:40 p.m., review of Resident #714's Wound Note, dated 6/7/16, revealed the following size and description of the wound: Type of Wound: Pressure. Date first observed: 5/11/16. Acquired. Evaluation date: 6/7/16. Location: head. Length/Width/depth: 1.0/1.1/0.2 cm (centimeters). Thickness/Stage II (superficial open sore in the upper layer of skin, superficial with a pale pink wound bed and serous, never serosanguinous drainage). Type of tissue: Slough. Wound bed: 70% slough. Exudate: Sero-sanguinous. Exudate Amount: Light. Surrounding Skin: [DIAGNOSES REDACTED]/Redness-Blanchable + Hardness/Induration. Wound edges: Unattached. Resident #714's initial Wound Notes (5/18/16) were compared to the most current Wound Notes (6/7/16). A decline in the pressure ulcer was noted. The notes indicated the PU had worsened over the last 21 days. The Wound Note, dated 5/18/16, revealed the following documentation: Length/Width/Depth: 0.6/0.5/0.10 cm. Tissue Type: [MEDICATION NAME]. Wound Bed: Slough 10%. Exudate Amount: None. Wound Edges: Attached. Surrounding Tissue: [DIAGNOSES REDACTED]/Redness-Blanchable. The Wound Notes did not indicate any history of debridements (the removal of nonviable tissue). Resident #714's face sheet indicated an admission into the facility on [DATE] and a re-admission on 4/14/16 with [DIAGNOSES REDACTED]. Resident #714's most current quarterly Minimum Data Assessment (MDS) assessment, dated 4/29/16, indicated an intact cognition and that she required extensive assistance with activities of daily living (ADLs). The MDS assessment also indicated that Resident #714 required extensive assistance for bed mobility with physical assistance of two persons. Resident #714 was observed lying on her left side with her neck cushion around her neck on the following dates and times: On 6/9/16 at 12:35 p.m., Resident #714's Certified Nursing Assistant (CNA E) was interviewed regarding Resident #714's repositioning and the use of the neck pillow. CNA E stated, It's easier for her to be on her left side. I noticed when she is up she leans to her left. She uses the pillow to help keep pressure off her scalp. I did not know that she was not supposed to use it. CNA E was asked to observe Resident #714's position at this time. CNA E observed Resident #714 lying/leaning on her left side. 6/7/16 at 7:10 p.m. 6/8/16 at 4:45 p.m. 6/9/16 at 9:45 a.m. 6/9/16 at 11:50 a.m. 6/9/16 at 12:35 p.m. On 6/9/16 at 1:00 p.m., UM F stated, She (#714) prefers to wear the neck pillow. She refuses to turn on her side due to complaints of dizziness. I did not know this until today. We thought the neck cushion applied more pressure. That is why we did not want her to use it. She (#714) wants the neck cushion. We just (today) discussed with her the risk versus the benefits of using the neck pillow. When queried if Resident was informed on not to use the neck pillow and if she was included or in agreement with the intervention to not use the neck pillow, UM F reported that she did not know. When asked why Resident #714 did not have a non-compliance care plan for refusals of care, UM F stated, No. On 6/8/16 at 12:35 p.m., record review revealed that Resident #707 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set ( MDS) assessment dated [DATE], Resident #707 had a severely impaired cognition and required extensive assist with dressing and personal hygiene and was completely dependent with transfers, bed mobility and bathing. Resident #707 needed limited assistance with eating. On 6/9/16 at 8:10 a.m., wound care was observed with Unit Manager D and revealed a wound that measured 0.9 centimeter (cm) x 0.9 cm x 0.2 cm. The wound was clean and no drainage noted at the time. The wound bed had some bleeding in the middle, however the top of the wound had yellow slough (dead tissue). Unit Manager D cleansed the wound and applied the dressing as ordered by the physician. On 6/9/16 at 9:00 a.m., record review revealed that on 5/14/16 at 10:08 a.m., the wound was first documented in the nurses notes and stated, Stage 3, 1.5 cm x 1.5 cm pressure ulcer was observed this morning on her right inner ankle. Tx (treatment) is in computer. Area was cleansed with NS (normal saline), pat dry, bordered foam dressing applied. Dr. was made aware. A physician order [REDACTED]. On 6/9/16 at 3:00 p.m., review of the Shower Aide Skin Assessment Forms revealed the following: 3/21/16 scab noted to left inner ankle 4/4/16-sore noted to left inner ankle 4/21/16-scab noted to left inner ankle 5/9/16-severe swelling in ankle 5/12/16-2 open areas noted to left inner ankle 5/16/16-open wound and small sore noted to left inner ankle All forms were signed by a nurse and a nurses aide. On 6/9/16 at 3:30 p.m., the Director of Nursing (DON) was queried regarding the resident's wound and skin assessments. The DON stated, Honestly, this has been something on my radar for the past two weeks. We just aren't doing good skin assessments. On 6/9/16 at 3:45 p.m., review of the facility's policy titled, Prevention of Pressure Ulcers, Reviewed/Revised 03/23/2011, revealed revealed the following documentation: Under #6, The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family and addressed. Identify risk factors for pressure ulcer development. On 6/9/16 at 3:55 p.m., the following policies were reviewed: The facility's policy titled Pressure Ulcer Risk Assessment, revised 