Every finding on record at Medilodge of West Bloomfield

This citation pertains to Intake Number(s): 3041709 and 3040038. Based on observation, interview, and record review, the facility failed to conduct ongoing and complete skin assessments and administer treatment according to physician's orders for two (R204 and R205) of three residents reviewed for wounds. Findings include:R204 A review of a complaint submitted to the State Agency revealed it was alleged that R204's wounds were not properly attended to and daily wound care was not performed. A review of a Grievance and Satisfaction Form dated 4/15/26 completed by R204's family member revealed the following grievance, .My wife needs her wound care done often and for 3 days her wound care was not done. Her guaze [sic] and wrap had fallen off & we asked several times and each time we were told it was about to get done .We are just worried about wound care not getting done . A review of R204's clinical record revealed R204 was admitted into the facility on 3/23/26 and discharged on 4/23/26 with diagnoses that included: heart failure, osteomyelitis (bone infection) of left ankle and foot, severe protein-calorie malnutrition, peripheral vascular disease (PVD), and adult failure to thrive. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R204 had intact cognition, was dependent for bed mobility, and had four venous or arterial ulcers that were present upon admission into the facility. A review of a Nursing admission Evaluation for R204 completed on 3/23/26 revealed R204 had the following skin impairments: Right foot .Other .Amputation . A review of R204's SW-Skin Issues Assessments revealed an assessment was completed on 3/24/26 and noted the following:Right Dorsum (upper surface) foot .Other skin issue .Present on admission .1.79 (cm - centimeters) x 5.29 (cm). There was no further documented description of the skin issue to include what type of skin impairment it was.Right Lateral midfoot (outer portion of the middle foot) .Other skin issue .Present on admission .2.53 (cm) x 2.68 (cm). There was no further documented description of the skin issue to include what type of skin impairment it was.Front right lateral lower leg .Abrasion .Present on admission .1.5 (cm) x 0.78 (cm) .Further review of R204's SW-Skin Issues assessment revealed they were assessed on 3/31/26. However, there were no measurements, description, or documentation of what kind of skin impairment they were. There were no other SW-Skin Issues assessments completed between 3/31/26 and R204's date of discharge on [DATE]. A review of R204's Physician's Orders and Treatment Administration Records (TAR) for March and April 2026 revealed the following: An order initiated on 3/24/26 for Foot wound Clean wound with betadine and pad heel with 4 x 4 gauze. Wrap entire foot and ankle with kerlix gauze and secure with tape. Bilateral. Every day shift AND as needed. (The Skin Issues assessments mentioned above did not document any impairment to the left foot.) According to the TARs, the treatment was not administered on 3/31/26, 4/4/26, 4/10/26, 4/13/26, 4/14/26, and 4/19/26. There was no documentation that indicated why the treatments were not completed. An order initiated on 3/25/26 for Right calf wound Cleanse wound with Normal Saline, apply Triad with foam dressing. Change dressing every 3 days or as needed every day shift every Mon (Monday), Wed (Wednesday), Fri (Friday) AND as needed. According to the Tars, the treatment was not completed on 4/10/26 and 4/19/26. An order initiated on 4/13/26 (20 days after admission) for Consult wound care clinic Re: Chronic arterial ulcers .foot .right calf . A review of a Physician Progress Note dated 3/25/26 revealed, .She follows with vascular and podiatry at (clinic name) for her wounds and also has a wound nurse which usually helps her once a week .multiple wounds over both lower extremities bilateral feet with necrotic changes on the right third toe right lateral foot right great toe .Arterial ulcer complicated with the peripheral arterial disease .Physical Exam .Extremities .present dressings intact bilateral feet right calf (There was no documentation of a physical assessment of each skin impairment at the time of that evaluation) .History of osteomyelitis in the right second toe status post amputation with necrotic changes currently also necrotic changes on third toe right lateral throat [sic] and right great toe Dry gangrene (dead tissue caused by lack of blood flow) likely with underlying chronic osteomyelitis with progressive bony changes without any acute changes or infection . A review of Physician Progress Notes dated 3/27/26, 4/8/26, 4/10/26, 4/15/26 revealed no documented description of each skin impairment. A review of a Physician Progress Note dated 4/13/26 revealed, .Dressings were intact on bilateral feet .Physical exam .noted dressing intact . There was no description, including measurements, of R204's wounds to the feet and lower leg. On 6/23/26 at 10:45 AM, an interview was conducted with the Wound Care Coordinator, Registered Nurse (RN) 'A'. RN 'A' explained they were the Assistant Director of Nursing (ADON) for the facility and recently stepped into the role of Wound Care Coordinator on 5/5/26 until the position was filled. When queried about the facility's protocol for assessing residents' skin upon admission and thereafter, RN 'A' reported the admitting nurse was responsible for the initial skin assessment. If any wounds were identified, they would take a photo using wound software and the software determined the measurements of the wounds. The admitting nurse was responsible for notifying the Wound Care Coordinator and the consulting Wound Provider, as well as management. RN 'A' reported the Wound Care Coordinator was responsible for assessing any wounds within 24 to 48 hours of admission or when a new wound was identified. RN 'A' said a Wound Provider came to the facility weekly. When queried about how wounds were monitored for improvement or worsening, RN 'A' reported when they rounded with the Wound Provider, a full evaluation was done and they were monitored at that time and any changes to treatments would be made. When queried about R204's lack of complete wound assessments on 3/24/26 and 3/31/26 and no assessments after that date, RN 'A' reviewed R204's clinical record and confirmed they were not complete and/or done at all after 3/31/26. RN 'A' confirmed there were missed treatments on the dates documented above and that there were no consultations by a Wound Provider prior to R204's discharge on [DATE]. RN 'A' reported a consult order should have been in place sooner than 4/13/26. RN 'A' was asked if they were aware of any identified concerns with skin management that the facility was working on and RN 'A' said they were unaware of any identified issues with skin management. On 6/23/26 at approximately 11:00 AM, an interview was conducted with the Director of Nursing (DON). The DON reported she became the DON two months ago. When queried about who was responsible to assess resident's skin upon admission, the DON reported the floor nurses were. The DON reported the Wound Provider was to be consulted and they would evaluate the resident on the next day they were in the building. When queried about the SW-Skin Issues assessment and what was to be included in the assessment, the DON reported it should document a thorough assessment of the wounds to include a description of the wound and the type of wound. At that time, the concerns with the lack of assessments and missed treatments for R204's wounds to their feet and leg were addressed with the DON. The DON reported that the resident was seen by the Physician. However, there should be documentation of the assessment of each wound to include a description and measurement of the wound in order to determine if it was improving or worsening. At that time, the DON was given the opportunity to provide any additional information regarding the care and treatment of R204's wounds. No additional information was provided prior to the end of the survey. R205 On 6/23/26 at 12:20 PM, R205 was observed to be in the office of the unit managers. Staff brought R205 to her room where she was observed repeatedly standing up from her wheelchair and difficult to redirect. R205 was making noise, but did not speak words. A review of R205's clinical record revealed R205 was admitted into the facility on 2/10/26 and readmitted on [DATE] with diagnoses that included: aphasia (difficulty speaking), Alzheimer's Disease, and dementia with severe agitation. A review of a MDS assessment dated [DATE] revealed R205 had severely impaired cognition. A review of a Pertinent Charting - Change in Condition progress note dated 6/22/26 revealed, Resident (R205) noted to be difficult to redirect throughout the shift and appeared increasingly agitated. I considered that a shower may be soothing and assist with calming the resident .During bathing, multiple areas of purple and blue bruising were observed on the coccyx and pubic area .Resident has remained free from falls or incidents during this shift. I inquired with assigned CNA (Certified Nursing Assistant) regarding any falls or incident during day shift; CNA denied any occurrences . On 6/23/26 at 12:30 PM, an observation of R205's abdominal, pelvic, and coccyx area was conducted with RN 'G' and RN 'H'. On R205's coccyx area, a dark purple discoloration the size of a large eggplant was observed. Purple circular bruising the size of a peach was observed to R205's pelvic area. A review of R205's weekly Skin Assessment forms revealed R205's skin was not assessed between the dates of 6/3/26 (readmission) and 6/22/26 when it was documented R205 had bruising to the pelvic and coccyx areas. On 6/23/26 at 2:20 PM, an interview was conducted with RN 'A'. When queried about how often residents skin was monitored for new skin impairments, RN 'A' reported the floor nurses were responsible to complete head to toe skin assessments on a weekly basis. The CNAs were responsible for reporting any skin changes to the nurse if identified during care. At that time, RN 'A' reviewed R205's clinical record and confirmed there were no skin assessments completed between 6/3/26 and 6/22/26. On 6/23/26 at 3:35 PM, a facility policy regarding skin management for non-pressure skin impairments was requested. It was not provided prior to the end of the survey.

This citation pertains to Intake Number(s): 3034017. Based on observation, interview, and record review, the facility failed to thoroughly investigate an allegation of verbal and physical abuse by a staff member for one (R205) of two residents reviewed for abuse. Findings include: A review of a Facility Reported Incident (FRI) submitted to the State Agency revealed a family member alleged they witnessed a staff member verbally and physically abuse R205 (yelled at and grabbed her arm). A review of R205's clinical record revealed R205 was admitted into the facility on 2/19/26 and readmitted on [DATE] with diagnoses that included aphasia (difficulty speaking), Alzheimer's disease, and dementia with severe agitation. A review of a Minimum Data Set (MDS) dated [DATE] revealed R205 had severely impaired cognition and daily wandering behaviors. On 6/23/26 at 12:20 PM, R205 was observed repeatedly standing up from the wheelchair while in her room with staff present. R205 appeared difficult to redirect. R205 was making noises but did not speak words. On 6/23/26 at 1:20 PM, an interview was conducted with Witness 'C' via the telephone. Witness 'C' explained they were a caregiver for another resident (not R205) who resided in the facility. Witness 'C' said they did not know the exact date but was almost positive it was a Monday. They went to the nurses' station on the 1st floor to ask for a cup of ice for their family member who was a resident there. They observed (R205) behind the desk and reported they often observed them there. Witness 'C' said R205 only made noises and did not talk and often stood up from the wheelchair. On that particular day, the nurse or nurse aide who was behind the desk was busy doing something and the resident tried to stand up from the wheelchair. Witness 'C' explained the nurse or nurse's aide (they were not sure of their name or their title) yelled, Oh we are not doing this today! and when (R205) continued to try to get out of the wheelchair, the staff member grabbed the older woman's (R205) arm very aggressively and yanked her down into the wheelchair. Witness 'C' said they were not sure who the staff member was. Witness 'C' reported they spoke directly to the Administrator about it. When queried about what the person looked like, Witness 'C' said they were a dark-skinned woman with smooth, shoulder length hair that was curled under like a [NAME] and they were about average build. A review of an investigation conducted by the facility revealed the following: The incident was discovered on 5/12/26 at 2:55 PM and it occurred on 5/11/26 at 4:00 PM. The Incident Summary noted, On 5/12/26, (R205's) daughter reported to the social worker that a 'nurse' with short-hair yelled at her mother to sit down; when she would not sit, the 'nurse' grabbed her arm to sit her down .There was not a specific perpetrator identified; facility to review staff assignments . A Statement provided by Social Worker (SW) 'E' noted it was not R205's family member who reported the incident and instead it was Witness 'C' who was the caregiver of another resident who resided in the facility. It was documented in statement that Witness 'C' said that a nurse with short hair yelled at (R205) to sit down. When (R205) did not sit down, she grabbed her arm and made her sit down. It was documented that happened at the A/B Nurse Station .Around 4pm on Monday (5/11/26). A Statement from Witness 'C' noted, .There was an elderly lady that sits at the nurse station and there were two staff at the desk with the lady. One walked away, and the lady stood up and the staff told her to sit down. The lady didn't sit down, and the staff yanked her arm to get her to sit down. I believe it was Monday (5/11/26) .I don't think there was any ill will, I think it was just frustration. It just looked aggressive . The third and final Statement was from Licensed Practical Nurse (LPN) 'F' who said they had not worked prior to 5/14/26. There were no additional statements included in the investigation with any staff who worked on 5/11/26 when the alleged abuse occurred. A review of a typed summary of the facility's investigation revealed, . (Witness 'C') reported to the social worker that a 'nurse' with short hair, yelled at (R205) to sit down. When (R205) did not sit, (Witness 'C') alleged that the staff member grabbed (R205's) arm to make her sit . (Witness 'C') was unable to identify a perpetrator. The facility reviewed staffing assignments and could not determine a specific perpetrator .Due to her cognitive status, (R205) is unable to be interviewed for this investigation .The facility interviewed (Witness 'C') .The facility asked (Witness 'C') id [sic] she could give a more detailed description of the perpetrator to which she stated light-skinned African-America [sic], smaller, with short-hair. She did not recognize the alleged perpetrator and could not specify what color scrubs the staff member was wearing .became unsure of when the allegation happened stating that it could have been the week prior, but believed it happened on Monday (5/11/26) .The facility interviewed the staff on the unit. The staff acknowledged that (R205) is busy and impulsive, but usually able to be redirected. The staff on the unit deny willfully abusing or hurting (R205) .The facility could not verify (Witness 'C's) allegation of abuse . There was no evidence provided regarding the staff on the unit that were interviewed other than LPN 'F' who did not work on 5/11/26. On 6/23/26 at 3:04 PM, an interview was conducted with the Administrator who was the Abuse Coordinator for the facility. When queried about what was done to attempt to identify the potential alleged perpetrator, the Administrator reported staff were interviewed. When queried about why LPN 'F' was interviewed when she did not work on 5/11/26 and if any other staff were interviewed, the Administrator reported he did not interview any other staff. A review of a facility policy titled, Abuse, Neglect and Exploitation, revised on 1/10/24, revealed, in part, the following, .Investigation of Alleged Abuse, Neglect and Exploitation .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 . Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations .Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause .Providing complete and thorough documentation of the investigation .

This citation pertains to Intake Number(s): 3034017. Based on observation, interview, and record review, the facility failed to report an injury of unknown origin to the State Agency for one (R205) of two residents reviewed for abuse. Findings include:On 6/23/26 at 12:20 PM, R205 was observed not in their room. R205 was in an office with the unit managers. At that time, staff brought R205 into their room where they were observed to repeatedly climb out of the wheelchair and was difficult for the staff to redirect. A review of R205's clinical record revealed R205 was admitted into the facility on 2/10/26 and readmitted on [DATE] with diagnoses that included: aphasia (difficulty speaking), Alzheimer's Disease, and dementia with severe agitation. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R205 had severely impaired cognition and daily wandering behaviors. A review of a Nurses' Notes progress note dated 5/27/26, written by Unit Manager, Licensed Practical Nurse (LPN) 'D', revealed, Resident observed with bruising to right forearm and swelling to right elbow. Resident unable to state what happened or identify cause of injury .Nurse Practitioner notified of findings. New order received for X-ray of right elbow/forearm . A review of a Progress Note - General dated 5/27/26, written by LPN 'B' revealed, Patient was observed to have light purple bruising located on the back of right upper arm and elbow. Swelling was noted around elbow. Doctor, DON (Director of Nursing), and guardian were notified of finding. Xray of the right arm was ordered . On 6/23/26 at 1:01 PM, all incident reports and investigations for R205 since 5/12/26 were requested from the Administrator. On 6/23/26 at 1:26 PM, the Administrator provide incident reports for R205. However, there were no incident reports or investigations for 5/27/26 to address the bruising and swelling to R205's arm/elbow. On 6/23/26 at 2:40 PM, an interview was conducted with LPN 'B' via the telephone. When queried about the facility's process when a resident was identified to have an injury of unknown origin, LPN 'B' reported they completed a change of condition assessment, a risk assessment (incident report), and contacted the physician, DON, and the resident's responsible party. LPN 'B' reported they were required to notify the Administrator who was the Abuse Coordinator, as well. When queried about the bruising and swelling to R205's right arm on 5/27/26 and what was done about that, LPN 'B reported they observed the bruising and swelling, completed a skin assessment and a risk assessment, and reported the injury to the nurse manager and Administrator. On 6/23/26 at 2:46 PM, an interview and conducted with the DON. When queried about the lack of incident report and investigation for the bruising and swelling to R205's right arm/elbow documented on 5/27/26, the DON reported there was an incident report for that. When queried about how it occurred, the DON reported the Administrator would have any investigation into it. On 6/23/26 at 3:04 PM, an interview was conducted with the Administrator. When queried about whether the bruising and swelling of unknown origin to R205's arm was reported to him on 5/27/26, the Administrator reported it was reported to him and investigated by the DON who determined R205 was walking in the hallway and leaned on the wall. The Administrator explained it was not reported to the State Agency because it was investigated and the cause was determined by the DON. When queried about where the investigation was documented as it was not provided, the Administrator reported it would be included with the incident report. At that time, the incident report and investigation were requested. A review of an incident report/risk assessment form for R205 dated 5/27/26 revealed the following, .Other Skin Injury .Pt (patient) was observed to have bruising to backside of upper right arm and elbow. Bruising appears light purple in color. Swelling is noted around elbow .Incident was not witnessed .Resident Unable to give Description . There was no investigation included with the incident report to explain how the injury occurred. On 6/23/26 at approximately 3:45 PM, the Administrator was asked if there was any additional information regarding the bruising and swelling to R205's right arm on 5/27/26. The Administrator reported they did not have any more information. A review of a facility policy titled, Abuse, Neglect and Exploitation, revised 1/10/24, revealed, in part, the following, .The facility will have written procedures that include .Reporting of alleged violations to the Administrator, state agency .and to all other required agencies .within specified timeframes as required by state and federal regulations .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, or .Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury . The facility's policy did not include any specific protocols that addressed injuries of unknown origin.

This citation pertains to Intake Number(s): 3041709 and 3040038. Based on interview and record review, the facility failed to conduct thorough and accurate skin assessments, ensure timely evaluation of existing pressure ulcers by a wound provider, administer wound treatments as ordered by the physician, and implement treatments in a timely manner for two (R203 and R204) of three residents reviewed for wounds. Findings include: R204 A review of a complaint submitted to the State Agency revealed it was alleged that R204's wounds were not properly attended to and daily wound care was not performed. A review of a Grievance and Satisfaction Form dated 4/15/26 completed by R204's family member revealed the following grievance, .My wife needs her wound care done often and for 3 days her wound care was not done. Her guaze [sic] and wrap had fallen off & we asked several times and each time we were told it was about to get done .We are just worried about wound care not getting done . A review of R204's clinical record revealed R204 was admitted into the facility on 3/23/26 and discharged on 4/23/26 with diagnoses that included: heart failure, osteomyelitis (bone infection) of left ankle and foot, severe protein-calorie malnutrition, peripheral vascular disease (PVD), and adult failure to thrive. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R204 had intact cognition, was dependent for bed mobility, and had two stage II pressure ulcers (Partial-thickness skin loss with exposed dermis), one stage IV (intravenous) pressure ulcer (Full-thickness skin and tissue loss), and two unstageable pressure ulcers (Obscured full-thickness skin and tissue loss), that were present upon admission into the facility. A review of a Nursing admission Evaluation for R204 completed on 3/23/26 revealed R204 had the following skin impairments: .Coccyx (tailbone) .pressure .Left heel .pressure .Right heel .pressure .Right hip .pressure .Left hip .pressure . A review of R204's SW-Skin Issues Assessments revealed an assessment was completed on 3/24/26 and noted the following: Right Dorsum (upper surface) 1st metatarsal phalangeal joint (toe) .Pressure ulcer/injury .Present on admission .2.59 (cm - centimeters) x 2.17 (cm). There was no further documented assessment of the pressure ulcer to include the stage and presentation of the ulcer. Left heel .Pressure ulcer/injury .Present on admission .1.42 (cm) x 0.9 (cm). There was no further documented assessment of the pressure ulcer to include the stage and presentation of the ulcer. Coccyx .Pressure ulcer/injury .Present on admission .1.43 (cm) x 1.45 (cm). There was no further documented assessment of the pressure ulcer to include the stage and presentation of the ulcer. Front left trochanter (hip) .Pressure ulcer/injury .Present on admission .1.7 (cm) x 2.45 (cm) x 4 (cm - depth). There was no further documented assessment of the pressure ulcer to include the stage and presentation of the ulcer. The Skin Issues assessment indicated R204 also had multiple non-pressure wounds to their right foot (dorsum and outside of midfoot). Further review of R204's SW-Skin Issues assessment revealed R204 was assessed on 3/31/26. However, there were no measurements, description, or staging of the pressure ulcers. There were no other SW-Skin Issues assessments completed between 3/31/26 and R204's date of discharge on [DATE]. A review of R204's Physician's Orders and Treatment Administration Records (TAR) for March and April 2026 revealed the following: An order initiated on 3/24/26 for Left Trochanter. Irrigate wound with wound solution and pat dry. Apply skin barrier film, allow to dry. Moisten kerlix roll with wound solution and squeeze out excess solution, lightly pack into wound bed. Cover with foam dressing. Every day shift AND .as needed. According to the TARs, the treatment was not administered on 3/31/26, 4/4/26, 4/10/26, 4/13/26, 4/14/26, and 4/19/26. There was no documentation that indicated why the treatments were not completed. An order initiated on 3/24/26 for Gently cleanse buttocks and sacral area with mild soap and water. Sprinkle antifungal powder into the area and gently rub in. Spray with skin barrier over powdered area allow to dry. Apply Zinc oxide paste to area. Every day and night shift AND .as needed. According to the TARs, the treatment was not completed on 3/31/26 day shift, 4/4/26 day shift, 4/10/26 day shift, 4/13/26 day and night shift, 4/14/26 day shift, and 4/19/26 day shift. An order initiated on 3/24/26 for Foot wound (the order did not specify which foot and did not indicate if this was for the pressure ulcer to the left heel or the non-pressure wounds to the right foot) Clean wound with betadine and pad heel with 4x4 gauze. Wrap entire foot and ankle with kerlix gauze and secure with tape. Bilateral (admission skin assessment mentioned pressure ulcers on right and left heel, but skin assessment on 3/24/26 and 3/31/26 only indicated a pressure ulcer to the left heel. It is unclear what wounds that order is treating). Every day shift AND .as needed. According to the TAR, this treatment was not completed on 3/31/26, 4/4/26, 4/10/26, 4/13/26, 4/14/26, and 4/19/26. An order initiated on 4/10/26 (17 days after R204 was admitted into the facility) for Wound consult: Clean Coccyx with NS (normal saline) pat dry and apply triad. An order initiated on 4/13/26 (20 days after R204 was admitted into the facility) for Consult wound care clinic Re: .left trochanter .foot .coccyx . A review of R204's progress notes revealed no documented thorough assessment of their pressure ulcers to the coccyx, trochanter, and heel(s) that included staging of the ulcers, measurements of the ulcers, or description of the ulcers. A review of a Physician Progress Note dated 3/25/26 revealed, .Multiple wounds over her hips and lower extremities .Chronic bilateral lower extremity and upper extremity wounds left heel osteomyelitis and left hip wound .Left foot wounds CT (Computed Tomography) scan showing concerns for calcaneus (heel) osteomyelitis . There was no documented measurements, description, or staging of the mentioned wounds. A review of Physician Progress Notes dated 3/27/26, 4/8/26, 4/10/26, 4/15/26 revealed no documented description, measurement, or staging of R204's pressure ulcers. A review of a Physician Progress Note dated 4/13/26 (20 days after R204 was admitted into the facility) revealed, .nursing staff were able to lay her on her back to examine her wound while sitting in the chair she complained of severe pain in her bottom unable to relax .Upon evaluation she does have chronic ulcerations in her perirectal areas, we well as her dressings were intact on bilateral feet also examined her left trochanter wound .Left trachanter [sic] wound deep and need further evaluation without abx (antibiotic) wound care referral ordered and informed nursing staff . A review of a Appointment/Transportation Note dated 4/16/26 revealed, Resident has a wound care appointment on Thursday 04/23/2026 . Further review of R204's clinical record revealed there was no order for a wound care consultation prior to 4/13/26, 20 days after R204 was admitted into the facility with multiple pressure ulcers. On 6/23/26 at 10:45 AM, an interview was conducted with the Wound Care Coordinator, Registered Nurse (RN) 'A'. RN 'A' explained they were the Assistant Director of Nursing (ADON) for the facility and recently stepped into the role of Wound Care Coordinator on 5/5/26 until the position was filled. When queried about the facility's protocol for assessing residents' skin upon admission and thereafter, RN 'A' reported the admitting nurse was responsible for the initial skin assessment. If any wounds were identified, they would take a photo using wound software and the software determined the measurements of the wounds. The admitting nurse was responsible for notifying the Wound Care Coordinator and the consulting Wound Provider, as well as management. RN 'A' reported the Wound Care Coordinator was responsible for assessing any wounds within 24 to 48 hours of admission or when a new wound was identified. RN 'A' said a Wound Provider came to the facility weekly currently. When queried about how wounds were monitored for improvement or worsening, RN 'A' reported when they rounded with the Wound Provider, a full evaluation was done and they were monitored at that time and any changes to treatments would be made. When queried about R204's lack of complete wound assessments on 3/24/26 and 3/31/26 and no assessments after that date, RN 'A' reviewed R204's clinical record and confirmed they were not complete and/or done at all after 3/31/26. RN 'A' confirmed there were missed treatments on the dates documented above and that there were no consultations by a Wound Provider prior to R204's discharge on [DATE]. RN 'A' reported a wound consult order should have been in place sooner than 4/13/26. RN 'A' was asked if they were aware of any identified concerns with skin management that the facility was working on and RN 'A' said they were unaware of any identified issues with skin management. On 6/23/26 at approximately 11:00 AM, an interview was conducted with the Director of Nursing (DON). The DON reported she became the DON two months ago. When queried about who was responsible to assess resident's skin upon admission, the DON reported the floor nurses were. The DON reported the Wound Provider was to be consulted and they would evaluate the resident on the next day they were in the building. When queried about the SW-Skin Issues assessment and what was to be included in the assessment, the DON reported it should document a thorough assessment of the wounds to include a description of the wound and the type of wound. At that time, the concerns with the lack of assessments and missed treatments for R205's pressure ulcers to their trochanter, coccyx, and heel(s) were addressed with the DON. The DON reported that the resident was seen by the attending physician. However, there should be documentation of the assessment of each wound to include a description and measurement of the wound in order to determine if it was improving or worsening. At that time, the DON was given the opportunity to provide any additional information regarding the care and treatment of R204's wounds. No additional information was provided prior to the end of the survey. R203 A review of the medical record revealed that R203 was initially admitted to the facility in 2024 with a readmission date of 4/7/26 and diagnoses that included: sepsis, Bell's palsy, functional quadriplegia, and kidney failure. R203 required staff assistance for all Activities of Daily Living (ADLs). A review of a readmission Nursing note dated 4/8/26 at 6:07 AM, documented in part . Skin assessment completed, revealing multiple chronic pressure ulcers including stage 4 sacral ulcer with ongoing infection, as well as wounds to right posterior thigh/gluteal region, bilateral heels, left medial calf, right hip, and bilateral knees. Wound care orders reviewed and implemented per discharge instructions, including use of prescribed cleansing solutions, topical treatments, and appropriate dressings. Patient remains on pressure-relieving measures including specialty mattress and repositioning schedule. No new skin breakdown noted at this time. A review of the transferring hospital documents provided to the facility upon R203's readmission documented the following: An Internal Medicine consult dated 4/1/26 at 11:37 AM, documented in part . Septic shock likely secondary to infected sacral decubitus ulcer with suspected osteomyelitis of sacrum and coccyx. advance vascular dementia with bedbound status. remains under ICU (intensive care unit) care. Physical Exam. Skin. Stage 4 pressure ulcer to the right hip and left hips. Many of the other pressure ulcers are unstageable due to eschar overlying the areas. The hospital provided pictures of all identified wounds and noted the following in part, . Pressure injury heel left, Pressure injury heel right, Pressure injury hip left, Pressure injury hip right, Pressure injury leg lower left medial, Pressure injury leg lower right lateral, Pressure injury sacrum, Pressure injury anus, Pressure Injury knee left medial, Pressure Injury knee right medial, Pressure Injury leg lower left medial, Pressure Injury leg lower left posterior, Pressure Injury leg lower right posterior, Pressure Injury Penis. The resident was discharged back to the facility on 4/7/26. A review of the hospital discharge instructions provided to the facility upon R203's readmission documented the following in part, . Dakins (Half-Strength) Apply topically 2 (two) times daily. Per general surgery: Sacral wound care: pack wound with Wet to Dry Kerlix, secure with Allevyn twice per day with dankins <sic>. The hospital discharge documents did not contain treatment orders for R203's other pressure wounds. Review of the Physician orders and April 2026 Medication & Treatment Administration Records revealed the following: Acetic Acid Solution – Apple to sacrum, right lateral knee topically every day shift for wound care. Started on 4/8/26 and the last application was noted on 4/15/26. The hospital wound orders were not implemented as directed by the hospital and no treatment was implemented for the resident's other multiple identified wounds. A review of the record revealed no documentation on why the hospital wound orders were not implemented as directed and failed to contain documentation on why treatment was not implemented for all of the resident's wounds. A review of a skin assessment dated [DATE] at 3:32 PM, documented the following . Are there any new abnormal skin areas? No. Are there any existing abnormal skin areas? Yes. List site(s) of any existing abnormal skin areas. Coccyx- Stage 4 Pressure ulcer. Stage 4 pressure ulcer to left hip. Stage 4 Pressure ulcer to right hip. Left lower leg (front)- Stage 4 pressure ulcer. Left heel- Stage 3 pressure ulcer. Right heel- Stage 3 pressure ulcer. Right knee (rear)- Stage 3 pressure ulcer. Right thigh (front)- Stage 3 pressure ulcer (inner thigh). Right lower leg (front)- Pressure ulcer. Right lower leg (rear)- Pressure ulcer. Left knee (front)- Stage 3 pressure ulcer. Left lower leg (front)- Stage 3 pressure ulcer. Tx (treatment in place) The review of the record revealed treatment was not in place for all of the identified wounds. The Medical record noted that R203 was transferred to the hospital on 4/16/26 for wound debridement. The resident did not return to the facility. On 6/23/26 at 2:24 PM, the Assistant Director of Nursing (ADON) who served as the Wound Care Coordinator (WCC) A in May 2026 was interviewed. WCC A explained they took over as the wound care coordinator in May 2026 until the recent hire of a Wound Nurse. WCC A stated there was another wound nurse prior to May 2026 however that nurse no longer worked at the facility. WCC A was asked if a resident came from the hospital with wound treatment orders to be implemented on their discharge instructions, what was the facility's protocol. WCC A stated they would implement the orders as noted on the hospital records. When asked the facility's protocol for a resident admitted with wounds that had no treatment orders provided and WCC A replied the nurses are responsible for calling the provider to initiate treatment to prevent delay. WCC A was asked if they could review the medical record of R203 with their team and provide an explanation or documentation on why treatment was not implemented as ordered for the sacral wound and why treatment was not implemented for R203's multiple other wounds upon readmission on [DATE] or again on 4/15/26 when the facility identified all of R203's wounds. WCC A stated they would review the record with their team and follow back up. At 2:47 PM, WCC A returned and reported they were unable to find anything but will continue looking. A review of a facility policy titled, Pressure Injury Prevention and Management, revised on 3/20/24 revealed, in part, the following, .Licensed nurses will conduct a full body skin assessment on all residents upon admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record .Assessments of pressure injuries will be performed by a licensed nurse, and documented in the medical record .Interventions will be based on specific factors identified in the .skin assessment, and any pressure injury assessment .Evidence-based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present .Treatment decision will be based on the characteristics of the wound, including the stage, size, amount of exudate, and presence of pain, infection, or non-viable tissue . No further explanation or documentation was provided by the end of the survey.

This citation pertains to Intake 2659810.Based on observation, interview, and record reviews the facility failed to ensure infection control standards and practices were consistently implemented by the facility staff and failed to implement an effective infection control surveillance program. Findings include:Medication Observation On 2/24/26 at 9:01 AM, Licensed Practical Nurse LPN A was observed to have administered medications to four Resident's (R's) that included R's- 9 & 65 without performing hand hygiene before each medication administration for each resident. A review of the facility policy titled Medication Administration reviewed 1/17/23, documented in part . Medications are administered by licensed nurses. Wash hands prior to administering medication per facility protocol and product. Administer medication as ordered. Observe resident consumption of medication. Wash hands using facility protocol. On 2/25/26 at approximately 12:55 PM, the Director of Nursing (DON) was interviewed and asked the facility's protocol regarding hand hygiene with medication administration and acknowledged that nurses should be following the facilities protocol and performing hand hygiene before and after each medication administration for each resident. On 2/25/26 at 12:30 PM, The Facility Infection Control Registered Nurse (RN) B was interviewed to review the facility's Infection Control and Surveillance program. When asked if the facility had any recent outbreaks, RN B acknowledged in October 2025 there was a COVID outbreak that affected 13 residents and six staff members. RN B retrieved the facility Respiratory Surveillance Line List dated 10/01/25 and verified the names on the list were all those who had tested positive for COVID. The document did not document COVID but was a verbal confirmation by RN B Record Review of the document revealed demographics such as names, age, gender, resident/staff resident stay status (short/long) resident room/bed. Diagnostics for all names listed documented was NP (Nasopharyngeal Swab) Date of collection was blank. Type of test ordered was documented 4 (4: Other Specify) and not specified. Symptom onset date for some were N/A (not applicable) or blank. Columns for documenting signs and symptoms were all blank. Pathogen detected was documented 7 (7: Other Specify) with no documentation of what other was and the outbreak symptom resolution date was blank for all names. Infection Control RN B was asked if this was the entire surveillance list and they confirmed it was. When questioned if this was an outbreak, why was the surveillance lacking many key components, RN B was not sure, and replied, it was just blank. When asked to review October 2025 facility map of infections, the map did not indicate what residents had COVID for the month. Record review of the facility policy titled: Infection Prevention and Control Program dated 12/2023 documented: .Surveillance: A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for residents, staff, volunteers, visitors.The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings.

Based on interview and record review, the facility failed to ensure residents were treated with dignity and respect for two (R59 and R68) of three residents reviewed for dignity, including multiple anonymous residents that attended the confidential resident council interview. Findings include:R68 On 2/23/26 at 9:10 AM R68 was interviewed and queried about their stay at the facility. R68 reported, that the facility was okay but could be more initiative during the night shift. R68 reported that they could not get assistance on the night shift when they needed to use the restroom. R68 also reported that they only get changed once on the night shift and that is when the CNAs (Certified Nursing Assistant) first come around 11:00 PM/12:00 AM and they will not get changed again until 6:30 AM. R68 was then asked, how long did it take for someone to respond to the call light, R68, reported that someone will come in the room and ask what was needed and when they say bathroom, the CNA will turn light off and leave the room but not clean them up until the morning. R68 reported, that they us the restroom in their brief because during the nighttime, no one will assist them to the bathroom. A record review revealed that R68 was admitted to the facility on [DATE] with an admission diagnosis of Difficulty in walking, Polyneuropathy and primary insomnia. R68 had a Brief interview for Mental status Score (BIMs) of 15 which indicated no cognitive impairment. R59 On 2/23/25 at 10:03 AM, an interview was conducted with R59 and they were asked about their care at the facility. R59 reported that when they hit their call button to get assistance, it takes the CNA so long to respond that they forgot what they had called for. R59 also commented that it's hard for them to get their brief changed on the night shift and that they know the CNAs are short staffed. A record review revealed that R59 was admitted to the facility on [DATE] with the admitted diagnosis of Urinary Tract infection, and Disorder of muscle and had a Brief interview for mental status score of 15, which indicated no cognitive impairment. On 2/25/26 at 1:40 PM Family Member N requested to speak with someone from the state agency (SA) to report that the CNA's do not help R59 when they put their call light on at nighttime and the nurses do not give the nighttime medication until after 11:00 PM. Family Member N was then asked did they file a grievance with the facility and reported that the facility only gives grievance forms for missing items, not for nursing concerns. Family Member N also had a issue with the social worker at the facility, reported that the social worker never follows up or through on items or requests. On 2/25/26 at 2:30 PM, an interview with the facility staffing coordinator was conducted. The staffing coordinator was asked how the facility staffed and was there enough staff on each shift to ensure that residents needs were met. The staffing coordinator reported that they always overstaff the CNAs by one just to cover them if there is a call off, but each shift is filled with a lotted number, and the facility should never be short. On 2/25/26 at 2:44 PM, an interview with the Regional Director of Operations (RDO)Q was conducted, she was told the concerns about residents not being able to be toileted in a timely manner. RDO Q reported that, the facility had been working on that and understood the issue with the timeliness of residents being toileted. No additional information was provided by the exit of survey. According to the facility's policy titled, Promoting/Maintaining Resident Dignity dated 10/26/2023: .All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights.During interactions with residents, staff must report, document and act upon information regarding resident preferences.Speak respectfully to residents; avoid discussions about residents that may be overheard. Review of the past resident council minutes since September 2025 included the following dignity concerns reported by residents: The meeting on 9/23/25 documented, cleaning staff were rude. The meeting on 10/28/25 documented, Nurses and Aides are not being professional. The meeting on 11/25/25 documented, Nurses and Aides are not being professional.Name tags are an issue. The meeting on 12/30/25 documented, Nurse and aide's attitudes aren't professional.Name tags are an issue. The meeting on 1/27/26 documented, Nurse and aide's attitudes aren't professional.Name tags are an issue. Foley never being emptied. Complains CENA (CNA) demanded her to put on a brief and lectured her about her incontinence. On 2/24/26 at 1:30 PM, a resident council interview was conducted with eight residents that requested to remain anonymous. When asked if they felt staff treated them with dignity and respect, multiple residents reported ongoing concerns with lack of dignity. Resident responses included: No! Some of these aides and nurses don't have a heart for the people. You can tell they don't actually care. On 2/25/2026 at 10:45 AM, an interview was conducted with the Director of Nursing (DON) to review concerns from the resident council interview which included residents' expressions of feeling like staff are not treating them with dignity and respect. The DON reported they had not been aware of dignity concerns and would have to address that.

Based on observation, interview and record review, the facility failed to ensure an emergency pull cord to was available within the immediate shower area (accessible if lying on the floor) for two shower stalls, affecting all residents that utilize the C/D shower room. Findings include: On 2/24/26 at 1:30 PM, a confidential resident council interview was conducted with eight residents. When asked about whether there were any concerns regarding the facility's physical environment, several residents reported concerns. Responses included: I get my own showers and Nursing staff tell me they have to stay in, but some don't stay in. I'm solo when they step out of the shower room. The pull cord is across the room, what happens if I fall in the shower? There is no pull cord in the shower.On 2/25/2026 at 10:51 AM, the Director of Nursing (DON) was asked to observe the C/D unit shower room. Upon entering the shower room, there were two shower stalls and each of them did not have an emergency pull-cord in the vicinity. The closest emergency pull-cord was on the wall outside of the shower stalls approximately eight feet away. The shower stalls themselves were observed to have significantly pitched areas of the tiled flooring. The DON reported they were not aware of that and would have the Administrator come down.On 2/25/26 at 10:57 AM, an observation of the C/D shower room was conducted with the Administrator. During this time, the Administrator confirmed the same findings and further reported they were not sure how that had not already been identified prior to now.Review of the facility's policy titled, Call Lights: Accessibility and Timely Response dated 12/28/2023 did not address the proximity of the call-light in shower areas, or if a resident was lying on the floor.

Based on interview, and record review, the facility failed to monitor appropriate use of antibiotics for one (R14) of three reviewed for antibiotic stewardship program to ensure all resident's prescribed antibiotics are monitored for the right indication, dose, and duration. Findings include:On 2/25/26 at 12:30 PM, the Facility Infection Control Registered Nurse (RN) B was interviewed to review the facility's antibiotic stewardship program.Clinical record review revealed on 10/14/25, R14 was observed vomiting yellow green emesis was sent to the hospital and returned the same day with antibiotic orders for a Urinary Tract Infection (UTI), RN B replied they were diagnosed while they were at the hospital and sent back with the orders.The facility Infection Report Form completed by Infection Control RN B documented R14 onset date 10/13/25, suspected infection Urinary Tract infection classified as Healthcare Associated (HAI). Keflex (an antibiotic medication) 500 milligram (mg) given every six hours was to start on 10/14/25 and stop on 10/18/25. A second antibiotic, Macrobid 100 mg given twice a day was to start on 10/17/25 and stop on 10/22/25.The attached McGeer Criteria for Infection Surveillance Checklist documented R14's name, medical record, unit and date of infection documented 10/14/25. The criteria were not completed but RN B provided a spreadsheet indicating R14 did not meet McGeer's criteria.When questioned if R14 did not meet criteria, then why did they continue to receive antibiotics, RN B said they continued all orders because the hospital said they had a UTI and Doctor M wanted it continued. When asked where this conversation was documented, RN B replied there was no documentation. When questioned if R14 was reassessed after antibiotics were ordered RN B replied that do not personally reassess the residents and was not sure if the facility physicians assessed their relevance either.Review of the facility policy titled Antibiotic Stewardship Program dated documented.Monitor response to antibiotics.to determine if the antibiotic is still indicated or adjustments should be made.Antibiotic orders obtained from consulting, specialty, or emergency provider shall be reviewed for appropriateness.

Based on observation, interview and record review the facility failed to ensure expired medications were discarded from one medication storage room of two medication storage rooms reviewed. Findings include:On 2/25/26 at 12:10 PM, an observation and review of the medication storage room located on the ground floor was conducted with Registered Nurse (RN) E. Observed in the medication storage cabinet were the following expired medications with the date of 01/2026 - liquid pain relief acetaminophen 160 mg (milligram)/5 ml (milliliters), glucosamine and chondroitin (two bottles) and Vitamin B-6 (two bottles). RN E verified the expiration date and stated that all of the expired bottles should have been removed from the storage unit. RN E removed the expired bottles and stated they would ensure they were discarded per the protocol.On 2/25/26 at 12:53 PM, the Director of Nursing (DON) was interviewed and asked about the observation of the expired medication bottles in the facility's storage room. The DON stated central supply staff are supposed to maintain the medications in all of the facilities storage rooms. The DON stated they were made aware of the expired medications and had since removed them from the medication storage room.A review of the facility's medication Storage policy revised 1/30/24, documented in part . It is the policy of this facility to ensure all medications housed on our premises will be stored according to the manufacturer's recommendations.No further explanation or documentation was provided by the end of the survey.

Based on observation, interview and record review, the facility failed to ensure an environment free from accident hazards related to resident smoking and storage of smoking paraphernalia for three (R3, R5 and R88) of five residents reviewed for accidents and multiple residents that attended the confidential resident council interview. Findings include:According to the facility's Acknowledgment of Facility Smoking Policy, .It is the policy of this facility to establish and maintain safe resident smoking practices. This policy also includes electronic cigarettes. This policy is used to educate residents and representatives. The Facility permits smoking in designated areas only outside of the building(s) under the following conditions .Smoking times (cigarettes, lighters, etc.) will be kept secured in a designated are with limited staff access. Resident shall not keep any smoking materials in resident rooms .A list of smoking times shall be given to residents with smoking privileges. Residents will also be allowed to smoke in the designated smoking areas during off-scheduled times with a family member or visitor who is able to appropriately supervise the resident for smoking safety .Only Facility provided ashtrays shall be used .The Attending Physician and the Director of Nursing Services (DNS) shall have the authority to make the determination as to what restrictions, if any, will need to be placed on the resident's smoking privileges .Any resident with smoking privileges shall not be permitted to smoke without the direct supervision of a responsible staff member, family member, visitor or volunteer worker and direct supervision must be provided throughout the entire smoking period . Review of the facility's documentation provided for Resident Council included a concern from 9/23/25 regarding residents smoking outside under the canopy. On 2/24/26 at 1:30 PM, a resident council group interview as conducted with eight residents. All residents in attendance requested to remain anonymous. When asked about the facility's smoking practices for residents, several residents expressed concerns with other residents seen with smoking materials such as vapes and smoking near the entrance. One resident stated there were times they went outside in the summer and didn't feel like they could because there are residents smoking out there. One resident verbalized that they smoke but were aware they had to go to the sidewalk at the edge of the property. On 2/24/26 at 10:05 AM, an interview was conducted with the Administrator. When asked if they could explain more about what the concern was related to smoking as identified in the resident council, the Administrator reported there was a concern about a resident vaping in the facility. The Administrator reported R3 was observed pulling out vape materials and that their family was bringing those items in and were asked to stop bringing them in. The Administrator reported they thought it wasn't an issue lately and that was more in the past fall time. When asked to explain the facility's process for residents that smoked, including vapes, the Administrator reported they were technically a non-smoking facility, but residents were able to sign out on an LOA (leave of absence). The Administrator acknowledged there were residents that vaped and they were able to sign out on LOA. They further reported they had many discussions as an interdisciplinary team about changing the facility's smoking practices and didn't feel it was safe for residents to necessarily be on the sidewalk by the main road given the multiple elevation changes. The Administrator further acknowledged that although there was an acknowledgment of smoking policy, they were technically a non-smoking facility. When asked if residents were not their own responsible party, how were they able to sign themselves out on LOA, the Administrator reported they had QA'd (Quality Assurance) potential policy for dedicated times and also have issue with staff not wanting to be exposed to smoke and also discussion with the Ombudsman who said we can't take their smoking materials. The Administrator was asked given the facility staff were aware of residents that smoked, what processes were put in place to ensure they were assessed to be able to safely smoke unsupervised, or if they needed supervision and items such as a smoking apron, cigarette holder, etc., as well as where the smoking materials were stored. The Administrator reported they were not able to offer any further explanation. The Administrator was informed of the observations during survey of a resident observed with smoking paraphernalia and visible smoke cloud inside, and an unknown resident that requested a surveyor to pick up a cigarette butt from the ground outside the main entrance/awning and insisted that was their cigarette they intended to smoke and they reported they were not aware. R3: Review of R3's clinical record revealed there were no smoking assessments to identify if the resident had been assessed for safe smoking, handling of smoking materials and whether any adaptive needs were required. Review of the care plans included one initiated on 7/25/25 that read, Resident chooses to smoke. The one goal read: Resident will smoke safely at the designated area(s) at scheduled times through the next review. There were no current designated areas/scheduled times per Administrator. Interventions included: Adaptive equipment for safe smoking (SPECIFY). This was noted as initiated on 7/25/25, revised on 8/21/25, but was left incomplete and didn't identify any specific adaptive equipment. Observe the resident's safety during smoking. This was initiated on 7/25/25. Further review of the clinical record revealed R3 was admitted into the facility on 7/16/25 from another nursing home with diagnoses that included: acute diastolic (congestive) heart failure, chronic obstructive pulmonary disease, nicotine dependence, morbid obesity due to excess calories, adjustment disorder with mixed disturbance of emotions and conduct, borderline personality disorder, bipolar disorder in partial remission most recent episode mixed, other specified disorders of muscle, other specified depressive episodes, bipolar disorder, current episode mixed, severe, with psychotic features, mood disorder, conversion disorder with seizures or convulsions, and obstructive sleep apnea. On 2/25/26 at 10:30 AM, an interview was conducted with the Director of Nursing (DON). When asked who usually implements the care plans for residents that were identified as a smoker, the DON reported usually MDS Nurses do, the DON or Unit Managers. When asked if there were any assessments completed to determine safe smoking practices, the DON reported there was currently no option in the electronic medical record to do safe smoking. When asked about R3's history of vape use, the DON reported we educate and confiscate the ones she has, and family will bring in later. R88 On 2/23/26 at 11:32 AM, R88 was observed in their room throwing a purple vape pen in their purse. A dissipating smoke cloud was observed. On 2/25/26 at 9:57 AM, R88 was observed lying in bed. A black vape pen was observed on their bed. When asked if they used the vape pen in their room, R88 replied in part . I may do it from time to time. R88 explained that sometimes they would go out of the facility to use the vape pen as well. A review of the medical record revealed R88 was admitted to the facility on [DATE] with the primary diagnosis of malignant neoplasm of the lung (lung cancer). A review of the progress notes revealed the following: A Nursing note dated 1/6/26 at 3:25 AM, documented in part . Resident was caught in her bathroom smoking cigarettes. writer asked resident to give her the cigarettes and lighter. resident stated here go the cigarettes I don't know where the lighter is. resident handed the cigars to nurse. nurse locked cigars in cart. Administrator and DON, MD (Medical Doctor) notified. no new orders . A Nursing note dated 10/22/25 at 7:56 PM, documented in part . At approximately 2100 (9 PM), patient was found smoking in her room by the caregiver. The caregiver immediately reported the incident to writer. Upon assessment, patient was alert and oriented ×3, calm, and in no apparent distress. No burns, shortness of breath, or other injuries noted. The cigarette was extinguished and disposed of safely. Patient was reminded of the facility's no-smoking policy and educated on fire safety and health risks of indoor smoking. Patient verbalized understanding. Incident reported. Will continue to monitor and reinforce safety protocols . A review of the assessments revealed no smoking assessment was completed for R88. A review of the care plans revealed no care plan and/or interventions implemented for the usage of the vape pen. On 2/25/26 at approximately 12:57 PM, the Director of Nursing (DON) was interviewed and asked about the observations noted in the residents' chart and discussed the observations of the survey of R88. The DON acknowledged that the facility was a non-smoking facility, however recently found out that they had a policy for residents that smoke. The DON acknowledged the concern and stated they would follow up with their team. No further explanation was provided by the end of the survey. R5: On 2/25/26 at 9:30 AM, R5 was interviewed and openly acknowledged they are a smoker and acknowledged the facility knows their wishes do not want to quit. When asked where they get their cigarettes and lighter, R5 replied I keep them on my person R5 said there was never a smoking assessment performed for them and if there was, it was maybe when they were first admitted but could not confirm. Review of R5's care plan documented: Resident chooses to smoke. Date Initiated: 07/31/2025 Revision on: 07/31/2025 Inform resident or /family/responsible regarding the center's smoking policy, designated smoking areas, and storage of smoking materials. Date Initiated: 07/31/2025 Offer resident a smoking cessation.

This citation pertains to intakes 2659810 and 2718805.Based on observation, interview and record review, the facility failed to maintain a clean, comfortable, safe, and homelike environment, affecting all residents that access the ice machine and shower room. Findings include:On 02/23/2026 at 10:30 AM, the ice machine located in the upper-level pantry was observed to be leaking water onto the floor. The flooring was observed with a black, mold-like substance on the floor tiles. When queried at that time, Maintenance Supervisor S stated they were going to be getting a new ice machine but did not provide an explanation for why the mold-like substance on the floor had not been cleaned. In addition, in the upper-level pantry, the cupboard located under the sink was observed with visible water damage and a black, mold-like substance on the bottom shelf of the cupboard. Maintenance Supervisor S stated he had repaired a leak under that sink about a year ago but was not aware there was a new leak or water damage. On 02/23/2026 at 3:30 PM in the upper-level shower room located next to the nurse's station, there was a bariatric shower chair observed with the vinyl covering of the seat torn away from the base of the seat, leaving exposed foam underneath, and a surface that was no longer smooth and easily cleanable. When queried at that time, Maintenance Supervisor S stated the seat would be replaced. On 2/25/2026 at 10:51 AM, the Director of Nursing (DON) was asked to observe the C/D unit shower room. Upon entry into the shower room, there were two shower stalls. The shower stalls themselves were observed to have significantly pitched areas of the tiled flooring. The white vinyl shower curtain for the shower on the left was observed torn and heavily stained. The inside shower area was observed to have a heavy build-up of dark blackish colored debris along the wall and floor tiles. The tiled shower room walls were observed to have several chipped tiles, and the plastic corner coverings were observed to have missing caps at the top which exposed sharp metal and plastic edges. The DON reported they were not aware of that and would have the Administrator come down. On 2/25/26 at 10:57 AM, an observation of the C/D shower room was conducted with the Administrator. During this time, the Administrator confirmed the same findings and further reported they were not sure how that had not already been identified prior to now. When asked about the missing end caps, soiled/ripped shower curtain and dirty shower tile, the Administrator reported they would have housekeeping come now. According to the facility's policy titled, Safe and Homelike Environment dated 1/1/2022: .Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment.Report any unresolved environmental concerns to the Administrator.

Based on observation, interview and record review, the facility failed to ensure appropriate catheter care was provided for one resident (R6) of one resident reviewed for indwelling catheters. Findings include:On 2/23/26 at approximately 10:44 a.m., R6 was observed in their room, sitting up in their bed. R6 was observed to have an indwelling catheter with their catheter bag touching the floor and the tubing extended/taut. R6 was queried if they had any pain from the catheter tube pulling and they reported they did. Further observation of R6's catheter tubing revealed no method of securing the tubing to prevent pulling on the genitals. On 2/24/25 at approximately 10:26 a.m., R6 was observed in their room with Nurse E. R6's catheter tubing was observed to contain cloudy urine. R6's drainage bag was observed to be crumpled up in the privacy bag with urine unable to flow freely into the bag. Nurse E was queried to show R6's catheter securement device and they indicated that R6 did not have one, and they would have to get them one to prevent pulling on the genitals. On 2/24/26 the medical record for R6 was reviewed and revealed the following: R6 was initially admitted to the tacitly on 12/20/24, last readmitted on [DATE] and had diagnoses including Urinary tract infection and Bell's Palsy. A review of R6's MDS (minimum data set) with an ARD (assessment reference date) of 1/29/26 revealed R6 needed assistance from facility staff with their activities of daily living. R6's BIMS score (brief interview for mental status) was eight indicating moderately impaired cognition. A review of R6's care plans revealed the following: Focus-Resident has a need for indwelling catheter related to obstructive uropathy Date Initiated: 11/26/2025 Revision on: 02/09/2026 . A Physican's order dated 1/15/26 revealed the following: Change catheter securement device every night shift every 7 day(s) for management routine AND as needed for loose or soiled device. A review of R6's February 2026 treatment administration record (TAR) revealed the last administration of R6's catheter securement device was on 2/19/26. On 2/25/25 at approximately 12:55 p.m., during a conversation with the Director of Nursing (DON), the DON was queried regarding the standard of practice for ensuring appropriate catheter care and indicated that residents should have an anchor on to prevent pulling of the tubing on the genitals. On 2/25/26 a facility document pertaining to catheter care was reviewed and revealed the following: Policy: t is the policy of this facility to provide catheter care to all residents that have an indwelling catheter in an effort to reduce bladder and kidney infections, while maintaining their dignity and privacy. Catheter care may be provided by the nursing assistant and/or licensed nurse 1. Catheters should be secured to prevent pulling and damage to the urethral meatus. This may be accomplished by: a. Utilizing the appropriate drainage device (leg bag or catheter bag) b. Leg strap c. Velcro strap d. Linen/clothing clamp e. Adhesive securing device .

