Every finding on record at Medilodge of Munising

This citation pertains to intakes #2980097 and #2976728Based on observation, interview, and record review the facility failed to prevent an elopement for one Resident (#10) and failed to ensure safety measures were in place and care planned to prevent elopement and unsafe wandering for three additional Residents (#11, #12, and #13) in four of four residents reviewed for elopement risk.Findings include:Resident #10 (R10)On 4/7/2026, the State Agency (SA) received a complaint which read in part, The resident, (R10), eloped from the facility around 0500 (5:00 AM) in freezing temperatures a couple days ago. She walked a few blocks down the road, without a jacket , on the highway with her walker. Employees noticed after a while she was missing and found her. A nurse picked her up and brought her back. Nursing home employees saw in the camera that the DON checked the front door alarm and shut the alarm system off.On 4/10/2026, the SA received a second complaint which read in part, .on the morning of 4/1/26 around 5:15am or 5:20am the DON Shut off the main alarm that alerts staff when residents wearing a (brand name elopement prevention device) leave the facility. Complainant states the DON never called overhead to do a headcount, she instead went back to doing what she was doing disregarding the alarm completely. Complainant states another nurse somehow heard the alarm was shut off, went to inquire about it and through some investigating and speaking with other staff it was determined that an elope (elopement) risk patient was not in the building, staff began searching for resident in the facility, continuing the search outside when realized she must be outside. Complainant states resident, (R10) was found about 15-20 minutes later about a half mile away from the facility, walking with her walker on a main busy road with no coat on.Complainant states, resident was found at 5:40-5:45 am. Complainant states resident was located and taken back to the facility uninjured. Complainant states she is calling because she does not know if it was reported to the State, and the risk management was not filled out.The Electronic Medical Record (EMR) revealed R10 was admitted on [DATE] with diagnoses including bipolar disorder, anxiety disorder, depressive disorder, schizoaffective disorder, dementia and unsteadiness on feet. The most current Minimum Data Set (MDS) assessment of 4/2/2026 section C-Cognitive Patterns, indicated R10 had scored 3 of 15 on the Brief Interview for Mental Status (BIMS) indicative of severely impaired cognition. The MDS section E-Mood, indicated R10 asked Has the resident wandered? and was scored, Behavior of this type occurred daily. Physician orders include, Check function and expiration date of [(brand name elopement prevention device) device that alarms exit doors when bracelet nears doors)] ordered 12/5/25.On 4/29/2026, the facility presented an investigation of the elopement event which occurred on 4/1/2026. This report read in part, Description of Deficient Practice (why and how did it happen? (sic) On the early morning of 4/1/2026, (R10) went out of the facility setting off the front door alarm and the (brand name elopement prevention device). DON (Director of Nursing) was in the building and went to the door. She shut off the main alarm and realized the wander guard was going off. She looked outside to see if a resident had left the building. Nurse Aides (Certified Nurse Aide CNA A and CNA B) went outside to look in the parking lot and surrounding areas around the building. Nurse Aide, (CNA C) went to the door and talked with (DON). (DON) called for a head count of the people in the building. Nurse (Licensed Practical Nurse LPN D) noted that she could not find (R10). (LPN D) got into her car and drove around to the main street to see if she could find (R10). DON, received a call from (LPN D) stating she found (R10) walking down the sidewalk near the gas station, but (R10) refused to get into the car. Nurse, (Registered Nurse RN E) got into her car and drove to where (LPN D) and (R10) were located. Together they were able to convince her (R10) to get into the car and return to the facility. The facility investigation report of the elopement event included a summary of Concerns: Resident was able to get out of the building. The DON looked outside but did not leave and go out the front door. Other staff had gone out the back door, but no one went immediately out the front door. The resident was triggered earlier and has in the past attempted to get out of the facility.The investigation did not include many facts such as the weather conditions on the day of the elopement. Historical weather was investigated by this surveyor via the internet site: https://www.accuweather.com/en/us/munising-township/49862/april-weather/2638762 for 4/1/2026 and revealed the temperature on the day of the elopement was 22 - 29 degrees F.During a telephone interview conducted on 4/29/26 at 2:04 PM, CNA B stated, she was doing last bed checks with the DON who was working on the 100 hall. CNA B stated, I was helping her on the 100 hall as I was finished on 400. CNA B said it was then the DON mentioned (R10) went out the door and the staff checked all the rooms to see if she was in the building. CNA A went outside with CNA B, and they checked around the entire building. They got a phone call that (R10) was found.During a telephone interview conducted on 4/29/26 at 3:49 PM, CNA A reported a nurse came to her and said an alarm was sounding in the front of the building. CNA A said, I went outside yelling for (R10). Nurses got in the car looking for her. She was on the highway. She made it that far. CNA A stated the wind off the lake can set off the alarm but when I found out the wind had not set off the alarm and it was a code alert, I knew it was (R10) as she had given me a smirk earlier - like she was up to something. CNA A stated she was amazed that (R10) got so far while we were all looking for her in all the rooms of the building. During an interview conducted on 4/29/26 at 6:04 PM, CNA C stated if an alarm is going off, it could be and exit door alarm or (brand name elopement prevention device) alarm. CNA C stated, she met up with the DON at the front of the building. The DON said a (brand name elopement prevention device) was sounding at the front door. CNA C said, The DON said tell your staff over there (the back of the building) to do a head count. I thought it could be (R10) as I saw her in the hallway earlier that night. CNA C said they did a head count and indeed it was (R10). It took about 20 minutes until she was found, and it took a while to convince her to get in the car and back to the building after she was found. CNA C stated, (R10) used to live on 400 and moved to 200 and she does not handle change well.During an interview conducted on 4/29/26 at 6:15 PM, RN E stated, That door is an issue - door fatigue - we don't always tend to run to it. The smokers have free access - The alarms go off a lot because of 8 smokers, and they can go out at will and they do. RN E said the smokers go out to smoke sometimes up to five times a night and stated the facility has alarm fatigue. RN E described the elopement event. She said, At 5:10 (AM) I was passing meds on 100 hall when I heard an alarm sounding. I came out of the room and remember( LPN D) coming up, she heard there was a head count, but it was not announced over head. RN E stated, there was much confusion as the DON said the (brand name elopement prevention device) alarm went off, but there was not an overhead announcement per facility policy and we did not know which door had alarmed or if someone was missing. RN E said, I wanted to know which door was alarming. I did not know and (the DON) was in a resident's room. Then RN E said LPN D went into the room to talk to the DON. When LPN D came out she said the alarm sounding was the front door (brand name elopement prevention device) and the DON told her she had shut it off and told someone to do a headcount. RN E never heard the (brand name elopement prevention device) alarm while she was in a resident's room passing the medications. Rooms were being checked and she saw CNA C who looked alarmed and said( R10) is missing. RNE said they went outside and were yelling R10's name and thought they heard her answer way up on the main road. The service drive was all snowed in and there were no footprints in the snow. RN E said LPN D got in her car and she went to get her coat. LPN D called RN E and said, I've got her, but she won't get in the car. Then RN E got in her car and went to help R10 and LPN D who was trying to fit the walker into her car, but it would not fit. RN E said (R10) was cold. She was freezing. She had no coat on. R10 stated she was not going back, but she was so cold and the nurses convinced her she needed some hot chocolate so R10 got in the car and was brought back to the facility. RN E stated the elopement protocol is to keep the (brand name elopement prevention device) alarm on when there is an elopement until the resident was found. It took about 20 minutes to find the resident and then more time to pick her up and convince her to get in the car.During an interview conducted on 4/29/26 at 6:32 PM, LPN D stated the elopement event occurred at the end of the shift and she was working in the back of the building and could not hear the (brand name elopement prevention device) alarm from the 300 hall. LPN D stated, I can only hear the main door alarm it is going off all day and all night. The smokers go out at all hours. CNA C came and said that the DON said we should do a head count and she did not know which door had been alarming. LPN D explained the (brand name elopement prevention device) would set off the alarm at the door in which the resident wearing it had exited, and you would know someone went out. LPN D said, I was trying to think was it a main door alarm set off by a smoker or a wanderer? She said the CNAs were doing a head count and she remembered R10 walking down the hall earlier that night. LPN D said, I thought I should talk to (the DON) but I could not find her. She was in a resident's room and I asked, Was it a (brand name elopement prevention device)? She said yes. I grabbed my coat and keys, and I knew someone was outside probably (R10). LPN D said CNA A was going to sweep around the outside of the building. The head count was done so she got in her car. LPN D described the route she took, and she did not find R10 right away. She returned to the main intersection and saw a pickup down the main road and noticed they did a break check. She turned right and found R10 walking down the snow plowed sidewalk with her walker with a balloon tied to it. She could not fit the walker into her car, so she called RN E to say she had found R10 who did not want to come back to the facility. RN E drove to meet them, and they coaxed R10 into the car with the promise to get her a hot chocolate. LPN D stated the procedure for an elopement was to leave the alarm on and call overhead for a head count and not rely on word of mouth.The care plan for R10 included a focus target behavior of .Elopement risk: stating she hates it here and wants to 'live with at (sic) the tribe' Interventions included: If resident is located by an exit door, staff to intervene and remain present with resident until resident redirected or relocated away from exit door. Date Initiated: 04/09/2026. The care plan also included a separate focus of Resident is at risk for elopement related to exit seeking behavior, history of elopement, verbalizes wanting to leave the facility. Date Initiated: 09/19/2023 Revision on: 07/02/2024 Interventions for this care plan included, Promptly check when alarm system goes off to ensure resident is safe and remains in facility and Resident wears (brand name elopement prevention device) on Right Ankle, monitor placement/function/expiration. Date Initiated: 09/192023 Revision on: 12/08/2025Nurses progress notes on the date of the elopement revealed R10 had recently undergone a room change and was frustrated with the move, 4/1/26 at 00:00 (midnight) Note text: Resident was aggressive towards staff and other residents swearing and charging towards them. Resident was redirected to getting ready for bed and admitted being frustrated not knowing where her room was. These behaviors at midnight on 4/1/26 were like the identified triggers in R10's care plan listed as: RESIDENT TRIGGERS INCLUDE: not getting her own way. desire to leave. being told what to do. when her personal space is invaded or when she feels threatened. Date initiated 09/20/2023 Revision on 03/23/2026. The elopement event was documented as occurring shortly after 5:00 AM the same day as the triggers were documented in R10's chart.During an interview on 4/30/26 at approximately 10:00 AM, RN H stated R10 had previously eloped from the building on 6/2/2025. The care plan had been updated on 6/4/2025 as well.During an interview on 4/29/26 at 5:41 PM, Social Services designee (Staff F) stated she tracked all residents who were at risk for elopement and wore a (brand name elopement prevention device). She presented a current handwritten list of residents with an elopement risk but did not have previous months lists. Staff F said, Everyone with a (brand name elopement prevention device) is on the list. Staff F stated the elopement risk list is updated monthly or added to if a new at-risk for elopement resident was admitted .Resident #11 (R11)On 4/29/26 at 11:41 AM, R11 was observed in bed with her shoes on. Her left ankle contained a (brand name elopement prevention device) bracelet. R11 was pleasantly confused and was trying to lift her feet from the bed exposing her ankle.On 4/30/26 at 8:25 AM, R11 was observed standing at the door to service hallway trying to go through the door toward the outside exit. Activity Director (Staff I) and this Surveyor were coming out of the service hall and encountered R11 trying to come through. When the door was opened, R11's (brand name elopement prevention device) triggered the alarm. R11 had to be redirected away from the door as she tried to enter the service hallway toward the outside exit.A review of the EMR for R11 revealed and admission date of 11/15/2024. The most current MDS assessment of 2/20/2026 section C-Cognitive Patterns, indicated R11 had scored 5 of 15 on the BIMS assessment indicative of severely impaired cognition. The MDS section E-Mood, indicated R11 asked Has the resident wandered? and was scored, Behavior of this type occurred 4 to 6 days, but less than daily. Although a wander guard bracelet was on R11's ankle there was not a physician order for this device or an order to check the function of this device. The care plan for R11 included a focus: TARGET BEHAVIOR 1: Resident often wanders around building throughout the day. Often gets confused and forgets location of room. Initiated 11/19/2024. Revision on 05/06/2025. The interventions for the behavior care plan which included wandering did not include the wearing of a (brand name elopement prevention device).The elopement risk list which had been presented by Staff F as containing all residents who were wearing a (brand name elopement prevention device) was reviewed. R11 was not on the elopement risk list.Resident #12 (R12)On 4/29/26 at 5:08 PM, CNA G was in the dining room and checked R12's ankle and confirmed R12 was observed wearing a (brand name elopement prevention device).A review of the EMR for R12 revealed and admission date of 4/10/2024. The most current MDS assessment of 4/28/2026 section C-Cognitive Patterns, indicated R12 had scored 0 of 15 on the BIMS assessment indicative of severely impaired cognition. The MDS section E-Mood, indicated R12 asked Has the resident wandered? and was scored, Behavior of this type occurred daily. There was a physician order for Check function and expiration at bedtime Check function and expiration date of (brand name elopement prevention device)/electronic bracelet ordered 12/5/25. The care plan for R12 included a focus: TARGET BEHAVIOR 1: Elopement risk: increases at night - asking when her family will pick her up, putting on her coat - may attempt to go out service doors or front door. Initiated 8/3/2023. Revision on 07/01/2025. The interventions for the behavior care plan which included wandering did not include the wearing of a (brand name elopement prevention device) although R12 was included on the elopement risk list.Resident #13 (R13)On 4/29/26 at 5:10 PM, R13 was observed wandering in the dining room in her wheelchair. She was moving in and around the dining room tables and was unable to communicate where she would like to go. CNA G checked R13's ankle and confirmed R13 was wearing a wander guard (brand name elopement prevention device).A review of the EMR for R13 revealed and admission date of 8/26/2025. The most current MDS assessment of 4/27/2026 section C-Cognitive Patterns, indicated R13 had scored 0 of 15 on the BIMS assessment indicative of severely impaired cognition. The MDS section E-Mood, indicated R13 asked Has the resident wandered? and was scored, Behavior of this type occurred daily. There was a physician order for Check function and expiration every night shift. Check function and expiration date of (brand name elopement prevention device)/electronic bracelet ordered 9/7/25. The care plan for R13 included a focus: TARGET BEHAVIOR 4: Intrusive Wandering: Resident has a hx (history) of intrusive wandering, in and out of other resident rooms, around the building. Initiated 8/28/2025. Revision on 04/07/2026. The interventions for the behavior care plan which included wandering did not include the wearing of a (brand name elopement prevention device).The elopement risk list which had been presented by Staff F as containing all residents who were wearing a (brand name elopement prevention device) was reviewed. R13 was not on the elopement risk list.The facility presented the policy titled, Unsafe Wandering and Elopement Prevention last reviewed 1/1/2022. This policy read in part, 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. Nursing personnel must report and investigate all reports of missing residents.

Based on interview and record review, the facility failed to report an elopement which lasted over 25 minutes in dangerous wintery conditions for one Resident (#10) of four Residents reviewed for unsafe wandering.Findings include:Resident #10 (R10)On 4/7/2026, the State Agency (SA) received a complaint which read in part, The resident (R10), eloped from the facility around 0500 (5:00 AM) in freezing temperatures a couple days ago. She walked a few blocks down the road, without a jacket , on the highway with her walker. Employees noticed after a while she was missing and found her. A nurse picked her up and brought her back. Nursing home employees saw in the camera that the DON checked the front door alarm and shut the alarm system off.On 4/10/2026, the SA received a second complaint which read in part, .on the morning of 4/1/26 around 5:15 am or 5:20 am the DON Shut off the main alarm that alerts staff when residents wearing a (brand name elopement prevention device) leave the facility. Complainant states the DON never called overhead to do a headcount, she instead went back to doing what she was doing disregarding the alarm completely. Complainant states another nurse somehow heard the alarm was shut off, went to inquire about it and through some investigating and speaking with other staff it was determined that an elope (elopement) risk patient was not in the building, staff began searching for resident in the facility, continuing the search outside when realized she must be outside. Complainant states resident, (R10) was found about 15-20 minutes later about a half mile away from the facility, walking with her walker on a main busy road with no coat on.Complainant states, resident was found at 5:40-5:45 am. Complainant states resident was located and taken back to the facility uninjured. Complainant states she is calling because she does not know if it was reported to the State, and the risk management was not filled out.On 4/29/2026 at 11:30 AM, the facility presented an investigation of the elopement event which occurred on 4/1/2026. This report read in part, Description of Deficient Practice (why and how did it happen? (sic) On the early morning of 4/1/2026, (R10) went out of the facility setting off the front door alarm and the (brand name elopement prevention device). (Director of Nursing), DON was in the building and went to the door. She shut off the main alarm and realized the (brand name elopement prevention device) was going off. She looked outside to see if a resident had left the building. Nurse Aides (Certified Nurse Aide CNA A and CNA B) went outside to look in the parking lot and surrounding areas around the building. Nurse Aide, (CNA C) went to the door and talked with (DON). (DON) called for a head count of the people in the building. Nurse (Licensed Practical Nurse LPN D) noted that she could not find (R10). (LPN D) got into her car and drove around to the main street to see if she could find (R10). DON, received a call from (LPN D) stating she found (R10) walking down the sidewalk near the gas station, but (R10) refused to get into the car. Nurse, (Registered Nurse RN E) got into her car and drove to where (LPN D) and (R10) were located. Together they were able to convince her (R10) to get into the car and return to the facility. The facility investigation report of the elopement event included a summary of Concerns: Resident was able to get out of the building. The DON looked outside but did not leave and go out the front door. Other staff had gone out the back door, but no one went immediately out the front door. The resident was triggered earlier and has in the past attempted to get out of the facility.During an interview conducted on 4/29/26 at 6:15 PM, RN E stated At 5:10 (AM) I was passing meds on 100 hall when I heard an alarm sounding. There was much confusion as the DON said the (brand name elopement prevention device) alarm went off, but there was not an overhead announcement per facility policy and we did not know which door had alarmed or if someone was missing. The service drive was all snowed in and there were no footprints in the snow. LPN D had gone out in her car to search and called RN E and said, I've got her, but she won't get in the car. Then RN E got in her car and went to help R10 and LPN RN E said (R10) was cold. She was freezing. She had no coat on. R10 stated she was not going back, but she was so cold and the nurses convinced her she needed some hot chocolate so R10 got in the car and was brought back to the facility. RN E It took about 20 minutes to find the resident and then more time to pick her up and convince her to get in the car.On 4/29/26 the investigation was reviewed and found to be missing many details, but it was confirmed R10 left the building on 4/1/2026 around 5:15 AM and was gone over 25 minutes walking with her walker.The investigation did not include many facts such as the weather conditions on the day of the elopement. Historical weather was investigated by this Surveyor via the internet site: https://www.accuweather.com/en/us/munising-township/49862/april-weather/2638762 for 4/1/2026 and revealed the temperature on the day of the elopement was 22 - 29 degrees F.R10 eloped from the building in freezing temperatures with potential slippery conditions in the dark morning hours and was gone for over 20 minutes without adequate warm clothing. R10 was found on the sidewalk next to the main highway through the center of town. This situation represents a risk to the resident's health and safety and placed R10 at the risk of cold exposure and danger of being struck by a car.The elopement was not reported to the SA.The facility presented the policy titled Abuse, Neglect and Exploitation last reviewed 1/10/2024. The policy read in part, 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 abuse, neglect, exploitation, and misappropriation of resident property. 4. Reporting of alleged violations to the Administrator, state agency, and to all other required agencies. within specific timeframes as required by state and federal regulations: . b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

This citation pertains to intakes #2980097 and #2976728Based on interview and record review the facility failed to ensure that a complete and thorough investigation was completed in a timely manner for an incident of elopement for one Resident (#10) of one resident reviewed for accidents and hazards.Findings include:Resident #10 (R10)On 4/7/2026, the State Agency (SA) received a complaint which read in part, The resident (R10), eloped from the facility around 0500 (5:00 AM) in freezing temperatures a couple days ago. She walked a few blocks down the road, without a jacket , on the highway with her walker. Employees noticed after a while she was missing and found her. A nurse picked her up and brought her back. Nursing home employees saw in the camera that the DON checked the front door alarm and shut the alarm system off.On 4/10/2026, the SA received a second complaint which read in part, .on the morning of 4/1/26 around 5:15 am or 5:20 am the DON Shut off the main alarm that alerts staff when residents wearing (brand name elopement prevention device) leave the facility. Complainant states the DON never called overhead to do a headcount, she instead went back to doing what she was doing disregarding the alarm completely. Complainant states another nurse somehow heard the alarm was shut off, went to inquire about it and through some investigating and speaking with other staff it was determined that an elope (elopement) risk patient was not in the building, staff began searching for resident in the facility, continuing the search outside when realized she must be outside. Complainant states resident, (R10) was found about 15-20 minutes later about a half mile away from the facility, walking with her walker on a main busy road with no coat on.Complainant states, resident was found at 5:40-5:45am. Complainant states resident was located and taken back to the facility uninjured. Complainant states she is calling because she does not know if it was reported to the State, and the risk management was not filled out.On 4/29/2026, the facility presented an investigation of the elopement event which occurred on 4/1/2026. This report read in part, Description of Deficient Practice (why and how did it happen? (sic) On the early morning of 4/1/2026, (R10) went out of the facility setting off the front door alarm and the (brand name elopement prevention device) alarm. (Director of Nursing), DON was in the building and went to the door. She shut off the main alarm and realized the (brand name elopement prevention device) was going off. She looked outside to see if a resident had left the building. Nurse Aides (Certified Nurse Aide CNA A and CNA B) went outside to look in the parking lot and surrounding areas around the building. Nurse Aide, (CNA C) went to the door and talked with (DON). (DON) called for a head count of the people in the building. Nurse (Licensed Practical Nurse LPN D) noted that she could not find (R10). (LPN D) got into her car and drove around to the main street to see if she could find (R10). DON, received a call from (LPN D) stating she found (R10) walking down the sidewalk near the gas station, but (R10) refused to get into the car. Nurse, (Registered Nurse RN E) got into her car and drove to where (LPN D) and (R10) were located. Together they were able to convince her (R10) to get into the car and return to the facility. The facility investigation report of the elopement event included a summary of Concerns: Resident was able to get out of the building. The DON looked outside but did not leave and go out the front door. Other staff had gone out the back door, but no one went immediately out the front door. The resident was triggered earlier and has in the past attempted to get out of the facility.During an interview on 4/29/26 at 2:10 PM, the Nursing Home Administrator (NHA) gave the details of the elopement event. She stated the facility did have cameras which were focused on the exit door R10 exited from. When the footage was requested for review, the NHA stated, We did not save footage. We do not know how to. We watched the video. The NHA stated the Maintenance Director (Staff J) knew how to rewind it, but it was not saved for long and has been taped over. The NHA stated, We saw her go out but it was too dark to see where she went.During an interview on 4/29/26 at 2:17 PM, Staff J stated he was able to see the video. He said, (R10) walked out the door in her everyday clothes, jeans and a flowy top, and then out of camera view. We could see her vaguely in the parking lot area. It was very dark. He stated he thought the NHA had documented the elopement times on a post it note. He stated, Time went by (the DON) and another nurse went to the door. Staff J said R10 came back into the same door, but he did not know what time that was. It was on the video, but he did not write it down.The investigation did not include the times recorded on the video footage such as when R10 exited the building, who went out the door, or when the resident was found and came back into the building. The investigation did not include the conditions at the time of the elopement. The investigation did not include the route the resident took. It should be noted that the elopement event occurred when there was snow in the area and a walker and a person on foot may have left evidence of the exact path taken, but this was not considered in the investigation. There was no measurement of the distance the resident traveled.The investigation did not include many facts such as the weather conditions on the day of the elopement. Historical weather was investigated by this Surveyor via the internet site: https://www.accuweather.com/en/us/munising-township/49862/april-weather/2638762 for 4/1/2026 and revealed the temperature on the day of the elopement was 22 - 29 degrees F.The risk management report was presented and reviewed. It was written by the DON (who was also the nurse responding to the alarm) and begins This writer heard door alarm going off and responded to alarm at about 0517 ish (5:17 AM). The report is dated and timed as written 4/1/2026 05:14. This means the report was inaccurately stated as written before the DON responded to the elopement alarm.The risk management report also included written witness statements of only two CNAs, one nurse, and the DON involved, even though all staff took part in the head count and may have had information relevant to the investigation. The second nurse who assisted the resident back to the facility was not included as a witness in the investigation.The risk management witness statement of the DON was documented as written on 4/1/2026 but was linked to a progress note in the chart. When the progress note was reviewed, it was found to be a late entry note written by the DON on 4/15/2026, over two weeks after the elopement.During an interview conducted on 4/29/26 at 6:32 PM, LPN D stated the elopement event occurred at the end of her shift and the resident who had eloped (R10) was her resident. She stated she felt she should do the risk management report. LPN D stated, (The DON) asked me if she wanted her (the DON) to do the risk management, even though it was my patient. LPN D said, A while afterwards, quite a while, I checked for a risk management in the chart. She did not see one. LPN D said, I ask (the DON), she said I am still working on it. She said I am doing it. It is not there yet. I had to remind her to do it. I am responsible for my resident.During an interview on 4/30/26 at 10:00 AM, Regional Registered Nurse (RN) H stated she would expect the risk management report and documentation of the event to be completed as part of the investigation as soon as possible and certainly sooner than two weeks later.The facility presented the policy titled, Unsafe Wandering and Elopement Prevention last reviewed 1/1/2022. This policy read in part, 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. Nursing personnel must report and investigate all reports of missing residents. 8. Upon return of the resident to the facility the Director of Nursing Services or Charge Nurse should:.Complete and file an incident report. 10. Upon return of the resident to the facility the Director of Nursing Services or Charge Nurse should:.Complete and file an incident report and Make appropriate entries into the resident's medical record.