3/23/1011, revealed the following documentation: The purpose of this procedure is to provide guidelines for the assessment and identification of residents at risk of developing pressure ulcers. A pressure ulcer risk assessment will be completed upon admission, with each additional assessment, quarterly, annually and with significant changes. Staff will maintain a skin alert, performing routine skin inspections daily or every other day as needed. Nurses will conduct skin assessments at least weekly to identify changes. The admission evaluation helps define those initial care approaches. The facility's policy titled Repositioning, revised 3/24/2013, revealed the following documentation: Repositioning is critical for a resident at risk of friction or shearing during repositioning .Positioning the resident on an existing pressure should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing. Residents who are in bed should be on an every two hour turning plan based on individual assessment. For residents with a stage I or above pressure ulcer, every two hour turning may be inadequate. Notify the supervisor if the resident refuses the procedure. The facility's policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol, reviewed/revised 3/23/2011, revealed the following documentation: The physician will help the staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. ( / )

This citation pertains to MI 778 and MI 786. Based on interview and record review, the facility failed to provide supervision and interventions to prevent a laceration for 1 (Resident#2) and prevent a fall for 1 (Resident #5) resident of 2 sampled residents reviewed for falls and accidents, from a total of 7 sampled residents, resulting in Resident #2 sustaining a laceration on her leg that required 10 sutures and Resident #5 falling to the floor. Findings include: Resident #2 Review of the face sheet and the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was a [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #2 had clear speech, was sometimes understood, sometimes understands, was severely impaired cognitively and required extensive assistance of 2 people for transfers. Review of the incident and accident form dated 10/16/15 revealed, (Resident #2) was being transferred using a sit to stand lift - leg was bumped and began bleeding. Further review of the form revealed that Certified Nursing Assistant (CNA) E was putting Resident #2 to bed when Resident #2 Hit left leg (calf) on the bed frame and the bed had a missing plastic guard. Further review of the form revealed that Resident #2 suffered a laceration to the left mid calf, and was sent to the hospital. Review of the medical chart, failed to reveal that any type of assessment of Resident #2's left leg was documented, including the appearance and the size of the laceration. In fact, it was not until 10/21/16, 5 days after the incident that an assessment was documented in the medical chart. Review of that wound note revealed, that the laceration measured 10.5 centimeters and required 10 sutures. Review of Resident #2's mobility/activities of daily living care plan dated 12/11/13 revealed that Resident #2 required a Sit to Stand and 1 person assist for all transfers. During an observation on 2/24/16 at 9:30 a.m., CNA E demonstrated how Resident #2 was sitting on the middle of the bed. CNA E stated that she needed to move Resident #2 further towards the head of the bed, I was attempting to get her up and when I twisted (Resident #2) is when her leg caught the edge of the frame and caused her leg to be cut. CNA E pointed to a portion of the bed frame, which had a plastic end cap on it and said, It was that piece of plastic that was missing. When asked why she did not use the Sit to Stand Lift to position Resident #2 further up in the bed, CNA E stated, I had just used it for her, I have done this before and we have never had issues. During on observation on 2/23/16 at 2:10, with Assistant Director of Nursing present, a scar was observed on Resident #2's left leg. The scar measured about 12 centimeters, it started at the middle of Resident #2's calf, and wrapped around and up to the outer aspect of Resident #2's leg. Resident #2 did not have any recollection as to what happened to her leg. Resident #5 Review of the face sheet and most recent Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #5 was a [AGE] year old resident readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #5 had clear speech, was understood, understands, was moderately impaired cognitively and required extensive assistance for activities of daily living. Review of the incident and accident report dated 12/18/15 revealed that Resident #5 had suffered a fall when he was attempting to transfer himself form the his wheelchair to his bed. Further review of this report revealed that new interventions of applying pressure alarms to Resident #5's bad and wheelchair were initiated. Review of Resident #5's falls careplan revealed that the intervention of pressure alarms to bed and wheelchair were not initiated until 12/21/15, 3 days after Resident #5 suffered the initial fall. Review of the incident and accident report dated 1/3/16 revealed Resident #5 was, noted to be on floor seated on bottom at end of bed on floor near wheelchair; stated he went to sit down and slid to the floor. Further review of the report, in the Were Planned Interventions in place, the box next to no was checked, Alarm not in place on wheelchair at time of transfer, staff educated on need to check alarms are in place at start of shift. ( )