This citation pertains to intakes 2696875 and 2718805.Based on interview, and record review, the facility failed ensure provision of medically-related social services regarding psychosocial well-being post abuse allegations, resident-to-resident incidents, and/or changes in mood/behavioral concerns for two (R35 and R49) of two residents reviewed for behavioral/emotional needs. Findings include:Review of complaints reported to the State Agency (SA) included concerns that R49 had been physically assaulted by R35, and the allegations that the facility's social worker was not assisting with necessary discharge paperwork to transfer to another facility or making time to visit with the resident.On 2/24/26 at 9:07 AM, the facility was requested to provide documentation of the facility's investigation regarding a resident-to-resident incident between R35 and R49. R35:Review of the clinical record revealed R35 was admitted into the facility on 7/18/25 and readmitted on [DATE] with diagnoses that included: vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. According to the most recent Minimum Data Set (MDS) assessment dated [DATE], R35 had severe cognitive impairment (Brief Interview for Mental Status/BIMS score was 5/15), and had verbal behavioral symptoms directed towards others which occurred one to three days during this look back period of seven days.Review of the documentation provided revealed the facility became aware of an allegation on 12/11/25 in which R49 had been physically and verbally assaulted by R35. The facility identified that R35 had moderate cognitive impairment according to the Minimum Data Set (MDS) assessment dated [DATE] and R49 had severe cognitive impairment according to the MDS assessment dated [DATE].The facility's assessment further revealed that the facility was unable to verify the allegation of abuse, but interventions were implemented to move R49 to a different room. The facility further identified that the facility social worker followed both residents and noted no effect to mood or routine was observed. The facility's documentation further identified that the social worker would follow up to monitor for changes in the resident's mood/behavior.Review of R35's progress notes revealed several entries of R35 swearing, resisting care, including medication. The most recent progress note on 2/2/26 at 10:40 PM read, Pt (patient) was verbally aggressive with roommate which led to pt getting physically violent with roommate. Writer observed pt attempting to hit roommate through the curtain and called the administrator to inform of the situation. Writer was advised to remove the pt until the morning.Review of the social service documentation revealed there were only two progress notes since December 2025 on 12/10/25 and 1/29/26 in which the family consented for continued medication (there were no details as to what medication they were consenting to).Review of the psych consultations included an entry on 1/7/26 at 2:35 PM by psych services read, .Psych Follow up flat affect mood lower motivation.(R35) has exhibited flat affect, low mood, decreased motivation, and lower body weight. She reports poor sleep and poor appetite.Today: Adjustment disorder remains on the active problem list in the long-term care setting. Plan: Provide ongoing supportive counseling/behavioral support through the facility and monitor for anxiety/depressive symptoms and behavioral changes.Further review of the social service documentation included an annual Social Service Progress Review completed by Social Service Director (SSD 'C') dated 1/16/26 and locked on 1/19/26. This assessment was left incomplete for many pertinent sections and documented R35 was oriented, had no memory issue, was independent in daily decision-making skills, had a BIMS (Brief Interview for Mental Status) of 12 (moderate impairment) and the date of the most recent BIMS was 7/21/25. The section for Additional Cognitive/Mental Status comments was left blank.The section for Mood/Behavior/Emotional Status documented the most recent mood evaluation had been completed on 7/21/25 and the sections for Current Mood Status, Current behavior status, Things that make you become anxious/agitated, Things that calm or soothe you, What are your comfort foods/drinks when anxious/stressed?, Describe and indicate any interventions being used to address mood or behavior problems/deficits were left blank.The section for Psychoactive Medication Review which prompted the assessor to List the psychoactive medication name, related diagnosis and last GDR (Gradual Dose Reduction) or contraindication was left blank.Review of R35's social service documentation revealed there was no follow up following the resident-to-resident incident in December or February. R49:Review of the clinical record revealed R49 was admitted into the facility on 9/24/25 and discharged to hospital on 2/22/26 with return expected. Diagnoses included: major depressive disorder recurrent, generalized anxiety disorder, unspecified dementia, unspecified severity, with other behavioral disturbance, and adjustment disorder.According to the MDS assessment dated [DATE], R49 had severe cognitive impairment (scored 3/15 on BIMS exam) and had no mood or behavior concerns.Review of the social service assessments revealed there was only one assessment completed with a date of 9/29/25 and a lock date of 10/1/25. There was no quarterly assessment available for review. This assessment also revealed multiple incomplete sections which included: .Behavior, Medical, and Psychiatric History .Document major health occurrences and the social, behavioral, emotional impact .(left blank) .admitted on a psychoactive medication(s) .a. Yes .PARoxetine .Admitting behaviors or mood disorders (left blank) .History of other behaviors or mood disorders (left blank) .Things that make you become anxious/agitated (left blank) .Things that calm or soothe you( left blank) .What are your comfort foods/drinks when anxious/stressed? (left blank) .Any foods/drinks you have every day/consistently? (left blank) .How do you handle conflict? (left blank) .BIMS score 3 .Further review of the clinical record revealed:An entry on 1/7/26 at 8:04 PM read, Pts family informed writer that roommate was being verbally aggressive with pt. Pts family wanted roommate to be removed from the room so that the situation would not escalate. Writer temporarily moved pts roommate to room [redacted] per administrator's orders. There was no documented follow-up by SSD 'C' following this incident.An entry on 12/19/25 at 2:31 PM by SSD 'C' revealed no documentation they had assessed or evaluated the resident's psychosocial well-being following the alleged incident on 12/11/25 with R35. This note only identified the family was contacted regarding psychotropic medication consent.An entry on 12/10/25 at 2:00 PM by psych read, .The patient has been experiencing ongoing depression and anxiety related to her loss of physical abilities, particularly her inability to walk, and expresses distress about her loss of autonomy and total reliance on facility staff to meet her needs.Staff has reported that she becomes agitated and frustrated at times when her needs are not immediately addressed. Behavioral notes have documented episodes of yelling/screaming, verbal aggression, threatening behavior, and refusing care. She has exhibited helpless and hopeless ideation but has consistently denied any intent to harm herself.Review of the social service documentation revealed there was no follow up following the resident-to-resident incident in December or February, or the more recent progress note entries identified above.On 2/24/26 at 8:33 AM, an interview was conducted with SSD 'C'. When asked to explain how they assessed residents for their psychosocial needs, including those with behavioral needs, assessment, and monitoring, SSD 'C' reported they would have to get back with this surveyor. When asked how the direct care staff knew to monitor for behavioral changes specific to each resident, SSD 'C' reported they were not sure what the direct care staff could see. When asked if they discussed anything at interdisciplinary meetings, SSD 'C' reported they did daily stand ups and words that staff entered would get flagged for discussion. When asked if they utilized a behavioral management program to discuss and review interventions for residents with behavioral needs, SSD 'C' reported they did not and referred to psych services. When asked where their notes would be documented in the clinical record, they reported those would be under progress notes. They were unable to offer any further explanation as to the lack of complete and/or accurate assessments.On 2/25/26 at 1:05 PM, an interview was conducted with the Administrator. At that time, the Administrator was informed of the concerns regarding lack of complete and accurate social service assessments, or follow-up following the resident-to-resident incident with R35 and R49. The Administrator reported SSD 'C' was expected to follow-up as a general process following incidents such as those and further reported if there was a barrier to why SSD 'C' was not able to do that, that was not expressed. The Administrator further reported they had several previous discussions with SSD 'C' about similar issues and they would have to follow-up.According to the facility's policy titled, Social Services dated 10/30/23: .The social worker, or social service designee, will complete an initial and quarterly assessment of each resident, identifying any need for medically-related social services of the resident. Any need for medically-related social services will be documented in the medical record.Services to meet the resident's needs may include.Identifying and promoting individualized, non-pharmacological approaches to care that meet the mental and psychosocial needs of each resident.Meeting the needs of residents who are grieving from losses and coping with stressful events.The resident's plan of care will reflect any ongoing medically-related social service needs, and how these needs are being addressed.will monitor the resident's progress in improving physical, mental, and psychosocial functioning.

This citation pertains to Intake 2561059.Based on interview and record review, the facility failed to honor a full code advance directive for one (R146) of one reviewed, who wanted to receive all possible medical interventions in the event of a cardiac or respiratory arrest. R146 was found unresponsive, was not provided cardiopulmonary resuscitation (CPR) or other life saving measures as elected in their advance directives. Findings include:A review of a Facility Reported Incident (FRI) intake 2561059 reported the facility failed to ensure resident (R146) was free from neglect.Clinical record review revealed R146 was admitted on [DATE] and had diagnoses that included Parkinsons Disease (progressive neurological disorder) with dyskinesia (complication of Parkinson's Disease leading to involuntary movements of face, arms, legs, and torso) and encephalopathy (brain disease, damage, or malfunction). A Brief Interview of Mental Status (BIMS) reviewed from the Minimum Data Set (MDS) dated [DATE] scored 0/15 indicating R146 had severe cognitive impairment.Record review of the FRI revealed on Sunday [DATE], Licensed Practical Nurse (LPN) F went to care for R146 around 4:45 PM and observed R146 .unresponsive, eyes open-fixed, mouth open, checked his pulse, tried to get a blood pressure, no vitals. LPN F then had approached LPN G and told them R146 had passed. LPN F inquired the code status, and LPN F stated they were a Do Not Resuscitate (DNR). Around 4:56PM Registered Nurse (RN) B was called and pronounced the death of R146. LPN G reported that while LPN F was pulling the profile for R146 to identify the funeral home, it was documented R146 was in fact a full code.On [DATE] at 9:35 AM, an interview was conducted with RN B, who confirmed they were the RN in the facility that day. Per RN B they received a call that R146 had passed and needed to be pronounced. RN B said when they arrived, it was obvious R146 was deceased as they felt cooler (to touch) and were not breathing, I then pronounced (R146) and went back downstairs. Minutes later, (LPN G) called and said R146 was a full code at which time we ran our protocol, initiated full code measures and started CPR. Per RN B, nursing is responsible for knowing their residents code status and LPN F verbally confirmed R146 was a DNR.RN B further revealed after the miscommunication of code status, LPN F remarked why would we start CPR on someone if they are not breathing. RN B said .it was uncomfortably weird. that the nurse did not understand that is the reason you start CPR.On [DATE] at 10:25 AM, LPN F was phoned for an interview. Per LPN F it was a normal day. After they had returned from break, which was around afternoon shift change, they began rounding, went into R146's room which was the bed closest to the window and was observed unresponsive, and not breathing. LPN F stated they went for another nurse (LPN G) to help them. LPN F could not recall any details other than they were instructed to call the on-call supervisor. LPN F stated, (RN B) asked what I was doing on the phone, we need to run a code. Per LPN F they felt all alone, stated they did not know the rules there, was informed to just call the guardian. LPN F acknowledged they did not know the code status of R146, or any code status of all their assigned residents. LPN F did not know who was ultimately responsible for knowing resident code status and had no idea where it was documented. Per LPN F all the information regarding code status was not revealed until during the investigation of R146's death.Record review of the Facility Policy titled; Residents' Rights Regarding Treatment and Advance Directives dated [DATE]; documented: .Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the residents care.On [DATE] an interview with the Administrator confirmed due to the unexpected death of R146, determined that the facility's response to provide CPR and or other life saving measures was delayed. R146 was first found unresponsive on [DATE] at 4:45 PM, at 5:31 PM, Emergency Medical Services (EMS) were dispatched at 5:31 PM and arrived at the facility at 5:36 PM. This was confirmed by telephone on [DATE] at 12:53 PM by Emergency Dispatch J.During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included:The Director of Nursing Services educated social services staff and licensed nurses regarding the documentation procedures for Advance Directives/code status. A chart audit of all residents was completed. Audits of new admissions and those residents on the MDS assessment schedule for consistent documentation of the resident's Advance Directive/code status throughout the electronic medical record.

Based on interview and record review the facility failed to ensure the appropriate Notice of Medicare Non-Coverage (NOMNC) and a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) were provided and completed for three (R10, R127 and R164) of three residents reviewed for beneficiary notification, resulting in the residents and/or representatives to be uninformed of the potential private pay charges for continued services at the facility, and the inability to file an appeal. Findings include:On 2/23/26 at 1:20 PM, during an interview with R10's family, they expressed concerns with the facility's documentation for Medicare A coverage.On 2/25/26 at 2:30 PM, the Administrator was requested via email to complete and provide the applicable documentation in accordance with the instructions provided on the SNF (Skilled Nursing Facility) Beneficiary Worksheet for each of the following three residents R10, R127 and R164. These residents were identified on the documentation provided by the facility (Residents for the past six months that had Medicare A benefits and were either discharged home or remained in the facility). The instructions on the SNF Beneficiary Worksheets identified to NOT include those residents that exhausted their Medicare A benefits.Review of the documentation provided by the facility revealed only the SNF Beneficiary Notification Review worksheets for R10, R127 and R164. There was no additional documentation as instructed on the worksheet to provide the Notice of Medicare Non-Coverage (NOMNC) and/or if a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) documents for any of the residents.On 2/25/26 at 4:00 PM, the Administrator was not available and the Regional Director of Operations (RDO 'Q') offered to assist. They were informed of the concern with the initial request and lack of documentation provided and they stated they would follow-up.Further review of the available documentation provided revealed:The SNF Beneficiary Worksheet for R127 documented their Medicare A benefits started on 9/1/25, their last covered day was 11/19/25 and they were not issued a SNFABN or NOMNC because they exhausted benefit days.The SNF Beneficiary Worksheet for R10 documented their Medicare A benefits started on 12/29/25, their last covered day was 2/16/25 and they were not issued a SNFABN or NOMNC because they exhausted benefit days. R10 was also identified on the facility list provided as being cut from Medicare A benefits on 10/8/25 and remained in the facility. There was no other documentation provided for this benefit period.The SNF Beneficiary Worksheet for R164 documented their Medicare A benefits started on 7/15/25, their last covered day was 9/5/25 and they were issued a NOMNC. However, the NOMNC was not provided for review.On 2/25/26 at 4:25 PM, the Administrator was informed of the concerns with lack of documentation provided for review per the instructions on the worksheets. At that time, the Administrator provided a NOMNC for R10 that documented their Medicare A benefits would end on 10/7/26 and a note from the Social Service Director (SSD 'C') on the bottom of the form read, Patient refused to sign. Left copy at bed side. 10-3-25. There was no documentation provided that a SNFABN was provided since the resident remained in the facility after 10/7/26 to explain potential expenses. There was no second facility representative witness annotation on the ABN having attested to witness the provision and refusal per facility policy.On 2/26/26 at 10:04 AM, the Administrator reported they did not have any additional documentation to provide (including additional NOMNC notices) and also confirmed there were no SNFABN notices for residents that remained in facility.According to the facility's policy titled, Advance Beneficiary Notices dated 10/30/2023: .It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage.The current CMS-approved version of the forms shall be used at the time of issuance to the beneficiary (resident or resident representative).For Part A items and services, the facility shall use the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN).A Notice of Medicare Non-Coverage (NOMNC).shall be issued to the resident/representative when Medicare covered service(s) are ending, no matter if resident is leaving the facility or remaining in the facility. This informs the resident on how to request an appeal or expedited determination from their Quality Improvement Organization (QIO).This notice is used when all covered services end for coverage reasons.An exhaustion of benefits is not considered a termination for coverage reasons.The Social Service Director or designee is responsible for issuing Part A notices.The facility shall issue a notice each time, and as soon as, it makes the assessment that Medicare payment certainly or probably will not be made.Beneficiary refusals to sign.Have a second facility representative witness the provision of the ABN and the beneficiary's refusal to sign and sign an annotation on the ABN attesting to having witnessed said provision an refusal.

This citation pertains to intake 2621417. Based on interview and record review, the facility failed to ensure a safe discharge for one resident (R144) of two residents reviewed for discharge planning. Findings include: On 2/23/2026 a complaint submitted to the State Agency was reviewed which alleged the facility delayed in submitting the notification to the Michigan Department of Health and Human services that R144 had discharged from the facility and as a result, they could not access community level Medicaid services. On 2/24/26 the medical record for R144 was reviewed and revealed the following: R144 was initially admitted to the facility on [DATE] and discharged back to the community on 8/1/25. A review of R144's payor source at the time of their discharge was Medicaid-MI On 2/25/26 at approximately 10:55 a.m., during a conversation with the facility's Regional Business Office Manager I (RBOM I), RBOM I was queried regarding the process for switching a resident's Medicaid health insurance over from Nursing home level Medicaid to Community level Medicaid. RBOM I reported that the task is completed by the facility business office and it is usually done in electronic form but that due to the facility sale to another provider around that time, it would have had to be completed in paper or a call to the Department of Human Services (DHS). RBOM I was asked when the facility submitted the request to DHS to switch R144's Nursing home level Medicaid to community level Medicaid and RBOM I indicated that R144 discharged on 8/1 but a request for switching to community Medicaid was not made until 8/28/25. RBOM indicated it is usually done the day of discharge or the next day and at latest by end of the week. RBOM I was asked why there was an extensive delay in submitting the notification and they reported the previous business office manager was leaving at that time, and that was the reason for the delay in processing the notification to DHS. On 2/25/26 a facility document titled Social Services was reviewed and revealed the following: Policy: The facility, regardless of size, will provide medically-related social services to each resident, to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being The social worker, or social service designee, will pursue the provision of any identified need for medically-related social services of the resident. Attempts to meet the needs of the resident will be handled by the appropriate discipline(s). Services to meet the resident's needs may include: a. Assisting residents with financial and legal matters

Based on interview and record review, the facility failed to submit a notification of transfer to the state ombudsman's office for one resident (R141) of one resident reviewed for hospitalization.Findings include:On 2/24/26 the medical record for R141 was reviewed and revealed the following: R141 was initially admitted to the facility on [DATE], transferred to the hospital on [DATE] and had diagnoses including Congestive heart failure and Chronic obstructive pulmonary disease A review of R141's progress notes pertaining to their hospitalization revealed the following:11/27/2025-12:26 Progress Note-General: Pt (patient) observed to be extremely lethargic and confused, writer assessed pt upon assessment BP (blood pressure) 118/62, 78 HR (heart rate) RR (respiratory rate)14 Blood sugar 183 and 89% o2 on oxygen via nasal cannula. NP (Nurse Practitioner) contacted and gave order to transfer pt to [local hospital] 911 . On 2/24/26 at approximately 8:26 a.m., a request for documentation that notifications of transfer/discharges sent to the State Long term care Ombudsman's office was made from the Administrator for transfers/discharges during November and December 2025. On 2/25/26 at approximately 11:42 a.m., during a conversation with the facility Administrator, the Administrator was queried regarding the ombudsman's notifications for residents who are transferred to the hospital. The Administrator reported that they had not been sending notifications of transfers/discharge to the State Ombudsman's office. The Administrator indicated that the Social Services Department was responsible for sending the notifications to the Ombudsman's office, but none had been completed for 2025 and they had started in 2026. On 2/25/26 at approximately 11:45 a.m., Social Worker C (SW C) was asked if they had any documentation that they had sent notification of transfers/discharges to the State Long Term Care Ombudsman's office for November and December 2025 and they indicated they did not complete the notifications for the requested time period and had started in 2026 to send notifications. No documentation that the notice of transfer to the hospital for R141 had been sent to the Ombudsman's office was provided by the end of the survey.

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR) Level II evaluation (community mental health assessment) was completed and implemented within the resident's plan of care for one (R3) of one resident reviewed for PASARR. Findings include:Review of the clinical record revealed R3 was admitted into the facility on 7/16/25 (from another nursing home) with diagnoses that included: adjustment disorder with mixed disturbance of emotions and conduct, borderline personality disorder, bipolar disorder in partial remission most recent episode mixed, other specified depressive episodes, bipolar disorder, current episode mixed, severe, with psychotic features, and mood disorder.According to the Minimum Data Set (MDS) assessment dated [DATE], R3 had intact cognition and exhibited verbal behavioral symptoms directed towards others which occurred one to three days.According to the MDS assessment dated [DATE], R3 was marked as No for Is the resident currently considered by the state level II PASARR process to have serious mental illness and/or intellectual disability or a related condition?.Review of R3's level I (3877 form) dated 6/5/25 completed by the resident's previous facility documented, Bipolar disorder, current episode mixed, severe with psychotic features, borderline personality disorder, adjustment disorder with mixed disturbance of emotions and conduct; prescribed olanzapine 5 mg (milligram) tablet, haloperidol 5 mg tablet, divalproex sod dr 500 mg tab.Further review of R3's clinical record revealed there was no documentation that identified if a level 2 evaluation had been completed (comprehensive mental health assessment required to be completed prior to admission unless exempted).On 2/24/26 at 8:30 AM, an interview was conducted with the Social Service Director (SSD 'C'). When asked to explain the process for ensuring the required PASARR documentation was completed and available for review, SSD 'C' reported the admissions department usually gets the paperwork. When asked if they reviewed to ensure that was completed, SSD 'C' reported sometimes they did. When asked if that had been done for R3, SSD 'C' reported they guessed it was done by the social worker at her previous facility. SSD 'C' was asked to review R3's clinical record to see if that information might have been in another location and verified there was none available in R3's current clinical record. SSD 'C' was asked who had access to the computerized PASARR system to verify assessments were completed or submitted when needed and they reported they were the only person that had access to that system currently.On 2/24/26 at 9:20 AM, SSD 'C' reported they located R3's level II evaluation and they uploaded it into the electronic clinical record. When asked if they had identified any recommendations, they proceeded to review the level II document and was unable to offer any further explanation. When asked to clarify who was responsible to ensure the PASARR documentation was available upon admission, SSD 'C' reported that was usually admissions. When asked if the social service department reviewed that as part of their process even if a resident transferred from another facility, SSD 'C' reported they should have and was unable to offer any further explanation.Review of the Level II PASARR evaluation that was uploaded into the clinical record on 2/24/26 at 9:13 AM documented, in part: .Bipolar I disorder, Current or most recent episode unspecified-Primary .Alcohol use disorder, Moderate-Secondary .Cocaine dependence, uncomplicated-Secondary .Specify Mental Health Services (Other Mental Health or Specialized Services) to be provided: Nursing Home Mental Health Monitoring, Individual Therapy, Psychiatric Medication Review, Psychiatric Follow-up, Psychiatric Consultation .Requires Re-Evaluation in 364 Days .Reviewer's Recommendation Please pursue less restrictive placement when consumer's medical and physical status improves enough to safely do so .Specialized Mental Health Services: (X)Yes .[R3] is a [AGE] year-old Caucasian female who admitted to [name of other nursing facility] on May 28, 2025. [R3] has a long history of mental illness, and she is diagnosed with F31.9 Bipolar disorder. She requires ongoing mental health services. It is recommended that [R3] remain at her current placement where she can continue to receive the appropriate care for her mental, physical, and medical health needs. She seems to have some difficulty adjusting to the nursing facility. Therefore, it is also recommended that she receives specialized mental health services from the [community mental health] social worker in the form of nursing home monitoring and advocacy as needed. It is also recommended that she continue to receive mental health services from [contracted psych services]. Her services should include psychotropic medication, medication management, and therapeutic support to address her agitation, mood swings, and depression as well as other symptoms that may be present. [R3] should be encouraged to participate in the nursing facility's recreational activities for moral support and to increase her social skills . There was no documentation available in the clinical record that identified that R3 had been followed by social work from NSO.Further review of R3's care plans and social service assessments and/or progress notes revealed the above recommendations were not included.According to the facility's policy titled, Resident Assessment - Coordination with PASARR Program (Michigan) dated 10/30/2023 documented, in part: .This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder (MD), intellectual disability (ID), or a related condition receives care and services in the most integrated setting appropriate to their needs.PASARR Level II - a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs.The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status, and referring to the appropriate authority this includes annual reviews and change of condition.Recommendations, such as any specialized services, from a PASARR level II determination and/or PASARR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care.

Based on observation, interview and record review the facility failed to ensure the facility nurses consistently followed the standards of practice for the administration and documentation of a controlled medication observed for the medication administration (R65) and failed to ensure that physicians orders were transcribed and carried out as ordered for one (R162) resident of three residents reviewed for closed records. Findings include:On [DATE] at 8:16 AM, LPN A was observed preparing the morning medications for R65. Included in the morning medications prepared was Ativan 0.5 mg (milligrams). LPN A was observed to have obtained one tablet of Ativan from the controlled medication locked drawer and added to the rest of R65 morning medications. LPN A failed to verify R65's current Ativan count and failed to document the dose they removed on the controlled count sheet. LPN A was observed to have prepared and administered three additional residents' morning medications, without signing out the Ativan dose administered to R65. At 9:10 AM, LPN A was asked about their process of signing out the controlled medications they administered. LPN A replied they sign for their controlled medications after the administration of all the morning medications to the residents. LPN A was asked if that was the facility's protocol and LPN A responded some nurses sign out the medication after they remove the pill from the controlled count and some sign for it after they have administered all of the morning medications to their assigned residents. A review of a facility policy titled Controlled Substance Administration & Accountability revised [DATE], documented in part . It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. a control count sheet which accompanies the medication will be placed in the controlled substance binder. The general standard of practice for documenting usage of . controlled medications is to. record each dose administered, subtract the dose administered from the previously recorded. and record the amount. On [DATE] at 12:53 PM- the Director of Nursing (DON) was interviewed and was asked about the observation of LPN A to have administered the controlled medication without signing and subtracting for the controlled medication from the count. The DON stated they were aware of the observation with LPN A and had started education with the nurses. No further explanation or documentation was provided by the end of the survey. A record review revealed R162 was admitted to the facility on [DATE], expired at the facility on [DATE] with the admission diagnosis of Chronic diastolic heart failure and Stage 3 chronic kidney disease. R162 had a brief interview for mental status score of 00 which indicated severe cognitive impairment. A further review of the recorded revealed a progress note completed on [DATE] read in part: Pt (patient) noted to be lethargic and difficult to arouse. Blood pressure observed to be low 102/72 P (pulse) 62 02 (oxygen saturation level) 97% RA (room air) R (respirations)18 temp (temperature) 97.6. patient respond to verbal stimuli and sternum rub but quickly falls back to sleep. Skin warm and dry. respirations even and unlabored. No acute distress noted at this time. Vitals obtained and repeated for accuracy. Patient repositioned for comfort and safety.MD (Medical Doctor) notified new lab orders STAT CBC w/ diff 9Complete Blood Count), CMP (Comprehensive Metabolic Panel), UA (urinalysis)/urine culture. New order IV (intravenous) hydrations 0.9 normal saline 70 cc/ hr (cubic centimeters per hour) for one liter. Q6 (every six hours) vitals x24 hours. will continue to monitor vital signs. call light within reach safety maintained. Upon a further review of the record, it revealed that the orders for Intravenous (IV) Fluid 0.9 normal saline at 700 milliliters (CC) per hour for one liter was transcribed in the medical record for an incorrect start date which created a delay in medical treatment for R162. It was transcribed as . Sodium Chloride Solution 0.9 % Use 70 ml/hr intravenously everyday shift for 1 liter for 1 Day -Start Date-[DATE] 0700 On [DATE] at 10:21 AM, 11:45 AM and 1:15 PM an attempt to call the nurse who transcribed the order was contacted via phone with no answer. On [DATE] at Approximately 2:00 PM an interview with the Regional Nurse Consultant(RNC) R was conducted. The RNC R was asked about the expectations for documenting and transcribing orders during a change in condition of a resident. They reported that it is expected that staff assess and monitor the residents, notify the provider and carry out any orders given. the RNC R also explained they should call the party responsible and if needed send the residents out to a higher level of care. RNC R was then asked why the order for IV hydration was set to start for the following day if it was ordered to be started on the same day. The RNC R reported that they were unable to speak on why it was not transcribed correctly. They were asked to see if they could get in contact with the nurse who created the order. The RNC R reported they would try as the nurse who transcribed the order no longer worked for the facility. There was no additional information provided by the exit of the survey

Based on observation, interview and record reviews the facility failed to ensure the coordination of a Cardiology appointment and failed to communicate with the legal guardian for one (R9) of one resident reviewed for the coordination of medical appointments. Findings include:On 2/23/26 at 12:54 PM, a telephone interview was conducted with the guardian for R9. The guardian reported they drove to R9's cardiologist appointment on 2/19/26 for a pacemaker follow up. The facility staff did not ensure that R9 attended their appointment. The guardian expressed their frustration that the facility staff did not notify them before they traveled to another city to meet R9 for their appointment.A review of the medical record revealed R9 was admitted to the facility on [DATE], with diagnoses that included a presence of a pacemaker and dependence on renal dialysis.On 2/23/26 at 10:11 AM, R9 was observed in a geri chair. A brief interview was conducted with the resident.A review of the medical record revealed no documentation on why R9 missed their appointment on 2/19/26.On 2/25/26 at 11:51 AM, an interview was conducted with Unit Secretary (US) K (the facility staff responsible for scheduling the resident appointments) and US K was asked about the Cardiologist appointment for R9 on 2/19/26. US K initially stated the appointment was cancelled but then stated that the resident's MRI (Magnetic Resonance Imaging) appointment was the appointment that was cancelled. When asked why R9 did not make it to the Cardiologist appointment on 2/19/26, US K stated the transportation did not pick up the resident as scheduled. US K was asked if anyone had informed R9's guardian of the cancellation and US K stated they found out that transportation never showed up to take R9 to the appointment after the resident was scheduled to be there. US K stated they did not speak to the family at that time.On 2/25/26 at 1:18 PM, Unit Manager (UM) L (the nurse assigned to R9 on 2/19/26 dayshift) was interviewed and asked why R9 missed their cardiologist appointment on 2/19/26. UM L stated the transportation company arrived that day to take R9 to their appointment, but they could not find paperwork for the appointment. UM L explained all appointments are usually written on the communication board and there were no appointments noted for R9. UM L then stated US K informed them that the appointment was cancelled. UM L stated about thirty minutes after that a second transportation company came to transport R9 to the appointment, and they informed them the appointment was cancelled. When asked if they informed R9's guardian that was meeting them at the Cardiologist appointment, UM L stated they did not talk to the guardian.On 2/25/26 at 1:01 PM, the Administrator was interviewed and asked about the miscommunication amongst the facilities departments when it pertained to R9 appointment and the lack communication with the family/legal guardian. The Administrator acknowledged the concern and stated they planned to follow up with the nurses.No further explanation or documentation was provided.

This citation pertains to complaint: 2641546. Based on interviews and record reviews the facility failed to develop an adequate safety plan, failed to consistently implement the plan of care and adequate supervision for one (R127) of one resident reviewed for falls with injury, resulting in multiple injuries that included: a hematoma to the right side of forehead, bruise to the right shoulder, pain, bruising/edema to the right eye, laceration to the left side of forehead, a small focus of extra-axial hemorrhage along the anterior left frontal lobe (minor collection of blood outside the brain tissue) and required a transfer to the Emergency Department (ED) for further evaluation. Findings include: A review of the preadmission documents provided to the facility upon R127's admission documented the following in part: .1/31/2025. History and Physical. Chief Compliant: Fall. admitted to the hospital after having an unwitnessed fall down 11 12 stairs. Imaging done. showed SDH (subdural hematoma), SAH (subarachnoid hemorrhage), and IPH (intraparenchymal hemorrhage) as well as T1 acute fracture, T3 and T5, age indeterminate fractures (spinal fractures), as well as left rib 911 fractures, right orbital fracture (break in bones surrounding right eye) with pneumocephalus (presence of air or gas within the cranial cavity). 3/4/2025. Attending Physician. Progress Notes. Pt (patient) is awake. Wean restraints as tolerated and hydroxyzine added. 3/1 -Patient is seen at bedside today, awake and alert, tracks me when I call her name however does not follow commands patient continues to be restless with legs outside the bed rail.Despite the documentation of the resident to be restless and noted to have required restraints the facility accepted the resident to be admitted . A review of the medical record revealed R127 was admitted to the facility on [DATE] with diagnoses that included: intracerebral hemorrhage in hemisphere, subdural hemorrhage, tracheostomy, dysphagia, restlessness, agitation, difficulty walking and lack of coordination. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status score of 00, which indicated severely impaired cognition. R127 required staff assistance for all Activities of Daily Living (ADLs).A review of the medical record and the facility's fall incident reports revealed a total of 10 falls while inpatient from March to September 2025- 3/21/25, 5/10/25, 8/17/25, 9/18/25, 9/23/25, 9/24/25, two on 9/25/25 and two on 9/28/25. A review of the care plan titled Resident is at risk for falls r/t (related to) History of fall(s), Impaired safety awareness, Cognitive impairment, Gait/balance problems, Impulsiveness, constantly moving and trying to get up unattended was initiated on 7/28/25. This care plan included the following interventions . 1:1 (one on one) sitter will switch off with the CNA (certified nursing assistant) for the set resident is in or charge nurse when sitter needs to go on break or take eyes off of resident. Staff educated regarding 1:1 duties.Review of the progress notes revealed the following: A Nursing note dated 9/17/25 at 2:58 PM (late entry), . pt (patient) very agitated during shift. Pt stood up from chair and began walking and would not allow staff to redirect her and would not sit down. Writer had to put wheelchair behind pt for her to fall back into. Dr (doctor) in building and witnessed pt anxiousness and stated she would call guardian to discuss medications. Social work present and witness pt agitation and inconsolableness. Psych dr present and evaluating pt medication and speaking with pt guardian.A Nursing note dated 9/18/25 at 7:37 AM, documented . Cena (aide) stated pt stood up from wheelchair and fell over onto floor, pt was Lying on right side, Pt assessed for injuries, pt has hematoma to right side of head and brise <sic> to right shoulder at this time. Physician notified and ordered neuro-checks, NP (Nurse Practitioner) ordered x-ray for skull, facial and right shoulder.A NP note dated 9/18/25 at 3:23 PM, documented in part . Acute falls secondary to generalized weakness. Patient evaluated today following an acute fall attributed to generalized weakness. According to the staff, the patient stood up from her wheelchair and subsequently fell onto her right side. During the fall, the patient struck her head but did not lose consciousness. A medium-sized hematoma was observed on the right forehead. The patient expressed experiencing pain and also discomfort in her right shoulder. The patient is under the supervision of a 1- on -1 sitter. the fall was witnessed by the sitter. The nursing staff is closely monitoring the patient.A Nursing note dated 9/18/25 at 4:55 PM, documented . upon visitation of family member at 1:39, family concerned about hematoma. After visitation at approximately 4:00 family member called facility and requested for resident to be transferred to hospital for CT scan (computed tomography scan) and further evaluation.A review of a Emergency Medicine hospital note dated 9/18/25 at 7:59 PM, documented in part . Sent to the ED (emergency department) from ECF (extended care facility) for evaluation after unwitnessed fall. Found to have contusion of the forehead. The patient's sister and guardian she noticed a large hematoma on the right forehead with visiting here with her this afternoon and spoke to the patient's physician at ECF and was sent to the ED for further evaluation. Patient has some element of sedation at times secondary to receiving Xanax (anti-anxiety medication) and trazodone. Imaging no trauma related abnormality. A review of NP note dated 9/23/25 at 10:31 AM, documented in part . The patient was seen today for a follow-up regarding an acute fall that occurred on 09/18/2025. At that time, the patient presented with a contusion on the right side of the forehead. The patient's tracheostomy was removed, and she is to follow up for the adult video fluoroscopic swallowing study. The patient exhibited restlessness or irritability but showed no signs or symptoms of generalized pain or discomfort. She is being closely monitored for care and is in no acute distress. Patient trach remove at at <sic> appt (appointment) on 9/19/25.An incident report dated 9/23/25 at 7:00 PM, noted a fall however failed to note a description and/or details of the fall. A Psychiatry note dated 9/24/25 at 1:17 PM, documented in part . Psychiatric follow-up for vascular dementia anxious restless falling risk with impulsive behaviour <sic>. She has been anxious, restless, up at night, with falling risk, requiring one-on-one care due to her unstable gait, resistance to care, and inability to be redirected. confused and uncooperative anxious restless falling risk with impulsive behaviour <sic> at time. patient appears anxious restless up down falling risk safety awareness decline. ATTENTION/CONCENTRATION- impaired, difficult to assess due to aphasia (difficulty speaking) JUDGMENT- impaired INSIGHT- impaired IMPULSE CONTROL- impaired.This consults notes a vascular dementia diagnosis which was not identified under the residents medical diagnoses in their electronic medical record.An incident report dated 9/24/25 at 8:45 PM, documented a witnessed fall while the resident was leaning forward in the doorway of their room.A Nursing note dated 9/25/25 at 8:12 AM, documented . pt observed on the floor to the right side of her bed. Pt unable to communicate what happened or if she hit her head. Pt was assessed for injuries, vitals obtained and pt was assisted back into bed, dressed, put into wheelchair and brought out to nursing station.A NP note dated 9/25/25 at 12:41 PM, documented in part . Recurrent repeated acute fall secondary to generalized weakness. seen today due to an acute fall on 9/24/25 and another on 9/25/25. Additionally, the patient experienced an acute fall on 9/18/25, during which she sustained a hematoma on her right forehead. According to the nursing staff, the patient had a fall on 09/24. who stated that the patient got out of bed and fell at approximately 5:52 this morning. The nurse informed the writer about the patient's fifth fall. The patient was found on the floor on her right side and was unable to communicate the circumstances of the fall. The nursing staff is closely monitoring the patient for any signs of increased neurological changes. due to the series of falls. The nursing staff continues to monitor the patient closely. hematoma to right forehead, bruising to right forehead and right eye.A Nursing note dated 9/25/25 at 2:59 PM, documented . pt continues to attempt to stand up from chair. She is not easily redirected and will not stay in chair.A Nursing note dated 9/25/25 at 3:32 PM, documented . Writer contacted NP in regard to resident experiencing increased anxiety. Resident displaying increased agitation and being very hard to redirect. Orders given to increase resident Xanax 0.5 mg (milligram) q8 (every 8) to q6 (every six) and to give a one time only dose right now.The next nursing note documented on 9/25/25 at 6:40 PM, . while doing rounds pt was observed face down on the floor to the right of her bed. Pt was conscious and bleeding from her head. Area bleeding was cleansed and laceration across forehead was observed. NP was notified of fall and orders to send pt out 911 given. Vitals taken and pt assessed for any further injuries.A review of the hospital record documented the following:A Neurosurgery consult dated 9/25/25 at 11:20 PM, documented in part . Patient seen at 2200 (10:00 PM). significant for TBI (traumatic brain injury) after a fall in [DATE] resulting in PEG (percutaneous endoscopic gastrostomy) and Trach placement (Trach reversed 9/19/25). family reported ruptured aneurysm and she fell from stairs was drinking at that time. presented to ED after an unwitnessed fall at skilled nursing facility. reported 4 falls over the last one week secondary to patient's impulsive nature due to TBI. Per report from skill nursing facility, she fell from bed (1 foot high from ground) onto padded floor mat. Patient has bilateral forehead hematomas which per sister is progressively worsening over the last one week. Neurosurgery consulted because CT head showed there is interval small area of extra-axial hyperdensity in the left frontal location consistent with subarachnoid hemorrhage. She has trauma collar on. Physical Exam. Alert, impulsive and not follow commands. Bilateral forehead hematoma Right side larger than the left. Ecchymosis and edema noted on right eye and forehead. Plan: No acute neurosurgical interventions. Repeat CT head after 6 hours from initial scan (0145). If stable, she can be discharge from neurosurgery stand point from ED.A Nursing ED (emergency department) note dated 9/25/25 at 11:34 PM, documented in part Pt restless, trying to get out of bed; confused. Pt's sister working with pt to keep her in bed.A Nursing ED note dated 9/25/25 at 11:53 PM, documented in part . Pt restless, confused; attempting to get out of bed; Zyprexa IM (intramuscular) given. Pt's sister to leave for home soon.A Nursing ED note dated 9/26/25 at 12:46 AM, documented in part . bed alarm activated by pt activity, x2. pt confused, pulling at c-collar, reaching her left arm out repetitively.A Emergency Medicine note dated 9/25/25 at 11:21 PM, documented in part . presents to the ER after fall at facility. Concern for head injury. Recent falls as well. Multiple contusions and abrasions to the face and forehead in varying stages of healing. Large hematoma appears to be healing on the right side. Given extensive trauma unwitnessed will obtain CT head neck blunt. Level 2 trauma activated after initially being a geriatric trauma. Workup notable for small subarachnoid hemorrhage. Spoke with neurosurgery who saw the patient. They feel she is stable clinically and they recommend repeat CT head in about a couple of hours for an interval CT. They state if stable can be cleared from their perspective.A Trauma Surgery consult dated 09/26/25 at 10:10 AM, documented in part . Rpt (repeat) CTH (CT-scan of head) IMPRESSION: Stable small focus of extra-axial hemorrhage along the anterior left frontal lobe. New Findings: None. Discharge Plan: Skill nursing facility.The facility accepted the resident back for readmission on [DATE]. A review of a Nursing note dated 9/28/25 at 7:03 AM, documented in part . alert with confusion observed on floor on floor mat with feeding tube still attached. 0 (zero) new injuries noted.A review of a Nursing note dated 9/28/25 at 7:31 AM, documented . CNA (aide) was toileting resident when resident started reaching for clean towels on the sink and slid off toilet seat. 0 new injuries noted.A review of a NP note dated 9/30/25 at 8:29 PM, documented in part . Acute fall secondary to generalized weakness. Patient seen today for reported fall on 09/28/2025. Patient has recently been experiencing recurrent falls due to patient experiencing generalized weakness and patient being unaware of safety. Staff <sic> patient was being toileted by Cena, Patient started to reach for towels and slid off of toilet. Patient had a prior fall where she sustained a contusion to her right side of her head which has since decreased in size, some yellowish/purplish bruising noted, around the right forehead, and small purplish bruising in the center of the contusion to her right head, with yellowish/purplish around the right eye. Due to the potential risk of bleeding, and has since been discontinued (aspirin) per patients DC (discharge) recommendations due to patients repeated falls and risk for bleeding. does have Xanax for anxiety management. She's been monitored closely by nursing staff. She is being redirected when she attempts to get up out of her wheelchair. Patient is unaware of her own safety.The next NP note dated 10/2/25 at 10:27 AM, was noted as a discharge summary for a . discharge scheduled on 10/6/25.On 10/21/25 at 10:20 AM, an interview was conducted with the complainant who was also noted as R127's legal guardian. Legal guardian (LG A) verbalized the concern of the multiple falls R127 had while at the facility. LG A stated they had received a call from the (facility's Social Worker Name) who requested a face to face meeting with them. LG G stated when they arrived to the facility for the meeting they were met by the Social Worker (SW), Director of Nursing (DON) and a Social Worker in training. LG G then stated they informed them that the facility could no longer provide a one on one sitter for R127. LG G stated the staff then informed them that they (the facility) was not .equipped to deal with a resident like this. LG G stated they did not understand why all of a sudden the facility could no longer provide the staff to keep R127 safe. LG G stated they asked the SW, DON and the SW in training why the facility accepted the resident into the facility if they could not provide the proper care and safety and no one responded. LG G went on to say how the facility staff had asked them if they would pay for the one on one sitter needed for R127 and LG G replied they could not afford to provide a one on one sitter for R127. LG G stated the facility staff then told them that they were the legal guardian and was responsible to keep R127 safe. LG G stated they approached the facility's Administrator to discuss their concerns over the matter but was not resolved. LG G stated they found a different facility and had R127 transferred. A review of the medical record revealed no documentation of this meeting or discussion with LG G, the SW, DON and SW in training. On 10/21/25 at 12:14 PM, Registered Nurse (RN) C (the nurse assigned to R127 on 9/25/25 who transferred the resident to the hospital and they were also was the nurse assigned to the resident multiple times) was interviewed and asked to describe R127 as a resident. RN C stated . anxious. hard to redirect. would constantly try to get up. that was pretty much all of the time. When asked if it was difficult to care for R127 they replied in part . Yes, it was just her restlessness. When she had a sitter it was much better. Because that was what she needed. RN C then went on to say how the Administration removed the one on one sitter prior to R127 fall on 9/25/25. RN C was asked about the 9/25/25 fall that required R127 to be transferred to the hospital and RN C stated at that time . the one on one was removed. When asked why R127 did not have a one on one as documented in their fall care plan, RN C stated they were unsure of why it was removed but was told by management. RN C explained the resident fell asleep in their wheelchair and they asked the aide to put the resident into their bed. RN C stated they along with the aide would frequently check on the resident but during one of their checks they noted R127 on the floor bleeding. RN C stated they assessed the resident, notified the doctor and transferred the resident out. RN C stated they informed the Administration team how difficult it was to complete their duties and provide the needed supervision to R127 and when asked what the Administration response to them was, RN C stated they got a one on one sitter back on dayshift at one point prior to R127 transfer out of the facility. This confirmed the facility removed the one on one sitter for R127 at some point prior to R127's fall on 9/25/25, despite the fall care plan to have had an intervention since 3/24/25 for a one on one sitter. The facility failed to ensure this intervention was consistently implemented and followed. The facility was well aware of R127 impulsiveness and restlessness which was documented by multiple medical providers/staff and the facility still failed to ensure adequate supervision. On 10/21/25 at 1:33 PM, the facility's Social Worker (SW) D was interviewed and asked about the meeting they arranged with LG A. SW D stated they would have to talk to their team and get back to the surveyor. SW D was asked why they would have to consult with their team on that question if they were the one that contacted LG A for the meeting and the interdisciplinary team was not included in that meeting, SW D did not reply. SW D was again asked why they arranged the meeting with LG A and SW D stated it was regarding (R127's name) care. When asked what about the care that was a cause for concern, SW D stated . She (R127) needed more supervision than we could provide. When asked why all of the sudden the facility was no longer able to provide adequate supervision per the resident's plan of care, considering the resident had been at the facility since March 2025 (for several months) SW D replied they . could not recall (the reason) and would follow up. At 2:09 PM, SW D returned and stated they discussed with (LG A) about (R127) needed appropriate staff to care for (R127) and asked (LG A) if they could help with that. When asked why R127 was readmitted back to the facility and why the plan of care noted the intervention for a one on one sitter if the facility was unable to provide it to ensure the safety for R127, LG A did not provide a response but acknowledged the concern. The DON was not on duty at the time of the survey and the Regional Director of Clinical (RDC B) filled in for the DON for the survey. On 10/21/25 at 3:07 PM, the RDC B along with the Administrator was interviewed and asked about the one on one intervention for R127 and the failure of the facility to consistently implement the intervention. The Administrator acknowledged there was a meeting with LG A who was informed that . we are getting away to providing a one on one with (R127 name). We asked the guardian to provide a resource one on one at night. The Administrator stated they believed they had a good strategy in place regarding the supervision of R127 per removal of the one on one sitter service. The RDC B and Administrator was asked what strategy was in place, why was the one on one sitter documented in the plan of care, when was the sitter service removed, and why LG A was asked to provide or help provide one on one sitter service if a good strategy was in place. The strategy plan was not provided to the surveyor. RDC B stated they would look into the concerns and follow back up. At 3:41 PM, RDC B returned and stated they spoke to the DON who stated . they were truly concerned about her (R127) that's why the decision was made to put her (R127) at the nurses station. RDC B asked how the nurses were expected to care for their other residents', administer medications and provide one on one supervision for R127 too, RDC B replied the facility staff should be able to take care of all residents who are impulsive and a high fall risk. When asked if any other resident had the intervention to have a one on one sitter like R127, RDC B stated they would have to look into it. No further explanation or documentation was provided by the end of the survey. A review of a facility policy titled Accidents and Supervision revised 12/27/23, documented in part . Each resident will be assessed for accident risk and will receive care and services in accordance with their individualized care plan. Each resident will receive adequate supervision and assistive devices to prevent accidents. Supervision/Adequate Supervision refers to intervention and means of mitigating risk of an accident. initiates interventions on the resident's baseline care plan, as indicated by the resident's level of risk. Supervision is an intervention and a means of mitigating accident risk. The facility provides adequate supervision to prevent accidents. Adequacy of supervision is. Defined by type and frequency. Based on the individual resident's assessed needs and identified hazard's in their environment.

This citation pertains to intake # MI00140255. Based on interview and record review, the facility failed to ensure a resident's change in condition was immediately reported, monitored, and had timely interventions implemented to address these changes for one (R804) of three residents reviewed for change in condition, resulting in delayed follow-up care, and delayed hospitalization for treatment following observations of the resident's right lower extremity being cold to the touch, with two plus pitting edema following a surgical repair two weeks earlier; and a fall with subsequent dislocated metallic prosthesis on the right hip. Findings include: A complaint was filed with the State Agency (SA) that alleged the facility failed to identify and address changes in a resident's clinical condition. According to a facility reported incident (FRI) that was reported to the State Agency on 12/12/23, R804 had been in the room with therapy and complained of right hip pain. Further diagnostic testing revealed a suspected fracture and the resident was sent to the hospital. On 12/13/23, the hospital had notified the Director of Nursing (DON) that the x-ray results showed a transcervical fracture through the right femoral neck with mild superior subluxation of distal fracture fragment. R804 underwent surgery for repair and returned to the facility on [DATE]. It should be noted that prior to the resident's initial admission into the facility on [DATE], they had sustained a fractured left femur from their previous living situation. Review of the clinical record revealed R804 was admitted into the facility on [DATE], discharged to hospital on 12/12/23, readmitted on [DATE], discharged to hospital on 1/2/24 and had not returned as of 1/31/24. Diagnoses included: encounter for other orthopedic aftercare, fracture of unspecified part of neck of left femur (11/27/23), presence of right artificial hip joint (12/15/23), fracture of unspecified part of neck of right femur (12/12/23), and unspecified dementia. Further review of the clinical record revealed: An entry on 12/30/23 at 12:46 AM by Nurse 'L' read, CNA (Certified Nursing Assistant) on unit alerted writer to the resident's room and stated pointed out to the writer that the resident's hip appeared to be out of place, upon assessment the writer agreed with the CNA, the resident's hip bone appears to be protruding out further than earlier in the shift, the resident shows signs of pain when palpated. The resident denies falling and was in bed when we arrived to her room. The resident's RLE (Right Lower Extremity) feels cold to the touch and she has +2 pitting edema. The doctor has been contacted about the situation and the writer is waiting for a follow up . There was no further documentation as to whether the Physician had returned the call, or that Administration had been notified of the resident's change in condition. The next documented entry was on 12/30/23 at 8:08 PM by Nurse 'F' that read, Acetaminophen Tablet 325 MG (Milligrams) Give 3 tablet by mouth every 8 hours as needed for General Discomfort - pt (patient) c/o (complained of) pain. The next documented entry was on 12/31/23 at 6:43 AM by Nurse 'F' that read, oxyCODONE HCl Oral Tablet 5 MG Give 1 tablet by mouth every 6 hours as needed for Pain related to FRACTURE OF UNSPECIFIED PART OF NECK OF LEFT FEMUR, SUBSEQUENT ENCOUNTER FOR CLOSED FRACTURE WITH ROUTINE HEALING (S72.002D) - pt c/o pain. The next documented entry was not until 12/31/23 at 8:59 AM by Nurse 'F' that read, Upon Cena making her rounds, pt (patient) was observed on the floor, Pt was lying on left side facing the door on the left side of bed and was soiled, bed was in lowest position, call light, hydration, bed control and tv control all within reach of pt while in bed. pts air mattress was inflated properly, pt did not use call light for assistance. Pt assessed for injuries none present at this time. Vitals taken, BP (Blood Pressure)-115/61, P (Pulse)-62, Resp (Respirations)-18, T (Temperature)-97.2, SPo2 (Pulse Oximetry)-96%, pt assisted back to bed by Cena and writer, ROM (Range of Motion) performed on upper and lower extremities with Pain to right hip pain, pain meds given, pt had previous hip surgery, Physician notified, Granddaughter notified, Neurochecks initiated. Frequent monitoring initiated. The next documented entry was a Late Entry Created on 1/2/24 at 1:12 PM for 1/1/24 at 1:11 PM by Physician 'I' which documented .Reason for visit .Status post fracture of the right hip .the patient is status post-ORIF (Open Reduction and Internal Fixation - surgical repair). Continue physical and occupation therapy as planned. Labile and stable . There was no identification, or indication that they had addressed R804's change in condition identified by nursing staff on 12/30/23, or the resident's fall on 12/31/23. The only other physician/extender entry was a late entry on 1/2/24 at 12:52 AM (after resident was discharged to the hospital) for 12/28/23 at 9:51 AM (prior to R804's change in condition) by Nurse Practitioner (NP 'M'). Review of an eINTERACT transfer form dated 1/2/24 by Nurse 'N' included minimal documentation of the resident's status and noted the reason for transfer was an abnormal hip x-ray. There were no radiology results available in the resident's clinical record for review. Further review of the nursing skilled charting assessments revealed no indication of any changes in R804's condition following the change identified on 12/30/23. There was no eINTERACT assessment completed on 12/30/23 with their change in condition. On 1/30/24 at 10:56 AM, a phone interview was conducted with Nurse 'A' who reported they no longer worked at the facility. When asked to recall their documentation and review events in which they assisted in transferring R804 to the hospital on 1/2/24, Nurse 'A' reported they were unable to recall any specific details or provide any additional information. On 1/30/24 at 1:53 PM, a phone interview was conducted with Nurse 'L' who reported they usually worked on the midnight shift. When asked to recall what they could from R804's change in status on 12/30/23 at 12:46 AM, Nurse 'L' reported concerns that they had attempted to contact Physician 'I' and the DON but neither returned their call. Nurse 'L' further reported they had notified the oncoming nurse and didn't know what happened after that. On 1/30/24 at 2:09 PM, Nurse 'F' was attempted to be contacted by phone. There was no return call by the end of the survey. On 1/30/24 at 2:21 PM, an interview was conducted with the DON. When asked about R804's change of condition identified on 12/30/23, and lack of physician response/follow-up, the DON reported the nurse should've completed an eINTERACT' assessment and the physician should've been contacted. The DON confirmed this had not been completed for R804. The DON further reported the facility had identified this as a concern a few weeks ago and had begun implementing education/training, monitoring with audits, and discussed in their Quality Assurance meeting. When asked what the facility's process was when staff identified a resident's change of condition, the DON reported they were to call the Physician, then call the Unit Manager and if they couldn't get a hold of them, they could call the nurse on call who can then get into contact with the Medical Director. On 1/30/24 at 2:35 PM, an interview was conducted with Nurse Manager 'B'. They reported that they were the nurse on call on 12/30/23 and denied being contacted by any nursing staff regarding R804's change in condition. They further reported had they known, they would've called the Medical Director if there were any concerns with the attending Physician not returning the call. Nurse Manager 'B' further reported Nurse 'L' should have initiated an eINTERACT assessment at the time of the incident and stated whoever recognizes that change in condition would be the person responsible for completing that documentation, no matter what time it is, even if close to the next shift starting. When asked if for some reason, the Physician and DON were contacted and staff still had not returned the call, what should happen, Nurse Manager 'B' reported anything clinical should be called in to the on-call phone, or use nursing judgment to send out to the hospital. At that time, Nurse Manager 'B' provided an x-ray dated 1/1/24 at 10:08 PM which read, PROCEDURE: RIGHT HIP 2 views .FINDINGS RIGHT HIP .Dislocated metallic prosthesis .FINDINGS PELVIS .Dislocated metallic prosthesis on the right hip. On 1/30/24 at 3:22 PM, a phone interview was conducted with Physician 'I'. When asked about whether they had any other practitioners on call, they reported it was just themselves. When asked since they did not have any other practitioners, how did they make sure they were available to respond timely when nursing staff contacted them, Physician 'I' reported, As long as I'm up, but sometimes at 2:00 AM or 3:00 AM it goes through pager. When asked if they recalled anyone reaching out regarding R804's change in status on 12/30, or 12/31 following the documented change in RLE feeling cold to touch and +2 pitting edema and fall, Physician 'I' No don't remember, usually in these important things, they (Nurse's) have the ok to send to hospital for a change in condition. When asked if they had been notified of R804's change in condition on 12/30 and fall on 12/31, what would they have recommended, Physician 'I' stated, I would've had her sent out 911. When asked about their late entry on 1/2/24 for 1/1/24 (the same date of R804's fall) and why there was no mention of the change of condition, Physician 'I' reported they were not able to offer any further explanation. According to the facility's policy titled, Nursing Administration dated 7/11/2018: .The nurse will notify the resident's Attending Physician or physician on call when there has been a(an) .accident or incident involving the resident .discovery of injuries of an unknown source .need to transfer the resident to a hospital/treatment center .specific instruction to notify the Physician of changes in the resident's condition .The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status .

