Every finding on record at Michigan Masonic Home

Based on interview and record review, the facility failed to provide dignified care to 3 residents (R5, R11, and R87) of 4 residents reviewed for dignity.Findings include: R5 Review of an admission Record revealed R5 admitted to the facility on [DATE] with pertinent diagnoses which included cerebral palsy and periodic limb movement disorder. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R5, with a reference date of 12/24/2025 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15, out of a total possible score of 15, which indicated R5 was cognitively intact. Further review of same MDS assessment revealed R5 was occasionally incontinent of urine. Review of the current toileting Care Plan intervention for R5, with a revision date of 1/26/2022, directed staff to toilet resident for bowel and bladder on request and offer a urinal every two hours around the clock. In an interview on 1/26/2026 at 1:36 PM, R5 reported he routinely waited for 30 minutes for his call light to be answered. R5 reported he took medication that caused him to urinate a lot, and the call light response was not always fast enough to prevent episodes of incontinence. Review of R5's call light report from 1/20/2026 to 1/27/2026 revealed the following.1/20/2026- call light activated at 8:29 AM with 28 minutes elapsed until answered1/22/2026- call light activated at 6:14 AM with 27 minutes elapsed until answered1/22/2026- call light activated at 7:47 PM with 31 minutes elapsed until answered1/24/2026- call light activated at 7:02 AM with 59 minutes elapsed until answered1/24/2026- call light activated at 10:08 AM with 24 minutes elapsed until answered1/24/2026- call light activated at 11:54 AM with 18 minutes elapsed until answered1/24/2026- call light activated at 6:37 PM with 27 minutes elapsed until answered1/25/2026- call light activated at 4:46 PM with 28 minutes elapsed until answered1/25/2026- call light activated at 6:33 PM with 36 minutes elapsed until answered1/25/2026- call light activated at 8:15 PM with 19 minutes elapsed until answered1/26/2026- call light activated at 1:44 AM with 20 minutes elapsed until answered1/26/2026- call light activated at 10:12 PM with 26 minutes elapsed until answered In an interview on 1/28/2026 at 10:21 AM, R5 reported the previous Saturday, 1/24/2026, he waited an extended period in bed after pressing his call light (59 minutes per call light report) that morning and was unable to hold his urine and wet himself. R5 reported this made him feel undignified. R11 Review of an admission Record revealed R11 admitted to the facility on [DATE] with pertinent diagnoses which included Parkinson's Disease and unsteadiness on feet. Review of a current toileting Care Plan intervention for R11, with a revision date of 9/9/2025, directed staff to toilet resident every 2 hours while awake and upon request. In an interview on 1/26/2026 at 2:55 PM, R11 reported he often waited 30 minutes for his call light to be answered and often urinated on himself because he could not hold his urine that long. R11 reported this made him feel like he was not wanted. Review of R11's call light report from 1/20/2026 to 1/27/2026 revealed the following.1/20/2026- call light activated at 9:43 AM with 32 minutes elapsed until answered1/21/2026- call light activated at 8:24 AM with 18 minutes elapsed until answered1/21/2026- call light activated at 11:20 AM with 22 minutes elapsed until answered1/21/2026- call light activated at 2:01 PM with 27 minutes elapsed until answered1/21/2026- call light activated at 2:43 PM with 28 minutes elapsed until answered1/22/2026- call light activated at 6:32 AM with 31 minutes elapsed until answered1/22/2026- call light activated at 3:09 PM with 17 minutes elapsed until answered1/22/2026- call light activated at 6:43 PM with 19 minutes elapsed until answered1/22/2026- call light activated at 7:28 PM with 25 minutes elapsed until answered1/23/2026- call light activated at 12:50 AM with 22 minutes elapsed until answered1/23/2026- call light activated at 5:46 AM with 28 minutes elapsed until answered1/23/2026- call light activated at 7:06 AM with 29 minutes elapsed until answered1/23/2026- call light activated at 9:13 AM with 34 minutes elapsed until answered1/23/2026- call light activated at 4:21 PM with 28 minutes elapsed until answered1/23/2026- call light activated at 9:02 PM with 24 minutes elapsed until answered1/24/2026- call light activated at 5:11 AM with 18 minutes elapsed until answered1/24/2026- call light activated at 10:04 AM with 23 minutes elapsed until answered1/24/2026- call light activated at 5:20 PM with 30 minutes elapsed until answered1/24/2026- call light activated at 6:34 PM with 25 minutes elapsed until answered1/24/2026- call light activated at 9:38 PM with 21 minutes elapsed until answered1/25/2026- call light activated at 1:36 AM with 24 minutes elapsed until answered1/25/2026- call light activated at 6:48 AM with 37 minutes elapsed until answered1/25/2026- call light activated at 9:38 AM with 27 minutes elapsed until answered1/25/2026- call light activated at 9:43 PM with 61 minutes elapsed until answered1/26/2026- call light activated at 1:45 AM with 39 minutes elapsed until answered1/26/2026- call light activated at 10:15 AM with 32 minutes elapsed until answered1/26/2026- call light activated at 7:06 PM with 23 minutes elapsed until answered1/26/2026- call light activated at 11:12 PM with 26 minutes elapsed until answered R87 Review of the Electronic Medical Record (EMR) admission Record reflected R87 admitted to the facility 8/5/24 with pertinent diagnoses that included diagnoses that included Orthostatic Hypotension (a measurable drop in blood pressure when standing from lying or sitting that may result in lightheadedness), Syncope (fainting), and Collapse. The Minimum Data Set (MDS) (a resident assessment tool) dated 11/5/25 reflected a Brief Interview for Mental Status (BIMS) (a scale used to assist to determine a resident's cognitive status) reflected R87 had a score of 15 out of 15 which indicated the Resident was cognitively intact. On 1/26/26 an interview was conducted with R87 in her room. R87 reported she fell about 6 months prior because she self-transferred to use the bathroom when staff did not respond timely to her call light. R87 reported she has a walker, but staff have told her to wait for assistance because she might fall and break her hip. R87 stated that scares me. R87 reported since then there have been instances of slow call light response when she wanted to use the bathroom that resulted in either soiling or wetting herself. R87 reported this makes her feel helpless and had asked staff, how it would make them feel if they had to sit in their own poop and pee. R87 reported once she soiled herself when started on bowel medication. The Resident indicated she is proud and has visitors but doesn't want people coming to see her when the room smells like poop. R87 reported it really bothers her when she voids on herself. Review of the call light report for R87 from 1/20/26 to 1/25/26 revealed: 1/20/26 call light activated at 8:44 AM with 26 minutes elapsed until suspended. 1/21/26 call light activated at 2:19 AM with 29 minutes elapsed until suspended. 1/22/26 call light activated at 1:00 PM with 22 minutes elapsed until suspended. 1/23/26 call light activated at 8:03 AM with 37 minutes elapsed until suspended. 1/23/26 call light activated at 9:55 AM with 36 minutes elapsed until suspended. 1/23/26 call light activated at 11:20 AM with 28 minutes elapsed until suspended. 1/24/26 call light activated at 6:46 PM with 31 minutes elapsed until suspended. 1/24/26 call light activated at 8:40 PM with 36 minutes elapsed until suspended. 1/25/26 call light activated at 9:53 AM with 29 minutes elapsed until suspended. 1/25/26 call light activated at 8:11 PM with 32 minutes elapsed until suspended. During a second interview conducted 1/28/26 at 9:22 AM R87 reported instances when staff had turned off the call light and returned later to provide the aid needed. R87 added, They are real busy. R87 reported at these times she had not re-initiated the call light but that sometimes she was unable to hold her urine until staff returned.

Based on observation, interview, and record review, the facility failed to implement a pressure relieving care plan for 1 Resident (R28) of 1 Resident reviewed for care plans.Findings included:R28Review of R28's admission record dated 1/28/26 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: chronic pain, dysuria (frequent urination), reduced mobility, and chronic kidney disease. R28 was her own responsible party.Review of R28's Brief Interview of Mental Status (BIMS), a mental/cognitive assessment, dated 12/2/25 revealed R28 scored 15 out of 15 (normal mental status).Review of R28's skin integrity care plan revision date of 11/06/25 revealed, I have actual impairment to skin integrity r/t (related to) hemiplegia/hemiparesis (paralysis of half of the body). Interventions included: cushion for chair dated 10/25/25. No interventions were noted for the toilet or bedpan.On 1/27/26 at 1:26 PM, R28 was observed sitting in her room in her wheelchair. R28 complained of buttock pain, pain when she sits on the toilet and bed pan for extended periods of time. Certified Nursing Assistant (CNA) H came in the room to assist R28 and R28 was agreeable to allowing the Surveyor to check the skin on her buttock. CNA H assisted R28 to stand and remove R28's pants. R28 pointed to her coccyx area when explaining where she hurt. The coccyx and sacral area were coated with a thick white substance. Some skin was observed to be darker in the sacral area than the rest of her buttock. The coccyx was not visible. R28 was sitting on a green pad. CNA H said R28 was to be sitting on a pressure relief cushion. CNA H could not locate the cushion that was normally in R28's wheelchair. CNA H obtained a different seat cushion. R28 took the disposable cover off her drink and ran her finger around the edge and said the outside of the cup was like the bed pan and explained the edge hurt her buttock when she sat on it.During an observation and interview with R28 on 1/29/26 at 10:37 AM, R28 was sitting on the toilet in her bathroom. R28's feet were several inches off the floor and R28 was complaining of the toilet seat hurting her buttock. R28's Charge Nurse, CN M was asked to come evaluate R28's buttock pain and need for assistance. CN M asked R28 if she could shift her weight off where it hurt. R28 tried but said she could not. CN M handed R28 the bed pan she uses and asked where the bedpan hurt her and R28 pointed to the narrow sides with her fingers.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent falls for 2 residents (R11 and R38) of 5 residents reviewed for falls.Findings include:R11 Review of an admission Record revealed R11 admitted to the facility on [DATE] with pertinent diagnoses which included Parkinson's Disease and unsteadiness on feet. Review of a current toileting Care Plan intervention for R11, with a revision date of 9/9/2025, directed staff to toilet resident every 2 hours while awake and upon request. In an interview on 1/26/2026 at 2:55 PM, R11 reported he often waited 30 minutes for his call light to be answered. R11 reported he was unable to hold his urine that long and often urinated on himself while waiting for assistance. Review of R11's Note Text in the Electronic Medical Record (EMR), dated 1/13/2026 at 2:04 PM revealed .This writer was called into resident's room by CNA, who stated that resident was noted to be sitting on the floor of his bathroom. Resident stated that he needed to use the bathroom and could not wait so he tried getting on the toilet but was unable to make it onto the toilet, and he had to sit down on the floor. Review of R11's Note Text in the EMR, dated 1/27/26 at 2:38 PM, revealed .IDT (Inter-Disciplinary Team) post fall huddle and Root-Cause Analysis performed. On 1/13/26 at 1250 (R11) was observed to be seated on the floor of his bathroom. He reported to the staff that he was trying to get on the toilet but was unable to make it onto the toilet and he sat down on the floor. He had urinated on the bathroom floor. He had his call light on prior to self-transferring, but (R11) is not patient and. tries to transfer without being strong enough to complete the transfer safely. Root causes of irritability and impulsiveness were discussed by IDT. Further review of the report revealed it did not state how long R11's call light had been activated prior to staff finding him on the bathroom floor and it did not identify the length of the call light wait time as part of the root cause of this fall. In an interview on 1/28/2025 at 3:47 PM, the Nursing Home Administrator (NHA) reported she would provide the call light report for R11 on 1/13/2025. The NHA did not know why this information was not reviewed in the post fall huddle Root-Cause Analysis. Review of R11's Past Calls report, dated 1/13/2026, revealed his bathroom pull station call light was activated at 12:25 PM with 28 minutes elapsed until staff turned the call light off at 12:53 PM. In an interview on 1/29/2026 at 10:22 AM, Registered Nurse (RN) Charge Nurse M discussed the 28-minute wait time in between when R11 activated the bathroom call light at 12:25 PM and the staff response at 12:50 PM. RN Charge Nurse M reported 28 minutes was longer than a resident should be required to wait for assistance using the bathroom. In an interview on 1/29/2026 at 10:42 AM, the NHA did not have a reason that the call light wait time was not included in the post fall Huddle and Root Cause Analysis performed for this fall. Review of the facility policy/procedure Incidents & Accidents Policy, revised 11/2023, revealed .The purpose of incident reporting can include: Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care. Conducting a root cause analysis to ascertain causative/contributing factors as part of the Quality Assurance Performance Improvement (QAPI) to avoid further occurrences. R38 Review of an admission Record revealed R38 admitted to the facility on [DATE] with pertinent diagnoses which included Parkinson's disease, dementia, psychotic disorder with hallucinations, delusional disorder, and major depressive disorder. In an observation on 01/29/2026 at 8:19 AM, R38 ambulated into the hallway from his room utilizing a two-wheeled walker. R38 walked down the opposite hallway from his room (closed rooms) and observed a lighted sign on the wall. R38 was without staff presence at the end of this hallway. R38 attempted to enter another resident room in the hallway as he ambulated toward the nurse's station. Staff members walked through the hallway past R38 and did not attempt to approach. R38 then ambulated to the common area where the television played an Elvis video. R38 stepped backward multiple steps tipping his front walker legs off from the floor. Staff noted to be in another hall and in other resident rooms. One staff member was observed with a breakfast hall tray that she returned to the kitchen; another staff member was observed in the dirty linen room. R38 ambulated back to the end of the same hallway (closed rooms) and proceeded to turn around when he reached the end of the hallway. R38 ambulated without his walker back from the hallway to lean against the nurse's station. There were no staff present at the nursing station or within sight. Review of a current activities of daily living Care Plan intervention for R38, initiated 04/17/2025, directed staff that R38 required supervision with a two-wheeled walker for ambulation. In an interview on 01/29/2026 at 8:49 AM, Licensed Practical Nurse (LPN) K was queried what supervision with ambulation would mean in the care plan. LPN K replied that supervision with ambulation means that staff keep visual eyeline at all times with the resident. LPN K observed during response that R38 was standing at the nursing station without his walker. LPN K assisted R38 to obtain his walker and redirected him to his room. In an interview on 01/29/2026 at 8:59 AM, Certified Nursing Assistant (CNA) E was queried what supervision with ambulation would mean in the care plan. CNA E stated it meant staff were supposed to keep R38 visually in sight. In an interview on 1/29/26 at 9:06 AM, CNA F was queried what supervision with ambulation would mean in the care plan. CNA F stated you have to watch them when they walk. When asked which residents on the unit required supervision with ambulation CNA F was unable to identify which residents required supervision with ambulation. In an interview on 1/29/26 at 9:13 AM, Registered Nurse (RN) Charge Nurse N was queried what supervision with ambulation would mean in the care plan. RN Charge Nurse N stated you would be with that resident; you are supervising them. RN Charge Nurse N reported that supervision is when staff always has that resident in their line of sight.

Based on interview and record review, the facility failed to consistently provide clear and concise medical records for 2 residents (R9 and R12) of 20 residents reviewed.R9Review of a resident admission Record revealed R9 admitted to the facility on [DATE] with pertinent diagnoses which included parkinsonism, bipolar disorder, anxiety disorder, and heart failure. Review of R9's electronic medical records (EMR) revealed (Facility Name) Interdisciplinary Conference Report Sheets dated 02/11/25, 5/13/25, and 8/12/25 were marked as the Quarterly option with an X. Further review revealed Resident in attendance: Yes or No all sheets presented with a check mark beside No. Resident family/legal representative in attendance? Yes or No the sheets presented with a check mark beside No. Further review revealed check mark stating completion of a baseline care plan summary encompassing updates to goals, medications, dietary information, and treatments since the last care plan summary had been completed with Resident and/or Resident family/legal representative although Resident and Resident family/legal representative were both marked as not in attendance. Review of R9's EMR revealed (Facility Name) Interdisciplinary Conference Report Sheet dated 10/21/25, with the Quarterly option check marked. Further review revealed Resident in attendance: Yes or No presented a check mark beside No. Resident family/legal representative in attendance? Yes or no presented blank. Further review revealed check mark stating completion of a baseline care plan summary encompassing updates to goals, medications, dietary information, and treatments since the last care plan summary had been completed with Resident and/or Resident family/legal representative although Resident and Resident family/legal representative were both marked as not in attendance. R12Review of a resident admission Record revealed R12 admitted to the facility on [DATE] with pertinent diagnoses which included Alzheimer's disease and major depressive disorder.Review of R12's EMR revealed (Facility Name) Interdisciplinary Conference Report Sheet dated 10/16/25, with the Quarterly option checked yes. Further review revealed Resident in attendance: Yes: or No: presented blank. Resident family/legal representative in attendance? Yes: or No: presented blank. Further review revealed check mark stating completion of a baseline care plan summary encompassing updates to goals, medications, dietary information, and treatments since the last care plan summary had been completed with Resident and/or Resident family/legal representative although Resident and Resident family/legal representative were both marked as not in attendance. Review of R12's electronic medical record on 01/27/2026 revealed (Facility Name) Interdisciplinary Conference Report Sheet dated 01/13/2026, with Annual option checked yes. Report Sheet requested Resident in attendance: Yes: or No: presented a check mark beside No. Resident family/legal representative in attendance? Yes: or No: presented blank. Further review revealed check mark stating completion of a baseline care plan summary encompassing updates to goals, medications, dietary information, and treatments since the last care plan summary had been completed with Resident and/or Resident family/legal representative although Resident and Resident family/legal representative were both marked as not in attendance. In an interview and record review on 01/28/2026 at 9:00 AM the Social Service Designee (SSD) R reported that care conferences were completed on paper and when the care conference was completed the paper was taken to be signed by the resident's physician and after the physician signed the care conference was uploaded into the resident's chart. SSD R reported the care conference paperwork should be filled out in its entirety to assist with family involvement.In an interview on 01/28/2026 at 1:00 PM, questioned the Registered Nurse (RN) Charge Nurse N if the expectation would be to have resident/representative involvement for the section that states Baseline Care Plan summary completed with resident/representative including to updates to goals, medications, and dietary information, services, and treatments since initial baseline care plan, RN Charge Nurse N responded yes. Review of facility policy/procedure Nursing Documentation Policy, updated 03/2023, revealed .each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate and timely documentation .

Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), resulting in the potential for increased risk of respiratory infection among all residents in the facility. Findings include: On 01/27 at 9:13AM, a drinking fountain was observed that appears to be used inconsistently, located in the unused Boardroom wing on the Ground Level. The basin of the drinking fountain was dry at time of observation. Director of Environmental Services (DES) U was asked about use of the drinking fountain and the flushing schedule for the fountain at that time. DES U indicated they were unsure about the flushing schedule or use of the drinking fountain due to the area being used mainly for storage and that sometimes the restroom facilities are used by facility personnel. Record review of the facility's policy, Michigan Masonic Home, Water Management Program Policy MN-D 153 Procedure 2, states A risk assessment will be conducted by the water management team annually., indicating the drinking fountain would have been assessed annually and status of flushing schedule known.

Based on interview and record review the facility failed to monitor lab results and promote communication between health care providers to maintain an effective antibiotic stewardship program to ensure timely identification and treatment of an infection for one Resident (R103) of six residents reviewed for medications. Findings include:Review of the Electronic Medical Record (EMR) reflected R103 admitted to the facility 8/18/16 with pertinent diagnoses that included a history of urinary tract infections (UTI).Review of the EMR Progress Note entry on 1/2/26 at 4:31 PM reflected a urinalysis was ordered by a physician.Review of the EMR Progress Note entry on 1/4/26 at 2:49 PM reflected the urine specimen had been obtained and sent to the laboratory for analysis.Review of the EMR revealed abnormal urine lab results on 1/4/26 and that a culture and sensitivity (C and S) was to be completed. The document included a physician note dated 1/7/26 at 9:31 AM, UA positive for kleb penumoniae (sic) (a bacterial urinary tract infection), will start 7-day course of Ceftin (antibiotic). Extended course due to hematuria (blood in urine) as well. Called (name of facility) to update result.Review of the EMR revealed documentation of Culture and Sensitivity results Last Resulted 1/6/26 at 7:47 AM. The result reflected the culture result of >100000 col/ml Klebsiella Pneumoniae. The document included the same note from the physician that (name of facility) had been contacted and that the 7-day course of an antibiotic would be started.Review of the EMR did not reflect documentation of the positive lab result for UTI or the need for an antibiotic until 1/16/26 at 15:28 when an antibiotic was ordered. ) No documentation was found in the EMR of monitoring for the results of the urine specimen submitted by facility 1/4/26.Review of the January 2026 Medication Admisnistration Record (MAR) for R103 reflected antibiotic therapy was initiated the evening of 1/16/26.On 1/28/26 at 11:38 AM, an interview was conducted with Infection Preventionist (IP) G. IP G reported that the charge nurses will inform her of residents with suspected infections, if a urine sample was sent to the lab, or if a physician wanted to start an antibiotic. The IP reported that she would follow up to make sure a note was entered into the medical record. IP G reported that the Medical Director follows most of the facility residents but that another Physician at the facility was responsible for a small number of residents. IP G reported that this Physician was following R103. The IP reported that the documentation of the lab results and the order for an antibiotic were placed in a separate hospital EMR and not the facility EMR. The IP indicated there was a miscommunication despite documentation in the facility EMR that a urine sample had been sent to the lab and was without monitoring for the results. The policy provided by the facility titled Infection Surveillance Policy last revised 9/2025 was reviewed. The policy reflected It is the policy of (name of facility) to have a system of infection surveillance services as a core activity of the (facility's) infection prevention and control program's purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices . And Procedure: .2. The nurses participate in surveillance through assessment of residents and reporting changes in condition to the resident's physicians and management staff, per protocol for notification of changes and in-house reporting of communicable disease and infections. Examples of notification triggers include, but not limited to: a. Resident develops signs and symptoms of infection.c. A microbiology test is ordered.

Based on observation and interview, the facility failed to maintain general cleanliness and repair of the premises. Findings include: On 01/27/2026 at 8:30AM, a patch of black mold-like substance was observed, 2 feet long by 1 foot wide, at eye level, on the wall in the Water room, located in Maintenance and Laundry wing of Ground Level. Director of Facilities (DF) T confirmed the observation at the time of walk through. There was no visible explanation at time of observation, as the wall was dry and there were no notable high humidity issues in the room.

Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all of the residents in the facility. Findings include: During a tour of the main dry storage area for the kitchen, at 11:38 AM on 12/16/24, an interview with Life Safety Emergency Manager (LSEM) K and Director of Dining Services (DDS) M found that this area is no longer used for its intended purpose of being a serving kitchenette. Observation found multiple water fixtures including a preparation sink, a hand sink, a steam table fill, and pot fill fixture on the cook line, that had been stagnant and not under any routine flushing schedule. Sink compartments were found covered, dry and dusty. The hot and cold water lines for the kitchenette hand sink was turned on and brown water came out momentarily before turning clear. During a tour of the first floor North Kitchenette, starting at 11:54 AM on 12/16/24, an interview with DDS M found that dietary staff don't use the back dish room portion of the first-floor kitchenette. When asked if this area is on a regular flushing schedule for removing stagnant water, LSEM K stated that they will add this area to the list. During a review of the facilities Water Management Plan (WMP), starting at 1:40 PM on 12/16/24, with DDS M, LSEM K, Director of Facilities (DOF) J, and Director of Environmental Services (DES) I, an interview with staff found that they do regular flushing of water as part of their risk prevention. When asked if the facility currently sent anything to a lab for testing or if they did any testing in house, DOF J stated that they currently do not. When asked if there was any other control measures or limits the facility was using to decrease the risk of Legionella or other OPPP, staff were unsure. During a tour of the facility, at 3:10 PM on 12/16/24, it was observed that a janitors closet on the second floor North hall, was found with a faucet and no chemical pre dispense. When asked if staff use this sink, DES I asked EVS Aide L and he stated, nobody ever uses that sink. When asked if this was a fixture that is routinely flushed, LSEM K stated they would add it to the list. During a tour of the Ventilation Unit, at 3:10 PM on 12/16/24, it was observed that a water line that used to service the flush valve of a hopper, was protruding from the wall with crusted debris residue on the outside indicating it was still servicing water and was a stagnant line. An interview with DOF J found that he was unsure if the water line had been disconnected or if it was a stagnant line. A record review found an Infection Control Risk Assessment, dated 11/30/17, with no facility layout or instructions on how water flows through the facility. A review of the Michigan Masonic Home Water Management Program Procedure, revised 09/2024, found that .3. A risk assessment will be conducted by the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the Homes water system. The risk assessment will consider the following elements: a. Premises plumbing: This includes water system components as described in the documentation of the Homes water system . A review of the Michigan Masonic Home Water Management Program Policy, revised 9/2024, found that 3. Based on the risk assessment, control points (locations in the water systems where a control measure can be applied) will be identified. 4. Control measures will be applied to address potential hazards at each control point. A variety of measures may be used, including physical controls, temperature management, disinfection level control, visual inspections, or environmental testing for pathogens. 5. Testing protocols and acceptable ranges (control limits) will be established for each control measure.

Based on observation and interview the facility failed to maintain a safe, functional, sanitary, and comfortable environment. This resulted in an increased potential for contamination, affecting residents, staff, and the public. Findings Include: During a tour of the kitchen, at 11:15 AM on 12/6/24, observation of the dish machine area found that the dirty side of the machine had a roughly 10 foot long built in rinse stream, that drains into the garbage disposal. The rinse stream had multiple submerged inlets that hang below the overflow rim of the rinse table and was not observed with an atmospheric vacuum breaker (AVB) that would protect the potable water supply from potential back siphonage (due to the submerged inlets). An interview with Director of Facilities (DOF) J found that he has only been here a couple months and was not sure if the submerged inlets were protected with an AVB. When asked if he could see an AVB anywhere in line of the submerged inlets, DOF J sated he could not. During a tour of the first floor North clean holding room, at 2:18 PM on 12/16/24, it was observed that a mop sink faucet was found left on and connected to a chemical pre-dispense. No wasting tee or sidekick device was present to remove constant back pressure from the faucet's internal AVB. An interview with Director of Environmental Services (DES) I found that the faucet should be shut off between use. During a tour of the second floor North spa room, at 2:40 PM on 12/16/24, it was observed that a stack of towels and wash cloths were found stored open and exposed next to the shower. An interview with Life Safety Emergency Manager K found that linens should not be stored open and exposed. During a tour of second floor North, at 2:45 PM on 12/16/24, it was observed that the tabletop ice machine was found directly connected to the wastewater drain. Food contact equipment must be air gapped in order to remove the risk of contamination due to wastewater back flow. During a tour of the Ventilation Unit spa room, at 2:55 PM on 12/16/24, it was observed that four towels and six wash cloths were found stored open and exposed next to the shower. During a tour of the Ventilation Unit soiled utility room, at 3:09 PM on 12/16/24, it was observed that a mop sink faucet was found installed over an area where a hopper used to be installed. At this time, no wastewater access was available for this water fixture and water would run down onto the floor. During a tour of the laundry room, at 3:30 PM on 12/16/24, it was observed that one of the clean laundry carts was found with an accumulation of paper trash and debris under the carts false bottom.

Based on observation, interview and record review, the facility failed to maintain self-esteem, honor preferences and ensure care was given in a dignified manner for one resident (R47) out of 22 residents reviewed for dignity. Findings: Review of an Admission Record reflects R47 admitted to the facility with diagnosis that included Parkinsonism (a group of movement disorders that share similar symptoms to Parkinson's disease), difficulty walking, unspecified mood disorder, anxiety and agoraphobia (fear of places and situations that might cause panic, helplessness and embarrassment) with panic disorder. During an observation and interview on 12/16/24 at 10:31 AM, R47 was in a maroon-colored t-shirt and athletic shorts. The t-shirt was soiled with what appeared to be food spills, a crucifix around his neck was caked with an unknown substance. R47 reported his breakfast spilled the day before and no one came to help him clean it up. During an observation and interview on 12/17/24 at 9:07 AM, R47 was wearing the same soiled clothes he had on the day before. R47 reported that he does not like his showers because he does not like showers given to him by women. R47 said that he would be more willing to shower if a male attendant helped him. R47 repeated that women showering him was not appropriate and embarrassed him. During an interview on 12/17/24 at 9:13 AM, Registered Nurse (RN) N reported she was aware R47 did not like women showering him. RN N said R47's preference to have male caregivers is not care planned, but there is a male Certified Nurse Aide (CNA) who could help if needed and the facility should be able to accommodate this need. Review of a Task Monitor for showering and bathing for the last 30 days (11/22/2024-12/16/2024) reflected R47 had one shower on 11/22/2024 with Set-up or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. The report showed that R47 refused a shower on 11/25/2024 and 12/10/2024. The report showed Not Applicable on 12/2/2024 and 12/16/2024. Review of a Care Plan initiated on 2/25/2021 reflected R47 required assistance with ADL (activities of daily living), mobility and toileting. Interventions and tasks related to this focus included BATHING supervision x 1 (one assist) as I allow. The care plan did not specify R47's preference for male caregivers. Further review of the entire care plan revealed R47 was taking psychotropic medications for depression, anxiety and agoraphobia with fluctuating symptoms of anxiousness. The care plan did not include interventions to address R47's reported embarrassment with female caregivers and preference for male caregivers for showers. During an interview on 12/18/2024 at 11:54 AM, Registered Nurse (RN)/Assistance Director of Nursing (ADON) O reported that she was very familiar with R47 and knew he did not like women giving him showers. RN/ADON O said the staff needed to do a better job of documenting R47's refusal to shower and attempts to reapproach when needed. RN/ADON O said there is a male CNA who could accommodate R47's preference for male caregivers when showering.

Based on observation, interview and record review, the facility failed implement interventions to prevent falls for three residents (R12, R38, and R87) of 6 residents reviewed for falls. Finding include: Resident #87 (R87) Review of R87's face sheet dated 12/18/24 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: Dementia, pain and edema. He was not his own responsible party. Review of his Brief Interview of Mental Status (BIMS) score dated 9/24/24 revealed a score of 2/15, indicating he is severely cognitively impaired. R87 was observed on12/16/24 at 11:01 AM in his room in a recliner chair with his feet up and not supervised. A couple minutes later, R87 was observed walking by himself in his room to the bathroom with no assistive device. A few minutes later, he was observed walking back to his recliner alone. During an observation and an interview on 12/17/24 at 3:00 PM, R87 was in his room in a recliner alone with his feet up. No walker was observed in his room. Registered Nurse (RN) C came to the resident's room and was asked about how much assistance R87 needed for ambulation. RN C reported he required a walker with one person to assist for ambulation. Review of R87's incident report dated 12/6/24 at 5:50 AM revealed he had a witnessed fall in his room. The CNA (Certified Nursing Assistant) was in his room at the time to take him to the bathroom. Review of R87's Fall Root Cause Summary dated 12/10/24 at 14:40 (2:40 PM), for the fall that occurred on 12/9/24, revealed he was last observed in bed at midnight and was dry at that time. (3 hours and 17 minutes prior to being found on the floor in the hallway). Interventions included: assist to the bathroom every 2 hours while awake (standard of care), gripper strips to the floor by the bed, gripper strips to the floor in front of recliner, keep in supervised area while up and therapy to screen due to weakness. There was no indication that supervision when awake was implemented. Review of the Fall Root Cause Summary dated 12/9/24 at 17:07, for the 12/6/24 fall for R87 revealed he was last observed at 5:50 AM, last time toileted 2:00 AM. Summary of incident. Resident was standing up from recliner to go to the bathroom with staff in room at the time. Resident became weak and went to his knees. Resident did not hit his head. Abrasion LT (left) knee. Intervention: Remind and encourage me to use my call light as needed during acute illness. Review of R 87's incident report dated 12/9/24 at 3:17 AM revealed R87 had an unwitnessed fall in the hallway. Interviews revealed he was confused but did not indicate other behaviors or give details about amount of sleep or any routine patterns of care that were the same or different that night. Review of R87's fall care plan revealed he is at high risk for falls due to dementia, pain, history of falls, incontinence, poor safety awareness and self-transfers often, dated 9/19/24. The fall interventions included keep in supervised area while up, initiated on 12/9/24. (Which is not reflected on the Kardex). Review of R87's Kardex dated 12/18/24 revealed that he was to be assisted to the bathroom every 2 hours while awake, he was not to be left unattended in the bathroom, he was to use a front wheeled walker with limited assistance of one person to walk. There was no intervention for him to be in a supervised area while he is awake. (This intervention was on the care plan). Resident #12 (R12) Review of R12's face sheet dated 12/18/24 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: Vascular dementia, sleep apnea, and unsteady on feet. She was not her own responsible party. During an observation and an interview with Registered Nurse (RN) C on 12/17/24 at 2:49 PM she pointed out R12 in the main dining area on the unit playing bingo at that time. She confirmed that R12 was a fall risk, and they try to keep her in supervised activities. Review of R12's incident and accident report dated 9/27/24 at 11:12 AM revealed R12 had a witnessed fall in the day room. The Certified Nurse aide reported R12 was self-transferring and noticed R12's knee was shaking. The report said R12 used the toilet at 8:30 AM and was last seen in the day room [ROOM NUMBER] minutes prior to the fall. The report did not indicate any activity was happening at the time of the fall or provide any details of care provided or behaviors. Review of R12's Fall Root Cause Summary dated 10/1/24 at 16:13 (4:13 PM) for the fall that occurred on 9/27/24 revealed R38 was seen sitting in a chair in the sunroom [ROOM NUMBER] minutes prior to being found on the floor. The summary of incident revealed, Resident was self-transferring to the bathroom in the day room when her leg knee gave out. Staff had observed her transferring and not asking for help. Due to her cognition resident does not always remember to ask for assistance. Intervention placed was a bell provided in day room when sitting in day room to ring for help. Review of R12's incident report dated 10/7/24 at 10:58 AM revealed R12 had an unwitnessed fall in the sunroom. R12 indicated that she needed to use the bathroom. She was last observed at 10:30 AM sitting in the sunroom with her eyes closed. R12 did not use the bell. The report did not indicate when she was last assisted to the toilet. The report did not indicate any activity, or supervision was being provided at the time of the fall. No interventions placed. Review of R12's Fall Root Cause Summary dated 10/15/24 for the fall that occurred on10/7/24, revealed R12 was observed sitting in a recliner in the sunroom with her eyes closed at 10:30 AM, she had tennis shoes with grip and had a walker in use at that time. Summary of incident, Resident observed on the floor in sunroom in front of sunroom chair. Resident stated she was attempting to get up and use the bathroom when her right leg gave out. Resident did not use her bell provided to ask for assistance. Resident does have a history of self-transfers and d/t cognition does not always ask for help. Interventions placed, assist to common area when up, dycem placed in in chair in sunroom, Therapy to focus on transfers for the chairs in the sunroom. One person assists on and off the unit. Previous intervention was to provide a bell in the sunroom. Previous fall was also in sunroom, providing a call bell was not effective for a severely cognitively impaired resident. There was no indication that the dycem would prevent self-transfer and no indication of how they would be addressing the unsafe transfers or meeting her toilet needs. Review of R12's fall care plan dated 4/23/24 revealed that R12 was high risk for falls related to dementia, history of falls, unsteady on feet, poor safety awareness, and history of self-transfers. She has been noted to rush when she is walking and needs to be reminded to slow down. She is on diuretic, seizure and psychotropic medications. She has seizure like activity. She uses a walker to walk. She has occasional incontinence and sometimes takes herself to the bathroom. Interventions included: assist me to common area when up 10/7/24, Dycem (nonskid material) in chair in the sunroom where she enjoys sitting most days. Provide bell in day room when I am sitting in there 9/27/24, Therapy to focus on transfers from the chair in the sunroom. Resident #38 (R38) Review of R38's face sheet dated 12/18/24 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: Alzheimer's disease, chronic kidney disease with heart failure. She was not her own responsible party. Review of R38's Minimum Data Set (MDS) nursing assessment dated [DATE] revealed she was severely cognitively impaired. Review of R38's incident report dated 7/14/24 at 15:30 (3:30 PM) revealed she had an un-witnessed fall in the dining room near her wheelchair. Review of R38 fall care plan revealed no new fall intervention was placed after this fall. Review of R38's Root Cause Summary dated 7/16/24 at 13:34 (1:34 PM) for the fall on 7/14/24 revealed the same information that was on the incident report dated 7/14/24 at 3:30 PM. The new intervention placed was pain cream was discontinued, and a pain patch started, therapy screen for strengthening and she was referred to a physician for increased behaviors. No documentation was located that indicated R38 had signs/symptoms of pain prior to the fall. The documentation did not include any behaviors prior to the fall. It was not clear why pain and behaviors were determined to be the root cause of her fall. Review of R38's incident and accident report dated 7/30/24 at 17:30 (5:30 PM) revealed she had an unwitnessed fall in the hallway. Staff statements revealed she had been in bed at 4:00 PM and she refused to use the bathroom at that time. She had shoes on. When R38 was asked what she was doing she said she slid out of bed and scooted in the hallway. There was no indication how long she had been in bed, when was the last time she used the toilet, or how she had responding to care earlier that day. (or when her needs were last met). R38's Fall Root Cause documentation for fall on 7/30/24 dated 8/6/24 at (7 days after the fall). New interventions were blood sugar checks before meals for 1-day, orthostatic blood pressures for 3 days and bowel and bladder monitoring for 3 days. There were no meaningful or sensical interventions to address or prevent future falls based on investigation. Review of R38's incident and accident report dated 10/11/24 at 20:25 (9:25 PM) revealed R38 had an unwitnessed fall in her room. Staff statements revealed R38 was watching TV at 19:30 (8:30 PM) in an unknown location. No information was documented that provided to indicate what R38's behaviors were that day, when she went to bed, how long she slept or the last time she had used the toilet. New interventions work order for gripper strips in front of the recliner and bed. Review of R38's Fall Root Cause dated 10/17/24 at 17:03 (5:03 PM) regarding the fall on 10/11/24 revealed that R38 was in her recliner watching TV at 19:30 (approximately 1 hour prior to her fall). There was no indication of the last time she used the bathroom, behaviors prior to the fall, when she slept last. There was no indication of any changes in condition or behavior noted. The new intervention placed was gripper strips in front of the recliner and side of bed. Not enough information provided to show a thorough investigation of a fall to show gripper strips as an appropriate intervention. Review of R38's incident and accident report dated 11/14/24 at 2:45 AM revealed she had an un-witnessed fall in her room, she was on the floor in front of the bathroom, her walker was in the bathroom and her shoes were on the opposite feet. They moved her closer to the nurse's station for observation. Staff statements revealed R38 was seen 45 minutes prior to the fall, sleeping in bed. No indication of how long R38 had been sleeping prior to the fall. Review of R38's Fall Root Cause dated 11/18/24 at 17:00 (5:00 PM) for the 11/14/24 fall revealed R38 used the toilet at 12:31 AM. No indication of behaviors, sleep pattern or amount of time resident had been sleeping was found. Under interventions was offer, encourage an assist me to the bathroom every 4 hours (old intervention and according to the root cause was provided that night.) No new interventions were located. Review of R38's Kardex (care giver instructions) dated 12/18/24 (date of this survey) included the following information in the safety section: do not leave me unattended in my bathroom, offer, encourage and assist me as need to the bathroom every 4 hours, and when I am awake in the night and ambulating, assist me to the common area. Mobility included: ambulation extensive assist x 1 using 4 wheeled walker, bed mobility independent, toilet use extensive assist of 1 encourage, offer, and assist with toileting before and after meals and at bedtime. Transfer extensive assist of 1 with 4 wheeled walker. Review of R38's Activities of Daily Living (ADL) care plan dated revision on 11/19/24 revealed, I will frequently attempt to self-transfer and ambulate on my own. I have poor safety awareness and do not utilize my call light consistently. I have a history of declining the use of a gait belt. I choose not to consistently us my walker in my room. I prefer to sleep in at times and may yell at staff and become combative with cares. Review of R38's fall care plan dated revision on 12/17/24 revealed that R38 has had a history of falls, frequently does not use her walker and takes medications that can alter her balance. She had poor safety awareness and is impulsive. She had a history of using furniture in her room to walk, laying on the floor in her room. She is taking diuretic medication (causing urination). She can be resistive and combative with care. On 3/23/23 the intervention to take R38 to the common area when she is awake and at night when walking was added. During an interview with Unit Manager A on 12/18/24 at 9:00 AM, Unit Manager A was asked about the process of coming up with new interventions and what were the new interventions placed for R38 on 7/14/24 and 7/30/24. Unit Manager A used the electronic medical record to review R38's care plan and fall documents. She could not locate new interventions or information on how they determine the interventions. Unit Manager A called the Assistant Director or Nursing (ADON) and the ADON came and started reviewing the record for resolved care plans as she could not locate a new intervention in the current care plan. The Director of Nursing joined the interview and explained that they do an initial meeting with staff and document what happens. They take that information and do a Root Cause Analysis. They are to place interventions at the time and add interventions based on the Root Cause Analysis. The surveyor requested the Root Cause Analysis documentation of this process for: R38, R13 and R87. It was not clear how the faciltiy was going to improve safety or supervision of these residents as they were all severely cognitively impaired, were known to not use call lights, known to self-transfer and had poor safety awareness.

Based on observation, interview, and record review, the facility failed to safely transport one resident (R25) in a wheelchair, resulting in the potential for serious injury. Findings include: A review of R25's Admission Record, dated 10/26/23, revealed R25 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R25's Admission Record revealed multiple diagnoses that included chronic respiratory failure with hypoxia, anxiety, depression, and post-traumatic stress disorder. A review of R25's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 9/27/23, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15 which revealed R25 was cognitively intact. In addition, R25's MDS revealed she could propel herself in a wheelchair with supervision or touching assistance (helper provides verbal cues or touching/steadying assistance as the resident completes the activity) for distances of at least 50 feet and partial/moderate assistance (helper does less than half the effort) for distance of at least 150 feet in a corridor or similar space. During an observation on 10/25/23 at 1:15 PM, R25 told Registered Nurse (RN) B that she wanted to go to the dining area to participate in an activity. RN B pushed R25 in her wheelchair without foot pedals from R25's room to the dining area. R25 had her legs extended straight out in front of her and raised at approximately a 90-degree angle while she was being pushed. During an interview on 10/26/23 at 10:30 AM, RN E stated staff are not supposed to push residents in their wheelchairs without foot pedals, because the resident could put their feet down and fall on their face. During an interview on 10/26/23 at 10:35 AM, RN D stated staff are not supposed to push residents in their wheelchairs without foot pedals, even if the resident can hold their feet up. She stated their feet could fall to the floor and get caught under the wheelchair. She also stated the resident could fall out of their wheelchair if their feet becomes caught under the wheelchair. A review of the facility's Personnel Vehicle Wheelchair Transportation Policy, dated 4/15/20, revealed, Identification of hazards and risks is the process through which the interdisciplinary team becomes aware of potential hazards in the positioning and transportation of a resident in a wheelchair and the risk of a resident having an avoidable accident . Caregiver staff should make a reasonable effort to identify the hazards and risk factors for each resident before beginning transportation of that resident . Considerations . Are their feet resting flat on the foot plates (foot pedals)? . Quick Check (after resident is transferred into the wheelchair) - buttocks to the back of the chair - Pelvis level - Feet appropriately supported on footplates .