This citation pertains to intake number(s) MI 786, MI 789, MI 932, MI 778, MI 885 and MI 783. This citation has 2 DPS statements A. and B. A. Based on interview and record review, the facility failed to ensure a resident received the necessary care and services to maintain the highest practicable well-being for 1 (Resident #6) of 1 resident reviewed for post operative care, from a total sample 7 residents, resulting in Resident #6 not being seen by her orthopedic surgeon in a timely manner. Review of the face sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #6 was an [AGE] year old female resident admitted to the facility on [DATE] for rehab following left hip surgery. Review of the MDS revealed that Resident # 6 had clear speech, was understood, understands and was cognitively intact. Review of the hospital discharge instructions dated 1/3/16 revealed, Follow up with Ortho (orthopedics) to have staples removed in 10 days. Review of the medical record revealed that it was not until 1/27/16 that a follow up appointment was made for Resident #6. The appointment was made for 1/29/16. Review of the progress note dated 1/15/16 revealed, Need (follow up) with Ortho to remove staples . During an interview on 3/1/16 at 10:05 a.m., Director of Nursing (DON) B stated, I called the ortho doctor's office and that appointment (on 1/29/16) was not made until the 26 th (1/26/16). ( ) B. Based on observation, interview and record review, the facility failed to ensure residents received the necessary care and services to maintain the highest practicable well-being by not administering medications in timely manner for 5 of 5 (Residents #2, #3, #4, #5 and #7) residents and 2 supplemental residents (#8, #11) reviewed for medication administration from a total sample of 7 residents, resulting in Resident #5 suffering 3 [MEDICAL CONDITION], Resident #7 having uncontrolled pain and not being able to participate in therapy, and the remaining resident having the potential for inconsistent medication administration, and adverse effects on not receiving a prescribed medication. Findings Include: Review of the facility's Medication Administration-General Guidelines dated October 2015 revealed, Medications are administered in accordance with written orders of the attending physician .Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered, based on mealtimes . Review of the facility's Medication Discrepancy Reporting Policy dated January 2015 revealed, Upon notification of a medication error either pharmacy or nursing: the nurse will complete the following: 1. Complete a Medication Discrepancy Report . During an interview on 3/1/16 at 1:05 p.m., when asked if a medication was administered late, should it be treated as a medication error, Director of Nursing (DON) B stated, If it is a timed medication then the nurse should treat it like a medication error, should call the doctor, and see when the next dose is due. Upon entry into the facility, this surveyor requested to see all the medications errors for the month of January and February, and only received 1 Medication Discrepancy Report. During an interview on 3/1/16 at 1:50 p.m., when asked if there were any other Medication Discrepancy Reports related to medications being administered late, Director of Nursing (DON) B stated, I have the one, that is all I have for late medications. During an interview on 2/24/16 at 11:00 a.m., when asked if medications were routinely delivered late to residents, Registered Nurse (RN) F stated, Yes, recently .after getting report on all of the residents, I would be late to the floor, and would already be an hour behind, and so I was late with med's (medications) .I focus on the pain med's first, there are times that they are late yes, residents do complain about their med's being late. It is the resident's that were cognitive enough to know that they are late. When asked what is done if a medication is administered late RN F stated, If a medication is late, the system forces you to document a note, and that is when we will document, 'given as ordered', and the time stamp on the note, is the time the medication was administered. When asked if when coming on shift if it was noted that the previous shift either did not administer medications, of if they were administered late, RN F stated, Yes, I have come in and there were med's that were late. When asked what contributing factors was leading to resident's medications being late, RN F stated, On the long term halls (500, 600 and 700 halls), we have about 60 lodgers (residents), there used to be 3 nurses, so each nurse had about 20 lodgers, then we changed to 1 nurse on the 500 hall and one nurse on the 600 hall, and we split the 700 hall, so we went from 20 lodgers to 30 lodgers. During an interview on 2/24/16 at 11:36 a.m. when asked if medications are routinely administered to residents late, Licensed Practical Nurse (LPN) G stated, I would say so, I am up to 31 residents at this time. During a different interview on 3/2/16 at 12:19 p.m., when asked what is done when medications are administered late to residents, LPN G stated, It's a note that you have to put in the system, we were told to document 