Based on interview and record review, the failed to fully implement and operationalize its Abuse Program Policy and Procedure and immediately report to the State Agency allegations and actual resident to resident abuse for 9 Residents (Residents #4, #10, #52, #55, #R63, #100, #101, #102, & #103) from 13 residents reviewed for abuse, resulting in Resident #4 being involved in multiple incidents of resident to resident abuse, the potential for continued abuse and falls with major injury in the facility to go unrecognized, and Resident #4 grabbing on to the wrist of Resident #102, causing pain, fear and increased anxiety.Findings include:Resident #4 (R4)Review of an admission Record revealed R4, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Dementia.Review of a Minimum Data Set (MDS) assessment for R4, with a reference date of 12/27/25 revealed a Brief Interview for Mental Status (BIMS) score of 00/15 which indicated R4 was cognitively impaired.Further review of R4's MDS assessment dated [DATE] read in part: Behavioral Symptoms E0200. Behavioral Symptom - Presence & Frequency Note presence of symptoms and their frequency.MDS-12/27/25- R4 was coded 1 for this section. A. Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually)MDS-12/27/25- R4 was coded 1 for this section. B. Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others)MDS-12/27/25- R4 was coded 1 for this section. C. Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) .Further review of R4's MDS quarterly assessments dated 5/7/25, 8/7/25 and 11/5/25 read in part: (MDS Coding: 2 Behavior of this type occurred 4 to 6 days, but less than daily)R4 was coded 2 for this section. A. Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually)R4 was coded 2 for this section. B. Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others)R4 was coded 2 for this section. C. Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) .Review of a Nurse's Note dated 10/19/2025 16:30 read in part: Nurses' Notes Text: (R4) was in the hallway, and another resident was in their wheelchair, and he grabbed her arm. (non-sampled female resident #102 name of resident omitted). he raised his fist at her and then at me and said, Fuck you (Facility NHA-DON and RCD AA-made aware of this incident by this surveyor and R102 was identified at 01/07/2026 5:20 PM).Review of R4s Pertinent Charting-Note read in part 5/18/2025 15:19 Text: Behavior (R4) Attempted to kick a cup out of a blind residents' hands then tried to kick him in the head .In an interview on 01/06/2026 2:02 PM., Registered Nurse (RN) A reported R4 was very aggressive with both staff and residents in the facility. RN A reported R4 has had multiple physical altercations as well as daily verbal altercations with just about any resident in his way RN A reported R4 has injured both residents (male and female) as well as staff members. RN A reported she was unaware if any of the incidents have been reported to the State Agency (SA) or investigated further than a nursing/behavioral note. RN A reported R4 should not be left unattended around other residents and should always have 2 staff when assisting with cares.Review of R4s Pertinent Charting read in part: 5/26/2025 12:54 Pertinent Charting-Behavior Note Text: resident was very obsessive with the letter on residents GR door - resident would stop others in hallway and shout read read read this letter !!!.Review of a Nurse's Note dated 7/3/2025 17:01 read in part: Note Text: resident (R4) was in a verbal altercation with another resident. On 1/6/26 at 4:13 PM., requested incident accident reports, facility reported incidents (FRI's-State Agency reports from Nursing Home Administrator (NHA), Director of Nursing (DON)-both NHA and DON reported they are new to the facility in their roles, and they would attempt to retrieve any and all information regarding R4's incidents and all other resident to resident altercations/incidents for Residents #4, #10, #52, #55, #R63, #100, #101, #102, & #103. This surveyor informed NHA/DON we would review the documentation on 1/7/26. Review of a Nurse's Note read in part: 10/5/2025 19:25 Nurses' Notes Note Text: (R4) was found in dining room by another resident family, I was notified that resident had blood on face. I walked in to dining room seeing resident (non-sampled male resident-#100-name of resident omitted) on left side of dining room at table. (non-sampled male resident-#101 name of resident omitted) in the middle of dining room and (R4) at the middle back table with blood coming from his forehead. There were potato chips and an empty bowl on the floor, as well as fruit punch on the floor and tablecloth, the fruit punch cup was at (R4's) feet. There was an empty coffee cup on the floor with coffee spilt on (R4) and the chair in front of him. (R4) laceration was cleaned up . (Facility NHA-DON and RCD AA-made aware of this incident by this surveyor and R100, #101 were identified at 01/07/2026 5:20 PM).Review of a R4's Nurse's Note dated read in part: 10/19/2025 00:20 Nurses' Note Text: (R4) attempted to enter another resident's room and became aggressive when told to leave. I stepped in between the residents and R4 became aggressive with me. CNA) brought him a snack to try and de-escalate, and he hit her in the face. (R4) then started becoming verbal with a different resident (unknown-non-sampled resident) . R4 started throwing his wheelchair, shoes, cups and spitting. I can see he has two skin tears one on each arm which we put bandages on. Review of a Nurse's Note dated 10/19/2025 16:30 read in part: Nurses' Notes Text: (R4) was in the hallway, and another resident was in their wheelchair, and he grabbed her arm. (non-sampled female resident #102 name of resident omitted). he raised his fist at her and then at me and said, Fuck you (Facility NHA-DON and RCD AA-made aware of this incident by this surveyor and R102 was identified at 01/07/2026 5:20 PM).In an interview on 1/06/2026 at 5:27 PM., RN B stated I don't recall the actual events, it seems so long ago, (R4) is always getting into some sort of altercation, either with another resident or staff members . RN B reported she did not do an incident report or report the incident to the Abuse Coordinator at the time of the incident. RN B stated our policy and reporting guidelines are to report any and all allegations/alleged abuse immediately to our abuse coordinator . RN B reported she did not follow protocol.Review of a Nurse's Note dated 11/3/2025 05:51 read in part: (R4) entered another resident's (unknown resident #103) room through the bathroom because, they were being loud and yelling out all night. (R4) stated he wanted to beat his ass if he didn't shut up. (Facility NHA-DON and RCD AA-made aware of this incident by this surveyor and R102 was identified at 01/07/2026 5:20 PM).Resident #10 (R10)Review of an admission Record revealed R10, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: AmputationReview of a Minimum Data Set (MDS) assessment for R10, with a reference date of 11/14/25 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated R10 was cognitively intact. In an interview on 01/05/2026 2:34 PM R10 reported dementia and behavioral residents have come into his room without his permission. R10 reported recently a resident who paces up and down the hall yelling and spitting at other residents and at times threating other residents that he will punch them in the face had come into his room while his roommate was gone. R10 reported that the resident came in, sat down on his room-mates bed, and ate his room-mates lunch because the lunch tray had just been [NAME] in. R10 reported he did not say anything to the resident because he doesn't get around quickly because he is an amputee. R10 reported he needs a lot of staff assistance so he was fearful if he said anything that the unknown male resident might lash out at him. R10 reported he just ate lunch, laid in bed for a while and then got up and left the room. R10 reports he feels unsafe and fearful at times when there are not enough staff, especially on nights and weekends, and that is around the time the residents who have increased behavior seem to start acting out, wandering into other resident rooms and trying to get out of the building. Resident #55 (R55)Review of an admission Record revealed R55, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: history of falling.Review of a Minimum Data Set (MDS) assessment for R55 with a reference date of 10/06/2025 revealed a Brief Interview for Mental Status (BIMS) score of 11/15 which indicated R55 had mild cognitive impairment. In an observation/interview on 1/05/2026 at 11:35 AM, R55's room door was shut completely. This surveyor knocked and heard a voice asking who was there. This surveyor presented oneself and was granted permission to enter R55's room with R55 sitting upright in his bed eating his lunch. R55 reported he keeps his door shut because of the aggressive residents who wander into his room, other resident rooms and their bathrooms. R55 reported there are a lot of residents who are always pacing up and down the halls which bothers him. R55 reported at times the residents who pace up and down the hall yell out so loud, hit at each other, and will randomly grab other residents clothing, arms or push them in their wheelchairs. R55 reported the resident in the next room over leaving his TV on so loud, he can barely hear myself think which was he kept his door closed. R55 stated I hate to say it, but I get upset, I am pissed and frustrated that there are not enough staff to keep a closer eye on aggressive residents. R55 reported he fears for the little older ladies who care barely protect themselves In an interview on 1/5/26 at 1:22 PM., Certified Nurse Aide (CNA) V reported R4, R52 and R63 all are well known for having very aggressive behaviors towards one another, other residents including female residents. CNA V reported there have been all out brawls with some of the ambulatory/semi-ambulatory (residents who can walk) resident especially during common activities, or mealtimes. CNA V reported we have to keep our heads on a swivel around here because one minute everything is fine and the next 2-4 resident are in a screaming or punching match over a cup of pudding. CNA V reported any incidents of resident-to-resident altercations should be reported to the NHA, but she (CNA V) reported recently there has been a change over in management and prior to the new management any concerns or issues staff or residents had, landed on deaf ears. CNA V reported hopefully things will get better, and more staff will be able to help on the units especially during busy times like shift changes, meals and activities. Resident #63 (R63)Review of an admission Record revealed R63, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: heart disease.Review of a Minimum Data Set (MDS) assessment for R63, with a reference date of 11/14/24 revealed a Brief Interview for Mental Status (BIMS) score of 11/15 which indicated R63 was cognitively impaired.Review of R63's Care Plan with a revision date of 5/8/25 read in part: Resident has history (hx) of behaviors evidenced by: TARGET BEHAVIOR 1: Verbal Aggression EX: Cussing/inappropriate statements towards others .Review of R63's Nurses Notes read in part: Effective Date: 07/03/2025 17:03 Type: Nurses' Notes Note Text : resident was in a verbal altercation with another resident . (Facility NHA-DON and RCD AA-made aware of this incident by this surveyor and no incident reports, and or FRIs, facility investigations were made available to this surveyor, nor was the other resident involved known).Resident #52Review of an admission Record revealed R52, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Dementia.Review of a Minimum Data Set (MDS) assessment for R52, with a reference date of 9/30/25 revealed a Brief Interview for Mental Status (BIMS) score of 03/15 which indicated R52 was cognitively impaired.Review of a R52's Pertinent Charting-Behavior Note read in part: Event date: 7/12/2025 21:35 resident has been going in and out of other residents' rooms; he started shouting and being very rude. Resident also had angry eyes staring at staff; very unlike him.Review of a R52's Pertinent Charting-Behavior Note read in part: 7/22/202514:40 Resident yelling back at other residents Resident is very agitated at constant hollering out. Writer was able to redirect after several minutes.In an interview on 1/7/26 at 3:44 PM., LPN Z reported R4, R63, and R52 all are known to have very aggressive behaviors. LPN Z reported the facility was short staffed and it was challenging to keep an eye on all of the residents with known aggressive behaviors such as physical, verbal, spitting, yelling out one another and it makes it very difficult to re-direct some of the many residents who have these behaviors because many of them can get around the facility quite well. LPN Z reported she hears a lot of resident-to-resident altercations that happen, and staff are supposed to fill out incident report and report all allegation of abuse to the NHA who is the abuse coordinator. LPN Z reported she does not think that happens enough because of the time constraints on staff.In an interview on 1/7/26 at 5:20 PM., DON reported R4 had been very aggressive with other residents and staff, at this time she (NHA, DON, and RCD AA) are looking for any Incident Reports or FRI's reported to the State Agency. RCD AA reported it does not appear that the previous NHA and DON completed incident reports, state agency reports, and facility investigations for R4 and/or any other residents showing up in R4s EMR-Progress/Behavioral notes. NHA reported they would continue to investigate this matter, as well as reach out to their corporate oversight to find any information they may have to assist this surveyor with the lack of information on resident-to-resident altercations going on in the facility.Review of a Facility Policy-Abuse, Neglect and Exploitation-with a revision date of 1/10/24 read in part: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property.Definitions:. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology . Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, and misappropriation of resident property. and exploitation that achieves: A. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship. B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents. Identification of Abuse, Neglect and Exploitation.A. The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations.B. Possible indicators of abuse include, but are not limited to:1. Resident, staff, or family report of abuse2. Physical marks such as bruises or patterned appearances such as a handprint, belt, or ring mark on a resident's body3. Physical injury of a resident, of unknown source4. Resident reports of theft of property, or missing property'5. Verbal abuse of a resident overheard6. Physical abuse of a resident observed7. Psychological abuse of a resident observed8. Failure to provide care needs such as comfort, safety, and feeding. bathing, dressing, turning & positioning9. Evidence of photographs or videos of a resident that are demeaning or humiliating in nature, regardless of whether the resident provided consent and regardless of the resident's cognitive status.10. Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place, or feelings of guilt or shame.Investigation of Alleged Abuse, Neglect and ExploitationA. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.B. Written procedures for investigations include:1. Identifying staff responsible for the investigation.2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence).3. Investigating different types of alleged violations.4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations.5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and6. Providing complete and thorough documentation of the investigation.Identification of Abuse, Neglect and ExploitationA. The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations.B. Possible indicators of abuse include, but are not limited to:1. Resident, staff, or family report of abuse2. Physical marks such as bruises or patterned appearances such as a handprint, belt, or ring mark on a resident's body3. Physical injury of a resident, of unknown source4. Resident reports of theft of property, or missing property5. Verbal abuse of a resident overheard6. Physical abuse of a resident observed7. Psychological abuse of a resident observed8. Failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning & positioning9. Evidence of photographs or videos of a resident that are demeaning or humiliating in nature, regardless of whether the resident provided consent and regardless of the resident's cognitive status.10. Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place, or feelings of guilt or shame.Investigation of Alleged Abuse, Neglect and ExploitationA. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.B. Written procedures for investigations include:1. Identifying staff responsible for the investigation. 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence).3. Investigating different types of alleged violations.4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations.

Based on observation, interview, and record review, the facility failed to safely transport linen, review and update infection control policies annually, and ensure infection prevention and control practices were implemented for two Residents (#3 and #51) of 5 residents reviewed for infection prevention and control. This deficient practice resulted in the potential for the transmission of pathogens between residents and the spread of infectious organisms to all 74 residents in the facility. Findings include:Resident #3 (R3)R3 was admitted to the facility 4/21/25 with a primary diagnosis of Alzheimer's Disease. R3 had a urinary catheter due to retention of urine.On 1/7/26 at 7:44 AM, Resident #3 (R3) was observed in a wheelchair in the hallway. A urinary catheter drainage bag was partially connected to the bottom of the seat of the wheelchair; the other portion of the drainage bag and the drainage tubing were on the floor.Certified Nurse Aide (CNA) BB approached R3 and started propelling his wheelchair down the hallway. CNA BB stopped after approximately 10 feet and said, What is dragging? CNA BB looked under the wheelchair of R3 and noted the catheter drainage bag and tubing on the floor. CNA BB reached under the wheelchair with bare, uncleansed hands and picked up the catheter tubing and drainage bag. CNA BB secured the drainage bag under the seat of the wheelchair and positioned the tubing to keep the drainage bag and tubing off the floor. CNA BB did not perform hand hygiene after touching the drainage bag and tubing. After securing the drainage bag and tubing, CNA BB placed her uncleansed hands on the handles of R3's wheelchair and propelled him down the hall and into the dining room. Licensed Practical Nurse (LPN) CC was behind CNA BB in the hallway and observed CNA BB throughout the interaction with R3's drainage bag and tubing. LPN CC did not provide instruction or direction to CNA BB on hand hygiene or donning gloves.LPN CC was interviewed on 1/7/26 at 7:57 AM. LPN CC said she was a nurse manager. LPN CC admitted she observed CNA BB touching the urinary catheter tubing and drainage bag of R3 with her bare hands. LPN CC said catheter drainage bags and tubing are not to touch or drag on the floor. When asked what CNA BB should have done differently, LPN CC said CNA BB should have performed hand hygiene and put on gloves prior to touching the drainage bag and catheter tubing. LPN CC said after the task was completed, CNA BB should have removed her gloves and performed hand hygiene before touching the handles of R3's wheelchair and assisting him to the dining room.Resident #51 (R51)R51 was admitted to the facility 1/25/23 with a primary diagnosis of Diabetes. R51 had a urinary catheter for urinary retention. R51 had a stage 3 pressure injury (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss) on her right heel.On 1/7/26 at 8:05 AM, Registered Nurse (RN) C was preparing supplies to change the dressing on R51's heel and said she was waiting for towels. LPN O was observed walking down the hall with towels folded in his arm and held against his uniform. LPN O went to the treatment cart where RN C had prepared dressing supplies and placed the towels that had been held against his uniform on top of the cart next to the supplies.RN C told LPN O she had everything ready to complete the dressing change for R51. LPN O picked up the towels from the top of the treatment cart and placed them back against his uniform as he walked into R51's room. LPN O spread out the towels on the overbed table at the foot of R51's bed to use as a barrier for the dressing change supplies brought in by RN C.After the dressing supplies were set on the barrier, LPN O put on a pair of gloves without first performing hand hygiene. LPN O put on a gown but did not tie the gown behind him. The gown was equipped with ties at the neck and waist to secure the gown after being donned.LPN O assisted R51 to transfer from her wheelchair into her bed. After the transfer, LPN O bent over to remove the catheter drainage bag from the wheelchair of R51 and secure it to the bedframe of the bed. During the relocation of the drainage bag, the gown LPN O was wearing began sliding forward from his body due to not being secured and tied behind him. LPN O pushed the gown up into place wearing the same gloves used to touch the catheter drainage bag. LPN O moved toward the foot of the bed where the dressing change supplies were located on the overbed table and began arranging the supplies wearing the same pair of gloves he had used to move the drainage bag and reposition his gown.The Infection Preventionist (IP) was interviewed in the presence of the Director of Nursing (DON) on 1/7/26 at 3:02 PM. The IP said staff were educated on the appropriate method of donning and doffing personal protective equipment (PPE). When asked about wearing gowns, the IP said staff are expected to secure gowns at the neck and waist using the provided ties on the gown. When asked about transporting linen, the IP said staff should never hold clean towels up against their uniforms due to the risk of contamination and the potential spread of infectious organisms. When asked about infection control practices after touching a catheter drainage bag, The IP said staff are expected to perform hand hygiene before putting on gloves and touching the drainage bag. The IP said gloves should be removed and hand hygiene should be performed immediately after touching a drainage bag. When asked about staff repositioning catheter tubing or drainage bags with bare hands, the IP said it is never acceptable to touch catheters, catheter tubing, or drainage bags with bare hands. When asked the last time infection prevention and control policies had been reviewed or updated, the IP said he wasn't sure, but the date would be on each policy. When asked the frequency of policy reviews or revisions, the IP said he did not know.The policy Hand Hygiene dated as reviewed/revised 12/13/2023 documented, in part: .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table.The policy Hand Hygiene contained an attached hand hygiene table indicating conditions under which staff are expected to utilize soap and water versus alcohol-based hand rub (ABHR). The table indicated ABHR should be utilized under the condition: After handling items potentially contaminated with blood, body fluids, secretions, or excretions.after handling contaminated objects.Before applying and after removing personal protective equipment (PPE), including gloves. Before performing resident care procedures.Before and after handling clean or soiled dressings, linens, etc.The following infection prevention and control policies were not dated as reviewed or revised annually: Hand Hygiene dated with reviewed/revised date of 12/13/2023 Enhanced Barrier Precautions (EBP) dated with reviewed/revised date of 3/26/2024 Influenza Vaccination dated with reviewed/revised date of 10/26/2023 Pneumococcal Vaccine (Series) dated with reviewed/revised date of 10/30/2023 Personal Protective Equipment dated with reviewed/revised date of 12/7/2023 Antibiotic Stewardship Program dated with reviewed/revised date of 12/13/2023 Infection Surveillance dated with reviewed/revised date of 10/26/2023During Quality Assurance review with the Administrator (NHA) on 1/7/26 at 3:38 PM, the NHA said the policies provided were the most recent policies and had not been reviewed or updated since the date on the policies.

Based on interview and record review, the facility failed to maintain sufficient nursing staff to provide nursing and related services to meet resident needs for 1 (Resident #55) of 18 residents reviewed for staffing, and 6 of 10 residents from a confidential group interview reviewed for call light wait times, nursing care, staffing, and quality of care resulting in feelings of frustration, unmet resident needs and the potential for harm with negative physical, mental and psychosocial outcomes.Findings include:Review of the facility Mandatory Submission of Staffing Information Payroll Based Journal (PBJ) Staffing Data Report revealed the facility was triggered for Low weekend staffing for the 4th quarter of 2025. This information was retrieved from the Centers for Medicare & Medicaid Services (CMS) facility [NAME] report during off-site preparation for the facility Annual Recertification. Resident #55 Review of an admission Record revealed R55, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: history of falling. Review of a Minimum Data Set (MDS) assessment for R55 with a reference date of 10/06/2025 revealed a Brief Interview for Mental Status (BIMS) score of 11/15 which indicated R55 had mild cognitive impairment. In an interview on 1/05/2026 at 11:35 AM., R55 reported the staff are very nice here, but it takes them a very long time to answer the call lights. R55 reported on night shifts and weekends it takes about 30 minutes or longer. R55 reported he keeps his door shut a lot because the staff are so busy, and the number of other residents who wander into his room and are pacing up and down the halls bother him. R55 reported that sometimes the staff will come in and ask what he needs, turn the call-light off and say they will be back, but they don't come back. R55 reported he almost missed a dental appointment in a town that is over an hour away because they didn't have enough staff to bring him, and the transportation van was broke down. R55 stated they don't follow up with any concerns, my next-door neighbor leaves his TV on so loud, I can't hear myself think that is why I keep my door shut. I hate to say it, but I get upset, I am pissed and frustrated. Back in December they didn't have a driver that day, my son had to take off work, and it took him over 5 hours total round trip plus the time it took to sit with me and make sure I made the appointment and back here. In an interview on 1/5/26 at 1:22 PM., Certified Nurse Aide (CNA) V reported staffing can be challenging especially on weekends. CNA V reported staff call in, and we do not use agency staff. CNA V reported R55 did have a dental appointment and his family member picked him up because the transportation vehicle was not running that week. In an interview on 1/7/26 at 4:26 PM., Licensed Practical Nurse/Scheduler (LPN) K reported the facility has times where the staffing is short, and weekends can be challenging. LPN K reported currently the facility is holding hiring fairs in the community to try and recruit more staff. LPN K reported at this time the facility needs the following open positions filled: Fulltime (FT) Nurses 12-hour shifts - (3) 2 for night shifts, and 1 for day shift. – CNA's (FT) (4) 3 for day shift, 1 for night shift LPN K reported at this time we hire a qualified nurse or CNA to fill the gaps. LPN K reported Unit Managers (UM), Director of Nursing (DON) and other qualitied staff are filling the gaps especially over the last month or so with bad weather, and the holidays. During a confidential group interview on 1/6/26 at 1:30 p.m., (Confidential Resident #5) CR#5 stated, They do not have enough staff. CR#2 reported I wait twenty minutes and up to an hour for help.My old roommate had to wait for thirty minutes when her poop bag (colostomy bag which is a pouch that collects stool and gas from the body) came off and there was poop everywhere.they are short of staff on the weekend and weekdays. CR#8 reported The staff have been short for a long time but the last several weeks with the holidays have been really bad. CR#4 reported It really doesn't matter whether it is the weekend or weekday, they don't have enough staff to help us. During and interview on 1/7/26 at 6:38 a.m., Certified Nurse Aide (CNA) R reported, Staffing is bad during the week and weekend.I have worked where there is only one person per hall. During a follow-up interview at 11:34 a.m., CNA R reported The residents yell out so much and there are so many lights going off that there is just not enough of us to take care of them.some of the residents get neglected because we just can't take care of them. Some of the residents need two of us to take care of them and there is only one of us down each hall.many staff leave because they are so burned out from working short so much.

Based on observation, interview, and record review the facility failed to maintain general cleanliness and repair of the premises and proper storage of clean and sanitary supplies, resulting in an increased potential for contamination and a possible decrease in satisfaction of living affecting all residents in the facility.Findings Include:On 1/5/2026 at 9:10 AM, paint was observed peeled off from the wall in room [ROOM NUMBER] behind the bed of the resident. The section was approximately one and a half feet wide by 3 feet high. The baseboard heat cover in this room was also observed to have paint loss in several places.On 1/5/2026 at 11:12 AM, observation of the exterior back door in the maintenance hall showed the door-sweep on the bottom of the exterior door is damaged and daylight is visible below part of the door.On 1/5/2026 at 3:25 PM, the floor under the vegetable wash 2 bin sink was observed soiled with a built-up accumulation of food debris and grime. A policy is in place for cleaning and sanitizing the kitchen, including equipment and the general premise. Cleaning and to-do lists are made on a regular basis and posted by the office door. During interview at this time, Dietary Manager (DM) F stated it is reviewed by staff on a regular basis. On 1/5/2026 at 3:31 PM, the cove base molding was noted peeled away from the wall and floor in a section of wall behind the cook line. The cove base molding along this wall was also noted with a buildup of grease and grime. On 1/6/2026 at 8:50 AM, during an observation of the shower room on the 300 Wing, the privacy curtain beside the toilet was visibly soiled. During interview at this time with housekeeping employee I she stated it was housekeeping's responsibility to check the curtains and let their manager, Environmental Services Director (ESD) J, know when the curtains needed to be changed. On 1/6/2026 at 8:55 AM, during an interview, ESD J, stated the curtains are changed out when a notification is received stating they need to be changed. ESD J stated they have 10 extra curtains per hall to replace soiled ones as soon as they receive notification they are soiled.

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety, resulting in the potential to spread food borne illness among all residents that consume food from the kitchen.Findings include:On 1/5/2026 10:45 AM, while on a kitchen tour with Dietary Manager (DM), F, kitchen staff H was observed taking an uncovered drink from a small counter space next to the office where employees store personal food and drinks and going to the prep table with the uncovered drink. When asked, kitchen staff H stated it was his drink. DM F had him put a lid on the drink.According to the 2022 FDA Food Code section 2-401.11 Eating, Drinking, or Using TOBACCO PRODUCTS.(B) A FOOD EMPLOYEE may drink from a closed BEVERAGE container if the container is handled to prevent contamination of: (1) The EMPLOYEE'S hands; (2) The container; and (3) Exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. On 1/5/2026 at 11:35 AM, observed kitchen staff H, adjust his beard net with his bare hands and then go to the stove and use a utensil to stir a food item being cooked in a stock pot. No handwashing was observed after touching the beard net before using the utensil to stir the food item. According to the 2022 FDA Food Code section 2-301.14 When to Wash.FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and:,. and (I) After engaging in other activities that contaminate the hands. A review of facility policies shows that employees are required to wash their hands any time their hands become contaminated and before touching food and clean utensils. On 1/5/2026 at 2:50 PM, a slicer was observed covered with a clear plastic bag. When asked what the purpose of the plastic bag on the slicer was for, DM F stated this meant it had been cleaned. The slicer was observed with some food debris under the blade and on the casing.On 1/5/2026 at 3:15 PM, the can opener bracket that holds the handheld crank table-top can opener was noted with a buildup of food debris. At the time of this observation DM F stated the can opener itself is sent through the dish machine each time it is used. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch.On 1/5/2026 at 3:20 PM, two rubber spatulas were observed dried out and degraded with flakes of rubber missing and were visibly noted to be no longer smooth, durable or easily cleanable.According to the 2022 FDA Food Code section 4-202.11 Food-Contact Surfaces (A) Multiuse FOOD-CONTACT SURFACES shall be: (1) Smooth; Pf (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; PfOn 1/5/2026 at 3:25 PM, the floor around the drain lines under the two-bin vegetable wash sink were observed with a buildup of food debris. The floor under the cooking range line along the wall also had observed buildup of food debris. The cove base molding behind the range on the cook line was peeled away from the wall and was very soiled with food debris build up.According to the 2022 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions. (A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean.

Based on interview and record review, the facility failed to ensure evening snacks were offered for six of eight Residents in a confidential group meeting. Findings include: During a confidential resident group interview on 1/6/26 at 1:30 p.m., one of the confidential residents stated, Sometimes we don't get our snacks at night . another confidential resident reported, The staff tell us they don't have any snacks to give us if we ask for something. FOur additional confidential residents agreed snacks were not provided for them at night when they are requested.During an interview on 1/7/25 at 6:34 a.m., Certified Nurse Aide (CNA) S reported We sometimes don't have any snacks or food at night for the residents. we would like to give them something to eat but there isn't anything.there are many nights the residents can't have anything to eat during the late evening or night.During an interview on 1/7/26 at 2:43 p.m., Nursing Home Administrator (NHA) acknowledged the importance of having snacks for the residents and was unaware of the absence of snacks for the residents.Review of policy titled Frequency of Meals last reviewed/revised 7/1/25, read in part .For those residents who desire to eat at non-traditional times or outside of scheduled meals service times.snacks will be provided.nutritious snacks and convenience foods.shall be available.

Based on observation, interviews, and record review, the facility failed to fully implement and operationalize its Abuse Program Policy and Procedure and immediately identify, report and thoroughly investigate repeated incidents of physical and verbal abuse for 9 Residents (Residents #4, #10, #52, #55, #R63, #100, #101, #102, & #103) from 13 residents reviewed for abuse, resulting in a laceration to Resident #4's forehead, and based on the reasonable person concept would cause feelings of fear and intimidation for Residents #10, and #55. Findings Include:Resident #4 (R4)Review of an admission Record revealed R4, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Dementia.Review of a Minimum Data Set (MDS) assessment for R4, with a reference date of 12/27/25 revealed a Brief Interview for Mental Status (BIMS) score of 00/15 which indicated R4 was cognitively impaired.Further review of R4's MDS assessment dated [DATE] read in part: Behavioral Symptoms E0200. Behavioral Symptom - Presence & Frequency Note presence of symptoms and their frequency. Coding: 0. Behavior not exhibited. (1)-Behavior of this type occurred 1 to 3 days. (2)- Behavior of this type occurred 4 to 6 days, but less than daily . (3). Behavior of this type occurred daily.R4 was coded 2 for this section. A. Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually)R4 was coded 2 for this section. B. Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others)R4 was coded 2 for this section. C. Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). (MDS Coding: 2 Behavior of this type occurred 4 to 6 days, but less than daily)Further review of R4's MDS assessments dated 8/7/25 read in part: Behavioral Symptoms E0200. Behavioral Symptom - Presence & Frequency Note presence of symptoms and their frequency. R4 was coded 2 for this section. C. Coding: Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) . (2. Behavior of this type occurred 4 to 6 days, but less than daily) . Further review of R4's MDS assessments dated 11/5/25 read in part: Behavioral Symptoms E0200. Behavioral Symptom - Presence & Frequency Note presence of symptoms and their frequency. R4 was coded 2 for these sections: A. Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) B. Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) . (2. Behavior of this type occurred 4 to 6 days, but less than daily) .Further review of R4's MDS assessment dated [DATE] read in part: Behavioral Symptoms E0200. Behavioral Symptom - Presence & Frequency Note presence of symptoms and their frequency.MDS-12/27/25- R4 was coded 1 for this section. A. Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually)MDS-12/27/25- R4 was coded 1 for this section. B. Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others)MDS-12/27/25- R4 was coded 1 for this section. C. Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) .(MDS Coding: 1 Behavior of this type occurred 1 to 3 days) .Review of R4s Pertinent Charting read in part: Pertinent Charting-Behavior Note Text: dated 5/5/2025 14:25 resident yelled and followed PT (physical therapy) calling him a piss ant resident refused to sit in to wheelchair resident used various language under his breath .Review of R4s Pertinent Charting read in part: Behavior Note Text dated 5/9/2025 18:46 resident chased PT employee down hallway and wanted to hit him with his shoe. Resident was redirected without further incident .Review of R4s Pertinent Charting-Note read in part 5/18/2025 15:19 Text: Behavior (R4) Attempted to kick a cup out of a blind residents' hands then tried to kick him in the head .In an interview on 01/06/2026 2:02 PM., Registered Nurse (RN) A reported R4 was very aggressive with both staff and residents in the facility. RN A reported R4 has had multiple physical altercations as well as daily verbal altercations with just about any resident in his way RN A reported R4 has injured both residents (male and female) as well as staff members. RN A reported she was unaware if any of the incidents have been reported to the State Agency (SA) or investigated further than a nursing/behavioral note. RN A reported R4 should not be left unattended around other residents and should always have 2 staff when assisting with cares.In an interview on 01/06/2026 4:13 PM Nursing Home Administrator (NHA), Director of Nursing (DON) and Regional Clinical Director (RCD) AA were asked to provide this surveyor with all Incident Reports (IR's), Facility Reported Incidents (FRI's)-State Agency (SA) Abuse reportable incidents) NHA responded she was new as the acting NHA and would look for the requested documentation for R4 and get back with this surveyor.Review of R4s Pertinent Charting read in part: 5/25/2025 02:51 Behavior Note Text: Elder very agitated this shift. Spit out medication and all that he had to drink. Being aggressive .Review of R4s Pertinent Charting read in part: 5/26/2025 12:54 Pertinent Charting-Behavior Note Text: resident was very obsessive with the letter on residents GR door - resident would stop others in hallway and shout read read read this letter !!!.Review of a Nurse's Note read in part: 6/8/2025 16:38 (R4) woke up from morning nap, he walked straight towards front door, attempted to open the door to leave facility. Yelling you Mother Fuckers I am not going in the ground yet! . (R4) started violently pushing the (wheel) chair at Certified Nurse Aide) CNA to where (CNA) was stuck between the chair and the wall. (R4) refused to sit in the chair, I followed resident down the hall behind him. coaching him out of resident's rooms as we walked down the 400 halls. Resident turned around and hit me in the throat after stating I am done with this you fucker.Review of a Nurse's Note read in part 6/21/202512:06 Nurses' Notes Note Text: (R4) is hitting and kicking staff when they were trying do cares on him. Tried to help him sit up for lunch and still the same he starts kicking.Review of a Nurse's Note dated 7/3/2025 17:01 read in part: Note Text: resident (R4) was in a verbal altercation with another resident.Review of a Nurse's Note read in part: 10/5/2025 19:25 Nurses' Notes Note Text: (R4) was found in dining room by another resident family, I was notified that resident had blood on face. I walked in to dining room seeing resident (non-sampled male resident-#100-name of resident omitted) on left side of dining room at table. (non-sampled male resident-#101 name of resident omitted) in the middle of dining room and (R4) at the middle back table with blood coming from his forehead. There were potato chips and an empty bowl on the floor, as well as fruit punch on the floor and tablecloth, the fruit punch cup was at (R4's) feet. There was an empty coffee cup on the floor with coffee spilt on (R4) and the chair in front of him. (R4) laceration was cleaned up . (Facility NHA-DON and RCD AA-made aware of this incident by this surveyor and R100, #101 were identified at 01/07/2026 5:20 PM).Review of a R4's Nurse's Note dated read in part: 10/19/2025 00:20 Nurses' Note Text: (R4) attempted to enter another resident's room and became aggressive when told to leave. I stepped in between the residents and R4 became aggressive with me. CNA) brought him a snack to try and de-escalate, and he hit her in the face. (R4) then started becoming verbal with a different resident (unknown-non-sampled resident) . R4 started throwing his wheelchair, shoes, cups and spitting. I can see he has two skin tears one on each arm which we put bandages on. Review of a Nurse's Note dated 10/19/2025 16:30 read in part: Nurses' Notes Text: (R4) was in the hallway, and another resident was in their wheelchair, and he grabbed her arm. (non-sampled female resident #102 name of resident omitted). A CNA intervened. As I was walking back down the hallway, he raised his fist at her and then at me and said, Fuck you. He went back into his room, and the other resident went further down the hall away from his room. (Facility NHA-DON and RCD AA-made aware of this incident by this surveyor and R102 was identified at 01/07/2026 5:20 PM).In an interview on 1/06/2026 at 5:27 PM., Registered Nurse (RN) B reported (R4) has had many behaviors and a long history of both physical and verbal aggression towards other residents . RN B reported on 10/19/25 R4 was in the hallway, when she (RN B) was passing medications and heard a CNA holler out for (R4) to stop, she then turned to see R4 and R102 (non-sampled female resident#102 name of resident omitted) next to one another with a CNA separating the two residents. RN B reported she went to assist and separated the 2 residents. RN B reported R4 had grabbed for R102's wrist while she was self-propelling in her wheelchair., RN B reported R4 never made physical contact with R102 he grabbed me (RN B) instead. When asked why her (RN B) current interview with this surveyor contradicts the Electronic Medical Record (EMR) documentation (RN B) documented: (read in part: Review of a Nurse's Note dated 10/19/2025 16:30). RN B stated I don't recall the actual events, it seems so long ago, (R4) is always getting into some sort of altercation, either with another resident or staff members . RN B reported she did not do an incident report or report the incident to the Abuse Coordinator at the time of the incident. RN B stated our policy and reporting guidelines are to report any and all allegations/alleged abuse immediately to our abuse coordinator . RN B reported she did not follow protocol. Review of a Nurse's Note dated 10/22/2025 18:08 read in part: Nurses Note Text: Residents (Durable Power of Attorney) DPOA is concerned about the yelling coming from the resident in room (next to R4) DPOA states this is a trigger. The resident in room (shared bathroom) was yelling, while in the bathroom. He unlocked and opened the bathroom door twice in the last 20 minutes. DPOA is concerned for resident (R4) and does not want resident to have to be medicated for the reaction this will cause.Review of a Nurse's Note dated 11/1/2025 18:26 read in part: (R4) was in his room throwing things and he broke his bedside table. He was trying to throw things out the window. At first, he was throwing things that would not break, then it turned into throwing larger items. He threw his wheelchair, it was lying on its side, and the bedside table was broken. There was no consoling or redirecting the resident. Review of a Nurse's Note dated 11/3/2025 05:51 read in part: (R4) entered another resident's (unknown resident #103) room through the bathroom because, they were being loud and yelling out all night. (R4) stated he wanted to beat his ass if he didn't shut up. Staff redirected him with food back into his own room and locked the bathroom door so he couldn't enter the room again. (Facility NHA-DON and RCD AA-made aware of this incident by this surveyor and R102 was identified at 01/07/2026 5:20 PM).Review of R4s Pertinent Charting read in part: Event date: 11/26/2026 (R4) went into the office hallway and peed on the floor. (R4) was assisted back to his room and showed where his restroom was.Review of a Nurse's Note read in part: Event date: 12/26/2025 The resident became aggressive on this shift, he hit the Director of Nursing (DON) and this nurse when we entered the room to plug in his call light that he had pulled out of the wall.In an interview on 1/7/26 at 5:20 PM., DON reported R4 had been very aggressive with other residents and staff, at this time she (NHA, DON, and RCD AA) are looking for any Incident Reports or FRI's reported to the State Agency. RCD AA reported it does not appear that the previous NHA and DON completed incident reports, state agency reports, and facility investigations for R4 and/or any other residents showing up in R4s EMR-Progress/Behavioral notes. NHA reported they would continue to investigate this matter, as well as reach out to their corporate oversight to find any information they may have to assist this surveyor with the lack of information on resident-to-resident altercations going on in the facility. Resident #10 (R10)Review of an admission Record revealed R10, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: AmputationReview of a Minimum Data Set (MDS) assessment for R10, with a reference date of 11/14/25 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated R10 was cognitively intact. In an observation/interview on 01/05/2026 2:34 PM R10's room door was closed, this surveyor knocked and R10 welcomed this surveyor in his room to conduct a private interview. R10 reported he keeps his door closed 90% of the time because of the number of residents with dementia and behavioral who have come into his room without his permission. R10 reported recently a resident who paces up and down the hall yelling and spitting at other residents and at times threating other residents that he will punch them in the face had come into his room while his roommate was gone. R10 reported that the resident came in, sat down on his room-mates bed, and ate his room-mates lunch because the lunch tray had just been [NAME] in. R10 reported he did not say anything to the resident because he doesn't get around quickly because he is an amputee. R10 reported he needs a lot of staff assistance so he was fearful if he said anything that the unknown male resident might lash out at him. R10 reported he just ate lunch, laid in bed for a while and then got up and left the room. R10 reports he feels unsafe and fearful at times when there are not enough staff, especially on nights and weekends, and that is around the time the residents who have increased behavior seem to start acting out, wandering into other resident rooms and trying to get out of the building. (Throughout the survey and multiple observations from 1/5/26-1/7/26 R10's bedroom door was closed).Resident #55 (R55)Review of an admission Record revealed R55, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: history of falling.Review of a Minimum Data Set (MDS) assessment for R55 with a reference date of 10/06/2025 revealed a Brief Interview for Mental Status (BIMS) score of 11/15 which indicated R55 had mild cognitive impairment. In an observation/interview on 1/05/2026 at 11:35 AM, R55's room door was shut completely. This surveyor knocked and heard a voice asking who was there. This surveyor presented oneself and was granted permission to enter R55's room with R55 sitting upright in his bed eating his lunch. R55 reported he keeps his door shut because of the aggressive residents who wander into his room, other resident rooms and their bathrooms. R55 reported there are a lot of residents who are always pacing up and down the halls which bothers him. R55 reported at times the residents who pace up and down the hall yell out so loud, hit at each other, and will randomly grab other residents clothing, arms or push them in their wheelchairs. R55 reported the resident in the next room over leaving his TV on so loud, he can barely hear myself think which was he kept his door closed. R55 stated I hate to say it, but I get upset, I am pissed and frustrated that there are not enough staff to keep a closer eye on aggressive residents. R55 reported he fears for the little older ladies who care barely protect themselves (Throughout the survey and multiple observations from 1/5/26-1/7/26 R55's bedroom door was closed).In an interview on 1/5/26 at 1:22 PM., Certified Nurse Aide (CNA) V reported R4, R52 and R63 all are well known for having very aggressive behaviors towards one another, other residents including female residents. CNA V reported there have been all out brawls with some of the ambulatory/semi-ambulatory (residents who can walk) resident especially during common activities, or mealtimes. CNA V reported we have to keep our heads on a swivel around here because one minute everything is fine and the next 2-4 resident are in a screaming or punching match over a cup of pudding. CNA V reported any incidents of resident-to-resident altercations should be reported to the NHA, but she (CNA V) reported recently there has been a change over in management and prior to the new management any concerns or issues staff or residents had, landed on deaf ears. CNA V reported hopefully things will get better, and more staff will be able to help on the units especially during busy times like shift changes, meals and activities. Resident #63 (R63)Review of an admission Record revealed R63, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: heart disease.Review of a Minimum Data Set (MDS) assessment for R63, with a reference date of 11/14/24 revealed a Brief Interview for Mental Status (BIMS) score of 11/15 which indicated R63 was cognitively impaired.Review of R63's Care Plan with a revision date of 5/8/25 read in part: Resident has history (hx) of behaviors evidenced by: TARGET BEHAVIOR 1: Verbal Aggression EX: Cussing/inappropriate statements towards others .Review of R63's Nurses Notes read in part: Effective Date: 07/03/2025 17:03 Type: Nurses' Notes Note Text : resident was in a verbal altercation with another resident . (Facility NHA-DON and RCD AA-made aware of this incident by this surveyor and no incident reports, and or FRIs, facility investigations were made available to this surveyor, nor was the other resident involved known). Resident #52 (R52)Review of an admission Record revealed R52, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Dementia.Review of a Minimum Data Set (MDS) assessment for R52, with a reference date of 9/30/25 revealed a Brief Interview for Mental Status (BIMS) score of 03/15 which indicated R52 was cognitively impaired.Review of a R52's Pertinent Charting-Behavior Note read in part: Event date: 7/12/2025 21:35 resident has been going in and out of other residents' rooms; he started shouting and being very rude. Resident also had angry eyes staring at staff; very unlike him.Review of a R52's Pertinent Charting-Behavior Note read in part: 7/22/202514:40 Resident yelling back at other residents Resident is very agitated at constant hollering out. Writer was able to redirect after several minutes. Review of a Facility Policy-Abuse, Neglect and Exploitation-with a revision date of 1/10/24 read in part: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property.Definitions. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology . Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, and misappropriation of resident property. and exploitation that achieves: A. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship. B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents. Identification of Abuse, Neglect and Exploitation.A. The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations.B. Possible indicators of abuse include, but are not limited to:1. Resident, staff, or family report of abuse2. Physical marks such as bruises or patterned appearances such as a handprint, belt, or ring mark on a resident's body3. Physical injury of a resident, of unknown source4. Resident reports of theft of property, or missing property'5. Verbal abuse of a resident overheard6. Physical abuse of a resident observed7. Psychological abuse of a resident observed8. Failure to provide care needs such as comfort, safety, and feeding. bathing, dressing, turning & positioning9. Evidence of photographs or videos of a resident that are demeaning or humiliating in nature, regardless of whether the resident provided consent and regardless of the resident's cognitive status.10. Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place, or feelings of guilt or shame.Investigation of Alleged Abuse, Neglect and ExploitationA. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.B. Written procedures for investigations include:1. Identifying staff responsible for the investigation.2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence).3. Investigating different types of alleged violations.4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations.5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and6. Providing complete and thorough documentation of the investigation.Identification of Abuse, Neglect and ExploitationA. The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations.B. Possible indicators of abuse include, but are not limited to:1. Resident, staff, or family report of abuse2. Physical marks such as bruises or patterned appearances such as a handprint, belt, or ring mark on a resident's body3. Physical injury of a resident, of unknown source4. Resident reports of theft of property, or missing property5. Verbal abuse of a resident overheard6. Physical abuse of a resident observed7. Psychological abuse of a resident observed8. Failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning & positioning9. Evidence of photographs or videos of a resident that are demeaning or humiliating in nature, regardless of whether the resident provided consent and regardless of the resident's cognitive status.10. Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place, or feelings of guilt or shame.Investigation of Alleged Abuse, Neglect and ExploitationA. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.B. Written procedures for investigations include:1. Identifying staff responsible for the investigation. 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence).3. Investigating different types of alleged violations.4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations.