This citation pertains to Intake Number(s): MI00136540, MI00138044, MI00135715, and MI00140171. Based on observation, interview, and record review, the facility failed to conduct an accurate fall risk assessment and implement effective interventions to prevent falls for three (R100, R16, and R92) of five residents reviewed for falls, resulting in R100 being transferred to the hospital two times on the same day after falls that resulted in a rib fracture, skin tear, and a laceration to the left side of the head that required sutures; R16 falling out of bed and being transferred to the hospital with a hematoma to the forehead; and R92 sustaining a traumatic posterior scalp hematoma and abrasion which required an emergency transfer to the hospital. Findings include: R100 Review of a Facility Reported Incident (FRI) submitted to the State Agency revealed a report that R100 sustained a fracture after an unwitnessed fall. Review of R100's clinical record revealed R100 was admitted into the facility on [DATE] for a five day respite stay (temporary relief of care from the primary caregiver), readmitted on [DATE] for a five day respite stay, and discharged on [DATE] with diagnoses: senile degeneration of brain and a fracture of one rib on the right side on 9/13/23. R100 received hospice services (supportive care that promotes comfort and quality of life for those approaching end of life). There was no comprehensive Minimum Data Set (MDS) assessment completed due to the resident's (short) length of stay. Review of a Nursing Admission Screening/History dated 9/12/23 at 1:10 PM revealed the reason for admission according to the resident/POA (power of attorney) was utd and the reason for admission from paperwork was respite. It was documented that R100 was admitted from home and was alert and oriented to person and time. The section that documented the assessment of R100's Motor Control was left blank and did not indicate a history of falling or recent fall. It was documented R100's cognition was intact. In the ADL's (activities of daily living)/Functional Devicessection, the nurse documented R100 was Totally Dependent for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing and was not assessed for walking or locomotion. No assistive devices were checked on the assessment. Review of a hand written document that was explained to be the orders and instructions provided to the facility by the hospice agency revealed R100 was admitted for a five day respite and required fall precautions. Review of the hospice referral revealed hospice documentation from when R100 was signed onto hospice, previous hospice visit notes, and plan of care. Review of a hospice Visit Note Report dated 7/21/23 revealed R100's Terminal diagnosis was Senile degeneration of the brain. The following was documented, .Reason for hospice - including history .Pt was intact verbally and could hold full conversations 3 months ago, but now speaks in small sentences ,mostly asking confused questions or talking to loved ones who've passed .3 months ago pt was up independent and steady with walker, now she is up with walker and SB (stand by) assist but has history of multiple falls, one last week and one two days ago. Pt is WC (wheelchair) appropriate and family will be attempting to transition pt to wc . The Fallssection documented R100 had history of falls, was at risk for falling, and ambulated with assistive device. R100's Mental/Cognitive Assessment findings revealed R100 was Alert .oriented to person .disoriented .forgetful .confused .agitated .hallucination .abnormal cognitive functioning . with abnormal attention, remote memory, recent memory, and new learning ability. R100 had abnormal thought process, thought content, perceptions, insight, and judgement with incoherence, delirium, obsessions, compulsions, hallucinations, and anxiety . Review of a Fall Risk assessment dated [DATE] revealed R100 was low risk for falling and had never fallen before. Review of R100's progress notes revealed the following: A General Progress Note dated 8/19/23 that read, Writer was standing at the med (medication) cart and heard a thump and heard the walker fall to the floor. Writer ran into resident rom <sic> and asked what happen she stated, 'I don't know' .skin assessment revealed: A lump located in the back of the head and a dark purplish lump on the left arm new order to send resident to he hospital . This event occurred during the first respite stay in the facility which was from 8/15/23 to 8/20/23. A General Progress Note dated 9/12/23 revealed R100 was a new admission to the facility with multiple discolorations noted to BLE (bilateral lower extremities) .a hematoma to RLE (right lower extremity) . A General Progress Note with an effective date of 9/13/23 at 5:08 PM noted, While writer was sitting at the nursing station, writer heard a loud bang coming from (R100's room number). Writer immediately ran into resident's room and observed resident sitting at 90 degree with her back parallel to the bathroom doorframe. Writer asked resident what happened and resident stated that she fell and hit her head. Writer inspected resident's head and noticed slight erythema (redness) on occipital region of head (back of head) with no bleeding present .Resident is not complaining of dizziness or trouble breathing .no change in ROM (range in motion) in any of resident's extremities. Resident has small dime sized skin tear on LLE (left lower extremity). Resident states that she has pain in her head. Writer contacted NP (Nurse Practitioner) and ordered resident to be sent to (hospital) for evaluation. EMS (Emergency Medical Services) arrived at 1640 (4:40 PM) to transport resident . A General Progress Note with an effective date of 9/13/23 at 10:36 PM, written by LPN 'E' noted, Pt (patient) returned from .hospital around 10:35 pm via EMS, with no new orders, diagnosis from the hospital was a closed fracture to one rib of the right side . A General Progress Note with an effective date of 9/14/23 at 2:26 AM noted, Pt came back to facility around 10:35pm (on 9/13/23) from hospital, Around 10:55pm (on 9/13/23), while writer was assisting another pt, cena (Certified Nursing Assistant) came to get writer and stated that the pt was sitting on the floor bleeding, pt was sitting on the floor on the side of the bed near the door, pt stated she wanted to get up to use the bathroom, Pt assessed for injuries, pt has laceration on the left side of head, no other skin alterations noted at this time .Pt assisted back to bed, Bed in low position, call light and hydration within reach, NP notified and ordered to send pt to hospital, 911 was called . A General Progress Note with an effective date of 9/14/23 at 8:25 AM noted, Resident returned from (hospital) at 8:25am with no new orders .Resident had a fall and has a laceration over left eyebrow with 2 sutures placed at the hospital . Review of R100's care plans revealed a plan of care created on 8/17/23 and initiated on 9/13/23 that indicated R100 was at risk for falls. The interventions were to ensure R100 wore appropriate footwear when ambulating or mobilizing in wheelchair, to ensure the call light was within reach, and to follow facility fall protocol. Review of a General Progress Note dated 9/14/23, written by the Director of Nursing (DON), revealed, Daughters .at resident's bedside. Spoke with them regarding incident and resident being transferred to the hospital. Daughters stated that this is the resident's behavior at home and that she needs constant supervision, resident constantly gets up to go to the bathroom. One time resident got up 87 times stating she needed to go to the bathroom per daughter .Daughters stated that they were constantly looking for ways to try and keep her safe . On 10/18/23 at 2:43 PM, an interview was conducted with Admissions Director 'C'. When queried about the process for admission for respite care, Admissions Director 'C' reported the admission process was the same as any other admission, but hospice typically came within an hour of admission to see the resident and coordinate care with the facility nurse. On 10/18/23 at 3:15 PM, an interview was conducted with LPN 'G' via the telephone. When queried about R100, LPN 'G' reported they were familiar with the resident. LPN 'G reported R100 had dementia and was a fall risk. LPN 'G' explained R100's daughter said they had to constantly monitor the resident at home because she would get up to go to the bathroom. When queried about the first fall that occurred on 9/13/23, LPN 'G' reported they were near R100's room and heard a loud bang. They ran into R100's room and the resident was leaning against the frame of the bathroom door. R100 reported they were trying to get to the bathroom. When queried about whether it was known that R100 was a fall risk prior to the fall, LPN 'G' reported they were aware which is why they were trying to keep an eye on them. On 10/18/23 at 3:54 PM, an interview was conducted with LPN 'E' via the telephone. LPN 'E' reported they did not remember R100, their readmission to the facility with a fractured rib from a fall on 9/13/23, or the second fall and hospital transfer that occurred on 9/13/23. On 10/19/23 at 9:27 AM, an interview was conducted with the DON. When queried about how the facility ensured interventions were implemented for the immediate needs of residents admitted for respite care, the DON reported they were admitted like any other resident admitted into the facility. The referral from hospice was reviewed that included orders for care, and a hospice nurse typically came to the facility the same day the resident was admitted to coordinate care with the nurse. At that time, the DON was asked to provide any information provided by hospice on 9/12/23. The DON explained that any fall risk would be considered based on information from hospice. When queried about R100 and the fall risk assessment that documented R100 did not have any previous falls and was at low risk for falls even though the resident fell in the facility during the previous respite stay the previous month, the DON reported the assessment was not accurate and should have taken into consideration previous falls. When queried about any interventions put into place upon admission on 9/12/23 to prevent falls and what was put into place after R100 was readmitted on [DATE] after a fall with a rib fracture, the DON reported she would look into it. When queried about when a resident should be assessed after being readmitted into the facility, the DON reported it should occur right away unless there was something else important happening. On 10/19/23 at 11:20 AM, the DON followed up and reported R100 was ambulatory and the intervention that was in place for her was to ensure she had appropriate footwear. The DON was unable to explain where R100's ambulation status was assessed prior to the first fall on 9/13/23. When queried about what should have been done to prevent a second fall upon readmission to the facility on [DATE], the DON reported the resident fell before anything could be implemented. The DON reported the facility was not aware of R100's fall risk and after talking to family on 9/14/23 they learned about it. It should be noted that it was known that R100 fell in the facility on 8/19/23 and it was documented in R100's hospice paperwork that was provided to the facility that they were at risk for falls. R16 On 10/17/23 at 10:42 AM, R16 was observed lying in bed. R16 made slight eye contact but did not speak. R16 received oxygen via a tracheostomy (a tube surgically placed into the windpipe in order to provide assistance with breathing). R16's hand appeared contracted and they were propped up with a foam wedge. It did not appear that R16 was able to reposition in bed without assistance. Review of a complaint submitted to the State Agency alleged R16 fell out of bed on 6/30/23 and was hospitalized with a golf ball sized contusion on her forehead, her face was swollen and she had bruising on the side of her face. It was alleged the facility staff were not able to explain how the resident fell out of bed but the nurse blamed the CNA (Certified Nursing Assistant) and the CNA blamed the nurse. Review of R16's clinical record revealed R16 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: cerebral infarction, anoxic brain damage, asthma, chronic respiratory failure, seizures, epilepsy, and contractures. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R16's cognition was not assessed and they were totally dependent on at least two staff members for bed mobility, toilet use, and bathing; they were not transferred from bed during the assessment period; and and was totally dependent on one staff member for dressing, eating, and hygiene. R16 received all nutrition via a Percutaneous Endoscopic Gastostomy (PEG) tube (a tube surgically placed into the stomach to deliver nutrition). Review of R16's progress notes revealed the following: A Skilled Nursing progress note dated 6/30/23 at 11:59 PM, written by Registered Nurse (RN) 'A', noted, Nurse was in (another resident's room number) .when I heard the CNA calling for help. When I went into patients' room she was hanging out of bed. 2 CNAS present. We assisted pt back to bed. Nurse assessed. Hematoma noted to forehead .Nurse was in patients' room about 5 min (minutes) prior to fall. Pt (patient) was in bed comfortable. Pt can't state what happened. On call NP (Nurse Practitioner) notified. Neuro checks ordered. Mother notified and requested a hospital transfer . Review of an incident report for R16 dated 6/30/23 and completed by RN 'A' revealed there were no predisposing environmental, physiological, or situational factors that contributed to the fall. No witnesses were included on the report. It was documented on 7/6/23 that, IDT (interdisciplinary team) team met to discuss resident/incident. After thorough investigation it was determined that the incident occurred as a result of resident not being positioned properly in bed. Appears resident may have been placed too close to side/edge of bed. Corrective action for this incident is staff was in services on bed mobility and positioning. Perimeter mattress placed on bed . Review of R16's care plans revealed the following: A care plan initiated on 3/29/22 and revised on 3/24/23 that read, Resident has an ADL (activities of daily living) deficit r/t (related to) debility, quadriplegia, hx (history) CVA (cerebral vascular accident - stroke), anoxic brain injury, limited ROM (range of motion), multiple contractures, aphasic (difficulty speaking), seizures, chronic respiratory failure w/ tracheostomy, non-verbal, unable to follow commands. Review of interventions revealed R16 was dependent for bed mobility initiated on 3/1/23. A care plan initiated on 3/29/23 and revised on 7/3/23 that read, Resident at risk for falls . An intervention was initiated on 3/29/22 that noted, Provide assistance as needed for mobility tasks and assure utilization of appropriate devices . On 10/19/23 at 1:17 PM, an interview was conducted with the Director of Nursing (DON). When queried about any investigation that was done regarding R16's fall from bed on 6/30/23, the DON reported she did not have a written investigation but it was determined the CNA (CNA 'AA') did not position the resident properly and therefore R16 fell out of the bed. The DON reported RN 'A' reported they were in R16's room five minutes prior to the CNA finding them on the floor and RN 'A' should have noticed R16 not being positioned properly and ensured they were repositioned. Review of a facility policy titled, Fall, adopted on 7/11/18, did not include the facility's protocols on how to prevent falls. 38271 R92 On 10/18/23 a concern submitted to the State Agency was reviewed which alleged R92 had multiple falls with a significant injury during their stay at the facility. On 10/19/23 The medical record for R92 was reviewed and revealed the following: R92 was initially admitted to the facility on [DATE] and had diagnoses including Repeated falls, Weakness and Adult failure to thrive. A review of R92's MDS with an ARD (Assessment reference date) of 3/8/23 revealed R92 needed extensive assistance with most of their activities of daily living. R92's cognition was documented as severely impaired cognition. A review of R92's progress notes revealed the following: 3/7/2023-Received pt (patient) A&Ox 2 (knows self and place), Pt denies any Pain or discomfort at this time, All admission assessments completed, Medication entered into PCC (electronic medical record), Physician notified, Pt educated on the use of call light and other remotes, hydration within reach, bed in low position, pt has history of falls, frequent monitoring initiated .Pt has small bruise to lower left abdomen and left antecubital . [Physician Services Note] 3/7/2023-HISTORY & PHYSICAL EXAMINATION CC (chief complaint): debility and weakness for the past one week HPI (history of presenting illness): yrs old male with history of admitted for nursing support and rehabilitation. Patient presented to acute care facility after he sustained a fall. Patient is very poor historian although information obtained from the medical records apparently the patient presented to [local hospital emergency room ] after he sustained a fall he does have expressive aphasia secondary to history of a glioblastoma status post resection. He does have history of recurrent falls he is getting weaker and weaker . 3/13/2023 at 18:49-Writer call to residents room by spouse, resident was sitting on floor in front of wheelchair. Spouse stated that she broke his fall and sat resident on the floor. Resident was trying to sit in wheelchair and didn't lock the wheels . 3/14/2023 at 12:00-Resident was observed on the floor. Resident was assessed while on the floor then put in wheel chair. Resident had a skin tear that was on the back of head .Doctor was notified, doctor ordered for resident to be sent to the hospital for a CT Scan (computed tomography) . 3/14/2023 at 20:39-Resident returned from the hospital on a stretcher .Doctor was notified of return. Nurse placed a wound care consult for resident . 3/14/2023 at 23:00-Resident was observed on the floor. Resident had no complaints of pain or discomfort. Resident was able to to complete full range of motion on all extremities with no limitation due to immobility or pain during assessment. Doctor was notified, no new orders . 3/15/2023 at 17:49-Medical Practitioner Progress Note (Physician/PA/NP)-Reason for the visit E/M (evaluation/management) for s/p (status/post) fall .EXAMINATION Awake, aware x1 .HEENT (Head, eyes, ears, nose, and throat) traumatic posterior scalp hematoma and abrasion .A/P (Assessment/Plan): 1. s/p fall: patient sent to hospital for evaluation and returned same day .continue fall protocol, vital signs, and neuro checks. utilize fall precautions 3/15/2023 at 20:28-Patient was found laying on matt <sic>, vital signs and physical assessment were done, no new bruising noticed, pain assessment was done, Wife was called and Physician called. Neurological evaluation is being done. 3/18/2023 at 18:20-At 5pm resident wife walked into his room and observed him on the floor laying on his back on the floor mat and bed was in the lowest position. Wife called writer into room and I called the aide to help assist resident back into bed. A review of R92's comprehensive plan of care revealed the following: Focus-Resident at risk for falls r/t (related to) Debility .Further review of R92's care plan did not reveal any frequent monitoring intervention as indicated on the 3/7/23 Nursing progress note. A review of R92's incident and accident forms (I&A) for their falls during their time in the facility revealed the following: 3/13 at 9:06-Incident Description-Writer called to residents room by spouse. Resident was sitting on floor in front of wheelchair. Spouse stated that she broke his fall and sat resident on the floor. Resident was trying to sit in wheelchair and didn't lock the wheels . 3/14 at 1300-Incident Description-Resident was observed on the floor. Resident was assessed before putting him in his wheelchair .Immediate Action Taken-Resident was assessed and doctor was notified immediately. Doctor ordered for resident to be sent out to the hospital . 3/15 at 2015-Incident Description-While doing rounds with another nurse, opened door and noticed patient laying on floor on top of mat . 3/18 at 1700-Incident Description-Wife walked in and then came out ad <sic> states her husband was on the floor. Writer walked in and he was laying on his back on the side of the bed on the floor mat. Bed was in lowest position and both floor mats was on the floor . 3/23 at 0700-Incident Description-Writer was making rounds and observed patient on floor mats . On 10/19/23 at approximately 9:25 a.m., during a conversation with the DON, a review of R92's falls was conducted and the DON was queried regarding the implementation of the interventionfrequent monitoring indicated per the Nursing progress note on 3/7 due to residents previous noted history of falls and they indicated it should have been added to the careplan and a system set up to document what frequent monitoring had meant. The DON was also queried regarding the post fall analysis (Incident and accident form) form for the second fall on 3/14 after R92's return from the hospital and what the immediate interventions were to prevent another fall once R92 had returned from the hospital after their first fall that day at 1300. The DON reported they would look for additional documentation and follow up. On 10/19/23 at 12:38 p.m., during a follow up conversation with the DON, the DON reported frequent monitoring was never added to the plan of care to notify staff of the need to increase supervision for R92. The DON also reported there was no post fall analysis for the second fall on 3/14 nor was an incident/accident form done for it to address the root cause. No documentation that frequent monitoring initiated indicated on 3/7/23 had been completed or that an incident/accident-post fall analysis for R92's second fall on 3/14/23 at 2300 had been done was provided by the end of the survey.

This citation pertains to intake #MI00133791 Based on observation, interview, and record review the facility failed to ensure one resident (R501) was free from sexual abuse, out of three residents reviewed for abuse, resulting in R501's being sexually abused by a staff member, physical trauma, feelings of psychological trauma and fear, and criminal charges filed against the staff member. Findings include: Several complaints were received by the State Agency regarding a resident sexually abused by a staff member. At the time of the original investigation (1/12/23) into the complaints, evidence was requested but unable to be obtained until 1/26/23. A follow-up investigation after review of additional evidence was conducted on 1/27/23. A review of a facility provided policy titled, Abuse and Neglect updated 10/31/22 was conducted and read, POLICY: It is the policy of this facility to provide professional care and services in an environment that is free from any type of abuse .Abuse includes: .4. Sexual . On 1/11/23 at 10:10 AM, a review of a facility provided investigation file that alleged R501 was sexually assaulted by a staff member was conducted. The file contained the following: A typed summary dated 12/12/22 indicated R501 reported to Nurse 'C', Certified Nurse Aide (CNA) 'D' was, .inappropriate with her while administering her bed bath . The summary indicated the allegation was also witnessed by Nurse 'E'. The summary continued to read, .(R501) reported to both nurses that the male CNA was wiping her vaginal area for a long time during care .she felt like he was inappropriate with his hands during care .(Nurse 'C') was instructed by the Administrator to notify the police to make a report .The male CNA had left the facility .The police arrived at the facility to speak with the resident and initiated their own investigation. The police instructed the nursing staff not to perform a complete skin assessment on the resident to allow this to be completed by a third party from (name redacted) Nurse 'F' (a forensic nurse) in lieu of ER (emergency room ) visit .The following morning, the police spoke with the administrator regarding the incident .Administrator and DON (Director of Nursing) visited resident .Upon interview, resident reports incident occurred on 12/12/22 .Resident reports that (CNA 'D') entered her room around 7:30-8pm with bathing supplies .Resident alleges that when he started to clean her private area, that he kept going 'deeper and deeper, while spreading her vaginal area open' and was washing her 'aggressively' .and 'she could feel him penetrate me with his fingers and I no longer could feel the wash cloth on his hand'. She stated that he continued to do this for about 5 minutes. She reports that she did not know what to do but lay there. 'He then flipped me over and washed my buttocks aggressively .after he got me dressed and started to exit he stated that he would be back when the coast is clear'. I told him 'you will absolutely not be coming back into my room ever'. Resident stated that after some time of crying that she reached out to her 'spiritual advisor' on what she should do . A typed, signed statement from CNA 'D' dated 12/19/22 that read, .When I went in there and asked if I could provide a bed bath she said 'yes'. Once I did that she reported she had a bowel movement .I started to set up the bed bath after I cleaned her up. I had a lot of soap and water and put the towels across her chest, and her bottom. She started to make moaning noises after I drapped <sic> the towels. I kept going with cleaning. She started moaning noises when I was cleaning her private area .After continuing she started to thrust her hips towards my hand that was cleaning. She kept doing it .And that's when things got weird .She was making comments that she has a 'young girl (expletive for vagina)' and that 'I haven't had a (expletive for penis) in 30-[AGE] years' to me. When I was exiting the room she was trying to call me back into the room she stated she hasn't (expletive for orgasm) yet .I feel like the lady had her part in this, but I don't feel like I raped her. A written, signed statement from Nurse 'C' dated 12/13/22 that read, .I was informed by CNA the resident (R501) wanted to see me. I went into room and asked her what was wrong and she began to say she felt like her CNA from earlier was inappropriate with her .Resident continued by saying she felt like her CNA was being inappropriate in her private area .She said she felt like the male CNA was being little rough and penetrated her with his fingers . A written, signed statement from Nurse 'E' dated 12/12/22 that read, .It was reported that the male was 'wiping her for a long time', she felt like he 'finger (expletive)' her. Reported that she was crying and visibly shaken up by the incident . On 1/11/23 at 11:00 AM, an interview was conducted with R501 in their room. R501 said on 12/12/22 they were sexually assaulted by CNA 'D'. R501 said CNA 'D' penetrated her vagina with his fingers. R501 continued to say Police Detective 'G' took their statement and had been following up with them on the case. R501 said they received a letter that informed them the County Prosecutor was filing charges against CNA 'D'. R501 said Detective 'G' told her CNA 'D' admitted to penetrating her vagina with his fingers. At that time during the interview, R501 started crying and said they did not like the male psychologist sent to see them after the incident and did not want to speak to the male social worker. R501 said a female social worker, Social Worker 'A' had been following up with them. R501 was visibly upset and continued to cry through the end of the interview. On 1/11/23 at 11:05 AM, R501 granted permission to review the letter they received from the Office of the Prosecuting Attorney. The letter revealed the court process and resources available to R501 as a victim of sexual crime. On 1/11/23 at 12:50 PM, a phone call was placed to CNA 'D', however; the call was unanswered and the voice mailbox had not been set up. On 1/11/23 at 1:30 PM, a review of R501's clinical records revealed they admitted to the facility on [DATE] with diagnoses that included: disc degeneration, low back pain, repeated falls, and morbid obesity. R501's most recent Minimum Data Set assessment dated [DATE] indicated they were cognitively intact, non-ambulatory, and required extensive assistance from one to two staff members for bed mobility, transferring, wheelchair mobility, dressing, toilet use, and personal hygiene. A review of R501's progress notes revealed the following: A physician's note dated 12/13/22 that read, .Pt (patient) is tearful today and states she is upset about an ongoing issues <sic> that has been addressed with staff. She is depressed . A Psychiatric Nurse Practitioner note dated 12/14/22 that read, .Complaint of sexual assault .She recalls the incidents <sic> on Monday, at first in the morning when she had to use the bedpan, when she thought the male aid <sic> was cleaning her down too deep in the genital areas .in the evening, it happened again when he had to do the bed bath .She becomes emotional and she recalls in detail how the male aide was very rough .and inappropriately placing his fingers inside of her vaginal area that lasted about 5 minutes. Her crying becomes intense as she states she just froze while this was happening .Patient has been in contact with the police, and social work .She agrees to increasing her zoloft (anti-depressant medication) from 100 to 150 mg (milligrams) .If crying persists, pt can benefit from temporary xanax (anti-anxiety medication) 0.5 mg . A Psychologist Note dated 12/14/22 that read, .seen following an alleged incident that occurred Monday night. She related a male CENA (CNA) as he was giving her bed bath, sexually molested her. She described how he inappropriately touched her breasts and inside her vaginal area .She related that she felt in shock .She was very upset and cried as she talked about the present incident. She related that she is trying to process what had happened to her. She stated there her 'heart is broken' by what he did to her and later that her 'heart hurts' .Asked if anything like this had ever happened to her she related when she was [AGE] years old, her uncle molested her .she never told anyone what had happened until she was an adult .(R501) is found to be alert and oriented x 3 (alert and oriented to person, place, and time), is insight oriented. She feels a sense of violation because of the incident .She feels angry and betrayed by what happened to her . On 1/11/23 at 3:22 PM, an interview was conducted with Nurse 'F', (a forensic nurse specialized in sexual assault assessment) who performed the forensic exam on R501 after the allegation of sexual abuse. Nurse 'F' was not able to share any information, but did provide the process to request R501's assessment. The process was followed and the documents were requested, however; they were never received. On 1/12/23 at 12:00 PM, an interview was conducted with Police Detective 'G'. Detective 'G' said an arrest warrant for CNA 'D' had been filed, the investigation had been closed and a request for the investigation from the police department could be initiated. A request for the police investigation was made on 1/12/23 at 12:31 PM. On 1/12/23 at 1:00 PM, an interview was conducted with the facility's Administrator regarding the incident. They acknowledged the fact the incident was being investigated criminally by the local police department, but were not able to obtain any of the police investigation information to aide in their facility investigation. They further indicated the facility followed their policy, but could not conclusively substantiate the allegation. They said they were afraid, something wasn't good given their follow-up conversations with Detective 'G'. On 1/26/23 at 9:44 AM, a copy of Detective 'G's police report and various investigation documents were provided via e-mail from the (City Name) Township Police Department. A review of documents revealed the following: A narrative from responding Police Officer 'H' that read, .(R501) advised me of the following: Between 1900-2000 (7P-8PM) hours, (CNA 'D) came into her room to give her a bed bath .When (CNA 'D') began cleaning her vaginal area, she advised me that he .began 'probing' her vagina with his fingers. She then stated that (CNA 'D') discarded the rag and began going deeper into her vagina with is <sic> fingers. For approximately five minutes, when she stated that (CNA 'D') 'finger (expletive) me'. (CNA 'D) then flipped (R501) over and began washing her buttocks .While cleaning her he kept rubbing the rear of her vagina .(R501) was extremely emotionally distraught when relaying the above information to me . A narrative from Detective 'G' that read, .Upon arrival, I met with (R501) in her room. (R501) reiterated her version of events that she told (Police Officer 'H'). I then contacted (company name) .I spoke to a support line employee and was able to facilitate a forensic exam that took place .12/14/22 .I interviewed (CNA 'D') in a recorded interview room where he told us the incident was consensual .(CNA 'D') admitted to inserting his fingers into her vagina .Conclusion (R501) is a resident/patient at (facility name) .(R501) is bed bound due to her weight and is unable to wash herself. (R501) alleges that (CNA 'D') forcibly and digitally penetrated her while he was giving her a bed bath .When confronted with these allegations, (CNA 'D') admitted to digitally penetrating (R501), but that (R501) was the instigator in the matter .The case will now be forwarded to (County Name) Prosecutor's Office for a warrant request . The documents reviewed also revealed a warrant for CNA 'D' was obtained on 12/28/22, and on 1/12/23 CNA 'D' was arraigned in District Court for criminal sexual conduct. Continued review of the documents provided from the (City Name) Township Police Department revealed Nurse 'F's medical forensic exam that read, .Brief history of the assault: .He washed my top part like normal .then started to wash my vagina. He was pushing down more and more. I could feel his fingertip, not the wash cloth pushing in and out of my vagina for about 5 minutes .I was so afraid he was in the building still .E. Symptoms since assault .Patient very tearful throughout exam and history. States that she is fearful of the assailant and worried staff may be talking about what happened .notes soreness to vagina . Continued review of the assessment form completed by Nurse 'F' revealed documentation of abrasions, tearing and generalized soreness to the genital area. On 1/27/23 at 9:00 AM, an interview was conducted with the facility's Administrator. They were informed a copy of the police report had been obtained from the (City Name) Township Police Department. They were asked if they had requested a copy of the report and said they had not. On 1/27/23 at 10:06 AM, an interview with Social Worker 'A' was conducted regarding follow-up visits with R501 after the sexual assault allegation. Social Worker 'A' said they were following up routinely, and at R501's request. They said R501 continued to report to them their feelings of trauma since the event.

This citation pertains to intake #s MI 532 and MI 173 and has two deficient practice statements. DPS #1 Based on observation, interview, and record review, the facility failed to accurately assess four residents (R#'s 33, 45, 72 and 44) with signs and symptoms of COVID19, immediately implement transmission based precautions (TBP) for one resident (R15) who tested positive for COVID19, ensure appropriate signs were posted for COVID19 TBP, and appropriately utilize personal protective equipment (PPE) including N95 face masks and isolation gowns for two residents (R#'s 63 and 17), resulting in an Immediate Jeopardy when R15 and R44 being hospitalized following positive COVID19 results, the continued spread of COVID19 during an active outbreak, and the increased likelihood for further spread of the COVID19 virus. These deficient practices resulted in an Immediate Jeopardy (IJ) beginning on 10/23/22 and with the likelihood for serious harm and or death for all residents living at the facility. Findings include: On 10/31/22 at 8:24 AM, RN (Registered Nurse) 'FF' was observed wearing a white N95 respirator face mask. It was observed the bottom strap intended to secure the mask around the back of the neck to ensure a proper seal was dangling under their chin. On 10/31/22 at approximately 9:00 AM, the survey team was informed the facility was currently experiencing an outbreak of the COVID19 virus and the [NAME] A unit had been identified as the COVID19 unit. On 10/31/22 at 9:52 AM, it was observed R63's and R17's room doors had a sign that indicated they were on droplet transmission-based precautions. The signs instructed anyone who entered the room to perform hand hygiene and make sure their eyes, nose and mouth were fully covered prior to entering the room. It was noted the sign did not indicate what type of face mask to be worn or any additional PPE (personal protective equipment) to be worn in the room such as a gown or gloves. On 10/31/22 at 11:09 AM, an interview was conducted with R17 and they were asked if they knew why they were on droplet transmission-based precautions; they said they did not know. On 10/31/22 at 11:25 AM, an interview was conducted with R63 and they were asked if they knew why they were on droplet transmission-based precautions. R63 said they thought it was because their roommate had contracted COVID19. On 10/31/22 at approximately 12:05 PM, a review of a facility provided spreadsheet of residents who were positive for the COVID19 virus was reviewed and revealed 19 residents tested positive for the virus and two residents had been sent to the hospital. On 10/31/22 at 2:20 PM, CNA (Certified Nursing Aide) 'AA' was observed in R17's droplet transmission-based precaution room wearing an isolation gown, gloves, and a surgical mask, not an N95 mask. On 11/1/22 at 9:25 AM, CNA 'BB' was observed wearing an N95 mask over top of another type of face mask. It was further noted the bottom strap of the N95 mask was not secured around the back of their neck, rather; it was dangling under their chin. On 11/1/22 at 9:28 AM, Housekeeper 'CC' was observed in R17's droplet transmission-based precaution room wearing only a surgical mask, eye protection and gloves. Housekeeper 'CC' was observed entering and exiting the room several times as they performed their housekeeping duties which included removing a plastic bag of used isolation gowns and placing it the garbage bin on the housekeeping cart parked in the hallway. On 11/1/22 at 9:30 AM, it was observed the droplet transmission-based precaution sign had been removed from R63's door. On 11/1/22 at 10:40 AM, a rolling cart with a completed COVID19 rapid test stored on top was observed in the hallway. Further observation of the test revealed the test to be positive for COVID19. During the observation, LPN (Licensed Practical Nurse) 'Z' approached the cart. They were asked about the test and said it belonged to R55 and confirmed R55 had tested positive for COVID19. They were then asked about the facility's policy for handling COVID19 positive rapid test results. LPN 'Z' said it was the policy of the facility to perform a second rapid test, and after two positive rapid tests they performed a PCR (polymerase chain reaction) test (another type of COVID19 test). LPN 'Z' was then observed to enter R55's room wearing only a surgical mask and eye protection to obtain the second the COVID19 rapid test. LPN 'Z' was not observed to don an N95 mask or gown. At 10:46 AM, LPN 'Z' reported R55 also tested positive on the second COVID19 rapid test and they were going to inform the facility's Infection Control Preventionist. On 11/1/22 at 11:15 AM, an observation of R55's room was conducted and revealed no signage on the door or PPE outside of the room to indicate they had been placed on droplet transmission-based precautions, despite their two positive rapid COVID19 tests. On 11/1/22 at 11:22 AM a review of R17 and R63's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/1/22 at 12:10 PM, an interview was conducted with RN 'F', the facility's ICP (Infection Control Preventionist) regarding the facility's COVID19 outbreak. RN 'F' said they started their position as the ICP at the beginning of October and had no prior experience with the role of ICP. RN 'F' said they believed the outbreak began with an employee, Activity Aide 'OO' who worked while they were symptomatic but twice tested negative on the facility scheduled testing days until 10/21/22 when they received a positive test result from a test taken in the community. They were asked specifically about the signs on the doors of R17 and R63's room and said they were placed on TBP (transmission-based precautions) because their roommates tested positive and R17 and R63 tested negative; but, because of the exposure to their roommates they had been placed on TBP. They were then asked specifically about the instructions on the signs that only indicated staff were to wear a face mask (no specific type defined) and eye protection, and RN 'F' had no explanation for the signs, but did indicate staff should wear an N95 mask, isolation gown, eye protection, and gloves when entering R17 and R63's room. RN 'F' was then asked if they were aware R63 no longer had a sign on the door that indicated they were on TBP. They said R63 had the sign yesterday, but further explained they could be taken off TBP because they were fully vaccinated and received the COVID19 booster. They were then asked if they were aware R55 had tested positive for COVID19 and said they were. They were asked if R55 had been placed on TBP and said they were, despite the observation no signs had been posted or PPE had been placed near R55's room between the time of 10:46 AM, when the first positive test result had been observed in the hallway and a second observation of the room at 11:15 AM. The observation of LPN 'Z' not initiating TBP for R55 after the first positive test, as well as entering R55's room with only a surgical mask and eye protection to obtain the second rapid test was shared with RN 'F', and they had no explanation for the identified concern. On 11/1/22 at 1:15 PM, R55's room was observed to have signs that indicated an N95 mask, gown, gloves, and eye protection were required for entry into the room. At that time, Housekeeper 'CC' was observed in the room cleaning the floor. Housekeeper 'CC' was observed to be wearing a gown, gloves, and eye protection, but did not have an N95 mask on, rather they were wearing a surgical mask. On 11/2/22 at 9:05 AM, R63's room was observed to again have a sign indicating they were on TBP precautions as well as a sign that indicated an N95 mask, isolation gown, gloves, and eye protection were to be worn when entering the room. On 11/2/22 at 2:58 PM a follow-up interview was conducted with RN 'F' for clarification on R63's transmission-based precaution status. They said someone from corporate told them to put R63 back in TBP. A review of facility provided policies was conducted and revealed the following: A policy titled, Infection Prevention and Control adopted 10/10/22 read, .Subject: COVID19 Core Practices .Staff members entering a resident room with suspected or confirmed [CONDITION(S)]-CoV-2 (COVID19) should use all recommended PPE, which includes use of a NIOSH (National Institute for Occupational Safety & Health) approved N95 or equivalent or higher-level respirator eye protection .gloves .and gown . On 11/2/22 at 12:20 PM, RN F was interviewed and asked how often the facility tested for COVID 19. IP F explained testing was done every Tuesday and Fridays for residents and staff. When asked if a resident was tested when symptoms started, or wait until the next testing day, IP F explained since they were testing two times a week, the resident would be tested on the testing day. Review of nursing assessments titled, Respiratory Symptom Evaluation revealed: R33 had an assessment completed on 10/23/22 with no symptoms noted. The assessment was not completed on 10/24/22. According to the facility's COVID 19 line listing, R33 had an onset of symptoms, fatigue, on 10/23/22. R33 was not tested until 10/25/22, and was positive for COVID 19. R45 had no assessment completed on 10/24/22. The assessments on 10/25/22 also listed no symptoms. According to the line listing, R45 had an onset of symptoms, runny nose, on 10/24/22. R45 was tested on [DATE] and was positive. R72 had no assessment completed on 10/24/22. Accordint to the line listing, R72 had onset of symptoms on 10/24/22. R72 was tested on [DATE] and was positive. R44 had no assessment completed on 10/25/22. According to the line listing, R44 had an onset of symptoms, runny nose and fatigue, on 10/25/22. R44 was tested on [DATE] and was positive. On 11/3/22 at 12:37 PM, RN F was interviewed and asked about the description of symptom onset and the delay in testing. RN F explained after the residents tested positive, she went and asked them if they had any symptoms before they tested positive, and that is what she put on her line listings. RN F was asked if nurses should have assessed the residents for the symptoms they had indicated they had before testing, considering the facility was in outbreak status. RN F had no answer. Review of a facility policy titled, COVID19 Core Practices adopted 10/10/22 read in part, .The facility will evaluate residents at least daily for fever and symptoms consistant with [CONDITION(S)]-CoV-2 (COVD -19) .The facility will follow local, state and federal guidance for testing residents . Review of Centers for Medicare & Medicaid Services (CMS) guidance titled, QSO-20-38-NH revised 9/23/22 read in part, .Testing Trigger: Symptomatic individual identified .Residents, regardless of vaccination status, with signs or symptoms must be tested . R15 A review of R15's clinical record noted the resident was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS indicated the resident had a BIMS score of 11/15 (moderately intact cognition) and required extensive two person assist for most Activities of Daily Living. Continue review of the resident's clinical record documented, in part, the following: General Progress Note (10/18/22): Resident had blood mixed in sputum .new orders for CBC, BMP and Sputum culture . General Progress Note (10/22/22): Writer reviewed results. Notified MD but he responded he was out of the country. Writer then called NP but not response. Notified NP through text. General Progress Note (10/22/22): Resident has a temperature of 99 at about 3:30 PM . General Progress Note (10/23/22): Writer received new orders for midline insertion for antibiotic therapy . Medical Practitioner Progress Note (10/24/22): .Patient seen and examined .chronic cough plus thick copious sputum .4 MDR Pneumonia: Sputum culture with E. coli, ESBL .[CONDITION(S)]. General Progress Note (10/25/22 at 6:39 AM): Resident had a brief moment where she began to have excessively thick [MEDICATION(S)] .Upon assessment resident stated that she could not breathe . General Progress Note (10/25/22 at 10:31 AM): Writer met resident this morning alert, but saying Help me, help me O2 was fluctuating between 89 and 90 Writer called 911 and patient was picked up by 10:15 AM for (redacted hospital) . General Progress Note (10/25/22): .was sent to Hospital .Also notified resident tested positive for covid today before being sent out . Order dated 10/25/22 (7 PM) Resident is on droplet precautions positive COVID 19. On 10/2/22 at approximately 3:39 PM, an interview was conducted with Infection Control (IC) Nurse F. Nurse F was asked as to R15's COVID testing as well as date of order for precautions. Nurse F reported that the resident was tested for COVID19 on 10/21/22 and again on 10/25/22. When asked why R15 was not placed on precautions until 10/25/22 after they were transferred to the Hospital, Nurse F stated that they had reviewed the resident's record and noted the resident should have been placed on precautions on 10/24/22 when it was determined they had [CONDITION(S)] pneumonia. On 11/1/22 at 1:48 PM, the Administrator was informed of the IJ that was identified on 11/1/22 and began on 10/23/22 when the facility failed to accurately assess residents with signs and symptoms of COVID19, immediately implement TBP, ensure appropriate signage, and ensure appropriate utilization of PPE. On 11/2/22 the survey team confirmed the facility implemented the following to remove the immediacy: 1. On 11/1/2022 the facility received a visit from the surveyors issuing F880 at an IJ level for Resident #15 and Resident #44, both residents have been discharged from the facility. 2. The nurse identified administering the COVID 19 test was educated on proper PPE when testing residents and those in TBP's by the DON (Director of Nursing). 3. All Staff are being educated on proper PPE specifically for those in TBP's and when administering COVID 19 test. 4. Licensed Nurses will be educated on testing residents upon the onset of symptoms for COVID 19 and initiate TBP's when deemed appropriate. 5. Residents were assessed by the Licensed Nurses for a respiratory evaluation. No new residents identified with signs/symptoms of COVID 19 from this audit. 6. Residents who have not been diagnosed with COVID 19 in the last 30 days were tested with 1 positive resident on 11/1/2022. Positive resident was put into TBP's. 7. ADM (Administrator), DON and IP (Infection Preventionist) were educated by the RNC (Regional Nurse Consultant) on COVID 19 policies to include the Guidance- CORE practices and IC procedures to mitigate the spread of infection. 8. The Nurse Management Team completed observation rounds to ensure staff were wearing the appropriate PPE and adhering to the infection control policies and procedures. 9. Medical Director was notified of these findings on 11/1/2022. 10. QAA Committee has reviewed the plan and will continue to review the audits to ensure adherence to the Infection Control Policies specifically to COVID 19. Although the immediacy was removed on 11/1/22, the facility remained out of compliance at a scope of Widespread and a severity of No actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance has not been verified by the State Agency. DPS #2 Based on observation, interview, and record review the facility failed to ensure appropriate hand hygiene and glove use for four residents (R#'s 79, 42, 48, and 88) of 23 residents reviewed for infection control, resulting in the potential for the spread of infection. Findings include: A review of a policy titled, Nursing Clinical updated 3/24/22 read, .Subject Hand Hygiene Healthcare personnel should use and alcohol-based hand rub or wash with soap and water for the following clinical indications .Immediately before touching a resident .Immediately after glove removal . On 10/31/22 at 8:39 AM, LPN (Licensed Practical Nurse) LPN 'LL' was observed obtaining R79's blood sugar in preparation for insulin administration. LPN 'LL' gathered the necessary equipment from the medication cart, entered R79's room donned a pair of examination gloves and obtained their blood sugar with the glucometer. LPN 'LL' then exited the room, doffed the gloves in the hallway, disposed of them in trash bin on the medication cart parked in the hallway and began preparing R79's morning medications. LPN 'LL' was not observed to perform hand hygiene upon entering R79's room or after doffing their gloves in the hallway prior to preparing R79's medications. After the medications (oral medications and an insulin pen) were prepared LPN 'LL' re-entered R79's room. They were not observed to perform hand hygiene upon entry. R79 refused two of the pill medications and LPN 'LL' was observed to remove them from the medication cup with their bare hands. After R79 took their morning oral medications LPN 'LL' was observed to attach a disposable needle to the insulin pen and administer the medication in the back of R79's right arm. LPN 'LL' was not observed to don gloves prior to administering the subcutaneous injection. At the completion of the medication administration, LPN 'LL' exited the room and was observed to finally perform hand hygiene. On 11/1/22 at 8:32 AM, RN 'V' was observed in the hallway preparing medications for R42. RN 'V' was observed to be wearing a pair of blue examination gloves while they prepared the medications. RN 'V' then entered R42's room with the gloves on, administered the medications and exited the room with the examination gloves on. RN 'V' was then observed to sign off the medications given, move the cart across the hall, and discard the gloves. RN 'V' was not observed to perform hand hygiene after doffing the gloves. RN 'V' then donned a new pair of blue examination gloves and began to prepare medications for R48. On 11/2/22 at approximately 8:46 AM, Medical Director L (MD L) was observed coming out of R88's room, a room designated to require contact precautions for C-diff ([CONDITION(S)], a highly contagious gastrointestinal bacteria). MD L was queried if they washed their hands before exiting the room and indicated they were wearing gloves but did not wash their hands before exiting the room. MD L was queried regarding the sign on the door that directed all persons who enter should wash their hands before leaving the room and MD L indicated that they forgot.

This citation pertains to intake #s MI 532, MI 065, MI 819, MI 003, MI 272 and MI 173. Based on interview and record review, the facility failed to ensure consistent and comprehensive skin assessments, wound care consultant's treatment orders were entered into the record, wound care treatments were performed, and timely care planning for pressure ulcers for one resident (R103) of five residents reviewed for pressure ulcers, resulting in the development and worsening of pressure ulcers. Findings include: A review of a facility provided policy titled, Policy/Procedure-Nursing Clinical adopted 7/11/2018 was conducted and read, .Subject: Skin Monitoring and Management-Pressure ulcer .It is the policy of this facility that: A resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition or other factors demonstrate that a developed pressure ulcer was unavoidable; and A resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new, unavoidable sores from developing .1. RESIDENT ASSESSMENT . A. Complete an admission assessment/evaluation and skin risk assessment to identify risk and to identify any alterations in skin integrity noted at that time . D. Develop comprehensive care plan if indicated following the evaluation/assessment. Care plans must be individualized and designed to meet the needs of the resident for whom they are being developed. E. Assessment of wounds on admission, readmission AND discharge: A licensed nurse (which may be the Wound Nurse) must assess/evaluate a resident's skin on admission. All areas of breakdown, excoriation, or discoloration, or other unusual findings, must be documented in the Admission Assessment. A licensed nurse (which may be the Wound Nurse) must assess/evaluate each wound that exists on the resident. This assessment/evaluation should include but not be limited to: Measuring the wound Staging the wound Describing the nature of the wound (e.g., pressure, stasis, surgical wound) Describing the location of the wound Describing the characteristics of the wound .I. Once a wound has been identified, assessed, and documented, nursing shall administer treatment to each affected area as per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 10/31/22 at 3:53 PM and 11/2/22 at 1:41 PM, reviews of R103's closed record revealed they admitted to the facility on [DATE], transferred to the hospital on 10/8/21, readmitted on [DATE], discharged again to the hospital on 10/18/21, and readmitted on [DATE]. R103's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R103's Minimum Data Set (MDS) assessment dated [DATE] indicated they had severe cognitive impairment, was non-ambulatory, and required extensive total assistance from two staff members for bed mobility, transferring, and wheelchair mobility. MDS section M. for skin conditions indicated R103 admitted to the facility with pressure ulcers. R103's admission Braden Score (a score calculated to determine risk for pressure ulcer development) was noted to be a 16, meaning they were at risk for the development of pressure ulcers. A review of R103's admission nursing assessment dated [DATE] was reviewed and revealed they admitted with a stage two pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough) on their left foot, a stage one pressure ulcer (intact skin with non-blanchable redness of a localized area usually over a bony prominence) on their right hip, and a stage one pressure ulcer on their right ankle. It was noted the assessment did not include any measurements or descriptions of the wounds, and a box at the bottom of the skin assessment was checked that read, Treatment ordered or required. A review of R103's orders and treatment administration records was conducted and revealed no treatments were ordered for R103's wounds upon admission. It was further noted the first treatment orders on the TAR (treatment administration record) were entered on 10/7/21, when the wound care consultant physician first saw R103. Continued review of R103's closed clinical record revealed a wound care consult dated 10/7/21 that indicated the following: A right hip deep tissue injury (DTI, persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters caused by damage to the underlying soft tissues. It is common for a thin blister to form over the surface of the dark wound bed, and the wound may further evolve to become covered by thin eschar) that measured 6.5 centimeters (cm) x 7.0 cm with a recommended order for a dry dressing every other day beginning on 10/8/21. It was noted the TAR was blank for the treatment on 10/8/21. A right posterior thorax DTI that measured 6.0 cm x 3.0 cm with 50% eschar (black, dead tissue) with a recommended order for [MEDICATION(S)] and foam dressing daily. A review of the TAR did not reveal this daily treatment had been ordered and performed. A left posterior thorax DTI that measured 1.0 cm x 4.0 cm with a recommended order for [MEDICATION(S)] and a foam dressing daily. A review of the TAR did not reveal this daily treatment had been ordered and performed. A left hip DTI that measured 3.0 cm x 5.5 cm with a recommended order for a border foam dressing every other day beginning 10/8/21. An order to clean the sacrum with soap and water and apply [MEDICATION(S)] every shift and as needed. A left medial ankle DTI that measured 1.0 cm x 1.5 cm with a a recommended order for [MEDICATION(S)] and cover with a bulky dressing daily. A review of the TAR did not reveal this daily treatment had been ordered and performed. It was noted, R103 discharged to the hospital on 10/8/21 and readmitted on [DATE], however; no re-admission assessment was documented in the record and no orders for any type of wound care treatments were implemented upon their re-admission. R103's next wound care consult dated 10/14/21 revealed the following: A right hip UTD (Unstageable ulcer, full thickness skin or tissue loss where the depth cannot be determined) that measured 8.0 cm x 7.0 cm with 100% eschar with a recommended treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the TAR did not reveal this daily treatment had been ordered and performed. It was further noted this wound worsened and increased in size from the 10/7/21 assessment. A left posterior thorax UTD that measured 3.0 cm x 6.0 cm with 90% eschar with a recommended treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the TAR did not reveal this daily treatment had been ordered and performed. It was further noted this wound worsened and increased in size from the 10/7/21 assessment. A left hip UTD that measured 3.0 cm x 5.0 cm with 80% eschar and 10% slough with a recommended treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the TAR did not reveal this daily treatment had been ordered and performed. It was noted R103 transferred to the hospital on 10/18/21 and readmitted on [DATE]. R103's admission assessment dated [DATE] was reviewed and the skin assessment section was noted to be blank. R103's next wound care consults dated 10/28/21 revealed the following: A right hip UTD that measured 6.0 cm x 7.7 cm with 100% eschar and a recommended treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the TAR did not reveal this daily treatment had been ordered and performed. A new right ankle UTD that measured 0.5 cm x 0.5 cm with a recommended treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the TAR did not reveal this daily treatment had been ordered and performed. Right posterior thorax UTD that measured 8.0 cm x 7.7 cm with 90% eschar and a recommended treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the TAR did not reveal this daily treatment had been ordered and performed. A left posterior thorax UTD that measured 5.7 cm x 6.0 cm with 100% eschar and a recommended treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the TAR did not reveal this daily treatment had been ordered and performed. It was further noted this wound worsened and increased in size from the 10/14/21 assessment. A left hip UTD that measured 4.5 cm x 10.0 cm with 100% eschar and a recommended treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the TAR did not reveal this daily treatment had been ordered and performed. It was further noted this wound worsened and increased in size from the 10/14/21 assessment. A review of R103's care plans was conducted and revealed the first care plan and interventions for R103's pressure ulcers was dated 11/9/21, over a month after R103 admitted to the facility with existing pressure ulcers. On 11/2/22 at 11:28 AM, an interview was conducted with the facility's Director of Nursing regarding the process of the coordination between the wound care consultant and the facility. They explained when the wound care consultant did assessments and made recommendations they were to be scanned into the resident's record, the orders were entered and the treatments were to be performed.