'given as ordered'. LPN G further stated that when a medication is administered late, the system will force you to document a note. LPN G further stated that it is the time stamp on that note that is the actual time the medication is administered. When asked if there would be a time that a medication would be administered on time, but then wasn't put into the computer to a later time, LPN G stated, There is really no time that you would give a medication and not document it. During an interview on 2/29/16 at 1:55 p.m., when asked if medications are routinely administered late to residents, LPN K stated, Yes, med's are late. During an interview on 2/29/16 at 2:10 p.m., when asked if medications are routinely administered late to residents, RN L stated, Yes, there are late med's, we recently had a half hall of residents added to my list, and we struggle with getting the residents their medications on time, its damn near impossible to get your job done on time. When asked if residents ever complain of their medications being late RN L stated, Absolutely residents complain about medications being late, and they take it out on the nurses, we have numerous diabetic med's and scheduled pain med's. During a different interview on 3/2/16 at 1:50 p.m., when asked what was documented when a medication is administered late, RN L stated that the system forces you to make a note, we have been told to document, given as ordered. When asked if there were times when a medication would be given, but a nurse would forget to document administering the medication, RN L stated, No, typically that would not happen. During an interview on 2/29/16 at 2:45 p.m., when asked if medications are routinely administered late to residents, LPN M stated, Yes, residents are getting their med's late, we have a large patient load and it is nearly impossible to get everyone their medications to them on time, each shift have multiple residents with late med's. Review of the Resident Council Meeting Minutes dated 1/5/16 revealed, (Name of Resident) & (Name of Resident) stated they received medicines late. Review of a Resident Assistance Form dated 1/22/16 revealed, that a resident had a concern with getting pain medications in a timely manner, Thought the doctor said pain med's were changed to scheduled (every) 4 hours. Not getting them scheduled. Further review of this form revealed that the resident documented that this is an ongoing problem. Review of a Resident Assistance Form undated revealed, I didn't even get my night med's until 12:30 (p.m.). Review of a Resident Assistance Form dated 12/14/15 revealed, it takes a long time to get pain med's. Review of Resident Assistance Form completed by Supplemental Resident #10 and dated 1/28/16 revealed, What is your complaint regarding? My medication. This morning I ask for a pain pill starting at 8 am then I had to aid check 2 more times. They came back and said she would be right there. At 10:15, I walked down to where the nurse was in hallway 100 and that's when she finally gave me my pills. This is too long for a full knee replacement to wait for a pain pill! Further review of the form, under the Is this an ongoing problem section, Supplemental Resident #10 documented, This is the third time in 10 days I had to wait a long time for pain pills. Resident #2 Review of the face sheet and the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was a [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #2 had clear speech, was sometimes understood, sometimes understands, was severely impaired cognitively and required extensive assistance of 2 people for transfers. Review of the Medication Administration Record [REDACTED] 1. Resident #2 was to receive [MEDICATION NAME] (medication used to treat low levels of [MEDICATION NAME]) 500 mg (milligrams) three times a day, 6:00 a.m., 2:00 p.m. and 9:00 p.m Further review of the MAR indicated [REDACTED]. 2. Resident #2 was to receive [MEDICATION NAME] (an antibiotic) 500 mg every 12 hours at 9:00 a.m. and 9:00 p.m. until 1/6/16. Further review of the MAR indicated [REDACTED]. 3. Resident #2 was to receive [MEDICATION NAME] (an antibiotic) 100 mg every 12 hours at 9:00 a.m. and 9:00 p.m. unit 1/22/16. Further review of the MAR indicated [REDACTED]. 4. Resident #2 was to receive Keflex (an antibiotic) 500 mg every 4 times a day from 1/5/16 until 1/18/16. Further review of the MAR indicated [REDACTED]. 5. Resident #2 was to receive [MEDICATION NAME] eye drops (an immunosuppressive agent) 1 drop every 12 hours at. Further review of the MAR indicated [REDACTED]. Review of the Medication Administration Record [REDACTED] 1. Resident #2 was to receive [MEDICATION NAME] (medication used to treat low levels of [MEDICATION NAME]) 500 mg (milligrams) three times a day, 6:00 a.m., 2:00 p.m. and 9:00 p.m Further review of the MAR indicated [REDACTED]. 