Based on interview and record review, the facility failed to ensure completion of a Level II PASARR (Pre-admission Screening/Annual Resident Review) for one Resident (#13) of one resident reviewed, resulting in the potential for lack of appropriate services for mental disorder [MD] or intellectual disability[ID]).Findings include:Resident #13 (R13)Review of the Minimum Data Set (MDS) assessment, dated 12/26/2025, revealed R13 was admitted to the facility on [DATE] and had active diagnoses including bipolar disorder, schizoaffective disorder, and dementia.Review of the electronic medical record (EMR) revealed a Level I PASARR (screening used to ascertain if a Level II PASARR evaluation and determination should be completed) was completed on 6/27/2025. Review of the Level I PASARR revealed the screening criteria listed yes to four of the six screening questions listed, including: a current diagnosis of mental illness and dementia; receiving treatment for mental illness and dementia; received one or more prescribed antipsychotic medication within the past 14 days; and there was presenting evidence of mental illness or dementia. Further review revealed no evidence a Level II PASARR was completed following the positive Level I screening for R13.During an interview on 1/6/2026 at 11:42 a.m., the facility Social Services Director, Staff N was asked to explain the process for completion of annual screenings, including who was responsible for making the referral to the appropriate state-designated authority for a Level II PASARR evaluation and determination when a resident was identified as having evident or possible MD or ID. Staff N reported since she was not a licensed social worker, she would forward the monthly list to the facility's Regional Social Worker for completion of the screenings. When asked who at the facility monitored for return of the Level II determinations from the designated authority, Staff N reported there was no prior formal process in place for monitoring, but the Director of Nursing (DON) had recently taken over the task of completion for both Level 1 and Level II PASARRs. During a record review at the time of the interview, Staff N confirmed she did not find a completed Level II PASARR determination in the EMR to accompany R13's positive Level I screening, dated 6/27/2025.During a record review with the DON on 1/6/2026 at 1:35 p.m., the DON reported she could not find a Level II PASARR or resulting determination for R13 following the positive Level I PASARR, dated 6/27/2025. The DON reported she would investigate the issue and report back to the survey team.During a follow-up interview on 1/6/2026 at 2:42 p.m., the DON reported she contacted the facility's Regional Social Worker and was told R13's Level II PASARR determination was still in the queue awaiting physician review and signature and could not be viewed at that time. The DON reported she had also been in touch with the facility's state designated authority regarding the assessment and was told the resident was deemed to be exempt from the full Level II evaluation following their review. The DON confirmed she was unaware the facility had not received R13's Level II determination until queried by this Surveyor. When asked to present the unsigned Level II determination reported as being in queue for physician review, the DON reported she could not produce the document for review. When asked the process for ensuring timely turnaround of Level II determinations, the DON reported she would be reviewing the process to ascertain if changes needed to be made and would conduct an audit to determine if any other residents had not received Level II determinations, if required.Review of the facility policy titled, PASARR - Pre-admission Screen and Resident Review, dated as last reviewed on 10/30/2023, revealed the following: When indicated on the Level I screen that a Level II screen is required, the facility will complete notification to the State's [PASARR] program notice for Level II screen (in accordance with State Laws) .

Based on observation, interview, and record review, the facility failed to provide meaningful activities for one Resident (#74) of two residents reviewed for activities.Findings include:Resident #74 (R74)Review of Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE] with active diagnoses that included: Alzheimer's disease and non-Alzheimer's dementia. R74 scored a 3 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of severe cognitive impairment.During an observation on 1/5/26 at 1:35 p.m., R74 was sitting on the edge of her bed in the dark with no music or TV on in her room.Observations on 1/6/26 revealed the following:9:07 a.m., R74 was sitting on the side of the bed staring at the blank wall with no lights on in her room, no music playing, the tv was not turned on, and she did not have any activity or sensory items to interact with.9:48 a.m., R 74 continued to sit in the dark with no stimulation or interaction from staff.11:18 a.m., R74 sitting in the same position on her bed with her head bowed down as she stared blankly at the floor with no activities, stimulation, or interaction from activity staff.11:52 a.m., R74 continued to sit on her bed leaning over to the left side and yelling out incoherently.During an observation on 1/7/26 at 10:20 a.m., R74 was sitting at the end of her bed with no music, and the TV was not turned on. R74 did not have any sensory stimulation or activities which she could independently do to keep herself occupied.During an interview on 1/7/26 at 11:34 a.m., Certified Nurse Aide (CNA) R reported R74 who stays in her room all day was not offered any activities . that I have ever seen.there are many behaviors down this wing with no activities.During an interview on 1/7/26 at 1:14 p.m., Licensed Practical Nurse (LPN) C reported, I have never seen any activity staff going in the resident rooms and doing any activities with the residents.if the residents don't go to group activities, they do not get any activities.During an interview on 1/7/26 at 2:45 p.m., Activity Director (AD) Q was queried about what activities where available for residents with dementia who stay in their rooms. AD Q could not describe any activities that are offered to residents in their rooms who do not attend group activities. AD Q was unable to explain what activities were offered to R74 when she sits in her room all day alone.Review of document titled Activities Evaluation dated 10/16/25 read in part activities (Mark the activities the resident enjoys) .movies/TV, music/talk radio.Review of R74 care plan revealed the following: Resident [R74] is at risk for altered activities patterns.is dependent on staff for activities cognitive stimulation and social interactions. Resident's preferred activities are: sensory activities, reading too, music.A policy for activities was requested and was not provided before exit.

Based on interview and record review, the facility failed to provide information to formulate an advanced directive for one Resident (#74) of one resident reviewed for advanced directives.Findings include:Findings include:Resident #74 (R74)Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE], with active diagnoses that included Alzheimer's Disease. R74 scored a 3 of 15 on the Brief Interview for Mental Status (BIMS) reflective of severe cognitive impairment.Review of the Electronic Medical Record (EMR) did not reveal that the resident/responsible party had received advanced directive information or formulated an advanced directive.During an interview on [DATE] at 3:18 p.m., Social Services Designee (SSD) N reported she did not have the advanced directive for R74.I complete them on admission and for a residents like R74 who has a DPOA the advanced directives are done also on annually.I have looked in my office for the advanced directive for R74 and I cannot find it and it is not in the EMR.During an interview on [DATE] at approximately 2:45 p.m., the Nursing Home Administrator (NHA) acknowledged R74 did not have advanced directive information and did not formulate an advanced directive.Review of policy titled Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS) last reviewed/revised [DATE], read in part .Advance directive is defined as a written instruction, such as a living will or durable power of attorney for health care.relating to the provision of healthcare when the individual is incapacitated.facility staff should verify the presence of an advanced directive or residents wishes regarding CPR upon admission.

Based on interview and record review, the facility failed to provide residents/responsible parties with written notifications of bed hold and transfer notifications and/or provide notification to the office of the state Ombudsman for facility initiated transfers, for three Residents (R9, R70, R1) of five residents reviewed for hospitalizations. Findings include: Resident #9R9 was transferred to the emergency department (ED) on 10/3/25, 10/18/25, and 12/17/25.The facility did not provide written notification of transfer to the resident/responsible party for the transfer on 10/18/28. There were no written notifications of bed hold issued when R9 was transferred to the ED on 10/18/25.The written notification of transfer dated 12/17/25 did not provide a reason for the transfer. The written notification of bed hold for the transfer on 12/17/25 did not have any boxes checked to indicate the choice of acceptance or declination of bed hold.The list of notifications to the Office of the State Long-Term Care (LTC) Ombudsman for the month of October 2025 did not include Ombudsman notification of the transfer of R9 on 10/3/25.The Administrator (NHA) was interviewed on 1/6/26 at 2:28 PM. The NHA said the facility had concerns with issuance of written notifications of transfers and bed holds. The NHA said there was no written notification of transfer or bed hold when R9 went to the ED on 10/18/25. The NHA confirmed the written notification documents should be fully completed with no blanks. The NHA was unable to explain the reason the Ombudsman notification list of October 2025 did not include the transfer of R9 on 10/3/25.Resident #70 (R70)R70 was transferred to the ED on 11/15/25.The facility did not provide a written notice of transfer to the resident/ responsible party for the transfer to the ED on 11/15/25.The written notification of bed hold form in the electronic medical record (EMR) did not have any boxes checked and were blank where the resident/responsible party would elect or decline a bed hold. The bed hold document did not contain the signature of the resident/resident representative and the EMR did not contain documentation indicating the bed hold information had been provided to the resident/responsible party. During an interview with the NHA on 1/6/26 at 2:28 PM, the NHA confirmed there were no written notification of transfer completed when R70 went to the ED on 11/15/25.Resident #1 (R1)R1 was transferred to the ED on 10/10/25 and 10/11/25.The written notification of transfer on 10/11/25 contained blank boxes where reason for transfer was intended to be documented.A written notification of bed hold was not located in the EMR of R1. A written notification of bed hold was requested but not provided by the NHA.The NHA and Regional Clinical Director (RCD) were interviewed on 1/7/26 at 9:28 AM. The NHA said the information for written notifications of transfers and bed holds and Ombudsman notifications had been provided. The RCD said the facility was missing some of the requisite information for transfers and there was no additional information available.

Based on observation, interview and record review, the facility failed to ensure a medication error rate at or below five percent (5%), with three errors out of 31 opportunities resulting in a medication error rate of 9.68%, affecting one Resident (#85) of four residents reviewed.Findings include:On 1/6/2025 at 7:42 a.m., Licensed Practical Nurse (LPN) M was observed preparing to administer R85's medications. LPN M began administration by handing R85 a Trelegy Ellipta 200 mcg (microgram) - 62.5 mcg - 25 mcg inhaler. R85 was observed attempting to slide the cover of the inhaler open but her hand slipped and she closed the inhaler at which time LPN M took the inhaler, slid open the lid to load a dose of the medication before handing it back to the Resident. R85 then held the mouthpiece against her lips, inhaled the medication and exhaled immediately following the inhalation of the medication.Immediately following administration of the Trelegy, LPN M handed R85 a medication cup with oral medications. R85 put the medications in her mouth followed by water and swallowed the medications. It was noted R85 did not rinse her mouth out after administration of the Trelegy or prior to swallowing the oral medications with water and no instruction to do so was provided by LPN M.Following administration of R85's oral medication, LPN M handed R85 a fluticasone-salmeterol (Advair) 250 mcg - 50 mcg inhaler. R85 held the inhaler with the mouthpiece pointed in the up position and used her left thumb to push the lever down to load a dose of medication but was unable to do so. LPN M assisted R85 by pressing the lever down as the inhaler was still being held in a vertical position by R85. R85 then put the mouthpiece in her mouth and inhaled the medication and immediately exhaled. R85 then took a drink of water from her over bed table and swished and swallowed the water. It was noted LPN M did not instruct R85 to position the inhaler so the mouthpiece and dose loading lever were in a horizontal position, to hold her breath for 10 seconds following administration of the medication, or to spit out the water she used to rinse her mouth after administration.Following administration of R85's inhalers and oral medication, LPN M proceeded to administer Humalog (rapid-acting insulin) KwikPen 15 units by subcutaneous injection into R85's right mid-abdomen, approximately two inches right of the umbilicus. After administration of the Humalog, LPN M reported R85 was also ordered to receive Lantus (long-acting insulin), but she had to retrieve a new pen from medication storage. Upon returning with the Lantus Solostar pen, LPN M prepared the insulin pen to deliver 60 units and asked R85 where she wanted this injection. R85 reported she would prefer the injection to be on left side of her abdomen, opposite from where she received the Humalog injection. LPN M agreed then used an alcohol swab to disinfect an area on R85's left mid-abdomen, then proceeded to inject the 60 units of Lantus insulin into R85's right mid-abdomen, approximately two inches to the right of the umbilicus and the same site she had injected the Humalog insulin.Review of the manufacturer's insert for Trelegy Ellipta, accessed on 1/7/2026, revealed instructions following inhalation of the medication to Rinse your mouth with water after you have used the inhaler and spit the water out. Do not swallow the water.Review of the manufacturer's insert for Advair, accessed on 1/7/2026, revealed instruction to hold the [inhaler] in a level, flat position with the mouthpiece toward you. Slide the lever away from the mouthpiece as far as it will g until it clicks . Do not tilt the [inhaler] . Put the mouthpiece to your lips. Breath in quickly and deeply . hold your breath for about 10 seconds . Rinse your mouth with water after breathing in the medicine. Spit the water out. Do not swallow it.Review of R85's January 2026 Medication Administration Record (MAR) revealed LPN M documented administration of R85's Humalog insulin as being injected in the Residents Abdomen - LUQ (left upper quadrant), opposite from the observed injection site of the right mid-abdomen.Review of the American Diabetes Association guideline titled, Insulin Routines, accessed 1/07/2026, insulin injection sites should be rotated. Further review of the guideline revealed Don't inject the insulin in exactly the same place each time . If you inject insulin near the same place each time, hard lumps or extra fatty deposits may develop. Both of these problems are unsightly and make the insulin action less reliable.On 1/7/2026 at 1:35 p.m., the Director of Nursing (DON) reported LPN M was not working and was unavailable for interview. The DON was queried regarding the observation of R85's medication administration observed on 1/06/2026. The DON reported nursing should be administering inhaled medications unless the Resident has been assessed as competent to administer their own medications. During a record review at the time of the interview, the DON reported R85 was not assessed for self-administration of medications, therefore nursing staff should be loading the doses of the inhalers and instructing the residents accordingly. When asked about correct procedures for insulin administration, the DON reported injection sites should be rotated and if two insulins are administered, they should be injected in different locations.

Based on observation, interview and record review, the facility failed to discontinue an inhaled medication per pharmacy recommendations and physician order for one Resident (#85) failed to ensure non-pharmacological interventions were attempted prior to the administration of as needed pain medications for three Residents (#5, #85, #55) and failed to implement not pharmacological interventions prior to the start of an antipsychotic medication and utilize physician ordered as needed (PRN) anti-anxiety medications for one Resident (#5) of five Residents reviewed for unnecessary medications.Findings include:Resident #5 (R5) Review of an admission Record revealed R5, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Dementia. Review of a Minimum Data Set (MDS) assessment for R5 with a reference date of -10/22/25 revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which indicated R5 was cognitively intact. In an observation and interview on 1/5/2026 at 2:24 PM., R5 was noted in her room sitting upright in a chair. R5 stated yes, please come in and sit with me when this Surveyor knocked and asked to enter her room. R5 reported she was admitted to the facility a few months ago because she is dying of colon cancer that has spread everywhere R5 started to cry as she told this Surveyor it could be any day, I just wish I could be at home and pass away with my family there, I am so afraid, I am terrified of being alone when that time comes R5 speech was coherent and easily understood, she was able to articulate every question asked by this surveyor with ease. When asked about her medications R5 stated I don't need the medications they have me on, and I know they are psychiatric medications, I am not crazy, I am dying, I want to be near my family, and I am afraid of dying alone! .R5 reported at times she gets frustrated and speaks loudly to the staff because they do not visit as much as she would like . Review of R5's Physicians Orders read in part: RisperDAL Oral Tablet 0.5 MG (milligram) . Give 1 tablet by mouth one time a day related to ADJUSTMENT DISORDER WITH DEPRESSED MOOD start date.12/31/2025 09:00 . Review of R5's Progress Notes read in in part: 12/30/2025 15:45 Nurses 'Notes Text: hospice was in today resident was very upset and angry, and this has been happening more, so hospice doctor ordered Risperdal 0.5 mg daily to help her mood DPOA Son was called and left message to call back . Review of R5's Behavioral Health-Psychiatry Follow up Date of Service: 2025-12-22 13:52:00 note read in part: .(R5) is currently resting in bed. She recently started Aricept (medication to treat symptoms of dementia) and has been tolerating this medication well . The family is interested in adding Namenda (medication to treat symptoms of dementia) to her regimen.Her Celexa (Citalopram/Celexa antidepressant medication) dosage was previously decreased, and she has remained overall stable on this medication.(R5) is currently on hospice care (end of life) for colon cancer .Previously, the patient experienced a urinary tract infection (UTI) and had increased agitation and aggression primarily related to her confusion due to dementia. During visits, she required frequent redirection, was easily distracted, and had difficulty staying focused with very limited insight. Review of the online (Risperidone) Package Insert read in part: BLACK BOX WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTI. -Elderly patients with dementia. treated with antipsychotic drugs are at an increased risk of death. RISPERDAL is not approved for use in patients with dementia-related psychosis. (5.1) .Risperidone is used to treat schizophrenia, bipolar disorder, or irritability associated with autistic disorder. This medicine should not be used to treat behavioral problems in older adults who have dementia. Using this medicine with any of the following medicines is usually not recommended: Citalopram/Celexa (which R5 was prescribed: Citalopram Hydrobromide Oral Tablet 20 MG (Citalopram Hydrobromide) Give 1 tablet by mouth at bedtime related to ANXIETY DISORDER, UNSPECIFIED dated 11/11/25 . During an interview/record review on 1/6/26 at 1:10 PM., Registered Nurse (RN) Y reported, any resident starting on an antipsychotic medication should have a complete assessment and well documented behaviors to ensure the medication is necessary. RN Y reported R5 was a very sweet resident who is fearful of dying, she has expressed loneliness and misses her family a lot. RN Y reported R5 had physician orders for anti-anxiety medication which should have been used when R5 was struggling with mood, behaviors, aggression and anxiety RN Y reported R5 also recently had a Urinary Tract Infection (UTI) which often causes increased behaviors in elderly residents, which can be mistaken for mood disorders, or other behaviors. Review of a facility Policy and Procedure read in part: Unnecessary Drugs-Without Adequate Indication for Use Date Implemented: 10/30/2020 Date Reviewed/ Revised: 10/26/2023 Policy: It is the facility's policy that each resident's drug regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical and psychosocial well-being free from unnecessary drugs. Indications for use is the identified, documented, clinical rationale for administering a medication that is based upon an assessment of the resident's condition and therapeutic goals, and is consistent with manufacturer's recommendations and/or clinical practice guidelines, clinical standards of practice, medication references, clinical studies, or evidence-based review articles that are published in medical and/or pharmacy journals.Policy Explanation and Compliance Guidelines: 1. The indications for initiating, withdrawing, or withholding medications(s), as well as the use of nonpharmacological approaches will be determined by assessing the resident's underlying condition, current signs, symptoms, expressions, preferences, and goals for treatment including identification of underlying causes (when possible).2. The attending physician will assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with residents and/or representatives, other professionals, and the interdisciplinary team. Each resident's drug regimen will be reviewed on an ongoing basis. Resident #85 (R85) Review of R85's admission record revealed admission to the facility on [DATE] with diagnoses including heart failure, diabetes, Multiple Sclerosis (MS), spinal stenosis, muscle weakness and history of falling. An observation of medication administration on 1/6/2026 at 7:45 a.m., revealed R85's administered medications included inhaled doses of fluticasone-umeclidinium-vilanterol (Trelegy) and fluticasone-salmeterol (Advair). Review of R85's Note to Attending Physician/Prescriber, written by the facility's Consultant Pharmacist and dated 12/22/2025, revealed the following recommendation: This patient is on Trelegy and Advair (inhaled medications used to treat symptoms of COPD and Asthma) inhalers. This is duplicate therapy and potentially harmful to the patient. Please d/c (discontinue) the Advair inhaler. Further review of the Note revealed the physician responded to d/c Advair, in a written order in the Physician/Provider Response section, signed and dated 12/24/2025. Review of R85's December 2025 and January 2026 Medication Administration Record(s) (MAR) revealed active orders for both Trelegy and Advair daily. Further review revealed R85 was consistently administered both inhaled medications on a daily basis from 12/19/2025 through the date of the medication administration observation on 1/6/2026. During an interview on 1/6/2026 at 1:03 p.m., the Director of Nursing (DON) confirmed R85 continued to receive doses of both inhaled medications through the date of the interview due to a failure to discontinue the Advair inhaler per the pharmacy recommendation and physician order on 12/24/2025. Licensed Practical Nurse (LPN) O who was present during the interview reported he reviewed the physician order on 12/24/2025 per his initials on the bottom of the Note but was unsure why the medication was never discontinued. On 1/6/2026 at 2:42 p.m., the DON reported to the survey team, LPN O inadvertently discontinued R85's fluticasone nasal spray (Flonase, used to treat symptoms of nasal allergy symptoms) instead of the fluticasone-/salmeterol (Advair) inhaler. The DON confirmed R85 received unnecessary doses of the Advair inhaler after the pharmacy recommendation and physician's order to discontinue the medication. Further review of R85's December 2025 and January 2026 MARs revealed the following order: Oxycodone [opioid pain medication] oral tablet 5 MG [milligram]. Give 1 tablet by mouth every 6 hours as needed [PRN] for pain – severe . Start Date: 12/18/2025. Doses of oxycodone 5 mg were recorded as administered to R85 on 1/1/2026 at 11:09 a.m., 1/2/2026 at 9:55 a.m., 1/3/2026 at 9:42 a.m., 1/4/2026 at 11:09 a.m. and 1/5/2026 at 8:09 p.m. Further review of R85's electronic medication record (EMR) revealed no documentation of the use of non-pharmacological interventions prior to administering the PRN oxycodone. Review of R85's care plan revealed, Resident has/is at risk for pain . Offer non-pharmacological interventions to relieve pain and observe for effectiveness. Date Initiated: 12/18/2025. Resident #55 (R55) Review of R55's admission record revealed he was admitted to the facility on [DATE] and had diagnoses including dementia, alcohol dependence, constipation and pain. During an observation of medication administration on 1/7/2026 at 7:45 a.m., LPN P was observed preparing medications for administration to R55. LPN P was observed placing two acetaminophen 325 mg tablets into a cup with the remainder of R55's prescribed medications. LPN P stated, this isn't scheduled, I know I should ask [if he has pain] but I just know he wants it. LPN P then proceeded to enter R55's room and was observed administering R55's medications, including the acetaminophen 325 mg tablets to the Resident without asking if the Resident had pain or attempting the use of non-pharmacological interventions to relieve pain prior to the administration of the medication. LPN P then exited R55's room and returned to the medication cart. Review of R55's January 2026 MAR revealed the following order: Acetaminophen (non-opioid pain medication) oral tablet 325 MG. Give 2 tablets by mouth every 6 hours as needed [PRN] for pain . Date Initiated: 9/30/2025. Further review of the MAR revealed LPN P signed out the doses of acetaminophen 325 mg observed at 7:54 a.m. and listed a pain level of 4 (four on a scale of 10) for R55. Previous doses of the medication were recorded as administered on 1/2/2025 at 7:55 a.m. and 1/6/2025 at 11:17 a.m. Review of R55's EMR revealed no documentation of the use of non-pharmacological interventions prior to administering the PRN acetaminophen 325 mg tablets. Review of R55's care plan revealed, Resident has/is at risk for pain related to osteoarthritis . Offer non-pharmacological interventions to relieve pain and observe for effectiveness. Date Initiated: 9/30/2025. During an interview on 1/7/2026 at 1:35 p.m., the DON was queried to the process of administration of PRN pain medications. The DON reported a pain assessment should be completed and non-pharmacological interventions should be attempted prior to the administration of PRN pain medications. Review of the facility policy titled, Medications – PRN, last reviewed 1/30/2024, revealed the following: PRN medication refers to a medication that is taken as needed for a specific situation. It is not provided routinely, and requires assessment for need and effectiveness . When administering a PRN medication . Document the reason voiced by the resident and/or the assessment findings that show why the resident needs the medication . It was noted the facility policy did not include instructions on the use of non-pharmacological interventions prior to the administration of PRN pain medications.