This citation pertains to MI 505: Based on interview and record review the facility failed to promptly implement interventions and consistently perform treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: A complaint was received by the State Agency which alleged, in part, R#701 had ended up with a grade four bedsore on the left side above the buttocks that had not been present while the resident had been at a different facility. The complaint alleged R#701's care had been neglected. Review of the clinical record for R#701 revealed the resident was admitted to the facility 1/15/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's admission minimum data set (MDS) assessment dated [DATE] revealed the resident scored 4 out of 15 on a brief interview for mental status exam, which indicated the resident was severely cognitively impaired. Continued review of the resident's MDS assessment revealed R#701 had no unhealed pressure ulcers, was at risk for pressure ulcer development, required extensive assistance of one person for bed mobility, and required the extensive assistance of two plus persons for transfers. Review of the clinical record for R#701 revealed the following: Review of a NURSING ADMISSION SCREENING/HISTORY- V2 form for R#701 dated 1/15/21 did not reveal any documentation present on the skin section of the assessment. Per a BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK evaluation dated 1/15/21 and locked on 1/18/21 it was documented the resident had no impairment to sensory perception, skin exposure to moisture was occasionally moist, activity was documented as chairfast, mobility was slightly limited, nutrition was adequate, and friction/shear were a potential problem. The resident scored 17 on this assessment, which identified the resident as being at risk for pressure ulcer development. A .SKIN OBSERVATION TOOL-V 2 dated 1/15/21 documented a response of No to the following question: D. Patient has NEW alteration in skin integrity? Including open areas of any type, tears, bruising, red areas, rashes, etc. Review of a dietary evaluation for the resident dated 1/17/21 documented a response of No to the following question: Does patient have any skin integrity concern that could effect nutritional needs? Review of a Skin note dated 2/11/21 at 9:07AM documented, in part, Coccyx UTD pressure injury is presenting as coccyx stage IV pressure injury 9.0x8.0x5.0 with 100% brown loosely adherent tissue, copious purulent drainage, unattached edges, periwound is normal, NP (Nurse Practitioner) [Name Redacted] performed bedside debridement, due to appearance ofwound <sic> PT transported to Hosp for further exploration of wound. A Skin progress note dated 1/18/21 at 12:47PM documented, .Lt (left) glut 1.0x1.0cm (centimeter) R (right) glut 0.5x0.5xm coccyx 0.5x0.5cm partial thickness loss of dermis. No drainage noted. Bruising noted to surround skin. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Blanks were observed on R#701's January 2021 treatment administration record (TAR) for the 7AM documentation on 1/19/21 and 1/20/21. Per a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Per R#701's January 2021 TAR, this order had not been signed as completed on 1/19/21, 1/20/21, 1/21/21, or 1/22/21. Treatment had first been signed off as completed on 1/23/21. Per a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It was noted this order had been signed as completed on the 7PM area on the TAR for 1/20/21, 1/21/21, and 1/22/21, when the treatment order above had not been signed as completed, and the 7AM documentation on the TAR for 1/21/21 and 1/22/21 had been left blank. Also, blanks were observed on the TAR for the 7PM area on the TAR for the dates of 1/23/21 and 1/24/21. Review of a Skin progress note dated 1/21/21 at 3:36PM documented, in part, Late Entry .Coccyx UTD (unable to determine) 3.0x5.0x0.1cm. Partial thickness loss of dermis. Wound bed red/dry & non blanchable. Wound edges attached. No drainage noted. Peri-skin intact. A consult sheet dated 1/21/21 signed by the facility's former wound Nurse Practitioner (NP) 'Q' reflected the same coccyx wound measurements indicated in the note above. The consult included options circled on the form for the following wound treatment: Clean wound with wound cleanser, apply to wound bed: Calcium Alginate, [MEDICATION(S)] gel, Cover with border foam every day and as needed. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was noted to be active at the same time as the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A .SKIN OBSERVATION TOOL-V 2 dated 1/25/21 documented a response of No to the following question: D. Patient has NEW alteration in skin integrity? Including open areas of any type, tears, bruising, red areas, rashes, etc. Per the ADDITIONAL INFORMATION section of the form it was documented, coccyx-Partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed, with slough (non-viable yellow, tan, gray, green or brown tissue; usually moist). Review of a Skin progress note dated 1/28/21 at 1:13PM documented, in part, .Eound <sic> care unable to see due to loose stools and blood in urine. COCCYX UTD. Review of NP 'Q's consult sheet for the coccyx UTD wound for 1/28/21 documented, Did not see pt having loose stool blood in urine. No additional information was included on this form related to wound assessment. Review of a Skin progress note which had been documented by the facility's Director of Nursing (DON) dated 2/4/21 at 4:34PM documented, in part, Resident seen by wound care for coccyx wound UTD measuring at 6.0x7.0 eschar (dead or devitalized tissue) 100%, hard. Wound bed dry, eschar, non blanch. Surrounding skin intact. Clean with Dakin's and apply Calcium Alginate and [MEDICATION(S)] to wound bed with crushed [MEDICATION(S)]. Cover with border foam daily and PRN (as needed). New order for [MEDICATION(S)] PO BID (twice a day) X's 10 days . This assessment was also present on R#701's consult sheet dated 2/4/21 for R#701. Review of the TAR for R#701 the use of Dakin's was not present in physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Skin note dated 2/11/21 at 9:07AM documented, in part, Coccyx UTD pressure injury is presenting as coccyx stage IV pressure injury 9.0x8.0x5.0 with 100% brown loosely adherent tissue, copious purulent drainage, unattached edges, periwound is normal, NP (Nurse Practitioner) [Name Redacted] performed bedside debridement, due to appearance ofwound <sic> PT transported to Hosp for further exploration of wound. Review of a Medical Practitioner Note (Physician/PA/NP) note dated 2/11/21 at 11:32AM documented, in part, .seen per request of wound nurse. It has been reported pt worsening sacral woundwith <sic> with what appear to have fecal output. Today pt states he feel terrible. He has c/o (complaints of) weakness, sacral pain, nausea .He is pale in appearance has a foul odor permeating in the room .SKIN .Sacral wound not visualized but very notable odor coming from brief . Per a Surgical Wound Care Report dated 2/11/21 signed by former wound NP 'Q' it was documented, .Pt c (with) foul unstable eschar to wound, pt c ongoing flatulence, upon debridement liquid brown copious drainage, similar in odor (and sign) appearance to stool. Pt tolerated procedure. Large amount of brown slough-foul odor. Pt NP [Name Redacted] notified of concern regarding wound-advised ER . Review of a hospital record for R#701 ED (Emergency department) provider note dated 2/11/21 documented the resident's chief complaint as wound infection. It was documented, in part, .presenting today via EMS (emergency medical services) with complaints of worsening wound to his bottom area as well as abdominal pain. Staff at facility where patient lives reported wound is infected. Also, per an ED provider note dated 2/11/21 the following was documented per the physical exam skin section: Large sacral wound with malodorous drainage extending to the bone possible tracking-eschar noted. Review of a plan of care for R#701 created 1/18/21 documented, Resident has potential/actual impairment to skin integrity r/t (related to) incontinence. It was noted all interventions to the plan of care were dated 1/18/21. A plan of care was not observed to be present in the record to the address the actual wound to R#701's coccyx. On 3/23/21 at 3:25PM, Wound Care Nurse 'E' was queried in regard to wound care at the facility, and explained, in part, the following: Floor nurses would complete the treatments, skin assessments would be completed weekly by the nurse assigned to the unit on the shift, and it was acknowledged the facility did not take photographs of resident wounds. When queried in regard to R#701, Wound Care Nurse 'E' explained she was out of the facility for multiple weeks, determined to be all but one day of the resident's stay, and explained Registered Nurse (RN) 'T' had assisted with wounds during that time. On 3/23/21 at 4:25PM, NP 'Q' was queried in regard to R#701. When queried as to the documentation she had not seen the resident related to loose stools and blood in the urine, NP 'Q' explained she had been told the resident was possibly going out of the facility. On 3/23/21 at 4:56PM an interview was conducted with RN 'T', who had been assisting with wound care. Per RN 'T', she had completed wound rounds with Nurse Practitioner 'Q' for this resident. On 3/24/21 at 2:52PM the facility's Director of Nursing (DON) was queried in regard to R#701 and the wound process at the facility. The DON was queried in regard to the use of Medihol gel, and additional information was requested in regard to this product as to whether it had been delivered by pharmacy for the resident or a stock product. The DON explained she would need to look into this. The DON was queried about the resident's wound note on 2/4/21, explained she (the DON) had rounded with the facility's former wound NP 'Q' because there was no one available to do wound rounds, and had input the note from the NP's assessment. The DON acknowledged she had not seen the resident's actual wound (although it was noted the DON had rounded with the provider). The DON was queried as to whether concerns with the resident's wound had been brought to her attention, and the DON denied this having occurred. The DON explained if wounds were acquired/worsening, Wound Care Nurse 'E' normally told the DON. Per the DON, RN 'T' (who had been covering wound care in Wound Care Nurse E's absence) had not talked the DON about this. On 3/24/21 at 3:35PM the DON explained that she would be provided with a wound log (containing measurements, facility vs community acquired wounds, healing). Per the DON when wound care nurse 'E' had been off, the DON had not been receiving the log. It was further explained the wound care nurse was supposed to send this to the DON, and the DON was unable to answer when queried as to the length of time she had not received the wound log. The DON explained the frequency of the wound log as weekly. When queried if the wound log was updated when the DON was aware of the resident's situation, the DON explained the wound log had not been updated as she had been playing catch up. The DON was queried in regard to the progression/worsening of R#701's wound and explained she could not answer as to why the progression had occurred. Review of a facility policy titled, Skin Monitoring and Management-Pressure Ulcer dated 7/11/18 documented, in part, It is the policy of this facility that: -A resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition or other factors demonstrate that a developed pressure ulcer was unavoidable; and -A resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new, unavoidable sores from developing.

This citation pertains to Intake Number(s): MI 884 and MI 421. Based on interview and record review, the facility failed to assess residents for nutritional status on admission and implement interventions to address residents at high risk for impaired nutritional status for one (R709) of five residents reviewed for nutrition and hydration, resulting in an immediate jeopardy (IJ) when R709, a resident with a recent stroke that resulted in physical deficits, was not assessed by a registered dietitian (RD), monitored for nutrition and hydration status, and did not receive assistance with eating and drinking according to recommendations made by therapy, died of dehydration. Findings include: The IJ began on [DATE]. The IJ was identified on [DATE] at 3:00 PM. The facility was notified of the IJ on [DATE] and 1:30 PM. A plan to remove the immediacy was requested. The immediacy was removed on [DATE] based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the immediacy was removed the facility's deficient practice was not corrected and remained isolated with actual harm that is not immediate jeopardy. A complaint was submitted to the State Agency that alleged the facility failed to ensure the resident received proper nutrition and hydration, resulting in extreme dehydration and death. On [DATE], an unannounced onsite investigation was initiated. A review of a Certificate of Death for R709 was conducted. The death certificate documented R709 was pronounced dead at 2:05 AM on [DATE]. The Cause of Death was documented as Dehydration. A review of R709's clinical record was conducted and revealed the following: R709 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A 5-Day Minimum Data Set (MDS) assessment dated [DATE] documented R709 had severely impaired cognition and required extensive physical assistance for eating. A Nursing Home to Hospital Transfer Form documented R709 was transferred to the hospital on [DATE] (no time documented) for increased respirations, [CONDITION(S)] (low blood pressure), tachycardia (increased heart rate). R709's vitals signs were as follows: Blood Pressure = ,d+[DATE], Heart Rate = 112, Respiratory Rate = 35. The form was completed on [DATE] at 2:48 AM. It was not documented who the report was called into. Hospital Records for R709 were reviewed. An Emergency Department Note dated [DATE] at 12:47 AM documented, .Patient presents from nursing home for evaluation of difficulty breathing. Patient also hypotensive blood pressure ,d+[DATE] .Patient very weak. He is tachypneic (abnormally high) respiratory rate 36 pulse ox (oximetry) 97% on 3 L (liters) nasal cannula .He is in distress secondary to tachypnea .Very dry mucous membranes of the mouth tongue is very dry .Dry skin present . .Results for orders placed or performed during the hospital encounter of [DATE]: Sodium 155 (normal range is 135 - 145 mmol/L - millimoles per liter) .Potassium 3.2 (normal range is 3.5 - 5.0 mmol/L) .Chloride 128 (normal range is 98 - 111 mmol/L) .Blood Urea [MEDICATION(S)] 114 (normal range is 10 - 25 mg/dL - milligrams per deciliter) .Creatinine 4.00 (normal is less than 1.13 mg/dL) .Glucose 101 .GFR (Glomerular Filtration Rate) .13 (normal is greater than 60 ml/min/1.73 m2) .[MEDICATION(S)] 1.8 (normal range is 3.2 - 4.6 g/dL - grams per deciliter) . .Re-evaluation (1:15 AM) -patient had improvement in his blood pressure. It continued to rise with fluids Foley catheter has been placed urine is dark concentrated .patient remains tachypneic . (2:10 AM) last blood pressure ,d+[DATE]. He remains afebrile tachypneic with respiratory rate 30 pulse ox 99% on nasal cannula .Will continue IV (intravenous) fluids monitor urine output and I will admit the patient to hospital for further treatment and care .Patient's condition is critical he may not survive this hospital admission .at this time is a seems to be improving with fluids in the does have an acute kidney injury with acute [CONDITION(S)] secondary to most likely dehydration . A History and Physical dated [DATE] at 4:56 PM written by R709's attending physician at the hospital (who was also the resident's physician at the hospital prior to admission into the facility) documented, .On admission the patient was noted to have a blood pressure of ,d+[DATE], respiratory rate of around 36, and pulse ox of 97% on 3 L of oxygen. He was noted to have AKI (acute kidney injury) and [CONDITION(S)] (high levels of sodium in the blood) - all suggestive of dehydration .mouth with dried exudates on the posterior pharynx (back of throat), dry mucosa, lips are dry .ASSESSMENT AND PLAN .1. Severe dehydration-with free water deficit, patient has been started on IV fluids 2. AKI-due to # 1 above, should improve with IV fluids 3. [CONDITION(S)] (abnormally high sodium levels), hyperchloremia (abnormally high chloride levels)-secondary to dehydration and free water deficit. As above, continue IV fluids .[CONDITION(S)]-secondary to dehydration .10. Leukocytosis (elevated white blood count)-most likely reactive due to dehydration but patient at risk for aspiration pneumonia as well 11. Malnutrition-no plans for any PEG (percutaneous endoscopic gastrostomy - feeding tube) tube placement . A policy provided by the facility titled, Nutrition Monitoring and Management Program adopted on [DATE] was reviewed. The policy documented the following: It is the policy of this facility to ensure that all residents maintain acceptable parameters of nutritional status .PURPOSE: To provide care and services including: Assessing the resident's nutritional status and the factors that put the resident at risk of not maintaining acceptable parameters of nutritional status .Analyzing the assessment information to identify the medical conditions, causes and/or problems related to the resident's condition and needs .Defining and implementing interventions for maintaining or improving nutritional status that are consistent with resident needs, goals, and recognized standards of practice, or explaining adequately in the medical record why the facility could not or should not do so; and Monitoring and evaluating the resident's response or lack of response to the interventions; and Revising or discontinuing the approaches as appropriate, or justifying the continuation of current approaches .Each resident's nutritional status is assessed by the Registered Dietician or his/her designee on admission and at least quarterly thereafter, and following a change in condition .In connection with the above assessment of the Registered Dietician, the IDT (interdisciplinary team) will further assess nutritional needs and goals of the resident in the context of his/her overall condition, including the following: .Oral intake of foods and fluid .IV therapy .Functional status (assistive devices, cues, hand-over-hand, extensive assistance .Chewing and swallowing problems .Relevant conditions and diagnosis .Abnormal labs .Overall prognosis/condition . A policy provided by the facility titled, Hydration adopted on [DATE] was reviewed. The policy documented, .To ensure that each resident is encouraged to consume adequate fluids in order to maintain proper hydration for optimum functioning of various body systems. According to the United States National Library of Medicine, nutritional status is defined as, State of the body in relation to the consumption and utilization of nutrients. Further review of R709's clinical record revealed the following: A review of assessments revealed R709 was not assessed by a RD upon admission or during their stay at the facility. There was no documentation of R709's caloric or hydration needs for the duration of their admission from [DATE] through [DATE]. A Nursing Admission Screening dated [DATE] and locked three days later on [DATE] documented R709 was admitted for COVID-19. The LOC/Orientation/Neurological section documented R709 had CVA (cardiovascular accident) and dysphagia. It was documented R709's general appearance was well nourished with moist lips and tongue. The ADL's (Activities of Daily Living) section documented R709 was Totally Dependent for eating. Physicians Orders were reviewed and revealed the following diet orders: an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan initiated on [DATE] documented, Resident has nutritional problem or potential nutritional problem r/t (related to) . The care plan did not specify what the nutritional problem was related to. Interventions initiated on [DATE] documented, Provide, serve diet as ordered. Monitor intake and record q (every) meal. Report changes in consumption to nurse and/or dietician and Weigh resident per facility protocol, maintaining consistency in type of scale, time of day, etc. as able. There were no interventions related to assistance required for eating or consistency of diet. A care plan initiated on [DATE] documented, Resident has an ADL self-care performance deficit r/t. The care plan did not specify what the deficits were related to. Interventions initiated on [DATE] documented, Provide supportive care, assistance with daily care needs (ADLs) as needed. Document assistance as needed. The care plan did not specify the level of physical assistance R709 required for eating and drinking. A Baseline/Interim Care Plan dated [DATE] and locked on [DATE] documented R709's diet order was regular, puree, HTL (honey thickened liquids) in the Nutrition section. According to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . It was documented nutritional concerns were identified on evaluation/assessment. However, a nutritional assessment was never completed during R709's stay at the facility. The Nutrition section was signed by RD GG and was not dated in the section labeled Signature of staff participating in development of plan of care, title and date. The ADL section R709 was independent without assistive devices for eating. It was signed by Nurse P and did not include a title or date in the section labeled Signature of staff participating in development of plan of care, title and date. A Speech Therapy Plan of Care for services provided from [DATE] through [DATE] documented the following: Reason for Referral: .following admission secondary to ew <sic> CVA with [CONDITION(S)] and dysphagia . .Therapy Necessity .Without therapy patient at risk for inability to express wants and needs and aspiration . .Precautions: .R (right) [CONDITION(S)] (paralysis of one side of the body) .Aspiration risk Recommended diet is PUREE. Recommended liquids consistency is NECTAR THICK. Assistance with feeding, small bolus, slow rate, and alternation of solids and liquids .Discussed with the pt's nurse, NP (nurse practitioner), and RD . ST (speech therapy) Daily Treatment Notes were reviewed for R709. A note entered on [DATE] documented, .The pt (patient) was provided with his meal tray consisting of puree and NTL (nectar thick liquids) with 1:1 (one to one) assistance. Significant encouragement was required for PO (by mouth) acceptance .NTL was provided via straw initially however the pt was unable to acquire liquids. Labial seal (a swallowing process that prevents food and liquids from spilling out of the mouth) on a cup was poor therefore liquids were provided via spoon .Trialed HTL via spoon .Recommend diet change to puree with HTL . A note dated [DATE] documented, The pt was provided with puree and HTL with 1:1 assistance. The pt was highly resistant to eating and consistently expressed 'hang on' .HTL was provided via spoon, pt refused straw and cup .Significantly reduced intake was exhibited. Discussed with the pt's CNA who reported good intake during lunch meal yesterday. A note dated [DATE] documented, .HTL was provided via spoon . A ST - Therapist Progress & Discharge Summary for R709 signed on [DATE] documented, Recommend a puree diet with HTL, provided 1:1 assistance, small bolus, slow rate, and alternation of solid and liquids .provided pt, family, and staff education . An Occupational Therapy (OT) Plan of Care for services provided from [DATE] through [DATE] was reviewed and documented the following: .Reason for Referral: .High Complexity evaluation examination identified 5+ performance deficits including self care .ADL .that result in activity limitations and/or participation restrictions .Precautions: .Consult ST as appropriate. 1:1 assist with meals . .Initial Assessment .Functional Deficits .ADL Self Care, Self Feeding .Current Level .maximum assistance (,d+[DATE] % assist) .Self-Care, .Eating .Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort . .Functional Deficit Other .Impaired cognition, with delayed processing and impaired task initiation or sequencing .Pt unable to move RUE (right upper extremity) on command .Pt requires 1:1 assist with meals . An OT Daily Treatment Note documented the following on [DATE]: .Assessment identified performance deficits in all areas of self care .due to physical and cognitive deficits and significant comorbidities including stroke with RUE [CONDITION(S)], [CONDITION(S)], COVID-19 and prolonged hospitalization that result in activity and/participation restrictions . A note dated [DATE] documented, The patient was very hyper verbal throughout the session with writer only able to make out a few things he was trying to say. The patient did ask for something to drink requiring instruction in how to sip from a straw. The patient required several attempts before he was able to retrieve the liquid through the straw. Once the patient was able to grasp how to drink from the straw he successfully drank 75% of the thickened juice in his cup . An OT - Therapist Progress & Discharge Summary for R709 documented, .Functional Deficits .ADL Self Care, Self Feeding .dependent 100% assist . On [DATE] at 2:45 PM, the Director of Nursing (DON) was interviewed. When queried about the facility's protocol for implementing recommendations made by the therapy department, the DON stated, If speech therapy recommended something, the order would be given to dietary and dietary would communicate to nursing. When queried about who was responsible for ensuring the orders were on the care plan and Kardex (where the CNAs would look for any care instructions for residents), the DON stated, It depends. On [DATE] at 3:20 PM, the Administrator was interviewed. When queried about when a dietary assessment should be completed for a new admission, the Administrator reported no later than 48 hours after admission. When queried about R709 not having a dietary assessment during the eight days he was a resident at the facility, the Administrator reported it should have been done. On [DATE] at 10:50 AM, Speech Language Pathologist (SLP) R was interviewed, and the above documentation was reviewed. When queried about how recommendations made from ST were implemented, SLP R reported they would conduct an evaluation, if there were any recommendations regarding diet, they would discuss with the nurse and talk to the dietitian. When queried about recommendations made for R709, SLP R reported they continued with orders from the hospital for pureed food with NTL. When queried about the documentation of 1:1 assistance and being fed liquids with a spoon, SLP R stated, It was more of him refusing and not an inability to drink it. SLP R reported she saw R709 four times during the treatment period ([DATE]-[DATE]). SLP reported that she documented provided 1:1 assistance but that meant he needed assistance, not necessarily 1:1 feeding and the small bolus, slow, rate, and alternation of solids and liquids were safe swallowing strategies that she would recommend for anyone. When queried about whether R709 would be able to follow the safe swallowing strategies documented in the recommendations, SLP R reported he would not be able to follow that without 1:1 assistance from staff. A review of the Documentation Survey Report (a report of care provided by the Certified Nursing Assistants - CNAs) for [DATE] for R709 revealed the following: In the section labeled Document Amount of Meal Taken, it was documented by CNAs that the level of assistance provided by staff to assist R709 with eating varied from independent to totally dependent. It was documented R709 did not eat lunch or dinner on [DATE]. It was documented R709 ate 75 percent of breakfast and lunch on [DATE] with supervision (oversight, encouragement or cueing). Dinner was left blank on [DATE]. On [DATE], it was documented R709 ate 25 percent of breakfast and lunch with limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs) and ate 50 percent of dinner with extensive assistance (resident involved in activity). On [DATE], breakfast and lunch was left blank and it was documented R709 ate 25 percent of dinner with extensive assistance. On [DATE], it was documented R709 ate 25 percent of breakfast with limited assistance, 100 percent of lunch with limited assistance, and was totally dependent on staff for assistance with eating 25 percent of dinner. It was documented R709 refused to eat breakfast and dinner on [DATE] and consumed 100 percent of lunch with limited assistance from staff. On [DATE], it was documented R709 ate 100 percent of breakfast and lunch with limited assistance and ate 25 percent of dinner with extensive assistance. On [DATE] and [DATE], it was documented R709 was totally dependent on staff for eating all meals. On [DATE], it was documented R709 was not available for breakfast. Additionally, it was documented R709 ate 75 percent of lunch with limited assistance and 100 percent of breakfast on [DATE] with limited assistance. However, R709 was no longer in the facility at those times due to an emergency transfer to the hospital on the evening of [DATE]. In the section labeled, Hydration/Fluids Offered it consistently documented Hydration/Fluids offered during shift, including meals and that Hydration/Fluids consumed during shift. The amount of fluids consumed or how R709 consumed the fluids was not included in the documentation. The following entries were left blank: [DATE] 10:30 PM-6:30 AM (midnight shift), [DATE] 2:30 PM-10:30 PM (afternoon shift), [DATE] midnight shift, [DATE] 6:30 AM-2:30 PM (day shift), and [DATE] midnight shift. On [DATE] at 12:00 PM, the DON was interviewed and R709's clinical record was reviewed. The DON reported the dietary department was responsible for implementing therapy recommendations and the recommendations would be added to the meal ticked and care planned. The DON was queried about whether the recommendations for 1:1 assistance for feeding for R709 or any other therapy recommendations were implemented, and care planned. The DON reviewed R709's clinical record and stated, I did not see that it was implemented. When queried about how nursing staff were aware of R709's dietary (nutritional and hydration) and functional needs, the DON did not offer a response. On [DATE] at 12:52 PM, RD T was interviewed. When queried about when nutritional assessments were completed for new admissions, RD T stated, Best clinical practice is within 24 hours, but I try to get them done within five days. RD T reported all new admissions were to have a nutritional assessment completed and any orders or recommendations would be added to the care plan and CNA Kardex. When queried about R709, RD T did not remember the resident and did not know why a nutritional assessment was not completed. RD T reported the assessment document was opened on [DATE] (the day R709 was discharged ) but it was never completed. Further review of R709's clinical record was conducted. All progress notes were reviewed for the duration of R709's stay at the facility. There was no documentation of amount of intake of fluids or output of urine. There were no progress notes that documented any signs and symptoms of dehydration despite the hospital documentation that noted R709 was dehydrated and required IV fluids upon arrival to the emergency department. Between [DATE] and [DATE] there were no nursing notes that indicated R709 was showing signs and symptoms of dehydration. Skilled Charting assessments did not document the color, clarity, or odor of R709's urine. There was no care plan developed that indicated R709 was at risk for dehydration due to his cognitive and physical deficits due to the stroke or his medical diagnoses. R709 was seen by a nurse practitioner on [DATE] and [DATE]. There was no documentation that noted a physician or nurse practitioner was notified of any signs and symptoms of dehydration. A review of vital signs revealed R709 exhibited increased heart rate on [DATE] (111 beats per minute) and [DATE] (111 bpm). It was also noted that R709 required blood pressure medications to be held due to blood pressures being outside of parameters on [DATE], [DATE], and [DATE]. There was no documentation that a physician was notified. There were no nursing progress notes written between [DATE] and [DATE] when the following was documented, Patient observed by writer during rounds lethargic with increased respirations. Writer assessed patient, respirations 35, hr 112, bp ,d+[DATE] .Oxygen in place at 2 liters. MD notified and new order to send to hospital . A progress note written by Nurse Practitioner (NP) N on [DATE] documented R709's laboratory results from [DATE] were within normal limits seven days prior to being transferred to the hospital. (Na - Sodium 145, K - Potassium 3.8, Glu - Glucose 114, bun/creat - creatinine ,d+[DATE].82, GFR 95).

This citation pertains to Intake #'s: MI 828, MI 884, MI 2, MI 9, MI 1. Based on observation, interview and record review, the facility failed to timely, consistently and accurately assess and monitor resident's skin to promptly identify changes in skin conditions, ensure interventions were implemented in a timely manner, and complete treatment orders, to prevent the development and worsening of pressure ulcers for four (R#'s 708, 715, 716, and 720) of seven residents reviewed for wounds, resulting in R#720's development of a facility-acquired Stage IV (full thickness skin and tissue loss) pressure ulcer with drainage and foul odor which required a Wound VAC (vacuum-assisted closure), and the potential for the development and worsening of pressure ulcers for R#708 , R#715 and R#716. Findings include: R#720 On 2/11/21 at 10:18 AM, R#720 was observed lying in bed. Review of the clinical record revealed R#720 was originally admitted into the facility on [DATE] and readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) assessment dated [DATE], R#720 had severely impaired cognition, was totally dependent on two plus staff for all Activities of Daily Living (ADL's) and had one facility-acquired Stage IV pressure ulcer. Review of R#720's progress notes revealed: Skin note dated 8/20/20 that read, Resident was evaluated for wound care; No wounds noted. Wound care signs off. Change of Condition note dated 9/2/20 that read, Wound observed on coccyx. MD (Medical Doctor) notified and examined patient, new orders to follow . Skin note dated 9/3/20 that read in part, .#1 Coccyx-stage 4, sudden onset; 5.0 x 2.0 x 2.0 (centimeters - cm) full thickness with 80% eschar (dead or devitalized tissue, may appear scab-like)-soft, stable. Appears non blanch (non-blanchable), with eschar. Edges unattached, macerated (prolonged exposure to moisture), thin. Mod (moderate) sanguineous (bloody) drainage with foul odor . Review of R#720's skin care plan for The resident has potential/actual impairment to skin integrity of the (all) r/t (related to) fragile skin revised 8/23/18 revealed interventions that read: Monitor/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to MD. created 6/26/20. Observe skin daily with care activities. Report any changes in coloration, integrity, etc. to nurse. created 3/9/20. Review of a SKIN OBSERVATION TOOL for R#720 dated 8/28/20 documented No to, Patient has NEW alteration in skin integrity? Including open areas of any type, tears, bruising, red areas, rashes, etc. There was no documentation for Alterations in Skin Integrity in the sections for pressure ulcers, non-pressure ulcers, or all other alterations of skin. The assessment documented in additional comments, unstageable (obscured full-thickness skin and tissue loss) sacral decubitus ulcer noted with MASD (moisture-associated skin damage - inflammation or skin erosion) to buttocks. Treatment in place. It should be noted there were no physician orders put in place, no nursing progress note or change in condition note associated with the skin assessment dated [DATE]. It is also noted that the order in place on 8/28/20 for R#720's coccyx area read, barrier cream to bilateral glut (gluteus) preventative, three times a day for MASD AND as needed for brief changes dated 5/15//20, was not an approved treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the Documentation Survey Report (a report of care provided by the Certified Nursing Assistants - CNAs) for August 2020 for R#720 revealed the following Intervention/Task that read, REPOSITIONED: Q (every) 1 HOURS as documenting task complete yes/no q shift. The document had each day divided into three shifts: 6:30 AM-2:30 PM (morning), 2:30 PM-10:30 PM (afternoon) and 10:30 PM-6:30 AM (midnight). There were blanks in the document indicating the task was not done on: 8/2/20 day and midnight 8/4/20 midnight 8/5/20 midnight 8/7/20 midnight 8/8/20 midnight 8/11/20 day 8/13/20 day 8/16/20 afternoon 8/17/20 midnight 8/19/20 midnight 8/20/20 midnight 8/23/20 midnight 8/27/20 day 8/28/20 afternoon 8/30/20 afternoon and midnight 8/31/20 afternoon and midnight On 2/11/20 at 10:45 AM, a contracted Wound Nurse Practitioner (NP), NP I, was interviewed and asked about R#720's Stage IV pressure ulcer. NP I explained back in September 2020 she had received a call from the facility that R#720 had a large pressure ulcer, she was surprised when she saw it on 9/3/20 at the size and depth of the wound. NP I further explained she had ordered treatments and a Wound VAC to be used, and the pressure ulcer was almost healed, it was just a small opening. NP I was asked how often she was at the facility. NP I explained she was scheduled to be at the facility on Thursdays, but the nurses at the facility knew they could call her anytime. Review of a facility provided an Incident and Accident (I&A) report for R#720 completed 9/16/20 revealed an investigation that identified a sudden onset Stage IV pressure ulcer that began 9/2/20. The Facility Response to the investigation read in part, .Suspension [sic] to be a Kennedy wound due to sudden onset and r/t diagnosis . It should be noted that a Kennedy Terminal Ulcer (KTU) is a specific type of pressure ulcer that has unique and defining characteristics like location, shape, and onset. Most patients found with a KTU die within hours or up to six weeks of development. On 2/11/21 at 3:22 PM, the Director of Nursing (DON) was interviewed and asked about the investigation into R#720's pressure ulcer and why a KTU was suspected. The DON explained she was not sure why that was on the report. The DON was asked about the skin assessment on 8/28/20 that mentioned an unstageable pressure ulcer, but no treatments or interventions put in place, five days before the change of condition note on 9/2/20. The DON explained there should have been notification to the MD, and treatment orders put in when the wound was noticed on 8/28/20. On 2/11/21 at approximately 3:30 PM, NP I was interviewed and asked if R#720's pressure ulcer had been a KTU. NP I explained she had never said or diagnosed that it could have been a KTU. R#708 A complaint and a Facility Reported Incident (FRI) were made to the State Agency both alleging R#708 developed and/or did not receive treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the closed record revealed R#708 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS assessment dated [DATE], R#708 scored 00/15 on the Brief Interview for Mental Status Exam (BIMS), indicating severely impaired cognition. The MDS assessment also indicated R#708 required the extensive assistance of staff for all ADL's. Review of the FRI revealed R#708 had acquired a pressure ulcer in the hospital before being admitted into the facility. The hospital records indicate on 12/4/20 R#708 had a Stage II (partial-thickness skin loss with exposed dermis) right buttock injury with White;Pink (Comment) two areas are connected by white area, sm (small) open areas x 2 that began 11/20/20. The FRI also included a statement by the Wound Care Certified (WCC) Licensed Practical Nurse (LPN) H that read in part, On 12/7/20 . Pt (patient) did in fact have a dressing in place that was dated 12/4/20 from the hospital . Review of R#708's NURSING ADMISSION SCREENING/HISTORY assessment completed by Unit Manager D and dated 12/7/20, three days after R#708 was admitted on [DATE], revealed R#708 was alert and orientated to person only, that resident will or does not speak, and there was a pressure ulcer on the coccyx measuring 4.5 x 3.8 (cm). On 2/10/21 at 11:30 AM, Unit Manager D was interviewed and asked about R#708's nursing admission assessment. Unit Manager D explained she would check to see if admission assessments were completed on new admissions, if not, she would complete them. Unit Manager D was asked how often she had to complete admission assessments. Unit Manager D explained it happened frequently Monday mornings that there were no assessment, so she would complete assessments from over the weekends. Unit Manager D further explained she would educate the nurse who did not do the assessment. Further review of R#708's clinical record revealed no wound care treatment orders or impaired skin integrity care plan interventions were put into place until 12/7/20. Review of a skin progress note dated 12/10/20 read in part, Coccyx UTD (Unable to Determine Stage) has increased in size, 7.0x5.0cm 80% eschar hard, 20% pink non-blanchable epithelial tissue . On 2/11/20 at 10:47 AM, LPN H was interviewed and asked about R#708's pressure ulcer. LPN H explained as the wound care nurse, she would check new admissions Monday thru Fridays. LPN H further explained that on 12/7/20 when she assessed the pressure wound, the dressing on the wound was a foam dressing put on at the hospital, she removed the dressing and measured the wound at 4.5 x 3.8 cm, dark maroon and non-blanchable. LPN H was asked if R#708's pressure ulcer had gotten bigger while at the facility. LPN H explained the wound never opened while R#708 was at the facility, it had gotten bigger when assessed by NP I on 12/10/20, but then R#708 was discharged to the hospital on 12/15/20. On 2/11/21 at 2:37 PM, the DON was interviewed and asked about the nursing admission assessment completed on 12/7/20 when R#708 was admitted on [DATE]. The DON explained the admission assessment should be done on admission. The DON was asked how often admission assessments were not completed timely. The DON did not answer. The DON was asked who could put in consults for wound care. The DON explained the nurses could call the wound care nurse or wound care team for orders. R#715 & 716 Multiple complaints submitted to the State Agency documented in part, . (Nurse name redacted) RN (Registered Nurse) works at the facility and is not passing out medications and falsifying records . A lot of residents have wounds that are not being treated appropriately . A facility Disciplinary Action Record dated 12/8/20 documented in part, . Written Warning #1 . 11/17/20: False documentation during 7A-7P shift signed out treatments on eTAR (Treatment Administration Record) and treatments weren't completed . Two residents (R#'s 715 & 716) were identified for not having their wound treatments completed, although RN B signed they completed the treatments. A review of the clinical records revealed the following: R#715 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) dated [DATE] that documented a Brief Interview for Mental Status (BIMS) score of 00 (indicating severely impaired cognition) and required staff assistance for all Activities of Daily Living (ADLs). R#715's wound treatment order documented in part, . Cleanse sacral wound with dakins solution. Apply Black sponge to the wound bed and cover with vac draping, Apply wound vac to area . every day shift Tue (Tuesday), Thu (Thursday), Sat (Saturday) for Sacral wound care . R#716 was admitted into the facility on [DATE] with a readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A MDS assessment dated [DATE] documented a BIMS of 15 (indicating intact cognition) and required staff assistance with all ADLs. R#716's wound treatment order documented in part, . Calcium Alginate . Apply to abdomen topically every day shift for abdominal surgical wound gently cleanse with ns (normal saline), apply CalAlg, then cover with 6x6 border dressings . The November TAR's were reviewed for R#'s 715 and 716 and did document a completed (Initialed box) on 11/14/20 and 11/17/20 by RN B. Although RN B signed that they completed both wound treatments, the facility Wound Nurse found old wound dressings on both residents, dated before the date that RN B documented that they completed both resident wound treatments. Residents (R#'s 715 & 716) wound treatments was not completed as documented by RN B. On 2/9/21 at 1:09 pm, the Director of Nursing (DON) was queried on how the facility became aware that RN B had not completed the physician ordered wound treatments for R#'s 715 and 716 and stated in part, . It was found by the Wound Nurse (WN) and Wound Nurse Practitioner (WNP) during rounds . He was re-educated and given a disciplinary action . The November TAR's were reviewed for R#'s 715 and 716 and did document a completed (Initialed box) on 11/14/20 and 11/17/20 by RN B. Although RN B signed that they completed both wound treatments, the facility WN found old wound dressings on both residents, dated before the date that RN B documented that they completed the residents wound treatment. The resident's wound treatment was not completed as documented by RN B. A facility policy titled Skin Monitoring and Management . adopted 7/11/18, documented in part, .The purpose of this policy is that the resident does not develop pressure ulcers unless clinically unavoidable . The nurse responsible for assessing and evaluating the resident's condition on admission and readmission and is responsible to take the following actions: Complete an admission assessment/evaluation and skin risk assessment to identify risk and to identify any alterations in skin integrity noted at that time . A resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infections, and prevent new, unavoidable sores from developing . All wound or skin treatments should be documented in the resident's clinical record at the time they are administered .

This citation pertains to intake MI 540. Based on observation, interview, and record review the facility failed to prevent a severely cognitively impaired resident from exiting the facility without the knowledge of facility staff for one (R#801) of three residents reviewed for elopement, resulting in an Immediate Jeopardy when R#801 exited the facility via an alarmed door and was found by police, who were driving past the facility, near the end of the service driveway which lead to a busy main road with a speed limit of 45 miles per hour. Due to the deficient practice, R#801 and additional residents at risk for elopement had the increased likelihood for serious harm, serious injury, and/or death. Findings include: The Immediate Jeopardy started on 10/22/20. The Immediate Jeopardy was identified on 10/29/20. The Administrator was notified of the Immediate Jeopardy on 10/29/20 at 3:25PM, and a plan to remove the immediacy was requested. The immediacy was removed on 10/23/20 as verified onsite. Although the immediacy was removed, the facility remained out of compliance at the scope of isolated and a severity of potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency. Review of a facility policy titled, Elopement dated 7/11/18 and revised 2/5/20 documented, in part, .It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible .Routine Procedure for Wandering Residents and Prevention of Missing Residents/Elopement: 1. All residents shall be reviewed for safety awareness impairment and elopement/wandering concerns upon admission, readmission, quarterly, significant change in condition and as needed. 2. Residents identified as at risk for elopement/wandering will have a plan of care implemented to address their elopement/wandering behaviors. 3. All residents who are at risk for possible elopement/wandering shall be accompanied by staff or responsible party when leaving the residents unit and/or facility grounds .5. When a door alarm sounds, staff members shall immediately respond to determine the cause of the alarm. a. The staff person responding to the alarm will check the outside of the building/vicinity of the area to determine if a resident had exited the building .c. A head count will be initiated on all the units and completed accounting of the residents will be given to the Administrator/D.O.N. Per the section titled Procedure for Missing Residents and/or Elopement it was documented, in part, 1. Code Yellow is announced with the resident's unit. 2. Note the time that the resident was discovered to be missing. 3. The staff members assigned to the resident's unit report to the nursing station and verify that the resident has not been signed out. 4. Administrator and Director of Nursing and notified if not on the premises. Activate Recall Roster if necessary. 5. Facility management staff should report to the Incident Command Post for a briefing and instruction. 6. Activate the Incident Command System (ICS) to manage the incident. The most qualified staff member (in regard to the Incident Command System) on duty at the time assumes the Incident Commander position. 7. A thorough search is initiated by staff members to locate the resident. If the resident is not located, proceed with the following: A. Staff members search the entire facility and grounds. B. All areas of the facility, grounds, and neighboring streets within a 1 mile radius from the facility are systematically searched . Review of a facility reported incident (FRI) which was dated as having occurred 10/22/20 at 8:30 PM documented, in part, the following: The alarm door sounded off between 8:00 and 8:30 pm and receptionist announced a code for missing resident overhead. Staff reacted by checking their residents and some went outside to <sic> swept the area. At approximately 9:00pm, resident was observed in her wheelchair appropriately clothed within the driveway of the facility by the police and brought her back to the front main entrance . On 10/29/20 at 8:49AM R#801 was observed in their room in bed and appeared to be resting. On 10/29/20 at 2:01PM R#801 was observed in their wheelchair by the nursing station. The resident was observed to have a device to alert staff of wandering present to the left ankle. R#801 was queried as to whether they ever left the building and replied, Oh yeah. When queried as to where they went, R#801 explained they went home. When queried further in regard to their home, R#801 replied they were new to the area. Review of the clinical record for R#801 revealed the resident was admitted to the facility 5/20/20 with [DIAGNOSES REDACTED]. Per R#801's quarterly minimum data set (MDS) assessment dated [DATE] the resident scored 3 out of 15 on a brief interview for mental status exam, which indicated R#801 was severely cognitively impaired. Review of a statement authored by Corporate Culture Executive (CCE) 'I' for an incident date of 10/22/20 documented, in part, I arrived on facility campus at approximately 8:45pm .Upon entering the facility at approximately 8:50pm I was greeted by the receptionist, (Receptionist 'D') .I proceeded to enter the admissions office located behind the receptionist's desk and closed the door. I was in the office for a few minutes when I heard (Receptionist 'D') trying to gain my attention .She explained that she was on hold with the police and that they were informing her that they were bringing one of our patients (R#801) back to the facility, but that it would take a few minutes. I asked her if the resident was noted as missing, and she said No, not that I'm aware of. (Receptionist 'D'), who was apparently still on the phone with the officer then stated the police would be coming to the front entrance. I informed her that I was going to check with the resident's nurse (Licensed Practical Nurse (LPN) 'A') to find out what was the resident's status .Having arrived on the unit, I proceeded to Nurse (LPN 'A'), who was at the cart down the hall on his unit, and upon query as to (R#801), he stated, I'm unaware of resident being out of the building. He went on to say, I just saw her at the nurse station of unit (units redacted) about 20 minutes ago. I informed him of patient's status .I asked staff members on the unit (unit redacted, R#801 lived on one of these units) at the time if they had heard any alarms go off and no one reported having heard any alarms. Nurse (LPN 'A') said, No alarms have gone off.When I arrived back downstairs at reception the police had already exited, and (R#801) was at the receptionist desk with nursing staff from throughout the facility converging because a code had also been called and head count was still underway .The head count was completed, and all units were clear. As I got to unit (opposite side of building from where R#801 resided), staff members reported having heard an alarm earlier. The nurse for (redacted) unit stated that she heard the alarm at upper level exit earlier, and that CENA (Certified Nursing Assistant (CNA) 'B') went to check on it .Nurse (Name Redacted) stated she couldn't be accurate about the time of the alarm but could recall it occurred before 8:08pm because she recalled being down on the lower level by then and that was clearly after the time the alarm signaled and subsequent search by CENA, (CNA 'B') . Review of an incident/accident (I/A) report authored by Licensed Practical Nurse (LPN) 'A' dated 10/22/20 at 11:23PM documented, in part, Nursing Description: Resident eloped from facility and was brought back by Police at about 9:10pm. Resident was lastly seen few minutes after 8pm in wheel chair around nurses station before writer proceeded down the hall for care. Patient Description: Resident has a baseline of confusion and is unable to state reasons for leaving facility. Review of a statement authored by LPN 'A' dated 10/22/20 revealed, Writer received resident at about 720pm (7:20 PM) up in (w)heel chair close by nurses station, shift report <sic> optained as outgoing nurse indicated that resident is mostly up on her wheel chair while awake. Also was Passed on that resident is always around the nurses station, While writer was down the hallway giving care code green was paged (not code yellow) and receptionist also called writer down stairs stating (R#801) had <sic> elopped and brought inside by the police. Resident was unable to state reasons why leaving the facility, noted with confusions which is her baseline . An attempt was made to speak with LPN 'A' via telephone on 10/29/20 at 12:56PM, however a voicemail message was not able to be left at this time. Review of a statement by CNA 'C' dated 10/26/20 documented, I, (CNA 'C') was the responsible CNA for patient in room (R#801's room). I was not aware of the patient going missing due the care that was giving to another patient at the time of (R#801's) absence in the building. I last saw the patient around 8pm Thursday 10/22/2020, at the nursing Station with the nurse. Once the patient was located (the main lobby), She appeared to be cold . On 10/29/20 at 11:35AM CNA 'C' was queried in regard to R#801 and explained, in part, that she had been attending to other residents and 8:15PM was the last time she had seen R#801. Per CNA 'C', she had not heard the alarm or code, and was not sure the resident was missing until CCE 'I' had arrived. CNA 'C' explained CCE 'I' had asked who the nurse was for R#801, and she had replied LPN 'A'. CNA 'C' showed CCE 'I' where LPN 'A' was, and when approaching the nurse heard a code green overhead (not code yellow). CNA 'C' denied hearing a code yellow. CNA 'C' was queried in regard to R#801, and explained it was her first time being assigned to R#801. Review of an additional undated staff statement documented, Resident observed at nursing Station as writer (illegible) unit, Resident was rolling around in her wheelchair around nursing station making Conversations during report and writer Last Saw resident between 7.30pm and 8.15 <sic> befor narcotic Count and writer Started medication pass. Code green (not code yellow) was heard, writer Quickly did a head count of all resident assigned to her . Review of a statement by a nurse on a different unit than where R#801 resided documented, in part, I heard the code and checked all of my patients making sure they were all in their rooms. I did not hear the alarm go off .Approximate time code was heard was 8:30pm-9:00pm. Review of an additional statement by a staff member who did not work on the unit where R#801 resided documented, I was working on (Unit Redacted), when the alarm went off. The nurse asked what was the ringing noise, and my co-worker went to check the door . Review of a statement by CNA 'B' dated 10/22/20 documented, I am (CNA 'B') CNA Assign at (different unit than where R#801 resided) I reacted and make sure my residents are all counted and gave the census sheet to the nurse. I went outside the entrance door came back by the <sic> pack door by the break room but I did not see anybody. On 10/29/20 at 11:06AM CNA 'B' was queried via telephone in regard to the situation with R#801. CNA 'B' explained he had been working that day and had not been assigned to R#801. Per CNA 'B', he was in the hall (not where R#801 resided) where he was assigned to work, an alarm was sounding, and CNA 'B' determined it was from the main entrance. CNA 'B' explained that he moved to go to the direction it was coming from, and another staff was following him. Per CNA 'B', he went to the door (main door by Administrator's office), did not see anyone, disabled the alarm, and stepped out of the building. CNA 'B' explained he stepped out to see if he saw anyone. CNA 'B' was queried as to whether he knew who he was looking for and acknowledged he did not, but he wanted to figure out what was going on and just follow the protocol. Per CNA 'B' his residents were okay, and since he had not seen anyone, he thought it was probably staff or an ambulance that had activated it. Review of a typed statement (undated) by Receptionist 'D' documented, in part, On 10/22/2020 at 9:00 p.m., I received a phone call from (City Redacted) Police Department. They stated they have a (R#801 name) in front of the (Facility). I asked if she is walking or is she in a wheelchair. The 911 caller asked the police on site and they stated, she is in a wheelchair. The police brought her back into the facility within 5-10 minutes. The nurse, (Name Redacted Nurse 'K') asked was there something going on wrong with (R#801 name), I told her that she was outside, and the police was bringing her back in. She asked me to page a CODE GREEN (not code yellow). (Nurse 'K'), also paged a CODE GREEN. I asked her was that the alert code she intended to use, showing her the page with the CODES on it . It was noted per a list of codes provided by the facility that a Code Green was used to indicate an external disaster, documented with examples of tornado and earthquakes. Per the code explanation sheet, Code Yellow would be used for a missing resident. Handwritten on the statement for Receptionist 'D' was the following: Per telephone statement: 10/25/20 @ (at) 11:15am Initial Code was called Code Green per Nurse But then called Code Yellow there after as a clarification. Also documented was the following: 10/27/20 10:00am (Receptionist 'D') per phone call verified cops called @ 10 mins before resident arrived. Resident arrived @ 9:00pm. On 10/29/20 at 12:11PM Receptionist 'E', who was the receptionist at the main door used by the facility (near the rehab section of building, not where R#801 had exited the facility) was queried in regard to the camera screen device observed to the right of the computer at the reception desk. Receptionist 'E' explained the camera would activate when the doorbell was pushed, or the receptionist could activate the camera at any time. When queried as to whether the camera would activate if someone pushed the emergency bar (15 second release bar) present on the door, Receptionist 'E' explained the camera would not trigger unless the doorbell was used. Receptionist 'E' then showed the surveyor the images that were visible upstairs, one of which being a view of the lobby area near the main door near the Administrator's office where the resident had exited the facility, and also said they could monitor the atrium between the two doors. On 10/29/20 at approximately 12:20PM the facility's Administrator explained that police had found the resident by the driveway while they were doing their route check at night. The Administrator explained they had stopped and investigated and that was how R#801 had been found. Per the Administrator, the resident had been found at the end of the (service) driveway. On 10/29/20 at approximately 12:40PM Manager of Plant Operations 'G' was queried as to the length of the service driveway, and explained it was maybe 50 to 60 yards. Using google maps distance measuring tool, this distance was over 114 yards. On 10/29/20 at approximately 12:48PM an observation was made from set of double doors (main door) by the Administrator's office to the end of the service driveway. Once through the double doors, a concrete walkway lead to a circular driveway. Next was an asphalt driveway, where sidewalks were not observed to run the length of the drive to the street. The asphalt service driveway was observed to slope downwards to a stop sign, where the service drive intersected with a busy two lane road. At the end of the service driveway (when headed down the driveway) to the left a section of sidewalk was observed to dead end, and a sidewalk was present to the right side of the end of the service driveway. Review of a plan of care dated 7/9/20 for R#801 documented, in part, Resident is an elopement risk and/or exhibits wandering behavior r/t (related to) Disoriented to place, Impaired safety awareness. On 10/29/20 at approximately 2:15PM, the facility's Director of Nursing (DON) was queried as to whether R#801 walked and explained the resident could walk and also used a wheelchair. The DON explained she had viewed parts of the video surveillance and had seen R#801 pushing on the door with their rear end and pulling their wheelchair out. The facility submitted the following accepted plan of removal dated 10/29/20: 1. On 10/22/20 at 9:00 pm, Resident #801 returned to facility and was immediately assessed and found no injuries. 2. Staff started every 15-minute monitoring until 10/23/20 @ 0600, then 1:1 around the clock supervision on 10/23/20. 3. Resident #801 (device for wandering) was placed on her left ankle on 10/23/20, Care Plan was updated. 4. On 10/23/20 (device for wandering) sensor units were checked for function with no concerns noted. 5. On 10/22/20 & 10/23/20 Exit doors were assessed and found functional. 6. On 10/23/20, Resident #801 with (device for wandering) was assessed and found functional. Care plans were reviewed and updated. 7. All in-house residents were assessed by 10/23/20, one resident (#801) identified as an elopement risk based on exit seeking behavior 8. On 10/22/20 Staff responded to alarming door and initiated an outside search of the premise, stated they did not see resident during their search, Staff did not extend the perimeter of their search which prevented the staff member from seeing the resident at the end of the driveway. 9. On 10/23/20 at 12:35 am In-servicing was initiated on the Elopement Policy and Procedure including extending their perimeter search until resident is located. 10. On 10/23/20 the Administrator and DON conducted a facility elopement drill to ensure adherence to Elopement policy and procedure. Facility alleges that the likelihood for serious harm was removed 10/23/20. Resident #801 continues to be on every 15 minutes check during day shift and 1:1