2. Resident #2 was to receive [MEDICATION NAME] eye drops (an immunosuppressive agent) 1 drop every 12 hours at. Further review of the MAR indicated [REDACTED]. Review of the Medication Discrepancy Forms provided by the facility failed to reveal any forms for Resident #2. Furthermore, review of the medical record failed to reveal that Resident #2's physician was notified of these medications being administered late. Resident #3 Review of the facesheet and MDS dated [DATE] revealed Resident #3 was a [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #3 had clear speech, was understood, understands and had no cognitive impairment. During an interview on 2/23/16 at 10:50 a.m., Resident #3 stated, 1st and 2nd shift consistently administer med's (medications) late, they are definitely not 1 hour before or 1 hour after. They used to have 1 nurse per hall, now that is not the case. Review of the Medication Administration Record [REDACTED] 1. Resident #3 was to receive Accolate (medication used to treat lung disease) 20 mg (milligrams) two times a day, 8:00 a.m. and 8:00 p.m. starting on 1/20/16. Further review of the MAR indicated [REDACTED]. 2. Resident #3 was to receive [MEDICATION NAME] (an inhaled medication used to treat lung disease) 115-21 mcg (micrograms) two times a day, 9:00 a.m. and 9:00 p.m Further review of the MAR indicated [REDACTED]. 3. Resident #3 was to receive [MEDICATION NAME] (a muscle relaxer used to treat muscle spasms) 20 mg three times a day, at midnight, 8:00 a.m. and 4:00 p.m Further review of the MAR indicated [REDACTED]. 4. Resident #3 was to receive [MEDICATION NAME][MEDICATION NAME] (medication used to treat neuropathic pain) 25 mg twice a day, three times a day from 1/26/16 thru 1/31/16. Further review of the MAR indicated [REDACTED]. 5. Resident #3 was to receive [MEDICATION NAME] (medication used to treat allergies [REDACTED]. Further review of the MAR indicated [REDACTED]. 6. Resident #3 was to receive [MEDICATION NAME] (a laxative) 17 grams once a day at 12:00 p.m Further review of the MAR indicated [REDACTED]. 7. Resident #3 was to receive an inhaler Proair (medication used to treat lung disease) 90 mcg three times a day at midnight, 7:00 a.m. and 3:00 p.m. Further review of the MAR indicated [REDACTED]. Review of the Medication Administration Record [REDACTED] 1. Resident #3 was to receive Accolate (medication used to treat lung disease) 20 mg (milligrams) two times a day, 8:00 a.m. and 8:00 p.m. Further review of the MAR indicated [REDACTED]. 2. Resident #3 was to receive [MEDICATION NAME] (an inhaled medication used to treat lung disease) 115-21 mcg (micrograms) two times a day, 9:00 a.m. and 9:00 p.m. from 2/1/16 thru 2/11/16. Further review of the MAR indicated [REDACTED]. 3. Resident #3 was to receive [MEDICATION NAME] (a muscle relaxer used to treat muscle spasms) 20 mg three times a day, at midnight, 8:00 a.m. and 4:00 p.m Further review of the MAR indicated [REDACTED]. 4. Resident #3 was to receive [MEDICATION NAME] (medication used to treat allergies [REDACTED].m Further review of the MAR indicated [REDACTED]. 5. Resident #3 was to receive [MEDICATION NAME] (a laxative) 17 grams once a day at 12:00 p.m Further review of the MAR indicated [REDACTED]. 6. Resident #3 was to receive an inhaler Proair (medication used to treat lung disease) 90 mcg three times a day at midnight, 7:00 a.m. and 3:00 p.m. Further review of the MAR indicated [REDACTED]. Resident #4 Review of the facesheet and the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was a [AGE] year old male resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #4 had unclear speech, was sometimes understood, usually understands, was moderately impaired cognitively and required extensive assistance with activities of daily living. Review of the physician orders [REDACTED]. Review of the nursing note dated, 1/29/16 revealed, at shift change, writer and oncoming nurse checked placement of this lodgers [MEDICATION NAME]. patch was not found. writer notified management. MD was notified and obtained a new order to apply patch. patch was last observed by writer at 1:30 p.m. this afternoon. No change in pain level noted at this tie. Review of the nursing note dated 2/6/16 revealed, When checking patch placement for (Resident #4) today his patch was missing. His entire body was searched with negative results. The patch was not found in any of his clothing or sheets. It was (not on the) floor around the bed or in the trash .(Physician) was notified of missing patch and gave a verbal order to put on a new patch with todays dated. Resident #5 Review of the face sheet and most recent Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #5 was a [AGE] year old resident readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #5 had clear speech, was understood, understands, was moderately impaired cognitively and required extensive assistance for activities of daily living. Resident #5 no longer resided at the facility. Review of the Medication Discrepancy Report dated 1/10/16 revealed, (Resident #5) received [MEDICATION NAME] (an anti-epileptic medication used to treat [MEDICAL CONDITION] disorders) 8:00 a.m. dose late - between 2:45 p.m. and 3:30 p.m .(Resident #5) sent to ER (emergency room ) at 8:00 p.m. for [MEDICAL CONDITION] - had 3 [MEDICAL CONDITION] that day. Review of the nurse note dated 1/11/16 at 1:35 p.m., revealed, (Resident #5) was sent out (due to) [MEDICAL CONDITION] activity. ER physician concerned about blood levels and maintaining blood levels with (every) 12 hour dosing of [MEDICATION NAME]. Review of the progress note dated 1/11/16 revealed, (Resident #5) was sent out to the hospital overnight (status [REDACTED].Ensure [MEDICAL CONDITION] med's are given on time. Review of the Medication Administration Record [REDACTED] 1. Resident #5 was to receive [MEDICATION NAME] (a steroid used to treat inflammation) 4 mg (milligrams) two times a day, 8:00 a.m. and 8:00 p.m. Further review of the MAR indicated [REDACTED]. 