Based on observation, interview, and record review, the facility failed to accurately document wounds, determine wound etiology, and adhere to physician's orders for bilateral lower extremity compression devices for one Resident (R51) of 18 residents reviewed for quality of care. Findings include:On 1/5/27 at 11:46 AM, Resident #51 (R51) was observed sitting in a wheelchair next to her bed with her feet directly on the floor. The lower calves and feet of R51 had a purple hue with evident edema (swelling caused by fluid trapped in the body tissue). R51 said, I can get bad swelling in my legs. I'm supposed to wear special stockings, but they haven't put them on in a while. R51 was unable to recall the last time staff had applied the special stockings. Review of the electronic medical record (EMR) for R51 revealed an admission date to the facility on 1/25/23 with a primary diagnosis of Diabetes. A Minimum Data Set (MDS) assessment dated [DATE] documented R51 did not refuse care or display behavioral symptoms. The MDS disclosed R51 was dependent on staff for lower body dressing, including putting on and taking off footwear.Further review of the MDS revealed R51 had a diabetic foot ulcer and an unhealed stage 3 pressure injury (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss).The EMR of R51 contained a physician's order dated 8/14/25 that read: Ensure resident is wearing size F [Name Brand Stockings - designed to provide support and compression for various conditions including swelling to restore circulation, reduce edema, and enhance tissue stability] to bilateral lower extremities at all times.R51 was observed in a wheelchair at bedside with her bilateral feet directly on the floor without wearing [Name Brand Stockings] on 1/5/26 at 11:46 AM, 1/5/26 at 3:32 PM, 1/06/26 at 8:42 AM, 1/06/26 at 10:08 AM, 1/06/26 at 12:25 PM, 1/07/26 at 7:52 AM, and 1/7/26 at 8:05 AM.During a dressing change observation on R51's right heel on 1/7/26 at 8:05 AM, Registered Nurse (RN) C and Licensed Practical Nurse (LPN) O were asked why R51 was not wearing [Name Brand Stockings]. RN C said the physician ordered R51 to have [Name Brand Stockings] applied every morning and removed every night. When asked why the [Name Brand Stockings] were not worn as ordered by the physician on the above observation dates and times, RN C said, I don't know. When asked if R51 should have the [Name Brand Stockings] on, RN C and LPN O said, yes.The January 2026 Treatment Administration Record (TAR) of R51 was reviewed and revealed [Name Brand Stockings] were signed out on the TAR as being applied by RN C on 1/5/25, 1/6/25, and 1/7/25.A progress note entry dated 1/1/26 at 8:45 AM read, in part: .resident noted with compression stockings [Name Brand Stockings] missing and noted vascular changes to the shins. Will be monitoring for breakdown. Resident continues to spend large portions of the day sitting up in the dependent position leaving the legs and feet in a state of pooling [edema].There was no documentation in the EMR after 1/1/26 regarding the missing [Name Brand Stockings] or the increased pooling edema of the lower extremities. There was no documentation indicating the physician of R51 had been notified of the missing [Name Brand Stockings] to determine if further orders were indicated by the physician.The EMR documented R51 had a wound on the right heel, but documentation was inconsistent with wound etiology:Wound assessments documented the wound as a stage 3, facility-acquired pressure injury. The assessments that documented the wound as a pressure injury were dated 9/23/25, 9/30/25, 10/8/25, 10/14/25, 10/21/25, 10/28/25, 11/5/25, 11/12/25, 11/19/25, 11/25/25, 12/1/25, 12/8/25, 12/16/25, 12/22/25, and 1/1/26.Some progress notes documented the wound as a right heel diabetic ulcer. The progress notes that documented the wound as a right heel diabetic ulcer include notes on: 1/1/25 at 3:18 AM, 12/28/25 at 9:40 AM, 12/24/25 at 2:25 AM, 12/23/25 at 10:22 AM, 12/22/25 at 9:03 PM, 12/22/25 at 12:53 PM, 12/21/25 at 4:58 PM, 12/20/25 at 5:49 PM, 12/18/25 at 9:33 AM, and 12/17/25 at 1:41 AM.The skin and wound weekly assessments in the EMR documented R51 had a left heel diabetic ulcer documented as resolved on 12/8/25 with no documented wound assessments or measurements of the left heel after 12/8/25.The EMR contained a progress note dated 12/8/25 at 4:16 PM that read, in part: .Location: left heel. Issue type: Diabetic foot ulcer. Progress: Resolved. Wound healed and/or closed.Progress notes after 12/8/25 continued to document a diabetic wound on the left heel:12/9/25 at 1:48 AM documented, in part: .lle [left lower extremity] heel tx [treatment] in place.12/9/25 at 9:36 AM documented, in part: .Location of skin area being documented: L. lower heel Diabetic ulcer: Wound stable and slow to heal. No infection noted.12/10/25 at 9:28 AM documented, in part: .Location of skin area being documented: L. lower heel diabetic ulcer: wound stable and free of infection.12/24/25 at 9:11 AM documented, in part: .L. [left] foot diabetic ulcer. Wound stable. Daily treatments in place. No s/s of infection noted.12/25/25 at 12:27 AM documented, in part: . L. [left] foot diabetic ulcer. Wound stable. Daily treatments in place. No s/s of infection noted.12/25/25 at 9:07 AM documented, in part: .L. foot diabetic ulcer. No s/s of infection noted. Resident tolerating wound care well. No s/s [signs/symptoms] of deterioration.12/26/25 at 10:49 AM documented, in part: .L. foot diabetic ulcer. No s/s of infection noted. Resident tolerating wound care well. No s/s of deterioration.12/27/25 at 12:40 AM documented, in part: .Left foot dressing dry and intact.12/27/25 at 11:02 AM documented, in part: .Left foot treatment in place, no s/s of infection noted.12/29/25 at 2:00 AM documented, in part: .Left foot treatment in place.12/30/25 at 10:29 AM documented, in part: .L. foot diabetic ulcer of the L. heel: wound stable.1/5/26 at 9:23 AM documented, in part: .LLE diabetic ulcer wound stable and slow to resolve. No deterioration. Resident tolerating dressing changes well.1/6/26 at 10:07 AM documented, in part: .L. Heel diabetic ulcer. Treatments are daily and wound is stable.On 1/7/26 at 7:49 AM, RN C said R51 had an abrasion on the left shin and a diabetic ulcer on the right heel. RN C said R51 had no other wounds.On 1/7/26 at 8:05 AM, RN C and LPN O were observed completing a dressing change on the right heel of R51. Both legs of R51 were dry, scaly, purple in color, and edematous. After completing the dressing change, RN C and LPN O were asked to assess the left heel. LPN O said, That wound healed. RN C said, [R51] only has a wound on the right heel. The request was reiterated.LPN O lifted R51's left heel from the mattress to reveal an uncovered wound on the medial left heel approximately 1.5 cm (centimeters) x (by) 1.5 cm (length and width, respectively). The depth of the wound bed was unknown due to the presence of eschar (dead or devitalized tissue) adhered to the wound. LPN O said, Oh, it looks like it re-opened. LPN O said he completed the initial and weekly assessments of wounds in the facility and confirmed personally that the wound on the left heel was healed and resolved in early December 2025. When asked when the wound re-opened, LPN O said he did not know. RN C said she assessed the left heel last Wednesday (12/31/25) and the wound was not present. RN C did not supply a response when asked why progress notes documented a wound on the left heel, including documentation entered after 12/31/25.

Based on observation, interviews, and record review, the facility failed to revise/updated resident person centered care plans for 1 Resident (#5) of 13 residents reviewed for care planning resulting in unnecessary administration of psychiatric medications for R5, the potential for administration of unnecessary medications without proper indication, and the potential for inadequate goods and services for residents to maintain their highest practicable physical, mental and psychosocial well-being.Findings include:Findings include:Resident #5 (R5)Review of an admission Record revealed R5, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Malignant neoplasm of the (large intestine) colon cancer. Review of a Minimum Data Set (MDS) assessment for R5 with a reference date of 10/22/25 revealed a Brief Interview for Mental Status (BIMS) score of 12/15 which indicated R5 was cognitively intact.In an observation and interview on 1/5/2026 at 2:24 PM., R5 was observed in her room sitting upright in their chair. When speaking with R5 about her care at the facility, the topic of medications was brought up, R5 became tearful, and visible tears were noticed coming from her eyes. R5 was asked why she was crying. R5 stated I have colon cancer that has spread to my entire body, I am dying, it could be any day, I just wish I could be at home and pass away with my family there, I am so afraid, I am terrified of being alone when that time comes. When asked about her medications R5 stated I don't need the medications they have me on, and I know they are psychiatric medications, I am not crazy, I know what Risperdal is used for, I am dying! R5 reported she has at times gotten frustrated and speaks loudly and has been harsh too. R5 reported she did not want to be medicated during her last days, especially when her family visits, and her anxiety has been higher than normal because the holidays and weather has made it more difficult to have family make it to see her. R5's speech was coherent and easily understood, she was able to articulate every question asked by this surveyor during this observation and interview. Review of R5's Care Plan read in in part: FOCUS-(R5) Resident has behavior(s) related to Dementia as evidenced by: TARGET BEHAVIOR 1: Verbal Aggression: Resident at times with swear or make inappropriate statements towards the staff/others Possible triggers include discussing why she is here, talking about family, direct cares Date Initiated: 11/05/2025 .Revision on: 11/05/2025 GOAL: Resident will have no adverse effects related to behaviors through the next review.Date Initiated: 11/05/2025 Target Date: 01/26/2026 Resident will remain injury-free related to behaviors through next review. Date Initiated: 11/05/2025 Target Date: 01/26/2026.Review of R5's Care Plan read in in part: FOCUS-(R5) takes psychotropic/mood stabilizer medication as evidenced by antianxiety use Date Initiated: 10/16/2025 Revision on: 10/17/2025 GOAL- (R5) will be free of drug related complications and/or side-effects related to psychotropic medication use through the next review. Date Initiated: 10/16/2025 Target Date: 01/26/2026.INTERVENTIONS-Administer medications as ordered Date Initiated: 10/16/202. Refer to psychologist/psychiatrist as needed Date Initiated: 10/16/2025. Observe for and report to Physician/NP/PA adverse effects of antidepressant medication use (nausea/vomiting, weight gain, weight loss, diarrhea, sleepiness, suicidal ideations, worsening depression, panic attacks, insomnia, irritability, extreme increase in activity (mania), aggression, increased anger or violence). Date Initiated: 10/16/2025.Further review of R5's care plans revealed no care plans were in place for UTI's. There were no Compassion visits considered in care planning. There were also no Non-pharmacological FOCUS areas and/or interventions in place, or updated/revised to reflect R5 in person centered areas such as hopelessness, fear, death and dying, grieving and or root cause of mood/behaviors.During an interview/record review on 1/6/26 at 1:10 PM., Registered Nurse (RN) Y reported, any resident starting on an antipsychotic medication should have a care plan in place with the specific antipsychotic medications, such as Risperdal. RN Y reported R5's behaviors were not aggressive towards others and when she did have a few behaviors last month it was because she had a urinary tract infection (UTI) which can have symptoms that mimic behaviors. RN Y reported R5 was a very sweet resident who is fearful of dying, she expresses loneliness and misses her family a lot. RN Y reported R5 had physician orders for anti-anxiety medication and that could have been used if any of the nurses saw R5 struggling with mood, behaviors, aggression and anxietyReview of R5's Behavioral Health-Psychiatry Follow up note read in part: Date of Service: 2025-12-22 13:52:00.(R5) is currently resting in bed. She recently started Aricept (medication to treat symptoms of dementia) and has been tolerating this medication well . The family is interested in adding Namenda (medication to treat symptoms of dementia) to her regimen.Her Celexa (antidepressant medication) dosage was previously decreased, and she has remained overall stable on this medication.(R5) is currently on hospice care (end of life) for colon cancer .Previously, the patient experienced a urinary tract infection (UTI) and had increased agitation and aggression primarily related to her confusion due to dementia. During visits, she required frequent redirection, was easily distracted, and had difficulty staying focused with very limited insight.In an interview/record review on 1/7/26 at 4:40 PM, Registered Nurse (RN) E and this surveyor reviewed of R5's care plan which did not indicate did any revisions to her care plan regarding a new antipsychotic medication, nor did it indicate any revisions to R5's interventions about any new behaviors, she also did not have a care plan in place for being at Risk for UTI's which R5 had recently had. No interventions or revisions were noted on R5s care plan for indications of potential behaviors from UTI's. RN E reported the care plan should have been reviewed and revised to included something regarding behaviors and addressing her fear of passing away and being alone when she dies, not near her family.Review of a facility Policy- Comprehensive Care Plans-Date Reviewed/Revised 6/30/2022 read in part: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes 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 (Minimum Data Set). Definitions: Person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives.1. The care planning process will include an assessment of the resident's strengths and needs. Services provided or arranged by the facility.shall be culturally competent and trauma-informed.2. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care.3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team.

This deficiency pertains to MI00153258 Based on observation, interview, and record review the facility failed to use the appropriately sized sling with the mechanical lift, and provide adequate supervision during a transfer to prevent injury for one Resident (#1) of two residents reviewed for accident/hazards. This deficient practice resulted harm when R1 incurred deep purple bruises on arms and leg, an injured toe, discomfort during transfers and risk of additional injury during transfer. Findings include: Resident #1 (R1) Review of the Minimum Data Set (MDS) assessment for R1, dated 6/22/25, revealed admission to the facility on [DATE], with diagnoses that included the following, in part: Debility, cardiorespiratory conditions, heart failure, peripheral vascular disease (PVD), anxiety, post traumatic stress disorder (PTSD), chronic obstructive pulmonary disease (COPD), and morbid obesity. R1 scored 13 of 15 on the Brief Interview for Mental Status (BIMS) assessment, reflective of intact cognition, and was her own responsible party. R1 was totally dependent upon staff for all transfers. On 7/1/25 at 11:26 a.m., observation and interviews were completed during a transfer of R1 from the bed to an electric wheelchair. Certified Nurse Aide (CNA) F, assisted by CNA G and OT A used a blue sling with green binding surrounding the whole sling attached to a [Name Brand] 450 full mechanical lift. Prior to being transferred via mechanical lift, R1 was observed in bed with frank bleeding coming from the right second toe which was wrapped in what appeared to be Kerlix. Fresh, bright red, blood droplets were visible on the bed linens and inside the Kerlix dressing. When asked how the toe was injured R1 said it happened in the shower yesterday (6/30/25). R1 said she was finished with her shower and a CNA pushed her into the door frame on the way out of the shower door. When asked who the CNA was, R1 said it was CNA F who was present in the room and confirmed she had bumped R1's toe on the way out of the shower while the Resident was in a shower chair. CNA F and CNA G used blue sling (green banded) (presumed to be a large sling) to lift R1 from bed using the [Name Brand] 450 full mechanical lift. R1's abdominal sides were extending out the sides of the sling, and significant pressure was observed on R1's back, and lateral arms and legs. The sling hooks attached to the 450 mechanical lift, were fastened on the hooks farthest from the sling on the bottom, and closest to the sling on the top. When asked if they routinely used the [Name Brand] 450 mechanical lift, CNA F responded affirmatively, and R1 interjected, What? You are supposed to be using the [Name Brand] 600. When the bar comes down and my arms are kind of in front of me it [Name Brand 450] pinches me. When asked what size lift sling was being used, CNA F said it was a large sling. When asked how she knew it was a large sling, she said she didn't know and asked OT A what size the sling was. There was one missing label from the sling, and the other label was illegible. When asked what size sling R1 should be using, all staff present in the room were unsure. The sling appeared too small for R1, as it allowed her abdominal area to extend approximately 6 inches on each side, and the green binding did make contact on her arms and legs on and/or near the deep purple bruises on her arms and legs. CNA G assisted CNA F with the transfer. Review of R1's Care Plans revealed the following, in part: Focus: Resident has an ADL (activities of daily living) self-care performance deficit related to cognitive impairment, obesity, arthritis, cardiac status, and resp (respiratory) status. Revision on: 2/26/24 .Interventions . BATHING: 1 person assist, prefers showers 2x per week and PRN (as needed). Revision on: 1/21/2025 . TRANSFERS: with 2 person assist AND use of mechanical total lift and XXL blue or black sling per Invacare guidelines. Ensure that the sling that is used is full square sling per resident's preference. Revision on: 5/2/25 . Focus: Resident is at risk for abnormal bleeding or hemorrhage related to anticoagulant therapy, aspirin therapy. Date Initiated: 3/14/24 . Interventions: Observe for and report to MD (physician) as needed any signs & symptoms of abnormal bleeding . bruising . Report to Nurse any signs or symptoms of bleeding, such as . bruising, bleeding gums, excessive bleeding when shaving. Revision on: 12/19/24. Review of an Other Skin Injury incident report, dated 6/29/25 at 11:30 a.m., revealed the following Incident Description: Resident stated she wanted me to look at something, she showed me a deep purple large bruise to left inner upper arm, also one to right upper front leg, bruise to thigh area matched up with sling to the lift. Resident stated she believes the arm bruise is also related to the (mechanical lift) sling . Predisposing environmental Factors: Equipment . Predisposing Situation Factors : During Transfer . Resident states she believes bruising may be coming from the sling for the lift when being placed in wheelchair . Review of R1's Progress Notes, revealed the following, in part: 5/1/25 3:08 p.m., .while staff were trying to transfer resident from power chair into bed using the Hoyer lift, they were using the wrong sling with only 3 hooks on it and during transfer, her knee was smashed against the lift handle causing her pain . 5/2/25 1:10 p.m., .Resident expressed concerns about use of incorrect sling used to transfer resident to and from her wheelchair which caused increased pain to legs and side . Informed resident that staff would be educated to use square styled lift slings with resident at this time, Care plan updated to include specific style of sling to use with resident and communication placed at this time . 6/29/25 1:00 p.m., Asked by resident to look at her left upper arm, I noted a deep purple older bruise, no broken skin, no hematoma . she (R1) stated that she things it was either the sling to the mechanical lift or possibly when she went to the emergency room . While doing skin sweep, I also noticed another bruise to right upper thigh, the shape of the bruise matched up with the sling used to lift her . 6/29/25 5:00 p.m., A therapy referral is required for the following reasons .potential sling is causing pinching of skin and bruising . 6/29/25 7:00 p.m., Spoke with [Physician] and update given on new bruises, discussed with him that we thought sling was potential cause . 6/30/25 8:43 a.m., Bruising found to left upper, inner arm and on right side under abdominal skin fold. Resident (R1) stated that it's from the lift sling. 6/30/25 2:52 p.m., New wound orders entered for second toe, right foot. 7/1/25 1:27 p.m., Spoke with on call provider that confirmed he was notified about the injury. Treatment started 6/30/25. Resident noted with skin tear on the right second toe. During an interview on 7/1/25 at 1:05 p.m., RN H said there was no note related to R1's second toe on the right foot and the injury incurred in the shower chair. No Risk Management note was found by RN H at this time. During an interview on 7/1/25 at 1:45 p.m., Physical Therapy Assistant (PTA) J was asked to accompany this Surveyor to the mechanical lift sling storage area. Many of the green bound, blue slings had illegible or missing instructions. No instructions for assessing the correct sling size for residents was present in the storage room. During an interview on 7/1/25 at approximately 1:55 p.m., the Regional Director of Clinical Services K, Nursing Home Administrator (NHA), and Regional Consultant M were asked what mechanical lift and sling size should be used for a full-body lift for R1. Regional staff K and M both agreed an XXL sling with blue or black outer binding should be used with the [Name Brand] 600 mechanical lift. Discussed concern related to the use of the [Name Brand] 450 mechanical lift (that day 7/1/25) with a green bound sling, both Regional staff K and M expressed disbelief of this Surveyor's observations. Surveyor Notes compiled during the course of the survey were reviewed, and correctly identified the green bound sling, and the small [Name Brand] 450 were used for the transfer. Regional Director of Clinical Services K and Regional Consultant M said CNA F had verbally confirmed used of the [Name Brand] 600 and a blue or black bound sling, Both Regional staff K and M left the room to attempt to ascertain what sling was used. Regional staff K and M returned and acknowledged a green bound sling was still present underneath the resident, contrary to the verbal education of CNA F and care plan interventions present for R1's mechanical transfers. When asked for an incident report related to R1's second right toe injury due to staff error, Regional Director of Clinical Services K reviewed R1's Electronic Medical Record (EMR) and said no incident report was found. A progress note was found detailing the injury, without details at 1:27 p.m. today (7/1/25), entered by Registered Nurse (RN) H. RN H was made aware of the incident/injury to R1 on 6/30/25 by this Surveyor on 7/1/25 at 1:05 p.m., prior to her progress note entry. All Regional Staff K, L, and M, and the Interim NHA and new NHA expressed understanding of this Surveyors deficiency concerns related to accidents and hazards related to transfers using an incorrect sling size and mechanical lift. Review of the Safe Lifting and Movement of Residents policy, revised 1/1/2022, revealed the following, in part: A sufficient number of slings, in the sizes required by residents in need, will be available at all times . The transferring needs of residents shall be assessed on an ongoing basis. Resident transferring and lifting needs shall be documented in the care plan. Assessment of the residents' transferring needs shall include: A. Mobility of the resident (degree of dependency) B. Size of the resident C. Weight-bearing ability D. Cognitive status The Quality Assessment and Assurance Committee shall collect and evaluate data related to the frequency and types of injuries that occur during resident lifting and moving . Review of[Brand Name] Slings Optimal fit & Optima comfort brochure, dated 7/2023, revealed the following Selecting the right size information: Hip width and back height measured in the sitting position are the most important factors to select the right sling size .The client's weight needs to be considered mainly for the sling's maximum safe working load. It's inferior to indicate the right sling size . Sling colors on the brochure designated the following sizes: Red/XS, Orange/S, Yellow/M, Blue/L, Black/XL, and White/XXL. No slings bound with a green edge were referenced in this 2023 brochure.

Based on observation, interview, and record review, the facility failed to ensure the receipt and transcription of physician orders for immediate care upon admission of two Residents (R3 & R11) out of 9 residents reviewed for physician orders. This deficient practice resulted in lack of physician orders for necessary medications and treatments, and the potential for worsening of condition. Findings include: This deficiency pertains to Complaint Intake #MI00151891. Resident R3 Review of R3's Minimum Data Set (MDS) assessment, dated 3/2/25, revealed R3 was admitted to the facility on [DATE] with active diagnoses that included the following, in part: Alzheimer's disease, and visual loss. R3 had severely impaired cognition. During a telephone interview on 4/8/25 at 9:52 a.m., Complainant A reported the facility failed to provide necessary eye drop medications to R3 for approximately two weeks following their admission to the facility on [DATE]. Review of a pre-admission physician progress note for R3, dated 10/17/24, revealed the following Current Medications Taking, in part: Current Medications Taking . Timolol-Dorzolamide-Latanoprost 0.5 - 0.15 - 0.005% solution as directed Ophthalmic. Notes to Pharmacist: LEFT EYE . Active Problem List . Primary open angle glaucoma ([NAME]) of both eyes, mild stage . Visual loss . Clinical Notes: will continue with current meds to nursing home for care . Review of R3's Physician Order Summary, retrieved 4/8/25 at 1:37 p.m.,, revealed the following physician orders, in part: Cosopt Ophthalmic Solution 2-0.5% (Dorzolamide HCL-Timolol Maleate) Instill 1 drop in left eye every morning and at bedtime for comfort related to unspecified visual loss. This verbal physician order was dated 11/11/24 with a Start Date of 11/11/24. Latanoprost Ophthalmic Solution 0.005% (Latanoprost) Instill 1 drop in left eye at bedtime for comfort related to Unspecified Open-angle glaucoma, Stage Unspecified. Order and Start Date both 11/11/24. Both were started 12 days following admission. Review of R3's Progress Notes revealed the following, in part: 11/3/24 - Spoke with residents daughter who asked if [R3] was taking her eye drops, none had been ordered. I looked at home medication and can see she was taking them previously, spoke with [Physician] who ordered artificial tears qid (four times a day) one drop to both eyes daily. Family has asked that we contact eye doctor [Opthalmalogists Name] and get actual dosages and frequency and have it ok'd with [Physician] to start giving her the Timolol-Dorzolamide-Latanoprost. Did notice resident rubbing her eyes several times today. 11/4/24 - This writer called and spoke with [Opthalmologists Office Staff]. The are addressing the request from family for eye drops with him to see if she needs to remain on these. She was previously on timolol-Dorzolamide-0.5-2% 1 drop to left eye twice daily and Latanoprost .0005% 1 drop to left eye at bedtime .Waiting on a call back at this time. 11/4/24 - Pharmacy Medication Review Progress Note . Chart reviewed, recommendations sent to physician. 11/4/24 - This writer received a call back from [Opthalmologists Office Staff} stating that she (R3) should remain on the eye drops indefinitely to help protect the LEFT eye. Timolol-Dorzolamide 0.5-2% 1 drop to left eye twice daily and Latanoprost .0005% 1 drop to left eye at bedtime . 11/11/24 - Eye gtts (drops) as follow, Latanoprost 0.0005%, left eye daily at HS (hour of sleep) and Cosopt opth. solution 2-0.5%left eye BID (twice daily). Family is aware and [Physician] updated via fax. Review of R3's November 2024 Medication Administration Record (MAR), retrieved 4/8/25 at 1:42 p.m., revealed the Latanoprost Ophthalmic Solution 0.0005% and Cosopt Ophthalmic Solution 2-0.5% (Dorzolamide HCL-Timolol Maleate) both had a Start Date of 11/11/24, with no administration of these medications prior to that date. On 4/8/25 at 4:55 p.m., Senior Director of Nursing E was asked to review R3's 12-day delay in receipt of physician orders and administration of necessary eye medications for the Resident. On 4/8/25 at 9:11 a.m., when asked about the delay in the physician order and administration of R3's eye drops, Senior Director of Nursing E stated, I was not here at the time for [R3s'] eyedrops. I don't have a clear answer as to why it was not transcribed initially because it was on her (R3's) admission orders. Senior Director of Nursing E and the Nursing Home Administrator, both present at the interview, confirmed the medications should have been transcribed and available for administration upon admission. Resident R11 Review of R11s' admission Record revealed R11 was admitted to the facility on [DATE] with active diagnoses that included acute and chronic respiratory failure with hypoxia (lack of oxygen), pneumonia, and chronic obstructive pulmonary disease (COPD). R11 was her own responsible party and able to make her own medical decision. R11 used a wheelchair for mobility. On 4/8/25 at 10:15 a.m., R11 was observed sitting at a table in the dining room in their wheelchair playing cribbage with a family member. There was no oxygen tank, or equipment to hold an oxygen tank on R11's wheelchair. Two unidentified male staff members subsequently entered the dining room and looked at the residents wheelchair. One of the unidentified male staff members returned and placed an oxygen tank holder on the back of R11's wheelchair at approximately 11:00 a.m. On 4/8/25 at 11:40 a.m., Occupational Therapist (OT) O, was observed entering the dining room and checked R11s' blood oxygen level with a finger oxygen saturation device. OT O appeared to check R11s' oxygen (O2) saturation level several times. OT O stated, I am going to get the tubing (oxygen tubing to administer oxygen from the oxygen tank now on the back of R11's wheelchair). It (O2 saturation) was 87, and 88. The highest I can get it is 89. R11 was not wearing oxygen during the time they were in the dining room. Review of R11s' Physician Order Summary, retrieved 4/8/25 at 3:22 p.m., revealed a physician order for supplemental oxygen via nasal cannula was not present. No order for oxygen was found in R11's medical record. Review of R11s' Care Plans, retrieved 4/8/25 at 3:21 p.m., revealed the following interventions related to oxygen: Oxygen as ordered. Date Initiated: 3/30/25. Review of R11s' Progress Notes, retrieved 4/8/25 at 3:26 p.m., revealed the following entry, in part: 3/31/2025 04:48 (4:48 a.m.) . Resident was not wearing her oxygen. When I first checked her SpO2 (oxygen saturation) was 76. Oxygen placed at 3L (liters) . During an interview on 4/8/25 at approximately 3:50 p.m., when asked about the physician order for application of supplemental oxygen for R11 OT O said she was not sure if there was a physician order for oxygen for R11. During an interview on 4/8/25 at 4:55 p.m., Senior Director of Nursing E and the NHA were asked to review R11's physician orders for the presence of a physician order for supplemental oxygen. Senior Director of Nursing E was unable to find a physician order for oxygen for R11, but said she would continue to look. During an interview on 4/9/25 at 9:11 a.m., Senior Director of Nursing E, the DON and the NHA were present. All three agreed that there was no physician order for oxygen supplementation for R11 from her admission date of 3/29/25 through 4/8/25. Review of the Physician/Practitioner Orders - Consulting policy, reviewed/revised 3/20/24 revealed the following, in part: The attending physician shall authenticate orders for the care and treatment of assigned residents. 1. Consulting physician/practitioner orders are those orders provided to the facility by a physician/practitioner other than the resident's attending physician or physician/practitioner who is acting on behalf of the attending physician. A consulting physician/practitioner may include, but is not limited to, a resident's: . Ophthalmologist . nurse practitioner, clinical nurse specialist, or physician assistant to any of the above physicians . For consulting physician/practitioner orders received via telephone, the nurse will: a. Document the order on the physician order form, notating the time, date, name and title of the person providing the order, and the signature and title of the person receiving the order. b. Call the attending physician to verify the order. c. Document the verification of the order by entering the time, date, name and title of the physician/practitioner verifying the order, and the signature and title of the person receiving the verification order .d. Follow facility procedures for verbal or telephone orders including: noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record .