Based on interview and record review, the Facility failed to work with residents and/or legal representatives to ensure timely formulation of an Advanced Directives (legal documents that allow a person to identify decisions about end-of-life wishes/care) were completed and ensure Life Sustaining Treatment choices were valid and/or completed by the resident and/or legal representative for R#807, R#811, R#812, R#813 and R#814 of five residents reviewed for Advanced Directives, resulting in Immediate Jeopardy (IJ) when an invalid DNR (Do-Not-Resuscitate) order was followed for R#807 and the likelihood that R#811, R#812, R#813 and R#814's end of life wishes/medical preferences not being followed, placing multiple residents who reside at the facility at risk for serious harm, serious injury, serious impairment and/or death. The IJ began on [DATE], it was identified by the survey team on [DATE] and the facility was notified of the IJ on [DATE]. On [DATE], the State Agency completed onsite verification that the Immediate Jeopardy was removed on [DATE], however the facility remained out of compliance at a scope of pattern and severity of potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance that has not been verified by the State Agency. Finding Include: R#807 A review of R#807's clinical record documented that the resident was admitted to the Facility's COVID-19 HUB unit on [DATE] with [DIAGNOSES REDACTED]. Further review of the resident's Minimum Data Set (MDS) documented that the resident had a Brief Interview for Mental Status (BIMS) score of ,[DATE] (severely cognitively impaired) and required extensive one person assist for most Activities of Daily Living (ADL). It was documented that R#807 expired at the Facility on [DATE] at approximately 12:20 PM and did not perform CPR. Continued review of R#807's clinical record revealed, in part, the following: General Progress Note dated [DATE] (12:34 pm): .Nurse was notified by cna (certified nursing assistant) that pt (patient) was unresponsive. Nurse assessed. Pt DNR (do-not-resuscitate). RN (registered nurse) called death at 12:20 PM. A DO-NOT-RESUSCITATE ORDER documented: This do-not-resuscitate order is issued by (name redacted) Physician M attending physician for (R#807) .DECLARANT CONSENT (dated [DATE]) signature line (left blank). Signature of person who signed for declarant (signature of son 1-name redacted- POA (power of attorney) (B) PATIENT ADVOCATE CONSENT (dated [DATE]) (I authorize that in the event the declarent's heart or breathing should stop, no person shall attempt to resuscitate the declarant. I understand the full import of this order and assume responsibility for the execution. This order will remain in effect until it is revoked as provided by law. Patient Advocate signature (signature of Son #1 (name redacted)). GUARDIAN CONSENT(dated [DATE]) .Guardian signature (signature of son 1 name redacted). Physician signature (dated [DATE]) (signature of Physician M) ATTESTATION OF WITNESS .this individual who has executed this order appears to be of sound mind, and under no duress, fraud, or undue influence .signature (name redacted - Staff P dated [DATE]) and signature (name redacted-Social Worker O dated [DATE]). Medical Practitioner Note ([DATE] at 3:21 PM): (Patient Name/R#807) at Facility(name redacted) for COVID-19 pneumonia .Discussion with Son #2 (name redacted)) on the phone Per Son #2 he and his brother are DPOA, they have papers they have brought to facility .we reviewed code status as well today . An Order created by SW O (revision [DATE]) and ordered by Physician M indicated R#807 was a DNR. Continued review of R#807's clinical record, both electronically and via the resident's paper chart showed no indication that R#807 had a Durable Power of Attorney (DPOA) for Health Care. A request was made to the Facility to provide any documents that indicated a DPOA for Health Care was provided to the Facility. No documentation was provided by the end of the Survey. On [DATE] at approximately 2:40 PM, an interview was conducted with SW O. SW O was asked about the Facility's protocol for Advanced Directive and Life Sustaining Treatment/Code Status choices. SW O reported that when residents are admitted to the Facility they are asked to complete an Advanced Directive form, either by social services or nursing staff, that indicates their medical choices and end-of-life wishes and whether they have any DPOA forms. If they they are not able to complete the paperwork, they will ask family and/or Guardian to provide it and then they will determine the resident's competency to make decisions. SW O stated, generally residents with a BIMS score less than 10 are not able to make a decision. SW O asked about the DNR order form for R#807 (dated 6.26.20) that indicated Son #1 was either a DPOA or Guardian. When queried as to why their signature as a witness was completed 6.29.20, three days later, SW O reported that the late witness signature (6.29.20) was due to the lack of witnesses available due to COVID-19. SW O then confirmed that there was no documentation that indicated R#807 had a DPOA for Health Care. SW O was asked, based on the documents provided in the resident's clinical record, how was it determined that R# 807's end-of-life wish was DNR. SW O stated, I guess I can't say what their wishes were because we did not have the correct legal documents. On [DATE] at approximately 3:19 PM, an interview was conducted with Physician M. Physician M was queried as to R#807's code status. They reported that they recalled R#807's was in the Facility with COVID-19 and the Family was hoping the resident would be discharged to another Facility with their Spouse. Physician M further reported that the Resident's Son was supposed to bring proper DPOA Health Care documentation to the Facility and/or Social Worker. Until that was provided, a DNR order should not have been completed and indicated that a social worker cannot put an order in without legal DPOA paperwork. R#811 A review of the clinical record revealed the following: R#811 was admitted to the facility on [DATE] with a readmission date of [DATE] into the facility's COVID unit, with [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] documented a BIMS of 8 (indicating moderately impaired cognition) and required assistance from staff for all Activities of Daily Living (ADL's). A review of the clinical record revealed no code status or a physician's order regarding code status was documented. On [DATE] at 8:44 am, a review of the resident's hard copy chart was reviewed and revealed a red DNR (Do Not Resuscitate) sheet at the front of their chart. An Advance Directive sheet was observed blank. The form was not completed by facility staff or the resident. A review of the clinical record revealed no documentation that the Advance Directive information was ever provided to the resident. On [DATE] at 8:51 am, the sole nurse assigned to the COVID unit was queried on if the resident didn't have a code status or physicians order regarding their code status, what would they do in an emergency when they witness someone with no pulse and absence of breathing. The nurse replied that they would check the computer and if there was no order then the resident is considered full code. On [DATE] at 12:04 pm, the DON was queried on the guidance for the facility staff to follow if the resident doesn't have a code status order and the resident becomes unresponsive and the DON confirmed that if the resident doesn't have an order in the computer the staff are to consider them as full code. The DON stated the staff should also refer to the resident's chart. At 12:15 pm, the DON was asked about R#811's code status as a DNR, with no physician order to indicate the status to staff and the absence of the resident's Advance Directive. The DON requested time to look into the resident's chart. At 12:31pm, the DON acknowledged the concerns and stated that the resident's code status order was now in the system and the social worker was working on the Advance Directive. R#812 Resident #812 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of R#812's MDS documented the resident had a BIMS score of ,[DATE] (moderately intact cognition). No completed Advanced Directive Forms were noted in the Resident's electronic record and/or paper record chart. R#813 Resident #813 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of R#813's MDS documented that the resident was severely cognitively impaired. No completed Advanced Directive Forms were noted in the Resident's electronic record and/or paper record chart. R# 814 A review of the clinical record revealed the following: R#814 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS assessment was currently in progress at the time of the survey. A review of the resident's electronic clinical chart and physician orders revealed no documented code status for staff to follow if the resident became unresponsive. On [DATE] at 12:04 pm, the DON was queried on multiple residents found with no code status documented in the chart and the absence of multiple resident's Advance Directives and requested time to look into it. The DON later acknowledged that the social worker was working on all Advance Directives and the facility staff are completing all of the resident's code status. An interview was conducted with the Administrator on [DATE] at approximately 1:37 PM. The Administrator was queried as to the Facility's protocol pertaining to Advanced Directives/Life Sustaining Treatment options for residents, including those residents with COVID-19 who are a high risk for severe illness and/or death. The Administrator indicated that upon admission residents and their legal representatives should be provided with an admission package that contains information as to Advanced Directives to start to determine resident's wishes. This form includes code status and then follow-up should be completed by Social Services as to legal DPOA/Guardianship paperwork. When asked why several residents, including, but not limited to R#811, R#812, R#813 and R#814 had blank forms in their clinical records and no notes prior to [DATE] that indicated any discussion was made as to end-of-life wishes, the Administrator reported that they had been recently hired and indicated that the Facility process had failed. The Administrator indicated that there was an identified failure to ensure the Facility's Advanced Directive Policy was followed and needs to be immediately addressed. A review of the Facility Policy titled Advanced Directives (Adopted [DATE]) was conducted and documented, in part, the following: Policy: It is the policy of this facility to : 1. Provide written information to residents at time of admission regarding their right under State Law to accept or refuse medical treatment and the right to formulate Advance Directives . Procedure: 1. Designated staff will review and explain the specified State Law addressing Advance Directive options and Life Sustaining Treatment with the resident and/or representative. 2. Staff will provide the resident and/or representative with information .4.An Advance Directive .shall be completed with resident and/or legal representative to verify treatment options as well as code status. 5. Appropriate information will be added to Physician Order Sheet .9. Staff will also request documentation to (Name Redacted) is providing the following information to demonstrate that the immediacy of the cited deficiency has been removed.

Based on observation, interview and record review, the facility (a designated facility that provides care to residents with COVID discharged from hospitals or from other facilities) failed to increase monitoring of COVID-19 positive ill residents to identify changes in condition per Centers for Disease Control (CDC) protocol including continued assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory examination, at least three (3) times daily to identify and quickly manage serious infection concerns for three residents, #806, #807 and #808; and failed to ensure newly admitted and/or readmitted residents were monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID 19 PPE (personal protection equipment) for R#810 who was placed on a non-monitored transition unit from [DATE]-[DATE] and developed COVID-19, resulting in Immediate Jeopardy (IJ). These deficient practices placed ill COVID-19 positive residents, residents residing on R#810's unit and Health Care Personnel (HCP) staff who cared for the residents on (R#810's) unit at risk for serious harm, injury and/or death related to COVID-19. Findings include: The IJ began on [DATE], it was identified by the survey team on [DATE] and the facility was notified of the IJ on [DATE]. On [DATE], the State Agency completed onsite verification that the Immediate Jeopardy was removed on [DATE], however the facility remained out of compliance at a scope of pattern and severity of potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance that has not been verified by the State Agency. Failure to Increase Monitoring for COVID Positive Residents #806, #807 and #808 The Centers for Disease Control (CDC) Guidelines Preparing for COVID-19 in Nursing Homes (updated [DATE]) documents in part, .Residents with known or suspected COVID-19 should be cared for using all recommended PPE (personal protective equipment), which includes use of an N95 or higher level respirator (or facemask if a respirator is not available), eye protection (i.e. goggles or a face shield that covers the front and sides of the face), gloves and gowns .Increase monitoring of ill residents, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to at least 3 times daily to identify and quickly manage serious infection . R#806 A review of R#806's clinical record documented that the resident was admitted to the Facility's COVID-19 HUB unit on [DATE] with [DIAGNOSES REDACTED]. Further review of the resident's Minimum Data Set (MDS) documented that the resident had a Brief Interview for Mental Status (BIMS) score of ,[DATE] (severely cognitively impaired) and required extensive one/two person assist for most Activities of Daily Living (ADL). A Fall Risk Assessment form dated [DATE] indicated R#806 was at high risk for falls. It was documented that R#806 expired at the Facility on [DATE] at approximately 8:20 PM. Continued review of R#806's clinical record, documented, in part, the following: Admission progress note (dated [DATE]): Received (R#806) from Hospital (name redacted) .Admitting dx (diagnosis) +COVID-19 hx(history) of falls .lung sounds CTA (clear to auscultation, meaning normal lung sounds), non-labored breathing, no SOB (shortness of breath) .No distress or discomfort noted . Medical Practitioner Note (dated [DATE]. 22:35) .Pt (patient) tested positive for COVID .had no symptoms related to COVID .Advised 14 day isolation, no other acute symptoms or workup was necessary .PT had some respiratory distress during hospital stay .oxygen was added .Today, pt. is alert, able to answer simple questions .trying to climb out of bed and a fall risk .Plan .droplet isolation, monitor for respiratory distress . Medical Practitioner Note (dated [DATE] 13:04), .has c/o (complaint of) feeling like there is congestion in his lungs but .cough is not strong enough to clear .DIAGNOSIS/STATUS/PLAN .3. Acute cough .will order .inhaler 2 puff TID (three times per day) . Medical Practitioner Note (dated [DATE] 14:09): .Pt had a fall yesterday in room .states he is tired .sleeping but awakes spontaneously .has a small abrasion noted to the bridge of nose and slight [MEDICAL CONDITION] to left posterior eye .still has c/o congestion that is unable to clear with cough .O2 96% .will order Chest X-ray to r/o (rule out) infectious process . General Progress Note (dated [DATE]: 19:57): Pt c/o of pain in L(left) arm and asks to go to hospital . General Progress Note ([DATE] -19:58): Chest x-ray concludes mild left lower lobe pneumonia . Medical Practitioner Note ([DATE] 11:44): .increased number of falls. Pt seen recently .CXR(x-ray) ordered for increased congestion .today pt has som<sic> increased congestion .coughing and having a hard time bringing it up .pulse ox is 93% . Skilled Nursing ([DATE] : 1:12): Writer on coming to shift resident viewed by writer during nursing rounds .Around 8pm writer checked on resident still sleeping .8:40 PM writer alerted by staff upon care no breathing noted .cpr (cardiopulmonary resuscitation) initiated . resident not transf. (transfer) to hosp.(hospital) expired .body released to (name redacted) funeral home . R#806's Respiratory Symptom Evaluations (RSEs) were reviewed and revealed the following: [DATE] (one evaluation completed), [DATE] (no evaluations completed), [DATE] (one evaluation completed), [DATE] (one evaluation completed), [DATE] (two evaluations completed), [DATE] (two evaluations completed), [DATE] (two evaluations completed), [DATE] (no evaluations completed), [DATE] (one evaluation completed). [DATE] (the last evaluation completed by facility nursing staff E was completed at 11:00 AM, no evaluations/vitals were completed by Facility staff between 11:00 AM and 8:20 PM. It should be noted that R#806 expired on or about 8:20 PM. O2 Sats Summary from [DATE]-[DATE] were reviewed and documented: [DATE]: 98% (9:08 AM); 96% (08:23 PM) [DATE]: 95% (10:20 AM); 95% (11:04 PM) [DATE]: 96% (8:58 AM) [DATE]: 98% (9:07 AM); 92% (8:02 PM) [DATE]: 93% (11:00AM) An interview with Nurse E was conducted on [DATE] at approximately 2:30 PM. Nurse E reported that they had been employed at the Facility for almost one month. When queried as to what units they were generally assigned to, Nurse E indicated that they primarily were assigned to the COVID-19 unit. When asked if they had received any training by the Facility as to monitoring COVID-19 residents including resident's with declining conditions, Nurse E reported that they completed respiratory/vitals one time per shift and indicated that nurses work 12 hour shifts. It should be noted that R#806 last set of vitals was taken on [DATE] at 11:00 AM. O2 Sats were noted to be 93%. On [DATE] at approximately 10:35 AM, an interview was conducted with Physician M. When queried as to treatment of [REDACTED]. Physician M indicated that she would recommend at least every four hours. When queried as to R#806 who had shown a decline (coughing and confirmed pneumonia), Physician M indicated that the nursing staff should have increased monitoring for the resident and stated, It is nursing 101 to increase monitoring. R#807 A review of R#807's clinical record documented that the resident was admitted to the Facility's COVID-19 HUB unit on [DATE] with [DIAGNOSES REDACTED]. Further review of the resident's MDS documented that the resident had a BIMS score of ,[DATE] (severely cognitively impaired) and required extensive one person assist for most Activities of Daily Living (ADL). It was documented that R#807 expired at the Facility on [DATE] at approximately 12:20 PM. Continued review of R#807's clinical record documented, in part the following: Admit/Readmit note dated [DATE] (5:47 pm): Pt. admitted to facility ., Pt has 20 staples to L hip . Medical Practitioner Note dated [DATE] (3:21pm): .(R#807) at facility after hospitalization recently for COVID pneumonia . Medical Practitioner Note dated [DATE] (12:30 pm): .Pt resting in bed .is frail .joints are stiff .no lethargy noted .full passive ROM (range of motion) . Medical Practitioner Note dated [DATE] (5:41 pm): .Pt. is planning on Dc (discharge) home with son after 2nd negative Cosid <sic>test .however 2nd test results reported positive today. Pt. is to remain on droplet precautions with monitoring temp and O2 every 6 hours while in isolation . Medical Practitioner Note dated [DATE] (7:31 pm): .Pt. is to remain on droplet precautions with monitoring temp and O2 every 6 hours while in isolation . Medical Practitioner Note dated [DATE] (11:26 am): .decreased alertness .resting in bed mouth breathing .unable to take rx per nursing .drinking minimal fluids . General Progress Note dated [DATE] (2:58 pm): .Pt had previously been signed onto Hospice and taken off within 24 hours due to cost . General Progress Note dated [DATE] (4:05 pm): .Nurse verified with director of nursing that resident was not on hospice .at 4:00 pm resident received a dose of PRN (as needed) [MEDICATION NAME] and gurgling noted . General Progress Note dated [DATE] (12:34 pm): .Nurse was notified by cna (certified nursing assistant) that pt was unresponsive. Nurse assessed. Pt DNR (do-not-resuscitate). RN (registered nurse) called death at 12:20 PM. R#807's RSEs were reviewed. No evaluations were noted from [DATE]-[DATE]. RSEs from [DATE] through [DATE] revealed the following: [DATE] (one evaluation completed), [DATE] (one evaluation completed), [DATE] (two evaluations completed), [DATE] (two evaluations completed), [DATE] (one evaluation completed), [DATE] (one evaluation completed), [DATE] (one evaluation completed), [DATE] (no evaluations completed), [DATE] (one evaluation completed, [DATE] (one evaluation completed, [DATE] (two evaluations completed, [DATE] (two evaluations completed), [DATE] (one evaluation completed), [DATE] (two evaluations completed). The last set of vitals taken were taken on [DATE] at 4:49 PM and documented O2 SATS at 94% and Temp. 97.4 F. R#807 expired at the Facility on [DATE] and was pronounced dead at 12:20 PM. No evidence was noted that R#807 was monitored every 6 hours for O2 SATS or temps as ordered by the physician [DATE] as well as following CDC Guidelines that indicated Increase monitoring of ill residents, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to at least 3 times daily to identify and quickly manage serious infections . R#808 R#808 was admitted into the facility COVID unit on [DATE] with the single [DIAGNOSES REDACTED]. The resident Clinical Census documented that the resident expired on [DATE]. A review of the clinical record revealed the following: A Nursing noted dated [DATE] at 11:13 am, documented in part . Day 1 admit, Aox1 (alert and oriented, times one), confused and agitated. VS (Vital Signs) stable and recorded. Pt (patient) shows no facial grimaces of pain at this time. Pt has a <sic> order for IV (intravenous) Abt (antibiotic) for pneumonia and will be started on that today . A Medical Practitioner Note dated [DATE] at 15:33 (3:33 pm) documented in part . Pt had a fall . She is COVID+ on ,[DATE] . she has sutures above L (left) eyebrow with dried blood . very weak . A Nursing note dated [DATE] at 19:56 (7:56 pm) documented in part . Writer notified by staff while doing room rounds around 7:15pm resident unresponsive. Writer entered room, writer observed no rise and fall noted, sternum rub done no response, no vitals noted. Resident is DNR (Do Not Resuscitate) compass hospice notified, hospice states they will be in facility to pronounce TOD (Time of Death) and will notify family and make arrangements . The vital sign log was reviewed and revealed the facility failed to complete assessments per CDC's guidance for COVID in the nursing homes. The log documented the following: On [DATE] (taken twice on this day) 10:44 am- T (temperature)- 97.9 F (Fahrenheit), O2 sat (the level of oxygen in the blood)- 94% on RA (room air) and 22:32 (10:32 pm) - T- 97.4, O2 Sat- 96% on RA On [DATE] (taken twice on this day) 11:48 am- T- 97.6, O2 sat- 97% and 21:47 (9:47 pm) - T- 97.3, O2 sat- 97% On [DATE] (taken twice- temperatures were taken less than an hour apart)- O2 sat (10:52 am)- 96%, 13:52 (1:52 pm)- T- 97.6 and 14:50 (2:50 pm) - T- 97.9, O2 sat- 96% On [DATE] (taken twice on this day) 11:51- T- 98.2, O2 sat- 95% and 21:22 (9:22 pm) - T- 98.2, O2 sat- 95% On [DATE] (taken once on this day) 22:41 (10:41 pm) - T- 97.5, O2- 97% On [DATE] (taken twice on this day) 11:19 am- T- 98.1, O2 sat- 97% and 21:28 (9:28 pm) -T- 97.5, O2 sat 97% (9:29 pm) On [DATE] (taken once on this day) 1:27 am- T- 97.5, there were no O2 sats documented for [DATE]. R#808's Respiratory Symptom Evaluations were reviewed and revealed the following: [DATE] two evaluations completed, ,[DATE] one completed, ,[DATE] one completed, ,[DATE] one completed, ,[DATE] two completed, ,[DATE] one completed, ,[DATE] two completed, ,[DATE] two completed and there were no documented Respiratory Symptom Evaluation(s) for [DATE], ,[DATE], and ,[DATE]. The facility failed to consistently assess the resident on [DATE], who at 7:56 pm was found unresponsive and their death was pronounced shortly after. On [DATE] at 9:24 am, the DON and Corporate Infection Control Nurse (CICN) C was queried regarding the facility's lack of assessments and vital monitoring of residents with COVID and acknowledged the facilities deficient practice and the Infection Control Nurse stated in part . We would follow CDC's current recommendations . The facility policy titled Novel Coronavirus Control Plan (last updated [DATE]) was provided on [DATE] and documented in part, the following . Resident Care: . Daily temperature checks and monitoring for respiratory symptoms are recommended to assess for changes in the residents' condition . The policy revealed outdated guidance. The policy did not reflect CDC's current guidance for COVID in the nursing homes. New Admission Placement (R#810) The Centers for Disease Control (CDC) Guidelines Preparing for COVID-19 in Nursing Homes (updated [DATE]) documents in part, Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown. Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected . R#810 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] documented a BIMS of 7 (indicating severely impaired cognition) and R#810 was dependent on staff for all ADL's. The facility currently has two units dedicated for new and/or readmissions. On these two units, the facility staff are required to apply all recommended COVID-19 PPE while caring for these residents. CDC's guidance for new/readmissions in the nursing home documents in part . Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE . New residents could be transferred out of the observation area or from a single to a multi-resident room if they remain afebrile and without symptoms for 14 days after their last exposure (e.g., date of admission) . A Clinical Census report documented R#810 was admitted to a unit that was not designated for new and/or readmissions. A review of the clinical record revealed the following: A review of the physician orders [REDACTED]. A Nursing note dated [DATE] at 11:03 am documented in part b/p (blood pressure) ,[DATE], pulse 113, respiration 20, spo2 with 2-liter N/C 35 (normal levels ,[DATE] %), with 5-liter N/C 97%, patient confused, restless, not eating or drinking, notified son, requested to send him to hospital, notified doctor, son requested to send him to (hospital name redacted), NOTIFIED AMBULANCE . The facility Corporate Infection Control Nurse (CICN) C provided COVID-19 test results for R#810 that documented a positive COVID-19 test dated [DATE]. On [DATE] at 12:51 pm, the DON and DON in training was queried regarding R#810's initial placement into the facility on admission and staff not utilizing the proper PPE while providing care to the resident and acknowledged the deficient practice. At that time documentation was requested of COVID-19 test results for all other residents that resided on that unit during [DATE] and [DATE], as well as COVID-19 test results for all facility staff that provided care in that hallway during that time period. Delayed test results and inconsistent tracking of staff made it difficult to identify additional residents/staff members affected by this deficient practice. The facility policy titled Novel Coronavirus Control plan (last updated [DATE]) documented in part, . Resident Care: Observe new admission (residents) for development of respiratory symptoms and implement appropriate infection prevention practices for symptomatic residents . The policy revealed outdated guidance. The policy did not reflect CDC's current guidance for COVID in the nursing homes. Observations of both the COVID-19 Unit and the two monitoring units were conducted during the Survey as follows: On [DATE] at approximately 11:00 AM, Certified Nursing Assistant (CNA) N was observed exiting off the COVID-19 unit holding gowns and towels. When queried as to care of the COVID-19 residents, CNA N reported that they needed to leave the unit to obtain a mask for a resident. When queried as to whether masks were available on the COVID-19 unit, the CNA indicated that they may have been locked in the nursing cart, but the nurse was not on the unit. When queried as to the where the nurse was, CNA stated they were not sure. On [DATE] at 12:10 pm, Registered Nurse (RN) E, who was the only nurse assigned to the COVID unit, was observed outside of the COVID unit and sitting at the nurses station which contained all of the residents who resided on the COVID unit charts. RN E was observed on the phone with their face mask under their chin. When queried regarding their face mask, RN E stated they normally would not wear their mask below their chin. Further observation revealed the COVID unit crash cart located outside the contained doors of the COVID unit. RN E was then queried on if they had a resident in distress or unresponsive how would they know the residents code status and/or obtain the crash cart. RN E stated I would have to take off all of my PPE and leave off the COVID unit to get to the charts to check the code status and retrieve the crash cart and then go back on the COVID unit. On [DATE] at 1:37 pm, observations were completed on the two monitoring units. These units were designated by the facility to place new admissions and readmissions, to monitor them for 14 days per CDC's guidance. After entry onto the first monitoring unit, a housekeeping staff was observed coming out of a resident's room to go to their cart. This housekeeping staff was wearing a KN95 mask. At 1:45 pm, Certified Nursing Assistant (CNA) T was the only staff member observed on the unit (since entry at 1:37 pm). CNA T was asked what they would do if they found/observed a resident in respiratory distress. CNA T replied in part . well I would tell the nurse, but she isn't on the floor right now. I would have to take off all of my PPE (Personal Protective Equipment), go off of the unit and find management or a receptionist for them to page the nurse . At 1:52 pm, the second monitoring unit was observed. Four staff members (one nurse, 2 CNA's and one housekeeper) was observed entering and exiting resident rooms with no shield or protective eye equipment on. Licensed Practical Nurse (LPN) U was queried on why they weren't utilizing eye protective equipment when caring for the residents and stated in part . We were told to only use it if we came in contact with bodily fluids . LPN V was observed walking onto the second monitoring unit and after entry was observed donning on all PPE. LPN V was queried on if they are supposed to don on the PPE before or after entering the contained unit and stated in part that was my question . I was asking the same thing . At 2:05 pm, the facility's designated COVID unit was observed, upon entering the unit and walking throughout, there was no staff present on the unit and a resident's call light was blinking on and off. At 2:11 pm, a CNA arrived on the unit. The DON was queried on if this was normal practice for the facility to not have any staff member on the COVID unit, and if so, who would be able to promptly identify a change of condition with a resident as it occurs, The DON acknowledged the concern and stated a staff member should be on the unit at all times.

This citation pertains to intake: MI 004 Based on observation, interview and record review the facility failed to prevent a Stage II pressure ulcer from worsening to a Stage III pressure ulcer for one (R#801) of three residents reviewed for pressure ulcers, resulting in a complaint being submitted to the State Agency and the resident expressing concern on not being able to be discharged back to their assisted living facility due to the admission criteria of a stage II or less. Findings include: On 8/8/20 at 4:05 PM, a complaint was submitted to the State Agency that documented in part . The wound was supposed to be cleaned and changed on every shift, which was never done. Intermittently, it would be cleaned and changed, so the bed sore has gotten worse . On 8/19/20 at 12:08 PM, R#801 was observed in their bed, lying on their back. When queried regarding their wounds, the resident replied in part . I've had to tell them about not cleaning my wound and just slapping on a new dressing . I don't know what I'm going to. I have to leave here by the end of the month and my old facility won't accept me back unless I have a stage II or less . On 8/19/20 at 1:24 PM, the nurse was observed changing R#801's wound dressing, to the medial aspect of lower back. The nurse confirmed the status of a Stage III. A review of the clinical record revealed the following: R#801 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Date Set dated 6/10/20 documented Resident #801 was admitted with a stage II pressure ulcer which required pressure ulcer care, a Brief Interview for Mental Status score of 15 (indicating intact cognition) and required assistance from staff for all Activities of Daily Living (ADL's). An admission Nursing note dated 6/6/20 at 18:41 (6:41 PM), documented in part . Blister noted on Coccyx/lower back, clean dry dressing intact . A Nursing Admission Screening/History report, dated 6/6/20 at 15:23 (3:23 PM) with a Lock Date of 6/19/20 at 10:32 am (the lock date represents the date the document was locked to prevent any further editing to the document) documented in part . Coccyx Blister (no measurements noted) Other . Rt (right) lumbar, pressure 8.0 (length), 11.0 (width), 0.2 (depth), Stage III . This conflicted with the admission Nursing note which never documented a pressure wound to the Rt lumbar. A physician's orders [REDACTED]. Wound NP to eval (evaluate) coccyx wound . This wound consultation was ordered two days after R#801 was admitted into the facility. On 8/19/20 at 2:1, the Wound Nurse A was asked to provide all wound consultations for this resident. The initial wound consultation is dated 6/18/20 (10 days after the wound consultation was ordered). At that time, the WN A confirmed that the wound care practitioner comes to the facility, once a week on Thursdays. This revealed that the resident missed the 6/11/20 wound visit. WN A and the Director of Nursing (DON) was asked to provide additional documentation on why R#801 was not seen by wound care on 6/11/20 and by the end of survey no further documentation was provided. A Wound Care H&P (history and physical)/ Consult form dated 6/18/20 documented in part . Rt (right) lumbar stg (stage) III) . Length 8.0, Width 11.0, Depth 0.2 . Slough% 60 . Partial thickness . The measurements documented on the wound consultation for 6/18/20 is the same exact measurements documented on the resident's admission nursing assessment dated [DATE] with the lock date of 6/19/20. A physician's orders [REDACTED]. cleanse right medial flank area with n/s (normal saline) apply med honey and cover with boarder gauze . This order was discontinued on 6/18/20 and a review of the clinical record did not document the assessment of the right medial flank to indicate the need of the newly prescribed medication. A review of the nursing weekly skin assessments revealed no further worsening of the lower medial back/right medial flank area. On 8/19/20 at 3:17 PM, the DON and WN A was queried on who locked the admission document on 6/19/20, how the right lumbar measurements on admission is the same exact measurements as the initial wound consult, the delay in wound treatment and consultation and was asked to provide documentation of notification to the physician of R#801's wound worsening from admission to 6/18/20 (the date of the initial wound consultation). No further documentation was provided by the end of survey. On 8/20/20 at 4:10 PM, a review of the facilities policies (provided by the Administration staff) enclosed a facility wound roster dated 6/18/20. R#801 was found on the roster and the R (right) medial flank (ulcer?) was documented at a stage 2, size of 7x8. At 4:12 PM, WN A was queried regarding the report and could not provide any additional information. At 4:20 PM, the DON and Administrator was queried on the document and the DON acknowledged that was their weekly generated roster of the facility's wounds. The DON confirmed that R#801's medial flank wound was a stage II and the measurements of 7x8 was documented (for the date of 6/18/20) A care plan titled The resident has potential/pressure injury to coccyx, incontinence, limited mobility dated 6/6/20 was reviewed and revealed no notation of the wound area on the right medial flank. A care plan titled The resident has (Stg III) pressure ulcer (Right lumbar) r/t (related to) disease process . documented an created on date of 6/28/20. Further review of all of R#801's care plans revealed no mentioning of the right medial flank wound until 6/28/20. A facility policy titled Skin Monitoring and Management- Pressure Ulcer (dated 7/11/2018) documented in part . A resident would enter the facility without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition . A resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infections, and prevent new, unavoidable sores from developing . The nurse responsible for assessing and evaluating the resident's condition on admission and readmission and is expected to take the follow actions: Complete an admission assessment/evaluation . A skin risk assessment should be completed on a weekly basis . and following a change in the resident's condition . Develop comprehensive care plan if indicated following the evaluation/assessment . A licensed nurse (which may be the Wound Nurse) must assess/evaluate each wound that exists on the resident. This assessment/evaluation should include but not be limited to: Measuring the wound, Staging the wound, Describing the nature of the wound (e.g., pressure, stasis, surgical wound), Describing the locations of the wound, Describing the characteristics of the wound . Once a wound has been identified, assessed, and documented, nursing shall administer treatment to each affected area as per the physician's orders [REDACTED]., the resident/responsible party, Others as necessary to facilitate healing .

This citation pertains to MI 762: Based on observation, interview, and record review the facility failed to prevent a severely cognitively impaired resident with a known history of elopement and exit-seeking behavior from exiting the facility for one (R#801) of five residents reviewed for elopement, resulting in an Immediate Jeopardy when R#801 exited the facility via an alarmed door without the knowledge of facility staff, left the facility property, traveled via foot without shoes down a busy main road with a speed limit of 45 miles per hour, entered into a neighborhood, and was found in the road by a member of the public. Due to the deficient practice, R#801 and additional residents at risk for elopement had the increased likelihood for serious harm, serious injury, and/or death. Findings include: The Immediate Jeopardy started on 6/2/20. The Immediate Jeopardy was identified on 6/15/20. The Administrator was notified of the Immediate Jeopardy on 6/15/20 at approximately 3:05PM, and a plan to remove the immediacy was requested. The immediacy was removed on 6/16/20 as verified onsite. Although the immediacy was removed, the facility remained out of compliance at the scope of isolated and a severity of potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency. Review of a facility reported incident date of 6/2/20 documented, in part, the following per the incident summary: Resident (R#801) was observed walking outside of the facility. Resident was assisted back to the facility . Per the incident investigation summary it was revealed, in part, On 6/02/2020 around 6:10PM (LPN 'B') heard the door alarm sounding. She immediately responded by searching for the exit door on the upper level of the Facility. (Licensed Practical Nurse (LPN) 'B') noticed that the emergency exit patio door was alarming . An onsite investigation was completed 6/15/20 to 6/16/20. On entrance to the facility on [DATE] at approximately 8:30 AM an observation of the first floor patio and door was conducted. Observation revealed a door that lead to a small open area approximately six feet that lead to an emergency exit door with a keypad located on the left side of the door. A staff person keyed open the patio exit door and the surveyors exited outside. The patio had several cracks and uneven cement. A rusted handrail surrounded a handicap ramp, unkempt weeds and an old white fence with an unlocked door leading out to a cracked sidewalk was observed. On 6/15/20 at approximately 10:20 AM, R#801 was observed in their room in their bed. The resident was asked if they went outside, and said that they did. R#801 was queried as to whether the police had ever had to help them come back to the facility and said no. R#801 was queried as to whether they needed someone to go with them when they went out, and R#801 responded they did not. The resident was queried as to where they liked to go when the went out, and R#801 responded to go home. No staff person/one-to one staff supervision was observed in the room with R#801 at the time of the observation. The clinical record for R#801 was reviewed and revealed the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's quarterly minimum data set (MDS) assessment dated [DATE] documented the resident scored 4 out of 15 on a brief interview for mental status exam, which indicated the resident was severely cognitively impaired. Per this assessment it was documented the resident did not display wandering behavior, and the resident was assessed as not steady and only able to stabilize with staff assistance for balance during transitions and walking. Review of Letters of Guardianship for R#801 revealed the resident, documented as a legally incapacitated individual, had been appointed a full guardian on 8/15/19. Guardianship was documented as being active through 7/3/20. Review of physician orders [REDACTED]. Review of a police report dated 6/2/20 at 6:19PM documented, in part, the following: On 6/2/2020, I was flagged down at the north entrance of (Facility Name Redacted) by staff member, (CNA 'D'). He advised they had a resident walk away roughly five minutes ago. The resident's name was (R#801). (R#801) was an (physical description redacted), who suffers from dementia. (R#801) was possibly wearing a dark jacket and pants. I advised Officer (Name Redacted) located (R#801) at the intersection of (Street Name Redacted-neighborhood) and (Street Name Redacted-main road with 45 mile per hour speed limit), a few moments later. (R#801) was with a concerned citizen, (Citizen Name Redacted). (Citizen Name Redacted) advised she was driving east on (Street Name Redacted-neighborhood), when she noticed (R#801). She stated (R#801) was walking up the middle of (Street Name Redacted-Neighborhood), and stopped to check on her when Officer (Name Redacted) pulled up. (R#801) appeared to be in good health, but did not want to be transported back to (Facility Name) by officers. However, (R#801) consented to (Citizen Name Redacted) transporting her back. (Citizen Name Redacted) transported her back as Officer (Name Redacted) followed. (R#801) was turned back over to staff without incident . On 6/15/20 at approximately 11:45AM, Surveyors completed a walk to the (Name Redacted) road where R#801 was found by local police. The surveyors exited the patio area and walked down the Facility driveway leading to (Name Redacted) main road. The speed limit was observed to be 45 MPH. A left turn was made on the west side sidewalk which ended after a short distance at a dense wooded area. Surveyors crossed the street and continued to walk on the east side sidewalk and then crossed the street to (Name Redacted) street where #R801 was located by local police. The walk was approximately one fifth of a mile. Review of a progress note authored by LPN 'A' for R#801 dated 6/2/20 at 7:11PM documented, in part, the following: .Resident was observed by writer to be sitting in dining room nearest nursing station, once writer completed task with another resident went to locate (R#801) she could not be found as I looked for her in building co- worker went outside and found that she was picked up by a passer by and brought back to facility escorted by police . On 6/15/20 at approximately 10:30 AM an interview was conducted with Unit Manager, LPN A. LPN A was queried about the incident involving R#801 that occurred on 6/2/20. LPN A reported that they were assigned to R#801 during the afternoon shift and at approximately 5:45 PM, R#801 was sitting in the dining room near the LPNs station. LPN A reported that R#801 needed to be monitored due to their history of elopement and wandering. Per LPN A, R#801 tended to exhibit exit seeking behaviors and often would put on a coat, hat and gathers their briefs and inform staff that they were going home in the late afternoon often noted as sundowning. LPN A recalled completing the resident's insulin injection in the dining room and leaving the area to perform wound care for another resident. LPN A reported that as they left R#801 they noticed that LPN B was sitting at the A/B Nursing Station and thought they could keep an eye on R#801. LPN A indicated that R#801 was to have a 1:1 sitter that evening, but the scheduled staff person never arrived during the shift. LPN A indicated that they completed the wound care on the resident and returned to the dining area and noticed that R#801 and LPN B were no longer in the dining room area. LPN A stated, sometimes R#801 walks on her own so I went to look for them. I contacted LPN B and told her that I was looking for R#801, by that time the police had brought R#801 back to the Facility. I later learned that R#801 was brought back to the Facility by a bystander that found her on the street, the police followed R#801 who was in the bystander's car back to the Facility. LPN A was queried as to whether R#801 wore a (name redacted) wander device (an elopement/wander control system used to provide alerts through an alarm system as a notification of exit) and reported that R#801 did wear the device. When asked whether she could hear the wander device alarm, LPN A reported that she could not hear the wander alarm or the exit door alarm and indicated that LPN B who was in the bathroom could not hear the alarm from the bathroom. When further queried as to whether R#801 was assigned a Certified Nursing Assistant (CNA), LPN A reported she believed it was CNA D. An interview was conducted 6/15/20 at 12:30 PM with CNA D. CNA D reported being assigned to R#801 and recalled that during the dinner hour on 6/2/20, they were in a room assisting two residents with feeding. Following the feeding completion, CNA D exited the room to dispose of the dinner trays and was asked by LPN B to assist in looking for R#801. CNA D stated that he did not hear an alarm sounding, but LPN B was able to determine that the door to the patio had alarmed. CNA D stated, I told her (LPN #B) we should check the old entry first floor door and when we did not see R#801 in the parking lot, I headed closer to (Name Redacted) road looking for a resident. I waived down a police car. I gave a description and the officer called another officer and they found R#801 down the street with a bystander. The bystander brought R#801 back to the Facility in a car with the police officer following. When queried as to whether R#801 had ever left the Facility prior to 6/2/20, CNA D stated there was one time when she left, but it was a different door and someone heard the alarm and we were able to quickly get them back in the building. Review of a progress note authored by LPN 'B' for R#801 dated 6/2/20 at 11:01PM documented, in part, the following: .Writer was in restroom when alarm sounded. Alarm indicated that patio side door was open. Writer and attending aide went to searched <sic> for patient, patient was not in sight. Police officer rode pass <sic> and asked if Aide and I were searching for someone and her said <sic> that he seen <sic> someone walking towards (Road Name Redacted). Writer and Aide continued to search for patient. Police officer drove pass <sic> again and stated that the patient was being brought back to facility by someone who had passed accompanied by police. Primary LPN aware of incident, endorsed over to assigned LPN (LPN'A') . A phone call was placed to LPN B on 6/15/20 at 11:01AM, and a voicemail message was left at this time. On 6/15/20 at approximately 2:15 PM, LPN 'B' returned the telephone call and an interview was conducted pertaining to the elopement of R#801. LPN B reported that on the evening of 6/2/20 around 5:45 PM they were passing medication along the B unit. They indicated that they were not assigned to R#801 and knew that CNA D was. At some point, LPN B left the unit to use the restroom located off the A/B unit near the first floor lobby area. LPN B stated that while in the bathroom they did not hear any alarm(s) sounding, but heard an alarm after exiting the bathroom. LPN B reported that at the A/B unit they were able to determine an alarm was sounding at the side patio door per the alarm indication box. At that time LPN B did not know who or if a resident was missing and asked CNA D to assist. CNA D ran out to (name redacted) main road and CNA D flagged down Police Officer and reported that a resident was missing. Police Officer F made contact with Police Officer G who described a person that was found by a bystander. LPN B was queried as to whether R#801 was at risk for exiting and was monitored by 1:1 staff on the date at issue. LPN B was not sure if there was a 1:1 monitoring for R#801 that evening, but indicated that R#801 did have 1:1 assistance in the past. Continued review of R#801's medical records revealed a wandering risk scale assessment for R#801 dated 2/17/20 identified the resident as being at high risk to wander, scoring 13 on the assessment. Per the assessment question responses R#801 could not follow directions, was ambulatory, could communicate, had a history of [REDACTED]. It was noted per the assessment a score of 11 or greater would identify a resident as high risk to wander. Review of documentation provided by the facility revealed that on 5/2/20, the month prior to the resident's elopement on 6/2/20, R#801 had triggered their wandering alarm device and had been found sitting on a bench outside an exit door to the facility. Per a plan of care for R#801 created 12/19/19 and initiated on 2/21/20 it was documented, Resident is an elopement risk and/or exhibits wandering behavior r/t (related to) attempts to exit building. Per an intervention dated 6/2/20 it was documented, 1:1 supervision 24/7 related to elopement with no injuries on 6/2/20. On 6/15/20 at approximately 11:10 AM an observation and interview was conducted with Maintenance Director Staff C. Staff C was queried as to the system used that alerts the Facility that residents and others are leaving through locked exit doors, including the patio door. Staff C was asked to set the alarms off at two locations utilizing both the fire exit alarm as well as the (Name Redacted) wandering alarm system. A wander alarm sensor to alert staff was observed approximately 12 feet away from the front door to notify staff. A second alarm would sound if anyone including a resident would push on the front door. Both alarm sounds were the same tone. An observation of the patio door alarm system was made. Staff C explained that there was not a delay in when the (Name Redacted) wandering alarm wound be set off and when the patio door would alarm. It was observed that the alarm was set off at the same time and Staff C explained that the alarm was localized. When queried as to whether staff are able to hear the alarm sound in the building, Staff C reported that in some rooms the alarm noise could not be heard and that they were working on increasing the noise level. They were also working on making a differentiated noise so that staff would know if a resident wearing a (Name Redacted) wandering alarm had passed the sensor and was heading to a door. On 6/15/20 at approximately 1:20 PM an interview was conducted with Staff Scheduler E. Staff E had been working as the Facility scheduler for one month. When queried as to 1:1 scheduling for R#801, Staff E reported that 1:1 scheduling orders would be reported to her by either the Unit Manager or DON. With respect to R#801, Staff E reported a staff member was scheduled to provide 1:1 monitoring on the 6/2/20 afternoon shift. On 6/15/20 at approximately 2:20 PM an interview was conducted with the Administrator and Director of Nursing (DON) persuant to R#802's elopement on 6/2/20 and 5/2/20. The Administrator reported that on 6/2/20 at approximately 6:35 PM she was informed by LPN A that R#801 had exited the building and was located on a street off the main road by a bystander and brought back to the Facility in the bystander's vehicle. The Administrator indicated that R#801 had a history of [REDACTED]. When queried as to what interventions were put into place following R#801's exit on May 2, 2020, the Administrator indicated that R#801 was placed on 1:1 monitoring for 72 hours, staff received in-service training regarding the Facility's elopement policy and continued attempts to monitor and redirect the resident were made. When queried as to whether 1:1 monitoring was provided on 6/2/20 as indicated by Staff E, the Administrator indicated that she did not believe any 1:1 was ordered for R#602 on 6/2/20. The Administrator reported that the Facility had been working to make adjustments to the alarm system, including an increase in volume and stated, Patients should not even be able to get to the patio door, we should have responded faster. The Administrator further explained that Facility Policy required staff to initiate a Code Yellow which would alert the Facility as to a missing resident and indicated that it was not performed on 6/2/20. On 6/16/20 at approximately 9:15 AM the Surveyor heard an alarm sounding while sitting in a room near the first floor lobby entrance door. Following the alarm sound, the DON who was sitting in their office located near the Patio door was asked if they had heard the alarm sound. The DON stated, No. On 6/16/20 at 10:40 AM the Facility Elopement logbook located at the A/B Nursing Desk was reviewed. The logbook contained documentation for two residents noted for exit seeking and included R#801. The documentation provided a black and white photo of R#801 and listed general information including the residents room number. It was noted that the room number located on the document was incorrect. Review of a facility policy titled, Elopement dated 7/11/18 and revised on 2/5/20 revealed, in part, the following: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for wandering/elopement .3. All residents who are at risk for possible elopement/wandering shall be accompanied by staff or responsible party when leaving the residents unit and/or facility grounds. 4. Residents at risk for elopement shall be identified in the Elopement Book. The book will have the list of all residents assessed to be at risk for elopement with their name, room number and photo .5. When a door alarm sounds, staff members shall immediately respond to determine the cause of the alarm. a. The staff person responding to the alarm will check the outside of the building/vicinity of the area to determine if a resident has exited the building. b. If upon investigation no reason can be found for the sounding of the alarm, the Administrator/D.O.N./designee must be notified. c. A head count will be initiated on all the units and completed accounting of the residents will be given to the Administrator/D.O.N . Also per the policy was the following: The following procedure is utilized when a resident is determined to be missing: 1. Code Yellow is announced with the resident's unit. 2. Note the time that the resident was discovered to be missing. 3. The staff members assigned to the resident's unit report to the nursing station and verify that the resident has not been signed out. 4. Administrator and Director of Nursing are notified if not on the premises .5. Facility management should report to the Incident Command Post for a briefing and instruction. 6. Activate the Incident Command System (ICS) to manage the incident. The most qualified staff member (in regard to the Incident Command System) on duty at the time assumes the Incident Commander position. 7. A thorough search is initiated by staff members to locate the resident. If the resident is not located, proceed with the following: A. Staff members search the entire facility and the grounds. B. All areas of the facility, ground, and neighboring streets within a 1 mile radius from the facility are systemically searched The facility submitted the following accepted plan of removal: (Facility Name) Action steps taken to remove immediacy: 1.On June 2.2020, resident returned to facility and was immediately assessed and found no injuries. 2. 1:1 around the clock supervision was immediately assigned to resident on 6/2/2020 and continues. 3. Fire doors were assessed and found functional. 4. (Brand Name) guard was assessed and found functional. 5. Resident exited through the fire door and courtyard gate. The courtyard gate was assessed, and the latch was functional. 6. Maintenance monitors the gate and exit doors daily to ensure operational. 7. No other residents are at risk for elopement. Residing residents were assessed, resident 801 only resident identified as elopement risk based on exit seeking behaviors. 8. Staff that stated they did not hear the alarm was proven to be false. During elopement drill on 6/3 and 6/4, staff in the same location was able to hear and respond to the alarm appropriately. 9. Staff was educated and informed during drill to pay attention, not to become desensitized to sounds and respond to alarm sounding per policy and training to ensure safety of residents. 10. (Company Name Redacted) company was contacted to assess current system to add a destinctively different sound for the (Brand Name-alarm/alert device for wandering). 11. Maintenance ensure the alarms were at maximum volume.