Based on interview and record review, the facility failed to ensure a monthly pharmacy drug regimen review recommendation was reviewed by the physician in a timely manner for 1 of 5 residents reviewed (R35), resulting in R35 receiving a medication over an extended period of time that had insufficient evidence for its use, the potential for the physician not knowing of a pharmacy recommendation, the potential for a delay in implementing a pharmacy recommendation, and the potential for adverse effects from a medication that the pharmacy identified as potential medication issue. Findings include: A review of R35's Admission Record, dated 10/26/23, revealed R35 was a [AGE] year-old resident admitted to the facility on [DATE] with multiple diagnoses that included dementia, diabetes, and urinary incontinence. A review of R35's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 8/23/23, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 5 which revealed R35 was severely cognitively impaired. A review of R35's Pharmacy Consultation Report, dated 8/24/23, revealed to the pharmacist recommended that the physician discontinue R35's cranberry supplement due to insufficient evidence to promote using cranberry supplements to decrease Urinary Tract Infection (UTI) reoccurrence in older adults. R35's physician accepted the recommendation and signed it on 10/5/23 (42 days after the pharmacist made the recommendation). A reviewed of R35's medication administration records (MAR's), dated 8/24/23 to 10/26/23, revealed R35 received cranberry oral capsules (an unnecessary medication/supplement) from 8/24/23 to 10/6/23 (43 days after the pharmacist's recommendation to discontinue it). A review of the facility's Medication Regimen Review Policy, revised 8/10/17, revealed, 7. Upon completion of the MRR (Medication Regimen Review), the facility designee and/or physician, will respond to the recommendations in a timely manner . 10. Each residents' drug regimen remains free of unnecessary drugs. An unnecessary drug is any drug when used . b. For excessive duration . d. Without adequate indications for its use . During an interview on 10/26/23 at 03:30 PM, Assistant Director of Nursing (ADON) A stated the pharmacist usually sends their recommendations to the facility within a day or two of when they see the resident. She stated the physician will usually see the recommendation within a week of the facility receiving the recommendation. During an interview on 10/26/23 at 04:11 PM, the Director of Nursing (DON) stated the physician should address a pharmacy recommendation within a week or two. She stated the physician rounds weekly. The DON stated six weeks is a bit too long (not timely) for the physician to address a recommendation. She stated in the case of R35's cranberry supplement recommendation, it appeared she (the DON) had to re-issue the pharmacy recommendation for the physician to review because the copy that they have on file for R35 had a fax number on the top of the page, dated 10/5/23 at 9:10 AM. The DON stated that would indicate that she had to request another copy of R35's 8/24/23 pharmacy recommendation. The DON stated the original pharmacy recommendations do not have the fax number at the top of the page. The DON stated she did not know why the pharmacy recommendation had to be re-issued. She stated the system she uses to keep track of pharmacy recommendations just indicates that she received the recommendation, not the date it was received or if it had to be requested again.

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting all residents who receive meal services out of the facility's total census of 111 residents. Findings include: 1. On 10/24/2022 at 11:52 AM, the two-door continental reach in refrigerator located in the second floors north end kitchen was observed with its exterior temperature gauge reading 44 degrees F. At this time the surveyor inquired with the Director of Dining Services, staff A, on how the facility monitors the temperatures of the refrigeration units to which they stated, we check them daily. The surveyor then asked staff A if the facility takes food temperatures prior to serving from this unit to which they stated, yes, we keep them in our log book. On 10/24/2022 at 11:53 AM, observation of the refrigerator's internal thermometer revealed a temperature reading of 45 degrees F. At this time the surveyor asked staff A if they could review the temperature log book they had mentioned to which they stated, of course. On 10/24/2022 at 11:54 AM, record review of an undated document entitled, food service temperature log revealed sections for cold holding temperatures to be documented for items such as yogurt and cottage cheese left blank on the log. Upon observation the surveyor asked staff A if they would expect cold holding temperatures of these items to be taken prior to serving to which they replied, yes, before each meal. Let's take them now since the gauge was reading high on the refrigerator. On 10/24/2022 between 11:55 AM, and 11:58 AM, the following food product temperatures were verified via staff A's thermometer probe: Individually portioned cottage cheese cups at 47 degrees F Individually portioned yogurt cups at 46 degrees F Individual cartons of milk at 44 degrees F On 10/24/2022 at 11:59 AM, the surveyor inquired with staff A on what the facility would normally do in a situation like this to which they stated, put in a work order for the refrigerator and throw these out. At this time staff A was observed instructing staff to not serve any dairy products from the cooler. On 10/24/2022 at 12:00 PM, the surveyor asked staff A if any of dairy products from this cooler were actively being served as part of the lunch service to which they replied, we might have some in our frozen tub at our serving line, let's find out. On 10/24/2022 at 12:02 PM, seven individual ready care shakes and nine individual cartons of milk were identified by staff A to have come from the two-door continental reach in refrigerator and were discarded. On 10/24/2022 at 12:05 PM, staff A was observed by the surveyor instructing staff to, pull from the main kitchen for replacements for our meal tickets. Review of 2013 U.S. Public Health Service Food Code, Chapter 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding directs that: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57oC (135oF) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; P or (2) At 5 C (41 F) or less. P

Based on observation, interview and record review, the facility failed to treat two residents (Resident #84 (R84) and R104) with dignity and respect, resulting in unmet care needs, potential loss of self-worth, and embarrassment, and the potential for the dignity and self-perception of all facility residents to not be considered. Findings: R84 R84 was admitted to the facility 5/5/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 7 which indicated the Resident was cognitively impaired. The MDS reflected R84 was in Hospice, was non-ambulatory and required extensive assistance of one staff member for transfers, locomotion, and hygiene. The MDS also reflected that R84 was totally dependent for bathing. On 10/24/22 serial observations were conducted of R84: - 11:29 AM: R84 was observed in his room in front of a television seated in a Geri-chair (a special wheelchair). R84 was wearing a soiled sweatshirt, was unshaven, and had dried food at the corner of his mouth. - 1:55 PM: R84 was found in his room in front of the television bare-chested with a hospital gown on the floor. The Resident's chest was wet with drool, that had drained and soaked a Hoyer sling that he was seated on and a small puddle of drool had collected on the floor beneath the chair. A soft-touch call light was on the floor to the left of the Geri-chair unreachable to R84. A grab bar on the facing wall that was out of reach of the Resident had two grabber devices hanging from it. -2:32 PM: R84 remains in the Geri-chair in front of the television. The hospital gown and soft touch call light remain on the floor and drool continues to collect on the floor beneath the Resident. -2:39 PM: Certified Nurse Aide (CNA) O entered the room and asked R84 if he wanted the gown back on or a shirt. R84 responded no. The gown was thrown on the floor next to the wall and CNA O left the room without placing the call light within reach or addressing the drool. -3:15 PM: R84 remains in his Geri-chair in front of the television with the call light on the floor out of the Resident's reach. R84 continues to drool on his chest and the puddle on the floor. The puddle has run to the opposite side of the chair and dried in some areas. -3:25 PM: The presentation of R84 was unchanged and Registered Nurse (RN) Z was informed of the continued observations of inaccessible call light and drooling. RN Z stated Oh no and attended to R84. RN Z reported that towels have been attempted to address the drooling without success. Review of the Doctor's Orders and the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/25/22 at 10:19 AM, R84 was observed in a common area in his Geri-chair placed in front of the television. A coffee cup with spilled coffee lay on the floor next to the chair of R84. It was observed that other residents were spread about the common area engaged in individual activities. Four staff members were present talking with each other and various residents. No one was observed to interact with R84. At 10:26 AM R84 remained in front of the television and the spilled coffee and cup remained next to his Geri-chair. It was observed that R84 had not been shaved as also observed the previous day. R84 also had what appeared to be dried egg above his upper lip. Review of the Hospice documentation of 10/26/22 at 11:00 reflected a Hospice CNA documented All cares completed including a shave. R104 R104 was admitted to the facility 11/9/17 with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] reflected R104 was moderately cognitively impaired. However, section B of this MDS indicated R104 had clear comprehension but could not speak. The MDS further reflected that the Resident could eat with supervision by displayed total dependence for all other Activities of Daily Living (ADL). On 10/24/22 at 11:54 AM during a Dining observation conducted on the 2 North Dining Room. R104 was observed in a Geri-chair eating lunch using special utensils that enabled her to eat on her own. R104 was noted to have food on her chin and on her right cheek. RN Y was observed sitting in a chair approximately four feet to the left of R104 and was angled facing the dining area. RN Y was observed remaining seated watching as staff delivered trays, assisted set up of the meals and interacted with other residents. RN Occasionally looked in the direction of R104 but had not interacted or assist her. RN Y was asked about staff and reported no staffing issues at the facility. At that time RN Y did turn R104 and told the Resident she was doing a good job but did not offer to wipe the food from her face and chin. No other interaction between RN Y and R 104 was observed until the meal was over when the Residents face and chin were wiped. RN did not offer to wipe the food from the face and chin of R104 until the meal had completed. It was also observed during the meal that other staff would talk with RN Y while standing in front of R104, but none had interacted or wiped the food from her face. On 10/25/22 at 8:32 AM residents in the 2 North dining area had appeared to be finishing breakfast. R104 was observed with food on her face, chin, and clothing protector. RN Y was near R104 and reported that her role for being close to R104 was to provide supervision RN Y reported that R104 had been receiving nutrition through a feeding tube and only recently began eating. RN Y indicated she was present to ensure R104 did not choke. On 10/27/22 at 8:44 AM an interview was conducted with Nurse Manager (NM) Q. NM Q reported when staff are assisting residents with meals they should be interacting with them. I hope they are having a conversation with the resident. NM Q reported that she would expect staff to wipe food off the face of a resident they are in proximity to. The facility document titled Promoting/ Maintaining Resident Dignity During Mealtimes Policy issued 8/15/21 was reviewed. The document reflected, Policy: It is the policy of (the facility) to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life recognizing each resident's individuality and protecting the rights of each resident. And Procedure: 1. All staff members involved in providing feeding assistance to resident's promote and maintain resident dignity during mealtimes.

Based on observation, interview, and record review, the facility failed to ensure meaningful Activities were provided for one resident (Resident #84 (R84)), resulting in boredom and disengagement from social situations and the potential for all facility residents who are not able to advocate activity engagement for themselves are not offered regular meaningful Activities. Findings: R84 was admitted to the facility 5/5/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 7 which indicated the Resident was cognitively impaired. The MDS reflected R84 was in Hospice, was non-ambulatory and required extensive assistance of one staff member for transfers and locomotion. On 10/24/22 serial observations were conducted of R84: - 11:29 AM: R84 was observed in his room in front of a television seated in a Geri-chair (a special wheelchair). - 1:55 PM: R84 was found in his room in front of the television. A soft touch call light lay on the floor out of reach of the Resident -2:32 PM: R84 remains in the Geri-chair in front of the television. Call light remains out of reach. -2:39 PM: Certified Nurse Aide (CNA) O entered the room. CNA O left the room without placing the call light within reach or addressing the drool. R84 remained in front of the television. -3:15 PM: R84 remains in his Geri-chair in front of the television with the call light on the floor out of the Resident's reach. -3:25 PM: The presentation of R84 was unchanged. and Registered Nurse (RN) Z was informed of the continued observations. RN Z attended to R84. On 10/24/22 at 2:45 PM, R84 indicated that he does not engage in many Activities. R84 reported that he likes to play Bingo and that he could play if he was taken to the room where Bingo is played. On 10/25/22 at 10:19 AM, R84 was observed in a common area in his Geri-chair placed in front of the television. A coffee cup with spilled coffee lay on the floor next to the chair of R84. It was observed that other residents were spread about the common area engaged in individual activities. Four staff members were present talking with each other and various residents. No one was observed to interact with R84. At 10:26 AM, R84 remained in front of the television and the spilled coffee and cup remained next to his Geri-chair. On 10/27/22 at 11:44 AM an interview was conducted with Life Enrichment Director (LED) U. LED U reported that R84 is one Resident that is falling through the cracks. LED U reported, We definitely need to get him going. LED U reported that the facility used to have nine Activities staff but now only have five and that there is not an Activities person on each floor every day. LED U reported Activities is reliant on nursing staff to bring residents to the Activities areas. LED U reported that once a resident is in an Activities area Activities staff cannot leave them alone while they go to bring other residents in. LED U also reported that if a resident must use the bathroom during an Activity the nursing staff are often not able to bring the resident back. LED U reported We can still provide a good program if residents are brought to them.

This citation pertains to intake MI 699. Past Non-Compliance was accepted for this citation. Plan identified below. Based on observation, interview and record review, the facility failed to provide adequate assistance and ensure equipment was maintained while repositioning with a Hoyer to prevent falls for 1 resident (Resident #3) out of 4 residents reviewed for transfers and falls, resulting in a serious injury when the sling on the left side became detached. Findings: Review of an Admission Record reflected Resident #3 (R3) admitted to the facility with pertinent diagnosis [CONDITION(S)], Contractures of Right & Left Hands, Autonomic Dysreflexia, Cerebral Infarction. Review of NU-A 111 Lift Policy with a review date of 3/25/20 reflected, It is the policy of (NAME of Entity) to reduce and/or prevent staff injury during lifting and transferring of residents. Review of Care Plan Focus Area Revision on 1/12/22 reflected R3 o activities Daily Living (ADL) / MOBILITY / TOILETING I have ADL, toileting, and mobility deficits r/t to my Diagnosis: Cerebral anoxia complication, Traumatic subdural hematoma, [CONDITION(S)] as sequela of stroke, Hemorrhagic cerebral infarction, Subdural hematoma, autonomic dysreflexia. I am confined to my bed and my Broda Chair, I have ADL deficits and I am dependent on staff for all cares. I have Range of Motion (ROM) deficits and contractures of both my upper and lower body extremities. Staff must anticipate my needs as I have Communication deficits. I have enabler bars and Staff may use the Maxi slide for turning and repositioning when I am in my bed. Interventions include o Toileting: Dependent 1-2 I Do not use the bathroom. Check and Change for B/B Q 1 Hrs. Date initiated 08/04/21 TRANSFER: Dependent x2 with maxi move. yellow sling. Sling to remain under me when up in Broda chair. Date Initiated: 08/30/2021 FALLS I am at LOW risk for falls r/t my diagnosis: Intervention Included Ensure I am in center of bed with repositioning. Date Initiated 12/22/19. Review of an Incident Report dated 5/08/22 (subsequent to the original fall report on 4/24/22) reflected that Certified Nurse Aide (CNA) A was using a lift to adjust (Name of R3's) hips to reposition in bed, the maneuvering of body weight caused clip to come undone to the left side of the lift sling. (Name of R3's) left leg began to slide from the sling. The CNA attempted to push the legs of the left under the bed, the bed cords limited her ability to push the lift all the way over the bed. CNA (Name of CNA A) kept hold of (Name of R3's) leg and lowered the lift as far to the floor as possible, to minimize any impact or injury. (Name of R3) Was approximately 6 inches from the floor when her head came to rest on the lifts leg. Other than a small, raised area there were no apparent injuries. The report reflected the facility, initiated neuro-checks every shift for three days per facility policy, which were normal. Daily documentation indicated no changes in health condition until 4/29/22 when (Name of R3) was observed by nursing to have increase in lethargy, discomfort in her mouth with swelling and noted that her tongue and back of her throat had a white coating. The physician was notified, and (Name of Medication) was ordered for oral thrush treatment. The physician also ordered a complete blood count, a comprehensive metabolic lab panel and to obtain a urinalysis if able on 4/29/22 the guardians were notified of condition and new orders on 4/29/22. Results of ordered labs on 4/29/22 indicated within normal limits. Review of Medical Doctor's (MD) I Progress Note from 4/28/22 reflected the following for R3- patient was seen in the dining room while eating breakfast sitting in her wheelchair. Patient does have a past medical history of a TBI status post motorcycle accident five years ago, with resultant cognitive impairment and limited mobility. Patient is nonverbal, however is able to participate in limited communication with her picture board. I spoke with patient this morning during breakfast. She denied any pain and was comfortable while sitting and eating breakfast. Patient appeared to be at her baseline from previous visits. she did bump her head on the side rail of a Hoyer lift and developed a small bump, less than an eighth of an inch on her head, which has resolved. Patient did not lose consciousness and returned to baseline immediately. Review of the 5/8/22 CT scan findings reflected, suspicious for subdural hemorrage, possibly acute to subacute. There is no acute intraparenchymal hemorrhage, midline shift, mass effect or extra-axial fluid collection. Left-sided craniotomy changes . stable from prior. Futher hospital records reflected no treatment was necessary n or rendered for the findings. On 6/1/22 at 12:25 PM R3 observed eating lunch in her broad chair in the dining room. R3 was observed using adaptive equipment to feed herself. During the observation, a CNA walked by and stated they had taken her off 1 to 1 yesterday and that she was doing well. During an interview on 6/1/22 at 4:30 PM CNA A revealed she did not follow the care plan and make sure that all the residents clips were on good, and the cords were under the bed. I was repositioning her hip's; she is contracted and that's when the hook came off the maxi lift. During an observation on 6/2/2 at 11:00 AM Certified Nurses Aides K & D were transferring R3 from the bed to her Broda chair for lunch. Resident was able to communicate with this surveyor using her carrot and a communication board for answering yes and no answers on her care. No, staff are not mean to her. Yes, she fell . Yes, she hit her head. No, not on purpose. Yes, she was hungry. Yes, she wanted out of her room. Yes, she was done talking. Review of a Facility Reported Incident (FRI) dated 5/8/22 reflected the facility reported that the resident fell and sustained a Subdural Hematoma on 4/24/22 but due to a previous motorcycle accident with significant head injury, along with concurrent acute illnesses, the possibility of masked symptoms of a subdural hematoma are possible. Review of the facility investigation reflected the facility implemented to following interventions that identified the non-compliance: 1. On 4/24/22 at approximately 4:35 PM CNA A was assisting Resident #3 by repositioning her in bed while using the Hoyer lift. CNA attempted to adjust resident in the sling and the left side became detached. 2. On 4/24/22 CNA A was not using 2-person assistance as care planned and was using a Hoyer Lift for repositioning. 3. On 4/24/22 R3 was lowered to the floor from approximately 6 while performing a transfer by CNA A. 4. On 4/24/22 R3 was noted to have incurred a raised area to her head. No treatment required. 5. On 4/24/22 at approximately 5:00 PM The Post Fall -72 Hour Monitoring Report began. 6. On 4/24/22 at 5:10 PM, Physician notified that R3 bumped her head on the lift's leg. 7. On 4/24/22 prior to 1754 R3's family and guardian, notified of incident. 8. On 4/24/22 staff interviews completed on when they last saw, assisted the resident. 9. On 4/24- 4/25/22 an education and a competency were completed with CNA A. It was noted to be the only discipline in the CNA's [AGE] years of service. 10. On 4/25/22 at approximately 14:35, DON and Administrator, confirmed with Maintenance a work order has been placed, to place cords underneath beds, not laying on the floor. 11. Review of environment and surroundings. (Name of R3) resides in a private room. She utilizes a Broda Chair for mobility. Her room is without clutter. The bed chords under her bed were adjusted up and connected to her bed frame. 12. Review of 4/28/22 R3's physician progress notes reflected, resident to be baseline. Noted in record for bump to right side of the head. 13. On 4/29/22 it was first documented by nursing that (Name of R3) had increased lethargy, discomfort in her mouth with swallowing and noted that her tongue and back of throat had a white coating. The physician was notified and (Name of Medication) was ordered for oral thrush treatment. The physician also ordered a complete blood count, a comprehensive metabolic lab panel and to obtain a urinalysis, if able on 4/29/22. The guardians were notified of the condition and new orders on 4/29/22. Results of ordered labs on 4/29/22 indicated within normal limits. 14. On 5/1/22 R3's tongue continued with spots of white film, and she was not swallowing well and holding food in her mouth. The doctor was made aware of this on 5/1/22. 15. On 5/3/22 nursing documents that the oral thrush was improving and referral to speech was made. Nursing continued with the prescribed (Name of Medication) and assistance with meal intake. 16. On 5/7/22 oral (Name of Medication) 150mg was ordered daily for three days for oral thrush treatment. 17. On 5/8/22 at 8:00 AM (NAME of R3) was lethargic and refusing oral food and liquids. The physician was contacted, orders obtained to transport to the emergency department for evaluation. (Name of R3's) Mother and guardians were notified at this time. 18. On 5/8/22 (Name of R3) admitted to the hospital for a diagnosis that included, urinary tract infection, positive group A strep throat, oral thrush, and acute-to-subacute subdural hematoma. 19. On 5/8/22 at 5:55 PM, Administrator was notified of R3's subdural hematoma diagnosis. 20. On 5/8/22 at 6:27 PM, NHA reported incident to State Agency. 21. On 5/10/22 (Name of R3) returned to the facility. Resident's mobility and cognitive status are unchanged from previous status. 22. On May 18th, 2022 & May 19th, 2022, staff education was completed on care plans and monitoring for bed cords. 23. On 5/16/22 weekly audits initiated for monitoring of bed cords; transfers related to resident's plan of care. 24. Event referred to QAPI. From 5/31-6/2/22 surveyors reviewed documentation, conducted interviews, and made observations. A determination of past non-compliance was approved and verified by the state agency.

This citation pertains to intakes MI 338, MI 992, MI 417, MI 708, and MI 711: Based on observation, interview and record review, the facility neglected residents by failing to provide care and services for 4 resident's (R4, R6, R7, R8) and residents on the 1 South Unit on 11/23/21, reviewed for being at risk for abuse and neglect, resulting in an Immediate Jeopardy (IJ) that began on 11/23/21, as a result of the facility's failure to provide incontinence care and reposition residents leading to R4 having pain and discomfort, R6 developing an unstageable pressure ulcer, multiple Stage II ulcers, experiencing pain, R8 developing multiple stage II ulcers and experiencing pain, R7 experiencing pain and Residents on 1 South having the potential for skin breakdown and pain. R7 and R6 experienced neglect, pain and delayed care after a lack of thorough investigation into the neglect of R4 and R8 being reported to facility administration. This deficient practice has the high likelihood to affect all residents in this facility potentially resulting in further neglect, harm, serious injury or death. Findings include: According to the facility Abuse, Neglect and Exploitation Policy with a revision date 10/8/2019, read, in part, Abuse: means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical. Mental, and psychosocial well-being, The home will provide ongoing oversight and supervision of staff in order to assure that is (sic) policies are implemented as written, The home will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: . B Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed and certified staff on each shift, Possible Indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse 2. Physical marks such as bruises or patterned appearances such as a hand print, belt or ring mark on a resident's body, 3. Physical injury of a resident, of unknown source, 4. Resident reports of theft of property, or missing property, 5. Verbal abuse of a resident overheard, 6. Physical abuse of a resident observed, 7. Psychological abuse of a resident observed, 8. Failure to provide care needs such as feeding, bathing, dressing, turning, and repositioning, A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedure for investigation include: 1. Identifying staff responsible for the investigation, 2. Exercising caution in handling evidence that could be used in a criminal investigation, 3. Investigation different types of alleged violations, 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation, The home will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation, B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed, C. Increased supervision of the alleged victim and residents, D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator, E. Protection from retaliation, F. Providing emotional support and counseling to the resident during and after the investigation, as needed, and The home will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g law enforcement when applicable) within specified timeframes: a. 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 b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 2. Assuring that reporters are free from retaliation or reprisal .4. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following: a. analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences, b. defining how care provision will be changed and /or improved to protect residents receiving services, c. training of staff on changes made and demonstration of staff competency after training is implanted (sic), d. Identification of staff responsible for implantation (sic) of corrective actions, e. the expected date for implementation, and f. Identification of staff responsible for monitoring the implementation of the plan. R6 Review of R6's face sheet dated 11/23/21 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R 6 was not his own responsible party. On 12/1/21 at 9:20 AM, R6 was observed in bed. He was on his back and the head of bed was elevated 30 to 40 degrees and he was covered with a blanket. Registered Nurses (RN) O and P were in his room attempting to reinsert an IV (Intravenous) line. They reported he had pulled it out this morning and they were not able to get it back in. They said they were contacting another nurse in the facility and if they were not able to get it started, they would send him to the emergency room . R6 was complaining of pain in his buttock at that time. The Surveyor asked R6 if she could look at his buttock with the nurses to see if they could determine the cause of his pain. R6 agreed. R6 yelled out in pain several times with lowing the head of his bed and turning him. When the nurses removed R6's brief it was soiled with bowel movement but not wet. There was no indication he had soiled himself until the brief was pulled back. There was a large white pad/dressing placed over R6's left hip. No date or time was visible on the dressing. When the dressing was removed there was a large area, approximately 4 inches by 2 inches of black tissue with a bright red border. RN O called for a CNA to come into clean R6 up. RN O said she had 3 CNA's on her unit since 6:00 AM and normally had 2 CNA's. RN O the CNAs were L, M, and N. On 12/1/21 at approximately 9:30 AM, CNA M came to R6's room to clean him up. CNA M said she had not seen R6's buttock prior to this time today. RN O started helping CNA M clean up R6 and when CNA N arrived RN O instructed them to finish cleaning him up and off load his buttock on the left. CNA N said she had not seen R6 buttock prior to this time today and confirmed she started at 6:00 AM. Once R6 was cleaned up and new brief was on he was placed on his back and two bed pillows were tucked in between the mattress and his hips. There was a pillow under each hip which placed pressure directly on the large wound on R6's left hip and increased pressure to his right hip. This prevented any rolling or contact of the specialty pressure reliving mattress to the pressure ulcer area. The Surveyor questioned the CNA's as they had just been instructed to off load pressure from R6's left hip. Both CNAs responded the facility had educated them that this was how to off load the buttock. They were not able to recall who educated them or when they were educated. On 12/1/21 at 9:50 AM, RN O was at the nurses station. RN O reviewed R6's wound assessments documented in the electronic medical record (EMR). There was a picture of the wound on R6's left hip that was measured at greater than 9 cm x 4 cm and was covered with eschar (black tissue). The wound was labeled as a stage II ulcer. The Surveyor asked RN O if that was a stage II ulcer and RN O responded no it is unstageable. When questioning how it could be mislabeled RN O explained she had made the error when it changed from a stage II to unstageable. RN O went on to explain when she has days off agency nurses cover for her and they do not know how to run the camera or how to do many of the things that need to be done. When RN O returns to work she has to do the work of 2 nurses due to all of the things that were not completed when she was off. RN O was frustrated about her workload that contributed to her charting error. The Surveyor told RN O that the CNAs had placed pillows under both sides of R6's buttock and had told the Surveyor this is how the facility had educated them to off load resident to prevent pressure ulcers. RN O verified R6's pressure ulcer was not off loaded as she had instructed. RN O called CNA M, N and L to R6's room and instructed/assisted them to remove the pillows and place one pillow under R6's back on the left side above the pressure ulcer. This turned him to his right side and left air space between his left buttock and mattress. RN O had no idea who had trained the CNAs to do pressure relief incorrectly. CNA L said he had not seen R6's buttock that morning. On 12/1/21 at approximately 11:00 AM, after R6 was placed on his right side and his brief was changed, he reported he had no pain. Review of R6's Skin Integrity care plan dated 10/25/21 revealed, I have actual impairment of my skin integrity r/t incontinence, impaired mobility. I am weak and in need of assistance for all ADL's (activities of daily living). I have been noted to be confused at times. I am non ambulatory (cannot walk) and my main source of locomotion in my room and on the unit is my wheelchair. I prefer to sleep in my recliner chair. Review of R6's Pressure Ulcer care plan dated 11/23/21 revealed, I have a pressure ulcer to my L (left) ischial tuberosity (hip). I am receiving ATB (antibiotic) form my wound and I have been referred to the wound clinic for follow up care. No special instructions for pressure relief were located. A power turn mattress was applied to the bed. (Standard of care is to turn, reposition and check for incontinence at least every 2 hours). Observations and interview conducted the morning of 12/1/21 indicated he had gone more that 2 hours with out his brief check for BM. He was not provided pressure relief as instructed by the RN in charge. Per review of R6's electronic medical record, he was sent to the emergency roiagnom on [DATE]. Review of R6's CT scan dated 12/1/21 at 1:50 PM revealed, There is a posterior gluteal fold ulceration with significant induration and [CONDITION(S)] and skin thickening. There is focal induration and fluid collection measuring 9.2 cm x 4.3 cm x 12.5 cm suggestion abscess. Review of R6's emergency room report dated 12/1/21 at 4:25 PM revealed, he had an ulceration along the left gluteal crease with [CONDITION(S)] and large abscess (infection)in the subcutaneous soft tissue extending to the deep fascia (tissue) measuring 12.5 cm. The plan was to do debridement (remove dead and infected tissue) of the wound 12/2/21. Under Number of diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Discussed CT findings of abscess underlying gluteal ulcer and resultant [CONDITION(S)] with surgery. Patient to be admitted for surgical debridement as well as IV Abx (antibiotic's). R8 Review of R 8's face sheet dated 12/1/21, revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was her own responsible party. On 11/23/21 at 10:15 AM, the Surveyor was not able to locate staff working on R8's nursing unit. Registered Nurse (RN) G was at the nurse's station and said she was just getting started on the unit. RN G was not able to locate a staffing list at the nurse's station. RN G went down the hall to the medication cart and was not able to locate a staffing sheet. RN G started going room to room to look for staff. At approximately 10:25 AM Certified Nurse Aide (CNA) I walked out of a resident room. CNA I said she had been the only person working on the unit all morning as CNA J was pulled to go to an appointment and CNA H was pulled to help but CNA H was not familiar with the residents on the unit, so she was not much help. CNA I said CNA H went back to whatever unit she was pulled from. CNA I was asked if she was able to provide any care for R4 that morning and she said she did turn her but did not do a brief check or change. CNA I said R4 ate and she feeds herself. CNA I said the only thing she had time to do was answer call lights. CNA I told RN G she was exhausted and needed to take her lunch. She said she would take her 30-minute lunch in her car so he could sleep. If she did not return in 30 minutes CNA I wanted RN G to send someone to the parking lot to wake her up. CNA I did not indicate she had provided any care for R8 at this time. On 11/23/21 at 10:49 AM, R8's call light was observed to be on. At 10:54 AM, a housekeeper went in R8's room and turned off her call light. The housekeeper reported R8 wanted to get out of bed. At 10:56 AM, R8 turned her call light on again. At 11:06 AM, CNA I went into her room, turned off the call light. CNA I said R8 wanted to get up, but R8 normally did not get out of bed so CNA I went to the computer on the wall to see how to get R 8 out of bed. CNA I said she had not provided any care for R8 that morning. After she checked the computer, she went to another resident's room to answer a call light. A few minutes later CNA B and CNA H went to R8's room and said they had been pulled from other units to do care. CNA B said she started at 6:00 AM on 1 South. CNA B said when she made rounds that morning, she found all of her residents soiled and care had not been provided by night shift. CNA B said night shift is from 6:00 PM to 6:00 AM and most of the staff are agency. CNA B said she reported this neglect to her charge nurse Licensed Practical Nurse (LPN) K and directly to the Director of Nursing (DON). CNA B said this has been an ongoing issue. CNA B said she reports it, but nothing happens. On 11/23/21 at approximately 11:15 AM, the surveyor introduced herself to R8 and asked if she could watch care. R8 agreed to the observation. CNA B and H pulled back R8's blanket and R8 had a shirt and an incontinence brief on. The brief was completely soaked through with urine and bowel movement (BM). As the CNA's turned R8 to provide incontinence care R8 cried out in pain multiple times. R8's soaker pad and sheet were saturated with urine and BM. The wet stain on the sheet went all the way up her back and past her buttock. When the brief was removed R8 had multiple open bloody areas between her legs and at least 10 open bloody areas on her buttock. R8 constantly cried out in pain and the CNAs cleaned her and changed her complete bedding. R8 said the last time she was changed was yesterday morning. R8 said she complains to the nurses about not getting changed but nothing happens. CNA B and H confirmed they have complained to management multiple times about this resident not getting changed and nothing happens. R8's shirt was covered in dry skin and her face had dried crusted material on it. R8 said she could not recall the last time she had a shower but would take one anytime they would give her one. Review of R8's progress noted dated 11/23/21 at 6:25 PM revealed, R8 had multiple small open areas to her right and left ischial tuberosities (buttock bone areas). Physician was notified and R8 declined to have her family notified. A wound dressing was applied for 3 days. Review of R8's incontinence record revealed that on 11/22/21 R 8 was incontinent at 5:38 AM and 1:52 PM. No refusal of incontinent care was recorded on 11/22/21. (R8 only received incontinence care 2 times on 11/22/21 according to her medical record documentation). Review of R8's incontinence record for 11/23/21 revealed she was incontinent at 5:38 AM and again at 11:17 PM. There was no indication of refusal of incontinence care on 11/23/21. There was no record of the incontinence care the Surveyor observed at 11:15 AM. Review of R8's incontinence record from 11/18/21 to 11/23/21 only showed R8 was incontinent between 1 and 4 times a day. R8 refused incontinent care 1 time on 11/18/21, 11/20/21, and 11/22/21. Review of R8's incontinence record for 11/24/21 (2 day after receiving an IJ for lack of incontinence care) R 8 was only recorded to be incontinent 1 time at 7:20 AM. She had no refusals documented. Review of R8's incontinence record from 11/23/21 to 11/30/21 revealed no refusal of incontinence care form 11/24/21 until 11/30/21. Review of R8's progress note dated 11/24/21 at 9:41 PM revealed, Resident not fully herself in this recovery from COVID, still very tired throughout the shift. Reported to this nurse by CNAs that resident very hesitant and refusing most transfers out of her chair due to lethargy. During an interview with R8 on 11/30/21 at 2:04 PM, R8 was awake in bed, well-groomed and smiling. The Surveyor asked her if she had been refusing to let staff turn her or change her brief. R8 said when I am sleeping, and they come in to do care I am get confused sometimes. I know my butt is hurting because I do not get cleaned or turned. I really want them to clean me up and turn me even if I say, No. They have been doing a better job and my butt is getting better. Asked R8 if I could have the DON come talk to her so she could explain what she wanted staff to do, R8 agreed. DON returned with the Surveyor a few minutes later and R8 repeated what she told the Surveyor. The DON said they had just started documenting on paper when people get turned and cleaned. The DON said if they show you the sheet so you can see the last time, they did care would that work. R8 agreed. Review of R8's skin audit dated 11/23/21 no time revealed no skin issues on her buttock. 4 small circles were placed on the picture of the left inner thigh and scattered abrasions was written in with an arrow to the circles. This skin audit did not match the Surveyors observation during care the morning of 11/23/21 or the progress note dated 11/23/21 at 6:25 PM. The facility provided skin audits as part of the IJ removal. The DON was informed R8's skin audit done for the IJ removal did not match observations on 11/23/21 or 11/30/21. The DON was asked to address the accuracy of skin audits and documentation. Upon exit on 12/3/21 the DON did not provide any updated audits or information on correcting audits that had been completed. R4 Review of R4's face sheet dated 11/23/21 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 was her own responsible party. On 11/23/21 at 10:11 AM, R4 was observed sleeping in bed and on turned to her right side. R4's catheter bag was on the floor on the left side of her bed. The catheter tubing and bag had a dark blue color. R4 did not respond when her name was called. There was a medication cart in the hall, but no staff were located on the hall. On 11/23/21 at 10:15 AM, the Surveyor was not able to locate staff working on R4's nursing unit. Registered Nurse (RN) G was at the nurse's station and said she was just getting started on the unit. RN G was not able to locate a staffing list at the nurse's station. RN G went down the hall to the medication cart and was not able to locate a staffing sheet. RN G started going room to room to look for staff. At approximately 10:25 AM Certified Nurse Aide (CNA) I walked out of a resident room. CNA I said she had been the only person working on the unit all morning as CNA J was pulled to go to an appointment and CNA H was pulled to help but CNA H was not familiar with the residents on the unit, so she was not much help. CNA I said CNA H went back to whatever unit she was pulled from. CNA I was asked if she was able to provide any care for R4 that morning and she said she did turn her but did not do a brief check or change. CNA I said R4 ate and she feeds herself. CNA I said the only thing she had time to do was answer call lights. CNA I told RN G she was exhausted and needed to take her lunch. She said she would take her 30-minute lunch in her car so he could sleep. If she did not return in 30 minutes CNA I wanted RN G to send someone to the parking lot to wake her up. On 11/23/21 at 10:46 AM, R4 was observed in bed sleeping on her right side with a pillow under her left chest area and her catheter bag remained on the floor. On 11/23/21 at 11:24 AM, R4 was observed in bed and CNA I and J had just started care. R4 was on her right side and the CNAs were just starting to remove R4's brief. R4's brief and sheet were soiled with BM (bowel movement). R4 said she had not been changed since yesterday. CNA I and J confirmed they had started work at 6:00 AM today and this was the first time they had time to change her brief. CNA J said she was pulled at 7:30 AM to help a resident going out on an appointment. CNA I again said she was the only one providing care for all the residents on this hall when CNA J was pulled to assist a resident going out to an appointment. CNA I was not able to recall what time it was when she turned R4 on her right side. R4's entire right side was bright red. R4 said she reports not being changed and turned to the nurses but nothing every gets done. CNA I and J confirmed R4 frequently makes these complaints about night shift and they also report these concerns to management, but nothing gets done. Review of R4's ADL/MOBILITY/Toileting care plan dated initiated 7/22/21 and revised on 11/30/21 revealed. As of 7/22/21 R 4 required assistance extensive assistance of 2 people for bed mobility. Toileting schedule as of 2/3/20 was to offer and encourage bed pan and check and change every 2 hours. Toileting assistance was not offered the morning of 11/23/21 from 6:00 AM until 11:24 AM when she was found to be incontinent of bowel. R4 was observed in bed and awake on 11/30/21 at 10:15 AM, R4 reported staff were getting better at turning her and changing her brief, however nights was still the main problem. R4 said her brief had not been checked or changed yet this morning and she was agreeable to the Surveyor asking the CNA to check her brief. CNA Q came in a checked her brief. CNA did not have anyone assist her turn R4 or assist with removing her brief. When CNA Q pulled back R4's brief she found R 4 had a large solid BM. R4 said she did not know she had a BM as she has Multiple [CONDITION(S)] and cannot feel when she has a BM. R4 has a Foley catheter so the strip on the brief does not change colors to show it is soiled unless the BM is loose. CNA Q admitted she did not pull back R4's brief to check it when she turned her earlier. CNA Q and the Surveyor had N95 masks on and could not smell the BM. The Surveyor asked CNA Q if R4 was a one assist for turning and brief change or two and CNA Q said she did not know as she had only cared for her once or twice prior to today. On 11/30/21 at 10:45 AM, the Surveyor told the DON that CNA Q did not visually check R4 for a BM this morning and R4 had a BM noted at 10:15 AM. CNA Q turned R4 and removed her brief without assistance. R4 still reported night staff were not consistently checking her brief and turning her. The DON checked R4's care plan and said she was a two assist with turning and brief change. The DON said she would educate CNA Q. The DON provided an Employee Discipline Form for CNA Q dated 11/30/21 that revealed, On 11/30/21 upon arriving for shift staff member was educated on ensuring residents care plans are followed to ensure residents care needs are met timely as well as ensuring residents are turned/repositioned and toileted/checked and changed for incontinence every two hours. Staff member stated understanding and acknowledged that she needed to turn/reposition and toilet/check and change resident at a minimum of every 2 hours. Staff member stated that she did not know what resident's care level was for bed mobility but did not proceed to finding out prior to providing care with x1 assist. Resident is care planned for assist x 2 for bed mobility. Staff member stated she knew how to check residents care levels by viewing the Kardex in PCC (electronic medical record). The box for verbal counseling was marked. On 11/23/21 at approximately 12:45 PM, the Surveyor asked the Director of Nursing (DON) if CNA B had reported to her this morning that the residents on 1 South were left soiled and did not get care last night. The DON said CNA B had reported that to her. The Surveyor asked if the DON if she had started the facility reported incident (FRI) the DON said, no. The Surveyor said to the DON, a CNA reported to you this morning residents on 1 South were left soiled and did not get care this morning, which is goods and services not provided. The DON said, yes. The Surveyor asked why she had not started the FRI and the DON said she decides if something in neglect and she had not determined that was neglect. The surveyor said she had observed the care of R4 and R8 on 1 North that morning. R8 was so soiled that it went through her brief, soaker pad and sheet. R8's thighs and buttock's had bloody sores from being left soiled so long and the Surveyors eyes were still burning from the urea in the room. The Surveyor could smell the BM through her N95 mask it was so strong. R8 reported she had not been changed since yesterday. R4 was also observed to be soiled and in pain. R4 also reported she had not been changed since yesterday. The DON did not have any other comments or questions. The DON did not take any notes and did not appear concerned. On 11/23/21 at approximately 12:50 PM, the Surveyor went to the Nursing Home Administrator's (NHA) office and reported all the same information to NHA that she had just provided to the DON. The NHA took a few notes, appeared very concerned and said she would take care of it. The NHA offered no explanation as to why the DON would not have started FRI process at 6:00 AM when she received the first allegation of neglect. The NHA did not provide any additional information until 4:17 PM when the facility was served and Immediate Jeopardy (IJ) for neglect. The NHA said we interviewed the Residents and none of them said they were neglected. They Surveyor referred to the information in the IJ notification that provided R4 and R8's condition that was observed and reported to her around 12:50 PM by the Surveyor, Resident and Staff statements on neglect and the facility failure to act on these complaints. The NHA offered no additional information. The facility did start a FRI related to R4 and R8's concerns that were provided to the DON and NHA on 11/23/21. The facility did not do an FRI on CNA B allegation of the neglect of Residents on 1 South that she reported around 6:00 AM on 11/23/21. The FRI reports did not include the Surveyors report of R4 and R8's physical condition, complaints of care or staff interviews conducted by the Surveyor. The investigation did not include incontinence care records or Resident progress notes or skin evaluations. The facility did not complete a thorough investigation, and it did not determine neglect had occurred for R4 or R8. R 7 Review of R7's face sheet and electronic medical record revealed she admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R7's care plan revealed under COGNITION: My cognition at times does fluctuate. Due to my diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Under the section ADL/BOWEL/BLADDER/MOBILITY interventions include: toileting to be completed at 2:30 a.m., 4:40 a.m., and upon request throughout the rest if the day. For toilet use, R7 was noted as needing the extensive assistance of 1-2 staff. Under the focus area of FALLS R7 had an intervention of 15 minute checks . and anticipate and meet my needs. Under the focus area of PAIN interventions include: Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. On 11/24/21 at approximately 1:35 AM, while walking past R7's room, R7 could be heard moaning and a strong odor of feces was detected from the doorway. An interview was completed with R7, who was grimacing and squirming in her bed. R7 stated it hurts where I poop, please help. R7 was asked if she was wet or soiled and she stated that she had a bowel movement and can't remember when I was last helped, please get someone it hurts so bad down there. CNA (Certified Nursing Assistant) D was found in the hall and she was informed R7 stated she was in pain in her peri area, was soiled with feces and needed incontinence care. CNA D stated I just changed her at 1:10 PM and she had a BM (bowel movement). R7's room was entered with CNA D, the room had a strong smell of feces. CNA D asked the resident if she needed pain cream for her bottom and the R7 stated yes. CNA D did not ask if the resident needed incontinence care or check R7's brief despite there being a strong scent of feces in the room and being told by the surveyor that R7 was soiled, before exiting the room to get the nurse for pain cream. After CNA D left the room, R7 continued to grimace and discuss how much pain she was in and that she needed to be changed. Nurse F entered the room a few minutes later with a pain cream and turned R7 to apply the cream, when R7 was turned, it was observed she was soiled with feces that had soaked through her brief and to the bed pad. Nurse F informed R7 that she would need to find the aide to come back to assist R7 to be cleaned up. At approximately 1:50 AM, CNA D and CNA E entered the room to begin incontinence care for R7. On 11/23/21 at 4:17 PM, the NHA was informed of an Immediate (IJ) related to F 600 that began on 11/23/21 when the facility failed to recognize allegations of neglect when staff and residents reported on more than one occasion to management that residents were being left soiled for extended time periods, specifically on night shift. On 11/23/21 R4 and R8 stated they had previously reported being soaked for long periods of time on more than one occasion. On 11/23/21, CNA B reported when she comes in to complete cares on day shift she often finds residents soiled and lacking care from night shift. CNA B stated she has reported this to management on more than one occasion. On 11/23/21 the DON confirmed she received the reports of lack of care and did not determine it was neglectful. The identified risk of serious injury, serious harm, serious impairment or death was evidenced by: On 11/23/21 at 11:14 AM, R8 was observed to have bleeding of the buttocks on multiple areas, the entire buttocks were red and discolored.