This citation pertains to MI00148054: Based on interview and record review the facility failed to properly transcribe and administer medications per physicians orders for 1 Resident (#3) of 4 residents reviewed for quality of care, resulting in the lack of assessment, monitoring, and documentation and resulted in hospitalization and subsequent delay in treatment/resolution of the infection with the potential for worsening of condition. Findings include: Resident #3 (R3) Review of an Admission Record revealed R3 was originally admitted to the facility on [DATE] with diagnoses including, osteomyelitis (bone infection), left ankle and foot. Review of a Minimum Data Set (MDS) assessment for R3 with an assessment reference date (ARD) of 11/5/24 revealed a Brief Interview for Mental Status (BIMS) score of 4/15 indicating R3 was severely cognitively impaired. In an interview on 12/4/24 at 10:00 AM., R3 reported he was recently admitted to the facility for Rehabilitation and Intravenous (IV) antibiotics for his PICC (Peripherally Inserted Central Catheter-Type of IV) line, and wound care for his left foot. R3 reported the facility nursing staff did not administer his IV-Antibiotics for approximately 5 days that were prescribe for his (foot/wound/bone infection) infection. R3 Reported he had been at the facility a few days and went out on a Leave of Absence (LOA) for overnight with his guardian (whom is also a family member) to spend the night. R3 reported the next day, while at his guardians he was feeling ill. R3 reported his guardian was worried about the way his left foot, and leg looked, she (guardian) took him to the (local hospital name) hospital. R3 reported he was treated for a few things, including the worsened infection in his left foot. R3 reported they (facility nursing staff) didn't give antibiotics in his IV, and they didn't clean his wound properly. R3 reported during his stay for a few days in the hospital the doctors there said, I was going to lose my foot if the infection doesn't get treated immediately. R3 reported the hospital doctor ordered antibiotics IV, to be given once returning to the facility. R3 reported he was very scared and concerned about his left foot. Review of R3's Hospital Discharge Paperwork dated 10/31/24, including a Physicians Order-dated 10/30/24 (from the hospital to the facility upon R3s admission to the facility) revealed: Physicians Order-10/30/24 cefTRIAXone Sodium Intravenous Solution Reconstituted 2 GM (grams) PICC line Use 2 gram intravenously every 24 hours for 6 weeks intended use for osteomyelitis left foot .further reviewed in the Hospital Discharge Paperwork discharge instructions on medications to remain on and follow up included: cefTRIAXone Sodium Intravenous Solution Reconstituted 2 GM Use 2 gram intravenously and Normal saline flush 10 ml (milliliters) to (IV/PICC) bid (twice daily) . Review of R3's facility Nursing Progress note revealed: 11/1/24 14:43 p.m., Resident (R3) has wound on left great toe. PICC line present in right arm Review of R3's Care Plan revealed: Date Initiated: 11/01/2024 .Focus: Resident (R3) requires enhanced barrier precautions related to surgical wound, and PICC line. Revision on: 11/14/2024 . Review of R3's November 2024's facility Medication Administration Record (MAR) revealed: Normal saline flush 10 ml to (IV/PICC) bid (twice daily) every morning and at bedtime .discontinue order when line is removed -Start Date 11/04/2024 . further review of the MAR revealed R3 received no NS flushes twice daily 11/1/24-11-4/24 Review of R3's November 2024's facility Medication Administration Record (MAR) revealed: Treatment: Surgical, left 1st metatarsal (Toe). Wash with wound cleanser, pat dry. Apply Xeroform (wound dressing material) to wound bed and cover with silicone bordered foam dressing. in the afternoon every other day for Skin impairment -Start Date 11/02/2024 1100 . Further review of R3's 11/2024 MAR revealed no nursing documentation that the wound care as ordered to treat was completed from 11/2/23-11/5/24. Review of R3's facility Nursing Progress note revealed: 11/5/24 15:31 p.m., called pt. (patients)- next of kin (guardian) and was notified that the antibiotic was being ran (administered) . (guardian) was thankful for the call In an interview/record review on 12/4/24 at 10:55 AM., Registered Nurse' (RN) M reported R3 had went home on a overnight when he first arrived at the facility, about 4-5 days after he admitted . RN M reported R3 had a PICC line and was at the facility for rehabilitation for PICC/IV antibiotics and wound care originally. RN M reported R3 went out early November with his guardian. RN M reported they became concerned about is wound and he was ill, so she took him the hospital. RN M reported R3's guardian reported that R3's wound and leg looked swollen and red. RN M reported according to the MAR and nurses' notes (which were reviewed together with this surveyor) RN M reported something got missed, the flush for the PICC line, and original antibiotic order for 10/30/24 should have been transcribed before actual admission or within a few hours of admitting . RN M reported it appears for R3 November 2024 MAR and nursing notes, the orders were not followed. RN M reported after R3 was back from the hospital she recalls R3 was upset and scared about his left leg and foot might be amputated. RN M reported had the original physician's orders been followed and transcribed properly R3 should have been getting his PICC line flushed twice daily with NS, and this antibiotic administered from date of admission which was 11/1/24. In an interview on 12/4/24 at 3:30 PM.,the Director Of Nursing (DON) reported R3's initial hospital discharge paperwork came through on 10/31/24 from the hospital where R3 was discharged from, on admission to the facility. The DON reported R3's PICC/IV line Antibiotic and NS flushes for the PICC was missed during transcription of the physicians' orders. The DON reported the nursing staff missed' or did not catch the physicians' orders because the paperwork was a lot different than the hospital discharge paperwork other local hospitals around the area usually send. The DON reported R3 did in fact go a few days without his IV-Antibiotics and PICC line flush. The DON reported R3 went out with family for a night and it was noticed his foot and leg were swollen and red, so the guardian took him to the hospital. The DON reported R3 should not have missed his medications, and the nursing staff did not follow policy and procedures to ensure proper transcription of medications are administered, and/or ordered if not in stock. Review of R3's facility Incident Reported dated 11/11/24 revealed: Description-(R3) was admitted to the facility on [DATE]. The resident (R3) was found to have missed the start of his IV antibiotic (abx) medication on 11/11/24, it wasn't started until 11/5/24 . Resident admitted to the facility on [DATE]. Staff did not see the order for the IV abx . Staff were interviewed . thru that weekend (nurses who worked R3's admission weekend) 11/2 and 11/3. He (R3) was noted to have a PICC in place, but this was not researched by staff at the time Antibiotic order was noted to be in the admission paperwork as a separate order. Staff consensus was that they never saw an order for it. Monday AM it was initiated - (multiple nurses on the incident reported) stated it was the first time they knew anything about the IV abx, although they saw the PICC line) It is noted that the guardian was updated when the abx was running. Management was not aware of the delay until 11/11/24. Review of Nursing References Materials for medication transcription and physicians ordered revealed: Nurses must obey the orders of the physician in charge of a patient, unless an order would lead a reasonable person to anticipate injury if it were carried out, according to [NAME] in Law Every Nurse Should Know, 5th Edition, page 98 The Professional Standard of Quality for documentation of the residents health care in a medical record is the information must be true and complete. Under no circumstances should erroneous records be removed from the overall record and new pages submitted. (Fundamentals of Nursing, Concepts, and Practice. Mosby. [NAME], P.A., [NAME], A.G., 1985) The nurse is obligated to follow the physician's orders unless they believe the order is in error or would be detrimental to the resident. (fundamentals of nursing, concepts, process, and practice, mosby, [NAME] a. [NAME], [NAME] g. [NAME], 1985) The nurse is obligated to follow the physician's orders unless they believe the order is in error or would be detrimental to the resident. (Fundamentals of Nursing, Concepts, Process, and, Practice, Mosby, [NAME], P., [NAME], A., 1985) . The six rights of medication administration include: 1) the right medication, 2) the right dose, 3) the right client, 4) the right route, 5) the right time, 6) the right documentation. To identify a client correctly, the nurse checks the medication administration form against the client's identification bracelet. When asking the client's name, the nurse should not merely speak the name and assume that the client's response indicates that he or she is the right person. Instead, the nurse asks the client to state his or her name. (Fundamentals of Nursing, 6th edition, 2005, pgs. 841-842.)

This Deficient Practice Statement (DPS) has two parts: A and B. DPS A: Based on observation, interview, and record review, the facility failed to provide adequate supervision resulting in a fall with major injury for one Resident (#64) of five residents reviewed for accident hazards and supervision. This deficient practice resulted in serious bodily injury including a head laceration and a cervical (neck) fracture for Resident #64. Findings include: Resident #64 (R64): Review of R64's electronic medical record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including osteoporosis, repeated falls, a stroke affecting the right dominant side, and toxic encephalopathy (a brain condition often resulting in changes in cognitive function). Review of R64's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 8, indicative of moderate cognitive impairment. Review of R64's EMR revealed the following Nurse's Note: 10/20/24 at 2:15 PM: Resident had unwitnessed fall from wheelchair in front of 300 hall nurse desk, had large skin tear to forehead, left eye and left wrist .transferred per EMS [Emergency Medical Services] to emergency room for tx [treatment] and evaluation. On 10/23/24 at 11:50 AM, R64 was observed laying in bed with a large hematoma (bruise) to her left eye and a laceration across her forehead that had been secured with sutures (stiches). On 10/23/24 at 10:29 AM, an interview was conducted with Certified Nursing Assistant (CNA) E who verified she was familiar with R64's level of care. CNA E recalled responding to a fall code on 10/20/24 where she witnessed R64 on the floor with a bleeding laceration on her forehead. When asked R64's level of mobility, CNA E stated R64 for dependent for mobility and could not propel herself in a wheelchair. CNA E stated, Somebody placed her at the nurse's station for better supervision . I think this fall was after lunch, and residents are often placed at the nurse's station after lunch because there is only one care assistant [CNA] on the hall and the other is helping in the dining room. On 10/23/24 at 11:24 AM, a telephone interview was conducted with Registered Nurse (RN) O who verified she responded to the fall code for R64 on 10/20/24. RN O stated in previous days, R64 started trying to get out of bed and had sustained falls from bed, so she was brought to the nurses' station after lunch for increased supervision by the staff who were charting. RN O stated prior to the fall, she responded to a call light in a private resident room with the only CNA on duty on R64's unit. In the process of assisting in the private room, other RN O stated other staff must have left the nurses' station which left R64 unattended. RN O stated, We were spread too thin that day [in regard to staffing levels]. When asked if resident supervision is lacking when staffing level are short, RN O responded, Yes, definitely. On 10/23/24 at 2:18 PM, a phone interview was conducted with RN P who verified she was working on the hall adjacent to the nurses' desk by which R64 was stationed. RN P recollected responding to hearing a loud crash while in a nearby resident room and observing R64 laying on the floor. When asked about contributing factors to R64's fall, RN P stated, There was only one nursing aide on the hall that day Staffing has been challenging. Review of R64's EMR revealed the following entries: 1. Nurses' Notes on 10/22/2024 at 17:09 [5:09 PM]: Resident returned from hospital via EMS on comfort care .Resident with large, sutured laceration of the forehead, Scattered skin tears of the L [left] wrist .Resident mostly non-responsive but did open eyes with painful stimuli. Per MD [medical doctor] at hospital, resident has remained NPO [nothing by mouth] and is unable to swallow pills, food or drinks . 2. Pertinent Charting-Change in Condition note on 10/22/2024 at 20:59 [8:59 PM]: Change identified: decline with mental status and ADL [activities of daily living], unresponsive . 3. Pertinent Charting-Change in Condition note on 10/23/2024 at 9:49 AM [8:59 PM]: Originally identified change: Fall with change in mental status. Resident spent time in hospital following fall with head injury. Resident has returned to facility on comfort are with several skin issues, new C2 [second cervical (neck) vertebrae] fracture, change [in] LOC [level of consciousness] and new comfort care order for EOL [end-of-life] care. On 10/24/24 at 9:01 AM, an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) who confirmed low staffing levels and subsequent inadequate supervision has been an ongoing issue at the facility. Review of facility policy titled, Accidents and Supervision, revised 12/27/23, read, in part: .Supervision is an intervention and a means of mitigating accident risk. The facility provides adequate supervision to prevent accidents . DPS B: Based on observation, interview, and record review, the facility ensure supervision during smoke for one Resident (#15) of five residents reviewed for accident hazards and supervision. Findings include: Resident #15 (R15) Review of R15's electronic medical record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including tobacco use, history of falling, chronic obstructive pulmonary disease (COPD), and vascular dementia. On 10/22/24 at 3:02 PM, R15 was observed sitting on a four-wheeled walker outside the main facility entrance smoking a cigarette unsupervised. On 10/23/44 at 4:45 PM, R15 was again observed sitting on a four-wheeled walker outside the main facility entrance smoking a cigarette unsupervised. On 10/23/24 at approximately 4:50 PM, facility management was made aware of R15's whereabouts and lack of supervision. Assistant Administrator R stated, That's [R15], he's allowed to smoke by himself. When asked about R15's smoking plan of care, Assistant Administrator R was unsure of R15's interventions. Review of R15's Plan of Care revealed the following Goal, initiated 8/12/24: Resident will smoke safely at the designated area(s) at scheduled times through the next review. An intervention, initiated 8/12/24 read, Observe the resident's safety during smoking. Review of facility policy titled, Smoking Policy Smoking Campus-Residents, reviewed 5/31/23, read, in part: It is the policy of this facility to establish and maintain safe resident smoking practices . Any restrictions placed on smoking privileges shall be noted on the care plan so that all personnel may be alert[ed] to smoking restrictions . Any resident with smoking privileges shall not be permitted to smoke without direct supervision of a responsible staff member, family member, visitor or volunteer worker and direct supervision must be provided throughout the entire smoking period . All smoking privileges shall be so noted on the care plan .

This deficiency pertains to Complaint Intake MI00146981. Based on observation, interview, and record review, the facility failed to provide necessary treatment and services to prevent the development and promote the healing of pressure injuries for three Residents (#29, #22, and #36) of three residents reviewed for wounds. This deficient practice resulted in the deterioration of a left heel pressure injury in one Resident (#29) resulting in gangrene, sepsis, and the need for surgical amputation. Findings include: Resident #29 (R29): Review of R29's electronic medical record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including vascular dementia and type two diabetes. Review of R29's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 6, indicative of severe cognitive impairment. On 10/22/24 at 10:25 AM, R29 was observed sitting at the nurses' station in a wheelchair. R29 was observed with a compression sleeve on her left lower limb which appeared to be amputated at approximately mid-shin down. Review of R29's weekly Skin Assessments revealed a new abnormal skin area located the second digit of the right foot on 10/23/23. Review of progress note dated 10/27/23 at 7:30 AM, read, in part: .called to room by CNA [certified nursing assistant] for report of pressure injury to left heel. Back of heel open with loss of first layer of skin, purple area to center of wound, skin around wound intact, small amount of clear liquid drainage mixed with scant amount of blood . The next documentation of R29's left heel wound was recorded on 3/21/24, labeled as an existing abnormal skin area, nearly 5 months after the initial identification of the skin impairment. Review of R29's initial Wound Evaluation, dated 10/27/24, read: Deep Tissue Injury .left heel . in-house acquired . area 16.61 cm2 [centimeters] . Review of Wound Care Clinic progress notes revealed the following orders: -1/24/24: Keep weight off of affected area/limb at all times . offload heels - wear pillow boot at all times . -3/11/24: Keep weight off of affected area/limb at all times . offload heels - wear pillow boot at all times . -4/24/24: Keep weight off of affected area/limb at all times . offload heels - wear pillow boot at all times . Review of R29's physician orders read, Blue boots to bilateral feet while in bed, initiated 3/19/24. Review of R29's Plan of Care revealed a Focus that read, Resident is at risk for impaired skin integrity . with the following intervention initiated 1/12/24: Apply offloading heel protectors in bed as resident tolerates. On 10/23/24 at 3:56 PM, an interview was conducted with Assistant Director of Nursing (ADON) I who stated R29's pressure reducing interventions included turning and repositioning, a specialty mattress, and an offloading padded boot. When asked the frequency in which the offloading boot should have been applied, ADON I stated, all the time. When asked why the care plan specified the heel protectors should be worn in bed only, ADON I stated the care plan was never revised to reflect updated interventions. ADON I verified the CNAs were not provided with the correct interventions. On 10/23/24 at 12:45 PM, an interview was conducted with CNA U who recollected R29 had a blue boot to protect her heel. When asked how often R29 was required to wear the boot, CNA U could not confirm R29 wore it at all times stating, I tried to make sure it was on during my shift, but we're often short staffed. Stuff like that can get missed Review of R29's Wound Evaluations, revealed the following: -5/21/24: Progress: Deteriorating . Wound shows signs of deterioration at this time including macerated skin to periwound [area surrounding wound], increased erythema [redness], increased purulent drainage at time of assessment . -5/28/24: Progress: Deteriorating . Wound continues to deteriorate. Noted increased purulent drainage, odor to wound after cleaning, macerated tissues to periwound. Provider updated and wound culture obtained. Results back and provider ordered new antibiotic . -7/15/24: Progress: Deteriorating . Wound noted with discoloration to wound bed. Wound itself shows no signs/symptoms of infection at this time. Consulted with wound clinic related to declining wound . -7/30/24: Progress: Deteriorating . Wound shows deterioration this week with increased slough to wound bed. Periwound red but blanchable. No warmth to touch. Resident states occasional pain to area . -8/12/24: Progress: Deteriorating . Wound measurement shows nominal change but visible deterioration this week with brown eschar forming over 70% of the wound bed. PCP [primary care physician] was informed and witnessed. Standing order to send resident to ER [emergency room ] for evaluation if wound worsens . Review of R29's EMR revealed the following progress note: 8/19/24 at 10:40 AM: Wound to left heel has progressively worsened showing majority necrotic tissue with small area of bone showing . S/Sx [signs/symptoms] of localized infection present. Resident was sent to hospital for evaluation . Review of R29's plan of care revealed no updated care plan interventions since 1/12/24. Review of R29's ER History and Physical, dated, 8/20/24, read, in part: This patient presents with left foot diabetic gangrene with associated sepsis and is at increased risk of septic shock and death . Review of R29's hospital discharge summary, dated 9/6/24, read, in part: .female .was admitted to our hospital on 8/20/24 with left calcaneal [heel] diabetic ulcer . patient given surgery here, it was felt that she will unlikely heal the left wound. Left below-knee amputation was recommended. She was taken to the OR [operating room] on 8/28/24 and underwent left below knee-amputation . On 10/24/24 at 9:01 AM, an interview was conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) regarding R29's left heel pressure injury and subsequent amputation. The NHA and DON were unsure why the order for heel protection at all times was never reflected in R29's plan of care nor why updated interventions were not added despite deterioration of the wound. The DON could not explain R29's left heel injury was not documented on a skin assessment until 3/21/24 after initial identification on 10/27/23. The NHA stated, That's a big problem. Review of facility policy titled, Pressure Ulcer/Skin Breakdown - Clinical Protocol, reviewed 3/20/24, read, in part: .Because a resident at risk can develop a pressure ulcer/pressure injury (PU/PI) within hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent PU/PI . 45123 Resident #22 (R22) Review of R22's admission minimum data set (MDS), dated [DATE], revealed R22 did not have any open areas or impairments to their skin integrity, was at risk for developing pressure ulcers, and rejection of care. Review of R22's significant change MDS, dated [DATE], revealed R22 had developed one unstageable pressure ulcer and did not have any rejection of care. Review of R22's significant change MDS, dated [DATE], revealed R22 had developed a stage four pressure (severe skin tissue damage) ulcer. Review of R22's quarterly MDS, dated [DATE], revealed R22 had an existing stage four pressure ulcer and lacked any rejection of cares. On 10/21/24 at 1:16 PM, an observation was made of R22 lying in their bed. R22 had a wound vac device on their nightstand with a clear plastic tubing connected to the wound vac device. The plastic tubing was not connected to the other end of the wound dressing and was turned off. R22 was asked how long the wound vac had been turned off and replied, Since last night. On 10/21/24 at 1:30 PM, an interview was conducted with License Practical Nurse (LPN) M and was asked why R22 has wound care solution in their room that belongs to a different resident and replied, That is an excellent question. LPN M was asked why R22's wound vac is off and replied, The night shift nurse turned it off because it was alarming. All nurses have been educated on how to change R22's dressing and use the wound vac. I just don't trust them all to change R22's dressing and I just haven't gotten to it yet today. LPN M was asked what time they arrived at the facility today and replied, Eight o'clock this morning. Typically, we try and change them first thing in the morning. I found some supplies in the other storage room. I will change the dressing next. R22's wound vac dressing change was completed at 2:00 PM on 10/21/24 by LPN M. On 10/23/24 at 12:30 PM, an observation was made of R22 in their room sitting on the side of their bed eating lunch. R22 was asked if his wound vac was working properly today and replied, No, I shut it off because it was alarming. On 10/23/24 at 12:45 PM, an interview was conducted with LPN K and was asked if they were aware that R22's wound vac was turned off and replied, Yes, but I haven't had a chance to change the wound vac dressing. LPN K was asked if LPN M was aware so they could assist with the dressing change and replied, No. LPN M completed the dressing at 2:05 PM on 10/23/24 for R22 that was turned off at 10:00 AM. Review of R22's physician order, dated 8/27/24, read in part, NPWT (negative pressure wound therapy) [A treatment that uses a wound vac to help wounds heal] for coccyx: Change every Mon (Monday), Wed (Wednesday), Fri (Friday) days. Cleanse wound with wound cleanser, pat dry, apply skin sealant (skin prep) to peri wound, fill dead space with black foam, cover with sealant cover film and apply to NPWT tubing . Review of R22's physician order, dated 8/28/24, read in part, PRN (as needed); Coccyx. When Wound Vac fails or is not available. Wash gently with wound cleansing solution, pat dry. Apply calcium alginate to wound bed cover with ABD (abdominal) pad. Secure in place with tape . R22's as needed dressing change for their coccyx wound was not signed out on the treatment administration record (TAR) when the wound vac was turned off that evening. On 10/24/24 at 10:30 AM, an interview was conducted with the Director of Nursing (DON), and was asked what kind of dressing R22 had on when their wound vac had been turned off the night of 10/20/24 and replied, The night nurse did not apply the as needed dressing change. The nurse just took off the wound vac dressing, left the foam in place, covered the coccyx wound with an ABD pad, and secured the dressing with tape. The nurse did not do it correctly. Resident #36 (R36) Review of R36's quarterly MDS, dated [DATE], revealed no impairments to their skin or open areas. Review of R36's quarterly MDS, dated [DATE], revealed one unstageable open area of the skin and at risk for developing open areas or impairments of the skin. Review of R36's quarterly MDS, dated [DATE], revealed on stage three pressure ulcer of the skin, not present on admission, and lack any rejection of cares. On 10/21/24 at 12:35 PM, an interview was conducted with R36 in their room. R36 was lying in bed with the head of the bed up to approximately 80 degrees and was slouched down in an appearing uncomfortable position. R36 was asked if they had any open areas and replied, maybe so. R36 lacked any pillow behind her head during this observation. On 10/22/24 at 11:15 AM, an observation was made of R36 lying in their bed with the head of the bed at approximately a 70 to 80 degrees and was slouched down and hunched over asleep. On 10/24/24 at 8:45 AM, an observation was made of R36 lying in their bed with the head of the bed at approximately a 70 to 80 degrees and was slouched down and hunched over watching TV. R36 was asked if staff reposition them or remind them to reposition and replied, No. R36 was asked if they use a pillow behind their back to help offload and replied, I don't have a pillow behind my back. Should I have one? Review of R36's care plan, dated 8/29/24, read in part, .Focus: Resident has impaired skin integrity as evidence by: Stage 3 pressure ulcer (full thickness tissue loss) to upper spine .Interventions: Encourage resident to offload presure (sic) by repositioning self. Resident prefers to sit with head of bed at 30 - 45 degrees per .preference .Offer turn and Reposition, side to side (limit time on .back .) using pillows/wedge to prop behind back PRN (as needed) Review of R36's wound evaluation, dated 3/24/24, revealed an unstageable pressure ulcer that was six hours old, in house acquired, located on their spine, and measured 2.27 centimeters (cm) in length by 1.18 cm in width. Review of physical therapy consult note, dated 3/25/24, read in part, .Reason for screen: new ulcer to upper spine. Findings: PT (physical therapy) screen only. Pt. (patient) does not want therapy and is at baseline with functional mobility. Pt. does sit on EOB (edge of bed) frequently and rarely lays on .back per nurse . Review of R36's physician progress note, dated 4/4/24, revealed the lack of acknowledgement that R36 had any open areas or skin impairments, and the skin section of the progress note was blank. Review of R36's physician progress note, dated 4/18/24, read in part, .Asked to see patient for wound midback .wound midback approximately 2 cm x 0.5 cm, stage 2, minimal surrounding erythema (redness) .1. Wound care consult . Review of R36's wound clinic consult discharge instructions, dated 5/13/24, read in part, .Turn every 2 hours. Avoid position directing pressure to Wound site. Limit side lying to 30 degrees tilt. Limit HOB (head of bed) elevation to 30 degrees in bed . Review of R36's wound evaluation, dated 5/30/24, revealed a stage three pressure ulcer, in house acquired, located on their spine, and measured 0.83 cm length by 0.44 cm width by 0.2 cm depth. Review of R36's wound clinic consult note, dated 6/10/24, read in part, .Sharp debridement performed .Recheck in 1 month. Review of R36's wound clinic consult note, dated 8/6/24, read in part, .The wound is again covered with rather adherent slough. Sharp debridement performed .Recheck in 3 weeks. Review of R36's wound clinic consult note, dated 9/4/24, read in part, .She was placed on 10 days of doxycycline (antibiotic) at the nursing home for concern for wound infection. The wound had been improving the first 2 months of treatment, but then started to increase in size .claims .is not lying on it or pressing against it when seated. I would like staff to ensure this is the case .If .is leaning against it when seated, flat memory foam pillow should be used to offload pressure. Wound sharply debrided . return in 2 weeks for a recheck Review of R36's wound clinic consult note, dated 9/18/24, read in part, .measuring larger .continues to report .is not lying on it .Remainder of the wound sharply debrided .Ensure pressure is completely offloaded .Recheck in 1 month . Review of R36's wound evaluation, dated 10/21/24, revealed a stage 3 pressure ulcer to their spine, facility acquired, and measured 1.79 cm length by 1.65 cm width by 1.0 cm depth. On 10/24/24 at 9:21 AM, an interview was conducted with the Assistant Director of Nursing (ADON) / Registered Nurse (RN) I and was asked how R36's had developed a stage 3 pressure ulcer and replied, I am not sure. We identified there was an increase in pressure wounds around March and so we did a skin sweep and identified residents that had impaired skin or were at risk for breakdown. We added interventions for them at the time. That is when I believe R36's skin impairment was first identified. Interventions for turning and repositioning were added. We got rid of all the heavy absorbant pads because we felt they were adding extra moisture to the skin. The ADON / RN I was asked when the physician is made aware of newly identified open areas to residents' skin and replied, I would get the physician involved if a resident had a reddened skin area that was blanchable after the first few days it had not improved. The ADON / RN I was asked about wound vacs and staff training and replied, All nursing staff are trained on how to use and should be competent to do wound vac dressing changes. Wound vacs are a hit and miss for working. On 10/24/24 at 11:00 AM, an interview was conducted with the Director of Nursing (DON) and was asked if there were any added interventions to R36's care plan now that they were lying on their back more frequently and replied, No. I guess we need to have her evaluate by physical therapy again and see if they have any suggestions that would help with offloading. The DON confirmed R22's wound vac should not have been turned off for more than the amount of time to redress a new wound vac dressing and staff should be assessing proper function of the wound vac with every encounter with R22 and at a minimum of every two hours. Review of policy titled, Pressure Ulcer/Skin Breakdown - Clinical Protocol, dated 3/20/24, read in part, Policy: Based on the comprehensive assessment of a resident, a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing .

Based on observation, interview, and record review, the facility failed to prevent the development of a pressure ulcer and provide pressure ulcer care per professional standards of practice for two Residents (R4 and R8) of three residents reviewed for pressure ulcer care. Findings include: This citation is linked to intake MI00143371. A review of the Electronic Medical Record (EMR) revealed R4 developed an in house acquired unstageable pressure ulcer area on 2/18/24 which subsequently worsened to an increased size and developed into a stage IV pressure ulcer. The pressure ulcer continued to deteriorate from 2/18/24 through 3/11/24 with worsening measurements. R4 developed a pressure ulcer wound infection, requiring hospitalization , antibiotics, intravenous pain medication, wound debridement, a wound vac, and colostomy placement. The facility failed to consistently measure wound care assessments, failed to follow physician wound care orders, failed to ensure a wound care clinic consult was done timely, failed to implement wound care interventions timely, failed to prevent wound infection, and failed to appropriately turn/reposition R4 for pressure relief. Review of R4's census, revealed an admission to the facility on [DATE] and discharged on [DATE]. Review of R4's medical diagnoses, dated 2/7/24, revealed the following diagnoses: need for personal assistance, muscle weakness, pneumonia, fusion of spine, spinal stenosis cervical region and cervical disc disorder at C4 - C5 level with myelopathy, rheumatoid arthritis, and hallux valgus (a bony bump that forms on the joint at the base of the big toe). Review of R4's Minimum Data Set (MDS) assessment, dated 2/13/24, revealed functional abilities for toileting hygiene, shower/bath, upper and lower body dressing, putting on/off footwear, and rolling from left to right as a substantial/maximal assistance. R4 was dependent for transfers to chair to bed, toileting, and lying to sitting/sitting to lying. MDS Section E Behaviors, dated 3/13/24, revealed no rejection of care. Review of R4's electronic medical record (EMR), nursing assessment, dated 2/7/24, part I section V skin, revealed the following skin conditions; right heel - boggy (blanchable redness) and left buttocks - rash. No other skin condition or open areas were documented in the nursing assessment. Review of R4's EMR, skin assessment, dated 2/13/24, revealed no new abnormal skin areas and no existing abnormal skin areas. A subsequent wound evaluation for R4, dated 2/19/24, identified an unstageable pressure injury to the sacral coccyx area. The following measurements are for the same sacral/coccyx wound for R4 as follows: Review of R4's wound evaluation, dated 2/19/24, revealed a pressure injury, unstageable, measuring 12.47 cm (centimeters) in length x 12.83 cm wide. The wound was identified as one day old, in-house acquired. The surrounding tissue was described as excoriated (Wound picture showed a small amount of fecal matter in the rectal area and skin tissue appeared slough brown in color in the center. Edges near rectal area were white with small amounts of yellow color and edges around the wound were reddened.) and covered with foam boarded dressing. This was labeled as a new wound, healable, and the practitioner was notified. Review of R4's wound evaluation, dated 2/26/24, revealed a pressure injury, unstageable, measuring 10.37 cm x 10.71 cm (Area pictured appears larger and left side open towards lower torso. Center appeared brown/red in color and bordered edge on the right side had some spotty eschar noted and outer edges yellow slough with reddened edges). The evaluation noted a moderate amount of serosanguineous [blood mixed with light yellow color] drainage and turning and repositioning program was added to the care plan. Review of R4's wound evaluation, dated 3/4/24, revealed a pressure injury, unstageable, measuring 17.16 cm x 18.93 cm (Area pictured appears to now have depth, approximately 50% of the wound bed appeared to have eschar and increased redness to left buttocks surrounding area when compared to the previous pictured area). There was a heavy amount of purulent drainage with odor. Surrounding tissue had erythema and was noted to be fragile, pain was 3/10 [mild/moderate] intermittent, dressing appearance was saturated, and wound progress was deteriorating. Notes: New orders received to apply medihoney [medical grade honey dressing] to wound bed and new orders to send resident to wound clinic for consultation. Review of R4's wound evaluation, dated 3/9/24, revealed a stage 4 pressure ulcer, measuring 15.29 cm x 14.44 cm (Area pictured appears to have increased depth and a mixture of eschar/slough/tissue granulation. Surrounding redness appeared to be extending past the left gluteal cleft, and linens on resident bed in the photo revealed a large amount of drainage which appeared brownish and serosanguinous in color along with smaller amount of fecal matter). A heavy amount of serosanguinous drainage with a strong odor was documented. Surrounding tissue edges were noted to be non-attached, denuded [protected top layer missing] with erythema [redness], excoriated and fragile. Pain was rated 8/10 [severe] continuous. Wound progress was noted as deteriorating. Review of R4's care plan, dated 2/10/24, read in part, .Focus: Resident has impaired skin integrity as evidence by: Unstageable ulcer to coccyx (revised on 2/19/24) .bowel incontinence (revised on 3/5/24). Goal: Resident will show signs of healing and/or improvement .Interventions: Administer treatment(s) per orders .Assist resident with turning and repositioning .Turning schedule clock in room (revised 3/5/24) .Complete wound evaluation to observe the progress of the resident's skin condition .Pressure redistribution mattress to bed - low air loss mattress (date initiated 3/4/24). Provide incontinence care as needed (date initiated 3/4/24) .Wound consult as needed (date initiated 2/19/24) . Review of R4's physician order, dated 2/19/24, revealed the following, Coccyx, Left & Right buttocks - Gently cleanse with soap and water, pat dry. Apply skin prep and cover with boarder foam dressing. In the morning every Monday, Wednesday, Friday for pressure injury. Review of R4's physician order, dated 2/20/24, revealed the following, Coccyx area - Gently cleanse with soap and water, pat dry. Apply skin prep and cover with boarder foam dressing. In the morning for pressure injury. Review of R4's physician order, dated 3/5/24, revealed the following, Coccyx Pressure injury: 1. Wash wound with wound cleaner 2. Apply skin prep to periwound [skin surrounding wound] 3. Calcium alginate AG [silver] to wound bed 4. Cover with boarder foam dressing until medihoney is available every day shift. Review of R4's physician order, dated 3/5/24, revealed the following, Wound Care Clinic Consult .for unstageable wound to coccyx. *Note: Care plan stated the wound care consult was initiated on 2/19/24. Review of R4's physician order, dated 3/12/24, revealed the following, Coccyx Pressure injury: Wash wound with wound cleaner. Apply skin prep to periwound. Apply calcium alginate AG to wound bed. Fluffed AMD [anti-microbial dressing] gauze. Cover with boarder foam dressing until medihoney is available every day shift. Review of R4's progress note, dated 2/8/24 at 9:21 PM, read in part, [Physician M] in to see resident this am: [Physician M] wrotr (sic) as follows: 1.) Chest x-ray re: pneumonia, cough 2.) F/U (follow-up) with neurosurgery - per discharge order sheet 3.) F/U with Wound Care re: L toe ulcer - per discharge order sheet . Review of R4's progress note revealed the following: 2/18/24 at 5:44 AM, Large excoriated area to both butt cheeks and coccyx, complained of pain to site .bleeding redness and swelling noted . 2/19/24 at 2:48 AM, Unstageable pressure ulcer to coccyx and bilateral butt cheeks, 18 cm x 14 cm, complained of pain to area .center is dark purple and boggy as you extend out skin is open and with small amount of bleeding and serosanguinous drainage noted . 2/22/24 at 4:29 PM, .Wound deep red and black in color. Resident complained of increased pain in this area. 3/1/24 at 1:19 PM, .coccyx wound black with red/pink borders, foul smell .complained of pain when moved . 3/4/24 at 1:57 AM, .Wound to coccyx is getting deeper and larger, black soft very foul smell, complained of pain and burning . 3/5/24 at 1:42 PM, .Wound is worsening .Obtained consult to wound care clinic. 3/6/24 at 4:21 PM, .Resident on low air loss mattress. 3/7/24 at 12:40 PM, .Wound culture per MD (medical doctor). 3/9/24 at 5:11 AM, Resident is having large amount of purulent drainage with undermining to left buttock cheek, area is very warm to touch and has extremely foul smell, is close to rectum and you can hear a gas release sound when cleaning the rectal area . 3/9/24 at 7:16 AM, .site is getting worse daily and that it is draining large amounts of purulent matter, undermining noted, complained of pain 10/10 . 3/13/24 at 2:27 PM (late entry), Resident out to wound care appointment. Per wound care clinic resident was sent to [local hospital name] emergency department for treatment of sacral wound. Per [local hospital name] will require overnight stay. *Note: Wound care consult was 23 days after the intervention noted on the care plan and 8 days after the physician order written. Progress notes dated 2/7/24 through 3/13/24 lacked any documentation of non-compliance, behaviors, and/or refusals of care. Review of R4's admission history and physical, dated 2/7/24, completed by Physician M, read in part, .Physical examination: Wound left foot .addition comments: 1. Chest x-ray regarding: pneumonia/cough, 2. Follow-up with neurosurgery on order sheet, 3. Follow-up with wound care regarding left toe ulcer on order sheet .Signed off on 2/8/24 by nursing (unable to identify initials of Licensed Practical Nurse). *Note: Wound care consult was not completed by facility regarding left toe. Review of R4's physician communication fax, dated 2/20/24, read in part, Resident has acquired an unstageable ulcer to coccyx .looking for contributing factors such as ARF (acute respiratory failure), infection .Would like order for wound clinic consult please. Physician response: OK. Wound care consult. Signed 2/20/24. *Note: Physician agreed to the wound care consult on 2/20/24 and an order was not written for the wound care consult until 3/5/24. Review of R4's physician communication fax, dated 2/20/24, read in part, New unstageable pressure ulcer to coccyx and both butt cheeks 20 cm x 14 cm. Physician response: OK. Signed 2/20/24. Review of R4's physician progress note, dated 3/7/24, read in part, .Skin/wounds: Stage 4 coccyx pre .Assessment and plan: .4. Wound care consult. 5. Consider hyperbaric therapy, diverting colostomy. 6. Wound culture. Signed by Physician M and noted by Registered Nurse (RN) O. Review of R4's treatment administration record (TAR), dated 2/7/24 through 3/13/24, revealed three dressing changes were not documented as completed on 2/23/24, 2/29/24, and 3/4/24. There was an as needed dressing change order added on 3/4/24, however this was never documented as completed. Review of R4's Braden scale for predicting pressure sore risk, dated 2/7/24, revealed a risk for developing pressure sores. Review of R4's skilled nursing assessment, dated 2/13/24, revealed activities of daily living for rolling from left to right - substantial/maximum assistance. Review of R4's skilled nursing assessments, dated 2/13/24, 2/20/24, 2/22/24, 2/26/24, 3/3/24, and 3/4/24, revealed no documented education provided to R4 by nursing. Review of R4's wound culture, dated 3/11/24, revealed facility cultured coccyx wound positive for bacterial growth. Review of R4's task for turning and repositioning, dated 2/20/24 through 3/13/24, revealed the following: (*Times noted are when resident was documented as being turned and repositioned.) 1.) On 2/20/24 - not documented as turned between 2:21 AM and 2:00 PM, and not turned again between 8:00 PM and 3:08 AM (2/21/24), 2.) On 2/21/24 - not documented as turned between 9:05 AM and 12:03 PM, and not documented as turned again until 6:18 PM, 3.) On 2/22/24 - not turned between 3:26 AM and 8:03 PM, 4.) On 2/23/24 - not turned between 3:07 AM and 6:08 PM, and not turned again until 11:05 PM (last turned), 5.) On 2/24/24 - not documented as turned between 3:12 AM, and next turn was not until 2:00 PM, 6.) On 2/27/24 - not turned until 3:00 AM and then the next turn was not until 1:45 PM. *Note - Further review of turning documentation, dated 2/28/24 through 3/13/24 lacked multiple areas of documentation for turning and repositioning every two hours. Review of R4's hospital emergency department (ED) report, dated 3/13/24, revealed the following: Wound culture obtained was positive for bacterial growth, medications provided two different types of intravenous antibiotics, and an opioid hydromorphone 1 milligram for pain management related to pain 10/10. ED physician history and physical reported development of stage 4 pressure ulcer on coccyx with sacral exposure, necrotic tissue, and patient felt fatigued, weak, upset stomach, miserable, and low-grade fever. Also, reported wound care clinic thought he needed wound debridement and had not been on any antibiotics prior to hospital admission on 3/13/24. Furthermore, extensive large sacral wound with exposed bone, and very malodorous. Review of R4's hospital physician exam report, dated 3/13/24, revealed the following: Stage 4 sacral pressure ulcer measuring 12 cm x 16 cm with deep tunneling, large amounts of yellow drainage, and bone appearing gray and soft. Will likely need surgical debridement. General surgery consulted and reviewed and agrees with needing debridement and placement of wound vac. Diagnoses of stage 4 pressure ulcer to the sacral region and osteomyelitis. Review of R4's hospital general surgeon report, dated 3/13/24, revealed the following: Postoperative sacral decubitus ulcer wound debridement measuring 15 cm x 15 cm. Wound vac not feasible related to wound close proximity to anal margin. Patient will most likely require diverting ostomy to avoid stooling into the wound. Review of R4's hospital operative report, dated 3/13/24, revealed the following procedure end-sigmoid colostomy. Review of R4's hospital records, dated 3/18/24, revealed the following placement of a wound vac on the sacral region. On 4/3/24 at 8:15 AM, an interview was conducted with Occupational Therapist (OT) L and was asked about R4 having a pressure reduction cushion in his wheelchair and replied, Nursing came to me on 3/7/24 and that is when a pressure reduction cushion was implemented. OT L was then asked how R4 transferred and what type of locomotion he was and replied, He was a lift the entire time he was here and used a wheelchair for locomotion. OT L stated that if he was aware R4 had a pressure ulcer on his coccyx sooner he would have implemented to nursing the need for a pressure reducing cushion but had not been notified until 3/7/24. OT L was asked if he recalled any type of dressing to R4's left foot and replied, Yes, I do believe he had some type of dressing on his foot. On 4/3/24 at 9:06 AM, a phone call was placed to Registered Nurse (RN) E who initially discovered the coccyx wound on R4 and there was no answer. A message was left for RN E to call this Surveyor back with call back number. *Note: no return call was received during the survey. On 4/3/24 at 9:55 AM, a phone call was placed to Licensed Practical Nurse (LPN) G regarding skilled assessment education and R4's wound. A message was left for LPN G to call this Surveyor back with call back number. At 10:30 AM LPN G came in to the facility to see this Surveyor for an interview. LPN G was asked if she recalled R4 having a dressing on his left foot and replied, I do not recall. LPN G was asked what kind of mattress R4 had on admission and replied, Just the usual pressure reducing mattress. LPN G was not sure about a wheelchair cushion and added the wound was not that bad in the beginning. LPN G indicated the wound was red and excoriated then ended up with an area that was necrotic where it opened up and they were applying a foam gauze dressing 10 cm x 10 cm and it was tunneled. The wound nurse does the wounds and works the floor on Thursdays, and she is not here today. *Note: Wound Care Nurse was unavailable for an interview. On 4/3/24 at 1:10 PM, an interview was conducted with Certified Nurse Assistant (CNA) O, and was asked if they recalled R4 and replied, Yes. CNA O was asked what kind of care R4 required and what kind of person he was like and replied, He was a good guy. He needed extensive assistance and used a lift for transfers to his wheelchair. CNA O was asked if he refused care or was difficult and replied, No. Not that I can recall. On 4/3/24 at 2:00 PM, an interview was conducted with the Director of Nursing (DON) and Regional Clinical Nurse (RCN) H. They were asked if the medihoney ever came in prior to R4 being sent to the wound clinic and admitted back to the local hospital. The DON replied, No. It came in about two weeks ago. I think it was 3/18/24. Both nurses were then asked what their expectation was on wound care documentation and if depth should have been measured sooner when R4's wound showed depth and replied, Yes. Depth should have been measure as soon as the wound presented with depth and wound measurements should have been consistent. The DON was asked why R4 was not seen at the wound clinic sooner and had no reply. Both nurses were asked if they knew how R4's coccyx wound got infected and replied, We do not know. The DON was asked how often dressing changes were being completed on R4 and replied, Twice a day and as needed. The DON was asked if the physician wound dressing change orders reflected that and replied, Nope, it was once a day. Should have been changed if it was saturated. I think there is only one extra change documented. There was a prn order added on 3/4/24 but there are no extra dressing changes signed out. Both nurses were asked what the expectation for wound dressing documentation was and replied, The nurses should be documenting each dressing change in the treatment record. Both nurses were asked if there was not a space to document wound dressing changes as needed then how did they know this was being completed twice or more a day and replied, We do not know. The DON stated physician M did not physically see R4's wound until 3/5/24 and the medical director was requesting that the rounding physician physically see the wound once a month and make a progress note. The DON went on to say that she felt the rounding physician was overwhelmed. Resident # 8 (R8) R8 developed an unstageable pressure ulcer to his coccyx area that was facility acquired and resulted in further deterioration of the wound with increased size and depth. R8 also had placement of a urinary catheter to help promote healing of the coccyx wound. Review of R8's census, revealed an admission to the facility on [DATE]. Review of R8's medical diagnoses, dated 1/16/24, revealed the following diagnoses obesity, chronic obstructive pulmonary disease, cellulitis, and hypertension. Review of R8's MDS, dated [DATE], revealed functional abilities for shower/bath, upper and lower body dressing, and putting on/off footwear as a substantial/maximal assistance. R8 was partial/moderate assistance for toileting, transfers to chair to bed, and lying to sitting/sitting to lying. MDS section E Behaviors, revealed no rejection of care. MDS, dated [DATE], section E behaviors, revealed no rejection of care. The following measurements are for the same coccyx wound for R8 as follows: Wound evaluation, dated 3/4/24, revealed a pressure injury, unstageable, measuring 1.73 cm in length x 0.5 cm in width, seven hours old, in-house acquired, and progress new. Wound evaluation, dated 3/11/24, pressure injury, unstageable, measuring 1.85 cm in length x 0.86 cm in width x 2.1 cm in depth, seven days old, wound bed 80% slough, moderate amount of serosanguineous exudate, and practitioner notified. Wound evaluation, dated 3/18/24, pressure injury, unstageable, measuring 1.16 cm in length x 0.56 cm in width x 2.1 cm in depth, moderate amount of serosanguineous exudate, and practitioner notified. Wound evaluation, dated 3/24/24, pressure injury, unstageable, measuring 0.83 cm in length x 1.25 cm in width x 2.1 cm in depth, moderate amount of serosanguineous exudate, and practitioner notified. Wound evaluation, dated 4/2/24, pressure injury, unstageable, measuring 3.19 cm in length x 2.76 cm in width x 5.0 cm in depth, moderate amount of serosanguineous exudate, faint odor, and wond (sic) shows some deterioration. Measurements are larger this week. Faint odor noted after wound cleansed. Review of R8's care plan, dated 4/2/24, read in part, Focus: Resident has a need for indwelling catheter related to pressure ulcer(s) . Further review of R8's care plan, dated 3/22/24, read in part, Focus: Resident has impaired skin integrity as evidence by: .pressure injury to coccyx .Interventions: Air mattress 93/19/24) .administer treatment(s) per orders (2/22/24) . Review of physician order, dated, 3/5/24, revealed, Treatment: Coccyx Pressure Injury: 1. Wash with wound cleaner 2. Apply skin prep to periwound 3. Apply medihoney to wound bed 4. Cover with boarder foam dressing. Every day shift every 3 day(s) for skin impairment. Review of physician order, dated, 3/7/24, revealed, Treatment: Coccyx Pressure Injury: 1. Wash with wound cleaner 2. Apply skin prep to periwound 3. Apply hydrogel to wound bed 4. Cover with boarder foam dressing. Every day shift every 3 day(s) for skin impairment. Review of physician order, dated, 3/12/24, revealed, Treatment: Coccyx Pressure Injury: 1. Wash with wound cleaner 2. Apply skin prep to periwound 3. Apply hydrogel to wound bed 4. Apply fluffed gauze 5. Cover with boarder foam dressing. One time [11:00 AM] a day every 3 day(s) for pressure injury. Review of physician order, dated, 3/14/24, revealed, Treatment: Coccyx Pressure Injury: 1. Wash with wound cleaner 2. Apply skin prep to periwound 3. Apply hydrogel to wound bed 4. Apply fluffed gauze 5. Cover with boarder foam dressing. Every night shift every 3 day(s) for pressure injury. Review of R8's TAR, dated 3/1/24 through 3/31/24, revealed no documentation of a wound dressing change completed on 3/7/24 and 3/12/24. Review of R8's physician communication fax, dated 3/7/24, read in part, Resident has new pressure ulcer to buttocks .Please make note of wound and the deterioration of condition of wound. Review of R8's physician communication fax, dated 4/2/24, read in part, [R8] had large clot softball sized come out of his wound on his coccyx when his dressing was changed. Review of R8's progress note, dated 3/19/24, read in part, .Coccyx wound remains open. New order for foley placement to aide in wound healing . On 4/3/24 at 3:30 PM, an observation was made of R8's coccyx wound with RCN H and the DON. During the dressing change observation R8's wound was noted to have deteriorated and have a moderate amount of serosanguinous drainage. On 4/3/24 at 3:45 PM, an interview was conducted with the DON and RCN H, regarding the development of R8's coccyx pressure wound and stated that R8 developed the wound in the facility. The DON was asked if she was aware that a large clot was expelled from R8's coccyx wound on 4/2/24 and replied, No. I was not made aware of that. I will look into it. Review of policy titled, Wound Treatment Management, dated 10/26/23, read in part, Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidenced-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change . Review of policy titled, Pressure Injury Prevention and Management, dated 1/1/22, read in part, Policy: This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries . Policy Explanation and Compliance Guidelines: .3. Assessment of Pressure Injury Risk .c. Assessment of pressure injuries will be performed by a licensed nurse, and documented in the medical record .4. Interventions for Prevention and to Promote Healing .c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions .include .i. Redistribute pressure (such as repositioning, protecting and /or offloading heels, etc.); . iii. Provide appropriate, pressure-redistributing, support surfaces .f. Interventions will be documented in the care plan and communicated to all relevant staff . Review of policy titled, Pressure Ulcer/Skin Breakdown-Clinical Protocol, dated 1/1/22, read in part, Policy: Based on the comprehensive assessment of a resident, a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers .and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection . Policy Explanation and Compliance Guidelines: .4. The interdisciplinary team (IDT) will assess and document and individual's significant risk factors for developing PU/PI [pressure ulcer/pressure injury] .7. Continued assessment and management .PUSH [pressure ulcer scale for healing] tool completed on PU/PI weekly during the weekly wound measurements .15. The IDT team will review each pressure ulcer weekly for progress and changes .

Based on observation, interview, and record review, the facility failed to prevent physical and verbal abuse (staff to resident) involving two Residents (R23 and R26) of six residents reviewed for abuse, with the potential to affect all residents in the facility. This deficient practice resulted in physical harm (broken leg) for R23, feelings of helplessness, embarrassment, and serious psychosocial harm. Findings include: R23 Review of R23's Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her 6/18/22 Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 8/15 indicating mild cognitive impairment, and required extensive two person assist for bed mobility, extensive one-person physical assist for toileting, and total dependent two person assist for transfers. R23 was noted to be always incontinent of bowel and bladder. On 8/29/22 at approximately 12:30 p.m., an interview was conducted with R23. R23 stated that she felt staff were very quick to help her with Activities of Daily Living (ADL) cares (specifically toileting and positioning), and that they were in a rush to do things quickly. R23 stated that she was in a lot of pain due to a broken leg, and that staff were aware her leg was broken, but continued to rush through cares. R23 was observed attempting to reposition herself slightly in her bed and was wincing in pain. On 8/31/22 at approximately 9:00 a.m., an interview was conducted with R23 regarding her pain. R23 stated that she was in increasing pain due to her recent leg fracture. R23 began to describe an incident a few weeks ago when two nurses and a CNA (certified nurse aide) came into her room to obtain a urine sample using a straight catheter. R23 stated she originally told the staff members that she did not have to urinate, but that if they came back in an hour, she would be willing to attempt to give a urine sample at that time. R23 stated that the staff members refused to listen and began to hold her down and lift her legs to put a catheter in her. R23 said that she began to kick and scream, moving her body around because she did not want to have this procedure, when she was moving, her legs began to fall off the bed which at that point, one of the three staff members grabbed her leg and held it down. R23 stated that is when she heard and felt a 'pop' sound and knew something was wrong. A urine sample was not obtained before another staff member overheard from the hall way and stopped the procedure. R23 stated that the pain was so unbearable that she requested an x-ray and later found out that her leg was broken. R23 again was observed wincing in pain and requesting more pain medication for her leg pain. A review of R23's 8/19/22 Computed Tomography (CT) results revealed the following, in part, .CT Pelvis w/o (without) Contrast .Comparison 7/14/22 .Impression: There is a new subchondral fracture of the left superior femoral head . An interview was conducted with the Nursing Home Administrator (NHA) on 8/31/22 at 9:25 a.m. The NHA stated that they were made aware of R23's allegation of physical abuse by staff members on 8/12/22 and had completed a resident concern form about the incident. The NHA said that staff were attempting to get a urine sample and that R23 was moving around a lot and did not want the procedure done at that time. The NHA further stated that he interviewed R23 after being made aware of the incident and she told him that the staff were not rough and were not attempting to hurt her. The NHA stated that he did not report the incident to the State Agency (SA) as he did not feel there was physical abuse, and her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A request was made for the resident concern form. An interview was conducted with Licensed Practical Nurse (LPN) W on 8/31/22 at 9:45 a.m. LPN W confirmed that the three members who attempted to obtain a urine sample from R23 were Registered Nurse (RN) A, LPN B and CNA C. LPN W stated that they failed to obtain a sample, and she was able to get it later that day. LPN W confirmed that R23 stated to have increase in pain after the first attempt to obtain a urine sample and spoke to her about the incident that happened with RN A, LPN B and CNA C. A review of the facility's Quality Assistance Form dated 8/12/22 for R23 read, in part, .resident reported to therapy and ss (social services) incident that happened last Friday when staff trying to obtain UA (urine analysis) .staff assigned to review: (NHA) .plans/actions: Administrator to begin investigation . There were two witness statements attached to the Quality Assistance Form written by Social Services (SS) K and Occupational Therapist (OT) Y. SS K witness statement read, in part, .Date: 8/12/22 Resident reported to writer that last Friday 2 nurses (LPN B, RN A) were in her room trying to obtain a UA. Resident reports that said nurses were pinning her down and nurse 1 had resident right leg over her shoulder. Resident reported that she told staff 'Leave me alone because that hurts, and I just peed so my bladder is empty'. Resident reports that another nurse came into room (LPN W) and told the other two nurses to leave resident along [sic]. Nurse (LPN W) able to obtain UA after about an hour per resident. Resident also reported that nurse (LPN B) grabbed her leg when rolling her over and since has had pain in her left upper hip region and would like an x-ray. Resident reports a stabbing pain starting from the left hip and shooting down into her left leg . OT Y witness statement read, in part, .was working with (R23) this day (8/12/22) for occupational therapy and at approximately 12:45 PM (R23) reported that her arm and leg hurt and reported 'I was in a fight the other day'. I asked her 'What do you mean?' R 23 reported 'there were two nurses and a CNA that were working with me and moving me around. I told them to stop, but they would not. They had my leg above my shoulder.' I asked, 'When did this happen?' (R23) reported 'last Friday', which would have been 8/5/22. I immediately informed the administrator, who requested that I complete this report. There were no further follow-up, investigations, or witness statements attached to this Quality Assurance Form as of 8/31/22. The three staff members identified by R23, (RN A, LPN B, and CNA C), continued to work at the facility and provide care to R23 until 8/31/22 when they were suspended pending a facility investigation. An interview was conducted with OT Y on 8/31/22 at approximately 3:30 p.m. OT Y stated that when R23 told him of the incident, she was visibly upset. OT Y stated that he went directly to the NHA who told him to write a statement in regard to what R23 had told him. Review of R23's 'Progress Notes' revealed the following: 8/2/22 6:04 p.m.: . Straight Cath (catheter) for urine culture, send results to urology. One time only for 1 day Start Time 8/2/22 End Date 8/3/22 8/6/22 12:02: .Send to ER (emergency room ) for further evaluation r/t (related to) UA lab 2+ leukocytes results, decreasing BP (blood pressure), and recent unstable condition. 8/12/22 6:23 p.m.: .Writer spoke with resident r/t concern reported from therapy. 8/15/22 6:13 p.m.: N.O (new order) per (Physician X) labs reviewed. CT left hip ASAP regarding increased pain, increase [MEDICATION(S)] to 10mg (milligrams) po (by mouth) every 6 hours prn (as needed) pain. Prognosis grave. 8/15/22 7:51 p.m. c/o (complaints of) pain [MEDICATION(S)] 5 mg po given. 8/30/22 10:00 a.m.: refused to go to ultrasound appointment states she is into much pain and wants it rescheduled for later date. Review of a notification form to Physician X dated 8/9/22 read, in part, .Reason for notification .also is requesting to have X-ray of L (left) hip for pain? response: new or changes in orders: 1) X-ray L Hip .pain Physician Signature: 8/10/22. Review of R23's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .assessment and plan: CT L hip pain ASAP, severe, [MEDICATION(S)] 10 mg 1 q (every) 6 hours prn pain, prognosis GRAVE . Confirmation from the NHA on 8/31/22 revealed that R23 did not receive an X-ray for her left hip pain and that the only result she did have was from the CT on 8/19/22, four days after Physician X ordered the CT. Review of R23's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] On 8/3/22 at 0044 a signature was present for the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R23's pain level questionnaire which was to be completed three times a day per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R23 then began to show an increase in pain from 8/6/22 through 8/30/22. R23's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R23's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R23's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R23's 'Care Plan' interventions read, in part, .observe and report changes in. withdrawal or resistance to care. Resident #26 The electronic medical record revealed Resident #26 was cognitively intact. During an interview on 8/29/22 at 12:31 p.m., Resident #26 said Nurse Aide (NA) S verbally abused him. The Resident said NA S would use vulgar language regularly and he asked NA S to stop as he was offended by the language. The Resident said NA S did not stop using vulgar language and on 8/28/22, NA S was so offensive and directed the language at him, that he could no longer tolerate the behavior and told the Administrator (NHA) NA S verbally abused him. During an interview on 8/30/22 at 11:31 a.m., the NHA confirmed the allegation and said NA S denied the allegation. During a follow up interview on 8/30/22 at 2:33 p.m., Resident #26 elaborated on the details of the abuse. The Resident said NA S regularly came into his room unannounced and swore at him, calling him names. The Resident said NA S once noted a news program on the television and said, 'I can't believe you are a Trump fan. How F#CK#NG stupid are you?' The Resident stated he told NA S, This is harsh on my ears. The Resident said he never used language like that in his whole life and felt very offended by it. The Resident said about three months prior, NA S was beating on the bathroom door yelling 'mother F#CK#R! I can't stand this F#CK#NG place!' Resident #26 said he questioned NA S's safety in the building. The Resident said the NHA asked him to write a statement, which he did and gave it to the NHA. The Resident said NA S called him a 'dirty mother F#CK#R' three different times. The Resident was visibly upset and had tears welled up in his eyes during this interview. He threw his hands up and asked how anybody could treat someone that way. The Resident said NA S came into his room at about 7:00 p.m. on 8/28/22, unannounced, and started rifling through things on the wheelchair and in the room including going through his clothes. When asked why, NA S started screaming he was looking for his phone and that nothing in the room belonged to the Resident anyway; he could go through whatever he wanted. The Resident said NA S called him a 'dirty mother F#CK#R' again. The Resident said, with tears in his eyes, It was so violent. The Resident said he rode a bus to see his daughter regularly. One of these rides there was a woman on the bus who he made conversation with, that turned out to be a relation of NA S's. The Resident said NA S asked him once if he spoke with the relative and he confirmed he did. NA S became very angry and swore and told him he had no right to speak with anyone related to him. The Resident said NA S swore at him repeatedly and went ballistic. The Resident said he finally yelled for NA S to get out of his room. During a phone interview on 8/31/22 at 1:34 p.m., NA S confirmed he was in Resident #26's room on 8/28/22 at around 7:00 p.m. looking for his phone. NA S immediately was defensive, angry and spoke very quickly and tangentially. NA S repeatedly interrupted this Surveyor's questions and began an angry, loud, political tangent and said he had the right to search for his phone. NA S did confirm he entered Resident #26's room unannounced and did not explain what he was doing until the Resident asked. NA S continued to raise his voice, interrupt questions, and speak very quickly and defensively and blamed Resident #26, saying he was not in his right mind. NA S denied ever engaging the Resident in political conversation, but then confirmed he did see the television news station and did engage the Resident in politics. NA S said he was entitled to his opinions and confirmed he swore in the room and at the Resident. NA S confirmed he was not yet certified as a nurse aide but had taken courses. When asked what he learned regarding entering a resident room, he confirmed he should knock and announce himself. NA S confirmed he did not knock or announce himself on 8/28/22. NA S also confirmed he was very angry at Resident #28 for speaking with a relative of his on a public bus and told the Resident the same. Again, NA S got very upset and angry, almost yelling that Resident #26 had no right to speak with anyone related to him. NA S again blamed Resident #26 for intruding on his life. NA S said Resident #26 was always complaining about something. During an interview on 8/30/22 at 3:05 p.m., Registered Nurse (RN) I confirmed she once intervened with NA S telling him political arguments with Residents was not appropriate, and that NA S was condescending and dismissive with Resident #26. RN I said she told NA S to walk away from political conversations. RN I said NA S did the minimum required work and always walked with his head hung down, mumbled, and did not make eye contact. During an interview on 8/31/22 at 9:02 a.m., Certified Nurse Aide (CNA) G said staff were not allowed to carry their personal cell phones on the floor. CNA G said NA S walked around hunched over, looking at the ground and didn't make eye contact. The Performance Improvement Form, dated 1/18/22, revealed NA S was disciplined by the Director of Nursing (DON) for not completing resident cares, routine rounds (checks on residents), and documentation. Other issues noted included infection control breaches and leaving the floor without communication with the charge nurse. The form revealed NA S's response to the discipline was I'm only one person. The discipline noted NA S became defensive and easily angered when being given directives, suggestions for improvement, or questioned about care. The form also noted previous concerns with NA S including counseling and education for the previous issues. NA S signed the form on 1/21/22. The facility investigation notes, undated, revealed NA S said in an interview he had the right to look for his phone. The witness statement, dated 8/29/22, signed by Resident #26, revealed, .Last night, Sunday, I had and unfortunate and repeated incident with [NA S] .For the past months this involved verbal outbursts .about working conditions, staff and disgust with our political system in which every other word was filled with FU, MFU, GD etc .I don't appreciate the constant language .last night's outburst was over the top! [NA S] came in my room unannounced and rifled through my clothes .this happened a second time and then a third time .[NA S] unleashed the most violent verbal abuse I've ever experienced in my life .at the top of his lungs screamed I can go through anything I want. I feed you, wipe your butt, dress you and a list of attacks .but all screaming at me . Review of the facility's Abuse, Neglect and Exploitation policy last reviewed/revised on 1/1/22 read, in part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .the facility will designate an Abuse Coordinator in the facility who is responsible for reporting allegations or suspected abuse .to the state survey agency and other officials in accordance with state law. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written .prevention of abuse, neglect and exploitation .assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors .possible indicators of abuse include .resident, staff or family report of abuse .physical injury of a resident, of unknown source .investigation of alleged abuse .an immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include: 1) identifying staff responsible for the investigation .4) identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations 5) focusing the investigation on determine if abuse, neglect, exploitation and/or mistreatment has occurred, the extent, and cause; and 6) Providing complete and thorough documentation of the investigation. Protection of Resident .responding immediately to protect eh alleged victim and integrity of the investigation, examining the alleged victim for any sign of injury, including a physical examination .increased supervision of the alleged victim and residents; room or staffing changes .protection from retaliation; providing emotional support and counseling to the resident during and after the investigation .reporting/response .reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies .immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . An Immediate Jeopardy (IJ) began on 8/3/22, when facility staff held R23 down and attempted to obtain a urine sample. The IJ notification was communicated verbally to the Administrator, and Sr. DON E on 8/31/22 at 11:45 a.m. and was followed with an email copy with request for a removal plan. The removal plan was accepted on 8/31/22. An onsite verification of immediacy removal was made on 8/31/22. Facility Removal Plan 8/31/22 Identified staff members (RN A, LPN B and CNA C) have been immediately suspended pending investigation. An abuse investigation is currently in process 8/31/22 Resident #23 was evaluated by the primary care provider regarding pain medication and regimen for further orders 8/31/22 Resident #23 had a new pain assessment completed. 8/31/22 Therapy referral for pain management and positioning was completed. 8/31/22 Care plan will be reviewed and updated as needed regarding pain management. 8/31/22 All current residents residing in the facility will be reassessed for pain by the DON/designee. 8/31/22 Residents who report complaints of pain will have a review of his/her care plan by members of the IDT to ensure appropriate interventions are in place. Pain regimens will be reviewed and updated as needed with the provider. 8/31/22 Residents with a BIMS of 8 or higher will be interviewed by members of the IDT regarding procedures, specifically to determine if a procedure has been performed without his/her consent. 8/31/22 Residents who are unable to be interviewed will have a skin assessment completed to assess for signs of injury related to procedures. 8/31/22 The NHA and Director of Nursing were re-educated regarding abuse policy and procedure, including reporting requirements, by the Regional Senior Director of Nursing. 8/31/22 Abuse polices were reviewed by the NHA and DON and deemed appropriate. 8/31/22 NHA/designee is re-educating all staff on facility abuse policies, with ongoing oversight and monitoring of competency on all shifts seven days a week. And application with steps to take if a resident decline having a procedure completed. 8/31/22 Nurses will be re-educated, in addition to abuse policies, on pain management. Based on observation, interview, and record review on 8/31/22, the facility demonstrated removal of the immediacy during an onsite review. Although the IJ was removed on 8/31/22, the facility remained out of compliance at a scope and severity with the potential for more than minimal harm at an isolated level due to the inability to verify staff education, all policy updates, system changes, and sustained compliance.