This citation pertains to Intake Number: MI 938. Based on interview and record review, the facility failed to implement effective interventions to prevent the development of pressure ulcers and notify the physician and wound care nurse of worsening wounds for one (R#801) of three residents reviewed for pressure ulcers, resulting in the development of a deep tissue injury (DTI - Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) to the coccyx and buttocks worsening to a necrotic (devitalized, dead tissue) unstageable pressure ulcer (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough - non-viable yellow, tan, gray, green or brown tissue or eschar - dead or devitalized tissue that is hard or soft in texture), a stage III pressure ulcer (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and rolled wound edges are often present) to the right hip, and DTIs to the left heel, right outer ankle, and right outer foot. Findings include: A complaint submitted to the State Agency alleged R#801 developed pressure ulcers while at the facility. On 10/15/19, an unannounced, onsite investigation was conducted at the facility. A review of R#801's clinical record revealed the following: R#801 was admitted into the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. An Admission Minimum Data Set (MDS) assessment dated [DATE] documented R#801 had severely impaired cognition, no behaviors including rejection of care, required two person extensive assistance for bed mobility, was not transferred in the seven day look back assessment period, had one sided range of motion impairment to the upper and lower extremities, and had two unstageable DTIs which were coded as being present upon admission. A Nursing Admission Screening/History assessment dated [DATE] documented R#801 had left antecubital bruising (typically due to a blood draw). It did not mention any other skin alterations, including pressure ulcers. A ICP - Interim Care Plan document dated 7/5/19 documented R#801 did not have impaired skin integrity at admission and required staff assistance with activities of daily living (ADLs). A Skin Observation Tool dated 7/5/19 documented R#801 had Left antecubital bruising. A Baseline Care Plan dated 7/7/19 documented R#801 required two person physical assistance for bed mobility and transfers, had current skin integrity issues, redness to buttocks. An Admission Dietary Evaluation dated 7/9/19 did not document any skin issues. The evaluation documented R#801 was underweight and unable to feed himself. A Skin progress note dated 7/11/19 (six days after admission into the facility with no pressure ulcers) written by the wound care nurse, Nurse B, documented, .Patient was seen today by wound care for multiple pressure ulcers. DTI to left heel currently measures 3.0 x 3.0 (centimeters - cm), intact dark maroon, no drainage, no malodor, peri-wound discoloration, blanchable. Cleansed with NS (normal saline), pat dry, covered with dry bulky dressing. DTI to Coccyx/bilateral buttocks that measures 7.0 x 4.0 cm, dark purple discoloration, non-blanchable, no drainage, no malodor. Cleansed with NS, house barrier applied, covered with border gauze dressing .Patient is in bed/chair most of time, has possible friction problem and nutritional deficit. Medical history malignant neoplasm of prostate, CKD [MEDICAL CONDITION](hypertension). Patient has a high risk of future skin injury and delayed wound healing due to medical conditions. Interventions includes frequent repositioning, PRM (pressure relieving mattress), w/c (wheelchair) cushion, offloading of heels while in bed as tolerated. Patient is aware of wound status. Physician aware. There was no documentation prior to 7/11/19 that indicated Nurse B or the physician was notified on 7/7/19 when redness to R#801's buttocks was first observed, per the baseline care plan. There was no dietary assessment or intervention implemented at that time after the development of the above pressure ulcers. A Skin progress note dated 7/15/19 (late entry) documented, .Patient was seen today by wound care for multiple pressure ulcers. Unstageable coccyx to bilateral buttocks pressure ulcer that measures 9.0 x 9.0 cm, dark purple wound base, small ss (serosanguineous - a mixture of clear fluid and blood) drainage, irregular wound edges, fragile peri-wound, no malodor. (The pressure ulcer worsened as indicated by increased size, drainage, and noted as unstageable). Cleanse with NS, [MEDICATION NAME] to wound base, covered with foam dressing. Left heel unstageable pressure ulcer that measures 3.5 x 3.0 cm, dark purple wound base, no drainage, wound edges attached, peri-wound intact, no malodor .Interventions continues such as frequent repositioning, PRM, w/cushion and offloading of heels while in bed as tolerated . There were no changes to the interventions despite worsening of the coccyx/buttocks pressure ulcer. There was no indication in the clinical record that any changes to the pressure ulcer were reported to the physician or Nurse B prior to the weekly skin assessment. A Skin progress note dated 7/22/19 documented, .Patient was seen today by wound care for multiple pressure ulcers. Unstageable coccyx to bilateral buttocks pressure ulcer that measures 9.0 x 9.0 cm, 80% necrotic, 20% pink, moderate ss drainage, irregular wound edges, fragile peri-wound, no malodor. Cleanse with NS, [MEDICATION NAME] to wound base, covered with foam dressing. Left heel unstageable pressure ulcer that measures 3.5 x 3.0 cm, dark purple wound base, no drainage, wound edges attached, peri-wound intact, no malodor. Cleanse with NS, pat dry cover with dry bulky dressing. Interventions continues such as frequent repositioning, PRM, w/cushion and offloading of heels while in bed as tolerated . There were no changes to the interventions or treatment despite increased drainage from the coccyx/buttocks pressure ulcer. There was no indication in the clinical record that any changes to the pressure ulcer were reported to the physician or Nurse B prior to the weekly skin assessment. A Nutrition/Weight progress note dated 7/24/19 (13 days after the development of pressure ulcers) documented, RD (Registered Dietitian) notified re: food preferences resident reviewed for wounds SKIN: multiple Pressure ulcers per chart review. RD Reassessed protein needs r/t wounds: 98-131g PRO (protein)/day (using 1.5-2g/kg CBW for wound healing) .Continue ONS as ordered : 4oz medpass 2.0 TID, nutritional treat QD. Will add 30ml prosource BID (twice a day) r/t (related to) increased protein needs and for wound healing. Recommend 500mg Vitamin C BID, daily multi v/m (vitamin) for wound healing . A Skin progress note dated 7/29/19 documented, .Patient was seen today by wound care for multiple pressure ulcers. Stage 3 coccyx to bilateral buttocks pressure ulcer that measures 9.5 x 6.0 cm, necrotic/yellow base, large ss drainage, irregular wound edges, fragile peri-wound, no malodor. Cleanse with NS, medi-honey to wound bed, [MEDICATION NAME]/[MEDICATION NAME] to peri-wound, cover with border gauze. Left heel DTI pressure ulcer that measures 3.2 x 2.5 cm, dark purple wound base, no drainage, wound edges attached, peri-wound intact, no malodor. Cleanse with NS, pat dry cover with dry bulky dressing. Despite preventive interventions patient has developed right lateral ankle DTI that measures 2.5 x 2.5 cm, no drainage, wound edges attached, peri-wound intact, no malodor. Cleanse with NS, pat dry cover with dry bulky dressing. Right lateral foot DTI that measures 1.5 x 1.0, no drainage, wound edges attached, peri-wound intact, no malodor. Cleanse with NS, pat dry cover with dry bulky dressing. Interventions continues such as frequent repositioning, PRM, w/cushion and offloading of heels while in bed as tolerated . There was no indication in the clinical record that the pressure ulcers to R#801's right lateral foot and right lateral ankle were identified and addressed prior to Nurse B's weekly skin assessment. No additional interventions were implemented after the 7/29/19 skin assessment. A Skin progress note dated 8/5/19 documented, Patient was seen today by wound care for multiple pressure ulcers. Stage 3 coccyx to bilateral buttocks pressure ulcer that measures 9.5 x 8.5 cm, 50% pink 50% necrotic/yellow base, moderate ss drainage, irregular wound edges, fragile [DIAGNOSES REDACTED]tic peri-wound, no malodor. Cleanse with NS, medi-honey to wound bed, [MEDICATION NAME]/[MEDICATION NAME] to peri-wound, cover with border gauze. Left heel DTI pressure ulcer that measures 3.0 x 4.0 cm,dark purple wound base, no drainage, wound edges attached, peri-wound intact, no malodor. Cleanse with NS, pat dry cover with dry bulky dressing. Right lateral ankle DTI that measures 2.5 x 2.5 cm, no drainage, wound edges attached, peri-wound intact, no malodor. Cleanse with NS, pat dry cover with dry bulky dressing. Right lateral foot DTI that measures 1.5 x 1.0, no drainage, wound edges attached, peri-wound intact, no malodor. Cleanse with NS, pat dry cover with dry bulky dressing. Despite preventative measures patient has developed a Stage 3 right hip pressure ulcer that currently measures 3.5 x 1.8 cm, yellow base, small ss drainage, irregular wound edges, fragile peri-wound, no malodor .Interventions continues such as frequent repositioning, PRM, w/cushion and off-loading of heels while in bed as tolerated .Spoke in detail with daughter (name redacted) regarding unavoidable pressure ulcers. Patient has been evaluated by dietician for nutritional status. There was no indication in the clinical record that the stage III pressure ulcer to R#801's right hip was identified and addressed prior to Nurse B's weekly skin assessment. The dietician evaluated R#801 on 7/24/19 only related to wound healing. There was no indication in the clinical record that R#801 refused care, such as repositioning. A progress note dated 8/6/19 written by Unit Manager, Nurse D documented, Spoke with patients daughter in regards to patient needing a air mattress to assist with wound healing. patients daughter educated by wound care nurse that the mattress that patient currently has is for up to a stage 4 pressure ulcer . All General Progress Notes for R#801 were reviewed and did not document any refusals to be repositioned or turned. On 10/15/19 at 12:30 P.M., Nurse B was interviewed. Nurse B reported she does rounds on Mondays, reviews all skin assessments for new admissions and looks at progress notes. Nurse B stated, That's how I get my patients. Nurse B reported she followed residents with pressure ulcers until the wound healed or the resident discharged from the facility. When queried about how Nurse B became aware of new skin alterations on residents, Nurse B stated, The nurses let me know, I look at progress notes, and then we get a wound consult. The Nurse Practitioner (NP) follows with me on Mondays. When queried about whether or not she would be notified if a resident developed redness on a pressure area, Nurse B stated, I should be notified of all patients with all skin changes. Nurse B reported herself and the unit managers document regarding pressure ulcers and stated, If I am the first person to observe the wound, I would write a progress note with a description of the wound, implement a care plan, and start a treatment. If I'm not here, the unit manager can initiate a treatment and I will follow up. Nurse B reported that all pressure ulcers would be documented on the skin observation sheet, a progress note, and in a second electronic system for wounds. When queried about how it was confirmed that interventions were being followed, Nurse B stated, They are in the care plans and Kardex. I round when I'm here to see if the heels are floated, they are repositioned, and the unit managers are supposed to round as well. Nurse B reported that if a resident is admitted without pressure ulcers, but was at risk of development of pressure ulcers a special mattress, repositioning, floating heels, and dietary evaluation would be implemented to prevent breakdown. At that time, Nurse B was queried about R#801. Nurse B reported R#801 did not have any pressure ulcers on admission. Nurse B reported she first assessed R#801 on 7/11/19 after a rounding nurse asked me to look at him. Nurse B stated, I did a whole body assessment and he had multiple wounds. Nurse B reported that she was not notified of any skin changes for R#801 prior to 7/11/19 and stated, I am not at the facility Friday through Sunday. When queried about the interventions put into place after the discovery of a DTI to the coccyx and left heel on 7/11/19, Nurse B stated, Pressure reduction mattress, float heels, reposition, and a wheelchair cushion. When queried about the pressure reduction mattress, Nurse B stated, All of our mattresses are pressure reduction mattresses and go up to a Stage II pressure ulcer. When queried about her assessment of the worsening of the coccyx/buttock pressure ulcer on 7/15/19, Nurse B reported she was not notified that the pressure ulcer had increased in size or opened up. Nurse B reported the treatment was changed, but the other interventions stayed the same. Nurse B reported she was not contacted regarding the worsening of R#801's coccyx buttock wound assessed on 7/22/19 and that the treatment was not changed, the interventions stayed the same, and dietary was consulted. As mentioned above a nutrition note documented an protein supplement was added on 7/24/19 per the dietician's recommendation. When queried about why the dietician was not consulted when R#801 first developed pressure ulcers on 7/7/19, Nurse B stated, Because he already had supplements in place. When queried about the additional breakdown to R#801's right outer foot, right outer ankle on 7/29/19 and the development of a stage III pressure ulcer to R#801's right hip, Nurse B reported she changed the treatment, but that R#801 was medically declining and the breakdown was unavoidable. Nurse B was asked to explain how R#801 only developed pressure ulcers on his right side. Nurse B stated, He favored his right side and when we tried to reposition him he wanted to stay on his right side. Nurse B was unable to provide any documentation of R#801's preference to stay on his right side or any additional interventions to accommodate that preference. When queried about why R#801 did not get a specialized mattress if the standard pressure relieving mattress only went up to a Stage II pressure ulcer, Nurse B stated, Our previous manage told me that all of the mattresses accommodated up to a Stage IV pressure ulcer, but then I learned that we should be providing an air mattress if the residents have more than a Stage II pressure ulcer. Nurse B reported she would have gotten an air mattress for R#801 if she knew the mattress was not appropriate. Any manufacture information regarding the mattresses used in the facility was requested at that time. On 10/15/19 at 2:26 P.M., the Director of Nursing (DON - who was not employed by the facility at the time of R#801's admission) was interviewed. When queried about the standard pressure relieving mattresses used in the facility, the DON reported she was told they were effective up to a stage III or IV pressure ulcer, however, if a resident had more than a Stage II or multiple wounds they should be switched to a low air loss mattress or a specialty bed. R#801 was discussed with the DON at that time. When queried about whether or not a low air loss mattress would be indicated for a resident who favored one side or was difficult to reposition, the DON stated, Absolutely. When asked if multiple skin breakdowns in pressure areas on one side of the body would trigger a concern and evaluation of interventions, the DON stated, it would trigger a concern and to look into it further to see what is going on. The DON reported the wound nurse should always be contacted when a wound has changed. On 10/15/19 at 3:10 P.M., Nurse D was interviewed. When queried about whether or not she notified R#801 of the redness documented to R#801's buttocks, Nurse D stated, No. If there was redness we put a barrier cream on it we don't notify her if there's no open area. Further review of R#801's clinical record revealed the following: A Medical Practitioner note dated 7/11/19 that documented, .poor appetite .poor intake .No skin breakdown . A Medical Practitioner note written by the Wound NP on 7/15/19 (8 days after Nurse B documented DTIs to R#801's coccyx and left heel) documented, .Offload heels with offload heel boots Frequently reposition Pressure guard mattress (an alternating pressure air mattress) Discussed with Nsg. (nursing) . A Medical Practitioner note dated 7/17/19 documented, .He is eating and drinking well as per the caregiver. His oral intake was poor last week and required IV fluids, is on antibiotics for UTI (urinary tract infection) since last week. He has improved from that state. His strength in right side is improving . A Medical Practitioner note written by the Wound NP on 7/22/19 documented, .Pressure guard mattress Discussed with Nsg . A Medical Practitioner note written by the Wound NP on 7/29/19 documented, .Pressure guard mattress Discussed with Nsg . A Medical Practitioner note written by the Wound NP on 8/5/19 documented, .Pressure guard mattress Discussed with Nsg . physician's orders [REDACTED]. On 7/9/19 two nutritional supplements were ordered (related to nutrition, not wound healing per the dietary evaluation). On 7/10/19 body audits every day shift were ordered. On 7/24/19 an additional protein nutritional supplement was ordered for wound healing. A review of the Documentation Survey Reports for (MONTH) and (MONTH) 2019 (reports that showed the certified nursing assistants' documentation when a specific care task was completed) for the task of Repositioned revealed the following: There was no documentation that R#801 ever refused to be repositioned. There were multiple entries that were left blank including, 7/16/19 midnight shift and day shift, 7/17/19 afternoon shift, 7/20/19 day shift, 7/21/19 day shift, 7/22/19 day shift, 7/25/19 midnight shift, 7/26/19 afternoon shift, 7/27/19 afternoon and midnight shift, 7/30/19 day shift, 7/31/19 afternoon and midnight shift, 8/2/19 midnight shift, 8/3/19 and 8/4/19 day shift, 8/7/19 day shift, and 8/9/19 afternoon shift. This documentation was reviewed with the DON who reported if the task was completed it should be documented. The Treatment Administration Records (TARs) for (MONTH) and (MONTH) 2019 documented daily body audits were completed as ordered beginning on 7/11/19. However, there were no indications that the development of new pressure ulcers/skin alterations were identified by anyone other than Wound NP and Nurse B. A care plan initiated on 7/17/19 (six days after Nurse B documented DTIs) documented, The resident has coccyx to bilateral heel pressure ulcer . A care plan initiated 8/7/19 (nine days after the development of the right foot and ankle DTIs and two days after the documentation of a Stage III pressure ulcer to the right hip) documented, The resident has right hip, right lateral ankle, right lateral foot pressure sore . A care plan initiated 7/6/19 (the day after R#801 was admitted ) documented, The resident has actual skin impairement to skin integrity .redness to buttocks . A policy titled, Skin Monitoring and Management - Pressure Ulcer (dated 7/11/18) documented, .It is the policy of this facility that: A resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition or other factor demonstrate that a developed pressure ulcer was unavoidable .Resident Assessment .The nurse responsible for assessing and evaluating the resident's condition on admission and readmission is expected to take the following actions: .Identify risk factors which relate to the possibility of skin breakdown and/or the development of pressure ulcers which include, but are not limited to: Impaired/decreased mobility and decreased functional status .Co-morbid conditions .Cognitive impairment .Exposure of skin to urinary and fecal incontinence .All risk factors identified .should be documented in the resident's clinical record .A licensed nurse (which may be the Wound Nurse) must assess/evaluate a resident's skin on admission. All areas of breakdown, excoriation, or discoloration, or other unusual findings must be documented in the Admission Assessment .In order to prevent the development of skin breakdown or prevent existing pressure ulcers from worsening, nursing staff shall implement the following approaches as appropriate and consistent with the resident's care plan: .Monitor impact of interventions and modify interventions as appropriate based on any identified changes in condition .Reposition the resident .Use pressure relieving/reducing and redistributing devices (including but not limited to low air loss mattresses, wedges, pillows, etc .Obtain physician order [REDACTED].Involve the Registered Dietician in care planning process directed to wound prevention and healing .If the clinical assessment/evaluation indicates a change in condition or decline in the wound, the assessing/evaluating nurse will notify the physician and create a narrative nurse's note documenting that notification .Re-evaluate existing treatment regimen in connection with the resident's clinical presentation, to include current interventions and care plan considerations, if any wound is non-healing or not showing signs of improvement after 14 days or any time a wound is worsening .On shower days, CNAs to observe resident skin. Identify any areas of breakdown, discoloration, tears or redness. Communicate findings to licensed nurse .Licensed nurse to acknowledge findings, document pertinent information in resident's clinical record, and respond/obtain and implement treatment order as appropriate .

This citation has two deficient practices. Deficient Practice #1: This citation pertains to intake #MI 769. Based on observation, interview and record review, the facility failed to provide adequate assessment, monitoring and treatment for one (R#903) of three residents reviewed for medication management, resulting in high glucose levels and the need for multiple higher insulin administrations due to lack of following the physician's orders [REDACTED]. Findings include: Review of a complaint received by the State Agency on 8/26/19 included concerns that the facility had not provided R#903 the proper medication treatment which had been detrimental (increased confusion, anxiety/restlessness and discomfort). On 10/1/19 at 6:30 PM, the complainant was interviewed by phone and reported concerns that included the facility had not properly monitored R#903's BS levels prior to meals and that the resident received multiple additional insulin administrations because of the lack of diabetic management. On 10/2/19-10/3/19, an onsight investigation into the complainant's allegation was conducted. On 10/2/19 at 9:47 AM, R#903 was observed seated in a low reclined wheelchair across from the nursing station. At that time, the resident was observed anxious and asking anyone walking by When will (name of niece) be here? My niece. Staff provided the resident with a babydoll and attempted to redirect the resident. Review of the clinical record revealed R#903 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the admission Minimum Data Set (MDS) assessment dated [DATE], R#903 had mildly impaired cognition (scored 8/15 on Brief Interview for Mental Status exam), required extensive assistance of two people for bed mobility and transfers, and received insulin for seven days during this assessment period of seven days. Review of the resident's current physician orders [REDACTED].>[MEDICATION NAME] R Solution 100 Unit/ML (milliliter) Inject 24 unit subcutaneously three times a day for dm (diabetes mellitus) give before meals at 9:00 AM, 1:00 PM, and 5:00 PM. [MEDICATION NAME] R Solution 1000 Unit/ML Inject as per sliding scale: if 151-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 = 10 units; 401-450 = 12 units call MD (Medical Doctor) if Bs <70 (less than), >450 (greater than), subcutaneously before meals and at bedtime for dm at 7:00 AM, 11:30 AM, 5:00 PM, and 9:00 PM. [MEDICATION NAME] Solution 100 Unit/ML (Insulin [MEDICATION NAME]) Inject 46 unit subcutaneously two times a day for DM at 9:00 AM and 5:00 PM. Review of R#903's Medication Administration Records (MARs) from 8/7/19 - 10/3/19 revealed the following multiple late and/or missed blood sugar (BS) readings in accordance with the physician orders: October 2019 - in accordance with the [MEDICATION NAME] R Solution 100 unit/ML physician order: Date; BS to be done; BS actually done; BS result: 10/1; 7:00 AM; 8:51 AM; 163.0 10/1; 5:00 PM; 6:21 PM; 324.0 September 2019 - in accordance with the [MEDICATION NAME] Solution Pen-injector 100 unit/ML physician order: Date; BS to be done; BS actually done; BS result: 9/6; 9:00 PM; 10:35 PM; 171.0 9/8; 9:00 PM; 10:22 PM; 338.0 9/12; 9:00 AM; 10:40 AM; n/a (there was no BS at 10:40) 9/15; 9:00 AM; 12:21 PM; 450.0 9/16; 9:00 PM; 11:04 PM; 207.0 9/20; 9:00 AM; 11:25 AM; 428.0 9/27; 9:00 AM; 11:45 AM; 173.0 9/30; 9:00 AM; 10:54 AM; 352.0 September 2019 - in accordance with the [MEDICATION NAME] R 100 U/ML (3ML Vial) physician order: Date; BS to be done; BS actually done; BS result: 9/2; 1:00 PM; 3:09 PM; 312.0 9/3; 5:00 PM; 7:26 PM; 114.0 9/4; 2:00 PM; 4:10 PM; 321.0 9/4; 5:00 PM; 6:25 PM; (there was no BS documented at 5:00 or 6:25 PM; not until 9:56 PM) 9/5; 5:00 PM; 6:31 PM; 235.0 9/6; 9:00 AM; 10:30 AM; 270.0 9/9; 9:00 AM; 11:30 AM; 323.0 9/9; 1:00 PM; 1:57 PM; 525.0 (there was no documentation of follow up for this BS) 9/10; 5:00 PM; 6:12 PM; 437.0 9/11; 9:00 AM; 11:30 AM; 276.0 9/11; 1:00 PM; 3:00 PM; 300.0 9/12; 1:00 PM; 3:22 PM; 399.0 9/15; 9:00 AM; 12:20 PM; 450.0 9/15; 1:00 PM; 12:12 PM; 450.0 (next done at 4:26 PM = 442.0) 9/20; 9:00 AM; 11:25 AM; 428.0 9/23; 5:00 PM; 6:33 PM; 336.0 9/24; 1:00 PM; 2:53 PM; 350.0 9/25; 5:00 PM; 6:17 PM; 447.0 9/27; 9:00 AM; 11:49 AM; 173.0 9/27; 1:00 PM; 3:12 PM; 271.0 9/28; 9:00 AM; 11:04 AM; 318.0 9/28; 1:00 PM; 3:34 PM; 300.0 9/29; 1:00 PM; 2:36 PM; 333.0 9/29; 5:00 PM; 6:52 PM; 295.0 9/30; 9:00 AM; 10:50 AM; 352.0 September 2019 - in accordance with the [MEDICATION NAME] R Solution 100 Unit/ML physician order: Date; BS to be done; BS actually done; BS result: 9/1; 7:00 AM; 9:39 AM; 307.0 9/3; 11:30 AM; 1:59 PM; 329.0 9/4; 11:30 AM; 4:09 PM; 321.0 9/4; 5:00 PM; 6:24 PM; n/a (there was no BS documented at 6:24 PM; at 9:56 PM = 298.0) 9/6; 9:00 PM; 10:35 PM; 171.0 9/7; 11:30 AM; 4:09 PM; 321.0 9/8; 11:30 AM; 1:52 PM; 310.0 9/10; 5:00 PM; 6:12 PM; 437.0 9/11; 11:30 AM; 2:59 PM; 300.0 9/12; 11:30 AM; 3:22 PM; 310.0 9/13; 11:30 AM; 12:51 PM; 175.0 9/14; 11:30 AM; 2:30 PM; 365.0 9/15; 7:00 AM; 12:20 PM; 450.0 (there was no BS documented at 7:00 AM) 9/16; 9:00 PM; 11:03 PM; 207.0 9/18; 11:30 AM; 1:25 PM; 358.0 9/19; 7:00 AM; 8:35 AM; 190.0 9/20; 11:30 AM; 1:25 PM; 324.0 9/23; 11:30 AM; 1:53 PM; 394.0 9/25; 11:30 AM; 1:10 PM; 334.0 9/25; 5:00 PM; 6:16 PM; 447.0 9/28; 11:30 AM; 3:34 PM; 300.0 9/29; 11:30 AM; 2:36 PM; 333.0 9/29; 5:00 PM; 6:51 PM; 295.0 August 2019 - in accordance with the [MEDICATION NAME] R 100 U/ML (3 ML Vial) physician order: Date; BS to be done; BS actually done; BS result: 8/10; 9:00 AM; 12:02 PM; 394.0 8/10; 5:00 PM; 7:32 PM; 290.0 8/11; 9:00 AM; 11:40 AM; n/a (there was no BS documented at 11:40 AM; at 8:18 AM = 229.0) 8/11; 1:00 PM; 5:38 PM; 200.0 8/12; 5:00 PM; 7:41 PM; 280.0 8/13; 5:00 PM; 6:44 PM; 268.0 8/14; 9:00 AM; 11:22 AM; 326.0 8/14; 1:00 PM; 3:21 PM; 236.0 8/15; 9:00 AM; 11:02 AM; 182.0 8/19; 9:00 AM; 10:30 AM; 247.0 8/20; 5:00 PM; 6:44 PM; 328.0 8/21; 1:00 PM; 2:42 PM; 367.0 8/22; 9:00 AM; 10:35 AM; n/a (there was no BS documented at 10:35 AM; at 6:47 AM = 179.0) 8/23; 9:00 AM; 2:38 PM; 163.0 8/27; 5:00 PM; 6:13 PM; 228.0 8/28; 5:00 PM; 6:38 PM; 300.0 8/29; 5:00 PM; 7:03 PM; 215.0 August 2019 - in accordance with the [MEDICATION NAME] Solution Pen-injector 100 unit/ML physician order: Date; BS to be done; BS actually done; BS result: 8/10; 9:00 PM; 8/11 at 1:26 AM; 172.0 8/11; 9:00 PM; 8/12 at 12:48 AM; 306.0 8/12; 9:00 PM; 11:10 PM; 211.0 8/13; 9:00 PM; 11:31 PM; 186.0 8/16; 9:00 PM; 10:17 PM; 210.0 8/18; 9:00 PM; 10:55 PM; 279.0 8/20; 9:00 PM; 11:03 PM; 346.0 8/24; 9:00 PM; 11:41 PM; 182.0 8/25; 9:00 PM; 11:45 PM; 299.0 8/29; 9:00 PM; 11:02 PM; 145.0 8/30; 9:00 PM; 8/31 at 12:11 AM; 315.0 August 2019 - in accordance with the [MEDICATION NAME] R Solution 100 unit/ML physician order: Date; BS to be done; BS actually done; BS result: 8/10; 11:30 AM; 12:56 PM; 342.0 8/10; 5:00 PM; 7:32 PM; 290.0 8/10; 9:00 PM; 8/11 at 1:26 AM; 172.0 8/11; 11:30 AM; 5:39 PM; 200.0 8/11; 9:00 PM; 8/12 at 12:47 AM; 306.0 8/12; 7:00 AM; 9:15 AM; 395.0 8/12; 5:00 PM; 7:42 PM; 280.0 8/12; 9:00 PM; 11:10 PM; 211.0 8/13; 5:00 PM; 6:44 PM; 268.0 8/13; 9:00 PM; 11:30 PM; 186.0 8/15; 11:30 AM; 1:34 PM; 227.0 8/16; 11:30 AM; 2:13 PM; 371.0 8/20; 5:00 PM; 6:44 PM; 328.0 8/20; 9:00 PM; 11:41 PM; 346.0 8/24; 7:00 AM; 8:26 AM; 184.0 8/24; 9:00 PM; 11:03 PM; 346.0 8/25; 9:00 PM; 11:44 PM; 299.0 8/26; 11:30 AM; 1:22 PM; n/a (there was no BS documented at 1:22 PM; at 12:50 PM = 400.0) 8/28; 11:30 AM; 1:27 PM; 310.0 8/28; 9:00 PM; 6:38 PM; 300.0 8/29; 11:30 AM; 12:44 PM; 220.0 8/29; 5:00 PM; 7:02 PM; 215.0 8/30; 11:30 AM; 12:43 PM; 168.0 8/30; 9:00 PM; 8/31 at 12:10 AM; 315.0 8/31; 11:30 AM; 12:18 PM; 357.0 Review of R#903's vitals documentation, which included BS levels, documented on 9/9/19 at 1:57 PM a BS level of 525. Further review of the MAR and interdisciplinary progress notes revealed there was no additional insulin provided. Review of a Default PN (progress note) Type for eMAR on 9/9/19 at 1:58 PM documented by Nurse H read, (Name of Physician Extender-PE I) made aware via VM (voicemail). There was no evidence of any physician acknowledgement or further response for this elevated BS on 9/9/19. On 10/2/19 at 2:37 PM, an interview and record review was conducted with Unit Manager [NAME] At that time, when asked about the above late and/or missing BS levels and need for higher levels of insulin administrations, and the elevated BS beyond the physician prescribed parameters on 9/9/19, Unit Manager A acknowledged the documentation and reported, I'm going to have to find out and get back with you. On 10/2/19 at 3:00 PM, Unit Manager A reported, I spoke with the nurse from 9/9 and she said she called PE I. She didn't follow up with the physician. Expectation would be to follow up with the physician. On 10/2/19 at 4:27 PM, a phone interview was conducted with Physician D. When asked about R#903's diabetic management, Physician D reported she was not aware of concerns regarding elevated BS's, or that anyone had attempted to contact about a BS beyond the prescribed parameters. On 10/2/19 at 4:55 PM, the Director of Nursing (DON) was informed of the concerns regarding the above late and/or missing BS levels, need for higher levels of insulin administrations, and the lack of follow up for the elevated BS on 9/9/19. The DON reported, Nurses should follow physician's orders [REDACTED]. If there is no call back, call the Medical Director. Expectation is no more than five minutes if they don't hear back. When asked if insulin administration times were audited to identify irregularities, the DON reported, No, not on a regular basis. At that time, the DON was asked for a facility policy regarding diabetic management and reported, Policy is under med administration. On 10/3/19 at 3:50 PM, the DON reported, We don't have a policy for insulin .it's just a professional standard of practice. Deficient Practice #2: This citation pertains to MI 221: Based on interview and record review the facility failed to ensure prompt follow-up was completed for an identified alteration in skin condition for one (R#902) of three residents reviewed for assessment and monitoring, resulting in the presence of a blood clot and the lack of coordination of care between the facility's interdisciplinary care team. Findings include: Review of a complaint received by the State Agency alleged, in part, that the complainant had noticed the resident's feet were purple, and if the complainant had not noticed the resident's feet being purple no one would have contacted the doctor. It was also documented per the complaint that a blood clot had been discovered on an ultrasound. Review of the clinical record for R#902 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per review of R#902's quarterly minimum data set (MDS) assessment dated [DATE] it was documented the resident scored 15 out of 15 on a brief interview for mental status (BIMS) assessment, which indicated R#902 was cognitively intact. Review of a progress note for R#902 dated 8/21/19 at 7:31 PM revealed, in part, the following: Pt (patient) A&O (alert and oriented) x3. Focused assessment completed .Pt sitting up in wheelchair. Pt feet assessed, purple in color, improvement in coloring. (Compression stockings) on bil (bilaterally), feet elevated. Dr. (Name redacted) made aware of pt status and states to see pt tomorrow . R#902 was not observed to have any progress notes documented in the resident's electronic medical record for the date of 8/22/2019 to indicate the resident had been seen by the physician. Review of a progress note dated 8/27/19 at 11:04 AM revealed, in part, the following: Observed resident bilateral feet purplish and blue, call placed to assigned MD (medical doctor) with new orders given for arterial and venous ultrasound . Review of progress notes for R#902 between the time period of 8/21/19 at 7:31 PM and 8/27/19 at 11:04 AM (notes documented above) were not noted to address the condition of the resident's feet. Review of a Medical Practitioner Note dated 8/27/19 at 12:19 PM documented, Discussed concerns with (Family member) via phone. Reordered compression stockings and venous and arterial dopplers . Review of results of a venous doppler exam (examination date 8/28/19 at 2:05 PM) revealed, in part, the following: Findings: Thrombus is noted in the right distal femoral vein .Conclusion: Thrombus in the distal right femoral vein. Review of a Medical Practitioner Note dated 8/29/19 at 2:27 PM revealed, in part, the following: .HPI (history of present illness)- Nursing called. (Family member) requested phone call. States he had concerns due to (R#902's) legs being cool and purple throughout the day. Resolves at night when laying down. Venous and arterial ultrasound ordered. Venous doppler demonstrated RLE (right lower extremity)- femoral vein [MEDICAL CONDITION] ([MEDICAL CONDITION]. Started on (Brand name anticoagulant medication). Arterial doppler pending, as they could not do the same day per tech. Also per this assessment it was noted the resident had discoloration to the bilateral lower extremities, had faint pedal pulses bilaterally, and the resident's bilateral feet were assessed as being cold. On 10/3/19 the facility's Director of Nursing (DON) was queried in regard to physician documentation for R#902 for 8/22/19 and acknowledged they were not able to find any documentation. Review of a facility policy titled, Change in a Resident's Condition or Status dated 7/11/18 revealed, in part, the following: The facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.).

This citation pertains to intake #: . Based on interview and record review, the facility failed to assess and monitor for adverse reactions with the use of the anti blood clotting medication [MEDICATION NAME] for one (#701) of three sampled residents that had a known history of falling and was on multiple anticoagulation medications, resulting in a large hematoma requiring a hospitalization for acute blood loss and the resident needing blood [MEDICAL CONDITION]. Findings include: On 7/6/17 at 9:15 a.m., a record review of the face sheet and Minimum Data Set (MDS) assessment for Resident #701 was completed. According to the face sheet, Resident #701 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed that Resident #701 needed extensive, two person assist with transfers. The cognition for Resident #701 was not assessed on the MDS. On 7/6/17 at 9:30 a.m., a review of a nursing note dated 5/22/17 for Resident #701 revealed that he was transferred to the hospital for a critical hemoglobin (Hb) of 5.2 (a blood test from a laboratory (lab) blood draw that reveals if there is [MEDICAL CONDITION] or acute internal bleeding, a normal (Hg level is 13.5-17). There was no further documentation regarding the incident. On 7/6/17 at 9:35 a.m. a review of the physicians order dated 5/10/17 revealed that Resident #701 was on [MEDICATION NAME] 75 milligrams (mg) daily, [MEDICATION NAME] 80 mg every 12 hours, and Aspirin 81 mg every day. All three medications are used for the prevention of blood clots according to the Medication Administration Record. On 7/6/17 at 1:30 p.m., a review of the Concern Form dated 5/29/17 written by Family Member A (the responsible party for Resident #701) revealed that Resident #701 was in the hospital with a left side hematoma (an internal collection of blood) and newly fractured ribs and had a concern for the newly fractured ribs and not being notified of the transfer to the hospital. On 7/6/17 at 1:35 p.m., a review of nurses notes revealed that Resident #701 had fallen on 5/10/17 and 5/11/17. There were no other falls documented in the medical record. On 7/6/17 at 1:40 p.m., a review of the hospital records dated 5/23/17 revealed that Resident #701 had been admitted to the hospital intensive care unit for acute blood loss [MEDICAL CONDITION] requiring blood [MEDICAL CONDITION] and had acute fractured ribs of right ribs #7-9. In the notes, it also stated that Resident #701 had a, massive rectus muscle (abdominal) hematoma and flank ecchymosis (bruising) with uncertain etiology trauma and suspected unwitnessed fall. The hospital notes also included pictures of the bruising. The pictures confirmed massive dark purple bruising that affected the whole side (side unconfirmed) of Resident #701 extending on to the his back and large dark purple bruising behind his entire left knee. On 7/6/17 at 2:05 p.m., a review of the Treatment Administration Record (TAR) revealed that every Tuesday and Friday there is a skin audit completed. There were initials on 5/16/17 and 5/19/17 as if the audit was completed, however these were not available in the medical record. On 7/6/17 at 2:10 p.m., a review of the initial nursing assessment dated [DATE] under the skin assessment reveals no flank brushing found on Resident #701. On 7/6/17 at 2:15 p.m., an interview with Family Member A was completed. According to Family Member A, he was told at the hospital that Resident #701 had new rib fractures. On 7/6/17 at 2:20 p.m., an interview was completed with Family Member B, who was listed as the second contact on the face sheet for Resident #701. Family Member B stated, We didn't even know he (Resident #701) went out to the hospital until we got a call from the emergency room requesting a history (for Resident #701). When we got to the hospital, he (Resident #701) was already in the ICU (intensive care unit). Family Member B also stated, Those rib fractures were new. I feel like there was a fall and the facility covered it up and didn't tell anybody. I brought this up as a concern and never got a return phone call back from the Administrator or anyone else in the facility. On 7/6/17 at 2:25 p.m., an interview with the Director of Nursing (DON) was completed. The DON did not offer an explanation as to the hospital report stating that she had started after the incident occurred. The DON was also asked for skin assessments to verify whether or not the staff was completing skin assessments as stated on the TAR. The DON was unable to provide any skin assessments except for a paper copy dated 5/20/17, which revealed left thigh bruising. On 7/6/17 at 2:30 p.m., an interview with the Administrator was completed. According to the Administrator he had talked to the family (Family Member B) and the rib fractures had occurred prior to Resident #701's admission to the facility so he did not further investigate the situation. On 7/6/17 at 3:00 p.m., a record review was completed utilizing the 2016 Nursing Drug Reference Guide. According to page 507 under the title Interactions, when utilizing the medication [MEDICATION NAME] with an NSAID (nonsteroidal anti [MEDICAL CONDITION] drug; Aspirin is an NSAID), these two medications are to be used together cautiously due to an increased risk for bleeding and PT ([MEDICATION NAME] Time) and INR (International Normalized Ratio) (PT and INR are lab tests used to determine the clotting factors in blood. If the values are elevated, the blood will not clot and bleeding may occur) should be monitored. On 7/6/17 at 3:30 p.m., a review of a nurses note dated 5/19/17 revealed that Resident #701 had blood tinged urine. On 7/6/17 at 3:35 p.m., a review of the lab results dated 5/22/17 confirmed that Resident #701 had a Hb of 5.2. There were no PT or INR lab results in the medical record. On 7/6/17 at 3:45 p.m., an interview was completed with the DON. The DON was queried in regards to the PT and INR levels not being drawn. The DON stated, We don't usually do an INR for just [MEDICATION NAME]. When the DON was notified as to what the 2016 Nursing Drug Reference had stated about monitoring the PT and INR levels for people on Lovenonx and Aspirin (NSAID), the DON explained that she was unaware of the need for monitoring those labs. On 7/6/17 at 4:05 p.m., a record review of the the care plan titled, Anticoagulant dated 5/11/17 had stated that Resident #701 was at risk for adverse reactions. The interventions included: Administer the medication per order. Obtain labs and notify doctor of results. Report adverse reactions (blood in urine, stool, gums, nose bleeds, bruising). On 7/6/17 at 4:15 p.m., a review of the facility policy titled, Medication and Treatment Administration Guidelines updated 08/2006 revealed the following: Medications are administered in accordance with standards of practice and state specific and federal guidelines. [MEDICATION NAME]-lab test: CBC (complete blood count), BMP (basic metabolic panel), stool for occult at baseline (a stool test to check if there is blood in the stool that could indicate internal bleeding), then every 2 weeks.

This citation has two deficient practice statements. Deficient Practice #1 Based on observation, interview and record review, the facility failed to accurately assess and treat pain for one (#701) of eight sampled residents reviewed for pain from a total sample of 19, resulting in a resident yelling, crying, moaning and exhibiting signs of distress and unresolved pain. Findings include: On 12/14/15 at 8:45 A.M., during a tour of the facility, Resident #701 was heard yelling, Help! from the hallway of the unit. Upon entrance of the room, Resident #701 was observed lying on her back in the bed with a tray of food on the over bed table. Resident #701 stated, Help me! It's so uncomfortable. It hurts so bad. It's so uncomfortable. Resident #701 was holding the left side of her lower abdominal area and grimacing. Resident #701 was observed to be emaciated sunken cheek bones, sunken eyes, loose skin and boney prominences . A urinary catheter drainage bag was observed to have a small amount of urine in it. At 8:55 A.M., Resident #701 was heard from the hallway, yelling out, Please! Please help me! Certified Nurse Aide (CNA) J entered Resident #701's room and asked her if she was done eating and removed the tray of food. At 9:05 A.M., Resident #701 was interviewed. Resident #701 was observed moaning and grimacing. Resident #701 reported that she is in constant pain and stated, I'm always uncomfortable. It hurts so bad. When asked where the pain was located, Resident #701 pointed to her lower abdominal area and stated, And my back side. Resident #701 was asked if she received any pain medications and stated, I think so. Whatever they are giving me is not working. Resident #701 reported that she had been experiencing constant pain for about two weeks and stated Please!! Anything to make me more comfortable. Please! It's getting worse! Please! Please! Resident #701 was observed to be pulling at the middle section of her brief between her legs. At 9:15 A.M., Resident #701 was heard from the hallway, yelling, Please! Help! Please! On 12/14/15 at 12:00 P.M., Resident #701's clinical record was reviewed and revealed the following: Resident #701 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. An admission minimum data set (MDS) assessment, dated 10/18/15, documented that Resident #701 had intact cognition, required two person extensive physical assistance with transfers and bed mobility, did not experience pain, and did not receive PRN (as needed) or scheduled pain medications. Physician's orders for December 2015 were reviewed and revealed the following orders: - [MEDICATION NAME] HCL tablet 50 MG (milligrams), give one tablet by mouth (PO) every 6 hours as needed for pain, initial order from 10/11/15 - Pain evaluation every shift for monitoring A Skin progress note and a Wound Assessment Examination form, dated 12/8/15, documented that Resident #701 had a 10 cm (centimeter) by 9 cm by 1.5 cm wound on her coccyx (tailbone) with exposed bone and a wound on her spine that measured 9 cm x 4 cm x 0.1 cm. Resident #701's documented weight from 12/8/15 was 75 pounds. On 12/14/15 at 2:45 P.M., Resident #701 was observed yelling out, Please help me! Please! The urinary catheter drainage bag contained bright red fluid. Nurse A asked Resident #701 if she was having any pain and Resident #701 stated, Yes. Please help me. I have aches and pains. I'll do anything to stop this. Resident #701 was holding the left side of her lower abdominal area and reported to Nurse A that she was having pain in her backside. While Nurse A attempted to lower the head of Resident #701's bed, Resident #701 was observed to be moaning and crying and stated, Please help me! Nurse A told Resident #701 that he would check to see if more pain medications could be given at this time. Resident #701 yelled, It's not helping me!! I know you mean well, but it's not helping!! On 12/14/15 at 3:20 P.M., Resident #701's Medication Administration Record [REDACTED].M., Resident #701 received pain medication. Resident #701's pain level was documented as a 3 (a number identified by the resident when asked how much pain they are having by choosing a number between 0 - no pain to 10 - the worst pain imaginable). The MAR indicated [REDACTED]. On 12/14/15 at 3:35 P.M., Nurse A was queried about how Resident #701's pain was assessed at 9:44 A.M. when the pain medication was administered. Nurse A stated, She can't really tell you where it hurts all the time. I asked her and she said it was a '3'. At the time she was complaining of pelvic pain so I called the doctor and I reinserted her Foley (urinary catheter). There's blood now. When queried about the earlier observation of Resident #701 crying, moaning, grimacing, yelling for help, and expressing pain in her abdomen and backside and if those observations were taken into consideration when rating the resident's pain level, Nurse A stated, We go by what the resident says. On 12/14/15 at 5:15 P.M., an observation of Resident #701 was made with Nurse A. Resident #701 was moaning and grimacing. When asked by Nurse A if she was experiencing any pain, Resident #701 said, Yes .on my tooshie (backside). Nurse A was asked when the last time Resident #701 had received pain medications. Nurse A stated, The last time she had them was this morning. She gets them every four or six hours, as needed, I'm not sure. I think there's a new order for Tylenol. I gave her [MEDICATION NAME] this morning. Nurse A proceeded to reposition Resident #701 in bed, conduct a skin assessment, and provide wound care without administering any pain medication. On 12/15/15 at 7:30 A.M., Physician's orders dated 12/14/15 were reviewed and documented, Tylenol 325 MG 2 tablets by mouth TID (three times a day). Resident #701's MAR) for December 2015 was reviewed at this time. The MAR indicated [REDACTED].M. when Resident #701 was given 650 MG of Tylenol. The Pain Evaluation for the 7 AM-7 PM and 7 PM-7 AM shifts on 12/14/15 documented a pain level of 0. On 12/15/15 at 8:45 A.M., Resident #701 was heard yelling out, Please! Help me! from the hallway. Upon entering Resident #701's room, she was observed lying in bed with intravenous fluids infusing. Resident #701 stated, I have a gun, you know. That's how bad I feel. How would you feel to just lay here every day in pain. Nobody can help me. On 12/15/15 at 8:50 A.M.,Resident #701 was observed lying on her back in bed and yelling out. Director of Care Delivery (Nurse R) entered Resident #701's room. Nurse R asked Resident #701 if she was in pain. Resident #701 stated, Yes. When asked by Nurse R to rate her pain on a scale of one to ten, Resident #701 did not answer, but stated that it was really bad and reported that it was her back side that was painful. Resident #701 appeared very anxious and was yelling out, Please! Do anything to make me feel better! I'm so scared. Please! On 12/15/15 at 9:00 A.M., Nurse R was observed calling the physician and reported that Resident #701 was anxious and in pain. On 12/15/15 at 11:40 A.M., the wound nurse practitioner (NP) was interviewed. The wound NP stated, Her pain is so bad this morning, we are not comfortable going forward with her wound care. We have never seen her in this much pain before. When queried about what was causing Resident #701 so much pain, the wound NP reported it was likely the coccyx wound. The wound NP reported that Resident #701 was being followed by her due to having an unhealing sacral wound that had exposed bone. The wound NP stated, They are supposed to send her for an MRI to rule out osteo[DIAGNOSES REDACTED] (bone infection). It is very probable that she has osteo[DIAGNOSES REDACTED]. She is severely cachectic (emaciated) and completely bones. This wound is not going to heal .She will likely die from this wound. I have never seen her like this before though (in pain). On 12/16/15 at 9:30 A.M., the Director of Nursing (DON) was interviewed regarding the process for assessing residents' pain level. The DON stated, The nurses go in and ask the resident, if they are alert and oriented, about the location of pain and type of pain. If they are non-verbal, they would look for things like facial expressions and gestures that would indicate pain. The MAR for Resident #701 was reviewed with the DON at this time and the DON was asked if a pain level of 3 and 0 on 12/14/15 and a pain level of 1 on 12/15/15 would be accurate based on Resident #701 crying, yelling, moaning, screaming for help, and expressing very bad pain in her abdomen and backside. The DON stated, We have to go by what the patient says and if the pain medication was effective. For (resident #701) it could be other factors such as anxiety. When queried about possible pain from a wound with exposed bone on Resident #701's coccyx, the DON stated, She probably wouldn't feel pain from that because all the nerves are dead. Resident #701's clinical record was further reviewed on 12/15/15 at 4:00 P.M. and revealed the following: A care plan, initiated on 10/11/15 and revised on 10/20/15 for Pain left lower extremity evidenced by resident c/o pain >2/10 related to fracture. Goal of 0 .Interventions .Administer pain medications per physician's orders .reposition frequently . There was no care plan for pain related to Resident #701's coccyx and spine wounds. A nursing progress note, dated 12/14/15 at 9:16 P.M., written by Nurse A, documented, Pt (patient) c/o (complained of) pain this AM, pt unable to locate initially her pain, verbalized 3/10 .PRN med given, effective . There were no other nursing progress notes that documented the pain reported to Nurse A by Resident #701 on 12/14/15 at 3:35 P.M. and 5:15 P.M. and that she was crying out for help, moaning, and grimacing. The facility's pain management policy was requested. The facility provided a Pain Practice Guide, dated 11/2011. It was reviewed on 12/16/15 at 11:30 A.M. and documented the following: Pain Rating Scales .Pain is more than a number on a rating scale. Individual pain rating scales are completed as part of the admission screen and pain evaluations, and findings are documented daily on the Medication Administration Record [REDACTED]. .Numeric Pain Rating .The Numeric Pain Rating Scale is used for alert and oriented patients. In using the numeric rating scale, the patient is asked to identify how much pain they are having by choosing a number from 0 (no pain) to 10 (the worst pain imaginable . .Non-Specific Symptoms .Additional non-specific signs and symptoms that may suggest the presence of pain include: vocal (crying, moaning, groaning), facial expressions (wincing, frowning, grimacing, grinding teeth), bracing (clutching, tense) .verbal complaints .eating poorly .change in behavior .restlessness . .Re-evaluate patients with pain regularly .Patients may also benefit from pre-medication prior to initiating wound treatments. The licensed nurse evaluates the pain, treats the pain per the plan of care and contacts the physician for any additional orders . .If a patient experiences a change in condition, a re-evaluation of signs and symptoms of the pain is completed to determine if additional interventions or an alternative course of action is indicated. .Change in Condition .If a change in patient condition occurs, the licensed nurse re-evaluates the intensity, location, type and history of pain and documents findings in the progress notes of the patient's clinical record or on a pain evaluation. Based upon this evaluation, the physician is notified to obtain orders if indicated. The patient's plan of care is reviewed and updated . ( ) Deficient Practice #2 This citation refers for Intake #MI 588. Based on observation, interview and record review, the facility failed to ensure a follow up appointment with a podiatry surgeon was made and wound vac treatment started in a timely manner for one (#702) of 11 sampled residents reviewed for quality of care, from a total sample of 19, resulting in an the need for delay in care and potential exacerbation of a wound. Findings include: A complaint was received by the State Agency on 12/3/15 that alleged Resident #702 had been in the facility for 45 days with sutures in his foot and no follow up appointment had been scheduled. On 12/14/15 at 2:00 P.M., Resident #702 was observed to have a wound vac (a device that uses negative pressure/vacuum to promote wound healing) applied to his left foot. Resident #702 was interviewed at this time and reported that he had toes amputated on his left foot in October and was admitted to the facility for rehabilitation. Resident #702 reported that he had not seen his surgeon or had any follow up on his surgical wound, including removal of sutures, until 12/3/15. Resident #702 explained that he finally got an appointment for follow up on his foot after the facility told him he was going to be discharged . Resident #702 stated, My insurance ran out. The social worker came in and told me I was going to be discharged and I told them nobody had ever followed up on my foot and I still had sutures. It wasn't until then, 45 days later, that I finally got an appointment. The surgeon was mad because my foot was infected, skin grew over the bone, and now I have to have a wound vac. Resident #702's clinical record was reviewed on 12/16/15 at 11:30 A.M. and revealed the following: Resident #702 was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A minimum data set (MDS) assessment dated [DATE] documented that Resident #702 had intact cognition and required extensive assistance with all activities of daily living, including bed mobility and transfers. Hospital discharge records documented that Resident #702 was to follow up with the podiatry surgeon within 3-7 days. Physician's orders were reviewed from October 2015 through December 2015 and documented the following orders: On 10/27/15, an order to Follow up with (podiatry surgeon's name and phone number) Re: Left foot sugical wound and right heel diabetic ulcer. On 12/2/15, an order that documented, Pt has to F/up (follow up) with podiatry (podiatry surgeon's name) Re: L foot sutures and wound f/up .Call office for appt (appointment) . Physician's Progress Notes were reviewed for October 2015 through December 2015 and revealed the following: 10/28/15 - .Left foot TMA (transmetatarsal amputation - removal of the front part of the foot) .Left foot grangrene wound care .podiatry to see . 11/4/15 - .L foot TMA .Inf L foot . 11/10/15 - .L TMA .Podiatry to see pt . 11/18/15 - .B/L (bilateral) foot ulcers . 11/25/15 - .H/O (history of) L TMA .cont wound care . 12/2/15 - .B/L foot ulcers with granulation tissue (new tissue growth) .Sutures in L foot .Pt to be seen by podiatry and follow up with outpt (outpatient) podiatry (his podiatrist) .L TMA F/up with surgery . 12/9/15 - .Pt saw podiatry. Needs wound vac .Infected L TMA .Pt saw podiatry. Follow (interventions) .Needs wound vac . A letter from the podiatry surgeon's office, dated 12/4/15, documented, .Orders .Start wound vac therapy to left foot TMA stump today .Please change every Monday Wednesday and Friday . There was no physician's order written for the wound vac treatment until seven days later on 12/11/15. An interview was conducted with the Director of Nursing (DON) on 12/16/15 at 11:00 A.M. regarding a follow up appointment for Resident #702's left foot. The hospital discharge instructions that documented a follow up needed with the podiatry surgeon within 3-7 days were reviewed with the DON. The DON stated, The unit secretary told him about the need to follow up and he told her he would make his own appointment. He went a couple weeks ago. The DON was asked if Resident #702 had sutures in his left foot when he was readmitted on [DATE] and she reported that he did. The DON was asked if there was any documentation of Resident #702's request to schedule his own appointment or any attempts made to contact the podiatry surgeon to find out when the sutures should come out. No documentation was provided. Social Worker (SW) H was interviewed on 12/16/15 at 2:30 P.M. regarding Resident #702's discharge plan and follow up for his left foot. SW H stated, A discharge was scheduled a few weeks ago. It was already discussed with him by the case manager. I went in to let him know he was being discharged on this day, I think it was December 2nd and asked if he had any concerns. He had concerns about medical equipment. I checked in with him on that following Monday and he said he was concerned about being discharged because he didn't know how to do his wound care. I asked him if anyone had talked to him about a follow up appointment and he said 'no'. So an appointment was scheduled for the next day. SW H was queried about the process for scheduling follow up appointments and reported that the unit secretaries typically schedule the follow up appointments. Unit Secretary (US) P was interviewed on 12/16/15 at 2:40 P.M. regarding the process for scheduling follow up appointments for residents. US P reported that nursing would inform her of any follow up appointments that needed to be made. US P stated, I would take any necessary paperwork to the resident's room to inform them that they would need to set up any transportation to get to their appointment, if they were alert and oriented. I would give them a transportation list and encourage them to schedule their own appointment and transportation. We don't pay for transportation so that is they easiest way. US P was asked if she ever received a request for a follow up appointment for Resident #702. US P stated, Back in October I did. I copied it (the discharge instructions from the hospital) and gave it to him (Resident #702). I remember he was in bed. I told him we don't pay for transportation and to set up his appointment at his own leisure. US P was queried about any additional notifications from nursing or physician's orders to schedule a follow up appointment. US P stated, That was the only time until a couple weeks ago and because they asked me to set it up. The Administrator was interviewed on 12/16/15 at 3:40 P.M. regarding the process for scheduling follow up appointments for residents. The Administrator reported that the unit secretary looks for appointments that need to be set up. If the resident just had discharge papers from the hospital, the unit secretary didn't typically set up the appointment. The Administrator explained that a physician's order was needed and then the unit secretary would schedule the appointment. The physician's order for Resident #702 from 10/27/15 was reviewed with the Administrator. The Administrator stated, An appointment should have been made for him (Resident #702) if there is an order. A facility policy for follow up appointments was requested. However, no additional information was received prior to the end of the survey. The Administrator was asked on 12/16/15 at 5:00 P.M. if there was any additional information the facility would like to provide before the end of the survey. The Administrator said there was not. ( )