This citation pertains to intakes MI 992: Based on observations, interviews and record review, the Nursing Home Administrator and Director of Nursing failed to administer facility resources to effectively attain and maintain residents highest practical physical, mental and psychosocial well-being, resulting in residents experiencing pain and frustration when they were left soiled for extended periods of time, neglect when they were not provided care, and pressure ulcers. Findings include: According to CMS 2567 form dated 8/6/2021 the facility had deficient practices cited at an immediate jeopardy level for abuse and neglect. The facility also had deficient practices cited at a harm level for reporting and investigating abuse and neglect, pressure ulcer treatment and prevention, care plan development and implementation, and their quality assurance program. Sufficient staffing was also cited for deficient practice. During this abbreviated survey ending 12/3/2021, the facility was again issued an immediate jeopardy notice for abuse and neglect. Deficient practices were also found for reporting and investigating abuse and neglect, pressure ulcer treatment and prevention, care plan development and implementation, and staffing. During an interview with the NHA (Nursing Home Administrator) on 12/2/21 at approximately 11:30 AM, the QAPI (Quality Assurance Performance Improvement) program was discussed. The NHA stated since the annual survey in August, the QAPI team has been meeting every other week and they are still completing audits on previously cited areas. The NHA stated they are still monitoring and identifying concerns with wound care as well as staffing. The NHA stated they had only been focusing on abuse concerns and had not identified any issues with neglect. The NHA stated they do regular resident rounds asking about abuse and neglect but admitted they may not be asking the right questions. The NHA stated staff had not come to her directly with neglect concerns, and it was discussed that staff bringing neglect concerns to unit managers and the director of nursing should have been sufficient to initiate the investigation and reporting to the state agency of those concerns. The NHA was reminded the investigation and report of abuse and neglect was also previously cited on the annual survey. Review of facility policy: Quality Assessment and Assurance Committee with last revised date of 5/17/21 revealed a policy: to maintain a Quality Assessment and Assurance (QAA) Committee to identify quality issues and develop appropriate plans of action to correct quality deficiencies through an interdisciplinary approach. The committee will .identify and respond to quality deficiencies . and develop and implement corrective plans of action and monitor to ensure performance goals or targets are achieved and sustained. Review of facility policy: Quality Assurance and Performance Improvement (QAPI) Procedure with a last revised date of 5/17/21 revealed an objective: Key components of this process include, but are not limited to, the following: tracking and measuring performance; establishing goals and thresholds for performance improvements; identifying and prioritizing quality deficiencies; systemically analyzing underlying causes of systemic quality deficiencies; developing and implementing corrective action or performance improvement activities; and monitoring and evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. On 11/23/21 at approximately 12:45 PM, the Surveyor asked the Director of Nursing (DON) if CNA B had reported to her this morning that the residents on 1 South were left soiled and did not get care last night. The DON said CNA B had reported that to her. The Surveyor asked if the DON if she had started the facility reported incident (FRI) the DON said, no. The Surveyor said to the DON, a CNA reported to you this morning residents on 1 South were left soiled and did not get care this morning, which is goods and services not provided. The DON said, yes. The Surveyor asked why she had not started the FRI and the DON said she decides if something in neglect and she had not determined that was neglect. The surveyor said she had observed the care of R4 and R8 on 1 North that morning. R8 was so soiled that it went through her brief, soaker pad and sheet. R8's thighs and buttock's had bloody sores from being left soiled so long and the Surveyors eyes were still burning from the urea in the room. The Surveyor could smell the BM through her N95 mask it was so strong. R8 reported she had not been changed since yesterday. R4 was also observed to be soiled and in pain. R4 also reported she had not been changed since yesterday. The DON did not have any other comments or questions. The DON did not take any notes and did not appear concerned. On 11/23/21 at approximately 12:50 PM, the Surveyor went to the Nursing Home Administrator's (NHA) office and reported all the same information to NHA that she had just provided to the DON. The NHA took a few notes, appeared very concerned and said she would take care of it. The NHA offered no explanation as to why the DON would not have started FRI process at 6:00 AM when she received the first allegation of neglect. The NHA did not provide any additional information until 4:17 PM when the facility was served and Immediate Jeopardy (IJ) for neglect. The NHA said we interviewed the Residents and none of them said they were neglected. They Surveyor referred to the information in the IJ notification that provided R 4 and R 8 condition that was observed and reported to her around 12:50 PM by the Surveyor, Resident and Staff statements on neglect and the facility failure to act on these complaints. The NHA offered no additional information. The facility did start a FRI related to R4 and R8's concerns that were provided to the DON and NHA on 11/23/21. The facility did not do an FRI on CNA B allegation of the neglect of Residents on 1 South that she reported around 6:00 AM on 11/23/21. The FRI reports did not include the Surveyors report of R4 and R8's physical condition, complaints of care or staff interviews conducted by the Surveyor. The investigation did not include incontinence care records or Resident progress notes or skin evaluations. The facility did not complete a thorough investigation, and it did not determine neglect had occurred for R4 or R8. On 11/23/21 at 4:17 PM. the NHA was informed of an Immediate (IJ) related to F 600 that began on 11/23/21 when the facility failed to respond to the allegation that Residents on 1 South had not received incontinence care on the night shift and R 4 and R 8 made allegation of neglect. The Surveyor provided details of the condition R4 and R8 when they received care the morning of 11/23/21 and reported lack of staff to provide adequate care for Residents on 1 North. The NHA was provided this information verbally and in writing in the IJ notification.

This citation pertains to intakes MI 992: Based on interview and record review, the facility failed to identify and implement appropriate plans of action to correct quality deficiencies necessary to assure residents attained and maintained the highest practicable level of well-being, resulting in the potential for serious negative physical and psychosocial outcomes for all residents that resided at the facility. Findings include: According to CMS 2567 forms dated 8/6/2021 the facility had deficient practices cited at an immediate jeopardy level for abuse and neglect. The facility also had deficient practices cited at a harm level for reporting and investigating abuse and neglect, pressure ulcer treatment and prevention, care plan development and implementation, and their quality assurance program. Sufficient staffing was also cited for deficient practice. During this abbreviated survey ending 12/3/2021, the facility was again issued an immediate jeopardy notice for abuse and neglect. Deficient practices were also found for reporting and investigating abuse and neglect, pressure ulcer treatment and prevention, care plan development and implementation, and staffing. During an interview with the NHA (Nursing Home Administrator) on 12/2/21 at approximately 11:30 AM, the QAPI (Quality Assurance Performance Improvement) program was discussed. The NHA stated since the annual survey in August, the QAPI team has been meeting every other week and they are still completing audits on previously cited areas. The NHA stated they are still monitoring and identifying concerns with wound care as well as staffing. The NHA stated they had only been focusing on abuse concerns and had not identified any issues with neglect. The NHA stated they do regular resident rounds asking about abuse and neglect but admitted they may not be asking the right questions. The NHA stated staff had not come to her directly with neglect concerns, and it was discussed that staff bringing neglect concerns to unit managers and the director of nursing should have been sufficient to initiate the investigation and reporting to the state agency of those concerns. The NHA was reminded the investigation and report of abuse and neglect was also previously cited on the annual survey. Review of facility policy: Quality Assessment and Assurance Committee with last revised date of 5/17/21 revealed a policy: to maintain a Quality Assessment and Assurance (QAA) Committee to identify quality issues and develop appropriate plans of action to correct quality deficiencies through an interdisciplinary approach. The committee will .identify and respond to quality deficiencies . and develop and implement corrective plans of action and monitor to ensure performance goals or targets are achieved and sustained. Review of facility policy: Quality Assurance and Performance Improvement (QAPI) Procedure with a last revised date of 5/17/21 revealed an objective: Key components of this process include, but are not limited to, the following: tracking and measuring performance; establishing goals and thresholds for performance improvements; identifying and prioritizing quality deficiencies; systemically analyzing underlying causes of systemic quality deficiencies; developing and implementing corrective action or performance improvement activities; and monitoring and evaluating the effectiveness of corrective action/performance improvement activities and revising as needed.

This citation pertains to intakes MI 224, MI 338, MI 992, MI 417, MI 708, and MI 711: Based on observation, interview and record review the facility failed to report or report timely allegations of abuse and neglect for 4 Resident's (R1,R4, R6, R8) and Residents on the 1 South Unit on 11/23/21, reviewed for being at risk for abuse, as a result of the facility's failure to provide incontinence care and reposition Residents leading to R4 having pain and discomfort, R6 developing an unstageable pressure ulcer, multiple Stage II ulcers, experiencing pain, R8 developing multiple stage II ulcers and experience pain, and Residents on 1 South having the potential for skin breakdown and pain. R1's injury of unknown origin was not reported timely. This deficient practice can lead to ongoing abuse and neglect. Findings include: According to the facility Abuse, Neglect and Exploitation Policy with a revision date 10/8/2019, read, in part, Abuse: means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical. Mental, and psychosocial well-being, The home will provide ongoing oversight and supervision of staff in order to assure that is (sic) policies are implemented as written, The home will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: . B Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed and certified staff on each shift, Possible Indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse 2. Physical marks such as bruises or patterned appearances such as a hand print, belt or ring mark on a resident's body, 3. Physical injury of a resident, of unknown source, 4. Resident reports of theft of property, or missing property, 5. Verbal abuse of a resident overheard, 6. Physical abuse of a resident observed, 7. Psychological abuse of a resident observed, 8. Failure to provide care needs such as feeding, bathing, dressing, turning, and repositioning, A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedure for investigation include: 1. Identifying staff responsible for the investigation, 2. Exercising caution in handling evidence that could be used in a criminal investigation, 3. Investigation different types of alleged violations, 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation, The home will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation, B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed, C. Increased supervision of the alleged victim and residents, D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator, E. Protection from retaliation, F. Providing emotional support and counseling to the resident during and after the investigation, as needed, and The home will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g law enforcement when applicable) within specified timeframes: a. 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 b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 2. Assuring that reporters are free from retaliation or reprisal .4. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following: a. analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences, b. defining how care provision will be changed and /or improved to protect residents receiving services, c. training of staff on changes made and demonstration of staff competency after training is implanted (sic), d. Identification of staff responsible for implantation (sic) of corrective actions, e. the expected date for implementation, and f. Identification of staff responsible for monitoring the implementation of the plan. R 6 Review of R 6's face sheet dated 11/23/21 revealed he was a [AGE] year-old male admitted to the facility on 8/1/2019 and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R 6 was not his own responsible party. On 12/1/21 at 9:20 AM R 6 was observed in bed. He was on his back and the head of bed was elevated 30 to 40 degrees and he was covered with a blanket. Registered Nurses (RN) O and P (were in his room attempting to reinsert an IV (Intravenous) line. They reported he had pulled it out this morning and they were not able to get it back in. They said they were contacting another nurse in the facility and if they were not able to get it started, they would send him to the emergency room . R 6 was complaining of pain in his buttock at that time. The Surveyor asked R 6 if she could look at his buttock with the nurses to see if they could determine the cause of his pain. R 6 agreed. R 6 yelled out in pain several times with lowing the head of his bed and turning him. When the nurses removed R 6 brief it was soiled with BM but not wet. There was no indication he had soiled himself until the brief was pulled back. There was a large white pad/dressing placed over R 6's left hip. No date or time was visible on the dressing. When the dressing was removed there was a large area, approximately 4 inches by 2 inches of black tissue with a bright red boarder. RN O called for a CNA to come into clean R 6 up. RN O said she had 3 CNA's on her unit since 6:00 AM and normally had 2 CNA's. RN O the CNAs were L, M, and N. On 12/1/21 at approximately 9:30 AM CNA M came to R 6' room to clean him up. CNA M said she had not seen R 6's buttock prior to this time today. RN O started helping CNA M clean up R6 and when CNA N arrived RN O instructed them to finish cleaning him up and of load his buttock on the left. CNA N said she had not seen R 6 buttock prior to this time today and confirmed she started at 6:00 AM. Once R 6 was cleaned up and new brief on he was placed on his back and two bed pillows were tucked in between the mattress and his hips. There was a pillow under each hip which placed pressure directly on the large wound on R 6's left hip and increased pressure to his right hip. This prevented any rolling or contact of the specialty pressure reliving mattress to the pressure ulcer area. The Surveyor questioned the CNA's as they had just been instructed to off load pressure from R 6's left hip. Both CNAs responded the facility had educated them that this was how to off load the buttock. They were not able to recall who educated them or when they were educated. On 12/1/21 at 9:50 AM RN O was at the nurses station. RN O reviewed R 6's wound assessments documented in the electronic medical record (EMR). There was a picture of the wound on R 6's left hip that was measure at greater than 9 cm x 4 cm and was covered with eschar (black tissue). The wound was labeled as a stage II ulcer. The Surveyor asked RN O if that was a stage II ulcer and RN O responded no it is unstageable. When questioning how it could be miss labeled RN O explained she had made the error when it changed from a stage II to unstageable. RN O went on to explain when she has days off agency nurses cover for her and they do not know how to run the camera or how to do many of the things that need to be done. When RN O returns to work she has to do the work of 2 nurses due to all of the things that were not completed when she was off. RN O was frustrated about her workload that contributed to her charting error. The Surveyor told RN O that the CNAs had placed pillows under both sides of R 6's buttock and had told the Surveyor this is how the facility had educated them to off load resident to prevent pressure ulcers. RN O verified R 6's pressure ulcer was not off load as she had instructed. RN O called CNA M, N and L to R 6's room and instructed/assisted them to remove the pillows and place one pillow under R 6's back on the left side above the pressure ulcer. This turned him to his right side and left air space between his left buttock and mattress. RN O had no idea who had trained the CNAs to do pressure relief incorrectly. CNA L said he had not seen R 6's buttock that morning. On 12/1/21 at approximately 11:00 AM, after R 6 was placed on his right side and his brief was changed, he reported he had no pain. Review of R 6's Skin Integrity care plan dated 10/25/21 revealed, I have actual impairment of my skin integrity r/t incontinence, impaired mobility. I am weak and in need of assistance for all ADL's (activities of daily living). I have been noted to be confused at times. I am non ambulatory (cannot walk) and my main source of locomotion in my room and on the unit is my wheelchair. I prefer to sleep in my recliner chair. Review of R 6's Pressure Ulcer care plan dated 11/23/21 revealed, I have a pressure ulcer to my L (left) ischial tuberosity (hip). I am receiving ATB (antibiotic) form my wound and I have been referred to the wound clinic for follow up care. No special instructions for pressure relief were located. A power turn mattress was applied to the bed. (Standard of care is to turn, reposition and check for incontinence at least every 2 hours). Observations and interview conducted the morning of 12/1/21 indicated he had gone more that 2 hours with out his brief check for BM. He was not provided pressure relief as instructed by the RN in charge. Review of R 6's CT scan dated 12/1/21 at 1:50 PM revealed, There is a posterior gluteal fold ulceration with significant induration and [CONDITION(S)] and skin thickening. There is focal induration and fluid collection measuring 9.2 cm x 4.3 cm x 12.5 cm suggestion abscess. Review of R 6's emergency room report dated 12/1/21 at 4:25 PM revealed, he had an ulceration along the left gluteal crease with [CONDITION(S)] and large abscess (infection)in the subcutaneous soft tissue extending to the deep fascia (tissue) measuring 12.5 cm. The plan was to do debridement (remove dead and infected tissue) of the wound 12/2/21. Under Number of diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Discussed CT findings of abscess underlying gluteal ulcer and resultant [CONDITION(S)] with surgery. Patient to be admitted for surgical debridement as well as IV Abx (antibiotic's). R 8 Review of R 8's face sheet dated 12/1/21, revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was her own responsible party. On 11/23/21 at 10:15 AM the Surveyor was not able to locate staff working on R 8's nursing unit. Registered Nurse (RN) G was at the nurse's station and said she was just getting started on the unit. RN G was not able to locate a staffing list at the nurse's station. RN G went down the hall to the medication cart and was not able to locate a staffing sheet. RN G started going room to room to look for staff. At approximately 10:25 AM Certified Nurse Aide (CNA) I walked out of a resident room. CNA I said she had been the only person working on the unit all morning as CNA J was pulled to go to an appointment and CNA H was pulled to help but CNA H was not familiar with the residents on the unit, so she was not much help. CNA I said CNA H went back to whatever unit she was pulled from. CNA I was asked if she was able to provide any care for R 4 that morning and she said she did turn her but did not do a brief check or change. CNA I said R 4 ate and she feeds herself. CNA I said the only thing she had time to do was answer call lights. CNA I told RN G she was exhausted and needed to take her lunch. She said she would take her 30-minute lunch in her car so he could sleep. If she did not return in 30 minutes CNA I wanted RN G to send someone to the parking lot to wake her up. CNA I did not indicate she had provided any care for R 8 at this time. On 11/23/21 at 10:49 AM, R 8's call light was observed to be on. At 10:54 AM a housekeeper went in R 8's room and turned off her call light. The housekeeper reported R 8 wanted to get out of bed. At 10:56 AM R 8 turned her call light on again. At 11:06 AM, CNA I went into her room, turned off the call light. CNA I said R 8 wanted to get up, but she normally did not so CNA I went to the computer on the wall to see how to get R 8 out of bed. CNA I said she had not provided any care for R 8 that morning. After she check the computer, she went to another resident's room to answer a call light. A few minutes later CNA B and CNA H went to R 8's room and said they had been pulled from other units to do care. CNA B said she started at 6:00 AM on 1 South. CNA B said when she made rounds that morning, she found all of her residents soiled and care had not been provided by night shift. CNA B said night shift is from 6:00 PM to 6:00 AM and most of the staff are agency. CNA B said she reported this neglect to her charge nurse Licensed Practical Nurse (LPN) K and directly to the Director of Nursing (DON). CNA B said this has been an ongoing issue. CNA B said she reports it, but nothing happens. On 11/23/21 at approximately 11:15 AM the surveyor introduced herself to R 8 and asked if she could watch care. R 8 agreed to the observation. CNA B and H pulled back R 8's blanket and R 8 had a shirt and an incontinence brief on. The brief was completely soak through with urine and bowel movement (BM). As the CNA's turned R 8 to provide incontinence care R 8 cried out in pain multiple times. R 8's soaker pad and sheet were saturated with urine and BM. The wet stain on the sheet went all the way up her back and past her buttock. When the brief was removed R 8 had multiple open bloody areas between her legs and at least 10 open bloody areas on her buttock. R 8 constantly cried out in pain and the CNA's cleaned her and changed her complete bedding. R 8 said the last time she was changed was yesterday morning. R 8 said she complains to the nurses about not getting changed but nothing happens. CNA B and H confirmed they have complained to management multiple times about this resident not getting changed and nothing happens. R 8's shirt was covered in dry skin and her face had dried crusted material on it. R 8 said she could not recall the last time she had a shower but would take on anytime they would give her one. On 11/23/21 at approximately 12:45 PM the Surveyor asked the Director of Nursing (DON) if CNA B had reported to her this morning that the residents on 1 South were left soiled and did not get care last night. The DON said CNA B had reported that to her. The Surveyor asked if the DON if she had started the facility reported incident (FRI) the DON said, no. The Surveyor said to the DON, a CNA reported to you this morning residents on 1 South were left soiled and did not get care this morning, which is goods and services were not provided. The DON said, yes. The Surveyor asked why she had not started the FRI and the DON said she decides if something in neglect and she had not determined that was neglect. The surveyor said she had observed the care of R 4 and R 8 on 1 North that morning. R 8 was so soiled that it went through her brief, soaker pad and sheet. R 8's thighs and buttock's had bloody sores from being left soiled so long and the Surveyors eyes were still burning from the urea in the room. The Surveyor could smell the BM through her N95 mask it was so strong. R 8 reported she had not been changed since yesterday. R 4 was also observed to be soiled and in pain. R 4 also reported she had not been changed since yesterday. The DON did not have any other comments or questions. The DON did not take any notes and did not appear concerned. On 11/23/21 at approximately 12:50 PM, the Surveyor went to the Nursing Home Administrator's (NHA) office and reported all the same information to NHA that she had just provided to the DON. The NHA took a few notes, appeared very concerned and said she would take care of it. The NHA offered no explanation as to why the DON would not have started FRI process at 6:00 AM when she received the first allegation of neglect. The NHA did not provide any additional information until 4:17 PM when the facility was served and Immediate Jeopardy (IJ) for neglect. The NHA said we interviewed the Residents and none of them said they were neglected. They Surveyor referred to the information in the IJ notification that provided R 4 and R 8 condition that was observed and reported to her around 12:50 PM by the Surveyor, Resident and Staff statements on neglect and the facility failure to act on these complaints the NHA offered no addition information. The facility did start a FRI related to R 4 and R 8's concerns that were provided to the DON and NHA on 11/23/21. The facility did not do an FRI on CNA B allegation of the neglect of Residents on 1 South that she reported around 6:00 AM on 11/23/21. The FRI reports did not include the Surveyors report of R 4 and R 8's physical condition, complaints of care or staff interviews conducted by the Surveyor. The investigation did not include incontinence care records or Resident progress notes or skin evaluations. The facility did not complete a thorough investigation, and it did determine neglect had occurred for R 4 or R 8. Review of R 8's progress noted dated 11/23/21 at 6:25 PM revealed, R 8 had multiple small open areas to her right and left ischial tuberosities (buttock bone areas). Physician was notified and R 8 declined to have her family notified. A wound dressing was applied for 3 days. Review of R 8's incontinence record revealed that on 11/22/21 R 8 was incontinent at 5:38 AM and 1:52 PM. No refusal of incontinent care was recorded on 11/22/21. (R 8 only received incontinence care 2 times on 11/22/21 according to her medical record documentation). Review of R 8's incontinence record for 11/23/21 revealed she was incontinent at 5:38 AM and again at 11:17 PM. There was no indication of refusal of incontinence care on 11/23/21. There was no record of the incontinence care the Surveyor observed at 11:15 AM. Review of R 8's incontinence record from 11/18/21 to 11/23/21 only showed R 8 was incontinent between 1 and 4 times a day. R 8 refused incontinent care 1 time on 11/18/21, 11/20/21, and 11/22/21. Review of R 8's incontinence record for 11/24/21 (2 day after receiving an IJ for lack of incontinence care) R 8 was only recorded to be incontinent 1 time at 7:20 AM. She had no refusals documented. Review of R 8's incontinence record from 11/23/21 to 11/30/21 revealed no refusal of incontinence care form 11/24/21 until 11/30/21. Review of R 8's progress note dated 11/24/21 at 9:41 PM revealed, Resident not fully herself in this recovery from COVID, still very tired throughout the shift. Reported to this nurse by CNAs that resident very hesitant and refusing most transfers out of her chair due to lethargy. During an interview with R 8 on 11/30/21 at 2:04 PM, R 8 was awake in bed, well-groomed and smiling. The Surveyor asked her if she had been refusing to let staff turn her or change her brief. R 8 said when I am sleeping, and they come in to do care I am get confused sometimes. I know my butt is hurting because I do not get cleaned or turned. I really want them to clean me up and turn me even if I say, No. They have been doing a better job and my butt is getting better. Asked R 8 if I could have the DON come talk to her so she could explain what she wanted staff to do, R 8 agreed. DON returned with the Surveyor a few minutes later and R 8 repeated what she told the Surveyor. The DON said they had just started documenting on paper when people get turned and cleaned. The DON said if they show you the sheet so you can see the last time, they did care would that work. R 8 agreed. Review of R 8's skin audit dated 11/23/21 no time revealed no skin issues on her buttock. 4 small circles were placed on the picture of the left inner thigh and scattered abrasions was written in with an arrow to the circles. This skin audit did not match the Surveyors observation during care the morning of 11/23/21 or the progress note dated 11/23/21 at 6:25 PM. The facility provided skin audits as part of the IJ removal. The DON was informed R 8's skin audit done for the IJ removal did not match observations on 11/23/21 or 11/30/21. The DON was asked to address the accuracy of skin audits and documentation. Upon exit on 12/3/21 the DON did not provide any updated audits or information on correcting audits that had been completed. R 4 Review of R 4's face sheet dated 11/23/21 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R 4 was her own responsible party. On 11/23/21 at 10:11 AM R 4 was observed sleeping in bed and on turned to her right side. R 4's catheter bag was on the floor on the left side of her bed. The catheter tubing and bag had a dark blue color. R 4 did not respond when her name was called. There was a medication cart in the hall, but no staff were located on the hall. On 11/23/21 at 10:15 AM the Surveyor was not able to locate staff working on R 4's nursing unit. Registered Nurse (RN) G was at the nurse's station and said she was just getting started on the unit. RN G was not able to locate a staffing list at the nurse's station. RN G went down the hall to the medication cart and was not able to locate a staffing sheet. RN G started going room to room to look for staff. At approximately 10:25 AM Certified Nurse Aide (CNA) I walked out of a resident room. CNA I said she had been the only person working on the unit all morning as CNA J was pulled to go to an appointment and CNA H was pulled to help but CNA H was not familiar with the residents on the unit, so she was not much help. CNA I said CNA H went back to whatever unit she was pulled from. CNA I was asked if she was able to provide any care for R 4 that morning and she said she did turn her but did not do a brief check or change. CNA I said R 4 ate and she feeds herself. CNA I said the only thing she had time to do was answer call lights. CNA I told RN G she was exhausted and needed to take her lunch. She said she would take her 30-minute lunch in her car so he could sleep. If she did not return in 30 minutes CNA I wanted RN G to send someone to the parking lot to wake her up. On 11/23/21 at 10:46 AM, R 4 was observed in bed sleeping on her right side with a pillow under her left chest area and her catheter bag remained on the floor. On 11/23/21 at 11:24 AM R 4 was observed in bed and CNA I and J had just started care. R 4 was on her right side and the CNAs were just starting to remove R 4's brief. R 4's brief and sheet were soiled with BM. R 4 said she had not been changed since yesterday. CNA I and J confirmed they had started work at 6:00 AM today and this was the first time they had time to change her brief. CNA J said she was pulled at 7:30 AM to help a resident going out on an appointment. CNA I again said she was the only one providing care for all the residents on this hall when CNA J was pulled to assist a resident going out to an appointment. CNA I was not able to recall what time it was when she turned R 4 on her right side. R 4's entire right side was bright red. R 4 said she reports not being changed and turned to the nurses but nothing every gets done. CNA I and J confirmed R 4 frequently makes these complaints about night shift and they also report these concerns to management, but nothing gets done. Review of R 4's ADL/MOBILITY/Toileting care plan dated initiated 7/22/21 and revised on 11/30/21 revealed. As of 7/22/21 R 4 required assistance extensive assistance of 2 people for bed mobility. Toileting schedule as of 2/3/20 was to offer and encourage bed pan and check and change every 2 hours. Toileting assistance was not offered the morning of 11/23/21 from 6:00 AM until 11:24 AM when she was found to be incontinent of bowel. R 4 was observed in bed and awake on 11/30/21 at 10:15 AM, R 4 reported staff were getting better at turning her and changing her brief, however nights was still the main problem. R 4 said her brief had not been checked or changed yet this morning and she was agreeable to the Surveyor asking the CNA to check her brief. CNA Q came in a checked her brief. CNA did not have anyone assist her turn R 4 or assist with removing her brief. When CNA Q pulled back R 4's brief she found R 4 had a large solid BM. R 4 said she did not know she had a BM as she has Multiple [CONDITION(S)] and cannot feel when she has a BM. R 4 has a Foley catheter so the strip on the brief does not change colors to show it is soiled unless the BM is loose. CNA Q admitted she did not pull back R 4's brief to check it when she turned her earlier. CNA Q and the Surveyor had N95 masks on and could not smell the BM. The Surveyor asked CNA Q is R 4 was a one assist for turning and brief change or two and CNA Q said she did not know as she had only cared for her once or twice prior today. On 11/30/21 at 10:45 AM the Surveyor told the DON, CNA Q did not visually check R 4 for a BM this morning and R 4 had a BM noted at 10:15 AM. CNA Q turned R 4 and removed her brief without assistance. R 4 was still reported night staff were not consistently checking her brief and turning her. The DON checked R 4's care plan and said she was a two assist with turning and brief change. The DON said she would educate CNA Q. The DON provided an Employee Discipline Form for CNA Q dated 11/30/21 that revealed, On 11/20/21 upon arriving for shift staff member was educated on ensuring residents care plans are followed to ensure residents care needs are met timely as well as ensuring residents are turned/repositioned and toileted/checked and changed for incontinence every two hours. Staff member stated understanding and acknowledged that she needed to turn/reposition and toilet/check and change resident at a minimum of every 2 hours. Staff member stated that she did not know what resident's care level was for bed mobility but did not proceed to finding out prior to providing care with x1 assist. Resident is care planned for assist x 2 for bed mobility. Staff member stated she knew how to check residents care levels by viewing the Kardex in PCC (electronic medical record). The box for verbal counseling was marked. On 11/23/21 at 4:17 PM the NHA was informed of an Immediate (IJ) related to F 600 that began on 11/23/21 when the facility failed to respond to the allegation that Residents on 1 South had not received incontinence care on the night shift and R 4 and R 8 made allegation of neglect. The Surveyor provided details of the condition R 4 and R 8 when they received care the morning of 11/23/21 and reported lack of staff to provide adequate care for Residents on 1 North. The NHA was provided this information verbally and in writing in the IJ notification. R 1 Review of face sheet and electronic medical record revealed R 1 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility reported incident related to R 1 revealed he had an unwitnessed fall with a fracture on 11/4/21. Further review revealed the incident was documented as being discovered at 11/5/21 at 12:27 AM and was not reported to the state agency until 11/5/21 at 8:34 AM. Review of R 1's progress notes revealed the fall occurred at approximately 6:00 PM on 11/4/21 and on 11/5/21 at 12:30 AM: notified at (12:30 am) [name of emergency room staff] resident has a distal Femur Fracture, will be admitted . Review of facility policy Abuse, Neglect and Exploitation Policy with a last revised date of 10/8/19 revealed under the section Reporting/Response The home will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. 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 .

This citation pertains to intakes MI 338, MI 992, MI 417, MI 708, and MI 711: Based on observation, interview and record review, the facility failed to thoroughly investigate and recognize allegations of abuse and neglect for 4 Resident's (R4, R6, R7, R8) and Residents on the 1 South Unit on 11/23/21, reviewed for being at risk for abuse, as a result of the facility's failure to provide incontinence care and reposition Residents leading to R4 having pain and discomfort, R6 developing an unstageable pressure ulcer, multiple Stage II ulcers, experiencing pain, R8 developing multiple stage II ulcers and experience pain, and Residents on 1 South having the potential for skin breakdown and pain. R7 and R6 experienced neglect, pain and delayed care after a lack of thorough investigation into the neglect of R4 and R8 being reported to facility administration. This deficient practice can lead to ongoing abuse and neglect. Findings include: According to the facility Abuse, Neglect and Exploitation Policy with a revision date 10/8/2019, read, in part, Abuse: means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical. Mental, and psychosocial well-being, The home will provide ongoing oversight and supervision of staff in order to assure that is (sic) policies are implemented as written, The home will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: . B Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed and certified staff on each shift, Possible Indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse 2. Physical marks such as bruises or patterned appearances such as a hand print, belt or ring mark on a resident's body, 3. Physical injury of a resident, of unknown source, 4. Resident reports of theft of property, or missing property, 5. Verbal abuse of a resident overheard, 6. Physical abuse of a resident observed, 7. Psychological abuse of a resident observed, 8. Failure to provide care needs such as feeding, bathing, dressing, turning, and repositioning, A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedure for investigation include: 1. Identifying staff responsible for the investigation, 2. Exercising caution in handling evidence that could be used in a criminal investigation, 3. Investigation different types of alleged violations, 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation, The home will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation, B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed, C. Increased supervision of the alleged victim and residents, D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator, E. Protection from retaliation, F. Providing emotional support and counseling to the resident during and after the investigation, as needed, and The home will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g law enforcement when applicable) within specified timeframes: a. 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 b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 2. Assuring that reporters are free from retaliation or reprisal .4. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following: a. analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences, b. defining how care provision will be changed and /or improved to protect residents receiving services, c. training of staff on changes made and demonstration of staff competency after training is implanted (sic), d. Identification of staff responsible for implantation (sic) of corrective actions, e. the expected date for implementation, and f. Identification of staff responsible for monitoring the implementation of the plan. R6 Review of R6's face sheet dated 11/23/21 revealed he was a [AGE] year-old male admitted to the facility on 8/1/2019 and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6 was not his own responsible party. On 12/1/21 at 9:20 AM, R6 was observed in bed. He was on his back and the head of bed was elevated 30 to 40 degrees and he was covered with a blanket. Registered Nurses (RN) O and P (were in his room attempting to reinsert an IV (Intravenous) line. They reported he had pulled it out this morning and they were not able to get it back in. They said they were contacting another nurse in the facility and if they were not able to get it started, they would send him to the emergency room . R6 was complaining of pain in his buttock at that time. The Surveyor asked R6 if she could look at his buttock with the nurses to see if they could determine the cause of his pain. R6 agreed. R6 yelled out in pain several times with lowing the head of his bed and turning him. When the nurses removed R6 brief it was soiled with BM but not wet. There was no indication he had soiled himself until the brief was pulled back. There was a large white pad/dressing placed over R6's left hip. No date or time was visible on the dressing. When the dressing was removed there was a large area, approximately 4 inches by 2 inches of black tissue with a bright red boarder. RN O called for a CNA to come into clean R6 up. RN O said she had 3 CNA's on her unit since 6:00 AM and normally had 2 CNA's. RN O the CNAs were L, M, and N. On 12/1/21 at approximately 9:30 AM, CNA M came to R6's room to clean him up. CNA M said she had not seen R6's buttock prior to this time today. RN O started helping CNA M clean up R6 and when CNA N arrived RN O instructed them to finish cleaning him up and of load his buttock on the left. CNA N said she had not seen R6 buttock prior to this time today and confirmed she started at 6:00 AM. Once R6 was cleaned up and new brief on he was placed on his back and two bed pillows were tucked in between the mattress and his hips. There was a pillow under each hip which placed pressure directly on the large wound on R6's left hip and increased pressure to his right hip. This prevented any rolling or contact of the specialty pressure reliving mattress to the pressure ulcer area. The Surveyor questioned the CNA's as they had just been instructed to off load pressure from R 6's left hip. Both CNAs responded the facility had educated them that this was how to off load the buttock. They were not able to recall who educated them or when they were educated. On 12/1/21 at 9:50 AM, RN O was at the nurses station. RN O reviewed R 6's wound assessments documented in the electronic medical record (EMR). There was a picture of the wound on R 6's left hip that was measure at greater than 9 cm x 4 cm and was covered with eschar (black tissue). The wound was labeled as a stage II ulcer. The Surveyor asked RN O if that was a stage II ulcer and RN O responded no it is unstageable. When questioning how it could be miss labeled RN O explained she had made the error when it changed from a stage II to unstageable. RN O went on to explain when she has days off agency nurses cover for her and they do not know how to run the camera or how to do many of the things that need to be done. When RN O returns to work she has to do the work of 2 nurses due to all of the things that were not completed when she was off. RN O was frustrated about her workload that contributed to her charting error. The Surveyor told RN O that the CNAs had placed pillows under both sides of R 6's buttock and had told the Surveyor this is how the facility had educated them to off load resident to prevent pressure ulcers. RN O verified R 6's pressure ulcer was not off load as she had instructed. RN O called CNA M, N and L to R 6's room and instructed/assisted them to remove the pillows and place one pillow under R 6's back on the left side above the pressure ulcer. This turned him to his right side and left air space between his left buttock and mattress. RN O had no idea who had trained the CNAs to do pressure relief incorrectly. CNA L said he had not seen R 6's buttock that morning. On 12/1/21 at approximately 11:00 AM, after R6 was placed on his right side and his brief was changed, he reported he had no pain. Review of R6's Skin Integrity care plan dated 10/25/21 revealed, I have actual impairment of my skin integrity r/t incontinence, impaired mobility. I am weak and in need of assistance for all ADL's (activities of daily living). I have been noted to be confused at times. I am non ambulatory (cannot walk) and my main source of locomotion in my room and on the unit is my wheelchair. I prefer to sleep in my recliner chair. Review of R6's Pressure Ulcer care plan dated 11/23/21 revealed, I have a pressure ulcer to my L (left) ischial tuberosity (hip). I am receiving ATB (antibiotic) form my wound and I have been referred to the wound clinic for follow up care. No special instructions for pressure relief were located. A power turn mattress was applied to the bed. (Standard of care is to turn, reposition and check for incontinence at least every 2 hours). Observations and interview conducted the morning of 12/1/21 indicated he had gone more that 2 hours with out his brief check for BM. He was not provided pressure relief as instructed by the RN in charge. Review of R6's CT scan dated 12/1/21 at 1:50 PM revealed, There is a posterior gluteal fold ulceration with significant induration and [CONDITION(S)] and skin thickening. There is focal induration and fluid collection measuring 9.2 cm x 4.3 cm x 12.5 cm suggestion abscess. Review of R6's emergency room report dated 12/1/21 at 4:25 PM revealed, he had an ulceration along the left gluteal crease with [CONDITION(S)] and large abscess (infection)in the subcutaneous soft tissue extending to the deep fascia (tissue) measuring 12.5 cm. The plan was to do debridement (remove dead and infected tissue) of the wound 12/2/21. Under Number of diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Discussed CT findings of abscess underlying gluteal ulcer and resultant [CONDITION(S)] with surgery. Patient to be admitted for surgical debridement as well as IV Abx (antibiotic's). R8 Review of R 8's face sheet dated 12/1/21, revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was her own responsible party. On 11/23/21 at 10:15 AM, the Surveyor was not able to locate staff working on R8's nursing unit. Registered Nurse (RN) G was at the nurse's station and said she was just getting started on the unit. RN G was not able to locate a staffing list at the nurse's station. RN G went down the hall to the medication cart and was not able to locate a staffing sheet. RN G started going room to room to look for staff. At approximately 10:25 AM Certified Nurse Aide (CNA) I walked out of a resident room. CNA I said she had been the only person working on the unit all morning as CNA J was pulled to go to an appointment and CNA H was pulled to help but CNA H was not familiar with the residents on the unit, so she was not much help. CNA I said CNA H went back to whatever unit she was pulled from. CNA I was asked if she was able to provide any care for R4 that morning and she said she did turn her but did not do a brief check or change. CNA I said R 4 ate and she feeds herself. CNA I said the only thing she had time to do was answer call lights. CNA I told RN G she was exhausted and needed to take her lunch. She said she would take her 30-minute lunch in her car so he could sleep. If she did not return in 30 minutes CNA I wanted RN G to send someone to the parking lot to wake her up. CNA I did not indicate she had provided any care for R8 at this time. On 11/23/21 at 10:49 AM, R8's call light was observed to be on. At 10:54 AM a housekeeper went in R8's room and turned off her call light. The housekeeper reported R8 wanted to get out of bed. At 10:56 AM R8 turned her call light on again. At 11:06 AM, CNA I went into her room, turned off the call light. CNA I said R8 wanted to get up, but she normally did not so CNA I went to the computer on the wall to see how to get R8 out of bed. CNA I said she had not provided any care for R8 that morning. After she check the computer, she went to another resident's room to answer a call light. A few minutes later CNA B and CNA H went to R8's room and said they had been pulled from other units to do care. CNA B said she started at 6:00 AM on 1 South. CNA B said when she made rounds that morning, she found all of her residents soiled and care had not been provided by night shift. CNA B said night shift is from 6:00 PM to 6:00 AM and most of the staff are agency. CNA B said she reported this neglect to her charge nurse Licensed Practical Nurse (LPN) K and directly to the Director of Nursing (DON). CNA B said this has been an ongoing issue. CNA B said she reports it, but nothing happens. On 11/23/21 at approximately 11:15 AM the surveyor introduced herself to R8 and asked if she could watch care. R8 agreed to the observation. CNA B and H pulled back R8's blanket and R8 had a shirt and an incontinence brief on. The brief was completely soak through with urine and bowel movement (BM). As the CNA's turned R8 to provide incontinence care R8 cried out in pain multiple times. R8's soaker pad and sheet were saturated with urine and BM. The wet stain on the sheet went all the way up her back and past her buttock. When the brief was removed R 8 had multiple open bloody areas between her legs and at least 10 open bloody areas on her buttock. R8 constantly cried out in pain and the CNA's cleaned her and changed her complete bedding. R8 said the last time she was changed was yesterday morning. R8 said she complains to the nurses about not getting changed but nothing happens. CNA B and H confirmed they have complained to management multiple times about this resident not getting changed and nothing happens. R8's shirt was covered in dry skin and her face had dried crusted material on it. R8 said she could not recall the last time she had a shower but would take on anytime they would give her one. On 11/23/21 at approximately 12:45 PM the Surveyor asked the Director of Nursing (DON) if CNA B had reported to her this morning that the residents on 1 South were left soiled and did not get care last night. The DON said CNA B had reported that to her. The Surveyor asked if the DON if she had started the facility reported incident (FRI) the DON said, no. The Surveyor said to the DON, a CNA reported to you this morning residents on 1 South were left soiled and did not get care this morning, which is goods and services were not provided. The DON said, yes. The Surveyor asked why she had not started the FRI and the DON said she decides if something in neglect and she had not determined that was neglect. The surveyor said she had observed the care of R4 and R8 on 1 North that morning. R8 was so soiled that it went through her brief, soaker pad and sheet. R8's thighs and buttock's had bloody sores from being left soiled so long and the Surveyors eyes were still burning from the urea in the room. The Surveyor could smell the BM through her N95 mask it was so strong. R8 reported she had not been changed since yesterday. R4 was also observed to be soiled and in pain. R4 also reported she had not been changed since yesterday. The DON did not have any other comments or questions. The DON did not take any notes and did not appear concerned. On 11/23/21 at approximately 12:50 PM, the Surveyor went to the Nursing Home Administrator's (NHA) office and reported all the same information to NHA that she had just provided to the DON. The NHA took a few notes, appeared very concerned and said she would take care of it. The NHA offered no explanation as to why the DON would not have started FRI process at 6:00 AM when she received the first allegation of neglect. The NHA did not provide any additional information until 4:17 PM when the facility was served and Immediate Jeopardy (IJ) for neglect. The NHA said we interviewed the Residents and none of them said they were neglected. They Surveyor referred to the information in the IJ notification that provided R4 and R8 condition that was observed and reported to her around 12:50 PM by the Surveyor, Resident and Staff statements on neglect and the facility failure to act on these complaints the NHA offered no addition information. The facility did start a FRI related to R4 and R8's concerns that were provided to the DON and NHA on 11/23/21. The facility did not do an FRI on CNA B allegation of the neglect of Residents on 1 South that she reported around 6:00 AM on 11/23/21. The FRI reports did not include the Surveyors report of R4 and R8's physical condition, complaints of care or staff interviews conducted by the Surveyor. The investigation did not include incontinence care records or Resident progress notes or skin evaluations. The facility did not complete a thorough investigation, and it did determine neglect had occurred for R 4 or R 8. Review of R8's progress noted dated 11/23/21 at 6:25 PM revealed, R8 had multiple small open areas to her right and left ischial tuberosities (buttock bone areas). Physician was notified and R8 declined to have her family notified. A wound dressing was applied for 3 days. Review of R8's incontinence record revealed that on 11/22/21 R8 was incontinent at 5:38 AM and 1:52 PM. No refusal of incontinent care was recorded on 11/22/21. (R8 only received incontinence care 2 times on 11/22/21 according to her medical record documentation). Review of R8's incontinence record for 11/23/21 revealed she was incontinent at 5:38 AM and again at 11:17 PM. There was no indication of refusal of incontinence care on 11/23/21. There was no record of the incontinence care the Surveyor observed at 11:15 AM. Review of R8's incontinence record from 11/18/21 to 11/23/21 only showed R8 was incontinent between 1 and 4 times a day. R8 refused incontinent care 1 time on 11/18/21, 11/20/21, and 11/22/21. Review of R8's incontinence record for 11/24/21 (2 day after receiving an IJ for lack of incontinence care) R 8 was only recorded to be incontinent 1 time at 7:20 AM. She had no refusals documented. Review of R8's incontinence record from 11/23/21 to 11/30/21 revealed no refusal of incontinence care form 11/24/21 until 11/30/21. Review of R8's progress note dated 11/24/21 at 9:41 PM revealed, Resident not fully herself in this recovery from COVID, still very tired throughout the shift. Reported to this nurse by CNAs that resident very hesitant and refusing most transfers out of her chair due to lethargy. During an interview with R8 on 11/30/21 at 2:04 PM, R8 was awake in bed, well-groomed and smiling. The Surveyor asked her if she had been refusing to let staff turn her or change her brief. R8 said when I am sleeping, and they come in to do care I am get confused sometimes. I know my butt is hurting because I do not get cleaned or turned. I really want them to clean me up and turn me even if I say, No. They have been doing a better job and my butt is getting better. Asked R8 if I could have the DON come talk to her so she could explain what she wanted staff to do, R8 agreed. DON returned with the Surveyor a few minutes later and R8 repeated what she told the Surveyor. The DON said they had just started documenting on paper when people get turned and cleaned. The DON said if they show you the sheet so you can see the last time, they did care would that work. R8 agreed. Review of R8's skin audit dated 11/23/21 no time revealed no skin issues on her buttock. 4 small circles were placed on the picture of the left inner thigh and scattered abrasions was written in with an arrow to the circles. This skin audit did not match the Surveyors observation during care the morning of 11/23/21 or the progress note dated 11/23/21 at 6:25 PM. The facility provided skin audits as part of the IJ removal. The DON was informed R8's skin audit done for the IJ removal did not match observations on 11/23/21 or 11/30/21. The DON was asked to address the accuracy of skin audits and documentation. Upon exit on 12/3/21 the DON did not provide any updated audits or information on correcting audits that had been completed. R4 Review of R4's face sheet dated 11/23/21 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 was her own responsible party. On 11/23/21 at 10:11 AM, R4 was observed sleeping in bed and on turned to her right side. R4's catheter bag was on the floor on the left side of her bed. The catheter tubing and bag had a dark blue color. R4 did not respond when her name was called. There was a medication cart in the hall, but no staff were located on the hall. On 11/23/21 at 10:15 AM, the Surveyor was not able to locate staff working on R4's nursing unit. Registered Nurse (RN) G was at the nurse's station and said she was just getting started on the unit. RN G was not able to locate a staffing list at the nurse's station. RN G went down the hall to the medication cart and was not able to locate a staffing sheet. RN G started going room to room to look for staff. At approximately 10:25 AM Certified Nurse Aide (CNA) I walked out of a resident room. CNA I said she had been the only person working on the unit all morning as CNA J was pulled to go to an appointment and CNA H was pulled to help but CNA H was not familiar with the residents on the unit, so she was not much help. CNA I said CNA H went back to whatever unit she was pulled from. CNA I was asked if she was able to provide any care for R4 that morning and she said she did turn her but did not do a brief check or change. CNA I said R 4 ate and she feeds herself. CNA I said the only thing she had time to do was answer call lights. CNA I told RN G she was exhausted and needed to take her lunch. She said she would take her 30-minute lunch in her car so he could sleep. If she did not return in 30 minutes CNA I wanted RN G to send someone to the parking lot to wake her up. On 11/23/21 at 10:46 AM, R4 was observed in bed sleeping on her right side with a pillow under her left chest area and her catheter bag remained on the floor. On 11/23/21 at 11:24 AM, R4 was observed in bed and CNA I and J had just started care. R 4 was on her right side and the CNAs were just starting to remove R4's brief. R4's brief and sheet were soiled with BM. R4 said she had not been changed since yesterday. CNA I and J confirmed they had started work at 6:00 AM today and this was the first time they had time to change her brief. CNA J said she was pulled at 7:30 AM to help a resident going out on an appointment. CNA I again said she was the only one providing care for all the residents on this hall when CNA J was pulled to assist a resident going out to an appointment. CNA I was not able to recall what time it was when she turned R4 on her right side. R4's entire right side was bright red. R 4 said she reports not being changed and turned to the nurses but nothing every gets done. CNA I and J confirmed R4 frequently makes these complaints about night shift and they also report these concerns to management, but nothing gets done. Review of R4's ADL/MOBILITY/Toileting care plan dated initiated 7/22/21 and revised on 11/30/21 revealed. As of 7/22/21 R4 required assistance extensive assistance of 2 people for bed mobility. Toileting schedule as of 2/3/20 was to offer and encourage bed pan and check and change every 2 hours. Toileting assistance was not offered the morning of 11/23/21 from 6:00 AM until 11:24 AM when she was found to be incontinent of bowel. R 4 was observed in bed and awake on 11/30/21 at 10:15 AM, R4 reported staff were getting better at turning her and changing her brief, however nights was still the main problem. R4 said her brief had not been checked or changed yet this morning and she was agreeable to the Surveyor asking the CNA to check her brief. CNA Q came in a checked her brief. CNA did not have anyone assist her turn R4 or assist with removing her brief. When CNA Q pulled back R4's brief she found R4 had a large solid BM. R4 said she did not know she had a BM as she has Multiple [CONDITION(S)] and cannot feel when she has a BM. R4 has a Foley catheter so the strip on the brief does not change colors to show it is soiled unless the BM is loose. CNA Q admitted she did not pull back R 4's brief to check it when she turned her earlier. CNA Q and the Surveyor had N95 masks on and could not smell the BM. The Surveyor asked CNA Q is R4 was a one assist for turning and brief change or two and CNA Q said she did not know as she had only cared for her once or twice prior today. On 11/30/21 at 10:45 AM the Surveyor told the DON, CNA Q did not visually check R 4 for a BM this morning and R 4 had a BM noted at 10:15 AM. CNA Q turned R 4 and removed her brief without assistance. R 4 was still reported night staff were not consistently checking her brief and turning her. The DON checked R 4's care plan and said she was a two assist with turning and brief change. The DON said she would educate CNA Q. The DON provided an Employee Discipline Form for CNA Q dated 11/30/21 that revealed, On 11/20/21 upon arriving for shift staff member was educated on ensuring residents care plans are followed to ensure residents care needs are met timely as well as ensuring residents are turned/repositioned and toileted/checked and changed for incontinence every two hours. Staff member stated understanding and acknowledged that she needed to turn/reposition and toilet/check and change resident at a minimum of every 2 hours. Staff member stated that she did not know what resident's care level was for bed mobility but did not proceed to finding out prior to providing care with x1 assist. Resident is care planned for assist x 2 for bed mobility. Staff member stated she knew how to check residents care levels by viewing the Kardex in PCC (electronic medical record). The box for verbal counseling was marked. R 7 Review of R 7's face sheet and electronic medical record revealed she admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R 7's care plan revealed under COGNITION: My cognition at times does fluctuate. Due to my diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Under the section ADL/BOWEL/BLADDER/MOBILITY interventions include: toileting to be completed at 2:30 a.m., 4:40 a.m., and upon request throughout the rest if the day. For toilet use, R7 was noted as needing the extensive assistance of 1-2 staff. Under the focus area of FALLS R 7 had an intervention of 15 minute checks . and anticipate and meet my needs. Under the focus area of PAIN interventions include: Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. On 11/24/21 at approximately 1:35 AM, while walking past R7's room, R7 could be heard moaning and a strong odor of feces was detected from the doorway. An interview was completed with R7, who was grimacing and squirming in her bed. R7 stated it hurts where I poop, please help. R7 was asked if she was wet or soiled and she stated that she had a bowel movement and can't remember when I was last helped, please get someone it hurts so bad down there. CNA (Certified Nursing Assistant) D was found in the hall and she was informed R7 stated she was in pain in her peri area, was soiled with feces and needed incontinence care. CNA D stated I just changed her at 1:10 PM and she had a BM (bowel movement). R7's room was entered with CNA D, the room had a strong smell of feces. CNA D asked the resident if she needed pain cream for her bottom and the R7 stated yes. CNA D did not ask if the resident needed incontinence care or check R7's brief despite there being a strong scent of feces in the room and being told by the surveyor that R7 was soiled, before exiting the room to get the nurse for pain cream. After CNA D left the room, R7 continued to grimace and discuss how much pain she was in and that she needed to be changed. Nurse F entered the room a few minutes later with a pain cream and turned R7 to apply the cream, when R7 was turned, it was observed she was soiled with feces that had soaked through her brief and to the bed pad. Nurse F informed R7 that she would need to find the aide to come back to assist R7 to be cleaned up. At approximately 1:50 AM CNA D and CNA E entered the room to begin incontinence care for R7.