Based on observation, interview, and record review, the facility failed to implement an effective pain management program for one Resident (R23) out of four reviewed for pain management. This deficient practice resulted in R23 experiencing new, increasing, and unrelieved pain. Findings include: On 8/29/22 at approximately 12:30 p.m., an interview was conducted with R23. R23 stated that she felt staff were very quick to help her with Activities of Daily Living (ADL) cares (specifically toileting and positioning), and that they were in a rush to do things quickly. R23 stated that she was in a lot of pain due to a broken leg, and that staff were aware her leg was broken, but continued to rush through cares. R23 was observed attempting to reposition herself slightly in her bed and was wincing in pain with movements. On 8/31/22 at approximately 9:00 a.m., an interview was conducted with R23 regarding her pain management. R23 stated that she was in increasing pain due to her recent leg fracture. R23 began to describe an incident a few weeks ago when two nurses and a CNA (certified nurse aide) came into her room to obtain a urine sample using a straight catheter. R23 stated she originally told the staff members that she did not have to urinate, but that if they came back in an hour, she would be willing to attempt to give a urine sample at that time. R23 stated that the staff members refused to listen and began to hold her down and lift her legs to put a catheter in her. R23 said that she began to kick and scream, moving her body around because she did not want to have this procedure, when she was moving, her legs began to fall off the bed which at that point, one of the three staff members grabbed her leg and held it down. R23 stated that is when she heard and felt a 'pop' sound and knew something was wrong. A urine sample was not obtained before another staff member overheard from the hall way and stopped the procedure. R23 stated that the pain was so unbearable that she requested an x-ray and later found out that her leg was broken. R23 again was observed wincing in pain and requesting more pain medication for her leg pain. Review of R23's Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her 6/18/22 Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 8/15 indicating mild cognitive impairment, and required extensive two person assist for bed mobility, extensive one-person physical assist for toileting, and total dependent two person assist for transfers. R23 was also marked for receiving prn (as needed) pain medication and stating she had moderate pain per the verbal pain descriptor scale. A physician communication form for R23 dated 8/9/22 read, in part, .reason for notifications .also is requesting to have x-ray of L (left) hip for pain? response: x-ray of L hip related to pain . A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] .assessment and plan: .CT L hip. ASAP. Severe pain .[MEDICATION(S)] 10 mg 1 tab q (every) 6 hours prn. Prognosis grave . A review of R23's Behavioral Care Solutions progress note dated 8/5/22 read, in part, .states her moods are 'crap' and blames this on her ongoing pain. She says her sleep and appetite are poor from pain as well. She is irritable, does not want to talk today unless she is getting more pain meds .PCP (primary care provider) to manage chronic pain . A review of R23's Progress Notes read, in part, the following: 8/5/22 3:40 p.m. event date 7/27/22 .open areas noted on right heal and left calf. Pinpoint open areas on coccyx/buttock. Description: Right heal 3cm (centimeters) x 2.5cm x 0.1 mm (millimeter) open area. No active drainage; left calf 2.4cmx1.7cm no active drainage. Multiple pinpoint open areas on buttock/coccyx area . There was no documentation of R23's pain level. 8/15/22 4:13 p.m.: N.O (new orders) per (Physician X) .CT Left Hip ASAP regarding increase pain, increase [MEDICATION(S)] to 10 mg (milligrams) po (by mouth) every 6 hours prn pain, prognosis grave. 8/15/22 5:13 p.m.: c/o pain [MEDICATION(S)] 5 mg po given 8/30/22 10:00 a.m.: refused to go to ultrasound appointment states she is into much pain and wants it rescheduled for later date. A review of R23's care plan revealed a pain care plan, (R23) is at risk for chronic pain related to spontaneous rupture of extensor tendons, unspecified lower leg, [CONDITION(S)] date initiated 7/2/19. This care plan included interventions as followed: Give Tylenol 650 mg prn for breakthrough pain after [MEDICATION(S)] and ice therapy are given. Do not exceed 3000 mg in a 24-hour period date initiated: 4/17/18 .monitor and change [MEDICATION(S)] patch as ordered date initiated 4/26/22 .monitor/record/report to nurse resident complaints of pain or requests for pain treatment date initiated 12/17/18 .observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease movement or range of motion, withdrawal, or resistance to care date initiated 4/11/18 . A review of R23's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility policy titled, Pain Management revised on 1/1/2022 revealed, The facility will ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences .evaluate the resident for pain upon admission, during ongoing scheduled assessments, and with change in condition or status .identifying key characteristics of the pain: duration, frequency, location, onset, pattern, [CONDITION(S)] .the resident's goals for pain management and his/her satisfaction with the current level of pain control .The following are general principles for prescribing analgesics in the long term care setting: .In most cases, prescribe at least one scheduled, not as needed (PRN), analgesic medication .reassess and adjust the dose to optimize pain relief while monitoring and trying to minimize or manage side effects .reassess patients with pain regularly based on the facility's established intervals for effectiveness and/or adverse consequences .if re-assessment findings indicate pain is not adequately controlled, revise the pain management regimen and plan of care as indicated .

Based on observation, interview and record review, the facility failed to provide the necessary care to maintain the highest practicable well-being for one (#303) of three residents reviewed for necessary care, in a total sample of four residents. This deficient practice resulted in harm for Resident #303 when signs and symptoms of a diabetic emergency went unreported and treatment was delayed. The immediate jeopardy began on 4/10/16 when Resident #303's blood sugar (glucose) was at a high level of 420 mg/dl (milligrams per deciliter) following three days of hyperglycemic symptoms and the physician was not notified of this critical change in condition. The immediate jeopardy was identified on 5/13/16, and the Administrator was notified of the immediate jeopardy at 3:53 p.m. on 5/13/16. The immediate jeopardy was removed at 7:09 p.m. on 5/13/16 when the facility did the following: Identified all residents who were prescribed insulin. Revised care plans for all residents on insulin and revised the Medication Administration Record (MAR) to include specific guidelines for treatment of [REDACTED]. Provided education to licensed nurses on [MEDICAL CONDITION], diabetic ketoacidosis, and [DIAGNOSES REDACTED]; developed a plan for education of all licensed nurses prior to their return to care of residents with diabetes. The IJ was removed, but noncompliance remained at a pattern with the lower scope and severity level of potential for more than minimal harm for the 12 residents at the facility whose diabetes was being treated with insulin, until appropriate diabetes treatment is verified. Findings include: An abbreviated survey took place at the facility on 5/11/16 - 5/17/16 in response to a complaint regarding Resident #303's visit to the local emergency roiagnom on [DATE] and subsequent hospitalization . The complainant alleged Resident #303 had flu like symptoms with diarrhea over a period of 4- 5 days, was not treated appropriately, and was hospitalized . According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #303 was a [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment revealed Resident #303's Brief Interview for Mental Status (BIMS) score of 11/15, indicating she had moderately impaired cognition. A review of Resident #303's admitting hospital History and Physical dated 4/11/16 read, in part: She'd been feeling sick for the last 5 days . had insidious onset of nausea, dry heaving, and diarrhea . persistent for the last 5 days . decreased oral intake, inability to tolerate anything by mouth because of ongoing dry heaving, and nausea . she has missed several doses of her insulin for fear of inducing [DIAGNOSES REDACTED] . she went to . (local) emergency room today where she was found to be in diabetic ketoacidosis. Blood tests there showed a blood sugar of 574 (mligrams/deciliter, mg/dl) .subsequently transported to our emergency room here for further management . On 5/11/16 at 3:45 p.m. an interview was conducted with Resident #303's family member (FM) A. FM A stated, .She (Resident #303) was a brittle diabetic and had one kidney . Then we got a call from (Resident #303) that she had the flu, around April 10th or 11th, and not to come in. She had a hard time talking on the phone. She (Resident #303) was having a hard time breathing and told me not to come . At the hospital I was told she had diabetic ketoacidosis and she (Resident #303) was critical and the next 48 hours would tell us if she'd make it or not . If I were called (by the facility) and informed that (Resident #303) wasn't feeling well, I would have followed up on it right away .She had been dry heaving for 4 days and no one called me .(Resident #303) thought she had the flu even up in (the hospital). She wasn't thinking clearly. She wasn't getting enough oxygen to her brain. Review of the facility nursing progress notes for Resident #303 revealed the first entry identifying symptoms of illness was dated 4/8/16 at 2:00 a.m., documenting, .Res (Resident #303) states feels better today with no nausea, vomiting or loose stools, . (Yesterday res. had emesis & was not feeling well.) Nursing notes for Resident #303 dated 4/8/16 6p.m.-6a.m. read, in part: .nausea this evening & upset stomach, [MEDICATION NAME] given, helped some but nausea persisted for several hours . There were no nursing progress notes for 4/09/16. 4/10/16 nursing progress notes on Resident #303: 1830 (6:30 p.m.) resident continued with nausea this shift . 0005 (12:05 a.m.)Res became very SOB (short of breath) after being helped to bathroom. O2 (oxygen) sat (saturation) in low 80's. LS (lung sounds) diminished, rhonchi in R (right) upper & lower lobes. O2 on via n/c (nasal cannula) at 2L/min (2 liters per minute). O2 sat mid to upper 90's. 4/11/16 nursing progress notes on Resident #303: 0855 (8:55 a.m.) .FBS (fasting blood sugar) 480 (mg/dl) this a.m. & has been up past 3 days. Not feeling well with increased nausea during this time . 1120 (a.m.) Phoned Dr. (J) re HC (high critical) K+ (potassium) 6.7 (mmol/l- millimole per liter) left message with nurse . dry heaves & liquid stools X 3 days or so. Insulin has been held d/t (due to) not able to keep anything down . 1130 (a.m.) Call per .NP (nurse practitioner) send to ER (emergency room ). 1210 (p.m.) .Return anticipated. Bed hold in place . 4/19/16 nursing progress notes on Resident #303: late entry for 4/9/16. Resident continues with c/o (complaints of) nausea this shift . Review of Resident #303's April 2016 Medication Administration Record (MAR) documented fingerstick blood sugar (BG) results as: 4/08/16 at 1700 (5 p.m.): 73 mg/dl 4/09/16 at 0700 (7 a.m.): 308 mg/dl 4/09/16 at 1700 (5 p.m.): 51 mg/dl 4/10/16 at 0700 (7 a.m.): 420 mg/dl 4/10/16 at 1700 (5 p.m.): 182 mg/dl 4/11/16 at 0700 (7 a.m.): 480 mg/dl The April 2016 MAR for Resident #303 documented: If blood sugars are less than 50 or greater than 400 (mg/dl) notify MD (physician). There was no documentation of physician notification in the MAR or nursing notes for 4/10/16 or 4/11/16 of the blood sugar levels being greater than 400 mg/dl. Review of Resident #303's orders for treatment of [REDACTED].wait 15 minutes and re-check blood sugar. If blood sugar remains below 70 (mg/dl) and/or if symptoms continue, repeat treatment of [REDACTED].Document treatment and resident response in the PRN (as needed) record MAR and nurse note. There was no documentation of low blood sugar in the MAR or any documention in nursing notes for 4/9/16 regarding the low blood sugar of 51 being rechecked. On 5/12/16 at 1:35 p.m., Resident #303's FM B was interviewed. FM B stated, (Resident #303) was the one to call us and told us she was sick and told us she was getting sent to (the hospital emergency room ). That's how we knew. My mom (FM A) went to (local hospital) and was there when (Resident #303) got shipped to (regional hospital) . No one called from (the facility) to let us know what was going on. We were told she was her own person (made her own decisions). She (Resident #303) was contacting us. She told us she was really sick and didn't know why she didn't see a doctor . On 5/12/16 at 2:35 p.m. during an interview with the Director of Nursing (DON), she indicated circles on the MAR mean a medication was not given. On 4/10 the 1700 (5 p.m.) dose should have been given, there's no initials- (LPN C) is the nurse who wrote the 1832 (blood sugar) for that day (for Resident #303). The DON said she realized there was a problem when (Resident #303) went out and there wasn't much documented. On 5/12/16 at 2:40 p.m. the (DON) provided a Facility Past Non-Compliance Checklist dated 4/21/16 and signed by the DON. It documents Resident #303 as being injured and The resident (#303) started to become sick on or around 4/7 to 4/8/16. She had complaints of nausea per 4/8/16 documentation for several hours with an upset stomach. The nausea continued throughout the weekend until being transported to the hospital on [DATE]. She (Resident #303) became short of breath on 4/10/16 with a low oxygen stats and oxygen was started. There was a lack of documentation related to this resident's condition .The physician was not notified related to the patient's condition until 4/11/16. Orders were not obtained to hold insulin for 4/8 and 4/9/16 or 4/11/16 or for the use of oxygen. On 5/12/16 at 3:36 p.m. when interviewed about Resident #303's insulin orders, the DON stated, (staff I) our diabetic educator consults with the MD and he will approve/disapprove insulin orders. On 5/12/16 at 3:50 p.m. LPN C, who cared for Resident #303 on 4/10/16, was interviewed. LPN C acknowledged the MAR for Resident #303 was not initialed for the 4/10/16 1700 (5 p.m.) insulin dose. Resident #303's BG was documented as 182 mg/dl. LPN C stated, I'm not sure, I usually give it (insulin dose). I'm sure I did give it (insulin dose). The MAR for Resident #303 showed: [MEDICATION NAME] R *500 unit/ml* vial (order date 1/16/15), Inject 13 units subQ predinner if BG at or under 200 (mg/dl); inject 15 units if BG at or over 200(mg/dl). On 5/12/16 at 4:03 p.m. an interview was conducted with LPN D, who regularly cared for Resident #303. When asked if she knew the symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION] she said, diaphoretic, increased confusion, lethargic. When asked about symptoms for ketoacidosis LPN D stated, I don't know right offhand, no. At 4:15 p.m. LPN E, who also cared for Resident #303, was interviewed and asked about symptoms for [DIAGNOSES REDACTED]. She stated, feeling like you're going to pass out, weak, confused, nauseated. For symptoms of [MEDICAL CONDITION], LPN E stated, same type of symptoms, in my experience. For symptoms of ketoacidosis LPN E stated, frequent urination, that's all I can think of. Weakness, is all I come up with. Probably nausea. On 5/13/16 at 8:35 a.m. an interview was conducted with Registered Dietitian/Certified Diabetes Educator (RD) I. RD I said she typically does a yearly assessment with a plan and goals on diabetic residents and follows up approximately every 3 months. RD I said she confers with the physician via a written recommendation based on lab results and blood sugar results. The A1c (glycosylated hemoglobin level) is every 3 months. I was told by the facility that frequent blood sugar checks with residents shouldn't be done if they keep within a range specific to each resident . Any big change in (food) intake, especially those on insulin, is expected to be reported . I had come in the day (Resident #303) was sent to the hospital. The nurse told me she hadn't been eating and I wrote up a guideline which they faxed over to the doctor, and then I found out she (Resident #303) went to the hospital . I wasn't aware of all of her (Resident #303's) symptoms on that Monday (4/11/16). An interview was conducted on 5/13/16 at 8:57 a.m. with Physician J. Physician J stated the expectation: In the past if a blood sugar was greater than 400 (mg/dl), call the attending physician. Physician J stated, The staff should notify me if a diabetic resident is having nausea and vomiting over a course of a few days, 2-3 days . We may not be finding people who are ill with high blood sugars. On 5/13/16 at 9:45 a.m. Registered Nurse (RN) K was interviewed. RN K stated nursing staff use a website to look up disease processes under Lippincott's Nursing Procedures and Skills, or go to the book (Lippincott Manual). RN K accessed the Lippincott Manual of Nursing Practice, Eighth Edition, at the nurses desk, which reviewed Diabetes Sick-Day Guidelines on page 928 and Diabetic Ketoacidosis on pages 928 - 930. Under the Sick - Day guidelines it reads, in part: Never omit insulin dosage . Take at least the usual dose of insulin . Monitor blood glucose and urine [MEDICATION NAME] every 2-4 hours. Whenever blood glucose is greater than 240 mg/dl, test urine [MEDICATION NAME]. Record all test results . Contact health care provider if illness becomes severe or unmanagable. Fever, nausea, vomiting, and diarrhea increase risk of dehydration . Large amount of urine [MEDICATION NAME] or other signs and symptoms of diabetic ketoacidosis: call health care provider immediately. Under Diabetic Ketoacidosis it reads, in part: Clinical Manifestations- Early 1. Polydipsia, polyuria 2. Fatigue, malaise, drowsiness 3. Anorexia, nausea, vomiting 4. Abdominal pains, muscle cramps Later 1. Kussmaul respiration (deep respirations) 2. Fruity, sweet breath 3. [MEDICAL CONDITION], weak pulse 4. Stupor and coma . Nursing Alert- Severity of DKA (diabetic ketoacidosis) cannot be determined by serum glucose levels; acidosis may be prominent with glucose level of 200 mg/dl or less . Nursing Assessment- 1. Assess skin for dehydration . 3. Assess respiratory status- Kussmaul breathing . 4. Perform GI assessment- nausea, vomiting, extreme thirst, abdominal bloating and cramping, diarrhea . Nursing Alert- Electrolyte levels may not reflect the total body deficit of potassium (primarily) and sodium .Replacement is necessary despite normal to high values . Drug Alert- Interuption in insulin administration may result in reaccumulation of [MEDICATION NAME] bodies and worsening acidosis. Glucose will normalize before acidosis resolves . On 5/13/16 at 10:54 a.m. LPN L was interviewed. LPN L stated, On the 11th (of April), I got report that (Resident #303) was having nausea and dry heaves and wasn't eating related to fear of throwing up. I usually check blood sugars around 7:30 - 8 a.m. After checking, I was leery of giving the fast acting insulin . She seemed fine, her cognition was normal. LPN L said he told Resident #303 her blood sugar was 480 (mg/dl). LPN L stated, I was waiting to talk to the unit manager to determine if insulin should be given . The labs came in just after the unit manager got here. LPN L said when the labs come in, the unit manager notifies the physician. The blood sugar got reported at that time. When questioned on symptoms of [DIAGNOSES REDACTED], LPN L stated, diaphoretic, nausea, light headed, weak. When asked for symptoms of [MEDICAL CONDITION], LPN L stated, thirst, weight loss, fruity breath, and for ketoacidosis, like [MEDICAL CONDITION], fruity breath. On 5/13/16 at 12:00 p.m. Unit Manager/Registered Nurse (RN) N was interviewed. RN N said she usually comes in around 8:30 a.m. and does rounds. On the morning of 4/11/16, the lab called with critical values on (Resident #303). I called the doctor's office with the results. RN N stated, I don't think it was necessary for me to be here for him (LPN L) to call the doctor (for blood sugar results). It's our protocol to call the doctor. It doesn't say wait for (RN N). When asked for symptoms on [DIAGNOSES REDACTED] RN N stated, diaphoresis, nausea, shaking, altered mental status. For [MEDICAL CONDITION] she stated, Pretty much the same, actually, and for ketoacidosis RN N stated, I don't know right off hand. Nausea and vomiting. She stated Resident #303 started with the nausea and retching on Wednesday (4/6/16), but there were other residents with the same GI (gastrointestinal) symptoms. On 5/13/16 at 3:35 a.m. an interview was conducted with RN H. She stated, Multiple times (Resident #303) would often ask me to check her blood sugar. She felt she didn't eat enough and worried it would be low. When questioned on charting the random blood sugar checks RN H stated, I probably fell short on that, I'm sure there are times I should have, but I do always follow through on it. She stated the symptoms for [DIAGNOSES REDACTED] were confusion, grogginess, not feeling well, clammy skin; for [MEDICAL CONDITION], classic fruity breath, it's not as easy to recognize; and for ketoacidosis, fruity breath, increased thirst, frquent urination, checking blood sugar and it's really high. If any of these signs and symptoms a blood sugar is done. RN H stated, I think the night before she (Resident #303) went to hospital, for several nights, she was combating a [MEDICAL CONDITION] and she had IBS (irritable bowel syndrome). She (Resident #303) complained of nausea, didn't really vomit. She had diarrhea. She didn't eat and night before she went to hospital she said she couldn't breathe. Lung sounds were diminished. She was 'air hungry' . I gave her oxygen related to her O2 (oxygen) level in the 80's and then it went up into the 90's and she felt better. The facility Clinical Administrative Manual effective July 2015, revised April 2016, consisting of a cover sheet and one page, was provided on 5/17/16 by the Regional Director of Clinincal Services (RDCS) S. Review of the one page Notice read: This manual contains the policies and procedures for the center. For clinical situations not covered by these policies and procedures or for further guidance consult The Lippincott Manual of Nursing Practice (10th edition) and Lippincott's Textbook for Nursing Assistants, the preferred reference manual for nursing issues. The Lippincott Manual of Nursing Practice, Tenth Edition states: on page 962 under Standards of Care Guidelines 25-1, Caring for Patients with Diabetes Mellitus it states: When caring for patients with diabetes mellitus: Assess level of knowledge . Assess for signs of [MEDICAL CONDITION]: polyuria, polydipsia, polyphagia, weight loss, fatigue, blurred vision. Assess for signs of [DIAGNOSES REDACTED]: sweating, tremor, nervousness, tacchycardia, light-headedness,confusion . Make sure the appropriate insulin dosage is given at the right time and in relation to meals and exercise . Get help immediately for patient presenting with signs of either ketoacidosis (nausea and vomiting, Kussmaul's respirations, fruity breath odor, [MEDICAL CONDITION], and altered level of conciousness or hyperosmolar hyperglycemic nonketoni[DIAGNOSES REDACTED] (nausea and vomiting, hypothermia, muscle weakness, [MEDICAL CONDITION], stupor, coma) . ( )

Based on interview and record review, the facility failed to ensure a complete medical record was maintained for one Resident (#303) of three residents reviewed for completeness of medical records, from a total sample of four residents. This deficient practice resulted in limited clinical progress notes available in the medical record, preventing a collaborated approach to prompt treatment and continuity of care for Resident #303. Findings include: According to the MDS assessment dated [DATE], Resident #303 was a [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment revealed Resident #303 had a Brief Interview for Mental Status (BIMS) score of 11/15, indicating she had moderately impaired cognition. Review of the facility nursing progress notes for Resident #303 revealed the first entry identifying any symptoms of illness was dated 4/8/16 at 2:00 a.m., which documented, .Res (Resident #303) states feels better today with no nausea, vomiting or loose stools . (Yesterday res. had emesis & was not feeling well.) Nursing notes for Resident #303 dated 4/8/16, 6 p.m.-6 a.m. documented, .nausea this evening & upset stomach, [MEDICATION NAME] given, helped some but nausea persisted for several hours . There were no nursing progress notes for 4/09/16. 4/10/16 nursing progress notes on Resident #303 read, in part: 1830 (6:30 p.m.) resident continued with nausea this shift . 4/11/16 nursing progress notes on Resident #303: 0005 (12:05 a.m.) Res became very SOB (short of breath) after being helped to bathroom . 0855 (8:55 a.m.) .FBS (fasting blood sugar) 480 (milligrams/deciliter, mg/dl) this a.m. & has been up past 3 days. Not feeling well with increased nausea during this time . 1120 (11:20 a.m.) Phoned Dr. (J) re HC (high critical) K+ (potassium) 6.7 left message with nurse . dry heaves & liquid stools X 3 days or so. Insulin has been held d/t (due to) not able to keep anything down . 1130 (11:30 a.m.) Call per .NP (nurse practitioner) send (Resident #303) to ER (emergency room ). 4/19/16 nursing progress notes on Resident #303: late entry for 4/9/16. Resident continues with c/o (complaints of) nausea this shift . Review of Resident #303's April 2016 Medication Administration Record (MAR) documents fingerstick blood sugar/glucose results as: 4/08/16 at 1700 (5 p.m.): 73 mg/dl 4/09/16 at 0700 (7 a.m.): 308 mg/dl 4/09/16 at 1700 (5 p.m.): 51 mg/dl 4/10/16 at 0700 (7 a.m.): 420 mg/dl 4/10/16 at 1700 (5 p.m.): 182 mg/dl 4/11/16 at 0700 (7 a.m.): 480 mg/dl The April 2016 MAR documented If blood sugars are less than 50 or greater than 400 notify MD. There was no documentation of physician notification in the MAR or in nursing notes for 4/10/16 or 4/11/16 regarding the blood sugars which were greater than 400 mg/dl. Resident #303's orders for treatment of [REDACTED].wait 15 minutes and re-check blood sugar. If blood sugar remains below 70 (mg/dl) and/or if symptoms continue, repeat treatment of [REDACTED].Document treatment and resident response in the PRN (as needed) record MAR and nurse note. There was no documentation of low blood sugar nor physician notification in the MAR or in nursing notes for 4/9/16 through 4/11/16 regarding the blood sugars being greater than 400 mg/dl or of the low blood sugar of 51 being rechecked. On 5/12/16 at 2:40 p.m. the (DON) provided a Facility Past Non-Compliance Checklist dated 4/21/16 and signed by the DON. It documented Resident #303 as being injured and The resident (#303) started to become sick on or around 4/7 to 4/8/16. She had complaints of nausea per 4/8/16 documentation for several hours with an upset stomach. The nausea continued throughout the weekend until being transported to the hospital on [DATE]. She (Resident #303) became short of breath on 4/10/16 with a low oxygen stats and oxygen was started. There was a lack of documentation related to this resident's condition .The physician was not notified related to the patient's condition until 4/11/16. Orders were not obtained to hold insulin for 4/8 and 4/9/16 or 4/11/16 or for the use of oxygen. On 5/12/16 at 3:50 p.m. LPN C, who cared for Resident #303 on 4/10/16, was interviewed. LPN C acknowledged the MAR for Resident #303 was not initialed for the 4/10/16 1700 (5 p.m.) insulin dose. Resident #303's BG was documented as 182 mg/dl at that time. LPN C stated, I'm not sure, I usually give it (insulin dose). I'm sure I did give it (insulin dose). The MAR read: [MEDICATION NAME] R *500 unit/ml* vial (order date 1/16/15), Inject 13 units subQ predinner if BG at or under 200 (mg/dl); inject 15 units if BG at or over 200(mg/dl). On 5/13/16 at 3:35 a.m. an interview was conducted with RN H. She stated, Multiple times (Resident #303) would often ask me to check her blood sugar. She felt she didn't eat enough and worried it would be low. When questioned on charting these random blood sugar checks, RN H stated, I probably fell short on that, I'm sure there are times I should have, but I do always follow through on it. On 5/13/16 at 10:54 a.m. LPN L was interviewed. LPN L stated, On the 11th (of April), I got report that (Resident #303) was having nausea and dry heaves and wasn't eating related to fear of throwing up. I usually check blood sugars around 7:30 - 8 a.m. After checking (it was 480), I was leery of giving the fast acting insulin . She seemed fine, her cognition was normal. LPN L stated, I was waiting to talk to the unit manager to determine if insulin should be given . LPN L did not give the scheduled 7 a.m. dose of insulin as noted on the MAR, which was not documented in the progress notes. There was no documentation of the 7 a.m. insulin dose being held or given prior to Resident #303 being sent out to the hospital emergency room at 11:30 a.m. ( )

Based on observation, interview and record review, the facility failed to provide necessary treatment to prevent development of multiple and recurrent pressure ulcers, and failed to provide care and services to promote healing and prevent infection of existing pressure ulcers for 1 Resident (#502) of 4 residents reviewed for pressure ulcers from a total sample of 4 residents. This deficient practice resulted in the development of recurrent (one Stage II left (L) buttock) and new pressure ulcers (one Stage III right (R) heel; ; one stage III R outer ankle; one stage III R calf ; one ulcer on coccyx unstaged; with increased pain, increased risk of infection and the potential for delayed healing. Findings include: The Minimum Data Set (MDS) assessment for Resident #502 dated 8/17/2015, revealed he was [AGE] years old and admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the MDS assessment, Resident #502 required extensive, 2-person assistance with all repositioning and transfers, and was always incontinent of urine and frequently incontinent of bowel. Resident #502 scored a 12/15 on the Brief Interview for Mental Status (BIMS) reflective of moderate cognitive impairment. The MDS indicated Resident #502 was able to express ideas and wants, make himself understood, and was able to understand what was being said to him. Review of Resident #502's admission MDS assessment dated [DATE], revealed that Resident #502 was assessed upon entry to the facility to have one Stage II (L buttock) and one Stage III pressure ulcer (L heel). The Stage II pressure ulcer, located on the L buttock, measured at 2 cm (centimeters) x 1 cm and was graphically documented on the 'EHSI Skin Assessment' form completed and dated 2/11/15 at 1200 (12:00 p.m.) by Licensed Practical Nurse (LPN ) A. A 'Skin Grid-Pressure/[MEDICAL CONDITION] Ulcer/Other' (Skin Grid) form was also completed on 2/11/15 to track the Stage II pressure ulcer on the left buttock. The 'Skin Grid' was documented on 2/20/15 with D/C (discontinue) area healed (left buttock pressure ulcer). Review of the 'Weekly Pressure/Stasis Ulcer and Surgical Wound Report' received from LPN D on 10/22/15 at 1:20 p.m., revealed the following location, status, and progression of Resident #502's wounds; 9/16/15: R heel, in house acquired, stage III, 3 cm x 4 cm x 0.3 cm, , foul odor, not improving. R great toe (Hallux), in house acquired, Stage III, 2.8 cm x 2.5 cm x 0.2 cm, foul odor, not improving. R outer ankle, in house acquired, Stage III, 4 cm x 3.7 cm, x 0.3 cm, foul odor, not improving. 9/30/15: R heel, in house acquired, Stage III, 2.1 cm x 4.5 cm x 0.3 cm, foul odor. R bottom of heel, no Staging noted, identified this week, in house acquired, 3.3 cm x 3 cm sup (superficial). R great toe, Stage III, in house acquired, 2.6 cm x 2.4 cm x 0.2 cm, foul odor. R outer ankle, Stage III, in house acquired, 4 cm x 3.8 cm x 0.3 cm, foul odor. R calf posterior, Stage IV identified this week, in house acquired, 2 cm x 1.5 cm x 0.1 cm, mild odor. 10/7/15: R heel, in house acquired, Stage III, 4 cm x 4.7 cm x 0.4 cm, foul odor, not improving. R Hallux, in house acquired, not staged, 2.4 cm x 2.3 cm x sup,mild odor. R bottom of heel, not staged, in house acquired, 3.5 cm x 3.6 cm, not improving. R outer ankle, Stage III, in house acquired, 4 cm x 5.3 cm x 0.1 cm, foul odor, not improving. R calf posterior, Stage III, in house acquired, 2.4 cm x 2.5 cm, mild odor, not improving, L(left) buttock, identified this week, in house acquired, 1.4 cm x 1 cm x 0.1 cm. Review of Physician Orders, dated 10/8/15 for Resident #502's left buttock wound revealed the following: D/C tx (treatment) to L Buttock of [MEDICATION NAME] flex and solosite (Physician Ordered 10/4/15). New: Cleanse (with) Soap and H2O (Water) apply Allevyn (dressing), change q (every) 3 days and PRN (as needed) - D/C when healed then use dimethicone (cream). Review of Physician Orders right heel, right ankle, and right posterior calf revealed the following: Cleanse wounds with soap and H2O, rinse with NS (normal saline) gauze. During an interview on 10/21/15 at 9:45 a.m., when asked if Resident #502 felt the facility was taking good care of him, Resident #502 stated, No .wife was a nurse .she comes every day to check up on what they are doing . Resident #502 was observed at that time, to be lying on his back. During another brief interview on 10/22/15 at 7:45 a.m., when asked if he was repositioned every 2 hours, Resident #502 stated, No .don't reposition every two hours .I am always on my back . Resident #502 was observed, at the time, to be positioned on his back, with the head of the bed elevated approximately 45 degrees. During an observation of wound care on 10/21/15 between 9:50 a.m. and 10:25 a.m., performed by LPN A on Resident #502's right great toe, right heel, right ankle, right calf posterior, and left buttock, soap and water was not used to cleanse any of the wounds, per physician orders. Resident #502 was observed to grimace, flinch, and attempted to move his right leg when the wound dressings were removed and changed. When the old dressing was removed from the right calf posterior, the wound drainage on the dressing was observed, by this Surveyor, to be green. On 10/21/15 at approximately 10:10 a.m., when LPN A was asked by this Surveyor whether the drainage was green, he stated, Yeah, that's new today (green color) . When Resident #502's brief was removed on 10/21/15 at approximately 10:15 a.m., it was observed by this Surveyor, to be saturated with urine. No dressing was present on Resident #502's open left buttock wound. When LPN A was asked at that time, if there was supposed to be a dressing on the left buttock wound, LPN A stated, Yes .I have no idea why there is no dressing .(the) Certified Nurse Aide (CNA) usually comes to get me if the dressing is removed. This Surveyor observed the left buttock wound and coccyx to be covered in a white cream. The area was wiped clean with moistened gauze (no soap and water, per physician order) by LPN A, providing observation to LPN A and this Surveyor, of a left buttock wound and a coccyx wound not present on the treatment administration record, measured by LPN A to be 0.4 cm x 0.4 cm. LPN A stated, .that one is new (coccyx wound) .only one (wound) on the treatment orders .left buttock . During an interview on 10/21/15 at 10:25 a.m., when LPN A was asked why he didn't use soap to cleanse the wounds, as physician ordered, LPN A replied, I couldn't find the soap .normally (there is) some in the (treatment) cart . During an interview on 10/21/15 at 12:50 p.m. with CNA C, when asked if there was a dressing present on Resident #502's left buttock, CNA C stated, Dressing was kind of off and kind of on .(there) was one dressing on (the) left buttock cheek. CNA C reported she had removed the partially intact dressing and .put a little cream (unknown type) on it .his wife buys it . CNA C said that she did not tell the nurse that the dressing was off because .I didn't see (LPN A) this morning . CNA C reported that .yesterday (10/20/15) (Resident #502) did not have a dressing on his left buttock .(he) had just cream . applied to the open wound. During an interview on 10/21/15 at 4:15 p.m. with LPN A, when asked what the effect of not using soap per Physician Orders, would have on Resident #502's wounds, LPN A stated, Not getting contaminants out .more chance for infection .especially if it was (a) 3 day dressing change. LPN A reported that .cares for the day are documented at the end of my shift. LPN A was asked what thoughts he had regarding the new finding of green drainage on Resident #502's right calf posterior wound, and LPN A stated, .green usually means infection .(the) calf is a newer one to me (green drainage not present previously) . During an interview on 10/21/15 at 8:15 a.m., when the Director of Nursing (DON) was asked what her expectations were for her nursing staff regarding wound care, she stated, That they follow the treatment orders. The DON acknowledged she was aware that LPN A had not used soap and water to cleanse Resident #502's wounds during the dressing change. When asked what LPN A should have done with regard to using soap, the DON stated, .(staff) should wait until they get the supplies (soap) . The DON confirmed that according to the Physician Orders .it needed to be soap . When the DON was asked what could result from wound care with no soap, per physician orders, the DON stated, .(wounds) could worsen .could lead to infection . During the same interview on 10/21/15 at 8:15 a.m., the DON also stated that she would .expect the CNA to tell the nurse that (there was) no dressing (on Resident #502's left buttock). The DON commented that Butt Pastewas applied to Resident #502's open left buttock and newly developed coccyx wound. The DON acknowledged that there was no Physician order for [REDACTED]. During an interview on 10/22/15 at 3:30 p.m., when asked if the left buttock pressure ulcer was previously healed, LPN A stated, .(the left buttock wound) has completely healed a couple of times .I think it has healed twice and come back again .in the same place . ( ) --