Based on observation, interview and record review, the facility failed to provide assistance for eating and drinking for a resident who was assessed as needing one to one assistance, for one (#701) of 12 sampled residents reviewed for activities of daily living, from a total sample of 19, resulting in a severely emaciated resident exhibiting signs and symptoms of dehydration, verbalization of extreme thirst, displays of being in emotional and physical distress, an overall decline in health status, and the potential for further weight loss. Findings include: On 12/14/15 at 8:50 A.M., Resident #701 was heard yelling Help! from the hallway of the unit. The resident was observed lying in bed, on her back, with a untouched tray of food on the over bed table. The resident appeared extremely emaciated, weak and boney with sunken eyes, dry lips, and dry tongue. A styrofoam cup labled 12/14 MN was observed full and in front of Resident #701. The call light was observed to be hanging off the side of the left side of the bed not in reach of the resident. An intravenous (IV) pump was observed with an empty, undated bag of sodium chloride, not infusing. A urinary catheter bag was observed to have a small (about 20cc) amount of urine in it. Resident #701 stated, Help! It hurts. It's so uncomfortable! Please! while holding the left side of her lower abdominal area. At 8:55 A.M., Resident #701 continued to yell out, Please help me! Please! Certified nurse aide (CNA) J was observed entering Resident #701's room. CNA J asked Resident #701 if she was finished eating and removed the tray of food from the room. Additional observations were made at 9:05 A.M. and 9:13 A.M. on 12/14/15 of Resident #701, lying in bed on her back, complaining of pain, yelling out for help, holding her lower abdominal area. A styrofoam cup was observed full of liquid and labeled 12/14 MN. At 12:20 P.M. on 12/14/15, Resident #701 was observed positioned on her right side. An over bed table was positioned several inches away from the bed on the left side (Resident #701 was facing the opposite direction). A full cup of liquid labeled 12/14 MN and a full opened can of nutritional supplement sat on the table. On 12/14/15 at 2:30 P.M., Resident #701 was heard yelling, Help! Please help me! from the hallway. Resident #701 was observed lying on her right side. A styrofoam cup labeled 12/14 MN and a full opened can of nutritional supplement sat on the over bed table to the left of the bed. The call light was on the floor, under the bed on the left side. A urinary catheter drainage bag contained dark red fluid. Resident #701 stated, Help me! I need some water. Help me, help me, please! I'm so dry! I'm so dry! Resident #701 was observed with extremely dry lips, thrusting her tongue as if trying to create salivation, and sunken eyes. On 12/14/15 at 2:45 P.M., Resident #701 continued to yell out for help. Nurse A was observed in the hallway and summoned to Resident #701's room at this time. Resident #701 continued to moan and cried out saying, Please help me! Please help me! Nurse A observed the urinary catheter bag and stated, That's blood. I'll have to check on that. Resident #701 stated, I'm so thirsty. Please! Please help me! Nurse A was queried about the full cup of liquid on the over bed table and when it was filled and passed. Nurse A stated, It's from the midnight shift. Nurse A spilled out the water in the bathroom and stated, Let me get you some fresh water. Resident #701 was thrusting her tongue and clearing her throat and continued to cry out for help. Nurse A lowered the head of Resident #701's bed to reposition her. Resident #701 cried out, Please! I just want water. Oh please! and started crying. Nurse A asked CNA T to give Resident #701 some water at 3:00 P.M. Resident #701 was observed taking a sip, then stated, Oh please. I need some more of this water. After I take a sip, keep giving it to me. On 12/14/15 at 4:30 P.M., Resident #701 was observed lying in bed on her back with the head of the bed elevated with her body slouched down. An over bed table was in front of the resident and contained half of an egg salad sandwich, uneaten; a full opened can of nutritional supplement; water, graham crackers wrapped in the packaging and a jar of peanut butter. Nurse U entered Resident #701's room with a carton of milk and offered a sip. Resident #701 accepted the sip of milk. There was no attempt to offer the other items on Resident #701's over bed table. Resident #701 was licking her lips which appeared dry and cried out, Please don't leave. Don't go away! Please! What am I going to do? On 12/14/15 at 5:15 P.M., Resident #701 was observed with Nurse A. Nurse A was asked about the IV pump with the undated, empty fluids in the room. Nurse A stated, She was getting it (fluids) every 3 days. I'm not sure when the last time she had it was. There's a new order from the doctor for IV fluids. Nurse A reported that earlier in the day, a new foley (catheter) was inserted after observing a small amount of urine output. Nurse A stated, I called the doctor and she told me to remove the old foley. When I removed it, she urinated about 700cc. I reinserted the foley. Nurse A reported that he last emptied the drainage bag two hours ago and there was about 200 cc of clear urine. At 2:45 P.M., dark red fluid was observed in the catheter bag which Nurse A identified at that time as blood. Nurse A was asked what kind of assistance Resident #701 required for eating and drinking. Nurse A stated, She eats and drinks by herself. She eats when her son is here. Nurse A was asked about the opened can of nutritional supplement on the over bed table and when it was delivered to the resident. Nurse A stated, Probably lunch time, around 12. When queried about the amount consumed from the can, Nurse A stated, It looks full. Nurse A was asked if Resident #701 needed assistance with drinking and stated, She has to be assisted. Resident #701 was assessed at this time by Nurse A for sternal skin tenting (an indicator of fluid loss and possible dehydration). Resident #701 was found to be positive for skin tenting. Resident #701's family member arrived at approximately 5:30 P.M. and when asked about Resident #701's ability to feed herself, he stated, I feed her. She can do it, but you need to sit with her and help. They don't sit with her and help so I come every day for dinner to make sure she eats something and gets some nutrition. On 12/14/15 at 6:15 P.M., the Director of Care Delivery (Nurse R) was interviewed. Nurse R was asked about the level of assistance Resident #701 required for eating and drinking and stated, We would have to assist her. It's new as of Friday. Nurse R reported that they had looked into hospice for Resident #701 due to her poor intake and medical conditions, but the resident and her son are not ready to make that decision. When queried about who was responsible to ensure residents were being offered fluids and provided any required assistance for eating, Nurse R stated, The nurses are the supervisors of the floor. On 12/15/15 at 11:30 A.M., assignment sheets for the unit where Resident #701 resided were reviewed and documented that CNA M was her assigned CNA on 12/14/15 during the day shift. On 12/15/15 at 1:45 P.M., the food acceptance record for Resident #701 was reviewed and documented the following: 12/14/15 at 1:11 P.M. - 50% eaten - documented by CNA M 12/14/15 at 1:12 P.M. - 50% eaten - documented by CNA M 12/14/15 at 6:30 P.M. - 50% eaten - documented by CNA On 12/15/15 at 2:30 P.M., the registered dietician (RD) was interviewed about Resident #701's nutritional status and required assistance for eating and drinking. The RD reported that on 12/10/15, she saw Resident #701 for follow-up regarding wounds and observed the resident not eating well and unable to feed herself. The RD explained that she sat with the residents and fed her minimal amounts, downgraded her diet to enhanced mechanical soft, added nutritional drink and a concentrated protein supplement, and requested a consultation from speech language pathology (SLP). When asked if Resident #701 was supposed to be assisted with eating and drinking, the RD stated, She requires assistance since 12/10. On 12/16/15 at 7:55 A.M., Speech Language Pathologist (SLP) I was interviewed about Resident #701 and the ordered assessment from 12/10/15. SLP I reported that Resident #701 was evaluated on 12/11/15 and she was unable to feed herself, was slow to respond and had very poor intake. SLP I stated, I put on a physician's orders [REDACTED]. On 12/15/15 at 2:40 P.M., CNA M was interviewed via the telephone. CNA M was asked about what type of feeding assistance Resident #701 required. CNA M stated, Extensive. When queried about what extensive assistance entailed, CNA M stated, Set up the tray. Sit with her, prompt her to eat, and help, if she needed help, I would help. CNA M was asked if she assisted Resident #701 with eating breakfast or lunch on 12/14/15. CNA M reported that she was assigned to the dining room for meals on that day and CNA J was assigned to assist residents who ate in their rooms. CNA M was queried about the documentation on the food acceptance record that noted Resident #701 ate 50% of her breakfast and lunch meals and how that was determined. CNA M stated, That was what was told to me by the aide who fed her. On 12/15/15 at 5:15 P.M., the Director of Nursing (DON) was interviewed. The DON was asked how the facility monitored staff and residents to ensure they received the required assistance for eating and drinking. The DON reported that the resident would have a one on one with the dietician, the recommendations would be discussed in morning meeting, and added to the tasks (for CNAs). The DON was asked how often water should be offered to residents who require assistance with drinking and stated, Anytime they go into the room. When queried about the full cup of water from the midnight shift observed on 12/14/15 at 3:00 P.M. and Resident #701 begging and crying for water and observed with dry lips and tongue, the DON did not offer an explanation. On 12/16/15 at 8:00 A.M., CNA J was interviewed regarding any assistance she provided to Resident #701 on 12/14/15. CNA J reported that she brought her trays to her. When queried about any assistance that was provided with eating and drinking for Resident #701, CNA J stated, I set up the tray for her, then come back to check if she is done or needs anything. She eats slow and delicate. She mostly wants you to sit with her and talk. CNA J was asked how much of her meals, Resident #701 ate on 12/14/15 and stated, Only about 25%. When queried about how CNAs know what level of assistance a resident needs for eating or drinking, CNA J stated, Another CNA or nurse tells you when you come in. CNA J was asked how she would know if someone's feeding status had changed and stated, The nurse would tell me. On 12/16/15 at 1:30 P.M., Resident #701's POC Response History (electronic record where CNAs document care provided) for fluids offered for the past 30 days and it revealed the following: On 12/10/15 and 12/11/15, fluids were offered only on the midnight shift, no setup was provided, and resident was independent with the task. It was documented that Resident #701 accepted the fluids. On 12/14/15, it was documented that fluids were offered and accepted only once on the midnight shift with setup help only. There was no documentation of fluids being offered or accepted on the day or afternoon shift and what level of support was required. On 12/15/15, on the midnight shift, it was documented that Resident #701 received set up only for fluids. On 12/16/15 on midnight and day shift, it was documented that Resident #701 required total dependence from one person. On 12/14/15 at 12:00 P.M., Resident #701's clinical record was reviewed and revealed the following: Resident #701 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. An admission minimum data set (MDS) assessment, dated 10/18/15, documented that Resident #701 had intact cognition, required two person extensive physical assistance with transfers and bed mobility, and was independent with one person physical assistance for eating. Vital signs were reviewed for Resident #701 on 12/14/15 at 4:45 P.M. and revealed that Resident #701 had an elevated heart rate. Physician S was interviewed on 12/16/15 at 10:25 A.M. regarding the IV fluids ordered on [DATE] for Resident #701. Physician S reported that they fluids were ordered because the resident was not eating or drinking. Physician S stated, They were ordered to keep her going. Physician S was asked what signs and symptoms could indicate dehydration. Physician S stated, Dry oral mucosa, low blood pressure, elevated heart rate, skin turgor (tenting). Physician S further stated, I try to get a general sense of what the resident ate the day before. I asked the nurses and they said she hasn't eaten. In the past, I have seen food sitting right in front of her. If I'm in there, I will offer the food to her. Sometimes she accepts it. Sometimes not. The facility's policy regarding eating and drinking assistance was required, however, the administrator reported that they did not have one. The Administrator was asked on 12/16/15 at 5:00 P.M. if there was any additional information the facility would like to provide before the end of the survey. The Administrator said there was not. ( )

Based on observation, interview and record review, the facility failed to accurately assess for risk of skin breakdown, identify a new wound, consistently implement physical and nutritional interventions, and consistently provide treatment per physician's orders for pressure sores for one (#701) of 10 sampled residents reviewed for pressure sores, from a total sample of 19, resulting in the development of pressure ulcers to the spine and leg, a worsening stage IV pressure ulcer with exposed bone requiring hospitalization , and the potential for additional development and worsening of pressure sores. Findings include: On 12/14/15 at 8:50 A.M., Resident #701 was heard yelling Help! from the hallway of the unit. The resident was observed lying in bed, on her back, with her legs and feet lying against the mattress. A alternating pressure mattress (APM) console was observed attached to the foot of the bed and was turned off. The resident appeared extremely emaciated, weak and boney. There were no positioning or pressure off loading devices observed. At 8:55 A.M., Resident #701 continued to yell out, Please help me! Please! Certified nurse aide (CNA) J was observed entering Resident #701's room. CNA J asked Resident #701 if she was finished eating and removed the tray of food from the room. Additional observations were made at 9:05 A.M. and 9:13 A.M. on 12/14/15 of Resident #701, lying in bed on her back, slouched down with the head of the bed elevated, complaining of pain in her backside and lower abdominal area, and was yelling out for help, pulling at her gown and saying, It's so uncomfortable! Please Help!. The APM was turned off and no pillows or positioning devices were between the resident and the mattress. At 12:20 P.M. on 12/14/15, Resident #701 was observed positioned on her right side with no pillows or positioning devices under or between her lower extremeties. The APM was turned off. On 12/14/15 at 2:30 P.M., Resident #701 was heard yelling, Help! Please help me! from the hallway. Resident #701 was observed lying on her right side without any pillows or positioning devices under or between her lower extremeties. The APM was turned off. On 12/14/15 at 4:30 P.M., Resident #701 was observed lying in bed on her back with the head of the bed elevated with her body slouched down. Resident #701 was complaining of feeling uncomfortable and in pain and referred to her back side as the location of the pain. Resident #701 continued to say Please help me! and was tugging at her gown and attempting to move her body, as if trying to resposition herself off of her backside. The APM was on stand by, but not on. There were no pillows or positioning devices under or between Resident #701's lower extremities. Nurse U entered Resident #701's room and offered her a sip of milk. Resident #701 stated, Every day I go through this. I just want to get up in bed. Nurse U told Resident #701 that she would get somebody to get her out of bed and left the room. Resident #701 yelled out, Please don't leave! Don't go away! Please! On 12/14/15 at 4:40 P.M., Resident #701 was observed lying on her back, slouched down, APM was in stand by mode, and she was grimacing. Resident #701 stated, Nobody will help me. They won't come back. I just want to get up in bed. Just help me! On 12/14/15 at 5:15 P.M., Resident #701 was observed lying on her back, slouched down with the head of the bed elevated. A pillow was observed between Resident #701's knees, but there was nothing between Resident #701's legs and feet and the mattress. The APM was in stand by mode and not on. Nurse A asked Resident #701 if she had any pain. Resident #701 said, Yes. My tooshie (backside) A skin observation was done with Nurse A at this time after he positioned her onto her left side. The following observations were made of Resident #701's skin: On the left lateral calf, an undated dressing. When queried about what was underneath the dressing, Nurse A reported that he did not know. The dressing was removed by Nurse A and revealed an approximately 2 centimeter (cm) area of dark brown eschar (thick, leathery dead tissue) surrounded by a pale white raised area surrounded by a puffy, raised approximately 3-4 cm area. On Resident #701's mid-[MEDICATION NAME] spine, there was a dressing dated 12/14/15. Nurse A stated, I put that on today by myself. There was no dressing on it today. It gets changed every two days. When queried about what was on Resident #701's spine, Nurse A stated, It's a pressure sore. The pressure sore was along the length of the spine, approximately 9 cm long and 4 cm and was mostly covered in dark brown eschar. Resident #701's coccyx (tailbone) revealed an approximately 10 cm circular area with undermining and areas of yellow slough (moist dead tissue). It appeared white down the center of the pressure sore. When queried about what the white colored area was in the center of the wound, Nurse A stated, I can't tell. It might be bone. Nurse A reported that the coccyx wound had been previously debrided (a procedure to remove dead tissue to promote healing) and that Resident #701 had been prescribed antibiotics in the past for osteo[DIAGNOSES REDACTED] (bone infection) in that wound. Nurse A was queried about how often Resident #701 should be repositioned. Nurse A stated she should be repositioned frequently off of her backside. Nurse A stated, I positioned her myself today. I don't get any help from the aides. I try to do my best for the residents. Resident #701's son entered the room at 5:30 P.M. and was interviewed. Resident #701's son reported that Resident #701 did not have the pressure sores prior to being admitted to the facility. Resident #701's son stated, I don't know why they don't have an air matress or something. Resident #701's son was asked about the APM console attached to the foot of the bed and stated, I've never seen that on. I didn't even know if could turn on. Nurse A turned on the APM and stated, I don't know why that is off. Resident #701's son stated, Wow! You have to be kidding me. I don't think this has been on the whole time! On 12/14/15 at 12:00 P.M., Resident #701's clinical record was reviewed and revealed the following: Resident #701 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. An admission minimum data set (MDS) assessment, dated 10/18/15, documented that Resident #701 had intact cognition, required two person extensive physical assistance with transfers and bed mobility, and had one unstageable pressure sore on admission. A Patient Admission/Readmission Screen, dated 10/11/15, documented the following in the Skin section: Coccyx - redness on the coccyx approximately 11 cm in diameter. Braden Scale (a scored assessment to determine risk for skin breakdown) for Predicting Pressure Sore Risk Score: 15 .Braden Scale for Predicting Pressure Sore Risk Category: Low Risk for Skin Breakdown Progress notes from October 2015 through December 2015 revealed the following: 10/12/15 - A skin note that documented, Resident has a blanchable (skin loses redness with pressure) area at coccyx. DCD (director of care delivery) encouraged resident to reposition and shift her weight frequently . 10/13/15 - A skin note that documented, Patient seen by wound team today. Coccyx assessed, measurements as indicated: 8 cm x 8 cm, dry maroon surface .Continued interventions include: PRM (pressure reducing mattress), wheelchair cushion, reposition frequently, float heels, daily body audits . A skin progress note written by the wound team documented that on 11/17/15, the coccyx wound measured 6.5 x 6.5 x 0.1 cm, 70% yellow, 30% maroon tissue .Continued interventions include: PRM, wheelchair cushion, reposition frequently, float heels, daily body audits . A skilled nursing progress note, dated 11/23/15, documented that Resident #701 was on antibiotics for her wound. A skin progress note, dated 11/24/15 documented, .Coccyx wound measures 9.5 x 8.0 x 1.0 cm, with open area measuring 5.0 x 4.0 x 1.0 with proximal undermining (hallowed out tissue loss under the surface edge of the wound) of 1.5 cm, 60% maroon, 35 % yellow, 5% pink tissue .Continued interventions include: PRM, wheelchair cushion, reposition frequently, float heels, daily body audits . A skin progress note, dated 12/1/15, documented, .Coccyx wound measure 10.5 x 9.0 x 1.0 with circumference undermining of 3.0 cm, 30% maroon, 50% yellow, 20% pink tissue, bone exposure noted .Mid [MEDICATION NAME] spine wound measures 4.0 x 3.5 cm, dry maroon tissue .Continued interventions include: PRM, wheelchair cushion, reposition frequently, float heels, daily body audits . A note by the wound physician, dated 12/7/15, documented, .She has been seen by the wound care team and they have been treating the wounds including her sacral wound .Chronic Stage 4 sacral wound being followed by wound care team .Left leg venous ulcers along the knee and posterior leg/ankle .The patient may benefit from surgical debridement of the site (coccyx). But this may have to be done in the wound care clinic . A skin progress note, dated 12/8/15, documented, .Coccyx wound measure 10.5 x 9.0 x 1.5 with circumference undermining of 2.0 cm, 20% maroon, 50% yellow, 30% pink tissue, bone exposure noted .Mid [MEDICATION NAME] spine wound measures 9.0 x 4.0 x 0.1 cm, unstageable wound, 5% yellow, 95% dry maroon tissue .Continued interventions include: PRM, wheelchair cushion, reposition frequently, float heels, daily body audits . A progress note by the wound physician on 12/14/15 documented, Chronic stage 4 sacral wound being followed by wound care team and not examined today. Left leg venous ulcers along the knee and posterior leg/ankle are now all healed . There was no documentation of any skin changes or wounds on Resident #701's left lateral calf by nursing, the wound NP, or the wound physician. Braden Scale assessments were reviewed since admission on 10/11/15 and revealed the following: On 10/11/5, 10/18/15, 10/25/15, and 11/1/15, Resident #701 was scored as low risk for skin breakdown. A Pressure Ulcer assessment, dated 10/13/15, documented: Existing Pressure Ulcer:Coccyx 7.0 x 7.0 cm, dry maroon base, no odor, no drainage . Extrinsic Risk Factors: .confined to bed/chair all or most of the time .needs special mattress .slides down in bed .persistently wet from incontinence/wound drainage/perspiration .poor nutrition . Documentation: Patient was admitted with PU (pressure ulcer) to coccyx .Interventions PRM (pressure reducing mattress), ROHO (wheelchair seat cushion), frequent repositioning, incontinence care. Patient is likely to have future breakdowns and delayed wound healing d/t medical conditions . A Pressure Ulcer assessment, dated 12/1/15, documented: Existing Pressure Ulcer: Vertebrae (upper-mid), mid [MEDICATION NAME] spine 4.0 x 3.5 cm, dry maroon, no odor, no drainage . Extrinsic Risk Factors: .confined to bed/chair all or most of the time .needs special mattress .slides down in bed .cognitive loss .poor nutrition . Documentation: Patient has a suspected deep tissue injury on mid [MEDICATION NAME] spine .Patient is bed/chair most of the day, incontinent of bowel and bladder, nutritional deficit. Interventions: PRM, frequent repositioning. Patient is likely to have future breakdowns and delayed wound healing d/t medical conditions . Physician's Orders were reviewed from October 2015 through December 2015 and revealed the following wound care treatment and intervention orders: 10/13/15 - wound consult d/t redness in coccyx area 10/14/15 - body audit every day shift 10/14/15 - Coccyx/sacral wound care .apply foam dressing every 2 days and PRN (as needed) (discontinued on 10/21/15) 10/21/15 - Sacral/bilateral buttock care .Cleanse with NS (normal saline), Triad paste to affected are, cover with a dry padded dressing every night shift for wound care (discontinued on 11/4/15 and changed to Cleanse with NS (normal saline), Triad paste to wound and periwound areas, cover with a dry padded dressing every shift for wound care). 10/20/15 - elevate both extremeties while in bed 11/18/15 - a new order for sacral/coccyx wound care: Cleanse with NS, Triad to periwound, Therihoney Gel to wound bed, cover with dry padded dressing every day shift for treatments and PRN 11/18/15 through 12/2/15 - (an antibiotic) 100 milligrams (mg) every 12 hours for wound infection 11/24/15 - consult (wound physician) re: sacral/coccyx wound debridement 11/24/15 - a new order for sacral wound care: every day shift for 14 days cleanse with NS, apply Santyl (a debridement agent to remove dead tissue) and calcium aginate (an anti-microbial dressing) to wound bed, Triad paste to periwound, cover with a dry padded dressing every day and PRN x 14 days. 12/1/15 - a new order for Dakins solution (an antiseptic) 0.25% apply to sacral topically every shift for wound, clean wound with NS, apply Dakin's wet to dry dressing (lightly packed). Apply Triad paste to periwound and cover with padded dressing. 12/1/15 - a new order for Mid-[MEDICATION NAME] (spine) wound care every night shift every 2 days for wound care, Clean area with NS, apply foam dressing every 2 days and as needed. 12/5/15 - (wound physician) consult re: debridement of sacral wound The Medication and Treatment Administration Records (MAR and TAR) were reviewed for Resident #701 from October 2015 through December 2015 and documented the following: October 2015 Body audit every day shift for Skin observation - was left blank on 10/21/15 and 10/30/15. November 2015 Body audit every day shift for Skin observation - was left blank on 11/5/15, 11/10/15, 11/14/15, 11/20/15, 11/26/15, and 11/29/15. There were gaps (treatment not signed off) in the TAR on seven occassions for Sacral/Coccyx wound care. The dates are as follows: 11/4/15 7PM-7AM shift 11/5/15 7AM-7PM shift 11/10/15 7AM-7PM shift 11/14/15 7AM-7PM shift. 11/20/15 11/26/15 11/29/15 December 2015 Body audits were left blank on 12/1/15 and 12/8/15. There were gaps in the TAR for coccyx wound care on five occassions between 12/1/15 and 12/14/15. The dates are as follows: 12/2/15 7PM-7AM shift 12/8/15 7AM-7PM and 7PM-7AM shift 12/9/15 7AM-7PM shift 12/12/15 7PM-7AM shift The Director of Nursing (DON) was interviewed on 12/15/15 at 5:15 P.M. regarding Resident #701's pressure sores. The DON reported that Resident #701 was admitted with a pressure sore on her coccyx. When queried about any interventions that were put in place on admission, the DON reviewed the care plans and explained that Resident #701 needed to be repositioned frequently, her heels floated, and a pressure reducing mattress and wheelchair cushion was used. The care plan was dated 10/13/15 as the date the interventions were initiated. When asked about Resident #701's risk for skin breakdown, the DON stated, She used to get up in the chair. The admission skin assessment and subsequent Braden scale assessments were reviewed with the DON. When queried about how Resident #701 was assessed as low risk for skin breakdown, the DON did not offer an explanation. The DON was queried about Resident #701's current pressure sores and explained that she had a Stage IV (tissue loss exposing all layers skin and underlying bone) pressure ulcer on her coccyx and a suspected deep tissue injury on her spine. The DON reported that the coccyx pressure ulcer was closed on admission. The DON was asked what the facility was doing to prevent the development and worsening of pressure ulcers for Resident #701. The DON stated, With all of her comorbidities, her age, and malnutrition and poor intake, even if you are turning her regularly there will be breakdown. When queried about any assistance Resident #701 needed with eating and drinking, the DON stated, She definitely needs assistance. She didn't when she first got here, but after dietary saw her on 12/10/15, she required one to one feeding assistance. The observations from 12/14/15 of Resident #701 being positioned on her back with no pillows or positioning devices under or between her lower extremities, the APM being off and on standby from 8:50 A.M. until 6:00 P.M., and the lack of feeding and drinking assistance, was discussed with the DON. The DON did not offer an explanation. The DON was asked when the spine pressure ulcer was first identified and stated, It looks like it was first identified on 12/1/15. The DON was asked about the process for assessing residents' skin. The DON reported that it was documented on the medication administration record that a body audit was completed and if there were any changes or abnormalities, they would be documented in a nursing progress note. The DON reported that skin was also assessed during showers or baths. Shower/bath sheets were requested for Resident #701 since admission on 10/11/15. Resident #701's TARs from October 2015 through December 2015 were reviewed with the DON. The DON was asked what it meant, if a treatment or body audit was left blank on the TAR. The DON stated, It means they did not get around to doing it and it was passed on to the next shift. When queried about whether or not missed treatments and inconsistent implementation of interventions could contribute to the development and worsening of pressure ulcers, the DON did not offer an explanation. On 12/15/15 at 2:40 P.M., the DON provided three Skin Worksheets (bath/shower sheets) and stated, I only have a few. We don't keep them as part of the clinical record. When queried about where the identification of the spine pressure ulcer and the left lateral leg wound were documented, the DON did not offer a response. On 12/15/15 at 11:40 A.M., the wound nurse practitioner (NP) was interviewed. The wound NP stated, Her pain is so bad this morning, we are not comfortable going forward with her wound care. We have never seen her in this much pain before. When queried about what was causing Resident #701 so much pain, the wound NP reported it was likely the coccyx wound. The wound NP reported that Resident #701 was being followed by her due to having a worsened unhealing sacral wound that had exposed bone that was present upon admission and a spine wound that developed in the facility. The wound NP stated, They are supposed to send her for an MRI to rule out osteo[DIAGNOSES REDACTED] (bone infection) in the coccyx. It is very probable that she has osteo[DIAGNOSES REDACTED]. She is severely cachectic (emaciated) and completely bones. This wound is not going to heal .She will likely die from this wound. I have never seen her like this before though (in pain). The wound NP was queried about wound care and preventative interventions that were in place for Resident #701. The wound NP stated that other than the ordered wound care treatment, she should be repositioned from side to side frequently and not positioned on her backside. When asked how often Resident #701 should be repositioned, the wound NP stated, At the very least, every two hours, one hour would be even better, 30 minutes even better, every 15 minutes would be great. She has an APM though and that really helps with relieving pressure. The wound NP was asked if she was aware of the APM not being turned on regularly and that there were multiple missed treatments. The wound NP indicated that she was not aware. On 12/16/15 at 3:22 P.M., the wound care physician was interviewed and the wound on Resident #701's left lateral calf was observed along with Nurse R. The wound physician stated, I saw her (Resident #701) on Monday, there was no dressing on her leg. I didn't have any help and was in the room alone so I didn't get a good look at her legs. There was no dressing so I assumed it was healed, but then they notified me that there were still wounds on her legs. When queried if he put the dressing on the calf wound on Monday, the wound physician reported that he did not. Upon observation of the wound, the wound physician described it as unstageable with 100% eschar, and measured 1.5 cm by 1.8 cm. The wound physician reported that he could not tell what was under the eschar, but it is likely to the bone. When queried about whether or not the leg wound was a pressure sore, the wound physician stated, It could be. I'm going to say it's of mixed etiology, pressure versus metabolic. Nurse R reported that Resident #701 was being sent out to the hospital due to needing debridement of the coccyx wound and the ambulance had been called. Resident #701's clinical record (progress notes, physician's notes, wound notes, physician's orders, skin assessments) was further reviewed on 12/16/15 at 3:45 P.M. and revealed no documentation of the wound on Resident #701's left lateral calf and no physician's orders for treatment of [REDACTED]. On 12/14/15 at 12:00 P.M., Resident #701's clinical record was reviewed and revealed nutritional interventions to aid pressure sore healing and improve nutritional status and food intake were not implemented in a timely manner, and the amount of cuing and feeding assistance the resident needed during meals was not assessed in a timely manner. The following documentation was noted: Review of weight records revealed that Resident #701 was severely underweight on admission, documented as 79.2 pounds (lb) on 10/11/15, and had laboratory results indicative of poor nutritional status, with a decreased blood [MEDICATION NAME] (protein) and red blood cell levels. The resident continued to lose weight in the facility, with weights documented as 78.4 lb on 11/3/15, and 75 lb on 12/8/15, a 4.2 lb weight loss, or 5 percent (%) of body weight in two months. An Admission Nutrition assessment dated [DATE] at 10:52 A.M., documented no food preferences, no laboratory values, no pressure ulcers, and the following summary, Patient underweight. Declines supplements, however agreeable to Enhanced Mechanical Soft diet. Will continue to follow patient for further nutrition intervention needs. A Nutrition Care Plan for Resident #701, dated 10/12/15 (no revisions or updates since 10/12/15), entitled, Nutritional status as evidenced by potential weight loss/gain related to inadequate oral intake, underweight , included the following intervention, Provide additional calories/protein at meals per patient preference and provide supplements as ordered. Review of Physician ' s orders for Resident #701 revealed that Resident #701 was ordered an enhanced (extra nutrients added) diet on 10/12/15, but did not receive any other supplements until 11/10/15, Nutritional Juice Drink , and on 12/10/15, Ensure . Review of Dietary Progress notes for Resident #701 since admission revealed the following note dated 10/14/15, Seen per wound care consult secondary to coccyx wound measuring 8x8 centimeters (cm) Consuming 25 - 75% of meals. Continues to decline additional protein calorie supplementation secondary to increased needs with wound. Agreeable to high protein snack daily and additional high protein foods with meals. There was no documentation of additional high protein foods added to meals or of high protein snack, or of behavioral interventions to encourage food intake at meals. On 12/15/15 at 2:30 P.M., the registered dietician (RD) was interviewed about Resident #701's nutritional status and assistance for eating and drinking. The RD reported that on 12/10/15, she saw Resident #701 for follow-up regarding wounds and observed the resident not eating well and unable to feed herself. Resident #701 was supposed to be assisted with eating and drinking, the RD stated, She requires assistance since 12/10. The RD explained that she sat with the residents and fed her minimal amounts, downgraded her diet to enhanced mechanical soft, added nutritional drink and a concentrated protein supplement, and requested a consultation from speech language pathology (SLP). The RD reported that Resident #701 had a history of [REDACTED]. Observation of Resident #701 ' s meal trays on 12/14/15 at 8:55 A.M. and 1:45 P.M. and review of Resident #701 ' s documentation of food intake on the Facility Food Acceptance Record (FAR) for the same date revealed the facility was not accurately documenting the amount the resident was eating at each meal. On 12/14/15 at 8:50 A.M., Resident #701 was observed lying in bed, on her back, with a untouched tray of food on the over bed table. At 8:55 A.M., Certified nurse aide (CNA) J was observed entering Resident #701's room. CNA J asked Resident #701 if she was finished eating and removed the tray of food from the room. Review of the FAR for the first meal on 12/14/15 revealed the following: 12/14/15 at 1:11 P.M. - 50% eaten - documented by CNA M At 12:20 P.M. on 12/14/15, Resident #701 was observed positioned on her right side. An over bed table was positioned several inches away from the bed on the left side. (Resident #701 was facing the opposite direction). A full opened can of nutritional supplement sat on the table. The food acceptance record for Resident #701 was reviewed and documented the following entry for the second meal of 12/14/15:12/14/15 at 1:12 P.M. - 50% eaten - documented by CNA M. On 12/14/15 at 4:30 P.M., Resident #701 was observed lying in bed on her back with the head of the bed elevated with her body slouched down. An over bed table was in front of the resident and contained an uneaten half of an egg salad sandwich, a full opened can of nutritional supplement; an unopened package of graham crackers, and a jar of peanut butter with the lid shut. Nurse U entered Resident #701's room with a carton of milk and offered a sip. Resident #701 accepted the sip of milk. There was no attempt to offer the other items on Resident #701's over bed table. On 12/14/15 at 5:15 P.M., Nurse A was asked what kind of assistance Resident #701 required for eating and drinking. Nurse A stated, She eats and drinks by herself. She eats when her son is here. Nurse A was asked about the opened can of nutritional supplement on the over bed table and when it was delivered to the resident. Nurse A stated, Probably lunch time, around 12. When queried about the amount consumed from the can, Nurse A stated, It looks full. Nurse A was asked if Resident #701 needed assistance with drinking and stated, She has to be assisted. Resident #701's family member arrived at approximately 5:30 P.M. and when asked about Resident #701's ability to feed herself, he stated, I feed her. She can do it, but you need to sit with her and help. They don't sit with her and help so I come every day for dinner to make sure she eats something and gets some nutrition. She didn't want the one supplement they offered because she always ate natural foods, and didn't want to take something that was full of high fructose corn syrup. She needed someone to sit with her and keep her company and encourage and help her while she ate. On 12/15/15 at 2:40 P.M., CNA M was interviewed via the telephone. CNA M was asked about what type of feeding assistance Resident #701 required. CNA M stated, Extensive. CNA M was asked if she assisted Resident #701 with eating breakfast or lunch on 12/14/15. CNA M reported that she was assigned to the dining room for meals on that day and CNA J was assigned to assist residents who ate in their rooms. CNA M was queried about the documentation on the food acceptance record that noted Resident #701 ate 50% of her breakfast and lunch meals and how that was determined. CNA M stated, That was what was told to me by the aide who fed her. On 12/16/15 at 8:00 A.M., CNA J was asked whether she had provided any meal assistance to Resident #701 on 12/14/15. CNA J reported that she brought her trays to her. When queried about any assistance that was provided with eating and drinking for Resident #701, CNA J stated, I set up the tray for her, then came back to check if she was done. CNA J was asked how much of each meal Resident #701 ate on 12/14/15, and stated, Only about 25%. It was unclear why Resident 701's food intake on 12/14/15 was documented as 50% for each meal when CNA J , who was assigned to collect her meal trays reported she only ate 25% of each meal, and observation of Resident #701 ' s breakfast tray as it was removed on 12/14/15 at 8:55 A.M. revealed significantly less than 25% was eaten. CNA J stated, I set up the tray for her, then come back to check if she is done or needs anything. She eats slow and delicate. She mostly wants you to sit with her and talk. CNA J was asked how she would know if someone's feeding status had changed and stated, The nurse would tell me. The KARDEX (a care guide for CNAs) for Resident #701 documented, Special Need: 1:1 Feedings at all meals and was dated 12/10/15. Additionally, the KARDEX documented, Pressure reducing mattress, suspend heels, turn and/or reposition (frequently every 2 hours). Care Plans were reviewed on 12/15/15 at 4:15 P.M. and revealed the following: A care plan initiated on 10/13/15 (two days after admission on 10/11/15) and revised on 12/1/15 that documented, Pressure Ulcer at coccyx, mid [MEDICATION NAME] spine related to impaired mobility .Goals: Will show signs of continued healing .Interventions: Administer treatment per physician orders (initiated10/13/15), Encourage and assist as needed to turn and reposition; use assistive devices as needed (initiated 12/1/15), Float heels as able (initiated 10/13/15), Special mattress/cushion on bed/wheelchair (PRM, cushion) (initiated 10/20/15), Use pillows and/or positioning devices as needed (initiated 10/20/15). A care plan for ADL self care deficit initiated on 10/13/15 that documented, ADL self care deficit as evidenced by related to physical limitations .Interventions: Assist with .eating as needed . The facility's Skin Practice Guide was reviewed on 12/16/15 at 7:30 A.M. and documented the following: .The Braden Scale for Predicting Pressure Sore Risk aides in clinical decision making - the use of a clinically standardized validated risk assessment took helps to direct the process by which clinicians identify those at risk and quantify the level of identified risk . .Skin Observations .Nursing assistants perform daily skin observations with routine care . .Skin Evaluations .Patients at risk for skin breakdown have a head-to-toe skin evaluation weekly by a licensed nurse. Patients with pressure ulcers have a head-to-toe skin evaluation completed daily by the licensed nurse to identify additional skin changes. Documentation of the evaluation is located in the Treatment Administration Record or progress note . .A support surface can be used to manage tissue load, manage microclimate and redistrubute pressure . .Body positioning provides for pressure redistribution and can decrease pressure, friction and shear . .Nutrition and hydration management .Healing of acute and chronic wounds requires enough calories and protein so that the body will not use lean body mass for energy and wound repair .The Registered Dietician evaluated nutritional status, determines care interventions and assists with providing patient education related to food, nutrition and fluid needs. The RD evaluates weight status, adequacy of nutritional intake and patient's ability to eat independently . .If a change in patient condition occurs, such as a deterioration in or development of new risk factors or skin alterations, the licensed nurse notifies the physician, wound team, family or responsible party and documents findings in the clinical record. The patient's plan of care is then updated to reflect the patient's current status and care needs . .A member of the wound team evaluates the skin alteration and collborates with the licensed nurse and physici

Based on observation, interview, and record review, the facility failed to properly and thoroughly document, implement interventions timely, and provide adequate supervision for one (#501) of three sampled residents reviewed for accidents from a total of three, resulting in falls, pain, bone fracture, surgery, and hospitalization , and a potential for further falls/injuries. Findings include: This pertains to intake MI 477. On 12/2/15 at 11:00 a.m., per review of the clinical record and Incident reports for resident #501, the following was revealed: Resident #501 was initially admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum (MDS) data set [DATE] noted that the resident had severe cognitive impairment, required extensive assistance for transfers and ambulation, had unsteady balance, and had not fallen at the facility. Two Incident reports for resident #501 noted the following: 1. 11/5/15 at 4:30 a.m. - The patient with dementia found standing up from his bed but before the RN got to him he slides to the floor. He could not say why he is standing up. The corrective action: The patient to be getting up in the morning and check frequently. A falls risk care plan documented an added intervention of a scoop mattress on 11/5/15. 2. 11/22/15 at 9:00 a.m. resident #501 was observed on the floor in front of the nurses station. At approximately 5:00 p.m. facility staff was notified of x-ray results that identified resident #501 had a right hip and femur fracture. Clinical record review revealed: 11/22/15 nurse's notes documented the following, -(Resident #501) stated that he hit his head and was having bad knee pain. Doctor was notified and ordered an x-ray of the right hip 2 view right knee and femur. -Dr. notified that (resident #501) was complaining of his head hurting after the fall and gave orders to have patient transferred to hospital. Resident #501's hospital record was reviewed and revealed the following: -11/22/15 Radiology/Diagnostic note - Acute displaced comminuted right intertrochanteric fracture with valgus angulation of the right femur. -11/22/15 History and Physical - .admitted for right hip fracture after fall from chair .complaining of hip and knee pain. -11/26/15 Attending Physician note - Right hip fracture secondary to fall from wheelchair. The patient is status [REDACTED]. Physical therapy notes dated 11/4/15, 11/9/15, 11/16/15, 11/18/15, and 11/20/15 documented challenges related to gross motor coordination physical therapy goals such as a sit-to-stand due to confusion, cognition, and poor safety awareness On 12/2/15 at 3:20 p.m., Registered Nurse (RN) Staff A was interviewed regarding resident #501's fall on 11/22/15. Nurse A stated on 11/22/15 around breakfast time, resident #501 was sitting in his wheelchair at the nurse's station. We (nursing staff) hang out at the nurse's station so we can keep eyes on our patients who are fall risks. I remember maybe three residents at the nurse's station at the time of resident #501's fall. We were in the middle of our morning medication pass and (Resident #501) attempted to get up from his wheelchair. He was immediately told to sit back down by Licensed Practical Nurse (LPN) staff B who asked resident #501 if he was okay or if he needed something. It was about 20 seconds later, after I turned back to my medication cart, was when I looked up and saw (resident #501) in mid-fall and boom, he hit the floor. That's when everyone rushed over. Staff A stated he was approximately 15 feet from resident #501 when this occurred. On 12/2/15 at 3:30 p.m., LPN staff B was interviewed about resident #501. Staff B said, I've seen him trying to get up once before. I was at the nurse's station. (Resident #501) was in a position of trying to get up and I directed him not to stand up. I asked him if he needed something. Staff B was unable to recall the date this occurred. On 12/2/15 at 3:35 p.m., LPN staff C was interviewed about resident #501's fall on 11/22/15. Staff C said, When I came in that morning, (Resident #501) was already dressed and sitting by the nurse's station at 8:00 a.m. At about 8:50 p.m., I was coming out of a patient's room and was told by another staff member that one of your residents was on the floor. Staff C was queried if she ever saw resident #501 try to get up out of his chair before, and said, Oh yeah. When asked to explain further, staff C said, I will assume he was tired of sitting and was just trying to get out of the chair. He was told to sit back down. He was very easily redirected. It happened several times; like he would be in the dining room at the table trying to stand up, or before we could get him out of the bed, he would try to get out of the bed. On 12/2/15 4:00 p.m., Registered Physical Therapist (RPT), Staff D, resident #501 said, Resident #501 was a fall risk, confused, and could stand up and weight bear a little. The 10/28/15 Physical Therapy Assessment Summary indicated resident #501 had decreased safety awareness. On 12/2/15 at 4:22 p.m., Physical Therapy Assistant (PTA), Staff F, was interviewed regarding resident #501. Staff F stated, Resident #501 was very confused. When I would cue him and say (resident #501) we are about to walk, you do have to be very close and very hands on with him because he may not stand as instructed. Staff F was queried about how she managed to keep him safe during therapy and said, (Resident #501) would have to be told two or three times times to do something, provide tactile cueing or redirecting. Staff F was queried if she ever observed resident #501 trying to get up on his own while receiving therapy and said, No, but I've seen him try to get up on his own in the hallway and I've had to redirect him in the hallway. On 12/2/15 at 4:48 p.m., Certified Nurse Aide (CNA) staff E, was interviewed regarding resident #501. Staff E said, On 11/22/15 he was taken out of the dining room after breakfast and placed at the nurses station. Staff E state she did not witness the 11/22/15 fall. Staff E was queried if she every observed resident #501 trying to stand up from his wheelchair, and said, Yes, it is usually because he has to go to the bathroom to have a bowel movement. On 12/2/15 at 12:35 p.m., resident #501 was observed lying in his bed on a regular mattress. At 12:40 p.m., RN staff A and CNA staff G both stated resident #501 was lying on a regular mattress not a scoop mattress. On 12/2/15 at 5:00 p.m., the Director of Nursing (DON) stated that resident #501 should have a scoop mattress on his bed. At 5:05 p.m. an observation was made with the DON present that resident #501 was not lying on a scoop mattress. The DON stated the scoop mattress should be in place. On 12/2/15 at 5:10 p.m. the DON was interviewed regarding resident #501. The DON stated many of our high fall risk residents are at the nurses statement so they can be monitored a little more frequently. Regarding resident #501, the DON stated usually someone will take him from the dining room after breakfast and put him at the nurse's station so he can be monitored a little more frequently. The DON stated breakfast is served at 7:30. The DON said, Frequent monitoring does not have to be placed on the resident's care plan. Frequent monitoring is not an actual order or intervention that we would have to follow. It is up to the clinical judgement of the nurses. The DON stated she was unaware of occasions when resident #501 attempted to get out of his wheelchair prior to 11/22/15. The DON stated this information should have been communicated in the 24-hour report and/or documented in the progress notes. The DON said, They (staff) should be charting if someone is trying to stand (up from their wheelchair). When the DON was queried about the type of interventions a resident would require that demonstrated a history of trying to get out of their wheelchair, the DON listed the following, We would do lab work up for a UTI (urinary tract infection), we would do a drop in wheelchair, a scoop wheelchair as possible interventions. An At Risk for Falls care plan due to impaired balance/poor coordination, unsteady gait, initiated on 10/27/15, listed the following interventions and initiated dates: -bed in low position, 10/27/15 -encourage to transfer and change position slowly, 10/27/15 -scoop mattress, 11/5/15 -drop wheelchair, 11/22/15 -have commonly used articles within easy reach, 11/22/15 -provide assist to transfer and ambulate as needed, 11/22/15 The care plan did not mention supervision of the resident. On 12/2/15 at 5:22 p.m. the facility administrator was queried about why resident #501 fell and said, I have no opinion of why he fell . At 5:26 p.m. the DON was asked the same question and said, I'm not sure why he fell . On 12/2/15 at 5:30 P.M., the administrator was asked if there was any additional documentation or information that they would like to provide prior to the end of the survey and reported there was not.