2. Resident #5 was to receive [MEDICATION NAME] 200 mg two times a day, 10:00 a.m. and 10:00 p.m. Further review of the MAR indicated [REDACTED]. Review of the Medication Administration Record [REDACTED] 1. Resident #5 was to receive [MEDICATION NAME] (a steroid used to treat inflammation) 4 mg (milligrams) two times a day, 8:00 a.m. and 8:00 p.m. Further review of the MAR indicated [REDACTED]. 2. Resident #5 was to receive [MEDICATION NAME] (a controlled medication used to treat pain) 5-325 mg four times a day, midnight, 6:00 a.m. 12:00 p.m. and 6:00 p.m. Further review of the MAR indicated [REDACTED]. Resident #7 Review of the face sheet and Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was a [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #7 had clear speech, was understood, understands and had no cognitive impairment. Resident #7 was discharged from the facility on 1/29/16. During an interview on 3/3/16 a 9:00 a.m., Resident #7 stated, I had my right knee replaced in January, they (the facility) cut staffing 1 nurse was taking 1.5 halls. All the nurse could do was pass med's. I would be 8-10 hours without a pain pill, it was horrible .The issue was I couldn't do my therapy because I was in so much pain. I told the (Nursing Home Administrator) I can't stay here in this kind of pain, I could go home and take better care of my pain. Review of the MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. Supplemental Resident #8 Review of the face sheet dated 3/1/16 revealed Supplemental Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an observation on 2/22/16 at 1:13 p.m., Supplemental Resident #8 was observed in the dining room, she had completely finished eating her lunch. A nurse approached the resident and administered a medication to the resident. A review of Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. Review of the Medication Administration Record [REDACTED] 1. Supplemental Resident #8 was to receive [MEDICATION NAME] injection (a long acting insulin) 18 units every day at 8:00 a.m. Further review of the MAR indicated [REDACTED]. 2. Supplemental Resident #8 was to receive cough syrup every four hours while awake. Further review of the MAR indicated [REDACTED]. 3. Supplemental Resident #8 was to receive [MEDICATION NAME] (an antibiotic) to treat [MEDICAL CONDITION] from 1/13/16 through 1/18/16. Further review of the MAR indicated [REDACTED]. Supplemental Resident #11 During an interview on 2/23/16 at 3:00 p.m., Supplemental Resident #11 stated, Yes, my med's are routinely late. Staffing is short, how can you administer 8 o'clock med's to two different halls. Review of Supplemental Resident #11's Medication Administration Record [REDACTED].m According to the Physicians' Desk Reference, a source used by healthcare professionals (http://www.pdrhealth.com/drugs/[MEDICATION NAME]), Take [MEDICATION NAME] on an empty stomach, 30 minutes to 1 hour before eating breakfast. ( )

This citation pertains to MI 082. Based on interview and record review, the facility failed to provide appropriate assessment and care after a fall in 1 of 4 residents (Resident #101) reviewed for falls, from a total of 4 sampled residents, resulting in Resident #101 being moved after an altercation with another resident which caused Resident #101 a displaced [MEDICAL CONDITION] and severe pain. 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). Per the Facility Incident report - 24 Hours, dated 10/08/12, Resident #101 sustained a "fx (fractured) hip" on 10/05/12 at 3:15 PM because, "(Resident #101) slid out of w/c (wheelchair) ..." Per a statement, dated 10/06/12 (not timed), DON/Director of Nursing #1 documented, "Video evidence showed (Resident #101) in front of TV bending over playing with buttons on VCR (movie machine). (Resident #104) wheeled behind (Resident #101) and grabbed the arm of (Resident #101's) wheelchair to move her out of the way of the TV. (Resident #101) then slipped forward onto floor, as (RN/Registered Nurse #8) tried to catch (Resident #101) but couldn't get to her in time..." Per Resident #101's Minimum Data Set, dated dated [DATE], Resident #101 was a [AGE] year old woman who was admitted to the facility on [DATE], was 59 inches tall and weighed 99 pounds, had severe cognitive impairment, wandered daily, and had [DIAGNOSES REDACTED]. Per Resident #104's Minimum Data Set, dated dated [DATE], Resident #104 was a [AGE] year old man who was admitted to the facility on [DATE], was 72 inches tall and weighed 189 pounds, had severe cognitive impairment and no behaviors. Per nurses' Progress Notes, dated 10/05/12 at 11:22 PM, RN #8 documented, "At 3:15 PM (Resident #101) was in a altercation with (Resident #104) in one of the main TV rooms. (Resident #101) was found lying on her rgt (right) side in front of her w/c (wheelchair), next to (Resident #104) who was in his w/c. (Resident #101) was assisted back into w/c by two person assist and gait belt, (Resident #101) c/o (complained of) pain to left hip area, bilateral thigh areas, and pelvic area. (Medical Director) #14 here and assessed (Resident #101), ordered STAT X-rays to bilateral (both) hips and pelvis area. (Resident #101) was transferred from w/c to bed by 2 person assist for X-rays, (Resident #101) complained of pain with movement of