Based on observation, interview and record review, the facility failed to ensure an assistive device (transport van seatbelt) was securely fastened to hold one Resident (#201) in her wheelchair of 3 residents reviewed for facility transport van use from the facility population of 81 residents. This deficient practice resulted in Resident #201 sustaining a left leg femur fracture with subsequent amputation of her left leg. Findings include: Resident #201's Minimum Data Set (MDS) assessment dated [DATE], showed she had resided at the facility since 1/6/15 and was [AGE] years old. The MDS assessment and 1/2015 care plan showed Resident #201 made her own medical decisions. The care plan showed Resident #201's [DIAGNOSES REDACTED]. The facility's investigation report dated 4/1/15, showed on 3/26/15 at approximately 3:10 p.m., Resident #201 was seated in her wheelchair in the facility's transport van on her way to a scheduled physician's appointment. The report showed Resident #201 had been "dozing" when the transport van stopped for a traffic light. The report showed Resident #201 had begun to slide off the wheelchair seat with her left leg elevated in the wheelchair foot rest. Resident #201 stated her knee was hurting per the report, so after bringing the van to a stop Certified Nurse Aide (CNA) "J" assisted Resident #201 to a seated position on the floor of the van and called for an ambulance. The report showed the ambulance transported Resident #201 to the hospital. Interviews were conducted on 4/22/15 with transporter Certified Nurse Aide (CNA) "J" at 9:10 a.m. and 3:15 p.m. CNA "J" said she was taking Resident #201 to her physician's appointment on the afternoon of 3/26/15 when the incident occurred. CNA "J" stated she had secured Resident #201's wheelchair with the floor clamping system, and secured Resident #201 with a seat belt as she sat upright in the wheelchair with her left leg and foot supported in an approximate 45 degree upward angle. The resident had a previous amputation of the right leg above the knee (AKA). CNA "J" explained just prior to the incident, she had observed Resident #201 leaning to the side and "slightly" forward in her wheelchair sleeping. CNA "J" said as she brought the van to a stop at a traffic light she noticed (through the rear view mirror) Resident #201 falling forward in her wheelchair. CNA "J" said she pulled into a parking lot and when she reached Resident #201, the resident was was leaning forward and "barely" on the edge of the wheelchair seat "kind of dangling" with the right amputated leg almost touching the floor. CNA "J" stated Resident #201 was "yelling" for help, saying she had pain in her left leg. CNA "J" explained she could not get Resident #201 seated back into the wheelchair, so she assisted her to the floor of the van and because of Resident #201's leg pain, called for an ambulance. CNA "J" stated she notified the facility and Resident #201 was transported to the emergency room via the ambulance. During the interview on 4/22/15 at 9:10 a.m. with CNA "J", an observation of the facility's transport van and seatbelt system were observed. CNA "J" showed this surveyor, by using an empty wheelchair, how the wheelchair was secured to the floor of the van and how a resident would be secured in their seated position by fastening the seatbelt around their torso. CNA "J" demonstrated how the seatbelt mechanism locked into place. During the interview on 4/22/15 at 3:15 p.m. CNA "J" explained when she secured Resident #201 in the seatbelt and pulled the belt tight, there was approximately "twelve inches or so" extra length of the strap. CNA "J" stated when she went to release Resident #201 while she dangled on the "very front edge" of the wheelchair, CNA "J" noticed the belt strap had slipped, and there was only "a couple inches of strap left before the belt would've released..." CNA "J" said she believed the belt came loose as Resident #201 slept and leaned forward on the belt. An interview and an additional observation of the facility van seatbelt mechanism was conducted on 4/22/15 with Maintenance Director "E" at 10 a.m. Maintenance Director "E" showed this surveyor as he secured the seatbelt mechanism, (the same as was observed when CNA "J" performed the demonstration) how extensive force on the seatbelt did not loosen the belt. Maintenance Director "E" stated after the incident, the facility van was now "taken out of commission" due to door latch issues and county supported handicap vehicles had been used to date. Maintenance Director "E" supplied facility documents titled "VEHICLE INSPECTION REPORT" dated 1/29/15 and a "work schedule...Tasks for March" report dated 3/11/15. Maintenance Director "E" stated the seatbelt used for residents in wheelchairs would have been inspected during the 1/29/15 inspection, but he did not believe they were physically checked during the work schedule tasks for March (2015). During the interviews on 4/22/15 with CNA "J" at 9:10 a.m. and Maintenance Director "E" at 10 a.m., they were asked how they were trained on the use of the seatbelt for securing residents in their wheelchairs. CNA "J" said she had received training from the previous transporter, CNA "A". Maintenance Director "E" stated the previous maintenance director trained him. Both staff stated they did not believe there was anything written that described a procedure of how to secure a resident with a seatbelt while sitting in their wheelchair during van transports. The facility document titled, "Procedure Subject Comprehensive Vehicle Safety Policy..." (effective October 2013) was reviewed. No information was found which showed how to appropriately place and secure the seatbelt around a resident in a wheelchair while being transported in the facility van. Interviews were conducted on 4/23/15 with the training coordinator RN "H" and the Assistant Director of Nursing (ADON) "S" at 8:20 a.m. Both staff confirmed there was no facility training documentation or manufacturer's diagrams or descriptions, which showed how to appropriately place and tighten the seatbelt around a resident while they were seated in their wheelchair and being transported in the facility van. During the interview on 4/23/15 with Registered Nurse (RN) "H" at 8:20 a.m. and a phone interview conducted with the Director of Nursing (DON) on 4/23/15 at 9:30 a.m., both staff stated there had been no other incidents with the facility's transport van. Review of the 3/26/15 ambulance report showed "...WHEELCHAIR WAS STILL SECURED TO THE FLOOR AT THIS TIME. PATIENT IS IN OBVIOUS PAIN AND HER LEFT LEG IS ROTATED OUTWARD. PATIENT STATES THE PAIN IS 10/10 JUST ABOVE HER KNEE..." The hospital admission report dated 3/26/15 read, "(Resident #201) was brought to the emergency department with severe pain in her left leg near her knee and imaging reveals a distal femur fracture, fractured into a left knee prosthesis..." A hospital "Consultation" document read, "...the patient's history complicated her fracture because of her nonhealing ulcer on the left heel. The "Consultation" document showed on 3/30/15, Resident #201 received a "left above-the-knee (AKA)amputation". A phone interview was conducted with Resident #201 on 4/23/15 at 2:45 p.m. Resident #201 said she recalled the incident. Resident #201 explained she remembered being assisted into the van and CNA "J" putting the seatbelt around her prior to leaving for her physician appointment. Resident #201 said she had fallen asleep and woke up "upside down and dangling inches" from the van floor. She said the seatbelt had come loose, but it was all that was holding her from falling to the van floor. Resident #201 said her left leg was "already hurting bad" before she was lowered to the van floor. Resident #201 stated her left leg had been amputated during her stay at the hospital after the van incident. Resident #201 said she was told by Physician "Z" her left leg was amputated due to the complicated fracture to the leg, not because of the ulcers he ( Physician "Z") had been treating. Resident #201 explained she did not want her left leg amputated, but because of the fracture "It had to be done." A phone interview was conducted on 4/28/15 at 10:15 a.m. with Physician "Z". Physician "Z" stated he and his wound nurse had been treating the ulcers to Resident #201's left foot area. Physician "Z" said he had met with Resident #201 at the hospital after she had been brought in (3/26/15) due to the fractured femur. Physician "Z" explained he had evaluated the left foot ulcers at the hospital, and determined it was the "complicated fracture" to the left leg that warranted the amputation of the leg at this time. Physician "Z" stated if not for the fractured leg, he would have continued to treat the resident's foot ulcers and would not have agreed to the need for the left leg amputation. The facility could not produce documentation which showed transport staff had been following or had knowledge of what the manufacturers' recommendations were for the proper use of the seatbelt for Resident #201 prior to this incident. ( ) --

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND ASSURE ASSISTIVE DEVICES WERE IN PROPER WORKING ORDER TO PREVENT ACCIDENTS SECONDARY TO AN ELOPEMENT IN FOUR (#100, #101, #102 AND #103) OF FOUR RESIDENTS REVIEWED FOR RISK OF ELOPEMENT OUT OF A TOTAL OF NINE RESIDENTS IDENTIFIED AS BEING AT RISK FOR THE POTENTIAL OF UNAUTHORIZED EXIT FROM THE FACILITY. RESIDENT #100 WAS KNOWN TO BE AT RISK FOR ELOPEMENT, WAS COGNITIVELY IMPAIRED AND HIGHLY MOBILE. ON 6/8/13 AT APPROXIMATELY 3:40 A.M., THE FACILITY COULD NOT LOCATE RESIDENT #100. A SEARCH TO FIND RESIDENT #100 WAS UNSUCCESSFUL AND LOCAL POLICE WERE CONTACTED. THE FACILITY IS LOCATED ON THE SHORELINE OF LAKE SUPERIOR AND IS ABOUT A BLOCK AWAY FROM A DEEP WATER MARINA. RESIDENT #100'S LOCATION WAS UNKNOWN FOR APPROXIMATELY 2 HOURS. RESIDENT #100 WAS FOUND IN THE PARKING LOT OF A PAPER MILL FACTORY LOCATED OFF OF HIGHWAY 28, APPROXIMATELY .7 MILES AWAY FROM THE FACILITY. UPON DISCOVERY, RESIDENT #100 WAS SITTING IN A VEHICLE OF AN UNIDENTIFIED OWNER, DRESSED IN STREET CLOTHING. THE OUTSIDE TEMPERATURE FOR THE LOCAL AREA, AS IDENTIFIED BY "WUNDERGROUND" WEBSITE, IDENTIFIED TEMPERATURES BETWEEN 42 AND 46 DEGREES FAHRENHEIT BETWEEN 3:00 A.M. AND 6:00 A.M. ON 6/8/13. THIS DEFICIENT PRACTICE RESULTED IN IMMEDIATE JEOPARDY TO THE HEALTH AND SAFETY OF RESIDENT #100. ON 6/11/13 AT 5:00 P.M., THE FACILITY WAS NOTIFIED OF THE IMMEDIATE JEOPARDY THAT WAS IDENTIFIED ON 6/11/13 AND BEGAN ON 6/8/13 WHEN THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND FAILED TO ENSURE A FUNCTIONING ALARM SYSTEM TO PREVENT RESIDENT #100 FROM EXITING THE FACILITY DURING THE PRE-DAWN HOURS, WITHOUT THEIR KNOWLEDGE. DURING THE COMPLETION OF THE PARTIAL EXTENDED SURVEY ON 6/11/13 THROUGH 6/13/13, THE IMMEDIATE JEOPARDY WAS REMOVED ON 6/12/13 BY THE FOLLOWING FACILITY ACTIONS: - OBSERVATION WAS MADE OF RESIDENT #100 ON 6/10/13 AT APPROXIMATELY 3:00 P.M. ON THE "LIVING MOMENTS" SECURE RESIDENT UNIT OF THE FACILITY. THIS IS A LOCKED UNIT. - ON 6/11/13 AT 9:00 A.M., AN ENVIRONMENTAL TOUR OF THE FACILITY WITH MAINTENANCE STAFF "J", VERIFIED ALL ALARMS WERE WORKING ON ALL EXIT DOORS AND THE TWO EXITS IDENTIFIED AS HAVING THE CODE WATCH SYSTEM WERE ALSO IN PROPER WORKING ORDER. ALL DOOR ALARMS WILL HAVE CODES CHANGED WEEKLY INSTEAD OF MONTHLY THROUGHOUT THE FACILITY. THIS WILL BE DONE BY MAINTENANCE DURING THEIR WEEKLY ROUNDS AND DOCUMENTED ON THEIR ROUNDS SHEETS. - RESIDENT #100'S "CODE WATCH" TRANSMITTER HAD BEEN REPLACED WITH A NEW UNIT WITH A CURRENT BATTERY EXPIRATION DATE OF 3/2014 AND WAS OBSERVED ON HER ANKLE ON 6/11/13 AT APPROXIMATELY 10:00 A.M. - RESIDENT #100'S CARE PLAN WAS REVISED ON 6/8/13 AND 6/12/13. THESE REVISIONS IDENTIFIED THE FOLLOWING INTERVENTIONS TO PREVENT UNAUTHORIZED EXIT FROM THE BUILDING: 15 TO 30 MINUTE SAFETY CHECKS OF RESIDENT #100, CONTINUED USE OF THE CODE WATCH TRANSMITTER ON HER ANKLE AND A SECOND CODE WATCH UNIT IN HER PURSE. THE CARE PLAN REVISION IDENTIFIED RESIDENT #100 WOULD NOT LEAVE THE SECURE UNIT WITHOUT DIRECT STAFF SUPERVISION. - EFFECTIVE 6/12/13, PARAMETERS OF "EXIT SEEKING" BEHAVIOR WERE IDENTIFIED FOR RESIDENT #100, INCLUDING: MAKING STATEMENTS ABOUT GOING SOMEWHERE, MAKING STATEMENTS ABOUT THE MAFIA COMING TO GET HER, PERSISTENT STANDING BY EXIT DOOR, KNOCKING ON EXIT DOORS, ASKING STAFF TO LEAVE, AND EXCESSIVELY ASKING STAFF TO USE THE TELEPHONE. STAFF ARE DIRECTED TO PROVIDE 1:1 SUPERVISION IF THESE BEHAVIORS ARE EXHIBITED UNTIL THEY STOP. - A TOUR OF THE FACILITY ON 6/12/13 AT 3:00 P.M., VERIFIED SIGNAGE HAD BEEN PLACED AT THE FRONT/MAIN ENTRANCE WHICH DIRECTED VISITORS NOT TO LET ANYONE LEAVE THE BUILDING WITH THEM IF THEY WERE NOT CERTAIN OF THE PERSON'S IDENTITY. - AN INTERVIEW WITH SOCIAL WORKER (SW) "Z" ON 6/13/13 AT 1:30 P.M. REVEALED RESIDENT #100 HAD BEEN SEEN FOR PSYCHIATRIC CONSULTATION ON 6/12/13, WITH RECOMMENDATIONS MADE TO INCREASE ANTI-PSYCHOTIC MEDICATIONS. - AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) ON 6/13/13 AT APPROXIMATELY 11:00 A.M., REVEALED ALL RESIDENTS IDENTIFIED AS BEING AT RISK FOR ELOPEMENT HAD BEEN REVIEWED AS OF 6/8/13 FOR THE APPROPRIATENESS OF THEIR CARE PLANS. OBSERVATION OF THE FACILITY'S "ELOPEMENT BOOK" ON 6/13/13, CONFIRMED IT CONTAINED PICTURES AND WRITTEN DESCRIPTIONS OF ALL RESIDENTS CURRENTLY USING THE CODE WATCH TRANSMITTER. - ALL CODE ALERTS ARE CODED WITH DATE OF EXPIRATION AND FACILITY PRACTICE GOING FORWARD WILL BE TO CHANGE THE BRACELET ONE MONTH PRIOR TO EXPIRATION DATE. ALL MONITORING OF EXPIRATION DATES, PLACEMENTS AND CHANGE OF CODE ALERT BRACELETS IS OVERSEEN BY THE DIRECTOR OF NURSING AND THE CLINICAL TEAM. THIS TEAM WILL BE RESPONSIBLE FOR THE ONGOING MONITORING. THE DIRECTOR OF NURSING AND CLINICAL TEAM HAVE BEEN EDUCATED PERTAINING TO THE REQUIREMENT FOR MONITORING AS OF 6/12/13. A REVIEW OF NURSING RECORDS WHICH IDENTIFIED THE MANUFACTURER'S EXPIRATION DATES OF ALL CODE WATCH DEVICES, SHOWED THE EARLIEST ANY OF THE DEVICES CURRENTLY IN USE WILL EXPIRE IS 3/2014 (MARCH 2014). - ON 6/13/13 AT 1:00 P.M., AN INTERVIEW WITH REGISTERED NURSE (RN) "Y" VERIFIED SAFETY AND ELOPEMENT TRAINING OF ALL STAFF BEGUN ON 6/8/13 HAD NOT YET BEEN COMPLETED; TRAINING FOR THE REMAINING STAFF WAS OCCURRING AS THEY CAME TO WORK TO START THEIR NEXT SHIFT. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, DEFICIENT PRACTICE REMAINED AT A PATTERN LEVEL WITH POTENTIAL FOR NO MORE THAN MINIMAL HARM, POTENTIALLY AFFECTING RESIDENTS (#100, #101, #102 AND #103) PENDING: - COMPLETION OF SAFETY AND ELOPEMENT TRAINING OF ALL STAFF. - VALIDATION BY THE STATE AGENCY OF THE FACILITY'S ABILITY TO MAINTAIN SUBSTANTIAL COMPLIANCE WITH ENSURING ADEQUATE SUPERVISION AND PROPERLY WORKING ASSISTIVE DEVICES TO PREVENT RESIDENTS FROM EXITING THE FACILITY WITHOUT PROPER AUTHORIZATION TO ENSURE THEIR SAFETY AND WELL-BEING. FINDINGS INCLUDE: ON 6/10/13 AT APPROXIMATELY 2:45 P.M., AN INVESTIGATION WAS INITIATED OF A FACILITY REPORTED EVENT THAT IDENTIFIED RESIDENT #100 AS MISSING FROM THE FACILITY AT APPROXIMATELY 3:40 A.M. ON THE MORNING OF 6/8/13. A REVIEW OF THE FACILITY'S INVESTIGATIVE SUMMARY OF THE REPORTED INCIDENT, DATED 6/13/13, REVEALED THE FOLLOWING SEQUENCE OF EVENTS INVOLVING RESIDENT #100, AS REPORTED BY THE DIRECTOR OF NURSING (DON): ON 6/8/13 AT 3:45 A.M., THE DON WAS CALLED AT HOME BY REGISTERED NURSE (RN) "A" AND WAS INFORMED RESIDENT #100 WAS MISSING FROM HER ROOM AND COULD NOT BE LOCATED AT THE FACILITY. LOCAL POLICE WERE NOTIFIED AT 4:10 A.M., AFTER A THOROUGH SEARCH OF THE BUILDING AND THE PERIMETER OUTSIDE OF THE FACILITY DID NOT LOCATE RESIDENT #100. THE SEARCH CONTINUED UNTIL APPROXIMATELY 6 A.M., WHEN THE DON INDICATED LAW ENFORCEMENT HAD LOCATED RESIDENT #100 AT A LOCAL PAPER MILL, SITTING IN THE CAR OF ONE OF THE EMPLOYEES. RESIDENT #100 WAS RETURNED TO THE FACILITY BY 2 STAFF. THE DON STATED RESIDENT #100 WAS WEARING LONG PANTS, A THICK FLEECE LONG SLEEVED SHIRT, SHOES AND SOCKS. RESIDENT #100 WAS ASSESSED FOR INJURY BY THE DON AND NO EVIDENCE OF INJURY WAS IDENTIFIED. RESIDENT #100 COMPLAINED OF BEING "CHILLY". RESIDENT #100 REPORTEDLY TOLD THE DON IT WAS "NONE OF YOUR BUSINESS" WHEN ASKED WHERE SHE WAS GOING OR HOW SHE HAD EXITED THE BUILDING. A REVIEW OF THE FACE SHEET FOR RESIDENT #100, DATED 6/6/13, INDICATED RESIDENT #100 WAS admitted to the facility on [DATE] AND IS [AGE] years OLD. A REVIEW OF RESIDENT #100'S MOST RECENT MINIMUM DATA SET (MDS) ANNUAL ASSESSMENT, DATED 4/15/13, REVEALED CURRENT ACTIVE [DIAGNOSES REDACTED]. THE MDS ASSESSMENT IDENTIFIED BRIEF INTERVIEW OF MENTAL STATUS (BIMS) SCORES OF 8, WHICH INDICATED MODERATE COGNITIVE IMPAIRMENT. RESIDENT #100 IS IDENTIFIED AS BEING INDEPENDENT FOR TRANSFERS, BED MOBILITY, WALKING IN HER ROOM AND IN THE CORRIDOR. SHE IS ALSO IDENTIFIED AS BEING INDEPENDENT FOR DINING AND FOR USING THE TOILET. RESIDENT #100 HAD A PLAN OF CARE FOR ELOPEMENT, DATED 4/12/13, WHICH IDENTIFIED RESIDENT #100 HAS A HISTORY OF EXITING THE BUILDING OUT THE FRONT DOORS WITNESSED BY STAFF. INTERVENTIONS TO ADDRESS THIS PROBLEM INCLUDED THE USE OF A CODE ALERT ON LEFT ANKLE AND A CODE ALERT TO BE PLACED IN HER WHITE PURSE SEWN INTO THE FRONT POCKET (INITIATED 12/17/11). THE ELOPEMENT CARE PLAN ALSO DIRECTED STAFF TO MONITOR RESIDENT FOR PACKING HER BELONGINGS (2/18/12). RESIDENT #100'S "CARE DELIVERY GUIDE", LAST UPDATED 4/23/13, DOCUMENTED RESIDENT #100 WAS ON SCHEDULED 15-30 MINUTE SAFETY CHECKS. A DOCUMENT TITLED "ELOPEMENT RISK EDUCATION FLOW SHEET" WAS REVIEWED FOR THE MONTH OF 6/2013. STAFF WERE TO INITIAL IF 15-30 MINUTE CHECKS HAVE BEEN COMPLETED THROUGHOUT THEIR SHIFT. SEVERAL OF THE SHIFTS HAD NOT BEEN INITIALED, ALTHOUGH ALL SHIFTS HAD BEEN INITIALED AROUND THE TIME RESIDENT #100 EXITED THE BUILDING ON 6/7/13 AND 6/8/13. ON 6/11/13 AT 4:45 P.M., AN INTERVIEW WAS CONDUCTED WITH CERTIFIED NURSE AIDE (CNA) "C". CNA "C" INDICATED SHE WAS ASSIGNED TO THE CARE OF RESIDENT #100 ON THE NIGHT SHIFT STARTING AT 10 P.M. ON 6/7/13, AND ENDING AT 6 A.M. ON 6/8/13. CERTIFIED NURSE AIDE "C" STATED HER ROUTINE IS TO CHECK ALL OF HER RESIDENTS EACH NIGHT AT 11 P.M., 1 A.M. AND 3 A.M. CERTIFIED NURSE AIDE "C" STATED RESIDENT #100 WAS RARELY IN BED WHEN SHE CAME ON DUTY AND PUTS HERSELF TO BED. SHE STATED IT WAS NOT UNCOMMON FOR HER TO SLEEP IN HER CLOTHING. CNA "C" INDICATED SHE HAD COMPLETED 15-30 MINUTE VISUAL CHECKS ON RESIDENT #100 THROUGHOUT HER SHIFT. CNA "C" SAW RESIDENT #100 IN HER CHAIR IN HER ROOM AT 3:15 A.M. ON 6/8/13. CNA "C" STATED SHE HEARD NO ALARMS SOUNDING THAT SHIFT AND WAS TOLD BY HER CHARGE NURSE THAT RESIDENT #100 COULD NOT BE LOCATED AROUND 3:40 A.M. CERTIFIED NURSE AIDE "C" STATED A THOROUGH SEARCH OF THE FACILITY WAS CONDUCTED AFTER VERIFYING A HEAD COUNT. SHE STATED RESIDENT #100 HAD MADE NO REFERENCE TO LEAVING THE BUILDING THAT EVENING. CERTIFIED NURSE AIDE "C" STATED THEY WERE CHECKING RESIDENTS ON THE 300 HALL "MORE CLOSELY" THAT MORNING, AS HOUSEKEEPING WAS STRIPPING AND WAXING THE FLOOR IN THE MAIN HALL ON 300, AND THEY WANTED TO BE SURE THAT RESIDENTS STAYED IN THEIR ROOMS IF POSSIBLE. ON 6/11/13 AT 1:25 P.M., AN INTERVIEW WAS CONDUCTED WITH HOUSEKEEPING STAFF "B". HOUSEKEEPING STAFF "B" STATED SHE WAS WORKING THE 300 HALL BEGINNING AT 9 P.M. ON THE EVENING OF 6/7/13. SHE WAS STRIPPING AND WAXING THE FLOOR ON THE 300 HALL WHERE RESIDENT #100 LIVED. HOUSEKEEPING STAFF "B" STATED AROUND MIDNIGHT, SHE SAW RESIDENT #100 COME OUT OF HER ROOM, WALKING ON THE UNFINISHED FLOORS, AND SHE WAS ASSISTED BACK TO HER ROOM BY FACILITY STAFF. HOUSEKEEPING STAFF "B" STATED SHE DIDN'T WANT ANY RESIDENTS SLIPPING ON THE FLOOR. HOUSEKEEPING STAFF "B" REPORTED AROUND 3:30 A.M., SHE NOTED RESIDENT #100 WAS NOT IN HER ROOM. HOUSEKEEPING STAFF "B" WENT INTO THE ROOM AND CHECKED THE BATHROOM AND RESIDENT #100 WAS NOT THERE. HOUSEKEEPING STAFF "B" REPORTED SHE IMMEDIATELY REPORTED RESIDENT #100 MISSING TO REGISTERED NURSE (RN) "A" WHO ORDERED A FACILITY WIDE HEAD COUNT AND DETERMINED RESIDENT #100 COULD NOT BE ACCOUNTED FOR IN THE FACILITY. ON 6/11/13 AT 12 NOON, REGISTERED NURSE (RN) "A" WAS INTERVIEWED. RN "A" INDICATED HER 12 HOUR NURSING SHIFT BEGAN AT 6:30 P.M. ON THE EVENING OF 6/7/13 AND WAS SCHEDULED TO END AT 6:30 A.M. ON 6/8/13. REGISTERED NURSE "A" STATED SHE HAD CHECKED THE CODE WATCH TRANSMITTER ON RESIDENT #100 AT THE START OF HER SHIFT FOR PLACEMENT AND FUNCTIONING. SHE REPORTED AROUND 12 MIDNIGHT, SHE SAW RESIDENT #100 LEAVE HER ROOM AND WALK DOWN THE HALL IN THE DIRECTION OF THE HILLTOP NURSING STATION. RESIDENT #100 WAS BROUGHT BACK TO HER ROOM BY CNA "C". RN "A" REPORTED A SHORT TIME LATER, RESIDENT #100 LEFT HER ROOM AND WALKED DOWN HER CORRIDOR TO THE DINING ROOM. RN "A" RETURNED RESIDENT #100 TO HER ROOM AND ASKED HER TO REMAIN IN HER ROOM FOR HER SAFETY UNTIL FLOOR MAINTENANCE WAS DONE. REGISTERED NURSE "A" INDICATED AROUND 3:40 A.M., SHE WAS CONTACTED BY HOUSEKEEPING STAFF "B" WHO INFORMED HER RESIDENT #100 WAS NOT IN HER ROOM. REGISTERED NURSE "A" INITIATED A FACILITY WIDE HEAD COUNT AND RESIDENT #100 COULD NOT BE ACCOUNTED FOR IN THE FACILITY. RN "A" STATED SHE NEVER HEARD AN ALARM SOUNDING. RN "A" CONTACTED THE ADMINISTRATOR, DON AND LAW ENFORCEMENT, AND BEGAN TO CONDUCT A SEARCH OF THE FACILITY. AN ATTEMPT TO INTERVIEW RESIDENT #100 WAS MADE ON 6/12/13 AT 9:30 A.M. IN HER ROOM. RESIDENT #100 SHOOK HER HEAD TO INDICATE "NO", WHEN ASKED IF SHE WOULD BE WILLING TO SPEAK WITH THIS SURVEYOR REGARDING HER LEAVING THE FACILITY OVER THE WEEKEND. SHE NODDED HER HEAD "YES", WHEN ASKED IF STAFF TREATED HER WELL. RESIDENT #100 COULD/WOULD PROVIDE NO FACTS AS TO WHAT HAD HAPPENED. A REVIEW OF RESIDENT #101'S MEDICAL RECORD REVEALED A MDS assessment dated [DATE], WHICH REFLECTED RESIDENT #101 WAS COGNITIVELY IMPAIRED. RESIDENT #101'S "ELOPEMENT PLAN OF CARE" DATED 2/16/13, SHOWED RESIDENT #101 had a history of [REDACTED]. A REVIEW OF RESIDENT #102'S MEDICAL RECORD REVEALED A MDS assessment dated [DATE], WHICH REFLECTED RESIDENT #102 WAS COGNITIVELY IMPAIRED. RESIDENT #102'S "ELOPEMENT PLAN OF CARE" UPDATED 3/12/13 READ, "IS AT RISK FOR ELOPEMENT AT THIS TIME... RES.(RESIDENT #102) ATTEMPTING TO EXIT BUILDING, STATEMENT ABOUT WANTING TO GO HOME..." AND A CODE ALERT WAS APPLIED TO HER RIGHT WRIST. A REVIEW OF RESIDENT #103'S "ELOPEMENT PLAN OF CARE" UPDATED 2/1/13 READ, "IS AT RISK FOR ELOPEMENT AT THIS TIME... HAS HISTORY OF EXIT SEEKING AT FRONT DOORS..." AND A CODE ALERT WAS APPLIED TO HER RIGHT ANKLE. ( )