Based on observation, interview, and record review, the facility failed to properly and thoroughly assess, document, implement interventions timely, and provide adequate supervision for two (#601 and #602) of six sampled residents reviewed for accidents from a total of six, resulting in falls, pain, head contusion, apnea (not breathing), hypotension, extremity weakness, spinal cord compression, emergency hospitalization , and a potential for further falls/injuries. Findings include: This pertains to intake MI 387. Resident #601 On 6/24/15 at 1:55 PM, per review of the clinical record and Incident reports for resident #601, the following was revealed: Resident #601 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] noted that the resident had severe cognitive impairment, required extensive assistance for ambulation and transfers, had unsteady balance, and had not fallen at the facility. Four Incident reports and the clinical record for resident #601 noted the following: 1. 3/5/15 at 1 AM-The resident became combative in her room and was kicking, punching, and biting staff. The corrective action: Anxiety meds given as ordered. A review of the medication administration record (MAR) indicated that there was no anxiety medication given related to this incident. The MAR noted that the antipsychotic Seroquel, was given that night at 9:15 PM. An Agitation and Combativeness care plan, created by nursing staff with an initiation date of 3/5/15, noted one intervention: Call the resident's daughter when agitated. There were no interventions related to determining the root cause of behavior. 2. 3/7/15 at 7:58 PM-Patient rolled her wheelchair towards the wall and hit her head while at the nursing station. There was no documented injury. The corrective action: Patient monitored closely at all times. Patient education done on safety. Patient educated to ask for help when needed. On 6/24/15 at 3 PM the Director of Nursing (DON) did not respond when asked how this severely impaired resident (#601) could be educated on safety and be cognizant enough to understand to ask for help. Progress notes dated 3/9/15 at 4:04 AM, 3/10/15 at 8:06 PM, 3/11/15 at 3:16 AM, and 3/13/15 at 2:58 AM documented that the resident had to be kept at the nurses station for supervision due to repeated attempts to get up and out of the wheelchair and for agitation. Resident #601's MAR indicated that Ativan was given orally every 12-hours from 3/4/15 at 9 PM thru 3/14/15 at 9 AM for anxiety and given by injection once on 3/12/15 at 9 PM for agitation. 3. 3/13/15 at 11:45 AM-Patient observed lying on floor in assisted dining room by nurse.Patient complained of acute left shoulder pain.headache. contusion observed on left forehead.Patient appeared to slide out of wheelchair onto floor. The corrective action: Dycem (pad) applied to wheelchair to prevent patient from sliding. The MAR indicated that Tylenol 650 milligrams, the only pain medication ordered, was given one time during admission at 12:18 PM. The MAR indicated that an Exelon patch for Alzheimer's was applied one time during admission, on 3/14/15 at 9 AM. 4. 3/14/15 at 2:16 PM-At the nursing station in her wheelchair patient stood up (and) was observed falling to the ground.Patient noncompliant and not aware of her limitations. Prior (to) fall.continued redirections required by staff throughout morning. Per 3/14/15 progress notes, the resident was observed falling onto the floor face forward into a prone position and that pressure was applied to a head wound. Prior to the fall, she had been observed standing in front of her wheelchair multiple times. When assessed after the fall, resident #601's blood pressure was 59/38 and had an episode of apnea. Following a sternal rub (painful stimulation used when verbally unresponsive), the resident's respiratory rate was 8 (normal range=12-16 per minute). At 2:30 PM, the resident was transferred by emergency medical staff to the hospital. The corrective action on the Incident report post fall: Request family to provide sitter (one to one supervision) upon patient's return. An At Risk For Falls care plan due to unsteady gait, initiated on 3/4/15, indicated that an intervention was added on 3/14/15 to conduct a urinalysis. A progress note dated 3/16/15 (two days after transfer to the hospital) documented: Interdisciplinary team (IDT) recommends check urine for UTI (urinary tract infection). The care plan did not mention supervision of the resident. On 6/24/15 at 3:50 PM, nurse 'A' was interviewed regarding resident #601's fall on 3/14/15. Nurse 'A' stated that she was up the hallway and summoned to assist when the resident fell in front of the nurses desk and that nurses 'B' and 'C' had been sitting behind the desk when the fall occurred. She stated that a code blue (indicating cardio/respiratory arrest) was initiated. At 4:30 PM, nurse 'C' stated that he was sitting behind the nurses desk documenting notes, along with another nurse, saw the resident fall, and indicated that he could not intervene to prevent the fall from the other side of the desk. On 6/25/15 at 10 AM, the DON was queried regarding interventions to address the behaviors resident #601 exhibited upon admission and throughout her stay. The DON stated that a psychiatric evaluation should have been initiated upon admission by the Social Worker. She stated that the resident was combative while in the hospital prior to admission and that the resident was placed on Ativan there. On 6/25/15 at 11:22 AM, Social Worker (SW) 'D' was interviewed and his notes were reviewed regarding resident #601's behaviors and interventions. SW 'D' stated that he became aware of the resident's behavior on 6/5/15 during a morning IDT meeting and saw orders in the chart for Seroquel and Ativan. However, an assessment, and behavior and progress notes written by him for the resident dated 6/5/15 thru 6/13/15, did not mention her behavior at the facility. When asked, SW 'D' stated he should have documented it. SW 'D' stated that on 6/9/15, the resident was exhibiting behavior and indicated that a psychiatric evaluation was conducted that day because the mental health staff was already present in the facility for their routine weekly visit. When asked if he requested an evaluation when he first became aware of the behavior on 3/5/15, SW 'D' was unable to verify that he requested a psychiatric evaluation. SW 'D' was asked if UTIs could contribute to adverse resident behavior and responded yes. He indicated however, that an assessment of resident #601 for a UTI, was not discussed by the IDT during morning meetings. Care plans for resident #601 were discussed with SW 'D'. An At Risk For Behavior Symptoms care plan by nursing staff with an initiation date of 3/9/15, noted interventions that included: Psych referral as needed. There was no mention of the actual behaviors, evaluations for a possible root cause, such as UTI and pain, or the resident's incidents. When asked, SW 'D' stated that he had created a care plan related to the resident's behaviors and psychotropic drug use. A review of the At Risk For Changes In Mood care plan related to cognitive loss and depression, noted a creation date by SW 'D' of 3/13/15. The goals: Will accept care and medication as prescribed and Will maintain involvement with activities of daily living performance and social activities. The care plan had one intervention: Administer medication per physician orders. There was no mention of psychiatric referrals, interventions to determine the root cause of behaviors, or the resident's incidents. SW 'D' did not respond why there was no care plan by him before 3/13/15. On 6/25/15 at 2 PM, resident #601's hospital record was reviewed and revealed the following: 3/14/15 hospital Emergency Department notes-Puncture wound noted to left forehead. Patient moaning at this time.blood loss: moderate.responsive to voice.neurological examination was limited secondary to her mental status changes and not following commands.laceration length: 1 cm (centimeter). 3/14/15 History and Physical-.fall with injury to head, altered mental status and was found with UTI (urinary tract infection) while in emergency department.1 cm abrasion with 2 sutures on left sided forehead.altered mental status.Patient with history of dementia, per family is less than baseline.likely secondary to UTI.IV (intravenous) antibiotics (Cefepime). Resident #601's white blood count (WBC-used as an indicator of infection) was 11.3 (normal range=3.8-10.6). A report of a CAT scan to the cervical (neck area) spine dated 3/14/15 revealed: .cord compression is considered likely. IV Cefepime was discontinued on 3/17/15 and oral Augmentin (antibiotic) was started pending outcome of a urine culture collected on 3/14/15. On 3/18/15, the resident was placed on IV Vancomycin (antibiotic) after the urine culture result came back positive for Staphylococcus Aureus (staph infection). On that day, the resident's WBC had elevated from 11.3 to 18.1. Per a note dated 3/19/15 by a Hospitalist: A follow-up, repeat CAT scan was recommended for resident #601 due to upper extremity weakness. The CAT scan to the head dated 3/19/15 was negative. The spine showed flattening to the spinal cord. A Neurosurgical consultation dated 3/20/15 noted: .Chief complaint: Weakness of bilateral upper extremities.I recommend MRI of the cervical spine. A MRI of the cervical spine dated 3/21/15 revealed: .severe compression of the sac (membrane surrounding the spinal cord) and cord.Findings could relate to cord edema or possibly a cord contusion given recent history of trauma. A Neurology progress note dated 3/23/15 documented: Per patient's daughter, patient developed upper extremity weakness after her last fall (at the facility on 3/14/15). (Per a Neurological Evaluation Flow Sheet written by the facility after the head injury on 3/13/15, the resident's ability to move each limb, was checked every 30 minutes x 4-every 4 hours x 4-every 8 hours x 4 from 3/13/15 at 11:45 AM thru 3/14/15 at 1 PM. There was no documented new development of weakness.) Per Neurosurgical notes dated 3/24/15, resident #601 had decompression surgery that day for spinal cord compression at level C1-C2 (first and second cervical vertebrae) and a bone graft. The surgeon documented, She had a big problem in her neck at C1-C2 with cord compression, myelomalacia (damage to the spinal cord most commonly from injury).Actually C1 was sitting under C2 and pushing on the upper spinal cord in a very dramatic and severe, severe fashion.the bone was actually pushing inside the cord.The bone graft was obtained from the patient's own bone. On 6/25/15 at 3:50 PM, resident #601's facility Primary Care Physician (PCP) was interviewed by phone regarding the resident's behaviors, incidents/accidents, and possible contributing factors, such as a UTI. The PCP said, I think I saw her the day of one fall. I told the family she was high risk for falls and that she couldn't have someone with her all the time. I don't know if I worked her up for UTI.Should I have considered a UTI? (The hospital PCP prior to admission into the facility) told me that she had dementia and was on all kinds of meds already, so she was already having behaviors. On 6/25/15 at 4:05 PM, Activity Assistant 'E' was queried in the presence of Activity Director 'F' regarding resident #601's fall on 3/13/15 in the assisted dining room during an activity conducted by staff 'E'. Staff 'E' stated that she did not see the resident fall and could not recall if she was present in the room at the time. She said, If someone is a fall risk, I wouldn't leave them alone. Both staff 'E' and 'F' stated that at times, they would have to leave an activity in order to get other residents for attendance. They indicated that nursing staff would be asked to watch the room until their return. On 6/25/15 at 4:45 PM, the Administrator and the DON did not offer a response regarding resident #601's incidents/accidents, injuries, and hospitalization . Resident #602 On 6/24/15 at 1:40 PM, the clinical record and Incident reports for resident #602 were reviewed. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] noted that the resident had severe cognitive impairment, required extensive assistance for ambulation and transfers, had unsteady balance, and had falls prior to admission. Resident #602's At Risk For Falls care plan due to impaired balance/poor coordination, unsteady gait, history of falls, noncompliance with use of assistive devices with an initiation date of 6/7/15, noted goal: Minimize risk for falls. Interventions did not include supervision of the resident. The resident's Patient Admission Screen dated 6/7/15 noted that the resident had three fresh left hip surgical incisions from insertion of screws for fracture repair. Incident reports for resident #602 revealed the following: 1. On 6/22/15 at 1:40 PM, the resident stood up from her wheelchair in the hallway, apparently lost her balance, and fell to the floor. There was no indication that the fall was witnessed and the resident was being supervised. The corrective action: Continue to monitor closely. There was no documented injury. 2. On 6/22/15 at 9:45 PM, Patient was observed sitting on the floor on her buttock at the nursing station with legs stretched out and back leaning against wheelchair. The corrective action: Patient stayed at the nursing station with nurses. Scoop (concave with raised edges) mattress or one on one (supervision) recommended. There was no documented injury. On 6/24/15 at 9:50 AM, resident #602 was observed sitting in a wheelchair behind the desk at the nursing station. There was no staff present. The resident stood up independently. Approximately 30 second later an employee wearing street clothes walking down the hallway saw the resident, told her to sit down, gave her a magazine, and observed the resident for two minutes. This staff person then left the area out of the resident's view. The resident was again left along at the nursing station. Approximately two minutes later, resident #602 stood again, a second employee wearing a uniform walked up the hallway out of view of the resident, saw the resident standing and instructed resident #602 to sit down and immediately left the area out of view of the resident. The resident was again left along without staff supervision. On 6/25/15 at 2:30 PM, resident #602 was observed sitting at the nurses station with several staff in her presence. On 6/25/15 at 3:00 PM, the DON was queried regarding the level of supervision resident #602 requires and stated, (Resident #602) will be transferred to another facility on Monday that will better suit her needs. On 6/29/15 at 9 AM, the facility's Mood and Behavior Practice Guide dated 3/2011 and Falls Practice Guide dated 12/2001, were reviewed. Per the Mood and Behavior Practice Guide: When a behavior symptom develops, it is often problematic when it presents a safety risk, interferes with care delivery, or is stressful to others; Behaviors include anxious appearance, pacing without rest, wandering, and hitting. Complete an initial evaluation of residents with risk factors that predispose for falls, such as unsteady gait, dementia, and arthritis: Diagnostic tests, such as a urinalysis may assist in determining root cause for falls; During an initial evaluation, review risk factors for behaviors; If the resident exhibits behavior symptoms, the social worker must evaluate if the behavior indicates an adjustment problem and refer to psychiatric services if necessary. The IDT must develop a care plan designed to focus on all of the resident's issues associated with behavior that include pharmacological and non-pharmacological interventions; The goal is to treat the underlying cause of behavior, such as use of pain medication if pain is causing agitation. When a resident displays behavior symptoms, the IDT must analyze the root cause and document if the symptom could be related to pain, a change in blood chemistry, or unrecognized infection. The IDT's goal is timely alleviation of behavior symptoms through identification, assessment, care planning, and on-going analysis of the root cause of behavior. The guides did not address supervision of residents. ( ) ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 930. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT 1 OF 4 SAMPLED RESIDENTS (#103) REVIEWED FOR PRESSURE ULCERS, IN A TOTAL SAMPLE OF 8, WAS PROVIDED WITH ADEQUATE AND APPROPRIATE CARE TO PREVENT AND TREAT PRESSURES SORES, RESULTING IN PRESSURE SORE DEVELOPMENT WHEN RESIDENT #103 DEVELOPED A STAGE III PRESSURE SORE AT THE FACILITY ACCOMPANIED BY INFECTION AND PAIN. FINDINGS INCLUDE: REVIEW OF A FACE SHEET PRINTED ON 10/12/12 REVEALED THAT RESIDENT #103 WAS AN [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM DATA SET (MDS) ASSESSMENT, DATED 10/14/11 REVEALED THAT RESIDENT #103 NEEDED EXTENSIVE ASSISTANCE AND TWO OR MORE PERSON PHYSICAL ASSISTANCE FOR BED MOBILITY, TRANSFER AND TOILET USE. THIS MDS ASSESSMENT INDICATED THAT RESIDENT #103 NEEDED ONE PERSON PHYSICAL HELP IN PART OF BATHING ACTIVITY AND WAS FREQUENTLY INCONTINENT OF URINE AND ALWAYS INCONTINENT OF BOWEL. REVIEW OF TRANSFER DOCUMENTS FROM AN OUTSIDE HOSPITAL DATED 10/04/11, UNDER SKIN AND BACK PHYSICAL EXAMINATION, REVEALED THAT RESIDENT #103 HAD NO RASH OR DECUBITUS ULCER. REVIEW OF THE PATIENT DISCHARGE SUMMARY FROM THE OUTSIDE HOSPITAL, DATED 10/07/11 AT 10:44 AM, REVEALED THAT RESIDENT #103 HAD A WORKING DISCHARGE [DIAGNOSES REDACTED]. THERE WAS NO DOCUMENTATION SUGGESTING RESIDENT #103 HAD ANY ALTERATIONS IN SKIN INTEGRITY AT THE TIME OF THIS DISCHARGE SUMMARY. REVIEW OF THE PATIENT ADMISSION/READMISSION SCREEN, DATED AND SIGNED BY LICENSED PRACTICAL NURSE (LPN) #4 ON 10/07/11, UNDER SKIN ASSESSMENT SECTION, REVEALED THAT RESIDENT #103 HAD NO IDENTIFIED AREAS OF SKIN BREAKDOWN. REVIEW OF ADDITIONAL MONTHLY ORDERS (UNDATED WITH NO TIME) REVEALED THAT RESIDENT #103 WAS ORDERED TO BE ASSESSED FOR PRESSURE SORE RISK USING THE BRADEN SCALE (A TOOL TO IDENTIFY POTENTIAL LEVELS OF RISK FOR PRESSURE SORE DEVELOPMENT) X4 (FOUR TIMES) STARTING ON 10/14/11. REVIEW OF THE RECORD REVEALED NURSING CARE PLAN FOR AT RISK FOR ALTERATION IN SKIN INTEGRITY INITIATED 10/10/11 THAT INDICATED, UNDER INTERVENTIONS SECTION, RESIDENT #103 IS TO BE ADMINISTERED PREVENTATIVE TREATMENT AS ORDERED BY PHYSICIAN AND TO OBSERVE FOR S&S (SIGNS AND SYMPTOMS) OF DECREASED CIRCULATION/SKIN IMPAIRMENT. REVIEW OF NURSE'S NOTES DATED 10/12/11 AT 3:00 PM REVEALED THAT RESIDENT #103 COMPLAINED OF PAIN "ON HER BOTTOM" AND BENGAY ([MEDICATION NAME] HEAT RUB) PATCH WAS ORDERED TO BE APPLIED TO HER SACRUM AREA DAILY. REVIEW OF THE BRADEN SCALE PRESSURE SORE RISK FORM DATED 10/14/11, 10/21/11, AND 10/28/11 FOR RESIDENT #103 REVEALED THAT THE FORM HAD NOT BEEN COMPLETED ON 10/14/11, AS EVIDENCED BY BLANK AREAS ON FORM. REVIEW OF THE TREATMENT ADMINISTRATION RECORD (TAR) DATED FOR THE ENTIRE MONTH OF OCTOBER 2011, REVEALED THAT RESIDENT #103 DID NOT RECEIVE A BRADEN SCALE ASSESSMENT ON 10/14/11 AS EVIDENCED BY UNSIGNED BLANK AREA DATED 10/14/11 AND NO ADDITIONAL DOCUMENTATION BEING AVAILABLE INDICATING THAT RESIDENT #103'S PRESSURE SORE DEVELOPMENT RISK WAS EVALUATED ON 10/14/11. REVIEW OF NURSE'S NOTES DATED 10/15/11 AT 11:15 AM WRITTEN BY LICENSED PRACTICAL NURSE (LPN) #7 REVEALED THAT RESIDENT #103 WAS OBSERVED TO HAVE A "LARGE OPEN AREA" DURING AM (MORNING) CARE. THESE NOTES FURTHER INDICATED THAT THE PHYSICIAN WAS NOTIFIED AND A NEW TREATMENT WAS INITIATED. THIS TREATMENT WAS TO CLEANSE THE AFFECTED AREA WITH NS (NORMAL SALINE), PAT DRY, APPLY SANTYL, COVER WITH ABD (ABDOMINAL PAD) AND TAPE. REVIEW OF THE MEDICAL ORDER DATED 10/15/11 AT 12:00 PM SIGNED BY LICENSED PRACTICAL NURSE (LPN) #7 AND THE PHYSICIAN REVEALED THAT RESIDENT #103 WAS TO HAVE THE FOLLOWING TREATMENT: COCCYX CLEANSED WITH NS (NORMAL SALINE), PAT DRY, APPLY SANTYL, COVER WITH ABD (ABDOMINAL PAD) AND TAPE, CHANGE EVERY DAY AND AS NEEDED UNTIL HEALED. REVIEW OF NURSE'S NOTES DATED 10/19/11 WRITTEN BY REGISTERED NURSE (RN) #6 REVEALED THAT RESIDENT #103'S WOUND ON HER COCCYX WAS MEASURED AS BEING 4 X 3.5 (CM) WITH NOTED TO HEAVY ESCHAR AND SLOUGH PRESENT AND WITH MODERATE YELLOW DRAINAGE HAVING A FOUL SMELL.. THESE NOTES ALSO INDICATED THAT RESIDENT #103 HAD SMALL PRESSURE AREA TO HER L(EFT) BUTT(OCKS) 1.0 X 0.2 WITH PINK "EPITHEAL" ([MEDICATION NAME]) TISSUE. REVIEW OF A CLINICAL ASSESSMENT REPORT FOR PRESSURE ULCER DATED 10/19/11 SIGNED BY REGISTERED NURSE (RN) #6 REVEALED THAT RESIDENT #103 HAD AN EXISTING PRESSURE ULCER TO HER SACRUM AREA AND THAT THE RESIDENT (#103) HAD BEEN admitted TO THE FACILITY WITH A PRESSURE ULCER. REVIEW OF A MEDICAL ORDER DATED 10/20/11 (NO TIME) REVEALED THAT FACILITY STAFF WERE TO "DISCONTINUE RESIDENT #103'S BENGAY PATCH TO SACRUM." REVIEW OF THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. REVIEW OF THE MANUFACTURER'S RECOMMENDATIONS FOR PRODUCT USAGE (WWW.BENGAY.COM) REVEALED THAT THE BENGAY PATCH IS FOR EXTERNAL USE ONLY AND TO "(DO) NOT USE ON WOUNDS OR DAMAGED SKIN." REVIEW OF A PAIN EVALUATION DATED 10/21/11 AT 1:46 PM REVEALED THAT RESIDENT #103 EXPERIENCED MODERATE PAIN TO HER SACRUM, DESCRIBED AS ACHING WITH PRESSURE, HEAVINESS AND TINGLING. REVIEW OF MEDICAL ORDERS DATED 10/23/11 REVEALED THAT RESIDENT #103 WAS TO HAVE A WOUND CONSULT BECAUSE HER COCCYX AREA HAD A FOUL SMELL. REVIEW OF NURSE'S NOTES DATED 10/26/11 WRITTEN BY REGISTERED NURSE (RN) #6 REVEALED THAT RESIDENT #103'S WOUND TO HER COCCYX HAD INCREASED IN SIZE AND ODOR AND WAS MEASURED AS BEING 7.0 X 7.0 (CM) WITH TUNNELING, STRONG FOUL ODOR, HEAVY SLOUGH, AND HEAVY PURULENT DRAINAGE WITH INFECTION PRESENT. THESE NOTES INDICATED THAT RESIDENT #103 HAD AS AXILLARY TEMPERATURE OF 99.7 (ELEVATED). AT THAT POINT, THE MEDICAL DIRECTOR (MD) #8 AND THE ATTENDING PHYSICIAN (DO) #9 WERE CONSULTED AND ORDERED RESIDENT #103 TO BE SENT TO AN OUTSIDE HOSPITAL FOR WOUND DEBRIDEMENT AND FURTHER WOUND CARE. REVIEW OF A EMERGENT MEDICAL SERVICE (EMS) RUN FORM DATED 10/26/11 REVEALED THAT EMS WAS DISPATCHED to the facility on [DATE] AT 11:21 AM, ARRIVED AT RESIDENT #103 ON 10/26/11 AT 11:40 AM, AND ARRIVED AT DESTINATION (OUTSIDE HOSPITAL) WITH RESIDENT #103 ON 10/26/11 AT 12:16 PM. THIS EMS RUN FORM INDICATED THAT RESIDENT #103 HAD AN INJURY DESCRIPTION OF DECUBITUS AND PRIMARY COMPLAINT OF SACRAL DECUBITUS INCREASING IN SIZE AND IN NEED OF DEBRIDEMENT. REVIEW OF RESIDENT #103'S CLINICAL RECORD REVEALED NO EVIDENCE THAT FACILITY STAFF HAD DOCUMENTED RESIDENT #103'S SKIN CONDITION ON THE ROUTINE SHOWER SHEETS DURING RESIDENT #102'S COURSE OF STAY AT THE FACILITY. REVIEW OF THE OUTSIDE HOSPITAL DATED 10/26/11 REVEALED THAT RESIDENT #103 WAS admitted TO THE OUTSIDE hospital on [DATE] WITH PRIMARY [DIAGNOSES REDACTED]. REVIEW OF THE PHYSICIAN ASSISTANT ADMIT NOTE (ROUNDS REPORT) FROM THE OUTSIDE HOSPITAL DATED 10/26/11 REVEALED THAT RESIDENT #103 HAD AN INFECTED SACRAL DECUBITUS ULCER, MEASURED AS BEING "7 CM X 9 CM X 1-2 CM COVERED WITH GRAY GREEN STRINGS OF INFECTION WITH + (POSITIVE) FOUL ODOR (THAT WAS) APPARENT BEFORE ENTERING THE CURTAINED OFF ROOM IN ER (emergency room )." REVIEW OF A PROGRESS NOTE FROM THE OUTSIDE HOSPITAL DATED 10/26/11 AT 3:15 PM REVEALED INDICATED RESIDENT #103 HAD BEEN COMPLAINING OF LOW BACK PAIN FOR THE PREVIOUS WEEK AND HAD BEEN "SENT TO THE ED (EMERGENCY DEPARTMENT) TODAY (10/26/11) FOR INCREASED PAIN AND SKIN BREAKDOWN." THESE NOTES INDICATED THAT RESIDENT #103 HAD A" MALODOROUS SACRUM MIDLINE ULCER STAGE 3 (III)." DURING A CONFIDENTIAL INTERVIEW WITH CONFIDENTIAL INTERVIEWEE (CI) #12 ON 10/10/12 AT 11:55 AM, CI #12 SAID RESIDENT #103 DID NOT HAVE ANY PRESSURE ULCERS WHEN admitted to the facility on [DATE]. CI #12 SAID RESIDENT #103 DEVELOPED A PRESSURE SORE SOMETIME DURING COURSE OF STAY AT THE FACILITY. DURING AN INTERVIEW WITH LICENSED PRACTICAL NURSE (LPN) #7 ON 10/11/12 AT 12:50 PM, LPN #7 SAID SHE REMEMBERED RESIDENT #103 BY NAME ONLY BUT COULD NOT RECALL ANY DETAILS OR CIRCUMSTANCES INVOLVING RESIDENT #103'S COURSE OF STAY AT THE FACILITY. LPN #7 SAID, "IT WAS SO LONG AGO." DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) (EMPLOYEE #2) ON 10/12/12 AT 9:15 AM, THE DON SAID RN #6 TOLD HER THAT RESIDENT #103'S WOUND WAS "MUSHY" WHEN FIRST DISCOVERED. THE DON SAID THAT PHYSICIAN #9 HAD BEEN RESIDENT #103'S PRIMARY PHYSICIAN DURING COURSE OF STAY AT THE FACILITY. THE DON SAID PHYSICIAN #9 WAS CURRENTLY IN OUT OF THE COUNTRY AND THAT THERE WAS NO CONTACT INFORMATION AVAILABLE WHILE PHYSICIAN #9 WAS GONE. DURING AN INTERVIEW WITH MEDICAL DIRECTOR (MD) # 8 ON 10/12/12 AT 9:20 AM, MD #8 SAID PHYSICIAN #9 WAS THE PRIMARY PHYSICIAN FOR RESIDENT #103. MD #8 SAID SHE (MD #8) DID NOT BECOME INVOLVED IN THE CARE OF RESIDENT #103 UNTIL RESIDENT #103 NEEDED TO BE TRANSFERRED FROM THE FACILITY. MD #8 SAID SHE THINKS THE ADMISSION NURSE (LPN #4) MISSED THE WOUND DURING THE INITIAL ADMISSION SKIN ASSESSMENT ON 10/07/11. MD #8 SAID SHE THINKS RESIDENT #103 DEVELOPED THE PRESSURE ULCER AS A RESULT OF INTERNAL DAMAGE AND SUBSEQUENT LACK OF BLOOD SUPPLY TO THE SACRAL/COCCYX AREA. DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) (EMPLOYEE #2) ON 10/12/12 AT 11:20 AM, THE DON SAID THAT THE FACILITY HAD NO DOCUMENTATION INDICATING THAT SHOWER SHEETS AND BRADEN SCALE ASSESSMENTS WERE COMPLETED FOR RESIDENT #103 DURING HER (#103) COURSE OF STAY AT THE FACILITY. THE DON SAID RESIDENT #103 SHOULD HAVE HAD SHOWER SHEETS AND BRADEN SCALE DOCUMENTATION COMPLETED. THE DON SAID FACILITY STAFF ALSO USE SHOWER SHEETS TO MONITOR RESIDENT SKIN CHECKS. THE DON SAID BENGAY PATCHES SHOULD NOT BE ADMINISTERED TO AREAS OF DAMAGED OR WOUNDED SKIN. THE DON SAID SHE DID NOT KNOW HOW RESIDENT #103 DEVELOPED A PRESSURE SORE WHILE AT THE FACILITY, SHE COULD "ONLY THEORIZE." DURING AN INTERVIEW WITH REGISTERED NURSE (RN) #6 ON 10/12/12 AT 12:15 PM, RN #6 SAID ON AN UNKNOWN DATE, LPN #7 NOTIFIED HER TO OBSERVE A "PROBLEMATIC AREA" TO THE SKIN SURROUNDING RESIDENT #103'S SACRAL/COCCYX AREA. RN #6 SAID SHE OBSERVED RESIDENT #103 TO HAVE A 10 CM X 10 CM MUSHY FLUID FILLED AREA TO THE SACRAL/COCCYX AREA WITH NONBLANCHABLE SKIN. RN #6 SAID THE AREA WAS NOT A BLISTER AND "YOU COULD TELL SOMETHING WAS GOING ON UNDERNEATH...THERE WAS A SMELL." RN #6 SAID THE WOUND WAS UNSTAGEABLE AT THAT TIME AND IT CONTINUED TO HAVE A FOUL ODOR. LATER, THE AREA "BROKE OPEN AND BECAME WORSE." RN #6 SAID SHE DID NOT KNOW IF RESIDENT #103 WAS admitted TO THE FACILITY WITH THE PRESSURE SORE OR NOT. RN #6 SAID SHE DID NOT COMPLETE RESIDENT #103'S ADMISSION ASSESSMENT. DURING THE INVESTIGATION, THE SURVEYOR WAS UNABLE TO INTERVIEW PHYSICIAN #9 BECAUSE THE FACILITY WAS UNABLE TO PROVIDE ANY CONTACT INFORMATION. DURING THE INVESTIGATION, THE SURVEYOR MADE MULTIPLE UNSUCCESSFUL ATTEMPTS TO CONTACT LICENSED PRACTICAL NURSE (LPN) #4. THE SURVEYOR LEFT MESSAGES AND CONTACT INFORMATION BUT NO COMMUNICATION WAS RETURNED BY LPN #4. REVIEW OF THE SKIN PRACTICE GUIDE ISSUED JULY 2008, ON PAGE 16, UNDER SKIN PROCESS FLOW, REVEALED THAT A PATIENT AT RISK FOR SKIN BREAKDOWN IS TO HAVE BRADEN SCALE COMPLETED WEEKLY X4 (TIMES FOUR WEEKS).

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO INITIATE TIMELY INTERVENTIONS AND APPROPRIATE PRESSURE RELIEVING/ASSISTIVE DEVICES TO PREVENT THE DEVELOPMENT OF AVOIDABLE PRESSURES ULCERS FOR ONE (#714) OF ELEVEN RESIDENTS REVIEWED WITH PRESSURE ULCERS, OUT OF A TOTAL OF 18 SAMPLED RESIDENTS, RESULTING IN THE DEVELOPMENT OF BILATERAL UNSTAGABLE HEEL ULCERS. FINDINGS INCLUDE: ON 7/28/11 AT 1:50 P.M. OBSERVATIONS OF RESIDENT #714 WITH THE WOUND CARE NURSE REVEALED A RIGHT HEEL ULCER WITH MEASUREMENTS OF 2.4 CENTIMETERS (CM) BY 2.9 CM. THE WOUND CARE NURSE VERIFIED THE WOUND AS UNSTAGABLE. "THE SKIN WAS LOOSE BUT THERE WAS NO DRAINAGE NOTED". OBSERVATIONS OF THE LEFT HEEL YIELDED PURPLE BLACK SCANT SEROUS DRAINAGE. THE WOUND CARE NURSE AGAIN VERIFIED THE LEFT HEEL WAS UNSTAGABLE. REVIEW OF RESIDENT #714 FACE SHEET REVEALED AN admission date of [DATE] WITH [DIAGNOSES REDACTED]. THE ADMISSION ASSESSMENT WITH THE SAME DATE, DOCUMENTED RESIDENT #714'S BILATERAL HEELS AS INTACT. ON 7/28/11 AT 2:30 P.M., RESIDENT #714'S MEDICAL RECORD NURSE'S NOTE DATED 6/26/11, WAS REVIEWED WITH "A" UNIT MANAGER AND THE WOUND CARE NURSE. THE NURSE'S NOTE DOCUMENTED, "WHEN SKIN ASSESSMENT WAS PERFORMED IN A.M., PT HAD COMPLAINED OF LEFT HEEL PAIN AND WHEN OBSERVED SITE NOTICED A NON-BLANCHABLE DARK PURPLE SORE ON BOTTOM OF THE LEFT HEEL. NO DRAINAGE BUT UNSTAGABLE AT THIS TIME. MEASURED 1.4 BY 1.3 CM (CENTIMETERS)...SURROUND SKIN IS REDDEN...WOUND CONSULT." A physician's orders [REDACTED]. CLEANSE WITH NORMAL SALINE." THERE WAS NO DOCUMENTED EVIDENCE THAT RESIDENT # 714'S HEELS WERE FLOATED OR PROVIDED ANY OTHER PRESSURE RELIEVING INTERVENTIONS. REVIEW OF RESIDENT #714'S WOUND CARE NOTES REVEALED NO FURTHER DOCUMENTATION RELATED TO RESIDENT #714'S LEFT HEEL UNTIL 7/6/11 WHICH DOCUMENTED, "LEFT HEEL 4.2 BY 2.4 CM. BLISTER...HAS NO FLUID...TWO BLISTERS WITH BRIDGE." REVIEW OF THE PRESSURE SORE MONITORING TOOL (PUSH) WHICH DOCUMENT A HEALED PRESSURE SORE AS ZERO, DOCUMENTED RESIDENT #714'S RIGHT HEEL WITH A PUSH SCORE OF 12 ON 7/20/11 AND 10 ON 7/27/11. RESIDENT #714'S LEFT HEEL'S AVERAGE PUSH SCORE IS 7.4. REVIEW OF RESIDENT #714'S TREATMENT ADMINISTRATION RECORD (TAR) DOCUMENTED ON 7/7/11 A FOR YOUR INFORMATION (FYI) ORDER TO "FLOAT HEELS." OTHER CHANGES INITIATED ON 7/7/11 TO THE REVISED CARE PLAN INCLUDED: 1. ADMINISTERING PAIN MEDICATIONS 2. OBSERVING FOR AND REPORTING SIGNS AND SYMPTOMS OF INFECTION 3. OBSERVE AND REPORT CHANGES 4. OBSERVE FOR AND REPORT ANY NEW DISCOLORATIONS, OPEN AREAS, BRUISES, SKIN TEARS, REDNESS 5. PRESSURE RELIEVING MATTRESS AND 6. SUSPEND HEELS AS ABLE. REVIEW OF A WOUND CARE NOTE DATED 7/20/11 REVEALED A NEW PRESSURE ULCER ON RESIDENT #714'S RIGHT HEEL WITH MEASUREMENTS OF 3.3 BY 3 CM. PRAFO BOOTS WERE INITIATED FOR RESIDENT #714. ON 7/29/11 AT 11:15 A.M., THE WOUND CARE NURSE AND "A" UNIT MANAGER WERE QUERIED REGARDING WHY THERE WERE NO INTERVENTIONS PROVIDED TO PREVENT HEEL PRESSURE ULCERS UNTIL AFTER THE HEELS WERE BROKE DOWN. THE WOUND CARE NURSE STATED " I DON'T KNOW WHY THE HEELS WEREN'T FLOATED UNTIL THE BREAKDOWN WAS OBSERVED. THE HEELS SHOULD HAVE BEEN FLOATED AS SOON AS THE BREAKDOWN WAS OBSERVED". "A" UNIT MANAGER OFFERED NO EXPLANATION. ON 7/29/11 AT 12:20 P.M., THE DIRECTOR OF NURSING (DON) WAS QUERIED REGARDING THE ABSENCE OF PREVENTION INTERVENTIONS FOR UNDUE PRESSURE ON RESIDENT #714'S HEELS. THE DON STATED "THE NURSES DO A SKIN ASSESSMENT DAILY." WHEN QUERIED WHETHER THERE WERE MISSED DAYS THE DON STATED "I HOPE THEY (THE NURSES) WERE FOLLOWING THE POLICY." REVIEW OF THE SKIN ASSESSMENT SHEET REVEALED MISSING ASSESSMENTS FOR 7/5/11, 7/7/11, 7/12/11, 7/14/11, 7/16/11, 7/17/11 AND 7/26/11. ( )

THIS CITATION PERTAINS TO INTAKE #: MI 694 BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT THE DEVELOPMENT OR WORSENING OF PRESSURE SORES IN 3 OF 6 RESIDENTS (#101, #102, AND #103) RESULTING IN RESIDENT #101'S EXISTING PRESSURE SORES TO SIGNIFICANTLY WORSEN AND RESIDENTS #102 AND #103 TO DEVELOP PRESSURE ULCERS WHILE RESIDING AT THE FACILITY. FINDINGS INCLUDE: RESIDENT #101: A REVIEW OF THE CLOSED MEDICAL RECORD REVEALED THAT RESIDENT #101 WAS RE-admitted to the facility on [DATE] AFTER BEING hospitalized from [DATE] - 9/15/09 FOR STROKE SYMPTOMS. THE HOSPITAL'S DISCHARGE/TRANSFER FORM TO THE FACILITY DATED 9/15/09, INDICATED THAT RESIDENT #101 HAD 2 PRESSURE SORES ON HIS BUTTOCKS. THE FIRST PRESSURE SORE WAS DESCRIBED AS; 'HEALING WELL', NICKLE SIZED, STAGE 3, (TOTAL LOSS OF SKIN, EXPOSING SUBCUTANEOUS TISSUE). THE SECOND PRESSURE SORE WAS DESCRIBED AS: 3 CENTIMETER (CM) LONG, STAGE 2 (SHALLOW CRATER, WITH PARTIAL LOSS OF SKIN). THE PHYSICIAN'S admission orders [REDACTED]. ACCORDING TO THE NURSING ADMISSION ASSESSMENT ON 9/15/09, RESIDENT #101'S SKIN ASSESSMENT IDENTIFIED SCABS ON HIS RIGHT HEEL AND LEFT KNEE, AND 3 PRESSURE SORES ON HIS SACRAL-COCCYX (BUTTOCKS) AREA. PRESSURE SORE 'A' AND 'C', WERE DESCRIBED AS; STAGE 2, 2 CM x 2 CM, AND 1 CM X 2 CM, RESPECTIVELY. PRESSURE SORE 'B' WAS DESCRIBED AS; STAGE 3, 3 CM X 4 CM. ACCORDING TO THE FACILITY'S SKIN PRACTICE GUIDE ISSUED ON 7/08, ONCE A PRESSURE ULCER IS IDENTIFIED ON A RESIDENT; A QUALIFIED HEALTH PROFESSIONAL (PHYSICIAN, P.A. OR ADVANCED PRACTICE NURSE) EVALUATES THE RESIDENT WITHIN 24 HOURS, A PUSH TOOL IS INITIATED BY A MEMBER OF THE WOUND TEAM, AND THE PLAN OF CARE INCLUDES (BUT NOT LIMITED TO) THE FOLLOWING INTERVENTIONS; SUPPORT SURFACES/SPECIALITY MATTRESS, TURNING AND REPOSITIONING, AND THE ORDERED TREATMENTS. ONGOING WOUND EVALUATIONS INCLUDE ROUTINE SKIN OBSERVATIONS BY THE CERTIFIED NURSING ASSISTANTS (CNA) AT LEAST 2 TIMES A WEEK WITH THE RESIDENT'S SHOWER/BATH. RESULTS ARE THEN SUBMITTED TO THE NURSE FOR REVIEW AND FOLLOW-UP. A RECORD REVIEW FROM 9/15/09 - 9/22/09 REVEALED NO ADDITIONAL NURSING DOCUMENTATION TO SUPPORT SKIN ASSESSMENTS OR PUSH TOOL. ON 9/15/09, THE PHYSICIAN'S HISTORY AND PHYSICAL ASSESSMENT CIRCLED THE 'DECUBS' SECTION ON THE 'SKIN' FORM, BUT NO MEASUREMENTS, DESCRIPTION, OR ADDITIONAL PRESCRIBED INTERVENTIONS OR TREATMENTS WERE ORDERED. ON 9/22/09, (1 WEEK AFTER ADMISSION WITH PRESSURE ULCER), THE WOUND CARE PHYSICIAN DOCUMENTED RESIDENT # 101'S SACROCOCCYX PRESSURE SORE TO BE A STAGE 3 THAT MEASURED 10.5 CM X 6.0 CM WITH 0.2 CM DEPTH, (MORE THAN DOUBLED IN SIZE) WITH ADDITIONAL SCATTERED WOUNDS. THERE IS NO DOCUMENTATION REGARDING THE SCAB ON THE RIGHT HEEL UNTIL 10/6/09. ON 10/6/09, THE RIGHT HEEL IS DOCUMENTED BY THE WOUND CARE PHYSICIAN TO HAVE ESCHAR ( BLACKENED TISSUE) MEASURING 1.5 CM X 4.5 CM. A PUSH TOOL IS THEN INITIATED. ON 11/16/09, THE WOUND CARE PHYSICIAN PRESCRIBES A PROTECTIVE CARE BOOT TO THE RIGHT FOOT. ON 9/22/09, A NURSING NOTE DOCUMENTED THAT RESIDENT #101 HAD A STAGE 3 PRESSURE ULCER ON HIS BUTTOCKS THAT MEASURED 10.5 CM X 6.0 CM AND 0.2 CM DEPTH. ON 9/22/09, A PUSH (PRESSURE ULCER HEALING CHART) TOOL/SCORE WAS INITIATED AND IDENTIFIED RESIDENT # 101'S PRESSURE ULCER SCORE TO BE AT A '16'. ON 9/23/09, THE PHYSICIAN PRESCRIBED RESIDENT # 101 TO BE FREQUENTLY REPOSITIONED AND THE TREATMENT ADMINISTRATION RECORD WAS UPDATED TO INCLUDE FREQUENT REPOSITIONING OF RESIDENT #101. ACCORDING TO THE MEDICATION/TREATMENT ADMINISTRATION RECORDS (MAR/TAR) FROM 9/15/09 - 9/23/09, 3 OF THE 15 PRESCRIBED SKIN TREATMENTS ARE BLANK, (9/21, PM SHIFT, AND 9/22, BOTH AM AND PM SHIFT). THERE IS NO DOCUMENTATION ON ANY MAR/TAR, CARE PLAN, OR NURSING NOTE FROM 11/16/09 - 12/18/09 TO SUPPORT THE USE OF A PROTECTIVE BOOT TO THE RESIDENT'S RIGHT FOOT. ON 12/8/09, THE WOUND CARE PHYSICIAN DOCUMENTED THE RIGHT HEEL PRESSURE ULCER TO MEASURE 12 CM X 7.5 CM. ON 3/8/11 AT 1:20 P.M., REGISTERED NURSE (RN) # 3 SAID SHE COULD NOT RECALL IF RESIDENT # 101 HAD A PROTECTIVE BOOT TO HIS RIGHT FOOT WHILE AT THE FACILITY. ON 3/10/11 AT 2:50 P.M., DURING AN INTERVIEW AND RECORD REVIEW WITH THE DIRECTOR OF NURSING SHE COULD NOT PRODUCE ANY DOCUMENTATION TO SUPPORT THE USE OF A PROTECTIVE BOOT TO THE RESIDENT'S RIGHT FOOT, AS PRESCRIBED BY THE WOUND CARE PHYSICIAN. ( ) RESIDENT # 102: ACCORDING TO THE FACE SHEET DATED 1/7/11, RESIDENT # 102 WAS A [AGE] year OLD MALE WHO admitted to the facility on [DATE] WITH MULTIPLE [DIAGNOSES REDACTED]. THE BRADEN SCALE SKIN ASSESSMENT TOOL DATED 1/8/11, 1/15/11, AND 1/22/11 IDENTIFIED RESIDENT #102 AS BEING AT 'HIGH' RISK TO DEVELOP PRESSURE SORES. A CARE PLAN FOR SKIN INTEGRITY WAS INITIATED ON 12/27/10 THAT INCLUDED TO MONITOR SKIN CONDITION WITH ADL CARE, DAILY. ACCORDING TO THE (PRESSURE ULCER SCALE FOR HEALING-PUSH TOOL) INITIATED ON 1/23/11, RESIDENT # 102 DEVELOPED A RIGHT HEEL PRESSURE ULCER THAT MEASURED A PUSH SCORE OF 10. THE CARE PLAN FOR SKIN WAS UPDATED ON 1/27/11 TO INCLUDE THE INTERVENTION OF PRAVALON BOOTS TO WHILE IN BED. ON 3/3/11 A CARE PLAN FOR THE RIGHT HEEL PRESSURE ULCER IDENTIFIED THE FOLLOWING INTERVENTIONS; SUSPEND HEELS AS ABLE, PRAVALON BOOTS WHILE IN BED. ON 3/9/11, THE RIGHT HEEL PRESSURE SORE HAD A PUSH SCORE OF 13. ON 3/9/11 AT 10:30 A.M., RESIDENT # 102 WAS OBSERVED AWAKE AND LAYING IN HIS BED, WITH HIS HEELS RESTING ON THE MATTRESS. THE PRAVALON BOOTS WERE OBSERVED TO BE ON A CHAIR IN THE RESIDENT'S ROOM. AT 11:30 A.M., THE RESIDENT #102 AND THE PRAVALON BOOTS WERE OBSERVED IN THE SAME POSITION. REGISTERED NURSE (RN) # 4 WAS AT THE BEDSIDE PERFORMING CARE AND SAID THAT RESIDENT #102 "DOES NOT LIKE THE PRAVALON BOOTS, AND KICKS THEM OFF, SO WE DON'T PUT THEM ON ANYMORE". ON 3/9/10 AT 1:30 P.M., THE WOUND CARE NURSE SAID THAT RESIDENT #102 HAD ACQUIRED HIS HEEL PRESSURE SORE WHILE AT THE FACILITY AND THAT ALL HIS ASSESSMENTS AND INTERVENTIONS WERE IN PLACE TO PREVENT ANY FURTHER BREAKDOWN. ON 3/10/11 AT 11:30 A.M., RESIDENT #102 WAS OBSERVED TO BE IN HIS BED WITHOUT THE PRAVALON BOOTS IN USE, OR HIS HEELS SUSPENDED. THE DIRECTOR OF NURSING WAS PRESENT DURING THIS OBSERVATION AND SAID THE PRAVALON BOOTS HAD BEEN DISCONTINUED BY THE WOUND CARE TEAM. ON 3/10/11 AT 3:30 P.M., DURING THE EXIT CONFERENCE THERE WAS NO DOCUMENTATION TO SUPPORT THE DISCONTINUATION OF RESIDENT #102'S PRAVALON BOOTS, OR ANY ADDITIONAL INTERVENTIONS FOR CARE OF THE PRESSURE SORE. ( ) RESIDENT #103: ACCORDING TO THE FACE SHEET DATED 3/7/11, RESIDENT #103 WAS A [AGE] year OLD MALE WHO admitted on [DATE] WITH MULTIPLE [DIAGNOSES REDACTED]. THE BRADEN SKIN ASSESSMENT TOOL DATED 2/9/11, 2/19/11, AND 3/5/11 HAD IDENTIFIED RESIDENT #103 AS BEING AT LOW TO MODERATE RISK OF SKIN BREAKDOWN. HOWEVER, UPON RECORD REVIEW IT WAS DETERMINED RESIDENT #103 had a history of [REDACTED]. A CARE PLAN FOR SKIN INTEGRITY HAD THE FOLLOWING INTERVENTIONS ON 11/29/10, SUSPEND HEELS AS ABLE, MONITOR SKIN CONDITION WITH ADL (ACTIVITY OF DAILY LIVING) CARE DAILY, AND REPORT ABNORMALITIES. ON 3/8/11 AT 2:00 P.M., RESIDENT #103 WAS OBSERVED TO BE LAYING IN HIS BED, ASLEEP. RESIDENT #103 HAD A DRIED SEROSANGUINEOUS (CONTAINING BLOOD AND SERUM) STAIN ON THE HEEL OF HIS RIGHT SOCK. THERE WERE NO VISIBLE ASSISTIVE DEVICES OR PROPS TO SUSPEND THE RESIDENTS HEELS. ON 3/8/11 AT 2:05 P.M., LICENSED PRACTICAL NURSE (LPN) #7 SAID THAT SHE WAS UNAWARE IF RESIDENT #103 HAD A PRESSURE SORE, OR INJURY TO HIS RIGHT HEEL. ON 3/9/11 AT 9:50 A.M., RESIDENT #103 WAS LAYING IN BED WITH HIS HEELS RESTING ON THE BED. ON 3/9/11 AT 1:30 P.M., THE WOUND CARE NURSE SAID THAT RESIDENT #103 HAD ACQUIRED HIS HEEL PRESSURE SORE WHILE AT THE FACILITY AND THAT ALL HIS ASSESSMENTS AND INTERVENTIONS WERE IN PLACE TO PREVENT ANY FURTHER BREAKDOWN. ACCORDING TO THE (PRESSURE ULCER SCALE FOR HEALING) INITIATED ON 3/8/11, RESIDENT #103 DEVELOPED A RIGHT HEEL PRESSURE ULCER THAT MEASURED A PUSH SCORE OF 10. THE CARE PLAN FOR SKIN WAS UPDATED ON 3/9/11 TO INCLUDE THE INTERVENTION OF PRAVALON BOOTS WHILE IN BED AND TURN EVERY 2 HOURS. ON 3/10/11 AT 1:00 P.M., RESIDENT #103 WAS OBSERVED RESTING IN BED, RECEIVING CARE BY RN #4. DRESSING TO RIGHT HEEL WAS CLEAN, DRY AND INTACT. RESIDENT #103'S PRAVALON BOOTS WERE OBSERVED AT BEDSIDE, STILL ENCLOSED IN PLASTIC BAG. ( )

Based on record review, interviews and observations the facility failed to keep 2 of 3 sampled resident (resident #202) free from abuse, resulting in female resident #202 sustaining redness with finger imprint on her left cheek and resident's #202 and #203 becoming emotionally upset and crying about male resident entering their room and invading their personal space. Findings include: A review of the facility investigation report and Incident Report completed by the facility was reviewed. The Incident Report and Nurse Notes dated 11-28-2011 at approximately 1:00 P.M. resident #201 entered resident's #202 and #203's rooms to use their bathroom. Resident #202 asked resident #201 to leave and resident #201 replied that the room was his property and slapped female resident #202 on the cheek. Resident #202 stated she would call the police if he hit her again. Next, resident #201 slapped resident #202 again on the left cheek. Resident #202 called out for help. The nurse entered the room to observe resident #202 very upset and emotional with red mark present on the left cheek. Resident #202 was assessed with [REDACTED]. Vital signs: blood pressure 125/58, heart rate 86, respiration 18. The physician and family were contacted. The physician ordered [MEDICATION NAME] 0.25 mg two tablets per dose. Resident #202 felt unsafe in the facility and requested to file a police report and to be discharge home today (scheduled for Tuesday, 11-30-10). The physician approved the 11-28-10 discharge home and the police report was completed prior to leaving the facility. Resident #201 closed clinical record was reviewed. The resident was admitted [DATE] and had [DIAGNOSES REDACTED]. A review of the Resident Assessment and Care Screening dated 11-2010 noted that the resident had cognitive skills that were moderately impaired with behaviors. A plan of care was in place. The resident had behavior concerns due to Dementia. The resident was agitated, attempts to get up unassisted, combative and resistant to help. The resident is followed by psychiatric services with use of [MEDICAL CONDITION] medications. The resident had independent mobility by wheelchair. Interventions were in place to address the identified needs and included to monitor for increases in behavior. Following the incident resident #201 was placed on one-to-one monitoring. On 11-28-10 at 2:00 P.M. the resident was transferred to the hospital for psychiatric evaluation and treatment. The resident was no longer in the facility. Resident #202 closed clinical record was reviewed. The resident was admitted [DATE] for rehabilitation services. The resident had [DIAGNOSES REDACTED]. A review of the Resident Assessment and Care Screening dated 11-2010 noted that the resident had cognitive skills that were independent. A plan of care with interventions was in place. The resident was no longer in the facility. Resident #203 closed clinical record was reviewed. The resident was admitted [DATE] for rehabilitation services. The resident had [DIAGNOSES REDACTED]. A review of the Resident Assessment and Care Screening dated 11-2010 noted that the resident had cognitive skills that were independent. A plan of care with interventions was in place that included minimal assist with daily care needs. A review of nurse ' s notes dated 11-28-10 at 8:40 P.M. noted that resident had concerns due to altercation that occurred in room with resident #201. The resident was reassured that resident #201 was transferred from the facility. The resident was no longer in the facility. On 2-10-11 at 1:10 P.M. RN (registered nurse) #1 was interviewed. The RN #1 stated, "Resident #201 a fall risk that was placed in front of nursing station. Another resident ambulated unassisted so I went to assist. Leaving resident #201 unattended he ambulated by wheelchair into resident #202 ' s room. " I entered the room after RN #2 to help calm. I explained to resident #201 that it was not his room; he sat down and came out for me. The ladies (resident #202 and #203) were upset and tried to prevent him from entering instead of calling for help. Resident #201 had gone into a vacant room earlier. I assessed resident #202 and her left cheek was redden, pinkish red with finger tip print evident. Resident #202 was crying. " RN #1 completed the incident report On 2-10-11 at 1:10 P.M. RN (registered nurse) #1 was interviewed. The RN #2 (first to enter room) stated, "I went into the room and resident #203 stated resident #201 was in the bathroom and had hit her roommate (resident #202). I assisted resident#201 out the bathroom. He thought he was in his room. I was not familiar with him. I never saw him being aggressive just uncooperative with care. I went back to speak with resident #202 and ask if she was okay. Resident #202 was upset. I applied ice and tried to calm her down." The police report (#10- ) dated 11-28-10 at 10:00 P.M. was reviewed. It described the incident as noted above. Offense: assault/battery, simple. Brief summary: I spoke with the Administrator who advised resident #201 was sent to the hospital for evaluation and there have been no further problems. I advised that the prosecutors office would not charge due to mental state of Dementia. ( )

THIS CITATION PERTAINS TO INTAKE NUMBERS MI 101 AND MI 226. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROTECT 1 OF 4 RESIDENTS (#101) FROM ACCIDENTS RESULTING IN LEFT FEMORAL NECK (HIP BONE) FRACTURE, LEFT DISTAL RADIUS (FOREARM BONE) FRACTURE AND LEFT ULNA (FOREARM BONE) FRACTURE. FINDINGS INCLUDE: RESIDENT #101'S MEDICAL RECORD CONTAINS ROUTINE PHYSICIAN ORDERS [REDACTED]. RESIDENT #101'S MEDICAL RECORD CONTAINS A PATIENT ADMISSION/READMISSION SCREEN FORM DATED 10/28/10 AT 2:02 PM THAT SAID RESIDENT #101 NEEDS ASSISTANCE WITH AMBULATION, HAS A SPECIAL NEED FOR A WHEELCHAIR, IS COGNITIVELY IMPAIRED WITH MOBILITY, AND HAS UNSTEADY GAIT. THIS FORM ALSO SAID RESIDENT #101 WALKS OCCASIONALLY DURING THE DAY, BUT FOR VERY SHORT DISTANCES WITH OR WITHOUT ASSISTANCE, AND SPENDS MAJORITY OF EACH SHIFT IN BED OR CHAIR. RESIDENT #101'S MEDICAL RECORD CONTAINS A CARE PLAN INITIATED ON 10/28/10 AND CREATED BY LICENSED PRACTICAL NURSE (LPN) #4 THAT SAID RESIDENT #101 IS AT RISK FOR FALLS DUE TO PSYCHOTROPIC MEDICATIONS, IMPAIRED BALANCE/POOR COORDINATION, UNSTABLE HEALTH CONDITION, UNSTEADY GAIT, AND COGNITIVE IMPAIRMENT. THIS CARE PLAN HAD GOALS FOR RESIDENT #101 TO MINIMIZE RISK FOR INJURY RELATED TO FALLS AND MINIMIZE RISK FOR FALLS. RESIDENT #101'S MEDICAL RECORD CONTAINS PHYSICIAN ORDERS [REDACTED]. THESE ORDERS ALSO SAID RESIDENT #101 IS A FALL RISK. RESIDENT #101'S MEDICAL RECORD CONTAINS NURSE'S NOTES DATED 11/25/10 AT 1:45 PM SIGNED BY LPN #4 THAT SAID RESIDENT #101 RECEIVED ASSISTANCE OF ONE PERSON FOR ACTIVITIES OF DAILY LIVING AND TRANSFERS. RESIDENT #101'S MEDICAL RECORD CONTAINS NURSE'S NOTES DATED 11/25/10 AT 5:45 PM SIGNED BY LPN #4 THAT SAID RESIDENT #101 WAS FOUND ON FLOOR BY FRONT DESK CLERK NEAR FRONT LOBBY. THESE NOTES SAID RESIDENT #101 WAS ASSESSED AND X-RAYS WERE ORDERED. THESE NOTES SAID RESIDENT #101'S FAMILY BROUGHT WALKER IN ROOM AND RESIDENT #101 WALKED WITH WALKER UP TO FRONT LOBBY WITH ANOTHER RESIDENT. RESIDENT #101'S MEDICAL RECORD CONTAINS PHYSICIAN ORDERS/MAR (MEDICATION ADMINISTRATION RECORD) DATED 11/01/10 THAT SAID, ON 11/25/10 DURING THE 7:00 AM TO 7:00 PM SHIFT, RESIDENT #101'S WHEELCHAIR ALARM CHECK FOR PLACEMENT AND FUNCTION WAS INITIALED BY STAFF AS BEING COMPLETED. RESIDENT #101'S MEDICAL RECORD CONTAINS A PHYSICIAN ORDER [REDACTED]. RESIDENT #101'S MEDICAL RECORD FROM OUTSIDE HOSPITAL CONTAINS ED (EMERGENCY DEPARTMENT) NOTES DATED 11/25/10 AT 7:15 PM THAT SAID RESIDENT #101 HAD DIAGNOSTIC TESTING COMPLETED AND HAD LEFT FEMORAL NECK (HIP BONE) FRACTURE AND FRACTURES OF THE LEFT DISTAL RADIUS (FOREARM BONE) AND LEFT ULNA (FOREARM BONE). RESIDENT #101'S RECORD CONTAINS A FACILITY INCIDENT REPORT DATED 11/26/10 THAT SAID ON 11/25/10 AT 2:30 PM RESIDENT #101 fell WHILE AMBULATING TO LIVING ROOM WHILE USING A WALKER (MECHANICAL DEVICE USED TO ASSIST WITH AMBULATION) AND SUSTAINED A RIGHT HIP AND RIGHT WRIST FRACTURE. RESIDENT #101'S RECORD CONTAINS A FACILITY INVESTIGATION REPORT-5 WORKING DAYS ATTACHMENT DATED 11/26/10 THAT SAID ON 11/25/10 RESIDENT #101 USED HER WALKER TO AMBULATE TO WATER COOLER, LOST HER FOOTING AND fell TO FLOOR. THIS REPORT SAID RESIDENT #101 COMPLAINED OF PAIN TO THE LEFT HIP AND LEFT FOREARM AREAS AND X-RAYS TO THESE AREAS SHOWED FRACTURES TO RESIDENT #101'S LEFT DISTAL RADIUS (FOREARM BONE) AND SUBCAPITAL FRACTURE TO FEMORAL NECK (HIP BONE). THIS REPORT SAID RESIDENT #101 WAS TRANSFERRED TO AN OUTSIDE HOSPITAL. THIS REPORT SAID AN ORDERED CHAIR ALARM WAS NOT ON RESIDENT #101'S WHEELCHAIR AND THE WALKER IN RESIDENT #101'S ROOM WAS BROUGHT IN BY RESIDENT #101'S FAMILY. DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) ON 12/17/10 AT 1:00 PM, THE DON SAID ON 11/25/10 AT 2:30 PM RESIDENT #101 WALKED VIA WALKER WITHOUT THE ASSISTANCE OF STAFF FROM THE A-WING HALLWAY TO THE FRONT LOBBY. THE DON SAID RESIDENT #101 WAS AMBULATING WITH ANOTHER RESIDENT PRESENT. THE DON SAID RESIDENT #101 fell IN THE FRONT LOBBY AREA. THE DON SAID PHYSICAL THERAPY STAFF (PT) #5 PLACED RESIDENT #101 IN HER WHEELCHAIR PRIOR TO THE FALL. THE DON SAID RESIDENT #101 DID NOT HAVE AN ORDERED WHEELCHAIR ALARM IN PLACE WHEN THE FALL OCCURRED. THE DON SAID SHE DIDN'T KNOW IF RESIDENT #101 HAD an order for [REDACTED]. DURING AN INTERVIEW WITH CERTIFIED NURSE AIDE (CNA) #3 ON 12/20/10 AT 12:55 PM, CNA #3 SAID ON 11/25/10 AT AROUND 2:30 PM SHE AND LICENSED PRACTICAL NURSE (LPN) #4 OBSERVED RESIDENT #101 AMBULATING IN HALLWAY VIA WALKER WITHOUT THE ASSISTANCE OF STAFF. CNA #3 SAID RESIDENT #101 WAS WEARING SHOES AND WALKING WITH ANOTHER RESIDENT. CNA #3 SAID SHE DIDN'T THINK ANYTHING OF IT BECAUSE THE FACILITY LET FAMILIES BRING IN WALKERS FOR RESIDENTS ALL THE TIME. CNA #3 SAID, ON 11/25/10, SHE FIRST OBSERVED RESIDENT #101 IN WHEELCHAIR AT THE START OF THE WORK SHIFT AND, AGAIN, SITTING IN WHEELCHAIR WHILE EATING LUNCH. CNA #3 SAID RESIDENT #101 DID NOT HAVE A WHEELCHAIR ALARM IN PLACE ON 11/25/10. CNA #3 SAID, ON 11/25/10, SHE DID NOT HEAR ANY ALARMS COMING FROM RESIDENT #101 ' S ROOM OR WHEELCHAIR. CNA #3 SAID CNA #6 WITNESSED RESIDENT #101 FALL ON 11/25/10. DURING AN INTERVIEW WITH PHYSICAL THERAPY STAFF (PT) #5 ON 12/20/10 AT 1:20 PM, PT #5 SAID PHYSICAL THERAPY DID NOT GIVE RESIDENT #101 A WALKER. PT #5 SAID RESIDENT #101 DID NOT HAVE an order for [REDACTED].#101 OBTAINED A WALKER. PT #5 SAID RESIDENT #101 USED A WALKER WITH ONE PERSON ASSIST AND GAIT BELT DURING PHYSICAL THERAPY SESSIONS IN AN EFFORT TO IMPROVE BALANCE AND STRENGTH. PT #5 SAID, ON 11/25/10, RESIDENT #101 SHOULD NOT HAVE BEEN WALKING ALONE AND UNASSISTED WITH A WALKER BECAUSE SHE WASN'T STRONG ENOUGH. PT #5 SAID, ON 11/25/10, SHE LAST SAW RESIDENT #101 AT 12:15 PM SITTING IN WHEELCHAIR WITH WHEELCHAIR ALARM INTACT. EFFORTS TO INTERVIEW CERTIFIED NURSE AIDE (CNA) #6 ON 12/20/10 AT 1:40 PM WERE UNSUCCESSFUL. DURING AN INTERVIEW WITH LICENSED PRACTICAL NURSE (LPN) #4 ON 12/20/10 AT 1:45 PM, LPN #4 SAID RESIDENT #101 USED A WHEELCHAIR FOR MOBILITY AND USED A WALKER DURING PHYSICAL THERAPY SESSIONS. LPN #4 SAID SHE NEVER SAW RESIDENT #101 AMBULATING IN HALLWAY VIA WALKER ON 11/25/10. LPN #4 SAID, ON 11/25/10, RESIDENT #101 DID NOT HAVE A WHEELCHAIR ALARM IN PLACE. LPN #4 SAID, ON 11/25/10, CNA #3 DID NOT PLACE RESIDENT #101'S WHEELCHAIR ALARM IN PLACE. LPN #4 SAID, ON 11/25/10 AROUND 2:30 PM, STAFF NOTIFIED HER THAT RESIDENT #101 fell IN THE FRONT LOBBY. LPN #4 SAID SHE SAW RESIDENT #101 LYING ON FLOOR WITH WALKER STANDING NEARBY.