This citation pertains to intakes MI 338, MI 992, MI 708, and MI 711: Based on observations, interview and record review, the facility failed to implement care plans to prevent skin breakdown and pain for 5 Residents (R4, R5, R6, R7 and R8), resulting in R6 developing a large unstageable ulcer on his buttock and experiencing pain, R8 developing multiple stage II ulcers on her buttock and between her legs and experiencing pain, R4 and R7 experiencing delay and incontinence care and pain and R5 developing a stage 1 and a stage II ulcer on his buttock and experiencing pain. . Findings include: R6 Review of R 6's face sheet dated 11/23/21 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R 6 was not his own responsible party. On 12/1/21 at 9:20 AM, R6 was observed in bed. He was on his back and the head of bed was elevated 30 to 40 degrees and he was covered with a blanket. Registered Nurses (RN) O and P (were in his room attempting to reinsert an IV (Intravenous) line. They reported he had pulled it out this morning and they were not able to get it back in. They said they were contacting another nurse in the facility and if they were not able to get it started, they would send him to the emergency room . R6 was complaining of pain in his buttock at that time. The Surveyor asked R6 if she could look at his buttock with the nurses to see if they could determine the cause of his pain. R6 agreed. R6 yelled out in pain several times with lowing the head of his bed and turning him. When the nurses removed R6's brief it was soiled with bowel movement but not wet. There was no indication he had soiled himself until the brief was pulled back. There was a large white pad/dressing placed over R6's left hip. No date or time was visible on the dressing. When the dressing was removed there was a large area, approximately 4 inches by 2 inches of black tissue with a bright red border. RN O called for a CNA to come into clean R6 up. RN O said she had 3 CNA's on her unit since 6:00 AM and normally had 2 CNA's. RN O the CNAs were L, M, and N. On 12/1/21 at approximately 9:30 AM, CNA M came to R6's room to clean him up. CNA M said she had not seen R6's buttock prior to this time today. RN O started helping CNA M clean up R6 and when CNA N arrived RN O instructed them to finish cleaning him up and off load his buttock on the left. CNA N said she had not seen R6 buttock prior to this time today and confirmed she started at 6:00 AM. Once R6 was cleaned up and new brief was on, he was placed on his back and two bed pillows were tucked in between the mattress and his hips. There was a pillow under each hip which placed pressure directly on the large wound on R6's left hip and increased pressure to his right hip. This prevented any rolling or contact of the specialty pressure reliving mattress to the pressure ulcer area. The Surveyor questioned the CNA's as they had just been instructed to off load pressure from R6's left hip. Both CNAs responded the facility had educated them that this was how to off load the buttock. They were not able to recall who educated them or when they were educated. On 12/1/21 at 9:50 AM, RN O was at the nurse's station. RN O reviewed R6's wound assessments documented in the electronic medical record (EMR). There was a picture of the wound on R6's left hip that was measured at greater than 9 cm x 4 cm and was covered with eschar (black tissue). The wound was labeled as a stage II ulcer. The Surveyor asked RN O if that was a stage II ulcer and RN O responded no it is unstageable. When questioning how it could be mislabeled RN O explained she had made the error when it changed from a stage II to unstageable. RN O went on to explain when she has days off agency nurses cover for her and they do not know how to run the camera or how to do many of the things that need to be done. When RN O returns to work she has to do the work of 2 nurses due to all of the things that were not completed when she was off. RN O was frustrated about her workload that contributed to her charting error. The Surveyor told RN O that the CNAs had placed pillows under both sides of R6's buttock and had told the Surveyor this is how the facility had educated them to off load resident to prevent pressure ulcers. RN O verified R6's pressure ulcer was not off loaded as she had instructed. RN O called CNA M, N and L to R6's room and instructed/assisted them to remove the pillows and place one pillow under R6's back on the left side above the pressure ulcer. This turned him to his right side and left air space between his left buttock and mattress. RN O had no idea who had trained the CNAs to do pressure relief incorrectly. CNA L said he had not seen R6's buttock that morning. On 12/1/21 at approximately 11:00 AM, after R6 was placed on his right side and his brief was changed, he reported he had no pain. Review of R6's Skin Integrity care plan dated 10/25/21 revealed, I have actual impairment of my skin integrity r/t incontinence, impaired mobility. I am weak and in need of assistance for all ADL's (activities of daily living). I have been noted to be confused at times. I am non ambulatory (cannot walk) and my main source of locomotion in my room and on the unit is my wheelchair. I prefer to sleep in my recliner chair. Review of R6's Pressure Ulcer care plan dated 11/23/21 revealed, I have a pressure ulcer to my L (left) ischial tuberosity (hip). I am receiving ATB (antibiotic) form my wound and I have been referred to the wound clinic for follow up care. No special instructions for pressure relief were located. A power turn mattress was applied to the bed. (Standard of care is to turn, reposition and check for incontinence at least every 2 hours). Observations and interview conducted the morning of 12/1/21 indicated he had gone more than 2 hours without his brief check for BM. He was not provided pressure relief as instructed by the RN in charge. Review of R6's facility timeline for his skin break down revealed. The facility did not identify any skin break down until 11/14/21. They identified a stage II left ischial tuberosity that was 3.5 cm x 2.7 cm. On 11/21/21 it measured 5.5 x 4.7 cm and was a stage II, and on 11/29/21 it measured 9.9 cm x 4.3 cm and was changed to an unstageable. Review of R6's electronic medical record revealed in the wound section a photo a wound on his left ischial tuberosity the covered and area 6.9 cm was 3.45 cm in length and 2.7 cm with width, O at the deepest point. On 11/21 the wound was 17 cm in area, 5.45 in length and 4.7 cm in width. On 11/29/21 the area was 30 cm by 9.85 cm in length and 4.3 cm in width it was covered with black tissue and documented as unstageable. Review of a New Pressure report for R6 dated 11/14/21 at 22:20 (10:20 PM) revealed, This nurse noted residents urine smell and asked staff to help get him to the bathroom. When resident pants were pulled down an area to the left ischial tuberosity was noted. Area measures 3.5 cm x 2.7 cm. Area cleansed with soap and water and [MEDICATION(S)] (dressing) applied. Nurse manager and DON called and made aware. Name of physician made aware by fax. Review of R6's ADL (activity of daily living)/mobility/toileting care plan dated initiated 12/16/21 revealed he could not walk, transfers required extensive assistance of 1, bed mobility was extensive assistance of 1,1 toilet use was extensive assistance of one with commode over toilet and urinal has been noted to spill at times. Per review of R6's electronic medical record, he was sent to the emergency roiagnom on [DATE]. Review of R6's CT scan dated 12/1/21 at 1:50 PM revealed, There is a posterior gluteal fold ulceration with significant induration and [CONDITION(S)] and skin thickening. There is focal induration and fluid collection measuring 9.2 cm x 4.3 cm x 12.5 cm suggestion abscess. Review of R6's emergency room report dated 12/1/21 at 4:25 PM revealed, he had an ulceration along the left gluteal crease with [CONDITION(S)] and large abscess (infection)in the subcutaneous soft tissue extending to the deep fascia (tissue) measuring 12.5 cm. The plan was to do debridement (remove dead and infected tissue) of the wound 12/2/21. Under Number of diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Discussed CT findings of abscess underlying gluteal ulcer and resultant [CONDITION(S)] with surgery. Patient to be admitted for surgical debridement as well as IV Abx (antibiotic's). R8 Review of R8's face sheet dated 12/1/21, revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was her own responsible party. On 11/23/21 at 10:15 AM, the Surveyor was not able to locate staff working on R8's nursing unit. Registered Nurse (RN) G was at the nurse's station and said she was just getting started on the unit. RN G was not able to locate a staffing list at the nurse's station. RN G went down the hall to the medication cart and was not able to locate a staffing sheet. RN G started going room to room to look for staff. At approximately 10:25 AM Certified Nurse Aide (CNA) I walked out of a resident room. CNA I said she had been the only person working on the unit all morning as CNA J was pulled to go to an appointment and CNA H was pulled to help but CNA H was not familiar with the residents on the unit, so she was not much help. CNA I said CNA H went back to whatever unit she was pulled from. CNA I was asked if she was able to provide any care for R4 that morning and she said she did turn her but did not do a brief check or change. CNA I said R4 ate and she feeds herself. CNA I said the only thing she had time to do was answer call lights. CNA I told RN G she was exhausted and needed to take her lunch. She said she would take her 30-minute lunch in her car so he could sleep. If she did not return in 30 minutes CNA I wanted RN G to send someone to the parking lot to wake her up. CNA I did not indicate she had provided any care for R8 at this time. On 11/23/21 at 10:49 AM, R8's call light was observed to be on. At 10:54 AM a housekeeper went in R8's room and turned off her call light. The housekeeper reported R8 wanted to get out of bed. At 10:56 AM, R8 turned her call light on again. At 11:06 AM, CNA I went into her room, turned off the call light. CNA I said R8 wanted to get up, but R8 normally did not get out of bed so CNA I went to the computer on the wall to see how to get R8 out of bed. CNA I said she had not provided any care for R 8 that morning. After she checked the computer, she went to another resident's room to answer a call light. A few minutes later CNA B and CNA H went to R 8's room and said they had been pulled from other units to do care. CNA B said she started at 6:00 AM on 1 South. CNA B said when she made rounds that morning, she found all of her residents soiled and care had not been provided by night shift. CNA B said night shift is from 6:00 PM to 6:00 AM and most of the staff are agency. CNA B said she reported this neglect to her charge nurse Licensed Practical Nurse (LPN) K and directly to the Director of Nursing (DON). CNA B said this has been an ongoing issue. CNA B said she reports it, but nothing happens. On 11/23/21 at approximately 11:15 AM, the surveyor introduced herself to R8 and asked if she could watch care. R8 agreed to the observation. CNA B and H pulled back R8's blanket and R8 had a shirt and an incontinence brief on. The brief was completely soaked through with urine and bowel movement (BM). As the CNA's turned R8 to provide incontinence care R8 cried out in pain multiple times. R8's soaker pad and sheet were saturated with urine and BM. The wet stain on the sheet went all the way up her back and past her buttock. When the brief was removed R8 had multiple open bloody areas between her legs and at least 10 open bloody areas on her buttock. R8 constantly cried out in pain and the CNAs cleaned her and changed her complete bedding. R8 said the last time she was changed was yesterday morning. R8 said she complains to the nurses about not getting changed but nothing happens. CNA B and H confirmed they have complained to management multiple times about this resident not getting changed and nothing happens. R8's shirt was covered in dry skin and her face had dried crusted material on it. R8 said she could not recall the last time she had a shower but would take one anytime they would give her one. Review of R8's progress noted dated 11/23/21 at 6:25 PM revealed, R8 had multiple small open areas to her right and left ischial tuberosities (buttock bone areas). Physician was notified and R8 declined to have her family notified. A wound dressing was applied for 3 days. Review of R8's incontinence record revealed that on 11/22/21 R8 was incontinent at 5:38 AM and 1:52 PM. No refusal of incontinent care was recorded on 11/22/21. (R8 only received incontinence care 2 times on 11/22/21 according to her medical record documentation). Review of R8's incontinence record for 11/23/21 revealed she was incontinent at 5:38 AM and again at 11:17 PM. There was no indication of refusal of incontinence care on 11/23/21. There was no record of the incontinence care the Surveyor observed at 11:15 AM. Review of R8's incontinence record from 11/18/21 to 11/23/21 only showed R8 was incontinent between 1 and 4 times a day. R8 refused incontinent care 1 time on 11/18/21, 11/20/21, and 11/22/21. Review of R8's incontinence record for 11/24/21 (2 day after receiving an IJ for lack of incontinence care) R8 was only recorded to be incontinent 1 time at 7:20 AM. She had no refusals documented. Review of R8's incontinence record from 11/23/21 to 11/30/21 revealed no refusal of incontinence care form 11/24/21 until 11/30/21. Review of R8's progress note dated 11/24/21 at 9:41 PM revealed, Resident not fully herself in this recovery from COVID, still very tired throughout the shift. Reported to this nurse by CNAs that resident very hesitant and refusing most transfers out of her chair due to lethargy. During an interview with R8 on 11/30/21 at 2:04 PM, R8 was awake in bed, well-groomed and smiling. The Surveyor asked her if she had been refusing to let staff turn her or change her brief. R8 said when I am sleeping, and they come in to do care I am get confused sometimes. I know my butt is hurting because I do not get cleaned or turned. I really want them to clean me up and turn me even if I say, No. They have been doing a better job and my butt is getting better. Asked R8 if I could have the DON come talk to her so she could explain what she wanted staff to do, R8 agreed. DON returned with the Surveyor a few minutes later and R8 repeated what she told the Surveyor. The DON said they had just started documenting on paper when people get turned and cleaned. The DON said if they show you the sheet so you can see the last time, they did care would that work. R8 agreed. Review of R8's skin audit dated 11/23/21 no time revealed no skin issues on her buttock. 4 small circles were placed on the picture of the left inner thigh and scattered abrasions was written in with an arrow to the circles. This skin audit did not match the Surveyors observation during care the morning of 11/23/21 or the progress note dated 11/23/21 at 6:25 PM. The facility provided skin audits as part of the IJ removal. The DON was informed R8's skin audit done for the IJ removal did not match observations on 11/23/21 or 11/30/21. The DON was asked to address the accuracy of skin audits and documentation. Upon exit on 12/3/21 the DON did not provide any updated audits or information on correcting audits that had been completed R 4 Review of R4's face sheet dated 11/23/21 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 was her own responsible party. On 11/23/21 at 10:11 AM, R4 was observed sleeping in bed and on turned to her right side. R4's catheter bag was on the floor on the left side of her bed. The catheter tubing and bag had a dark blue color. R4 did not respond when her name was called. There was a medication cart in the hall, but no staff were located on the hall. On 11/23/21 at 10:15 AM. the Surveyor was not able to locate staff working on R4's nursing unit. Registered Nurse (RN) G was at the nurse's station and said she was just getting started on the unit. RN G was not able to locate a staffing list at the nurse's station. RN G went down the hall to the medication cart and was not able to locate a staffing sheet. RN G started going room to room to look for staff. At approximately 10:25 AM, Certified Nurse Aide (CNA) I walked out of a resident room. CNA I said she had been the only person working on the unit all morning as CNA J was pulled to go to an appointment and CNA H was pulled to help but CNA H was not familiar with the residents on the unit, so she was not much help. CNA I said CNA H went back to whatever unit she was pulled from. CNA I was asked if she was able to provide any care for R4 that morning and she said she did turn her but did not do a brief check or change. CNA I said R4 ate and she feeds herself. CNA I said the only thing she had time to do was answer call lights. CNA I told RN G she was exhausted and needed to take her lunch. She said she would take her 30-minute lunch in her car so he could sleep. If she did not return in 30 minutes CNA I wanted RN G to send someone to the parking lot to wake her up. On 11/23/21 at 10:46 AM, R4 was observed in bed sleeping on her right side with a pillow under her left chest area and her catheter bag remained on the floor. On 11/23/21 at 11:24 AM, R4 was observed in bed and CNA I and J had just started care. R4 was on her right side and the CNAs were just starting to remove R4's brief. R4's brief and sheet were soiled with BM (bowel movement). R 4 said she had not been changed since yesterday. CNA I and J confirmed they had started work at 6:00 AM today and this was the first time they had time to change her brief. CNA J said she was pulled at 7:30 AM to help a resident going out on an appointment. CNA I again said she was the only one providing care for all the residents on this hall when CNA J was pulled to assist a resident going out to an appointment. CNA I was not able to recall what time it was when she turned R4 on her right side. R4's entire right side was bright red. R4 said she reports not being changed and turned to the nurses but nothing every gets done. CNA I and J confirmed R4 frequently makes these complaints about night shift and they also report these concerns to management, but nothing gets done. R7 Review of R7's face sheet and electronic medical record revealed she admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R7's care plan revealed under COGNITION: My cognition at times does fluctuate. Due to my diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Under the section ADL/BOWEL/BLADDER/MOBILITY interventions include: toileting to be completed at 2:30 a.m., 4:40 a.m., and upon request throughout the rest if the day. For toilet use, R7 was noted as needing the extensive assistance of 1-2 staff. Under the focus area of FALLS R7 had an intervention of 15 minute checks . and anticipate and meet my needs. Under the focus area of PAIN interventions include: Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. On 11/24/21 at approximately 1:35 AM, while walking past R7's room, R7 could be heard moaning and a strong odor of feces was detected from the doorway. An interview was completed with R7, who was grimacing and squirming in her bed. R7 stated it hurts where I poop, please help. R7 was asked if she was wet or soiled and she stated that she had a bowel movement and can't remember when I was last helped, please get someone it hurts so bad down there. CNA (Certified Nursing Assistant) D was found in the hall and she was informed R7 stated she was in pain in her peri area, was soiled with feces and needed incontinence care. CNA D stated I just changed her at 1:10 PM and she had a BM (bowel movement). R7's room was entered with CNA D, the room had a strong smell of feces. CNA D asked the resident if she needed pain cream for her bottom and the R7 stated yes. CNA D did not ask if the resident needed incontinence care or check R7's brief despite there being a strong scent of feces in the room and being told by the surveyor that R7 was soiled, before exiting the room to get the nurse for pain cream. After CNA D left the room, R7 continued to grimace and discuss how much pain she was in and that she needed to be changed. Nurse F entered the room a few minutes later with a pain cream and turned R7 to apply the cream, when R7 was turned, it was observed she was soiled with feces that had soaked through her brief and to the bed pad. Nurse F informed R7 that she would need to find the aide to come back to assist R7 to be cleaned up. At approximately 1:50 AM CNA D and CNA E entered the room to begin incontinence care for R7. R5 Review of R5's face sheet and electronic medical record revealed he initially admitted to the facility on [DATE] and most recently admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of R5's medical records revealed in skin and wound assessments, R5 had an area of his right buttock that developed moisture associated skin damage (MASD) on 11/24/21. R5 also had a Stage 2 pressure ulcer on his sacrum that was discovered by the facility on 12/1/21. Review of R5's care plan revealed an intervention under focus area falls: anticipate and meet my needs. Under focus area of pain, interventions include: anticipate my need for pain relief and respond immediately to any complaint of pain. Under focus area of pressure injury, interventions included I am able to turn and reposition per self- Assist me as needed with turning and repositioning and encourage me to reposition frequently. The Stage II sacrum pressure ulcer was noted as a focus area, no new interventions were added after 12/1/21 related to this focus area. Under the focus area of skin integrity, MASD of the right buttock was noted on 11/24/21 as well as the stage II pressure ulcer to the sacrum. A roho cushion to wheelchair was added by the facility as an intervention on 12/1/21. On 12/1/21 at 10:29 AM, R5 was observed in his room sitting in a wheelchair on a standard black seat cushion. R 5 complained of his butt hurting. R5 was assisted to bed by Registered Nurse (RN) P and Certified Nurse Aide (CNA) T. CNA T removed R5's pants and incontinence brief. R5 had a 1-inch area of smeared bowel movement (BM) on his right buttock near his anus. CNA T said she took him to the toilet about 30 minutes ago and must have not got him completely clean. R5 buttock had a 3 inch non blanchable area around his coccyx and anus area that he said was painful. There was a small open area within the red area approximately 2 cm in diameter. R5 was agreeable to return to the bathroom to get cleaned up. CNA T said R5 was up in his wheelchair when she did rounds at 6:00 AM. RN P was asked when R 5 is able get pressure off his buttock and she said he stays in his wheelchair when he is awake because he is a fall risk. He is provided pressure relief about every 2 hours when he uses the toilet. Per email on 12/3/21 at 8:18 AM with the DON (Director of Nursing), interventions related to R5's sacrum and buttock skin integrity included: On 11/24/21, area was cleansed and protective ointment was initiated. Resident already had air mattress in place. 8/30/21 Roho cushion was put into chair on 12/1/21. Broda chair with cushion was put into place today for positioning. 12/2/21.

This citation pertains to intakes MI 338, MI 992, MI 708, and MI 711: Based on observations, interview and record review, the facility failed to prevent skin break down for 3 residents (R5, R6 and R8) of 5 Residents reviewed, resulting in R6 developing a large unstageable ulcer on his buttock, R8 developing multiple stage II ulcers on her buttock and between her legs and R5 developing a stage 1 and a stage II ulcer on his buttock. Findings include: R6 Review of R6's face sheet dated 11/23/21 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R 6 was not his own responsible party. On 12/1/21 at 9:20 AM, R6 was observed in bed. He was on his back and the head of bed was elevated 30 to 40 degrees and he was covered with a blanket. Registered Nurses (RN) O and P (were in his room attempting to reinsert an IV (Intravenous) line. They reported he had pulled it out this morning and they were not able to get it back in. They said they were contacting another nurse in the facility and if they were not able to get it started, they would send him to the emergency room . R6 was complaining of pain in his buttock at that time. The Surveyor asked R6 if she could look at his buttock with the nurses to see if they could determine the cause of his pain. R6 agreed. R6 yelled out in pain several times with lowing the head of his bed and turning him. When the nurses removed R6's brief it was soiled with bowel movement but not wet. There was no indication he had soiled himself until the brief was pulled back. There was a large white pad/dressing placed over R6's left hip. No date or time was visible on the dressing. When the dressing was removed there was a large area, approximately 4 inches by 2 inches of black tissue with a bright red border. RN O called for a CNA to come into clean R 6 up. RN O said she had 3 CNA's on her unit since 6:00 AM and normally had 2 CNA's. RN O the CNAs were L, M, and N. On 12/1/21 at approximately 9:30 AM, CNA M came to R6's room to clean him up. CNA M said she had not seen R6's buttock prior to this time today. RN O started helping CNA M clean up R6 and when CNA N arrived RN O instructed them to finish cleaning him up and off load his buttock on the left. CNA N said she had not seen R6 buttock prior to this time today and confirmed she started at 6:00 AM. Once R6 was cleaned up and new brief was on, he was placed on his back and two bed pillows were tucked in between the mattress and his hips. There was a pillow under each hip which placed pressure directly on the large wound on R6's left hip and increased pressure to his right hip. This prevented any rolling or contact of the specialty pressure reliving mattress to the pressure ulcer area. The Surveyor questioned the CNA's as they had just been instructed to off load pressure from R6's left hip. Both CNAs responded the facility had educated them that this was how to off load the buttock. They were not able to recall who educated them or when they were educated. On 12/1/21 at 9:50 AM, RN O was at the nurse's station. RN O reviewed R6's wound assessments documented in the electronic medical record (EMR). There was a picture of the wound on R6's left hip that was measured at greater than 9 cm x 4 cm and was covered with eschar (black tissue). The wound was labeled as a stage II ulcer. The Surveyor asked RN O if that was a stage II ulcer and RN O responded no it is unstageable. When questioning how it could be mislabeled RN O explained she had made the error when it changed from a stage II to unstageable. RN O went on to explain when she has days off agency nurses cover for her and they do not know how to run the camera or how to do many of the things that need to be done. When RN O returns to work she has to do the work of 2 nurses due to all of the things that were not completed when she was off. RN O was frustrated about her workload that contributed to her charting error. The Surveyor told RN O that the CNAs had placed pillows under both sides of R6's buttock and had told the Surveyor this is how the facility had educated them to off load resident to prevent pressure ulcers. RN O verified R6's pressure ulcer was not off loaded as she had instructed. RN O called CNA M, N and L to R6's room and instructed/assisted them to remove the pillows and place one pillow under R6's back on the left side above the pressure ulcer. This turned him to his right side and left air space between his left buttock and mattress. RN O had no idea who had trained the CNAs to do pressure relief incorrectly. CNA L said he had not seen R6's buttock that morning. On 12/1/21 at approximately 11:00 AM, after R6 was placed on his right side and his brief was changed, he reported he had no pain. Review of R6's Skin Integrity care plan dated 10/25/21 revealed, I have actual impairment of my skin integrity r/t incontinence, impaired mobility. I am weak and in need of assistance for all ADL's (activities of daily living). I have been noted to be confused at times. I am non ambulatory (cannot walk) and my main source of locomotion in my room and on the unit is my wheelchair. I prefer to sleep in my recliner chair. Review of R6's Pressure Ulcer care plan dated 11/23/21 revealed, I have a pressure ulcer to my L (left) ischial tuberosity (hip). I am receiving ATB (antibiotic) form my wound and I have been referred to the wound clinic for follow up care. No special instructions for pressure relief were located. A power turn mattress was applied to the bed. (Standard of care is to turn, reposition and check for incontinence at least every 2 hours). Observations and interview conducted the morning of 12/1/21 indicated he had gone more than 2 hours without his brief check for BM. He was not provided pressure relief as instructed by the RN in charge. Review of R6's facility timeline for his skin break down revealed. The facility did not identify any skin break down until 11/14/21. They identified a stage II left ischial tuberosity that was 3.5 cm x 2.7 cm. On 11/21/21 it measured 5.5 x 4.7 cm and was a stage II, and on 11/29/21 it measured 9.9 cm x 4.3 cm and was changed to an unstageable. Review of R6's electronic medical record revealed in the wound section a photo a wound on his left ischial tuberosity the covered and area 6.9 cm was 3.45 cm in length and 2.7 cm with width, O at the deepest point. On 11/21 the wound was 17 cm in area, 5.45 in length and 4.7 cm in width. On 11/29/21 the area was 30 cm by 9.85 cm in length and 4.3 cm in width it was covered with black tissue and documented as unstageable. Review of a New Pressure report for R6 dated 11/14/21 at 22:20 (10:20 PM) revealed, This nurse noted residents urine smell and asked staff to help get him to the bathroom. When resident pants were pulled down an area to the left ischial tuberosity was noted. Area measures 3.5 cm x 2.7 cm. Area cleansed with soap and water and [MEDICATION(S)] (dressing) applied. Nurse manager and DON called and made aware. Name of physician made aware by fax. Review of R6's ADL (activity of daily living)/mobility/toileting care plan dated initiated 12/16/21 revealed he could not walk, transfers required extensive assistance of 1, bed mobility was extensive assistance of 1,1 toilet use was extensive assistance of one with commode over toilet and urinal has been noted to spill at times. Per review of R6's electronic medical record, he was sent to the emergency roiagnom on [DATE]. Review of R6's CT scan dated 12/1/21 at 1:50 PM revealed, There is a posterior gluteal fold ulceration with significant induration and [CONDITION(S)] and skin thickening. There is focal induration and fluid collection measuring 9.2 cm x 4.3 cm x 12.5 cm suggestion abscess. Review of R6's emergency room report dated 12/1/21 at 4:25 PM revealed, he had an ulceration along the left gluteal crease with [CONDITION(S)] and large abscess (infection)in the subcutaneous soft tissue extending to the deep fascia (tissue) measuring 12.5 cm. The plan was to do debridement (remove dead and infected tissue) of the wound 12/2/21. Under Number of diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Discussed CT findings of abscess underlying gluteal ulcer and resultant [CONDITION(S)] with surgery. Patient to be admitted for surgical debridement as well as IV Abx (antibiotic's). R8 Review of R 8's face sheet dated 12/1/21, revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was her own responsible party. On 11/23/21 at 10:15 AM, the Surveyor was not able to locate staff working on R8's nursing unit. Registered Nurse (RN) G was at the nurse's station and said she was just getting started on the unit. RN G was not able to locate a staffing list at the nurse's station. RN G went down the hall to the medication cart and was not able to locate a staffing sheet. RN G started going room to room to look for staff. At approximately 10:25 AM Certified Nurse Aide (CNA) I walked out of a resident room. CNA I said she had been the only person working on the unit all morning as CNA J was pulled to go to an appointment and CNA H was pulled to help but CNA H was not familiar with the residents on the unit, so she was not much help. CNA I said CNA H went back to whatever unit she was pulled from. CNA I was asked if she was able to provide any care for R4 that morning and she said she did turn her but did not do a brief check or change. CNA I said R4 ate and she feeds herself. CNA I said the only thing she had time to do was answer call lights. CNA I told RN G she was exhausted and needed to take her lunch. She said she would take her 30-minute lunch in her car so he could sleep. If she did not return in 30 minutes CNA I wanted RN G to send someone to the parking lot to wake her up. CNA I did not indicate she had provided any care for R8 at this time. On 11/23/21 at 10:49 AM, R8's call light was observed to be on. At 10:54 AM a housekeeper went in R8's room and turned off her call light. The housekeeper reported R8 wanted to get out of bed. At 10:56 AM, R8 turned her call light on again. At 11:06 AM, CNA I went into her room, turned off the call light. CNA I said R8 wanted to get up, but R8 normally did not get out of bed so CNA I went to the computer on the wall to see how to get R8 out of bed. CNA I said she had not provided any care for R8 that morning. After she checked the computer, she went to another resident's room to answer a call light. A few minutes later CNA B and CNA H went to R8's room and said they had been pulled from other units to do care. CNA B said she started at 6:00 AM on 1 South. CNA B said when she made rounds that morning, she found all of her residents soiled and care had not been provided by night shift. CNA B said night shift is from 6:00 PM to 6:00 AM and most of the staff are agency. CNA B said she reported this neglect to her charge nurse Licensed Practical Nurse (LPN) K and directly to the Director of Nursing (DON). CNA B said this has been an ongoing issue. CNA B said she reports it, but nothing happens. On 11/23/21 at approximately 11:15 AM, the surveyor introduced herself to R8 and asked if she could watch care. R8 agreed to the observation. CNA B and H pulled back R8's blanket and R8 had a shirt and an incontinence brief on. The brief was completely soaked through with urine and bowel movement (BM). As the CNA's turned R 8 to provide incontinence care R8 cried out in pain multiple times. R8's soaker pad and sheet were saturated with urine and BM. The wet stain on the sheet went all the way up her back and past her buttock. When the brief was removed R8 had multiple open bloody areas between her legs and at least 10 open bloody areas on her buttock. R8 constantly cried out in pain and the CNAs cleaned her and changed her complete bedding. R8 said the last time she was changed was yesterday morning. R8 said she complains to the nurses about not getting changed but nothing happens. CNA B and H confirmed they have complained to management multiple times about this resident not getting changed and nothing happens. R8's shirt was covered in dry skin and her face had dried crusted material on it. R8 said she could not recall the last time she had a shower but would take one anytime they would give her one. Review of R8's progress noted dated 11/23/21 at 6:25 PM revealed, R 8 had multiple small open areas to her right and left ischial tuberosities (buttock bone areas). Physician was notified and R 8 declined to have her family notified. A wound dressing was applied for 3 days. Review of R8's incontinence record revealed that on 11/22/21 R 8 was incontinent at 5:38 AM and 1:52 PM. No refusal of incontinent care was recorded on 11/22/21. (R8 only received incontinence care 2 times on 11/22/21 according to her medical record documentation). Review of R8's incontinence record for 11/23/21 revealed she was incontinent at 5:38 AM and again at 11:17 PM. There was no indication of refusal of incontinence care on 11/23/21. There was no record of the incontinence care the Surveyor observed at 11:15 AM. Review of R8's incontinence record from 11/18/21 to 11/23/21 only showed R8 was incontinent between 1 and 4 times a day. R8 refused incontinent care 1 time on 11/18/21, 11/20/21, and 11/22/21. Review of R8's incontinence record for 11/24/21 (2 day after receiving an IJ for lack of incontinence care) R8 was only recorded to be incontinent 1 time at 7:20 AM. She had no refusals documented. Review of R8's incontinence record from 11/23/21 to 11/30/21 revealed no refusal of incontinence care form 11/24/21 until 11/30/21. Review of R8's progress note dated 11/24/21 at 9:41 PM revealed, Resident not fully herself in this recovery from COVID, still very tired throughout the shift. Reported to this nurse by CNAs that resident very hesitant and refusing most transfers out of her chair due to lethargy. During an interview with R8 on 11/30/21 at 2:04 PM, R8 was awake in bed, well-groomed and smiling. The Surveyor asked her if she had been refusing to let staff turn her or change her brief. R8 said when I am sleeping, and they come in to do care I am get confused sometimes. I know my butt is hurting because I do not get cleaned or turned. I really want them to clean me up and turn me even if I say, No. They have been doing a better job and my butt is getting better. Asked R8 if I could have the DON come talk to her so she could explain what she wanted staff to do, R8 agreed. DON returned with the Surveyor a few minutes later and R8 repeated what she told the Surveyor. The DON said they had just started documenting on paper when people get turned and cleaned. The DON said if they show you the sheet so you can see the last time, they did care would that work. R 8 agreed. Review of R8's skin audit dated 11/23/21 no time revealed no skin issues on her buttock. 4 small circles were placed on the picture of the left inner thigh and scattered abrasions was written in with an arrow to the circles. This skin audit did not match the Surveyors observation during care the morning of 11/23/21 or the progress note dated 11/23/21 at 6:25 PM. The facility provided skin audits as part of the IJ removal. The DON was informed R8's skin audit done for the IJ removal did not match observations on 11/23/21 or 11/30/21. The DON was asked to address the accuracy of skin audits and documentation. Upon exit on 12/3/21 the DON did not provide any updated audits or information on correcting audits that had been completed. R5 Review of R5's face sheet and electronic medical record revealed he initially admitted to the facility on [DATE] and most recently admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of R5's medical records revealed in skin and wound assessments, R5 had an area of his right buttock that developed moisture associated skin damage (MASD) on 11/24/21. R5 also had a Stage 2 pressure ulcer on his sacrum that was discovered by the facility on 12/1/21. Review of R5's care plan revealed an intervention under focus area falls: anticipate and meet my needs. Under focus area of pain, interventions include: anticipate my need for pain relief and respond immediately to any complaint of pain. Under focus area of pressure injury, interventions included I am able to turn and reposition per self- Assist me as needed with turning and repositioning and encourage me to reposition frequently. The Stage II sacrum pressure ulcer was noted as a focus area, no new interventions were added after 12/1/21 related to this focus area. Under the focus area of skin integrity, MASD of the right buttock was noted on 11/24/21 as well as the stage II pressure ulcer to the sacrum. A roho cushion to wheelchair was added by the facility as an intervention on 12/1/21. On 12/1/21 at 10:29 AM, R5 was observed in his room sitting in a wheelchair on a standard black seat cushion. R5 complained of his butt hurting. R5 was assisted to bed by Registered Nurse (RN) P and Certified Nurse Aide (CNA) T. CNA T removed R5's pants and incontinence brief. R5 had a 1-inch area of smeared bowel movement (BM) on his right buttock near his anus. CNA T said she took him to the toilet about 30 minutes ago and must have not got him completely clean. R5 buttock had a 3 inch non blanchable area around his coccyx and anus area that he said was painful. There was a small open area within the red area approximately 2 cm in diameter. R5 was agreeable to return to the bathroom to get cleaned up. CNA T said R5 was up in his wheelchair when she did rounds at 6:00 AM. RN P was asked when R5 is able get pressure off his buttock and she said he stays in his wheelchair when he is awake because he is a fall risk. He is provided pressure relief about every 2 hours when he uses the toilet. Per email on 12/3/21 at 8:18 AM with the DON (Director of Nursing) interventions related to R5's sacrum and buttock skin integrity included: On 11/24/21, area was cleansed and protective ointment was initiated. Resident already had air mattress in place. 8/30/21 Roho cushion was put into chair on 12/1/21. Broda chair with cushion was put into place today for positioning. 12/2/21.