bilateral lower extremities...Scheduled Tylenol given without any difficulty..." Per a statement, dated 10/05/12 at 11:22 AM, RN #8 documented, "At 3:15 PM (Resident #101) was in a altercation with another lodger in one of the main TV rooms. (Resident #101) was found lying on her (right) side in front of her wheelchair, next to (Resident #104) who was in his w/c (wheelchair). (Resident #101) was assisted back into w/c by two person assist and gait belt; (Resident #101) c/o (complained of) pain to left hip area, bilateral thigh areas, and pelvic area..." In an interview, on 12/12/12 at 11:25 AM, RN #8 reported that on 10/05/12 at 3:15 PM, there were no staff members in the TV room (also called the Bear Room) when she walked in and found Resident #101 lying on the floor. RN #3 stated, "I watched the video 3 days later...I was walking around the corner and heard noise from that room (Bear Room)...I didn't see (Resident #101) fall because of the wall. (Nurse aide #9) came in, we asked (Resident #101) how she was, sat her up, and we both assisted her back into the wheelchair...I asked (Resident #101) if she were in pain. (Resident #101) kept yelling 'Oh god, oh god. What happened?' There were no non-verbal signs of pain". When asked if she had checked Resident #101's vital signs, checked for symmetry in her legs, or did range of motion before moving Resident #101 into the wheelchair, RN #8 stated, "No, I did not...This was the first fall I had in this facility. I never assisted anyone off the floor. I used to do home care and private duty." RN #8 reported that after the incident, the Director of Nurse (DON #1) told her that she was supposed to perform range of motion before transferring Resident #101. RN #8 reported that Resident #101 was not able to bear weight when RN #8 and nurse aide #9 transferred Resident #101 from the floor to the wheelchair and subsequently from her wheelchair to bed on 10/05/12 after the fall. When asked what the purpose of a gait belt was, RN #8 stated, "Its' a lifting device", and then paused and stated, "it's more of an assistance". Per Resident #101's x-ray report, dated 10/05/12 at 6:43 PM, "There is an acute (sudden and severe) left femoral (hip) fracture present with partial displacement (moved from normal position) compatible with a Garden classification III fracture..." Per the EMS (ambulance service) report, dated 10/06/012 at 9:29 PM, "...Arrived to find (Resident #101) in bed. (Resident #101) verbalized severe pain..." Per a hospital history and physical examination ...(Resident #101) has been in severe pain since she has been here...she is very demented and cannot communicate...plans to take her to surgery..." In an interview, on 12/12/12 at 2:46 PM, PTA/Physical Therapy Assistant #11 reported that proper transfer techniques are taught to all nursing staff in orientation. PTA #11 reported that when a resident falls to the floor, it is required that staff, "get a nurse to assess and make sure there is no injury...We lay them on the floor...if unable to help/bear weight, use a Hoyer (mechanical lift) - safest for the resident. If injured or unable to assess, make comfortable, move objects, clear the area, allow (resident) to relax, don't sit them up until a thorough assessment is done. If it takes a half hour to calm them and assess the, that's what we're gonna do". In an interview, on 12/12/12 at 12:20 PM, DON #1 reported that RN #3 received no formal education or discipline following Resident #101's fall on 10/05/12. DON #1 stated, "(RN #8) did everything correct." DON #2 reported the video tape of Resident #101's fall was no longer available and no copy had been made. In a telephone interview, on 12/13/12 at 11:51 PM, Medical Director #14 stated, "I saw her when she was in the wheelchair (after the fall). Took an x-ray, then called the family. Medical Director #14 stated, "We should have a fall prevention policy", and reported he was not aware of any facility policy and procedure that addressed post-fall assessment and care that instructed staff how and when to, or when not to, move a resident that has fallen. On 12/12/12 at 11:20 AM, the facility's policy and procedures regarding falls were requested from DON #1 and this surveyor was given "How To Fill Out an Incident Report" procedure. Per the "(Facility) Policy Title: How To Fill Out an Incident Report", (not dated), "...6. A comprehensive assessment must be completed and documented. Vital signs should include capillary (small blood vessels) blood sugar and 0 2 stats (blood oxygen levels). Blood pressure should be repeated after five minutes to rule out orthostatic [MEDICAL CONDITION] (following a fall). 7. First aide administered may include hospitalization for evaluation and treatment. 8. Steps taken to safeguard the resident and eliminate the potential for repetition must be documented..." The document did not instruct nurses to perform range of motion, check for limb symmetry, assess for pain, or how/when to transfer a resident that is found on the floor. ( )