This citation pertains to intakes MI 338, MI 992, MI 708, and MI 711: Based on observation, interview and record review the facility failed to provided adequate pressure relieve and incontinence care for 4 Residents (R5, R6, R7 and R8) resulting in them experiencing high levels of pain during extended periods of time when they were left soiled and/or did not receive pressure relief. Findings include: R 6 Review of R6's face sheet dated 11/23/21 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6 was not his own responsible party. On 12/1/21 at 9:20 AM, R6 was observed in bed. He was on his back and the head of bed was elevated 30 to 40 degrees and he was covered with a blanket. Registered Nurses (RN) O and P (were in his room attempting to reinsert an IV (Intravenous) line. They reported he had pulled it out this morning and they were not able to get it back in. They said they were contacting another nurse in the facility and if they were not able to get it started, they would send him to the emergency room . R6 was complaining of pain in his buttock at that time. The Surveyor asked R6 if she could look at his buttock with the nurses to see if they could determine the cause of his pain. R6 agreed. R6 yelled out in pain several times with lowing the head of his bed and turning him. When the nurses removed R6's brief it was soiled with bowel movement but not wet. There was no indication he had soiled himself until the brief was pulled back. There was a large white pad/dressing placed over R6's left hip. No date or time was visible on the dressing. When the dressing was removed there was a large area, approximately 4 inches by 2 inches of black tissue with a bright red border. RN O called for a CNA to come into clean R6 up. RN O said she had 3 CNA's on her unit since 6:00 AM and normally had 2 CNA's. RN O the CNAs were L, M, and N. On 12/1/21 at approximately 9:30 AM, CNA M came to R6's room to clean him up. CNA M said she had not seen R6's buttock prior to this time today. RN O started helping CNA M clean up R6 and when CNA N arrived, RN O instructed them to finish cleaning him up and off load his buttock on the left. CNA N said she had not seen R6 buttock prior to this time today and confirmed she started at 6:00 AM. Once R6 was cleaned up and new brief was on, he was placed on his back and two bed pillows were tucked in between the mattress and his hips. There was a pillow under each hip which placed pressure directly on the large wound on R6's left hip and increased pressure to his right hip. This prevented any rolling or contact of the specialty pressure reliving mattress to the pressure ulcer area. The Surveyor questioned the CNA's as they had just been instructed to off load pressure from R6's left hip. Both CNAs responded the facility had educated them that this was how to off load the buttock. They were not able to recall who educated them or when they were educated. On 12/1/21 at 9:50 AM, RN O was at the nurse's station. RN O reviewed R6's wound assessments documented in the electronic medical record (EMR). There was a picture of the wound on R6's left hip that was measured at greater than 9 cm x 4 cm and was covered with eschar (black tissue). The wound was labeled as a stage II ulcer. The Surveyor asked RN O if that was a stage II ulcer and RN O responded no it is unstageable. When questioning how it could be mislabeled RN O explained she had made the error when it changed from a stage II to unstageable. RN O went on to explain when she has days off agency nurses cover for her and they do not know how to run the camera or how to do many of the things that need to be done. When RN O returns to work she has to do the work of 2 nurses due to all of the things that were not completed when she was off. RN O was frustrated about her workload that contributed to her charting error. The Surveyor told RN O that the CNAs had placed pillows under both sides of R6's buttock and had told the Surveyor this is how the facility had educated them to off load resident to prevent pressure ulcers. RN O verified R6's pressure ulcer was not off loaded as she had instructed. RN O called CNA M, N and L to R6's room and instructed/assisted them to remove the pillows and place one pillow under R6's back on the left side above the pressure ulcer. This turned him to his right side and left air space between his left buttock and mattress. RN O had no idea who had trained the CNAs to do pressure relief incorrectly. CNA L said he had not seen R6's buttock that morning. On 12/1/21 at approximately 11:00 AM, after R6 was placed on his right side and his brief was changed, he reported he had no pain. Review of R6's Skin Integrity care plan dated 10/25/21 revealed, I have actual impairment of my skin integrity r/t incontinence, impaired mobility. I am weak and in need of assistance for all ADL's (activities of daily living). I have been noted to be confused at times. I am non ambulatory (cannot walk) and my main source of locomotion in my room and on the unit is my wheelchair. I prefer to sleep in my recliner chair. Review of R6's Pressure Ulcer care plan dated 11/23/21 revealed, I have a pressure ulcer to my L (left) ischial tuberosity (hip). I am receiving ATB (antibiotic) form my wound and I have been referred to the wound clinic for follow up care. No special instructions for pressure relief were located. A power turn mattress was applied to the bed. (Standard of care is to turn, reposition and check for incontinence at least every 2 hours). Observations and interview conducted the morning of 12/1/21 indicated he had gone more than 2 hours without his brief check for BM. He was not provided pressure relief as instructed by the RN in charge. Review of R6's facility timeline for his skin break down revealed. The facility did not identify any skin break down until 11/14/21. They identified a stage II left ischial tuberosity that was 3.5 cm x 2.7 cm. On 11/21/21 it measured 5.5 x 4.7 cm and was a stage II, and on 11/29/21 it measured 9.9 cm x 4.3 cm and was changed to an unstageable. Review of R6's electronic medical record revealed in the wound section a photo a wound on his left ischial tuberosity the covered and area 6.9 cm was 3.45 cm in length and 2.7 cm with width, O at the deepest point. On 11/21 the wound was 17 cm in area, 5.45 in length and 4.7 cm in width. On 11/29/21 the area was 30 cm by 9.85 cm in length and 4.3 cm in width it was covered with black tissue and documented as unstageable. Review of a New Pressure report for R 6 dated 11/14/21 at 22:20 (10:20 PM) revealed, This nurse noted residents urine smell and asked staff to help get him to the bathroom. When resident pants were pulled down an area to the left ischial tuberosity was noted. Area measures 3.5 cm x 2.7 cm. Area cleansed with soap and water and [MEDICATION(S)] (dressing) applied. Nurse manager and DON called and made aware. Name of physician made aware by fax. Review of R6's ADL (activity of daily living)/mobility/toileting care plan dated initiated 12/16/21 revealed he could not walk, transfers required extensive assistance of 1, bed mobility was extensive assistance of 1,1 toilet use was extensive assistance of one with commode over toilet and urinal has been noted to spill at times. Per review of R6's electronic medical record, he was sent to the emergency roiagnom on [DATE]. Review of R6's CT scan dated 12/1/21 at 1:50 PM revealed, There is a posterior gluteal fold ulceration with significant induration and [CONDITION(S)] and skin thickening. There is focal induration and fluid collection measuring 9.2 cm x 4.3 cm x 12.5 cm suggestion abscess. Review of R6's emergency room report dated 12/1/21 at 4:25 PM revealed, he had an ulceration along the left gluteal crease with [CONDITION(S)] and large abscess (infection)in the subcutaneous soft tissue extending to the deep fascia (tissue) measuring 12.5 cm. The plan was to do debridement (remove dead and infected tissue) of the wound 12/2/21. Under Number of diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Discussed CT findings of abscess underlying gluteal ulcer and resultant [CONDITION(S)] with surgery. Patient to be admitted for surgical debridement as well as IV Abx (antibiotic's). R8 Review of R8's face sheet dated 12/1/21, revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was her own responsible party. On 11/23/21 at 10:15 AM, the Surveyor was not able to locate staff working on R8's nursing unit. Registered Nurse (RN) G was at the nurse's station and said she was just getting started on the unit. RN G was not able to locate a staffing list at the nurse's station. RN G went down the hall to the medication cart and was not able to locate a staffing sheet. RN G started going room to room to look for staff. At approximately 10:25 AM Certified Nurse Aide (CNA) I walked out of a resident room. CNA I said she had been the only person working on the unit all morning as CNA J was pulled to go to an appointment and CNA H was pulled to help but CNA H was not familiar with the residents on the unit, so she was not much help. CNA I said CNA H went back to whatever unit she was pulled from. CNA I was asked if she was able to provide any care for R4 that morning and she said she did turn her but did not do a brief check or change. CNA I said R4 ate and she feeds herself. CNA I said the only thing she had time to do was answer call lights. CNA I told RN G she was exhausted and needed to take her lunch. She said she would take her 30-minute lunch in her car so he could sleep. If she did not return in 30 minutes CNA I wanted RN G to send someone to the parking lot to wake her up. CNA I did not indicate she had provided any care for R8 at this time. On 11/23/21 at 10:49 AM, R8's call light was observed to be on. At 10:54 AM, a housekeeper went in R8's room and turned off her call light. The housekeeper reported R8 wanted to get out of bed. At 10:56 AM, R8 turned her call light on again. At 11:06 AM, CNA I went into her room, turned off the call light. CNA I said R8 wanted to get up, but R8 normally did not get out of bed so CNA I went to the computer on the wall to see how to get R8 out of bed. CNA I said she had not provided any care for R8 that morning. After she checked the computer, she went to another resident's room to answer a call light. A few minutes later CNA B and CNA H went to R8's room and said they had been pulled from other units to do care. CNA B said she started at 6:00 AM on 1 South. CNA B said when she made rounds that morning, she found all of her residents soiled and care had not been provided by night shift. CNA B said night shift is from 6:00 PM to 6:00 AM and most of the staff are agency. CNA B said she reported this neglect to her charge nurse Licensed Practical Nurse (LPN) K and directly to the Director of Nursing (DON). CNA B said this has been an ongoing issue. CNA B said she reports it, but nothing happens. On 11/23/21 at approximately 11:15 AM the surveyor introduced herself to R8 and asked if she could watch care. R8 agreed to the observation. CNA B and H pulled back R8's blanket and R8 had a shirt and an incontinence brief on. The brief was completely soaked through with urine and bowel movement (BM). As the CNA's turned R8 to provide incontinence care R8 cried out in pain multiple times. R8's soaker pad and sheet were saturated with urine and BM. The wet stain on the sheet went all the way up her back and past her buttock. When the brief was removed R8 had multiple open bloody areas between her legs and at least 10 open bloody areas on her buttock. R8 constantly cried out in pain and the CNAs cleaned her and changed her complete bedding. R8 said the last time she was changed was yesterday morning. R8 said she complains to the nurses about not getting changed but nothing happens. CNA B and H confirmed they have complained to management multiple times about this resident not getting changed and nothing happens. R8's shirt was covered in dry skin and her face had dried crusted material on it. R8 said she could not recall the last time she had a shower but would take one anytime they would give her one. Review of R8's progress noted dated 11/23/21 at 6:25 PM revealed, R8 had multiple small open areas to her right and left ischial tuberosities (buttock bone areas). Physician was notified and R8 declined to have her family notified. A wound dressing was applied for 3 days. Review of R8's incontinence record revealed that on 11/22/21 R 8 was incontinent at 5:38 AM and 1:52 PM. No refusal of incontinent care was recorded on 11/22/21. (R 8 only received incontinence care 2 times on 11/22/21 according to her medical record documentation). Review of R8's incontinence record for 11/23/21 revealed she was incontinent at 5:38 AM and again at 11:17 PM. There was no indication of refusal of incontinence care on 11/23/21. There was no record of the incontinence care the Surveyor observed at 11:15 AM. Review of R8's incontinence record from 11/18/21 to 11/23/21 only showed R 8 was incontinent between 1 and 4 times a day. R8 refused incontinent care 1 time on 11/18/21, 11/20/21, and 11/22/21. Review of R8's incontinence record for 11/24/21 (2 day after receiving an IJ for lack of incontinence care) R8 was only recorded to be incontinent 1 time at 7:20 AM. She had no refusals documented. Review of R8's incontinence record from 11/23/21 to 11/30/21 revealed no refusal of incontinence care form 11/24/21 until 11/30/21. Review of R8's progress note dated 11/24/21 at 9:41 PM revealed, Resident not fully herself in this recovery from COVID, still very tired throughout the shift. Reported to this nurse by CNAs that resident very hesitant and refusing most transfers out of her chair due to lethargy. During an interview with R8 on 11/30/21 at 2:04 PM, R8 was awake in bed, well-groomed and smiling. The Surveyor asked her if she had been refusing to let staff turn her or change her brief. R8 said when I am sleeping, and they come in to do care I am get confused sometimes. I know my butt is hurting because I do not get cleaned or turned. I really want them to clean me up and turn me even if I say, No. They have been doing a better job and my butt is getting better. Asked R8 if I could have the DON come talk to her so she could explain what she wanted staff to do, R8 agreed. DON returned with the Surveyor a few minutes later and R8 repeated what she told the Surveyor. The DON said they had just started documenting on paper when people get turned and cleaned. The DON said if they show you the sheet so you can see the last time, they did care would that work. R8 agreed. Review of R 8's skin audit dated 11/23/21 no time revealed no skin issues on her buttock. 4 small circles were placed on the picture of the left inner thigh and scattered abrasions was written in with an arrow to the circles. This skin audit did not match the Surveyors observation during care the morning of 11/23/21 or the progress note dated 11/23/21 at 6:25 PM. The facility provided skin audits as part of the IJ removal. The DON was informed R8's skin audit done for the IJ removal did not match observations on 11/23/21 or 11/30/21. The DON was asked to address the accuracy of skin audits and documentation. Upon exit on 12/3/21 the DON did not provide any updated audits or information on correcting audits that had been completed. R7 Review of R7's face sheet and electronic medical record revealed she admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R7's care plan revealed under COGNITION: My cognition at times does fluctuate. Due to my diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Under the section ADL/BOWEL/BLADDER/MOBILITY interventions include: toileting to be completed at 2:30 a.m., 4:40 a.m., and upon request throughout the rest if the day. For toilet use, R7 was noted as needing the extensive assistance of 1-2 staff. Under the focus area of FALLS R7 had an intervention of 15 minute checks . and anticipate and meet my needs. Under the focus area of PAIN interventions include: Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. On 11/24/21 at approximately 1:35 AM, while walking past R7's room, R7 could be heard moaning and a strong odor of feces was detected from the doorway. An interview was completed with R7, who was grimacing and squirming in her bed. R7 stated it hurts where I poop, please help. R7 was asked if she was wet or soiled and she stated that she had a bowel movement and can't remember when I was last helped, please get someone it hurts so bad down there. CNA (Certified Nursing Assistant) D was found in the hall and she was informed R7 stated she was in pain in her peri area, was soiled with feces and needed incontinence care. CNA D stated I just changed her at 1:10 PM and she had a BM (bowel movement). R7's room was entered with CNA D, the room had a strong smell of feces. CNA D asked the resident if she needed pain cream for her bottom and the R7 stated yes. CNA D did not ask if the resident needed incontinence care or check R7's brief despite there being a strong scent of feces in the room and being told by the surveyor that R7 was soiled, before exiting the room to get the nurse for pain cream. After CNA D left the room, R7 continued to grimace and discuss how much pain she was in and that she needed to be changed. Nurse F entered the room a few minutes later with a pain cream and turned R7 to apply the cream, when R7 was turned, it was observed she was soiled with feces that had soaked through her brief and to the bed pad. Nurse F informed R7 that she would need to find the aide to come back to assist R7 to be cleaned up. At approximately 1:50 AM CNA D and CNA E entered the room to begin incontinence care for R7. R5 Review of R5's face sheet and electronic medical record revealed he initially admitted to the facility on [DATE] and most recently admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of R5's medical records revealed in skin and wound assessments, R5 had an area of his right buttock that developed moisture associated skin damage (MASD) on 11/24/21. R5 also had a Stage 2 pressure ulcer on his sacrum that was discovered by the facility on 12/1/21. Review of R5's care plan revealed an intervention under focus area falls: anticipate and meet my needs. Under focus area of pain, interventions include: anticipate my need for pain relief and respond immediately to any complaint of pain. Under focus area of pressure injury, interventions included I am able to turn and reposition per self- Assist me as needed with turning and repositioning and encourage me to reposition frequently. The Stage II sacrum pressure ulcer was noted as a focus area, no new interventions were added after 12/1/21 related to this focus area. Under the focus area of skin integrity, MASD of the right buttock was noted on 11/24/21 as well as the stage II pressure ulcer to the sacrum. A roho cushion to wheelchair was added by the facility as an intervention on 12/1/21. On 12/1/21 at 10:29 AM, R5 was observed in his room sitting in a wheelchair on a standard black seat cushion. R5 complained of his butt hurting. R5 was assisted to bed by Registered Nurse (RN) P and Certified Nurse Aide (CNA) T. CNA T removed R5's pants and incontinence brief. R5 had a 1-inch area of smeared bowel movement (BM) on his right buttock near his anus. CNA T said she took him to the toilet about 30 minutes ago and must have not got him completely clean. R5 buttock had a 3 inch non blanchable area around his coccyx and anus area that he said was painful. There was a small open area within the red area approximately 2 cm in diameter. R5 was agreeable to return to the bathroom to get cleaned up. CNA T said R5 was up in his wheelchair when she did rounds at 6:00 AM. RN P was asked when R5 is able get pressure off his buttock and she said he stays in his wheelchair when he is awake because he is a fall risk. He is provided pressure relief about every 2 hours when he uses the toilet. Per email on 12/3/21 at 8:18 AM with the DON (Director of Nursing) interventions related to R5's sacrum and buttock skin integrity included: On 11/24/21, area was cleansed and protective ointment was initiated. Resident already had air mattress in place. 8/30/21 Roho cushion was put into chair on 12/1/21. Broda chair with cushion was put into place today for positioning. 12/2/21.

This citation pertains to intakes MI 338, MI 992, MI 417, MI 708, and MI 711: Based on observation, interview and record review, the facility failed to provide adequate trained nursing staff to ensure safe care for 5 Residents (R4, R5, R6, R7, R8) reviewed for abuse and Residents on 1 South that were left soiled on 11/23/21, resulting in residents experiencing pain, frustration, and skin breakdown. Findings include: R6 Review of R6's face sheet dated 11/23/21 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6 was not his own responsible party. On 12/1/21 at 9:20 AM, R6 was observed in bed. He was on his back and the head of bed was elevated 30 to 40 degrees and he was covered with a blanket. Registered Nurses (RN) O and P (were in his room attempting to reinsert an IV (Intravenous) line. They reported he had pulled it out this morning and they were not able to get it back in. They said they were contacting another nurse in the facility and if they were not able to get it started, they would send him to the emergency room . R6 was complaining of pain in his buttock at that time. The Surveyor asked R6 if she could look at his buttock with the nurses to see if they could determine the cause of his pain. R6 agreed. R6 yelled out in pain several times with lowing the head of his bed and turning him. When the nurses removed R6's brief it was soiled with bowel movement but not wet. There was no indication he had soiled himself until the brief was pulled back. There was a large white pad/dressing placed over R6's left hip. No date or time was visible on the dressing. When the dressing was removed there was a large area, approximately 4 inches by 2 inches of black tissue with a bright red border. RN O called for a CNA to come into clean R6 up. RN O said she had 3 CNA's on her unit since 6:00 AM and normally had 2 CNA's. RN O the CNAs were L, M, and N. On 12/1/21 at approximately 9:30 AM, CNA M came to R 6's room to clean him up. CNA M said she had not seen R6's buttock prior to this time today. RN O started helping CNA M clean up R6 and when CNA N arrived RN O instructed them to finish cleaning him up and off load his buttock on the left. CNA N said she had not seen R6 buttock prior to this time today and confirmed she started at 6:00 AM. Once R6 was cleaned up and new brief was on, he was placed on his back and two bed pillows were tucked in between the mattress and his hips. There was a pillow under each hip which placed pressure directly on the large wound on R6's left hip and increased pressure to his right hip. This prevented any rolling or contact of the specialty pressure reliving mattress to the pressure ulcer area. The Surveyor questioned the CNA's as they had just been instructed to off load pressure from R6's left hip. Both CNAs responded the facility had educated them that this was how to off load the buttock. They were not able to recall who educated them or when they were educated. On 12/1/21 at 9:50 AM, RN O was at the nurse's station. RN O reviewed R6's wound assessments documented in the electronic medical record (EMR). There was a picture of the wound on R6's left hip that was measured at greater than 9 cm x 4 cm and was covered with eschar (black tissue). The wound was labeled as a stage II ulcer. The Surveyor asked RN O if that was a stage II ulcer and RN O responded no it is unstageable. When questioning how it could be mislabeled RN O explained she had made the error when it changed from a stage II to unstageable. RN O went on to explain when she has days off agency nurses cover for her and they do not know how to run the camera or how to do many of the things that need to be done. When RN O returns to work she has to do the work of 2 nurses due to all of the things that were not completed when she was off. RN O was frustrated about her workload that contributed to her charting error. The Surveyor told RN O that the CNAs had placed pillows under both sides of R6's buttock and had told the Surveyor this is how the facility had educated them to off load resident to prevent pressure ulcers. RN O verified R6's pressure ulcer was not off loaded as she had instructed. RN O called CNA M, N and L to R6's room and instructed/assisted them to remove the pillows and place one pillow under R6's back on the left side above the pressure ulcer. This turned him to his right side and left air space between his left buttock and mattress. RN O had no idea who had trained the CNAs to do pressure relief incorrectly. CNA L said he had not seen R6's buttock that morning. On 12/1/21 at approximately 11:00 AM, after R6 was placed on his right side and his brief was changed, he reported he had no pain. Review of R6's Skin Integrity care plan dated 10/25/21 revealed, I have actual impairment of my skin integrity r/t incontinence, impaired mobility. I am weak and in need of assistance for all ADL's (activities of daily living). I have been noted to be confused at times. I am non ambulatory (cannot walk) and my main source of locomotion in my room and on the unit is my wheelchair. I prefer to sleep in my recliner chair. Review of R6's Pressure Ulcer care plan dated 11/23/21 revealed, I have a pressure ulcer to my L (left) ischial tuberosity (hip). I am receiving ATB (antibiotic) form my wound and I have been referred to the wound clinic for follow up care. No special instructions for pressure relief were located. A power turn mattress was applied to the bed. (Standard of care is to turn, reposition and check for incontinence at least every 2 hours). Observations and interview conducted the morning of 12/1/21 indicated he had gone more than 2 hours without his brief check for BM. He was not provided pressure relief as instructed by the RN in charge. Review of R6's facility timeline for his skin break down revealed. The facility did not identify any skin break down until 11/14/21. They identified a stage II left ischial tuberosity that was 3.5 cm x 2.7 cm. On 11/21/21 it measured 5.5 x 4.7 cm and was a stage II, and on 11/29/21 it measured 9.9 cm x 4.3 cm and was changed to an unstageable. Review of R6's electronic medical record revealed in the wound section a photo a wound on his left ischial tuberosity the covered and area 6.9 cm was 3.45 cm in length and 2.7 cm with width, O at the deepest point. On 11/21 the wound was 17 cm in area, 5.45 in length and 4.7 cm in width. On 11/29/21 the area was 30 cm by 9.85 cm in length and 4.3 cm in width it was covered with black tissue and documented as unstageable. Review of a New Pressure report for R6 dated 11/14/21 at 22:20 (10:20 PM) revealed, This nurse noted residents urine smell and asked staff to help get him to the bathroom. When resident pants were pulled down an area to the left ischial tuberosity was noted. Area measures 3.5 cm x 2.7 cm. Area cleansed with soap and water and [MEDICATION(S)] (dressing) applied. Nurse manager and DON called and made aware. Name of physician made aware by fax. Review of R6's ADL (activity of daily living)/mobility/toileting care plan dated initiated 12/16/21 revealed he could not walk, transfers required extensive assistance of 1, bed mobility was extensive assistance of 1,1 toilet use was extensive assistance of one with commode over toilet and urinal has been noted to spill at times. Per review of R6's electronic medical record, he was sent to the emergency roiagnom on [DATE]. Review of R6's CT scan dated 12/1/21 at 1:50 PM revealed, There is a posterior gluteal fold ulceration with significant induration and [CONDITION(S)] and skin thickening. There is focal induration and fluid collection measuring 9.2 cm x 4.3 cm x 12.5 cm suggestion abscess. Review of R6's emergency room report dated 12/1/21 at 4:25 PM revealed, he had an ulceration along the left gluteal crease with [CONDITION(S)] and large abscess (infection)in the subcutaneous soft tissue extending to the deep fascia (tissue) measuring 12.5 cm. The plan was to do debridement (remove dead and infected tissue) of the wound 12/2/21. Under Number of diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Discussed CT findings of abscess underlying gluteal ulcer and resultant [CONDITION(S)] with surgery. Patient to be admitted for surgical debridement as well as IV Abx (antibiotic's). R8 Review of R8's face sheet dated 12/1/21, revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was her own responsible party. On 11/23/21 at 10:15 AM, the Surveyor was not able to locate staff working on R8's nursing unit. Registered Nurse (RN) G was at the nurse's station and said she was just getting started on the unit. RN G was not able to locate a staffing list at the nurse's station. RN G went down the hall to the medication cart and was not able to locate a staffing sheet. RN G started going room to room to look for staff. At approximately 10:25 AM, Certified Nurse Aide (CNA) I walked out of a resident room. CNA I said she had been the only person working on the unit all morning as CNA J was pulled to go to an appointment and CNA H was pulled to help but CNA H was not familiar with the residents on the unit, so she was not much help. CNA I said CNA H went back to whatever unit she was pulled from. CNA I was asked if she was able to provide any care for R4 that morning and she said she did turn her but did not do a brief check or change. CNA I said R4 ate and she feeds herself. CNA I said the only thing she had time to do was answer call lights. CNA I told RN G she was exhausted and needed to take her lunch. She said she would take her 30-minute lunch in her car so he could sleep. If she did not return in 30 minutes CNA I wanted RN G to send someone to the parking lot to wake her up. CNA I did not indicate she had provided any care for R8 at this time. On 11/23/21 at 10:49 AM, R8's call light was observed to be on. At 10:54 AM, a housekeeper went in R8's room and turned off her call light. The housekeeper reported R 8 wanted to get out of bed. At 10:56 AM, R8 turned her call light on again. At 11:06 AM, CNA I went into her room, turned off the call light. CNA I said R8 wanted to get up, but R8 normally did not get out of bed so CNA I went to the computer on the wall to see how to get R8 out of bed. CNA I said she had not provided any care for R8 that morning. After she checked the computer, she went to another resident's room to answer a call light. A few minutes later CNA B and CNA H went to R8's room and said they had been pulled from other units to do care. CNA B said she started at 6:00 AM on 1 South. CNA B said when she made rounds that morning, she found all of her residents soiled and care had not been provided by night shift. CNA B said night shift is from 6:00 PM to 6:00 AM and most of the staff are agency. CNA B said she reported this neglect to her charge nurse Licensed Practical Nurse (LPN) K and directly to the Director of Nursing (DON). CNA B said this has been an ongoing issue. CNA B said she reports it, but nothing happens. On 11/23/21 at approximately 11:15 AM, the surveyor introduced herself to R8 and asked if she could watch care. R8 agreed to the observation. CNA B and H pulled back R8's blanket and R 8 had a shirt and an incontinence brief on. The brief was completely soaked through with urine and bowel movement (BM). As the CNA's turned R8 to provide incontinence care R8 cried out in pain multiple times. R8's soaker pad and sheet were saturated with urine and BM. The wet stain on the sheet went all the way up her back and past her buttock. When the brief was removed R8 had multiple open bloody areas between her legs and at least 10 open bloody areas on her buttock. R8 constantly cried out in pain and the CNAs cleaned her and changed her complete bedding. R8 said the last time she was changed was yesterday morning. R8 said she complains to the nurses about not getting changed but nothing happens. CNA B and H confirmed they have complained to management multiple times about this resident not getting changed and nothing happens. R8's shirt was covered in dry skin and her face had dried crusted material on it. R8 said she could not recall the last time she had a shower but would take one anytime they would give her one. Review of R8's progress noted dated 11/23/21 at 6:25 PM revealed, R8 had multiple small open areas to her right and left ischial tuberosities (buttock bone areas). Physician was notified and R8 declined to have her family notified. A wound dressing was applied for 3 days. Review of R8's incontinence record revealed that on 11/22/21 R 8 was incontinent at 5:38 AM and 1:52 PM. No refusal of incontinent care was recorded on 11/22/21. (R8 only received incontinence care 2 times on 11/22/21 according to her medical record documentation). Review of R8's incontinence record for 11/23/21 revealed she was incontinent at 5:38 AM and again at 11:17 PM. There was no indication of refusal of incontinence care on 11/23/21. There was no record of the incontinence care the Surveyor observed at 11:15 AM. Review of R8's incontinence record from 11/18/21 to 11/23/21 only showed R8 was incontinent between 1 and 4 times a day. R8 refused incontinent care 1 time on 11/18/21, 11/20/21, and 11/22/21. Review of R8's incontinence record for 11/24/21 (2 day after receiving an IJ for lack of incontinence care) R8 was only recorded to be incontinent 1 time at 7:20 AM. She had no refusals documented. Review of R8's incontinence record from 11/23/21 to 11/30/21 revealed no refusal of incontinence care form 11/24/21 until 11/30/21. Review of R8's progress note dated 11/24/21 at 9:41 PM revealed, Resident not fully herself in this recovery from COVID, still very tired throughout the shift. Reported to this nurse by CNAs that resident very hesitant and refusing most transfers out of her chair due to lethargy. During an interview with R8 on 11/30/21 at 2:04 PM, R8 was awake in bed, well-groomed and smiling. The Surveyor asked her if she had been refusing to let staff turn her or change her brief. R8 said when I am sleeping, and they come in to do care I am get confused sometimes. I know my butt is hurting because I do not get cleaned or turned. I really want them to clean me up and turn me even if I say, No. They have been doing a better job and my butt is getting better. Asked R8 if I could have the DON come talk to her so she could explain what she wanted staff to do, R8 agreed. DON returned with the Surveyor a few minutes later and R8 repeated what she told the Surveyor. The DON said they had just started documenting on paper when people get turned and cleaned. The DON said if they show you the sheet so you can see the last time, they did care would that work. R8 agreed. Review of R8's skin audit dated 11/23/21 no time revealed no skin issues on her buttock. 4 small circles were placed on the picture of the left inner thigh and scattered abrasions was written in with an arrow to the circles. This skin audit did not match the Surveyors observation during care the morning of 11/23/21 or the progress note dated 11/23/21 at 6:25 PM. The facility provided skin audits as part of the IJ removal. The DON was informed R8's skin audit done for the IJ removal did not match observations on 11/23/21 or 11/30/21. The DON was asked to address the accuracy of skin audits and documentation. Upon exit on 12/3/21 the DON did not provide any updated audits or information on correcting audits that had been completed. R4 Review of R 4's face sheet dated 11/23/21 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 was her own responsible party. On 11/23/21 at 10:11 AM, R4 was observed sleeping in bed and on turned to her right side. R4's catheter bag was on the floor on the left side of her bed. The catheter tubing and bag had a dark blue color. R4 did not respond when her name was called. There was a medication cart in the hall, but no staff were located on the hall. On 11/23/21 at 10:15 AM, the Surveyor was not able to locate staff working on R4's nursing unit. Registered Nurse (RN) G was at the nurse's station and said she was just getting started on the unit. RN G was not able to locate a staffing list at the nurse's station. RN G went down the hall to the medication cart and was not able to locate a staffing sheet. RN G started going room to room to look for staff. At approximately 10:25 AM, Certified Nurse Aide (CNA) I walked out of a resident room. CNA I said she had been the only person working on the unit all morning as CNA J was pulled to go to an appointment and CNA H was pulled to help but CNA H was not familiar with the residents on the unit, so she was not much help. CNA I said CNA H went back to whatever unit she was pulled from. CNA I was asked if she was able to provide any care for R 4 that morning and she said she did turn her but did not do a brief check or change. CNA I said R4 ate and she feeds herself. CNA I said the only thing she had time to do was answer call lights. CNA I told RN G she was exhausted and needed to take her lunch. She said she would take her 30-minute lunch in her car so he could sleep. If she did not return in 30 minutes CNA I wanted RN G to send someone to the parking lot to wake her up. On 11/23/21 at 10:46 AM, R4 was observed in bed sleeping on her right side with a pillow under her left chest area and her catheter bag remained on the floor. On 11/23/21 at 11:24 AM, R4 was observed in bed and CNA I and J had just started care. R4 was on her right side and the CNAs were just starting to remove R 4's brief. R 4's brief and sheet were soiled with BM (bowel movement). R4 said she had not been changed since yesterday. CNA I and J confirmed they had started work at 6:00 AM today and this was the first time they had time to change her brief. CNA J said she was pulled at 7:30 AM to help a resident going out on an appointment. CNA I again said she was the only one providing care for all the residents on this hall when CNA J was pulled to assist a resident going out to an appointment. CNA I was not able to recall what time it was when she turned R4 on her right side. R4's entire right side was bright red. R4 said she reports not being changed and turned to the nurses but nothing every gets done. CNA I and J confirmed R4 frequently makes these complaints about night shift and they also report these concerns to management, but nothing gets done. Review of R4's ADL/MOBILITY/Toileting care plan dated initiated 7/22/21 and revised on 11/30/21 revealed. As of 7/22/21 R4 required assistance extensive assistance of 2 people for bed mobility. Toileting schedule as of 2/3/20 was to offer and encourage bed pan and check and change every 2 hours. Toileting assistance was not offered the morning of 11/23/21 from 6:00 AM until 11:24 AM when she was found to be incontinent of bowel. R4 was observed in bed and awake on 11/30/21 at 10:15 AM, R4 reported staff were getting better at turning her and changing her brief, however nights was still the main problem. R4 said her brief had not been checked or changed yet this morning and she was agreeable to the Surveyor asking the CNA to check her brief. CNA Q came in a checked her brief. CNA did not have anyone assist her turn R4 or assist with removing her brief. When CNA Q pulled back R4's brief she found R 4 had a large solid BM. R4 said she did not know she had a BM as she has Multiple [CONDITION(S)] and cannot feel when she has a BM. R4 has a Foley catheter so the strip on the brief does not change colors to show it is soiled unless the BM is loose. CNA Q admitted she did not pull back R 4's brief to check it when she turned her earlier. CNA Q and the Surveyor had N95 masks on and could not smell the BM. The Surveyor asked CNA Q if R4 was a one assist for turning and brief change or two and CNA Q said she did not know as she had only cared for her once or twice prior to today. On 11/30/21 at 10:45 AM, the Surveyor told the DON, CNA Q did not visually check R 4 for a BM this morning and R 4 had a BM noted at 10:15 AM. CNA Q turned R4 and removed her brief without assistance. R4 still reported night staff were not consistently checking her brief and turning her. The DON checked R4's care plan and said she was a two assist with turning and brief change. The DON said she would educate CNA Q. The DON provided an Employee Discipline Form for CNA Q dated 11/30/21 that revealed, On 11/30/21 upon arriving for shift staff member was educated on ensuring residents care plans are followed to ensure residents care needs are met timely as well as ensuring residents are turned/repositioned and toileted/checked and changed for incontinence every two hours. Staff member stated understanding and acknowledged that she needed to turn/reposition and toilet/check and change resident at a minimum of every 2 hours. Staff member stated that she did not know what resident's care level was for bed mobility but did not proceed to finding out prior to providing care with x1 assist. Resident is care planned for assist x 2 for bed mobility. Staff member stated she knew how to check residents care levels by viewing the Kardex in PCC (electronic medical record). The box for verbal counseling was marked. On 11/23/21 at approximately 12:45 PM, the Surveyor asked the Director of Nursing (DON) if CNA B had reported to her this morning that the residents on 1 South were left soiled and did not get care last night. The DON said CNA B had reported that to her. The Surveyor asked if the DON if she had started the facility reported incident (FRI) the DON said, no. The Surveyor said to the DON, a CNA reported to you this morning residents on 1 South were left soiled and did not get care this morning, which is goods and services not provided. The DON said, yes. The Surveyor asked why she had not started the FRI and the DON said she decides if something in neglect and she had not determined that was neglect. The surveyor said she had observed the care of R 4 and R 8 on 1 North that morning. R8 was so soiled that it went through her brief, soaker pad and sheet. R8's thighs and buttock's had bloody sores from being left soiled so long and the Surveyors eyes were still burning from the urea in the room. The Surveyor could smell the BM through her N95 mask it was so strong. R8 reported she had not been changed since yesterday. R4 was also observed to be soiled and in pain. R4 also reported she had not been changed since yesterday. The DON did not have any other comments or questions. The DON did not take any notes and did not appear concerned. On 11/23/21 at approximately 12:50 PM, the Surveyor went to the Nursing Home Administrator's (NHA) office and reported all the same information to NHA that she had just provided to the DON. The NHA took a few notes, appeared very concerned and said she would take care of it. The NHA offered no explanation as to why the DON would not have started FRI process at 6:00 AM when she received the first allegation of neglect. The NHA did not provide any additional information until 4:17 PM when the facility was served and Immediate Jeopardy (IJ) for neglect. The NHA said we interviewed the Residents and none of them said they were neglected. They Surveyor referred to the information in the IJ notification that provided R4 and R8's condition that was observed and reported to her around 12:50 PM by the Surveyor, Resident and Staff statements on neglect and the facility failure to act on these complaints. The NHA offered no additional information. The facility did start a FRI related to R4 and R8's concerns that were provided to the DON and NHA on 11/23/21. The facility did not do an FRI on CNA B allegation of the neglect of Residents on 1 South that she reported around 6:00 AM on 11/23/21. The FRI reports did not include the Surveyors report of R4 and R8's physical condition, complaints of care or staff interviews conducted by the Surveyor. The investigation did not include incontinence care records or Resident progress notes or skin evaluations. The facility did not complete a thorough investigation, and it did not determine neglect had occurred for R4 or R8. R7 Review of R7's face sheet and electronic medical record revealed she admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R7's care plan revealed under COGNITION: My cognition at times does fluctuate. Due to my diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Under the section ADL/BOWEL/BLADDER/MOBILITY interventions include: toileting to be completed at 2:30 a.m., 4:40 a.m., and upon request throughout the rest if the day. For toilet use, R7 was noted as needing the extensive assistance of 1-2 staff. Under the focus area of FALLS R7 had an intervention of 15 minute checks . and anticipate and meet my needs. Under the focus area of PAIN interventions include: Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. On 11/24/21 at approximately 1:35 AM, while walking past R7's room, R7 could be heard moaning and a strong odor of feces was detected from the doorway. An interview was completed with R7, who was grimacing and squirming in her bed. R7 stated it hurts where I poop, please help. R7 was asked if she was wet or soiled and she stated that she had a bowel movement and can't remember when I was last helped, please get someone it hurts so bad down there. CNA (Certified Nursing Assistant) D was found in the hall and she was informed R7 stated she was in pain in her peri area, was soiled with feces and needed incontinence care. CNA D stated I just changed her at 1:10 PM and she had a BM (bowel movement). R7's room was entered with CNA D, the room had a strong smell of feces. CNA D asked the resident if she needed pain cream for her bottom and the R7 stated yes. CNA D did not ask if the resident needed incontinence care or check R7's brief despite there being a strong scent of feces in the room and being told by the surveyor that R7 was soiled, before exiting the room to get the nurse for pain cream. After CNA D left the room, R7 continued to grimace and discuss how much pain she was in and that she needed to be changed. Nurse F entered the room a few minutes later with a pain cream and turned R7 to apply the cream, when R7 was turned, it was observed she was soiled with feces that had soaked through her brief and to the bed pad. Nurse F informed R7 that she would need to find the aide to come back to assist R7 to be cleaned up. At approximately 1:50 AM CNA D and CNA E entered the room to begin incontinence care for R7. R5 Review of R5's face sheet and electronic medical record revealed he initially admitted to the facility on [DATE] and most recently admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of R5's medical records revealed in skin and wound assessments, R5 had an area of his right buttock that developed moisture associated skin damage (MASD) on 11/24/21. R5 also had a Stage 2 pressure ulcer on his sacrum that was discovered by the facility on 12/1/21. Review of R5's care plan revealed an intervention under focus area falls: anticipate and meet my needs. Under focus area of pain, interventions include: anticipate my need for pain relief and respond immediately to any complaint of pain. Under focus area of pressure injury, interventions included I am able to turn and reposition per self- Assist me as needed with turning and repositioning and encourage me to reposition frequently. The Stage II sacrum pressure ulcer was noted as a focus area, no new interventions were added after 12/1/21 related to this focus area. Under the focus area of skin integrity, MASD of the right buttock was noted on 11/24/21 as well as the stage II pressure ulcer to the sacrum. A roho cushion to wheelchair was added by the facility as an intervention on 12/1/21. On 12/1/21 at 10:29 AM, R5 was observed in his room sitting in a wheelchair on a standard black seat cushion. R5 complained of his butt hurting. R5 was assisted to bed by Registered Nurse (RN) P and Certified Nurse Aide (CNA) T. CNA T removed R5's pants and incontinence brief. R5 had a 1-inch area of smeared bowel movement (BM) on his right buttock near his anus. CNA T said she took him to the toilet about 30 minutes ago and must have not got him completely clean. R5 buttock had a 3 inch non blanchable area around his coccyx and anus area that he said was painful. There was a small open area within the red area approximately 2 cm in diameter. R5 was agreeable to return to the bathroom to get cleaned up. CNA T said R5 was up in his wheelchair when she did rounds at 6:00 AM. RN P was asked when R5 is able get pressure off his buttock and she said he stays in his wheelchair when he is awake because he is a fall risk. He is provided pressure relief about every 2 hours when he uses the toilet. Per email on 12/3/21 at 8:18 AM with the DON (Director of Nursing) interventions related to R5's sacrum and buttock skin integrity included: On 11/24/21, area was cleansed and protective ointment was initiated. Resident already had air mattress in place. 8/30/21 Roho cushion was put into chair on 12/1/21. Broda chair with cushion was put into place today for positioning. 12/2/21. Staff education Review of several employee files of employees that had been hired in October and November 2021 revealed no care competency checklists. An email was sent to the NHA and DON on 12/1/21 at 11:55 AM stating: I have reviewed [names of 4 employees] employee files, I am not seeing anything that verifies they were reviewed for general care competencies, only post tests and some limited specific competencies like PPE use, handwashing and lift use. Are there any other competencies they were observed and trained on? The information was requested again on 12/2/21 at 9:58 AM. On 12/2/21 at 10:08 AM an email response was received from the NHA We have not been able to locate the completed general competency forms.

This citation pertains to intakes MI 224, MI 338, MI 992, MI 417, MI 708, and MI 711: Based on observation, interview and record review the facility failed to implement their abuse policy for 5 Residents (R1, R4, R6, R7, R8) and Residents on the 1 South Unit on 12/23/21, reviewed for being at risk for abuse, resulting in the facility's failure to provide incontinence care and reposition Residents leading to R4 having pain and discomfort, R6 developing an unstageable pressure ulcer, multiple Stage II ulcers, experiencing pain, R8 developing multiple stage II ulcers and experience pain, R7 experiencing pain, and Residents on 1 South having the potential for skin breakdown and pain. The facility also failed to report allegations of abuse and neglect in a timely manner for R1, R4, R6 and R8. This deficient put all Residents at risk for ongoing abuse and neglect. Findings include: According to the facility Abuse, Neglect and Exploitation Policy with a revision date 10/8/2019, read, in part, Abuse: means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical. Mental, and psychosocial well-being, The home will provide ongoing oversight and supervision of staff in order to assure that is (sic) policies are implemented as written, The home will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: . B Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed and certified staff on each shift, Possible Indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse 2. Physical marks such as bruises or patterned appearances such as a hand print, belt or ring mark on a resident's body, 3. Physical injury of a resident, of unknown source, 4. Resident reports of theft of property, or missing property, 5. Verbal abuse of a resident overheard, 6. Physical abuse of a resident observed, 7. Psychological abuse of a resident observed, 8. Failure to provide care needs such as feeding, bathing, dressing, turning, and repositioning, A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedure for investigation include: 1. Identifying staff responsible for the investigation, 2. Exercising caution in handling evidence that could be used in a criminal investigation, 3. Investigation different types of alleged violations, 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation, The home will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation, B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed, C. Increased supervision of the alleged victim and residents, D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator, E. Protection from retaliation, F. Providing emotional support and counseling to the resident during and after the investigation, as needed, and The home will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g law enforcement when applicable) within specified timeframes: a. 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 b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 2. Assuring that reporters are free from retaliation or reprisal .4. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following: a. analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences, b. defining how care provision will be changed and /or improved to protect residents receiving services, c. training of staff on changes made and demonstration of staff competency after training is implanted (sic), d. Identification of staff responsible for implantation (sic) of corrective actions, e. the expected date for implementation, and f. Identification of staff responsible for monitoring the implementation of the plan. R6 Review of R6's face sheet dated 11/23/21 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6 was not his own responsible party. On 12/1/21 at 9:20 AM, R6 was observed in bed. He was on his back and the head of bed was elevated 30 to 40 degrees and he was covered with a blanket. Registered Nurses (RN) O and P (were in his room attempting to reinsert an IV (Intravenous) line. They reported he had pulled it out this morning and they were not able to get it back in. They said they were contacting another nurse in the facility and if they were not able to get it started, they would send him to the emergency room . R6 was complaining of pain in his buttock at that time. The Surveyor asked R6 if she could look at his buttock with the nurses to see if they could determine the cause of his pain. R6 agreed. R6 yelled out in pain several times with lowing the head of his bed and turning him. When the nurses removed R6 brief it was soiled with BM but not wet. There was no indication he had soiled himself until the brief was pulled back. There was a large white pad/dressing placed over R6's left hip. No date or time was visible on the dressing. When the dressing was removed there was a large area, approximately 4 inches by 2 inches of black tissue with a bright red boarder. RN O called for a CNA to come into clean R6 up. RN O said she had 3 CNA's on her unit since 6:00 AM and normally had 2 CNA's. RN O the CNAs were L, M, and N. On 12/1/21 at approximately 9:30 AM CNA M came to R6' room to clean him up. CNA M said she had not seen R6's buttock prior to this time today. RN O started helping CNA M clean up R6 and when CNA N arrived RN O instructed them to finish cleaning him up and of load his buttock on the left. CNA N said she had not seen R6 buttock prior to this time today and confirmed she started at 6:00 AM. Once R6 was cleaned up and new brief on he was placed on his back and two bed pillows were tucked in between the mattress and his hips. There was a pillow under each hip which placed pressure directly on the large wound on R6's left hip and increased pressure to his right hip. This prevented any rolling or contact of the specialty pressure reliving mattress to the pressure ulcer area. The Surveyor questioned the CNA's as they had just been instructed to off load pressure from R6's left hip. Both CNAs responded the facility had educated them that this was how to off load the buttock. They were not able to recall who educated them or when they were educated. On 12/1/21 at 9:50 AM RN O was at the nurses station. RN O reviewed R6's wound assessments documented in the electronic medical record (EMR). There was a picture of the wound on R6's left hip that was measure at greater than 9 cm x 4 cm and was covered with eschar (black tissue). The wound was labeled as a stage II ulcer. The Surveyor asked RN O if that was a stage II ulcer and RN O responded no it is unstageable. When questioning how it could be miss labeled RN O explained she had made the error when it changed from a stage II to unstageable. RN O went on to explain when she has days off agency nurses cover for her and they do not know how to run the camera or how to do many of the things that need to be done. When RN O returns to work she has to do the work of 2 nurses due to all of the things that were not completed when she was off. RN O was frustrated about her workload that contributed to her charting error. The Surveyor told RN O that the CNAs had placed pillows under both sides of R6's buttock and had told the Surveyor this is how the facility had educated them to off load resident to prevent pressure ulcers. RN O verified R6's pressure ulcer was not off load as she had instructed. RN O called CNA M, N and L to R6's room and instructed/assisted them to remove the pillows and place one pillow under R6's back on the left side above the pressure ulcer. This turned him to his right side and left air space between his left buttock and mattress. RN O had no idea who had trained the CNAs to do pressure relief incorrectly. CNA L said he had not seen R6's buttock that morning. On 12/1/21 at approximately 11:00 AM, after R6 was placed on his right side and his brief was changed, he reported he had no pain. Review of R6's Skin Integrity care plan dated 10/25/21 revealed, I have actual impairment of my skin integrity r/t incontinence, impaired mobility. I am weak and in need of assistance for all ADL's (activities of daily living). I have been noted to be confused at times. I am non ambulatory (cannot walk) and my main source of locomotion in my room and on the unit is my wheelchair. I prefer to sleep in my recliner chair. Review of R6's Pressure Ulcer care plan dated 11/23/21 revealed, I have a pressure ulcer to my L (left) ischial tuberosity (hip). I am receiving ATB (antibiotic) form my wound and I have been referred to the wound clinic for follow up care. No special instructions for pressure relief were located. A power turn mattress was applied to the bed. (Standard of care is to turn, reposition and check for incontinence at least every 2 hours). Observations and interview conducted the morning of 12/1/21 indicated he had gone more that 2 hours with out his brief check for BM. He was not provided pressure relief as instructed by the RN in charge. Review of R6's CT scan dated 12/1/21 at 1:50 PM revealed, There is a posterior gluteal fold ulceration with significant induration and [CONDITION(S)] and skin thickening. There is focal induration and fluid collection measuring 9.2 cm x 4.3 cm x 12.5 cm suggestion abscess. Review of R6's emergency room report dated 12/1/21 at 4:25 PM revealed, he had an ulceration along the left gluteal crease with [CONDITION(S)] and large abscess (infection)in the subcutaneous soft tissue extending to the deep fascia (tissue) measuring 12.5 cm. The plan was to do debridement (remove dead and infected tissue) of the wound 12/2/21. Under Number of diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Discussed CT findings of abscess underlying gluteal ulcer and resultant [CONDITION(S)] with surgery. Patient to be admitted for surgical debridement as well as IV Abx (antibiotic's). R8 Review of R8's face sheet dated 12/1/21, revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was her own responsible party. On 11/23/21 at 10:15 AM the Surveyor was not able to locate staff working on R8's nursing unit. Registered Nurse (RN) G was at the nurse's station and said she was just getting started on the unit. RN G was not able to locate a staffing list at the nurse's station. RN G went down the hall to the medication cart and was not able to locate a staffing sheet. RN G started going room to room to look for staff. At approximately 10:25 AM Certified Nurse Aide (CNA) I walked out of a resident room. CNA I said she had been the only person working on the unit all morning as CNA J was pulled to go to an appointment and CNA H was pulled to help but CNA H was not familiar with the residents on the unit, so she was not much help. CNA I said CNA H went back to whatever unit she was pulled from. CNA I was asked if she was able to provide any care for R4 that morning and she said she did turn her but did not do a brief check or change. CNA I said R4 ate and she feeds herself. CNA I said the only thing she had time to do was answer call lights. CNA I told RN G she was exhausted and needed to take her lunch. She said she would take her 30-minute lunch in her car so he could sleep. If she did not return in 30 minutes CNA I wanted RN G to send someone to the parking lot to wake her up. CNA I did not indicate she had provided any care for R8 at this time. On 11/23/21 at 10:49 AM, R8's call light was observed to be on. At 10:54 AM a housekeeper went in R8's room and turned off her call light. The housekeeper reported R8 wanted to get out of bed. At 10:56 AM R8 turned her call light on again. At 11:06 AM, CNA I went into her room, turned off the call light. CNA I said R8 wanted to get up, but she normally did not so CNA I went to the computer on the wall to see how to get R8 out of bed. CNA I said she had not provided any care for R8 that morning. After she check the computer, she went to another resident's room to answer a call light. A few minutes later CNA B and CNA H went to R8's room and said they had been pulled from other units to do care. CNA B said she started at 6:00 AM on 1 South. CNA B said when she made rounds that morning, she found all of her residents soiled and care had not been provided by night shift. CNA B said night shift is from 6:00 PM to 6:00 AM and most of the staff are agency. CNA B said she reported this neglect to her charge nurse Licensed Practical Nurse (LPN) K and directly to the Director of Nursing (DON). CNA B said this has been an ongoing issue. CNA B said she reports it, but nothing happens. On 11/23/21 at approximately 11:15 AM the surveyor introduced herself to R8 and asked if she could watch care. R8 agreed to the observation. CNA B and H pulled back R 8's blanket and R8 had a shirt and an incontinence brief on. The brief was completely soak through with urine and bowel movement (BM). As the CNA's turned R8 to provide incontinence care R8 cried out in pain multiple times. R8's soaker pad and sheet were saturated with urine and BM. The wet stain on the sheet went all the way up her back and past her buttock. When the brief was removed R8 had multiple open bloody areas between her legs and at least 10 open bloody areas on her buttock. R8 constantly cried out in pain and the CNA's cleaned her and changed her complete bedding. R8 said the last time she was changed was yesterday morning. R8 said she complains to the nurses about not getting changed but nothing happens. CNA B and H confirmed they have complained to management multiple times about this resident not getting changed and nothing happens. R8's shirt was covered in dry skin and her face had dried crusted material on it. R8 said she could not recall the last time she had a shower but would take on anytime they would give her one. On 11/23/21 at approximately 12:45 PM the Surveyor asked the Director of Nursing (DON) if CNA B had reported to her this morning that the residents on 1 South were left soiled and did not get care last night. The DON said CNA B had reported that to her. The Surveyor asked if the DON if she had started the facility reported incident (FRI) the DON said, no. The Surveyor said to the DON, a CNA reported to you this morning residents on 1 South were left soiled and did not get care this morning, which is goods and services were not provided. The DON said, yes. The Surveyor asked why she had not started the FRI and the DON said she decides if something in neglect and she had not determined that was neglect. The surveyor said she had observed the care of R4 and R8 on 1 North that morning. R8 was so soiled that it went through her brief, soaker pad and sheet. R8's thighs and buttock's had bloody sores from being left soiled so long and the Surveyors eyes were still burning from the urea in the room. The Surveyor could smell the BM through her N95 mask it was so strong. R8 reported she had not been changed since yesterday. R4 was also observed to be soiled and in pain. R4 also reported she had not been changed since yesterday. The DON did not have any other comments or questions. The DON did not take any notes and did not appear concerned. On 11/23/21 at approximately 12:50 PM, the Surveyor went to the Nursing Home Administrator's (NHA) office and reported all the same information to NHA that she had just provided to the DON. The NHA took a few notes, appeared very concerned and said she would take care of it. The NHA offered no explanation as to why the DON would not have started FRI process at 6:00 AM when she received the first allegation of neglect. The NHA did not provide any additional information until 4:17 PM when the facility was served and Immediate Jeopardy (IJ) for neglect. The NHA said we interviewed the Residents and none of them said they were neglected. They Surveyor referred to the information in the IJ notification that provided R4 and R8 condition that was observed and reported to her around 12:50 PM by the Surveyor, Resident and Staff statements on neglect and the facility failure to act on these complaints the NHA offered no addition information. The facility did start a FRI related to R4 and R8's concerns that were provided to the DON and NHA on 11/23/21. The facility did not do an FRI on CNA B allegation of the neglect of Residents on 1 South that she reported around 6:00 AM on 11/23/21. The FRI reports did not include the Surveyors report of R4 and R8's physical condition, complaints of care or staff interviews conducted by the Surveyor. The investigation did not include incontinence care records or Resident progress notes or skin evaluations. The facility did not complete a thorough investigation, and it did determine neglect had occurred for R4 or R8. Review of R8's progress noted dated 11/23/21 at 6:25 PM revealed, R8 had multiple small open areas to her right and left ischial tuberosities (buttock bone areas). Physician was notified and R8 declined to have her family notified. A wound dressing was applied for 3 days. Review of R8's incontinence record revealed that on 11/22/21 R8 was incontinent at 5:38 AM and 1:52 PM. No refusal of incontinent care was recorded on 11/22/21. (R8 only received incontinence care 2 times on 11/22/21 according to her medical record documentation). Review of R8's incontinence record for 11/23/21 revealed she was incontinent at 5:38 AM and again at 11:17 PM. There was no indication of refusal of incontinence care on 11/23/21. There was no record of the incontinence care the Surveyor observed at 11:15 AM. Review of R8's incontinence record from 11/18/21 to 11/23/21 only showed R8 was incontinent between 1 and 4 times a day. R8 refused incontinent care 1 time on 11/18/21, 11/20/21, and 11/22/21. Review of R8's incontinence record for 11/24/21 (2 day after receiving an IJ for lack of incontinence care) R8 was only recorded to be incontinent 1 time at 7:20 AM. She had no refusals documented. Review of R8's incontinence record from 11/23/21 to 11/30/21 revealed no refusal of incontinence care form 11/24/21 until 11/30/21. Review of R8's progress note dated 11/24/21 at 9:41 PM revealed, Resident not fully herself in this recovery from COVID, still very tired throughout the shift. Reported to this nurse by CNAs that resident very hesitant and refusing most transfers out of her chair due to lethargy. During an interview with R8 on 11/30/21 at 2:04 PM, R 8 was awake in bed, well-groomed and smiling. The Surveyor asked her if she had been refusing to let staff turn her or change her brief. R8 said when I am sleeping, and they come in to do care I am get confused sometimes. I know my butt is hurting because I do not get cleaned or turned. I really want them to clean me up and turn me even if I say, No. They have been doing a better job and my butt is getting better. Asked R8 if I could have the DON come talk to her so she could explain what she wanted staff to do, R8 agreed. DON returned with the Surveyor a few minutes later and R8 repeated what she told the Surveyor. The DON said they had just started documenting on paper when people get turned and cleaned. The DON said if they show you the sheet so you can see the last time, they did care would that work. R8 agreed. Review of R 8's skin audit dated 11/23/21 no time revealed no skin issues on her buttock. 4 small circles were placed on the picture of the left inner thigh and scattered abrasions was written in with an arrow to the circles. This skin audit did not match the Surveyors observation during care the morning of 11/23/21 or the progress note dated 11/23/21 at 6:25 PM. The facility provided skin audits as part of the IJ removal. The DON was informed R 8's skin audit done for the IJ removal did not match observations on 11/23/21 or 11/30/21. The DON was asked to address the accuracy of skin audits and documentation. Upon exit on 12/3/21 the DON did not provide any updated audits or information on correcting audits that had been completed. R4 Review of R4's face sheet dated 11/23/21 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 was her own responsible party. On 11/23/21 at 10:11 AM, R4 was observed sleeping in bed and on turned to her right side. R4's catheter bag was on the floor on the left side of her bed. The catheter tubing and bag had a dark blue color. R4 did not respond when her name was called. There was a medication cart in the hall, but no staff were located on the hall. On 11/23/21 at 10:15 AM the Surveyor was not able to locate staff working on R4's nursing unit. Registered Nurse (RN) G was at the nurse's station and said she was just getting started on the unit. RN G was not able to locate a staffing list at the nurse's station. RN G went down the hall to the medication cart and was not able to locate a staffing sheet. RN G started going room to room to look for staff. At approximately 10:25 AM Certified Nurse Aide (CNA) I walked out of a resident room. CNA I said she had been the only person working on the unit all morning as CNA J was pulled to go to an appointment and CNA H was pulled to help but CNA H was not familiar with the residents on the unit, so she was not much help. CNA I said CNA H went back to whatever unit she was pulled from. CNA I was asked if she was able to provide any care for R4 that morning and she said she did turn her but did not do a brief check or change. CNA I said R4 ate and she feeds herself. CNA I said the only thing she had time to do was answer call lights. CNA I told RN G she was exhausted and needed to take her lunch. She said she would take her 30-minute lunch in her car so he could sleep. If she did not return in 30 minutes CNA I wanted RN G to send someone to the parking lot to wake her up. On 11/23/21 at 10:46 AM, R4 was observed in bed sleeping on her right side with a pillow under her left chest area and her catheter bag remained on the floor. On 11/23/21 at 11:24 AM, R4 was observed in bed and CNA I and J had just started care. R4 was on her right side and the CNAs were just starting to remove R4's brief. R4's brief and sheet were soiled with BM. R4 said she had not been changed since yesterday. CNA I and J confirmed they had started work at 6:00 AM today and this was the first time they had time to change her brief. CNA J said she was pulled at 7:30 AM to help a resident going out on an appointment. CNA I again said she was the only one providing care for all the residents on this hall when CNA J was pulled to assist a resident going out to an appointment. CNA I was not able to recall what time it was when she turned R4 on her right side. R4's entire right side was bright red. R4 said she reports not being changed and turned to the nurses but nothing every gets done. CNA I and J confirmed R4 frequently makes these complaints about night shift and they also report these concerns to management, but nothing gets done. Review of R4's ADL/MOBILITY/Toileting care plan dated initiated 7/22/21 and revised on 11/30/21 revealed. As of 7/22/21 R4 required assistance extensive assistance of 2 people for bed mobility. Toileting schedule as of 2/3/20 was to offer and encourage bed pan and check and change every 2 hours. Toileting assistance was not offered the morning of 11/23/21 from 6:00 AM until 11:24 AM when she was found to be incontinent of bowel. R4 was observed in bed and awake on 11/30/21 at 10:15 AM, R4 reported staff were getting better at turning her and changing her brief, however nights was still the main problem. R4 said her brief had not been checked or changed yet this morning and she was agreeable to the Surveyor asking the CNA to check her brief. CNA Q came in a checked her brief. CNA did not have anyone assist her turn R4 or assist with removing her brief. When CNA Q pulled back R4's brief she found R4 had a large solid BM. R4 said she did not know she had a BM as she has Multiple [CONDITION(S)] and cannot feel when she has a BM. R4 has a Foley catheter so the strip on the brief does not change colors to show it is soiled unless the BM is loose. CNA Q admitted she did not pull back R4's brief to check it when she turned her earlier. CNA Q and the Surveyor had N95 masks on and could not smell the BM. The Surveyor asked CNA Q is R4 was a one assist for turning and brief change or two and CNA Q said she did not know as she had only cared for her once or twice prior today. On 11/30/21 at 10:45 AM the Surveyor told the DON, CNA Q did not visually check R4 for a BM this morning and R4 had a BM noted at 10:15 AM. CNA Q turned R4 and removed her brief without assistance. R4 was still reported night staff were not consistently checking her brief and turning her. The DON checked R4's care plan and said she was a two assist with turning and brief change. The DON said she would educate CNA Q. The DON provided an Employee Discipline Form for CNA Q dated 11/30/21 that revealed, On 11/20/21 upon arriving for shift staff member was educated on ensuring residents care plans are followed to ensure residents care needs are met timely as well as ensuring residents are turned/repositioned and toileted/checked and changed for incontinence every two hours. Staff member stated understanding and acknowledged that she needed to turn/reposition and toilet/check and change resident at a minimum of every 2 hours. Staff member stated that she did not know what resident's care level was for bed mobility but did not proceed to finding out prior to providing care with x1 assist. Resident is care planned for assist x 2 for bed mobility. Staff member stated she knew how to check residents care levels by viewing the Kardex in PCC (electronic medical record). The box for verbal counseling was marked. On 11/23/21 at 4:17 PM, the NHA was informed of an Immediate (IJ) related to F 600 that began on 11/23/21 when the facility failed to respond to the allegation that Residents on 1 South had not received incontinence care on the night shift and R4 and R8 made allegation of neglect. The Surveyor provided details of the condition R4 and R8 when they received care the morning of 11/23/21 and reported lack of staff to provide adequate care for Residents on 1 North. The NHA was provided this information verbally and in writing in the IJ notification. R 1 Review of face sheet and electronic medical record revealed R1 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility reported incident related to R1 revealed he had an unwitnessed fall with a fracture on 11/4/21. Further review revealed the incident was documented as being discovered at 11/5/21 at 12:27 AM and was not reported to the state agency until 11/5/21 at 8:34 AM. Review of R1's progress notes revealed the fall occurred at approximately 6:00 PM on 11/4/21 and on 11/5/21 at 12:30 AM: notified at (12:30 am) [name of emergency room staff] resident has a distal Femur Fracture, will be admitted . Review of facility policy Abuse, Neglect and Exploitation Policy with a last revised date of 10/8/19 revealed under the section Reporting/Response The home will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. 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 . R7 Review of R7's face sheet and electronic medical record revealed she admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R7's care plan revealed under COGNITION: My cognition at times does fluctuate. Due to my diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Under the section ADL/BOWEL/BLADDER/MOBILITY interventions include: toileting to be completed at 2:30 a.m., 4:40 a.m., and upon request throughout the rest if the day. For toilet use, R7 was noted as needing the extensive assistance of 1-2 staff. Under the focus area of FALLS R7 had an intervention of 15 minute checks . and anticipate and meet my needs. Under the focus area of PAIN interventions include: Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. On 11/24/21 at approximately 1:35 AM, while walking past R7's room, R7 could be heard moaning and a strong odor of feces was detected from the doorway. An interview was completed with R7, who was grimacing and squirming in her bed. R7 stated it hurts where I poop, please help. R7 was asked if she was wet or soiled and she stated that she had a bowel movement and can't remember when I was last helped, please get someone it hurts so bad down there. CNA (Certified Nursing Assistant) D was found in the hall and she was informed R7 stated she was in pain in her peri area, was soiled with feces and needed incontinence care. CNA D stated I just changed her at 1:10 PM and she had a BM (bowel movement). R7's room was entered with CNA D, the room had a strong smell of feces. CNA D asked the resident if she needed pain cream for her bottom and the R7 stated yes. CNA D did not ask if the resident needed incontinence care or check R7's brief despite there being a strong scent of feces in the room and being told by the surveyor that R7 was soiled, before exiting the room to get the nurse for pain cream. After CNA D left the room, R7 continued to grimace and discuss how much pain

This citation pertains to MI 332, MI 404, MI 202 and MI 618 Based on observation, interview and record review the facility failed to provide adequate supervision to protect residents from abuse for 8 residents (R 23, R 30, R 32, R 62, R 86, R 119, R 135, R 142) reviewed for being at risk for abuse resulting in an Immediate Jeopardy (IJ) that began on 05/18/21, as a result of the facility's failure to prevent R 30 from abusing other residents after she abused R 32, leading to R 142 and R 23 to be further abused by R 30 and suffer psychosocial harm. This deficient practice has the high likelihood to affect all residents in this facility potentially resulting in further harm, serious injury or death. Findings include: According to the facility Abuse, Neglect and Exploitation Policy with a revision date 10/8/2019, read, in part, Abuse: means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical. Mental, and psychosocial well-being, The home will provide ongoing oversight and supervision of staff in order to assure that is (sic) policies are implemented as written, The home will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: . B Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed and certified staff on each shift, Possible Indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse 2. Physical marks such as bruises or patterned appearances such as a hand print, belt or ring mark on a resident's body, 3. Physical injury of a resident, of unknown source, 4. Resident reports of theft of property, or missing property, 5. Verbal abuse of a resident overheard, 6. Physical abuse of a resident observed, 7. Psychological abuse of a resident observed, 8. Failure to provide care needs such as feeding, bathing, dressing, turning, and repositioning, A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedure for investigation include: 1. Identifying staff responsible for the investigation, 2. Exercising caution in handling evidence that could be used in a criminal investigation, 3. Investigation different types of alleged violations, 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation, The home will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation, B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed, C. Increased supervision of the alleged victim and residents, D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator, E. Protection from retaliation, F. Providing emotional support and counseling to the resident during and after the investigation, as needed, and The home will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g law enforcement when applicable) within specified timeframes: a. 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 b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 2. Assuring that reporters are free from retaliation or reprisal .4. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following: a. analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences, b. defining how care provision will be changed and /or improved to protect residents receiving services, c. training of staff on changes made and demonstration of staff competency after training is implanted (sic), d. Identification of staff responsible for implantation (sic) of corrective actions, e. the expected date for implementation, and f. Identification of staff responsible for monitoring the implementation of the plan. R 30 Review of R 30's face sheet dated 8/3/21, revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R 30 was not her own responsible party. Review of R 30's cognitive assessment completed for her Minimum Data Set (MDS) dated [DATE] revealed she was unable to answer any of the cognitive questions and was m marked as severely cognitively impaired. Review of R 30's mood/behavioral care plan initiated on 7/11/19 and revised on 5/19/21 revealed, wanders among the unit in and out of co-resident's rooms to seek comfort. -noted paranoia at times. -offered change of room to husband on 6/29/20 r/t (related to) embracing male co-resident, however husband declined to move, -I was involved in a peer-to-peer interaction 5/18/21. Review of R 30's progress note dated, 5/24/21 at 11:33 revealed, IDT met to review resident in EWBT (unknown) r/t (related to) indicating for behavioral symptom on the [NAME] report, for psych medications, and recent altercation. Noted behaviors include hitting, kicking, pushing, grabbing, pinching, and wandering over the last 30 days. Resident has dx of dementia. If [R30] is attempting to assist co-residents among the unit, thank her for her help, offer to trade places and complete task, as for [R30] enjoys helping others; If [R30] is entering co-resident's rooms, redirect to alternate activity and provide supplies as needed.; If observing exit seeking behavior, offer to walk with [R30] among the unit and attempt to redirect to alternate topic or task; Increase supervision when [R30] is moving independently on the unit; Monitor for tearfulness, agitation, anxiousness, changes in sleep patterns, mood, thoughts of death. R 32 Review of R 32's face sheet and electronic medical record revealed she was an [AGE] year old female who admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility reported incident revealed R 23 and R 32 had an altercation on 5/18/21 where R 32 reported R 30 came into her room and pulled her blankets up over her head and pushed down. Review of R 32's resident progress notes revealed a note by Nurse K for 5/18/21 at 8:30 PM: Upon entering residents room to pass meds to her, resident was found up out of bed and walking towards the door to find someone to help her. Resident was teary eyed and looked upset. When asked what was wrong she stated that women was in here again and this time she put my blankets over my face and I couldn't breathe. Resident stated that nobody here cares because they keep coming in the room. I assured the resident that staff definitely does care. Resident was asked to sit down and that we could talk about it. Resident then stated that would be fine and she sat down. Resident stated that she was asleep lying in bed and was awoken by [R 30] pulling her blankets up over her face and she was suffocating me. She then proceeded to show me with her hands to her face how she was pressing. She stated that she was terrified. She stated that she was trapped in her blankets or she would have half killed her. She said, I may be small, but I am not weak. Residents roommate than walked out of bathroom with [CNA CCC] who stated I am praying for us. They come in here all the time and do whatever they want. For residents feelings of being safe, this nurse pulled the UA to come and sit in their room with them until I could get a hold of the DON. [Nurse DD] unit manager and [Name of DON], DON was notified. DON placed [R 30] on a one on one for all of the residents safety and a full head to toe skin assessment was done on residents with no issues found. Resident denied pain and stated that she felt safer after talking to this nurse. [CNA CCC] was also in residents room the entire time that this situation was brought to my attention and stayed until this nurse left room to make phone call to managers. A progress note entered by Nurse DDD on 5/20/21 at 3:04 PM revealed: Resident speaking with CNA reported to have asked when co-resident's court date would be r/t recent altercation. Resident also stated she did not have to put up with people trying to kill her. Staff redirected conversation and stated that resident is safe and that staff are keeping close eye on co-resident. Resident participating in bingo today with activity staff. Resident did not report any concerns directly to this nurse when asked. Stop sign remains in place in doorway of resident's room. Social work follow up notes on 5/19/21 and 5/20/21 indicated R 32 was having trouble sleeping. A follow up note was written by the Assistant Director of Nursing (ADON) on 6/1/21 at 11:18 AM: Follow up to incident: On 5/18/21 at approximately 1930, CNA entered resident's room to assist her roommate to use the restroom. At that time, resident was ambulating from her bed to the doorway. resident stated that she was upset. resident stated that a woman came in her room as she was in bed and pulled her blankets up over her head and pushed the blankets down. resident stated that she was able to move her blankets in a short time, she estimated less than a minute that the blankets were on her head. resident stated that the woman did not talk to her. resident roommate, was in her recliner at the time. She stated that the woman walked into their room with an empty cup. She brought the cup to [Roommate of R 32] and attempted to hand it to her. Co-resident stated to the woman that she could not get her anything to drink as she could not get up out of her chair by herself. Co-resident stated that the woman took the cup and ambulated to resident's side of the room and attempted to take resident's cup. Co-resident then heard resident state to the woman to get out of her room. Co-resident stated she noted the woman to touch resident's blankets, but was not able to see what occurred after that as the privacy curtain was pulled blocking her vision. RN was entering the room at the same time that resident reported this to CNA as she was completing medication pass for resident. She was able to provide reassurance to both resident and co-resident. A skin and pain assessment was performed with resident and there were no significant findings. Following resident's statement, it was verified that a different co-resident was the woman that entered their room and she did indeed have a Styrofoam cup with her. UA was able to provide reassurance to resident and co-resident throughout the evening and stayed in their room. Another staff member guided co-resident to her room and provided increased supervision for her. Following the incident, a half door was installed on residents' room to deter others from entering their room. On 5/25/21, resident and co-resident moved to a different unit per their preference. Co-resident had labs and a urinalysis obtained. There were no significant findings with her labs and the urinalysis was negative for infection. The psychiatric nurse practitioner reviewed co-resident and made medication adjustments. Co-resident has received increased supervision from staff following the incident. A sleep study has been initiated for co-resident to assess her sleeping pattern. On 08/04/21 at 09:45 AM, an interview was completed with R 32. R 32 stated at least twice someone came into my old room. Someone held me down. R 32 put her hand close to her face and made a pushing motion when talking about being held down. Then, R 32 went from siting up in bed to collapsing down on her elbow and sighed, her voice broke and her face appeared distressed as she said I don't want to talk about it anymore, I just want to forget it. I'm glad got through it and was able to hit them away. On 08/04/21 at 9:55 AM, an interview was completed with R 32's roommate (who was also her roommate at the time of the 5/18/21 incident): She stated there were 2 or 3 of them that would come into the room all the time in their old room, she stated they usually they would eat food off their trays. But one time she thought they got physical with her roommate, but she couldn't remember all the details. An email was sent to the DON questioning why the incident with R 30 and 32 was not substantiated and the DON responded on 08/03/21 at 12:48 PM, Per our understanding, the substantiated tab reflects if the facility feels that abuse was purposeful/willful and verified. Based on the resident's cognitive status, the facility does not feel that it was purposeful/willful, therefore indicating it was unsubstantiated. A follow up email asked if the police department was contacted regarding the incident and the DON responded on 08/05/21 at 8:47 AM: Police were not notified. R 23 Review of R 23's face sheet dated, 7/30/21 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R 23 was her own responsible party. Review of R 23's Brief Interview of Mental Status (BIMS) score dated 4/27/21 was 15/15 (normal cognition). During an interview with R 23 on 7/27/21 at 10:46 AM, R 23 complained about residents wandering into her room. R 23 said R 30 wanders into her room and takes things and has a mean look on her face. R 23 said residents had stolen her remote control, a shirt and slippers. R 23 said the facility replaced the remote control and slippers. R 23 said one resident comes in and pees in her trash can. R 23 reported the wandering residents become more active after 5:00 PM and they come in and wake her up. R 23 said when she complained they gave her a half door but that does not keep them out. R 23 complained about having to move to the floor with the wandering residents and her over all care. R 23 said she has asked to have the facility find an apartment for her because she is so unhappy with the care. On 7/30/21 at 10:14 AM, UM DD was informed R 23 was upset with residents wandering into her room and made that allegation that they steal things and all items had not been replace. UM was informed that the wandering residents wake R 23 up and that the half door was not effective at keeping residents out. On 8/4/21 at 2:46 PM, the Nursing Home Administrator (NHA) emailed the Surveyor and indicated R 23 wanted to talk to the Surveyor. At this time the Surveyor went to R 23's room and R 23 said she just wanted to let me know she did not have any problems sleeping. R 23 said she does get awakened when residents wander into her room and confirmed the facility had asked her about her missing items and the shirt, she reported stolen 2 months ago was not located or replaced. R 23 said she is not afraid of the wandering residents, but she did slap one in the hand when she tried to take her water one time. R 23 said R 142 is across the hall from her and when they wander in her room, she yells really loud. Review of R 23's progress note dated 7/28/21 at 10:19 AM revealed R 23 stated, she didn't like the way agency people treat her. When Social Worker came in to do a depression assessment R 23 told the Social Worker she wanted to harm herself and had a plan. She was going to jump out the window. R 23 was started on 1:1 but when the 1:1 started R 23 began to cry and scream. R 23 said, I should never said anything. Review of R 23's progress note dated 7/30/21 at 10:06 revealed R 23 was asked about missing items and she stated she was missing a striped blue/green and white shirt. R 23 said she had told laundry about the missing shirt. R 23 said it came up missing the first week she came in this room. The missing shirt was reported to the Social Services Director. R 23 also reported R 30 took her remote and they gave her another one. When R 23 reported her slippers missing the Certified Nurse Aide (CNA) told her she knew where they were, and the CNA went and got them. R 23 was asked if she was fearful and she said, just a little. She said R 30 has a scary look on her face. Review of R 23's progress note dated 7/29/21 at 9:16 PM revealed R 23 responded to a survey, indicated feeling caregivers provide compassionately but not always timely. R 142 Review of R 142's face sheet dated 7/30/21 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R 142 was her own responsible party. Review of R 142's Brief Interview of Mental Status (BIMS) score dated 7/11/21 was 15/15 (normal cognition). During an interview with R 142 on 7/27/21 at 10:49 AM, R 142 said R 30 wandered into her room on Sunday 7/25/21 and she is afraid of her because people have reported she hits people. R 142 said staff are slow to respond to the call lights at night, so she yells until they come. R 142 said Sunday she was afraid staff would not get there in time, so she held up her assistive device she uses to reach things to defend herself. R 142 said staff did get R 30 out of her room before she could get close. R 142 said she would not want to hit R 30 but felt she needed to protect herself. R 142 said she complains to the nurses about residents wandering into her room, but they do not do anything. On 7/30/21 at 10:14 AM, UM DD said she was aware residents were wandering into R 142's room. UM DD said she was not aware of the incident Sunday night 7/25/21 or that R 142 was afraid of R 30. UM DD said she did not implement any new intervention when she became aware R 142 did not like residents wandering into her room. UM DD said we all try to watch for the wandering residents and guide them back out of rooms when we see them go in. UM DD said she did not have any documentation on R 142's concerns about wandering residents. UM DD said R 142 moved to her unit on 6/8/21 and the unit she came from did not have wandering residents. UM DD said she would look for documentation related to R 142's concerns about wandering residents. Upon exit no information related to R 142's concerns about wandering residents were provided. Review of R 142's note dated 7/30/21 at 10:47 AM revealed R 142 was questioned after the state person brought concerns forward, R 142 reported, the stop sign on the door does help, they just walk underneath it. She stated 2 come in her room and the one just watches TV for the most part. The other one has taken my walker once and my over the bed table. I got up and told her to get out of my room and was stern with her. I asked if she thought of any other way to keep other residents out of her room and she stated she wondered about a half door. Will make administration aware. When asked if she was fearful, she stated, not of unknown resident first name, the other one has a ornery look on her face. [Name of R 30] might hit me, but she hasn't. Review of R 142's progress noted date 7/30/21 at 10:43 AM revealed R 142 was questioned about residents entering her room. R 142 denied being fearful or losing sleep. R 142 said she had to be stern with R 30 entering her room. R 142 reported R 30 tried to take her walker, coffee table. On 7/30/21 at 8:21 AM, Unit Manager (UM) DD was asked about R 23 and R 142's concerns about residents wandering into their room. UM DD was informed both residents provided a resident first name. UM DD said she had two residents with that first name. UM DD said R 30 wanders into other residents' rooms daily and so it was most likely R 30. UM DD said she was aware R 23 and 142 were concerned about other residents wandering into their rooms. UM DD was unable to locate any paperwork or documentation in R 23 or R 142's medical record that indicated they had concerns about wandering residents. UM DD was informed R 23 had complained of Residents stealing items from her when they wander into her room, and they wake her up at night. UM DD denied any knowledge of stolen items or problems with being awaken at night. UM DD was informed R 142 was very frightened over the weekend when a resident came in her room at night, she held up her assistive device she uses to reach items to defend herself and yelled until staff came to get the resident out of her room. UM DD said she did not get a report of that incident. UM DD said she would interview both residents. On 7/30/21 at 9:21 AM, Social Service Director was asked if she had any concern forms or information on R 30 wandering into resident rooms. SSD was informed residents are reporting stolen items, fear and sleep being disturbed. SSD said she would look for concern forms and talk to the Social Workers. Upon exit SSD did not provide any documentation of addressing wandering residents or concern forms. During an interview with UM DD on 8/3/21 at 11:40 AM, this Surveyor followed up on the concerns she had discussed with her on 7/30/21 at 8:21 AM about R 23 and R 142 about wandering residents frightening them, waking them up and stealing from them. UM DD confirmed R 23 was still missing a shirt and the Social Work Director was following up on that concern. UM DD was asked what interventions she implemented to prevent residents from wandering into other residents' rooms after she confirmed the concerns. UM DD said she notified administration. The surveyor asked if the facility had notified the State Agency about the stolen items and Residents being fearful of wandering into her room and UM DD said she would have to check with administration. No report to the State Agency was located upon exit. R 62 Review of R 62's face sheet dated 7/28/21 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R 62 was her own responsible party. Review of R 62's Brief Interview of Mental Status (BIMS) date 7/30/21 at 5:46 PM, revealed a score of 14/15 (normal cognition). Review of R 62's Kardex (caregiver instructions) dated 729/21 revealed, toilet on request. Do not leave alone in the bathroom. Transferring: Limited assist x 1 with walker. Review of R 62's mobility care plan dated 2/12/21 revealed, Toilet Schedule: Toilet on request. Do not leave alone in bathroom, initiated 2/12/21. On 7/28/21 at 2:21 PM, R 62 was observed sitting on the toilet in her room, call light on in bathroom and phone in her hand. R 62 said she had called the nurses station to get help. Within a minute Certified Nurse Aide (CNA) X arrived to assist R 62 out of the bathroom and back into her recliner. The Surveyor did not hear a call alarm and asked CNA X how she knew R 62 needed help in the bathroom. CNA X demonstrated the call light in the bathroom turns on a light in the hall. CNA X said she put R 62 on the toilet and had to leave the unit so when she returned to the unit, she checked on R 62 first. CNA X was not sure what time it was when she assisted R 62 to the bathroom. CNA X was asked about the call light pager to see how long the call light had been on and CNA X said her pager battery was dead, so she did not know how long R 62 had been waiting for help. R 62 complained of diarrhea and upset stomach. CNA X went to get Licensed Practical Nurse (LPN) JJJ to address R 62's medical concerns. (CNA X did not remain in the bathroom after she transferred R 62 to the toilet as instructed on R 62's Kardex). During an interview with R 62 on 7/28/21 at 2:25 PM., R 62 said the Nursing Home Administrator (NHA) and Chief Executive Officer (CEO) talked to her in February 2021 about moving to the nursing home because she needed more care. R 62 said the care was not better. R 62 said she was left sitting in her recliner for 14 days. R 62 said she was not put in bed for 14 days. R 62 said she was on the 2nd floor and residents would wander in and out. R 62 said she complained about the care and the wandering residents, but no one cares. R 62 said she was so upset by the care that one day she took a razor to her wrist and tried to kill herself. R 62 said two nights ago she had a resident come in this room (R 62 currently is on the 1st floor). R 62 said the resident came in her room and sat on her legs in bed causing excruciating pain in her legs. R 62 said she was so upset now she wanted to start taking her [MEDICATION(S)] so she would die. Licensed Practical Nurse (LPN) JJJ was in the room. When R 62 reported the issue with a wandering resident last night LPN JJJ said they had put an alarm on the other resident so staff would hear when she got out of her room at night. When R 62 said she wanted to die because of the care the Surveyor asked LPN JJJ to get R 62's Unit Manager and her Social Worker. JJJ came back with Unit Manager (UM) KKK and Social Worker (SW) LLL. R 62 told UM KKK and SW LLL she wanted to die because of the care and questioned them about watching the video camera from the other night to see who came into her room. The NHA joined the conversation and reported the video camera did not show anyone entering R 62's room between 2:00 AM and 3:00 AM like R 62 reported. R 62 spoke to UM KKK, SW LLL and the NHA for a while. R 62 stressed the main thing she wanted was tender loving care for everyone. R 62 explained when they do not have enough staff or agency, they are not able to meet her needs. She said she knows she should not take herself to the bathroom but when they do not come, she takes herself. R 62 said one nurse and two caregivers is not enough help at night. The NHA said she recently increased staffing to two nurses at night but cannot do it every night. During an interview with the NHA on 7/29/21 at 1:05 PM, the NHA said she had not watched the video from R 62 hall the night of 7/27/21 prior to meeting with her on 7/28/21. The NHA said staff that watched the video must not have reviewed the correct night because the video did show a resident enter R 62's room the night of 7/27/21. The Surveyor reviewed the video with the NHA, and the video did show a resident in the room next door enter R 62's room at 2:24 AM and exit at 2:28 AM. The resident that entered the room was not assisted by staff and staff were not present to see the resident enter or exit. A Certified Nurse Aide (CNA) was observed entering R 62 room at 2:37 AM (13 minutes after a resident wandered into her room). The NHA was asked for all documentation related to the incident on 7/27/21 at 2:24 AM. The NHA said staff met with the resident and documented the meeting in the medical record. No other documentation was located. Review of R 62's Psychosocial note dated 7/19/21 at 3:48 PM revealed, Resident indicated she became upset and transferred herself to the bathroom this morning to have BM (bowel movement) without waiting for staff assistance. SS talked with resident and educated her about waiting for staff assistance when needing to transfer. Resident voiced understanding and acknowledged the possible outcomes of self-transferring. Resident continued to talk about call light times and SS reassured resident and offered to print off call light report 7/20/21 resident and SS will review call light times and discuss resident's expectations for call light time. Review of R 62's Psychosocial note dated 7/20/21 at 4:49 PM revealed, Resident and SS reviewed call light report and resident was appreciative of follow up. Resident and SS agreed to review again next week and compare results. Review of R 62's Psychosocial note dated 7/24/21 at 3:20 PM revealed, During meeting resident shared frustrations and feelings with nursing staff. SS (Social Services) suggested to schedule meeting with DON (Director of Nursing) and unit manager to discuss these concerns and resident was agreeable to this. SS scheduled meeting for 7/2621 at 2:00 pm with also inviting friend (friend name) for additional support per resident request. Review of R 62's Plan of Care Note dated 7/26/21 at 2:58 PM revealed, Care conference completed with resident, unit manager, DON, resident and resident's friend. During meeting resident discussed her frustrations and nursing concerns. Medications reviewed and discussed changing medication times to meet resident's preference; unit manager will be contacting PCP (primary care physician) to change orders. Resident shared her love for the facility and her history helping with various parts of the organization. Resident talked about her past suicide attempt/self-harm and shared it was the wrong decision. Discussed resident not consistently accepting antidepressant medication and will review times medication is given. Resident expressed multiple times about advocating for herself and other residents receiving tender loving care. At the end of the visit resident voiced appreciation for the meeting and listening to her concerns. SS will print off call light report 7/27/21. Review of R 62's progress note dated 7/27/21 at 3:34 PM revealed, Spoke with resident this am resident stated that another resident had come into her room last night and sat on her bed. Resident stated that she felt safe, and she just wanted someone to be aware. Social services to follow up. This writer to follow up as well. Per social services resident did agree to have a stop sign on her door at night. Review of R 62's Hospice Note dated 7/27/21 at 3:57 PM revealed, pt (patient) express concern over resident coming in her room, pt reassured that she was safe, and staff is aware. Review of R 62's Psychosocial Note dated 7/27/21 at 5:32 PM revealed, Resident expressed that she had and unexpected visit from a co-resident over the night while she was sleeping. Resident stated that staff was able to redirect co-resident out of her room and she was not harmed. Resident indicated she continues to feel safe in the facility and concerned for co-resident. SS reassured resident that IDT (interdisciplinary team) will be working on interventions for co-resident and that SS could not provide additional information d/t (due to) HIPPA; Resident agreed to having stop sign placed across doorway after going to bed, as for she does not wish to have door closed. Resident asked to review call light times and was ok with unit manager reviewing with her tomorrow. Resident desired to file a grievance, which SS started. No grievance was provided to the State. All documentation related to this incident was requested when the Surveyor met with the NHA on 7/29/21 at 1:05 PM. Review of R 62's Social Service Note dated 7/28/21 at 5:56 PM revealed, SSD (Social Services Director) and Unit Manager spoke with resident about residents' concerns. Resident made statements about self-harm. Resident stated that she wanted to take medication to die. As SSD and Unit Manager talked with resident, she then stated, She has a lot of [NAME] [TRUNCATED]