This citation pertains to intake # MI 201 Based on interview and record review the facility failed to provide adequate supervision to prevent accidents in 1 of 3 sampled Residents (Resident #101), of a total of 3 sampled Residents, resulting in Resident #101 rolling out of bed and sustaining multiple fractures (fracture of the neck at C 1, nasal bone fracture, nasal septum fracture, fracture of the right maxillary sinus (upper jaw), fracture of the left occipital condyle (eye area). fractured pubic rami (pelvis fracture) and a laceration to her head. Finding include: Resident #101 According to Resident #101's face sheet she was [AGE] years old female who was admitted to the facility on [DATE] with the following diagnoses; Dementia, Parkinson's and Diabetes Melitis. According to her Minimum Data Set ((MDS) dated [DATE] her cognition was severely impaired and she was totally dependent for bed mobility. Review of Resident #101's care plan for activities of daily living, dated 4-25-12 documented under approaches, "bed in lowest position when not providing cares". According to the incident/accident report investigation for Resident #101 dated 5-10-12, at 6:25 AM. Resident #101 had just had morning care provided when the Certified Nurses Aide (CNA) noticed Resident #101 clothing was saturated with urine. The CNA left the bed in a high position and the Resident on her back and left the bedside to get a new brief from the Residents closet. Another CNA in the Residents room requested assistance with transferring Resident #101's roommate and Resident #101 fell to the floor. Resident #101,was left on the floor while first aide was applied to her laceration on her head by a licensed nurse, Emergency Medical Services (EMS) were called, and transported Resident #101 to the emergency room . Review of the Patient Transfer Form for Resident #101, dated 5-10-12 revealed that Resident #101 had rolled out of bed during morning care and hit her head on an open drawer of a night stand and sustained a laceration over her left eye, a bloody nose and abrasions to her forehead. Review of the Emergency Medical Services run sheet for Resident #101, dated 5-10-12, revealed the call was received at 6:20 AM, and arrived on scene at 6:43 AM. Under narrative was documented, "The patient had been lying in bed which was about 4 feet off the ground in height and after falling had a likely impact with an open drawer on the dresser next to the bed. On our arrival the patient was on the ground with a 1 inch laceration above the left eye and multiple abrasion to the head and nose area. The patients oral and nasopharynx (nose and mouth area) had dried blood. The patient was alert and her eyes were spontaneously open but she was not able to verbally communicate because of a history of Dementia and Parkinson's Disease. Because we were unable to clearly elucidate the nature and level of pain that she was in, nor could ascertain the stability of the patients cervical spine I decide to place the patient in both a c-collar and back board. The patients remained stable throughout what was an uneventful transport." Review of the hospital emergency room history and physical for Resident #101, dated 5-10-12 revealed Radiological examinations showed a C-1 (cervical bone number 1) fracture, right nasal bone fracture, left occipital condyle (under eye) fracture, nasal (nose) septum fracture and hematoma, posterior ethmoid sinus fracture, right maxillary sinus fracture and a pubic rami (pelvis) fracture. According to a written statement by CNA #1, dated 5-10-12, CNA #1 provided morning care to Resident #101, CNA #1 stopped briefly to assist another CNA with a transfer of Resident #101's roommate when Resident #101 rolled out of bed. The charge nurse was immediately notified and began to assess Resident #101. During an interview with CNA #1, on 5-17-12, 11:45 AM, CNA #1 demonstrated in Resident #101's room how she provided care for Resident #101. CNA #1 raised Resident #101's bed to her waist area (approximately 3.5' off floor) CNA #1 explained after completing care for Resident #101 she rolled Resident #101 onto her back and noticed she was wet. CNA #1 left the bed at the raised level and went to get a new brief for Resident #101 and at that time the other CNA working with Resident #101's roommate requested help with a transfer, while transferring Resident #101's roommate CNA #1 heard a thud, CNA #1 returned to Resident #101's bedside and told the other CNA to get help,"it is really bad"and she started to cry. CNA #1 said RN #1 immediately came to the room and started assessing Resident #101. CNA #1 said it was a mistake with tears in her eyes, "I don't no why I did not put her pillow next to her or put her bed down." According to the progressive discipline report for CNA #1, CNA #1 was suspended pending the investigation related to a fall on 5-10-12. The Surveyor reviewed CNA #1 employment record did not find any disciplinary areas for care except for the event on 5-10-12. Review of RN #1 nurses note for Resident #101, dated 5-10-12 at 11:07 AM revealed RN #1 was called to Resident #101's room when Resident #101 fell out of bed. Resident #101 had a laceration above her left eye, abrasions over her right eye, bleeding from her nose, swelling over the bridge of her nose, 911 was called. Resident #101's bed was in a high position for care and the CNA explained she left the bedside to get a new brief and assist the other CNA with the roommate when Resident #101 fell . The Resident's Durable Power of Attorney (DPOA) #1was interviewed on the telephone on 5-17-12 at 10:50 AM., DPOA #1 explained that the hospital had to place a feeding tube into Resident #101 because she was not eating and over all she was not doing well. ( )