This citation pertains to MI 676 and MI 732 Based on observation, interview and record review, the facility failed to provide adequate supervision to ensure safety and implement interventions to prevent falls for six residents (R 129, R 13, R 20, R 40, R 46, and R 62) reviewed for being at risk for falls, resulting in an Immediate Jeopardy (IJ) that began on 07/21/21, as a result of the facility's failure to prevent R 129 from falling and fracturing her hip after being left alone in the bathroom. This deficient practice has the high likelihood to affect all residents in this facility potentially resulting in harm, serious injury or death. Findings include: R129 Review of R 129's face sheet and electronic medical record revealed she was an [AGE] year old resident initially admitted to the facility on [DATE], and most recently admitted [DATE] with diagnoses that included: senile degeneration of brain, anxiety, [CONDITION(S)], muscle weakness and urge incontinence. On 4/11/2021 a right humerus fracture and on 7/22/21 a neck of right femur fracture was added to R 129's diagnoses. Review of R 129's baseline care plan indicated she had a history of falls. R 129 passed away on 08/05/21. Review of R 129's incident/accident history revealed she sustained eight falls since her admission to the facility on [DATE]. On 3/8/21 a witnessed fall occurred when R 129 was self-propelling in a wheelchair, and she attempted to stand up. On 3/10/21 a witnessed fall occurred when R 129 self-transferred out of her wheelchair and tripped, falling, and hitting her head causing a skin tear to the eyebrow. On 4/3/21 an unwitnessed fall occurred when R 129 was observed sitting in a doorway on her right side. On 4/10/21 an unwitnessed fall occurred when R 129 was found in her room laying on her right side at the foot of the bed. R 129 fractured her right humerus as a result of the 4/10/21 fall. On 05/1/21 an unwitnessed fall occurred when R 129 was ambulating without assistance and was found laying on her stomach at the end of the bed. The incident report indicated the resident had taken themselves to the bathroom and her pajama bottoms were not fully pulled up. On 5/25/21 an unwitnessed fall occurred when R 129 was found on her floor at the end of the bed. R 129 sustained an abrasion to her right arm. On 07/14/21 an witnessed fall occurred when R 129 self-transferred out of a recliner in the common area, the resident was incontinent at the time of her fall and resident did not ask for any help from staff. On 7/21/21 an unwitnessed fall occurred when R129 was found sitting on the floor of her bathroom in front of her toilet behind her wheelchair .Resident's brief and pants were at her knees/calves and she was sitting on the floor. Per witness statements CNA (Certified Nursing Assistant) D had put resident on the toilet and then went and assisted another resident. The resident was crying out in pain and had a pain assessment of 10/10. R 129 sustained a right hip fracture as a result of the 7/21/21 fall. Review of R 129's care plan revealed she was on BEDREST AT THIS TIME related to falls and a newly added intervention Do not allow me to use the restroom unattended added on 07/21/21. Other interventions to prevent falls also included Anticipate and meet my needs. Under ADL care focus area, interventions included TOILET USE: TOTAL assist x 1 check and change every two hours staff to provide toilet hygiene, revised on 7/28/21, the previous intervention initiated on 03/12/21 was: TOILET USE: Extensive assist x 1 staff to provide toilet hygiene. Review of a hospice Visit Note Report for R 129 dated 7/15/21 revealed she was Dependent on caregiver for all ADL's including toileting. On 07/27/21 at 11:37 AM, R 129 was observed asleep in room and her husband was visiting her. R 129's husband stated R 129 has had a lot of falls, and one of the reasons she admitted to the facility was due to her frequent falls at home and dementia. He stated that R 129 had been weak on her right side for a long time. R 129's husband stated since being in the facility R 129 had fallen several times including a fall where she broke shoulder and then broke her hip about a week ago. R 129's husband stated she has declined since the last fall and is less alert. Staff have discussed interventions with him to reduce falls and he thought staff were waking her up and taking to bathroom, his understanding was that staff would assist her while going to the bathroom at all times. R 129's husband stated she has been in a lot of pain because of the two fractures and is no longer getting out of bed after the last fall with fracture. A follow up interview was completed with R 129's husband on 8/3/21 at approximately 1:30 PM. He stated R 129 had not woken up at all yesterday and had been awake for a short time today. He stated R 129 had stopped speaking and was continuing to decline. R 129's husband was told the details regarding her most recent fall, and he stated, I don't think she would do well if left alone. When asked why he stated, she would get impatient sitting and waiting and a lot of her previous falls were due to her impatiently self-transferring. On 7/29/21 at approximately 2:35 PM, an interview was completed with Hospice Nurse B, who was in R 129's room. R 129 was viewed to be asleep. Nurse B stated that R 129 is normally awake and communicative but stated staff have informed her she had been unusually lethargic lately. On 07/29/21 at approximately 2:50 PM, an interview was completed with CNA C who stated she cares for R 129 often. CNA C was asked about R 129's condition and she stated R 129 had fell and fractured a hip about a week ago and had been declining since the fall. CNA C stated at R 129's baseline functioning, she was alert and able to communicate some needs to you. R 129 would have to be reminded often to use her call light and was frequently self-transferring. Per CNA C R 129 was generally kept in the common area due to her impulsive transferring and frequent falls. CNA C was asked what R 129's bathroom assistance needs were, and she stated R 129 previously needed the assistance of one person in the bathroom. CNA C asked if R 129 was able to be left alone in the bathroom and she replied no, fall risks are never left alone in the bathroom. CNA C was asked if she considered R 129 a fall risk and she stated yes, since she has admitted , you can't turn your back on her for two seconds, even in a common area. CNA C was asked what the coding extensive assist in the bathroom meant to her and she replied, it depends on the resident, but it generally means they need help wiping, getting dressed and undressed and transferring. CNA C asked if residents requiring extensive assist should be left alone in the bathroom and she stated: no. On 07/29/21 at approximately 4:15 PM, an interview was completed with CNA D. CNA D confirmed she had been caring for R 129 on 7/21/21 when she fell in the bathroom. CNA D stated that on 7/21/21 she assisted R 129 to the bathroom, gave her the call light and left the room. CNA D stated all of a sudden there was screaming and her and a couple other staff responded to see R 129 on the floor. CNA D stated R 129 was not able to verbalize how it happened, so she wasn't sure how she fell . CNA D stated she worked with R 129 often and generally worked on the floor R 129 resided on. CNA D stated R 129 has always told me when she needs to go to the bathroom or when she is hungry CNA D was asked if R 129 had a history of falls and she stated that R 129 was not a fall risk per her care plan, I always leave her alone in the bathroom with her call light. CNA D was questioned further about R 129 being a fall risk and she stated, I think she may have fell a couple months ago and broke her shoulder, but I can't be sure. CNA D was asked what the coding extensive assist in the bathroom meant to her and she replied, they need help washing their bottom. CNA D was asked if it meant anything else and she said, I'm not sure, maybe they can't walk to the bathroom, I can't explain it. CNA D revealed she had worked for the facility for four years, and was not sure what the different ADL assistance level codes meant. CNA D stated she would ask a resident's regular aide on shift change if she was unsure of what assistance they needed. CNA D was asked if she would consider herself R 129's regular aide if she worked with her often and she did not answer. On 07/29/21 at 5:20 PM, CNA H was interviewed regarding assisting residents in the bathroom. CNA H was asked what the coding extensive assist in the bathroom meant to her and she replied that it depends on the resident but meaning at least helping with wiping, pulling up pants and doing most of the work with transferring. CNA H stated they generally would not leave a resident alone who required extensive assistance, but it would depend on other factors. CNA H was asked if a resident at risk for falls could be left alone in the bathroom and she stated, absolutely not. CNA H continued that if a resident had self-transferring history, fall history or impaired cognition they would be considered at risk to fall in the bathroom. CNA H stated the fall risk should be in the resident's care plan and staff discuss this at shift change when giving report. On 07/30/21 at approximately 11:08 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) were informed of an Immediate Jeopardy (IJ) related to F 689 that began on 07/21/2021 when the facility failed to prevent a fall for R 129, a cognitively impaired resident with a significant history of impulsive self-transferring behavior, who required extensive assistance with toileting and a history of multiple falls (3/8/21, 3/10/21, 4/3/21, 4/10/21, 5/1/21, 7/14/21) including a fall with fracture on 4/10/21 (right humeral fracture) was left unsupervised in the bathroom on 7/21/21 and fell and fractured her right hip resulting in a significant decline in level of function. Interviews with CNAs who provided direct care for the resident reflected not all staff were aware of her significant risk for fall with injury resulting in inadequate supervision despite care planned interventions. The identified risk of serious injury, serious harm, serious impairment or death was evidenced by: R 129 fractured her right femur on 7/21/21 due to a fall that occurred when she was left unsupervised in the bathroom. R 129 is confined to her bed due to the injury and has had significant pain due to injury as well as a change in condition. On 7/29/21 the resident was reported by hospice staff B and facility staff C to be lethargic and not easily aroused, which is a change from her baseline of being able to communicate her needs as well as have physical mobility out of bed. The need for immediate action was: All residents at risk for falls remain at risk for serious injury and or death due to potential for falls. Staff need to be available in sufficient numbers, educated in plans of care, trained to implement interventions, and provide supervision to prevent falls and accidents leading to serious injury. On 08/04/2021, the facility plan to remove the Immediate Jeopardy was accepted and the state agency began to validate the removal plan with which included: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. R 129 has been identified as the recipient that has suffered due to serious injury of right femur fracture. Category level of high risk, medium risk and low risk were determined by diagnosis, fall risk score, cognition and therapy recommendations. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action was initiated. The Administrator and DON provided 1:1 education with staff who were directly involved in the resident's fall. Beginning date 7/30/21. All residents will be reassessed using the COMS - Fall Risk Evaluation. Beginning date 7/30/21. All residents will be reassessed using the COMS - BIMS Evaluation for any resident who has not had one completed in the last 2 months. Beginning date 7/30/21. All residents identified as at risk for falls will have safety measures, as well as resident specific interventions, added to their care plans through an interdisciplinary process. Beginning date 7/30/21. At-risk Residents for falls will be identified in RED on the Door Plate. Beginning date 7/30/21. The safety measures and resident specific interventions that will be added to the care plans will also be reflected on the Kardex so that the CENA's have access to this information. Beginning date 7/30/21. CENA's will be educated 1:1 on how to review the updated Kardex prior to their next shift. Beginning date 7/30/21. Will update CENA Worksheets and Nurse 24-hour Worksheet to identify Residents who are At-Risk. Beginning date 7/30/21. Unit Managers will be included in Post-Fall Calls with Administrator and DON. Beginning date 7/30/21. Incorporate post fall huddles IDT within 72 hours post fall to recreate fall and assure appropriate interventions are in place. Beginning date 7/30/21. Identified residents as high risk, medium risk and low risk by assessing their diagnosis, fall risk cognition and therapy recommendation. Beginning date 8/4/21. Update resident name plates to identify risk: red is for high risk, yellow is for medium risk and white is for low risk. Beginning 8/5/21 Adding a star to the name plate for residents that can not be left alone in the bathroom. Beginning date 8/5/21. Update care plans to reflect if residents are at a high, medium or low risk. Beginning date 8/4/21. Implement signage for CENA's to include with badges that identify risk categories (high, medium, low) and extensive, limited, supervision, distant supervision and independent assistance guidance. Beginning date 8/5/21. Initiate staff education related to risk categories and definitions of level of assistance provided to residents. Beginning date 8/5/21. It was determined immediacy continued due to the continued observations of residents who were a fall risk: R 62 Review of R 62's face sheet dated 7/28/21 revealed she was a [AGE] year-old female admitted to the facility. Review of R 62's Brief Interview of Mental Status (BIMS) date 7/30/21 at 5:46 PM revealed a score of 14/15 (normal cognition). Review of R 62's Kardex (caregiver instructions) dated 729/21 revealed, toilet on request. Do not leave alone in the bathroom. Transferring: Limited assist x 1 with walker. Review of R 62's mobility care plan dated 2/12/21 revealed, Toilet Schedule: Toilet on request. Do not leave alone in bathroom, initiated 2/12/21. On 7/28/21 at 2:21 PM, R 62 was observed sitting on the toilet in her room, call light on in bathroom and phone in her hand. R 62 said she had called the nurses station to get help. Within a minute Certified Nurse Aide (CNA) X arrived to assist R 62 out of the bathroom and back into her recliner. The Surveyor did not hear a call alarm and asked CNA X how she knew R 62 needed help in the bathroom. CNA X demonstrated the call light in the bathroom turns on a light in the hall. CNA X said she put R 62 on the toilet and had to leave the unit so when she returned to the unit, she checked on R 62 first. CNA X was not sure what time it was when she assisted R 62 to the bathroom. CNA X was asked about the call light pager to see how long the call light had been on and CNA X said her pager battery was dead, so she did not know how long R 62 had been waiting for help. R 62 complained of diarrhea and upset stomach. CNA X went to get Licensed Practical Nurse (LPN) JJJ to address R 62's medical concerns. (CNA X did not remain in the bathroom after she transferred R 62 to the toilet as instructed on R 62's Kardex). Review of R 62's Fall Root Cause Summary dated 7/28/21 at 6:57 PM, revealed, Risk for Falls: visual impairment, de-conditioning, spinal stenosis, history of self-transferring. Last time observed: Staff observed incident. Last time toileted: Resident self-transferring to the bathroom at the time of this incident. Footwear at time of occurrence: Grippy socks. Assistive Devices in use during occurrence: Wheelchair. Summary of incident: Resident noted to self-transfer to bathroom. Staff entered bathroom and noted resident to be attempting to get off the toilet and pull up brief without waiting for staff assistance. When attempting to do so resident lost balance and sat back down on the left side of her buttock. Skin check completed and no areas of concern noted. Resident denied pain and the time of incident. Head-to-toe skin assessment/injuries: No injuries noted. Previous interventions in place/effective at time of occurrence: Resident not to be left alone in bathroom, non-skid footwear. (Resident was started on 1:1 per note on 7/28/21 at 5:56 PM related to self-harm statements. There was no indication in this note approximately 1 hour later that 1:1 care was in place). Review of R 62's order note dated 7/29/21 at 9:39 AM revealed, Physician notified to review Resident's 1:1. Resident was stating she wasn't aware of why she needed to have someone with her at all times. When reminded of the happening from 7/28/21, Resident denied this occurring. Physician was informed and approved to have 1-on-1 discontinued. Review of R 62's Narrative Note dated 8/2/21 at 3:16 PM, signed by the Nursing Home Administrator (NHA) revealed, Received completed grievance from 7/7/21. Resident had expressed concerns related to call light. After further discussion and investigation, resident expressed satisfaction and signed off from form. Resident was provided with written notification. (This form was not provided to the State Agency by the end of the survey). 08/04/21 Tour of building revealed approximately 55 white name plates and 96 red name plates. R 40 Review of R 40's face sheet and electronic medical record revealed he was an [AGE] year old resident who admitted to the facility on [DATE] with diagnosis that included: dementia, Alzheimer's disease, visual loss, hearing loss and history of falling. Review of R 40's baseline care plan revealed he was cognitively impaired, had a history of falls, was occasionally incontinent, fell within the last month prior to admission and per family has had increasing debility & confusion. He had a history of a rehab stay in 12/2020 r/t [related to] UTI & falls. Review of incidents and accidents for R 40 revealed on 7/2/21 he had an unwitnessed fall in his room. Review of a COMS-Fall Risk Evaluation- V 2 completed on 7/30/21 revealed a score of 8 which was labeled at NA. History of falls in the last 3 months was checked as no falls even though the resident had fallen on 7/2/21. Under ambulation/elimination status R 40 was checked as ambulatory/ continent despite his baseline care plan indicating he was incontinent, his gait/balance was checked as normal instead of Requires use of assistive devices (i.e. can, w/c walker, furniture) and R 40 uses a walker per his kardex, care plan and observations. Review of R 40's care plan revealed a focus of I am at risk for falls r/t h/o falls, UTI, [CONDITION(S)], Alzheimer's disease, DMI, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], hearing loss and vision impairment. I have had a fall at my home prior to my admission. I have poor safety awareness and I self transfer frequently. I receive an antihypertensive medication. 7/2/21 [fall] with no injury. Interventions included: Ensure I am wearing appropriate non-skid footwear when ambulating . On 08/04/21 at 8:54 AM, R 40 viewed ambulating in and out of room with stocking feet and no grippers. He presented as mildly confused. His name plate was white. R 46 According to the MDS Assessment, dated 5/4/21, R 46 had multiple diagnosis including [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)]. This same assessment indicated that R 46 required extensive assistance of two staff members for moving in bed, transferring, and dressing. One staff member was necessary for hygiene including bathroom assistance. Staff assessed R 46 as cognitively intact. According to an Incident report dated 4/13/21, R 46 was found on the floor in the bathroom. R 46 was sent to the emergency room for complaints of severe left hip pain. R 46 also obtained the following injuries from this fall: abrasions to the chest, left elbow and left upper arm, bruising to both knees, and skin tears to the scalp and back of right hand. A new intervention implemented following that incident included having staff remain with R 46 while in the bathroom for safety reasons. Review of R 46's Fall care plan revealed on 4/13/21 the facility initiated an intervention that read, staff to remain with me while I am in the bathroom for safety. During an observation on 8/4/21 at 8:49 AM, CNA X exited R 46's room. R 46 was not visible and CNA X stated that R 46 was in the bathroom. When asked if R 46 was alone, CNA X reported that he was and then stated that R 46 will not let anyone stay in the bathroom with him and that he knows how to pull the string. At 8:52 AM R 46 activated the bathroom call light and RN GGG responded after obtaining a gait belt. When asked if R 46 was alone in the bathroom RN GGG stated that he was. On 08/04/21 at 11:30 AM, the plan of removal was discussed with the DON and NHA. They confirmed 125 of 151 residents were identified as fall risks due to their ADL (activities of daily living) assistance needs. Fall risk evaluations were completed by facility staff and anyone scoring over 10 points was coded as a fall risk. It was discussed with the DON and NHA that 125 red name plates should have been viewed per their fall risk identification, so the discrepancy was confusing. The NHA and DON stated the red tag decisions were a combination of fall risk, BIMS (cognitive status) and the physical therapy review of their ability to be in bathroom alone. The NHA and DON were informed of the concerning observations with R 40 and R 46. It was discussed that R 40 had a recent fall and presented with continued fall risk behaviors, yet was not coded as a fall risk per the name plate system. The DON and NHA discussed R 46's fall risk and reported the last assessment indicated R 46 was not a fall risk (scored a 9 and those over 10 are at risk). It was reported that R 46 does not like staff to remain in the bathroom per the care plan. During the conversation on 08/04/21 at 11:30 AM, R 129's care plan was discussed with the DON and NHA. The NHA and DON clarified that the intervention do not leave resident alone in the bathroom was not in the plan of care prior to the 7/21/21 fall, it was an added intervention after the fall. It was discussed this intervention should have specifically been in the care plan prior to this fall due to the behaviors and risk factors displayed by R 129 and staff report that she should not have been left alone in the bathroom. There was discussion that R 129's previous intervention of needing extensive assist in the bathroom some staff interpreted as she could not be left alone and the staff member who left her alone when she fell and fractured her hip did not interpret extensive assist the same way. The review of all resident care plans to ensure complete and clear care plans for R 129 and other residents was discussed. R 13 Review of R 13's face sheet and electronic medical record revealed she most recently admitted to the facility on [DATE] and initially admitted on [DATE] with diagnosis that included: Alzheimer's disease, dementia, depression and anxiety. On 08/04/21 at 3:10 PM, R 13 was viewed ambulating in a wheelchair out of her room. R 13 was asked how she was, and she stated Awful, I just went to the bathroom myself and I don't like it. Her name plate was viewed to be white. Review of R 13's care plan revealed she was at risk for falls and had an intervention Do not leave me unattended in my bathroom. R 40 On 08/05/2021 at 1:43 PM an additional observation was made of R 40, who was observed ambulating in his room with stocking feet. His name plate was still white. On 8/5/21 at 10:35 AM, Certified Nurse Aide (CNA) BBB said she was provided fall education at the start of her shift today. CNA BBB said she did not remember what all of the colors stood for on the resident name plates. She was aware some resident should have stars but did not remember what the stars stood for. CNA BBB said was not provided any written material to remind her of what the colors or stars stood for. R 20 Review of R 20's face sheet and electronic medical record revealed she was a [AGE] year old resident who admitted to the facility on [DATE] with diagnosis that included: dementia, chronic pain, unsteadiness on feet and [CONDITION(S)]. Review of R 20's care plan indicated an ADL intervention: Toileting-Extensive x1 with commode. A focus area of Falls, indicating R 20 was a moderate fall risk and had a fall w/no injury on 06/19/21. Interventions included: Do not leave me unattended in my bathroom and room door to be left open when I am in room and I have an at-risk YELLOW identifier for falls outside my room. R 20's most recent COMS-Fall Risk Evaluation- V 2 indicated she had a score of 13, putting her at risk for falls. Concern areas included intermittent confusion, a history of fall in the past 3 months, poor vision status, balance problems, predisposing diseases, and medications. On 08/05/21 at 01:46 PM, R 20 was observed ambulating in her wheelchair in her room and opening the bathroom door, staff FF walked by as R 20 asked for the room door to be closed for her. Staff FF then closed door and kept walking down the hall. R 20's name plate viewed to be yellow with a star, indicating they were a moderate fall risk and not to be left alone in the bathroom. Staff FF was interviewed and stated that she had gotten education regarding the new name plates, Staff FF stated they thought yellow meant low fall risk and the star meant the resident is not to be alone in the bathroom. Staff FF was asked if R 20 had a star on their door and they replied yes. Staff FF was asked if R 20 was headed into the bathroom when they closed her door and they said, oh no! and went back to room and flagged down another staff member to assist R 20. On 08/05/21 at 2:15 pm, the DON was informed of continued concerns related to IJ immediacy removal related to R 20 and R 40. R 46 An additional observation and interview was completed on 8/5/21 at 3:20 PM regarding R 46. R 46 was noted to have a red placard with his name on it outside the room door. The red placard contained a star. CNA II stated that R 46 had a red placard with a star indicating that R 46 was a fall risk and staff were to remain with the resident while they are in the bathroom. When asked if R 46 allows staff in the bathroom, CNA II reported that he did not allow them to stay in the bathroom and that they did not know what they would do if they had to help him get into the bathroom. On 08/05/2021, the amended facility plan to remove the Immediate Jeopardy was accepted and the state agency began to validate the removal plan with which included: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. R 129 has been identified as the recipient that has suffered due to serious injury of right femur fracture. 125/151 Residents are at risk to have the potential to suffer an adverse outcome. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete The Administrator and DON provided 1:1 education with staff who were directly involved in the resident's fall. Beginning date 7/30/21. All residents will be reassessed using the COMS - Fall Risk Evaluation. Beginning date 7/30/21. All residents will be reassessed using the COMS - BIMS Evaluation for any resident who has not had one completed in the last 2 months. Beginning date 7/30/21. All residents identified as at risk for falls will have safety measures, as well as resident specific interventions, added to their care plans through an interdisciplinary process. Beginning date 7/30/21. At-risk Residents for falls will be identified in RED on the Door Plate. Beginning date 7/30/21. The safety measures and resident specific interventions that will be added to the care plans will also be reflected on the Kardex so that the CENA's have access to this information. Beginning date 7/30/21. CENA's will be educated 1:1 on how to review the updated Kardex prior to their next shift. Beginning date 7/30/21. Will update CENA Worksheets and Nurse 24-hour Worksheet to identify Residents who are At-Risk. Beginning date 7/30/21. Unit Managers will be included in Post-Fall Calls with Administrator and DON. Beginning date 7/30/21. Incorporate post fall huddles IDT within 72 hours post fall to recreate fall and assure appropriate interventions are in place. Beginning date 7/30/21. Reviewed [R40's] fall status and updated to not be left alone in bathroom. Beginning 8/5/21 All department education is being completed by Management staff upon next working shifting as well as receiving the name badge guide. Beginning date 8/5/21. Although the Immediate Jeopardy was removed on 08/05/2021, the facility remained out of compliance with a scope of pattern and severity of No actual harm with the potential for more than minimal harm that is not immediate jeopardy due to sustained compliance not being verified by the state agency.

This citation pertains to MI 676, MI 732, and MI 344 Based on observation, interview and record review, the facility failed to develop and implement comprehensive care plans for 9 residents (R 13, R 20, R 40, R 46, R 48, R 53, R 88, R 129, and R 141) reviewed for care resulting in unmet needs, increased risk of accidents/falls, actual falls with injury (R 129), abusive behaviors (R30) and decreased quality of life. Findings include: R 48 Review of R 48's face sheet and electronic medical record revealed they admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R 48's orders revealed they were prescribed [MEDICATION(S)] (anticonvulsant/[CONDITION(S)] disorder medication), [MEDICATION(S)] (anti-psychotic), [MEDICATION(S)] (anti-psychotic), [MEDICATION(S)] (anti-depressant), [MEDICATION(S)] (Alzheimer's disease medication), [MEDICATION(S)] (dementia/Alzheimer's medication) and [MEDICATION(S)] (high cholesterol medication). An order was also in place for MED MONITORING: Anti-Psychotic . which included [CONDITION(S)] and Ortho BP monthly r/t (related to) antipsychotic. Review of R 48's care plan revealed an intervention: Administer medications as ordered. Monitor/document for side effects and effectiveness, and Administer [CONDITION(S)] medications as ordered by physician. Monitor for side effects and effectiveness and Administer medications as ordered Obtain labs and diagnostic studies as ordered. Review of the medical record revealed no recent lipid panel and the vitals showed no proof of orthostatic blood pressures being completed. The treatment administration record showed some months with a refusal of orthostatic blood pressures but no proof of reapproach in the progress notes. Other months the treatment administration record was checked that orthostatic blood pressures were completed but the vitals section of the electronic medical record showed no corresponding orthostatic blood pressure readings. A request was made to the Nursing Home Administrator and the Director of Nursing for a recent lipid panel and proof of orthostatic blood pressure monitoring. The Director of nursing replied by email on 08/05/21 at 01:19 PM: Lipid panel was not completed recently. We have one scheduled for today. I was not able to locate the orthostatic blood pressures you requested. R 129 Review of R 129's face sheet and electronic medical record revealed she was an [AGE] year old resident initially admitted to the facility on [DATE] and most recently admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/11/2021 a right humerus fracture and on 7/22/21 a neck of right femur fracture was added to R 129's diagnoses. Review of R 129's baseline care indicated she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R 129's incident/accident history revealed she sustained 8 falls since her admission to the facility on [DATE]. On 3/8/21 a witnessed fall occurred when R 129 was self-propelling in a wheelchair and she attempted to stand up. On 3/10/21 a witnessed fall occurred when R 129 self-transferred out of her wheelchair and tripped, falling and hitting her head causing a skin tear to the eyebrow. On 4/3/21 an unwitnessed fall occurred when R 129 was observed sitting in a doorway on her right side. On 4/10/21 an unwitnessed fall occurred when R 129 was found in her room laying on her right side at the foot of the bed. R 129 fractured her right humerus as a result of the 4/10/21 fall. On 05/1/21 an unwitnessed fall occurred when R 129 was ambulating without assistance and found laying on her stomach at the end of the bed. The incident report indicated the resident had taken themselves to the bathroom and her pajama bottoms were not fully pulled up. On 5/25/21 an unwitnessed fall occurred when R 129 was found on her floor at the end of the bed. R 129 sustained an abrasion to her right arm. On 07/14/21 an witnessed fall occurred when R 129 self-transferred out of a recliner in the common area, the resident was incontinent at the time of her fall and resident did not ask for any help from staff. On 7/21/21 an unwitnessed fall occurred when R129 was found sitting on the floor of her bathroom in front of her toilet behind her wheelchair .Resident's brief and pants were at her knees/calves and she was sitting on the floor. Per witness statements CNA (Certified Nursing Assistant) D had put resident on the toilet and then went and assisted another resident. The resident was crying out in pain and had a pain assessment of 10/10. R 129 sustained a right hip fracture as a result of the 7/21/21 fall. Review of R 129's care plan revealed she was on BEDREST AT THIS TIME related to falls and a newly added intervention Do not allow me to use the restroom unattended added on 07/21/21. Other interventions to prevent falls also included Anticipate and meet my needs. Under ADL care focus area, interventions included TOILET USE: TOTAL assist x 1 check and change every two hours staff to provide toilet hygiene, revised on 7/28/21, the previous intervention initiated on 03/12/21 was: TOILET USE: Extensive assist x 1 staff to provide toilet hygiene. Review of a hospice Visit Note Report for R 129 dated 7/15/21 revealed she was Dependent on caregiver for all ADL's including toileting. On 07/27/21 at 11:37 AM, R 129 was observed asleep in their room and her husband was visiting her. R 129's husband stated R 129 has had a lot of falls, and one of the reasons she admitted to the facility was due to her frequent falls at home and dementia. He stated that R 129 had been weak on her right side for a long time. R 129's husband stated since being in the facility R 129 had fallen several times including a fall where she broke shoulder and then broke her hip about a week ago. R 129's husband stated she has declined since the last fall and is less alert. Staff have discussed interventions to reduce falls with him and he thought staff were waking her up and taking to bathroom, his understanding was staff would assist her while going to the bathroom at all times. R 129's husband stated she has been in a lot of pain due to having two fractures and is no longer getting out of bed after the last fracture. A follow up interview was completed with R 129's husband on 8/3/21 at approximately 1:30 PM. He stated R 129 had not woken up at all yesterday and had been awake for a short time today. He stated R 129 had stopped speaking and was continuing to decline. R 129's husband was told the details regarding her most recent fall and he stated I don't think she would do well if left alone. When asked why he stated she would get impatient sitting and waiting and a lot of her previous falls were due to her impatiently self-transferring. On 7/29/21 at approximately 2:35 PM an interview was completed with Hospice Nurse B, who was in R 129's room. R 129 was viewed to be asleep. Nurse B stated that R 129 is normally awake and communicative but stated staff have informed her she had been unusually lethargic lately. On 07/29/21 at approximately 2:50 PM an interview was completed with CNA C who stated she cares for R 129 often. CNA C was asked about R 129's condition and she stated R 129 had fell and fractured a hip about a week ago and had been declining since the fall. CNA C stated at R 129's baseline functioning, she was alert and able to communicate some needs to you. R 129 would have to be reminded often to use her call light and was frequently self-transferring. Per CNA C R 129 was generally kept in the common area due to her impulsive transferring and frequent falls. CNA C was asked what R 129's bathroom assistance needs were and she stated R 129 previously needed the assistance of one person in the bathroom. CNA C asked if R 129 was able to be left alone in the bathroom and she replied no, fall risks are never left alone in the bathroom. CNA C was asked if she considered R 129 a fall risk and she stated yes, since she has admitted , you can't turn your back on her for two seconds, even in a common area. CNA C was asked what the coding extensive assist in the bathroom meant to her and she replied it depends on the resident, but it generally means they need help wiping, getting dressed and undressed and transferring. CNA C asked if residents requiring extensive assist should be left alone in the bathroom and she stated: no. On 07/29/21 at approximately 4:15 PM an interview was completed with CNA D. CNA D confirmed she had been caring for R 129 on 7/21/21 when she fell in the bathroom. CNA D stated that on 7/21/21 she assisted R 129 to the bathroom, gave her the call light and left the room. CNA D stated all of a sudden there was screaming and her and a couple other staff responded to see R 129 on the floor. CNA D stated R 129 was not able to verbalize how it happened, so she wasn't sure how she fell . CNA D stated she worked with R 129 often and generally worked on the floor R 129 resided on. CNA D stated R 129 has always told me when she needs to go to the bathroom or when she is hungry CNA D was asked if R 129 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . CNA D was questioned further about R 129 being a fall risk and she stated I think she may have fell a couple months ago and broke her shoulder, but I can't be sure. CNA D was asked what the coding extensive assist in the bathroom meant to her and she replied they need help washing their bottom. CNA D was asked if it meant anything else and she said I'm not sure, maybe they can't walk to the bathroom, I can't explain it. CNA D revealed she had worked for the facility for four years, and was not sure what the different ADL assistance level codes meant. CNA D stated she would ask a resident's regular aide on shift change if she was unsure of what assistance they needed. CNA D was asked if she would consider herself R 129's regular aide if she worked with her often and she did not answer. On 07/29/21 at 5:20 PM CNA H was interviewed regarding assisting residents in the bathroom. CNA H was asked what the coding extensive assist in the bathroom meant to her and she replied that it depends on the resident but meaning at least helping with wiping, pulling up pants and doing most of the work with transferring. CNA H stated they generally would not leave a resident alone who required extensive assistance but it would depend on other factors. CNA H was asked if a resident at risk for falls could be left alone in the bathroom and she stated absolutely not. CNA H continued that if a resident had self-transferring history, fall history or impaired cognition they would be considered at risk to fall in the bathroom. CNA H stated the fall risk should be in the resident's care plan and staff discuss this at shift change when giving report. During the conversation on 08/04/21 at 11:30 AM R 129's care plan was discussed with the DON and NHA. The NHA and DON clarified that the intervention do not leave resident alone in the bathroom was not in the plan of care prior to the 7/21/21 fall, it was an added intervention after the fall. It was discussed this intervention should have specifically been in the care plan prior to this fall due to the behaviors and risk factors displayed by R 129 and staff report that she should not have been left alone in the bathroom. There was discussion that R 129's previous intervention of needing extensive assist in the bathroom some staff interpreted as she could not be left alone and the staff member who left her alone when she fell and fractured her hip did not interpret extensive assist the same way. The review of all resident care plans to ensure complete and clear care plans for R 129 and other residents was discussed. R 40 Review of R 40's face sheet and electronic medical record revealed he was an [AGE] year old resident who admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R 40's baseline care plan revealed he was cognitively impaired, had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] & falls. Review of incidents and accidents for R 40 revealed on 7/2/21 he had an unwitnessed fall in his room. Review of a COMS-Fall Risk Evaluation- V 2 completed on 7/30/21 revealed a score of 8 which was labeled at NA. History of falls in the last 3 months was checked as no falls even though the resident had fallen on 7/2/21. Under ambulation/elimination status R 40 was checked as ambulatory/ continent despite his baseline care plan indicating he was incontinent, his gait/balance was checked as normal instead of Requires use of assistive devices (i.e. can, w/c walker, furniture) and R 40 uses a walker per his kardex, care plan and observations. Review of R 40's care plan revealed a focus of I am at risk for falls r/t h/o (history of) falls, UTI, [CONDITION(S)], Alzheimer's disease, DMI, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], hearing loss and vision impairment. I have had a fall at my home prior to my admission. I have poor safety awareness and I self transfer frequently. I receive an antihypertensive medication. 7/2/21 [fall] with no injury. Interventions included: Ensure I am wearing appropriate non-skid footwear when ambulating . On 08/04/21 at 8:54 AM R 40 viewed ambulating in and out of room with stocking feet and no grippers. He presented as mildly confused. His name plate was white viewed to be white indicating he was not a fall risk. On 08/05/2021 at 1:43 PM an additional observation was made of R 40, who was observed ambulating in his room with stocking feet. His name plate was viewed to still be white. R 13 Review of R 13's face sheet and electronic medical record revealed she most recently admitted to the facility on [DATE] and initially admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/04/21 at 3:10 PM R 13 was viewed ambulating in a wheelchair out of her room. R 13 was asked how she was and she stated Awful, I just went to the bathroom myself and I don't like it. Her name plate was viewed to be white. Review of R 13's care plan revealed she was at risk for falls and had an intervention Do not leave me unattended in my bathroom. R 20 Review of R 20's face sheet and electronic medical record revealed she was a [AGE] year old resident who admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R 20's care plan indicated an ADL intervention: Toileting-Extensive x1 with commode. A focus area of Falls, indicating R 20 was a moderate fall risk and had a fall w/no injury on 06/19/21. Interventions included: Do not leave me unattended in my bathroom and room door to be left open when I am in room and I have an at-risk YELLOW identifier for falls outside my room. R 20's most recent COMS-Fall Risk Evaluation- V 2 indicated she had a score of 13, putting her at risk for falls. Concern areas included intermittent confusion, a history of fall in the past 3 months, poor vision status, balance problems, predisposing diseases and medications. On 08/05/21 at 01:46 PM, R 20 was observed ambulating in her wheelchair in her room and opening the bathroom door, staff FF walked by as R 20 asked for the room door to be closed for her. Staff FF then closed door and kept walking down the hall. R 20's name plate viewed to be yellow with a star, indicating they were a moderate fall risk and not to be left alone in the bathroom. Staff FF was interviewed and stated that she had gotten education regarding the new name plates, Staff FF stated they thought yellow means low risk and the star means the resident is not to be alone in the bathroom. Staff FF was asked if R 20 had a star on their door and they replied yes. Staff FF was asked if R 20 was headed into the bathroom when they closed her door and Staff FF said oh no! and went back to room and flagged down another staff member to assist R 20. Resident #141 Resident #141 was originally admitted to the facility 1/16/14 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) of 1 which indicated the Resident was severely cognitively impaired. Review of the Care Plan for Resident #141 reflected a Skin Integrity Care Plan implemented 7/17/19. The Care Plan revealed an intervention implemented 7/17/19 documented as, I have blue boots to wear. No documentation was found that indicated Resident #141 was to wear purple boots. On 8/5/21 at 2:34 PM, RN MMM reported that Resident #141 had two blisters on the tops of his feet and compromised skin on his right heel. RN MMM reported that the Resident had on purple boots when he was supposed to have blue boot on. RN MMM reported that the purple boots have straps, but the blue boots do not have straps. RN MMM indicated that the straps from the purple boots caused blisters on the feet of Resident #141. Review of the Nurse Practitioner's (NP) note of 7/27/21 reflected an evaluation of a fluid filled blister on the top of the Residents left foot and on the Resident's left heel. The documentation reflected Resident #141 had a doctor's order for blue boots, but purple been had been applied. Review of the documentation by the NP revealed, The Resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Purple boot straps were on causing the blister on the top of the foot. The documentation reflected that due to the straps from the purple boots the Resident was wearing, instead of the Care Planned blue boots, the Resident is now requiring medical treatment. R 46 According to the MDS Assessment, dated 5/4/21, R 46 had multiple diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This same assessment indicated that R 46 required extensive assistance of two staff members for moving in bed, transferring, and dressing. One staff member was necessary for hygiene including bathroom assistance. Staff assessed R 46 as cognitively intact. During an observation on 8/4/21 at 8:49 AM, CNA X exited R 46's room. R 46 was not visible in the room and CNA X stated that R 46 was in the bathroom. When asked if R 46 was alone, CNA X reported that he was and then stated that R 46 will not let anyone stay in the bathroom with him and that he knows how to pull the string. At 8:52 AM R 46 activated the bathroom call light and RN GGG responded after obtaining a gait belt. When asked if R 46 was alone in the bathroom RN GGG stated that he was. Review of R 46's Fall care plan revealed on 4/13/21 the facility initiated an intervention that read, staff to remain with me while I am in the bathroom for safety. Review of R 46's Nutrition care plan indicated beginning 2/25/21, revised 7/30/31, R 46 was on weekly weights and the dietitian was to monitor and evaluate weight trends. Review of R 46's weight log revealed weights were obtained on 5/3/21, 5/10/21, 6/7/21, 6/21/21, 7/12/21, and 7/26/21 (missed seven opportunities to weigh weekly). R 46 had a 12-pound weight loss between 3/4/21 and 7/26/21. During an interview on 8/6/21 at 2:33 PM Registered Dietician (RD) NN stated that R 46 had a habit of refusing to be weighed. RD NN stated that she will continue to educate staff that weights are due and will plan to coordinate weights with physical therapy. RD NN could not provide proof that weights had been performed per care plan by the end of the survey. R 53 According to the MDS assessment, dated 5/11/21, R 53 had multiple diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff assessed R 53 as cognitively intact. An observation on 7/27/21 at 10:30 AM revealed R 53 had a dark purple discoloration on the backside of his left arm. The discoloration extended the length of the arm, from the elbow to wrist. When asked, R 53 looked at his arm and stated that he did not know how it occurred and denied falling recently. Review of R 53's electronic medical record (EMR) revealed no documentation of this discoloration. According to the Skin care planned interventions, initiated 7/11/19, R 53 was to have weekly skin checks by a licensed nurse and the weekly treatment documentation is to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate (drainage) and any other notable changes or observations. The skin assessment found in R 53's EMR, dated 7/23/21, indicated no new wounds. A skin assessment performed on 7/31/21, and four days after the discoloration was noted by this surveyor, indicated no new wounds. R 88 According to the MDS assessment, dated 5/25/21, R 88 had multiple diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This same assessment indicated that R 88 required extensive assistance of one to two staff members for transferring, walking, and dressing. Staff assessed R 88 as cognitively intact. During an observation and interview on 7/29/21 at 8:12 AM, R 88 was observed sitting in their wheelchair, the call light was activated and R 88 stated, I need my clothes on. R 88 clarified that she is supposed to have cream on her knees and that her TED hose (compression stocking to aide circulation) is supposed to be on. R 88's feet were observed strapped in sandals, both feet were swollen against the straps and deep purple. R 88 stated that her legs felt awful. CNA X stated that she would get there soon. At 9:08 AM (an hour later), R 88 remained in the wheelchair with both feet resting on the floor, swollen, and deep purple in color, there were no TED hose on. A follow up interview that same day around 3:40 PM, R 88 had TED hose on and stated that the staff had put them on just before lunch (around noon). According to R 88's Skin care plan, an intervention initiated on 3/10/21 and revised on 6/3/21, read, Encourage ted hose on in am, off in pm.

This citation pertains to MI 332, MI 404, MI 202 and MI 618 Based on observation, interview and record review, the facility failed to fully investigate allegations of abuse and neglect and prevent further abuse for 8 residents, (R 23, R 30, R 32, R 62, R 86, R 119, R 135, R 142) reviewed for abuse, resulting in the potential for residents not being protected from an abusive individual, further abuse and neglect, psychosocial harm and injury. Findings include: According to the facility Abuse, Neglect and Exploitation Policy with a revision date 10/8/2019, read, in part, Abuse: means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical. Mental, and psychosocial well-being, The home will provide ongoing oversight and supervision of staff in order to assure that is (sic) policies are implemented as written, The home will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: . B Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed and certified staff on each shift, Possible Indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse 2. Physical marks such as bruises or patterned appearances such as a hand print, belt or ring mark on a resident's body, 3. Physical injury of a resident, of unknown source, 4. Resident reports of theft of property, or missing property, 5. Verbal abuse of a resident overheard, 6. Physical abuse of a resident observed, 7. Psychological abuse of a resident observed, 8. Failure to provide care needs such as feeding, bathing, dressing, turning, and repositioning, A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedure for investigation include: 1. Identifying staff responsible for the investigation, 2. Exercising caution in handling evidence that could be used in a criminal investigation, 3. Investigation different types of alleged violations, 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation, The home will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation, B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed, C. Increased supervision of the alleged victim and residents, D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator, E. Protection from retaliation, F. Providing emotional support and counseling to the resident during and after the investigation, as needed, and The home will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g law enforcement when applicable) within specified timeframes: a. 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 b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 2. Assuring that reporters are free from retaliation or reprisal .4. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following: a. analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences, b. defining how care provision will be changed and /or improved to protect residents receiving services, c. training of staff on changes made and demonstration of staff competency after training is implanted (sic), d. Identification of staff responsible for implantation (sic) of corrective actions, e. the expected date for implementation, and f. Identification of staff responsible for monitoring the implementation of the plan. R 30 Review of R 30's face sheet dated 8/3/21 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R 30 was not her own responsible party. Review of R 30's cognitive assessment completed for her Minimum Data Set (MDS) dated [DATE] revealed she was unable to answer any of the cognitive questions and was marked as severely cognitively impaired. Review of R 30's mood/behavioral care plan initiated on 7/11/19 and revised on 5/19/21 revealed, wanders among the unit in and out of co-resident's rooms to seek comfort. -noted paranoia at times. -offered change of room to husband on 6/29/20 r/t (related to) embracing male co-resident, however husband declined to move, -I was involved in a peer-to-peer interaction 5/18/21. Review of R 30's progress note dated, 5/24/21 at 11:33 revealed, IDT met to review resident in EWBT (unknown) r/t (related to) indicating for behavioral symptom on the [NAME] report, for psych medications, and recent altercation. Noted behaviors include hitting, kicking, pushing, grabbing, pinching, and wandering over the last 30 days. Resident has dx of dementia. If [R30] is attempting to assist co-residents among the unit, thank her for her help, offer to trade places and complete task, as for [R30] enjoys helping others; If [R30] is entering co-resident's rooms, redirect to alternate activity and provide supplies as needed.; If observing exit seeking behavior, offer to walk with [R30] among the unit and attempt to redirect to alternate topic or task; Increase supervision when [R30] is moving independently on the unit; Monitor for tearfulness, agitation, anxiousness, changes in sleep patterns, mood, thoughts of death. R 32 Review of R 32's face sheet and electronic medical record revealed she was an [AGE] year old female who admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility reported incident revealed R 32 and R 30 had an altercation on 5/18/21 where R 32 reported R 30 came into her room and pulled her blankets up over her head and pushed down. Review of R 32's resident progress notes revealed a note by Nurse K for 5/18/21 at 8:30 PM: Upon entering residents room to pass meds to her, resident was found up out of bed and walking towards the door to find someone to help her. Resident was teary eyed and looked upset. When asked what was wrong she stated that women was in here again and this time she put my blankets over my face and I couldn't breathe. Resident stated that nobody here cares because they keep coming in the room. I assured the resident that staff definitely does care. Resident was asked to sit down and that we could talk about it. Resident than stated that that would be fine and she sat down. Resident stated that she was asleep lying in bed and was awoken by [R 30] pulling her blankets up over her face and she was suffocating me. She then proceeded to show me with her hands to her face how she was pressing. She stated that she was terrified. She stated that she was trapped in her blankets or she would have half killed her. She said, I may be small, but I am not weak. Residents roommate than walked out of bathroom with [CNA CCC] who stated I am praying for us. They come in here all the time and do whatever they want. For residents feelings of being safe, this nurse pulled the UA to come and sit in their room with them until I could get a hold of the DON. [Nurse DD] unit manager and [Name of DON], DON was notified. DON placed [R 30] on a one on one for all of the residents safety and a full head to toe skin assessment was done on residents with no issues found. Resident denied pain and stated that she felt safer after talking to this nurse. [CNA CCC] was also in residents room the entire time that this situation was brought to my attention and stayed until this nurse left room to make phone call to managers. A progress note entered by Nurse DDD on 5/20/21 at 3:04 PM revealed: Resident speaking with CNA reported to have asked when co-resident's court date would be r/t recent altercation. Resident also stated she did not have to put up with people trying to kill her. Staff redirected conversation and stated that resident is safe and that staff are keeping close eye on co-resident. Resident participating in bingo today with activity staff. Resident did not report any concerns directly to this nurse when asked. Stop sign remains in place in doorway of resident's room. Social work follow up notes on 5/19/21 and 5/20/21 indicated R 32 was having trouble sleeping. A follow up note was written by the Assistant Director of Nursing (ADON) on 6/1/21 at 11:18 AM: Follow up to incident: On 5/18/21 at approximately 1930, CNA entered resident's room to assist her roommate to use the restroom. At that time, resident was ambulating from her bed to the doorway. resident stated that she was upset. resident stated that a woman came in her room as she was in bed and pulled her blankets up over her head and pushed the blankets down. resident stated that she was able to move her blankets in a short time, she estimated less than a minute that the blankets were on her head. resident stated that the woman did not talk to her. resident roommate, was in her recliner at the time. She stated that the woman walked into their room with an empty cup. She brought the cup to [Roommate of R 32] and attempted to hand it to her. Co-resident stated to the woman that she could not get her anything to drink as she could not get up out of her chair by herself. Co-resident stated that the woman took the cup and ambulated to resident's side of the room and attempted to take resident's cup. Co-resident then heard resident state to the woman to get out of her room. Co-resident stated she noted the woman to touch resident's blankets, but was not able to see what occurred after that as the privacy curtain was pulled blocking her vision. RN was entering the room at the same time that resident reported this to CNA as she was completing medication pass for resident. She was able to provide reassurance to both resident and co-resident. A skin and pain assessment was performed with resident and there were no significant findings. Following resident's statement, it was verified that a different co-resident was the woman that entered their room and she did indeed have a Styrofoam cup with her. UA was able to provide reassurance to resident and co-resident throughout the evening and stayed in their room. Another staff member guided co-resident to her room and provided increased supervision for her. Following the incident, a half door was installed on residents' room to deter others from entering their room. On 5/25/21, resident and co-resident moved to a different unit per their preference. Co-resident had labs and a urinalysis obtained. There were no significant findings with her labs and the urinalysis was negative for infection. The psychiatric nurse practitioner reviewed co-resident and made medication adjustments. Co-resident has received increased supervision from staff following the incident. A sleep study has been initiated for co-resident to assess her sleeping pattern. On 08/04/21 at 09:45 AM an interview was completed with R 32. R 32 stated at least twice someone came into my old room. Someone held me down. R 32 put her hand close to her face and made a pushing motion when talking about being held down. Then, R 32 went from siting up in bed to collapsing down on her elbow and sighed, her voice broke and her face appeared distressed as she said I don't want to talk about it anymore, I just want to forget it. I'm glad got through it and was able to hit them away. On 08/04/21 at 9:55 AM an interview was completed with R 32's roommate (who was also her roommate at the time of the 5/18/21 incident): She stated there were 2 or 3 of them that would come into the room all the time in their old room, she stated they usually they would eat food off their trays. But one time think they physical with her roommate, but she couldn't remember all the details. An email was sent to the DON questioning why the incident with R 30 and R 32 was not substantiated and the DON responded on 08/03/21 at 12:48 PM Per our understanding, the substantiated tab reflects if the facility feels that abuse was purposeful/willful and verified. Based on the resident's cognitive status, the facility does not feel that it was purposeful/willful, therefore indicating it was unsubstantiated. A follow up email asked if the police department was contacted regarding the incident and the DON responded on 08/05/21 at 8:47 AM: Police were not notified. R 23 Review of R 23's face sheet dated, 7/30/21 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R 23 was her own responsible party. Review of R 23's Brief Interview of Mental Status (BIMS) score dated 4/27/21 was 15/15 (normal cognition). During an interview with R 23 on 7/27/21 at 10:46 AM, R 23 complained about residents wandering into her room. R 23 said R 30 wanders into her room and takes things and has a mean look on her face. R 23 said residents had stolen her remote control, a shirt and slippers. R 23 said the facility replaced the remote control and slippers. R 23 said one resident comes in and pees in her trash can. R 23 reported the wandering residents become more active after 5:00 PM and they come in and wake her up. R 23 said when she complained they gave her a half door but that does not keep them out. R 23 complained about having to move to the floor with the wandering residents and her over all care. R 23 said she has asked to have the facility find an apartment for her because she is so unhappy with the care. On 7/30/21 at 10:14 AM, UM DD was informed R 23 was upset with residents wandering into her room and made that allegation that they steal things and all items had not been replace. UM was informed that the wandering residents wake R 23 up and that the half door was not effective at keeping residents out. On 8/4/21 at 2:46 PM, the Nursing Home Administrator (NHA) emailed the Surveyor and indicated R 23 wanted to talk to the Surveyor. At this time the Surveyor went to R 23's room and R 23 said she just wanted to let me know she did not have any problems sleeping. R 23 said she does get awakened when residents wander into her room and confirmed the facility had asked her about her missing items and the shirt, she reported stolen 2 months ago was not located or replaced. R 23 said she is not afraid of the wandering residents, but she did slap one in the hand when she tried to take her water one time. R 23 said R 142 is across the hall from her and when they wander in her room, she yells really loud. Review of R 23's progress note dated 7/28/21 at 10:19 revealed R 23 stated, she didn't like the way agency people treat her. When Social Worker came in to do a depression assessment R 23 told the Social Worker she wanted to harm herself and had a plan. She was going to jump out the window. R 23 was started on 1:1 but when the 1:1 started R 23 began to cry and scream. R 23 said, I should never said anything. Review of R 23's progress note dated 7/30/21 at 10:06 revealed R 23 was asked about missing items and she stated she was missing a striped blue/green and white shirt. R 23 said she had told laundry about the missing shirt. R 23 said it came up missing the first week she came in this room. The missing shirt was reported to the Social Services Director. R 23 also reported R 30 took her remote and they gave her another one. When R 23 reported her slippers missing the Certified Nurse Aide (CNA) told her she knew where they were, and the CNA went and got them. R 23 was asked if she was fearful and she said, just a little. She said R 30 has a scary look on her face. Review of R 23's progress note dated 7/29/21 at 9:16 PM revealed R 23 responded to a survey, indicated feeling caregivers provide compassionately but not always timely. R 142 Review of R 142's face sheet dated 7/30/21 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R 142 was her own responsible party. Review of R 142's Brief Interview of Mental Status (BIMS) score dated 7/11/21 was 15/15 (normal cognition). During an interview with R 142 on 7/27/21 at 10:49 AM, R 142 said R 30 wandered into her room on Sunday 7/25/21 and she is afraid of her because people have reported she hits people. R 142 said staff are slow to respond to the call lights at night, so she yells until they come. R 142 said Sunday she was afraid staff would not get there in time, so she held up her assistive device she uses to reach things to defend herself. R 142 said staff did get R 30 out of her room before she could get close. R 142 said she would not want to hit R 30 but felt she needed to protect herself. R 142 said she complains to the nurses about residents wandering into her room, but they do not do anything. On 7/30/21 UM at 10:14 AM, UM DD said she was aware residents were wandering into R 142's room. UM DD said she was not aware of the incident Sunday night 7/25/21 or that R 142 was afraid of R 142. UM DD said she did not implement any new intervention when she became aware R 142 did not like residents wandering into her room. UM DD said we all try to watch for the wandering residents and guide them back out of rooms when we see them go in. UM DD said she did not have any documentation on R 142's concerns about wandering residents. UM DD said R 142 moved to her unit on 6/8/21 and the unit she came from did not have wandering residents. UM DD said she would look for documentation related to R 142's concerns about wandering residents. Upon exit no information related to R 142's concerns about wandering residents were provided. Review of R 142's note dated 7/30/21 at 10:47 AM revealed R 142 was questioned after the state person brought concerns forward, R 142 reported, the stop sign on the door does help, they just walk underneath it. She stated 2 come in her room and the one just watches TV for the most part. The other one has taken my walker one and my over the bed table. I got up and told her to get out of my room and was stern with her. I asked if she thought of any other way to keep other residents out of her room and she stated she wondered about a half door. Will make administration aware. When asked if she was fearful, she stated, not of unknown resident first name, the other one has a ornery look on her face. [Name of R 30] might hit me, but she hasn't. Review of R 132's progress noted date 7/30/21 at 10:43 AM revealed R 142 was questioned about residents entering her room. R 132 denied being fearful or losing sleep. R 142 said she had to be stern with R 30 entering her room. R 142 reported R 30 tried to take her walker, coffee table. On 7/30/21 at 8:21 AM, Unit Manager (UM) DD was asked about R 23 and R 142's concerns about residents wandering into their room. UM DD was informed both residents provided a resident first name. UM DD said she had two residents with that first name. UM DD said R 30 wanders into other residents' rooms daily and so it was most likely R 30. UM DD said she was aware R 23 and 142 were concerned about other residents wandering into their rooms. UM DD was unable to locate any paperwork or documentation in R 23 or R 142's medical record that indicated they had concerns about wandering residents. UM DD was informed R 23 had complained of Residents stealing items from her when they wander into her room, and they wake her up at night. UM DD denied any knowledge of stolen items or problems with being awaken at night. UM DD was informed R 142 was very frightened over the weekend when a resident came in her room at night, she held up her assistive device she uses to reach items to defend herself and yelled until staff came to get the resident out of her room. UM DD said she did not get a report of that incident. UM DD said she would interview both residents. On 7/30/21 at 9:21 AM, Social Service Director was asked if she had any concern forms or information on R 30 wandering into resident rooms. SSD was informed residents are reporting stolen items, fear and sleep being disturbed. SSD said she would look for concern forms and talk to the Social Workers. Upon exit SSD did not provide any documentation of addressing wandering residents or concern forms. During an interview with UM DD on 8/3/21 at 11:40 AM, this Surveyor followed up on the concerns she had discussed with her on 7/30/21 at 8:21 AM about R 23 and R 142 about wandering residents frightening them, waking them up and stealing from them. UM DD confirmed R 23 was still missing a shirt and the Social Work Director was following up on that concern. UM DD was asked what interventions she implemented to prevent residents from wandering into other residents' rooms after she confirmed the concerns. UM DD said she notified administration. The surveyor asked if the facility had notified the State Agency about the stolen items and Residents being fearful of wandering into her room and UM DD said she would have to check with administration. No report to the State Agency was located upon exit. R 62 Review of R 62's face sheet dated 7/28/21 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R 62 was her own responsible party. Review of R 62's Brief Interview of Mental Status (BIMS) date 7/30/21 at 5:46 PM revealed a score of 14/15 (normal cognition). Review of R 62's Kardex (caregiver instructions) dated 729/21 revealed, toilet on request. Do not leave alone in the bathroom. Transferring: Limited assist x 1 with walker. Review of R 62's mobility care plan dated 2/12/21 revealed, Toilet Schedule: Toilet on request. Do not leave alone in bathroom, initiated 2/12/21. On 7/28/21 at 2:21 PM, R 62 was observed sitting on the toilet in her room, call light on in bathroom and phone in her hand. R 62 said she had called the nurses station to get help. Within a minute Certified Nurse Aide (CNA) X arrived to assist R 62 out of the bathroom and back into her recliner. The Surveyor did not hear a call alarm and asked CNA X how she knew R 62 needed help in the bathroom. CNA X demonstrated the call light in the bathroom turns on a light in the hall. CNA X said she put R 62 on the toilet and had to leave the unit so when she returned to the unit, she checked on R 62 first. CNA X was not sure what time it was when she assisted R 62 to the bathroom. CNA X was asked about the call light pager to see how long the call light had been on and CNA X said her pager battery was dead, so she did not know how long R 62 had been waiting for help. R 62 complained of diarrhea and upset stomach. CNA X went to get Licensed Practical Nurse (LPN) JJJ to address R 62's medical concerns. (CNA X did not remain in the bathroom after she transferred R 62 to the toilet as instructed on R 62's Kardex). During an interview with R 62 on 7/28/21 at 2:25 PM. R 62 said the Nursing Home Administrator (NHA) and Chief Executive Officer (CEO) talked to her in February 2021 about moving to the nursing home because she needed more care. R 62 said the care was not better. R 62 said she was left sitting in her recliner for 14 days. R 62 said she was not put in bed for 14 days. R 62 said she was on the 2 nd floor and residents would wander in and out. R 62 said she complained about the care and the wandering residents, but no one cares. R 62 said she was so up set by the care that one day she took a razor to her wrist and tried to kill herself. R 62 said 2 nights ago she had a resident come in this room (R 62 currently is on the 1st floor). R 62 said the resident came in her room and sat on her legs in bed causing excruciating pain in her legs. R 62 said she was so upset now she wanted to start taking her [MEDICATION(S)] so she would die. Licensed Practical Nurse (LPN) JJJ was in the room. When R 62 reported the issue with a wandering resident last night LPN JJJ said they had put an alarm on the other resident so staff would hear when she got out of her room at night. When R 62 said she wanted to die because of the care the Surveyor asked LPN JJJ to get R 62's Unit Manager and her Social Worker. JJJ came back with Unit Manager UM) KKK and Social Worker (SW) LLL. R 62 told UM KKK and SW LLL she wanted to die because of the care and questioned them about watching the video camera from the other night to see who came into her room. The NHA joined the conversation and reported the video camera did not show anyone entering R 62's room between 2:00 AM and 3:00 AM like R 62 reported. R 62 spoke to UM KKK, SW LLL and the NHA for a while. R 62 stressed the main thing she wanted was tender loving care for everyone. R 62 explained when they do not have enough staff or agency, they are not able to meet her needs. She said she knows she should not take herself to the bathroom but when they do not come, she takes herself. R 62 said one nurse and two caregivers is not enough help at night. The NHA said she recently increased staffing to 2 nurses at night but can not do it every night. During an interview with the NHA on 7/29/21 at 1:05 PM the NHA said she had not watched the video from R 62 hall the night of 7/27/21 prior to meeting with her on 7/28/21. The NHA said staff that watch the video must not have reviewed the correct night because the video did show a resident enter R 62's room the night of 7/27/21. The Surveyor reviewed the video with the NHA, and the video did show a resident in the room next door enter R 62's room at 2:24 AM and exit at 2:28 AM. The resident that entered the room was not assisted by staff and staff were not present to see the resident enter or exit. A Certified Nurse Aide (CNA) was observed entering R 62 room at 2:37 AM (13 minutes after a resident wandered into her room. The NHA was asked for all documentation related to the incident on 7/27/21 at 2:24 AM. The NHA said staff met with the resident and documented the meeting in the medical record. No other documentation was located. Review of R 62's Psychosocial note dated 7/19/21 at 3:48 PM revealed, Resident indicated she became upset and transferred herself to the bathroom this morning to have BM (bowel movement) without waiting for staff assistance. SS talked with resident and educated her about waiting for staff assistance when needing to transfer. Resident voiced understanding and acknowledged the possible outcomes of self-transferring. Resident continued to talk about call light times and SS reassured resident and offered to print off call light report 7/20/21 resident and SS will review call light times and discuss resident's expectations for call light time. Review of R 62's Psychosocial note dated 7/20/21 at 4:49 PM revealed, Resident and SS reviewed call light report and resident was appreciative of follow up. Resident and SS agreed to review again next week and compare results. Review of R 62's Psychosocial note dated 7/24/21 at 3:20 PM revealed, During meeting resident shared frustrations and feelings with nursing staff. SS (Social Services) suggested to schedule meeting with DON (Director of Nursing) and unit manager to discuss these concerns and resident was agreeable to this. SS scheduled meeting for 7/2621 at 2:00 pm with also inviting friend (friend name) for additional support per resident request. Review of R 62's Plan of Care Note dated 7/26/21 at 2:58 PM revealed, Care conference completed with resident, unit manager, DON, resident and resident's friend. During meeting resident discussed her frustrations and nursing concerns. Medications reviewed and discussed changing medication times to meet resident's preference; unit manager will be contacting PCP (primary care physician) to change orders. Resident shared her love for the facility and her history helping with various parts of the organization. Resident talked about her past suicide attempt/self-harm and shared it was the wrong decision. Discussed resident not consistently accepting antidepressant medication and will review times medication is given. Resident expressed multiple times about advocating for herself and other residents receiving tender loving care. At the end of the visit resident voiced appreciation for the meeting and listening to her concerns. SS will print off call light report 7/27/21. Review of R 62's progress note dated 7/27/21 at 3:34 PM revealed, Spoke with resident this am resident stated that another resident had come into her room last night and sat on her bed. Resident stated that she felt safe, and she just wanted someone to be aware. Social services to follow up. This writer to follow up as well. Per social services resident did agree to have a stop sign on her door at night. Review of R 62's Hospice Note dated 7/27/21 at 3:57 PM revealed, pt (patient) express concern over resident coming in her room, pt reassured that she was safe, and staff is aware. Review of R 62's Psychosocial Note dated 7/27/21 at 5:32 PM revealed, Resident expressed that she had and unexpected visit from a co-resident over the night while she was sleeping. Resident stated that staff was able to redirect co-resident out of her room and she was not harmed. Resident indicated she continues to feel safe in the facility and concerned for co-resident. SS reassured resident that IDT (interdisciplinary team) will be working on interventions for co-resident and that SS could not provide additional information d/t (due to) HIPPAA; Resident agreed to having stop sign placed across doorway after going to bed, as for she does not wish to have door closed. Resident asked to review call light times and was ok with unit manager reviewing with her tomorrow. Resident desired to file a grievance, which SS started. No grievance was provided to the State. All documentation related to this incident was requested when the Surveyor met with the NHA on 7/29/21 at 1:05 PM. Review of R 62's Social Service Note dated 7/28/21 at 5:56 PM revealed, SSD (Social Services Director) and Unit Manager spoke with resident about residents' concerns. Resident made statements about self-harm. Resident stated that she wanted to take medication to die. As SSD and Unit Manager talked with resident, she then stated, She has a lot of things to do. Resident was asked if she had a plan to hurt herself and resident noted that she did not. R4 Screen was completed indicating minimal risks. Residents room was searched for self-harming items. Items that could be potentials for self-harming were removed. Resident noted that s [TRUNCATED]

Based on interview and record review, the facility failed to identify and implement appropriate plans of action to correct quality deficiencies necessary to assure residents attained and maintained the highest practicable level of well-being, resulting in the potential for serious negative physical and psychosocial outcomes for all residents that resided at the facility. Findings include: According to CMS 2567 forms dated 4/1/21 and 5/19/21 the facility had deficient practices cited for care planning and falls. During this onsite annual survey, the facility was issued an immediate jeopardy notice for Abuse and Falls. The facility provided a copy of Quality Assurance Performance Improvement (QAPI) Plan dated 7/15/21 for review. The policy reflected, Root Cause analysis is a method of problem solving used to breakdown the current process and identify areas in need of improvement. Tools available used to identify the cause of the problem: Five Whys, Fish bone diagram, Investigation tools such as falls, wound, abuse/neglect unplanned adverse event, etc .Data Sources may include, but not limited to, grievance logs, staffing trends, incident and accident reports, quality measures, resident council meetings, family council meetings, hotlines and regulatory survey outcomes. During an interview on 8/6/21 at 2:55 PM, the Nursing Home Administrator (NHA) and the Director of Nursing (DON) stated that they were both involved in the QAPI process at the facility. The survey history was reviewed and identified the facility was found to be deficient with care planning and falls on in April, May, and again during this survey. When asked if the QA committee had previously identified any deficient practices prior to the annual survey with care plans and falls, the DON stated, No, we felt we were in compliance with falls. The NHA added that the facility did not continue with audits for falls after the State Agency found the facility back in compliance in June. The facility failed to maintain sustained compliance with care plans and falls utilizing the facility QAPI committee.

This citation pertains to MI 332, MI 404, MI 202 and MI 618 Based on observation, interview and record review the facility failed to follow abuse policies and procedures to protect residents from abuse for 8 residents (R 23, R 30, R 32, R 62, R 86, R 119, R 135, R 142) reviewed for being at risk for abuse, as a result of the facility's failure to prevent abuse, residents suffered psychosocial harm. This deficient practice has the high likelihood to affect all residents in this facility potentially resulting in further harm, injury and abuse. Findings include: According to the facility Abuse, Neglect and Exploitation Policy with a revision date 10/8/2019, read, in part, Abuse: means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical. Mental, and psychosocial well-being, The home will provide ongoing oversight and supervision of staff in order to assure that is (sic) policies are implemented as written, The home will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: . B Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed and certified staff on each shift, Possible Indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse 2. Physical marks such as bruises or patterned appearances such as a hand print, belt or ring mark on a resident's body, 3. Physical injury of a resident, of unknown source, 4. Resident reports of theft of property, or missing property, 5. Verbal abuse of a resident overheard, 6. Physical abuse of a resident observed, 7. Psychological abuse of a resident observed, 8. Failure to provide care needs such as feeding, bathing, dressing, turning, and repositioning, A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedure for investigation include: 1. Identifying staff responsible for the investigation, 2. Exercising caution in handling evidence that could be used in a criminal investigation, 3. Investigation different types of alleged violations, 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation, The home will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation, B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed, C. Increased supervision of the alleged victim and residents, D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator, E. Protection from retaliation, F. Providing emotional support and counseling to the resident during and after the investigation, as needed, and The home will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g law enforcement when applicable) within specified timeframes: a. 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 b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 2. Assuring that reporters are free from retaliation or reprisal .4. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following: a. analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences, b. defining how care provision will be changed and /or improved to protect residents receiving services, c. training of staff on changes made and demonstration of staff competency after training is implanted (sic), d. Identification of staff responsible for implantation (sic) of corrective actions, e. the expected date for implementation, and f. Identification of staff responsible for monitoring the implementation of the plan. R 30 Review of R 30's face sheet dated 8/3/21 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R 30 was not her own responsible party. Review of R 30's cognitive assessment completed for her Minimum Data Set (MDS) dated [DATE] revealed she was unable to answer any of the cognitive questions and was marked as severely cognitively impaired. Review of R 30's mood/behavioral care plan initiated on 7/11/19 and revised on 5/19/21 revealed, wanders among the unit in and out of co-resident's rooms to seek comfort. -noted paranoia at times. -offered change of room to husband on 6/29/20 r/t (related to) embracing male co-resident, however husband declined to move, -I was involved in a peer-to-peer interaction 5/18/21. Review of R 30's progress note dated, 5/24/21 at 11:33 revealed, IDT met to review resident in EWBT (unknown) r/t (related to) indicating for behavioral symptom on the [NAME] report, for psych medications, and recent altercation. Noted behaviors include hitting, kicking, pushing, grabbing, pinching, and wandering over the last 30 days. Resident has dx of dementia. If [R30] is attempting to assist co-residents among the unit, thank her for her help, offer to trade places and complete task, as for [R30] enjoys helping others; If [R30] is entering co-resident's rooms, redirect to alternate activity and provide supplies as needed.; If observing exit seeking behavior, offer to walk with [R30] among the unit and attempt to redirect to alternate topic or task; Increase supervision when [R30] is moving independently on the unit; Monitor for tearfulness, agitation, anxiousness, changes in sleep patterns, mood, thoughts of death. R 32 Review of R 32's face sheet and electronic medical record revealed she was an [AGE] year old female who admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility reported incident revealed R 32 and R 30 had an altercation on 5/18/21 where R 32 reported R 30 came into her room and pulled her blankets up over her head and pushed down. Review of R 32's resident progress notes revealed a note by Nurse K for 5/18/21 at 8:30 PM: Upon entering residents room to pass meds to her, resident was found up out of bed and walking towards the door to find someone to help her. Resident was teary eyed and looked upset. When asked what was wrong she stated that women was in here again and this time she put my blankets over my face and I couldn't breathe. Resident stated that nobody here cares because they keep coming in the room. I assured the resident that staff definitely does care. Resident was asked to sit down and that we could talk about it. Resident than stated that that would be fine and she sat down. Resident stated that she was asleep lying in bed and was awoken by [R 30] pulling her blankets up over her face and she was suffocating me. She then proceeded to show me with her hands to her face how she was pressing. She stated that she was terrified. She stated that she was trapped in her blankets or she would have half killed her. She said, I may be small, but I am not weak. Residents roommate than walked out of bathroom with [CNA CCC] who stated I am praying for us. They come in here all the time and do whatever they want. For residents feelings of being safe, this nurse pulled the UA to come and sit in their room with them until I could get a hold of the DON. [Nurse DD] unit manager and [Name of DON], DON was notified. DON placed [R 30] on a one on one for all of the residents safety and a full head to toe skin assessment was done on residents with no issues found. Resident denied pain and stated that she felt safer after talking to this nurse. [CNA CCC] was also in residents room the entire time that this situation was brought to my attention and stayed until this nurse left room to make phone call to managers. A progress note entered by Nurse DDD on 5/20/21 at 3:04 PM revealed: Resident speaking with CNA reported to have asked when co-resident's court date would be r/t recent altercation. Resident also stated she did not have to put up with people trying to kill her. Staff redirected conversation and stated that resident is safe and that staff are keeping close eye on co-resident. Resident participating in bingo today with activity staff. Resident did not report any concerns directly to this nurse when asked. Stop sign remains in place in doorway of resident's room. Social work follow up notes on 5/19/21 and 5/20/21 indicated R 32 was having trouble sleeping. A follow up note was written by the Assistant Director of Nursing (ADON) on 6/1/21 at 11:18 AM: Follow up to incident: On 5/18/21 at approximately 1930, CNA entered resident's room to assist her roommate to use the restroom. At that time, resident was ambulating from her bed to the doorway. resident stated that she was upset. resident stated that a woman came in her room as she was in bed and pulled her blankets up over her head and pushed the blankets down. resident stated that she was able to move her blankets in a short time, she estimated less than a minute that the blankets were on her head. resident stated that the woman did not talk to her. resident roommate, was in her recliner at the time. She stated that the woman walked into their room with an empty cup. She brought the cup to [Roommate of R 32] and attempted to hand it to her. Co-resident stated to the woman that she could not get her anything to drink as she could not get up out of her chair by herself. Co-resident stated that the woman took the cup and ambulated to resident's side of the room and attempted to take resident's cup. Co-resident then heard resident state to the woman to get out of her room. Co-resident stated she noted the woman to touch resident's blankets, but was not able to see what occurred after that as the privacy curtain was pulled blocking her vision. RN was entering the room at the same time that resident reported this to CNA as she was completing medication pass for resident. She was able to provide reassurance to both resident and co-resident. A skin and pain assessment was performed with resident and there were no significant findings. Following resident's statement, it was verified that a different co-resident was the woman that entered their room and she did indeed have a Styrofoam cup with her. UA was able to provide reassurance to resident and co-resident throughout the evening and stayed in their room. Another staff member guided co-resident to her room and provided increased supervision for her. Following the incident, a half door was installed on residents' room to deter others from entering their room. On 5/25/21, resident and co-resident moved to a different unit per their preference. Co-resident had labs and a urinalysis obtained. There were no significant findings with her labs and the urinalysis was negative for infection. The psychiatric nurse practitioner reviewed co-resident and made medication adjustments. Co-resident has received increased supervision from staff following the incident. A sleep study has been initiated for co-resident to assess her sleeping pattern. On 08/04/21 at 09:45 AM, an interview was completed with R 32. R 32 stated at least twice someone came into my old room. Someone held me down. R 32 put her hand close to her face and made a pushing motion when talking about being held down. Then, R 32 went from siting up in bed to collapsing down on her elbow and sighed, her voice broke and her face appeared distressed as she said, I don't want to talk about it anymore, I just want to forget it. I'm glad got through it and was able to hit them away. On 08/04/21 at 9:55 AM, an interview was completed with R 32's roommate (who was also her roommate at the time of the 5/18/21 incident): She stated there were 2 or 3 of them that would come into the room all the time in their old room, she stated they usually they would eat food off their trays. But one time thought they got physical with her roommate, but she couldn't remember all the details An email was sent to the DON questioning why the incident with R 30 and 32 was not substantiated and the DON responded on 08/03/21 at 12:48 PM, Per our understanding, the substantiated tab reflects if the facility feels that abuse was purposeful/willful and verified. Based on the resident's cognitive status, the facility does not feel that it was purposeful/willful, therefore indicating it was unsubstantiated. A follow up email asked if the police department was contacted regarding the incident and the DON responded on 08/05/21 at 8:47 AM: Police were not notified. R 23 Review of R 23's face sheet dated, 7/30/21 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R 23 was her own responsible party. Review of R 23's Brief Interview of Mental Status (BIMS) score dated 4/27/21 was 15/15 (normal cognition). During an interview with R 23 on 7/27/21 at 10:46 AM, R 23 complained about residents wandering into her room. R 23 said R 30 wanders into her room and takes things and has a mean look on her face. R 23 said residents had stolen her remote control, a shirt and slippers. R 23 said the facility replaced the remote control and slippers. R 23 said one resident comes in and pees in her trash can. R 23 reported the wandering residents become more active after 5:00 PM and they come in and wake her up. R 23 said when she complained they gave her a half door but that does not keep them out. R 23 complained about having to move to the floor with the wandering residents and her over all care. R 23 said she has asked to have the facility find an apartment for her because she is so unhappy with the care. On 7/30/21 at 10:14 AM, UM DD was informed R 23 was upset with residents wandering into her room and made that allegation that they steal things and all items had not been replace. UM was informed that the wandering residents wake R 23 up and that the half door was not effective at keeping residents out. On 8/4/21 at 2:46 PM, the Nursing Home Administrator (NHA) emailed the Surveyor and indicated R 23 wanted to talk to the Surveyor. At this time the Surveyor went to R 23's room and R 23 said she just wanted to let me know she did not have any problems sleeping. R 23 said she does get awakened when residents wander into her room and confirmed the facility had asked her about her missing items and the shirt, she reported stolen 2 months ago was not located or replaced. R 23 said she is not afraid of the wandering residents, but she did slap one in the hand when she tried to take her water one time. R 23 said R 142 is across the hall from her and when they wander in her room, she yells really loud. Review of R 23's progress note dated 7/28/21 at 10:19 revealed R 23 stated, she didn't like the way agency people treat her. When Social Worker came in to do a depression assessment R 23 told the Social Worker she wanted to harm herself and had a plan. She was going to jump out the window. R 23 was started on 1:1 but when the 1:1 started R 23 began to cry and scream. R 23 said, I should never said anything. Review of R 23's progress note dated 7/30/21 at 10:06 revealed R 23 was asked about missing items and she stated she was missing a striped blue/green and white shirt. R 23 said she had told laundry about the missing shirt. R 23 said it came up missing the first week she came in this room. The missing shirt was reported to the Social Services Director. R 23 also reported R 30 took her remote and they gave her another one. When R 23 reported her slippers missing the Certified Nurse Aide (CNA) told her she knew where they were, and the CNA went and got them. R 23 was asked if she was fearful and she said, just a little. She said R 30 has a scary look on her face. Review of R 23's progress note dated 7/29/21 at 9:16 PM revealed R 23 responded to a survey, indicated feeling caregivers provide compassionately but not always timely. R 142 Review of R 142's face sheet dated 7/30/21 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R 142 was her own responsible party. Review of R 142's Brief Interview of Mental Status (BIMS) score dated 7/11/21 was 15/15 (normal cognition). During an interview with R 142 on 7/27/21 at 10:49 AM, R 142 said R 30 wandered into her room on Sunday 7/25/21 and she is afraid of her because people have reported she hits people. R 142 said staff are slow to respond to the call lights at night, so she yells until they come. R 142 said Sunday she was afraid staff would not get there in time, so she held up her assistive device she uses to reach things to defend herself. R 142 said staff did get R 30 out of her room before she could get close. R 142 said she would not want to hit R 30 but felt she needed to protect herself. R 142 said she complains to the nurses about residents wandering into her room, but they do not do anything. On 7/30/21 at 10:14 AM, UM DD said she was aware residents were wandering into R 142's room. UM DD said she was not aware of the incident Sunday night 7/25/21 or that R 142 was afraid of R 142. UM DD said she did not implement any new intervention when she became aware R 142 did not like residents wandering into her room. UM DD said we all try to watch for the wandering residents and guide them back out of rooms when we see them go in. UM DD said she did not have any documentation on R 142's concerns about wandering residents. UM DD said R 142 moved to her unit on 6/8/21 and the unit she came from did not have wandering residents. UM DD said she would look for documentation related to R 142's concerns about wandering residents. Upon exit no information related to R 142's concerns about wandering residents were provided. Review of R 142's note dated 7/30/21 at 10:47 AM revealed R 142 was questioned after the state person brought concerns forward, R 142 reported, the stop sign on the door does help, they just walk underneath it. She stated 2 come in her room and the one just watches TV for the most part. The other one has taken my walker one and my over the bed table. I got up and told her to get out of my room and was stern with her. I asked if she thought of any other way to keep other residents out of her room and she stated she wondered about a half door. Will make administration aware. When asked if she was fearful, she stated, not of unknown resident first name, the other one has a ornery look on her face. [Name of R 30] might hit me, but she hasn't. Review of R 132's progress noted date 7/30/21 at 10:43 AM revealed R 142 was questioned about residents entering her room. R 132 denied being fearful or losing sleep. R 142 said she had to be stern with R 30 entering her room. R 142 reported R 30 tried to take her walker, coffee table. On 7/30/21 at 8:21 AM, Unit Manager (UM) DD was asked about R 23 and R 142's concerns about residents wandering into their room. UM DD was informed both residents provided a resident first name. UM DD said she had two residents with that first name. UM DD said R 30 wanders into other residents' rooms daily and so it was most likely R 30. UM DD said she was aware R 23 and 142 were concerned about other residents wandering into their rooms. UM DD was unable to locate any paperwork or documentation in R 23 or R 142's medical record that indicated they had concerns about wandering residents. UM DD was informed R 23 had complained of Residents stealing items from her when they wander into her room, and they wake her up at night. UM DD denied any knowledge of stolen items or problems with being awaken at night. UM DD was informed R 142 was very frightened over the weekend when a resident came in her room at night, she held up her assistive device she uses to reach items to defend herself and yelled until staff came to get the resident out of her room. UM DD said she did not get a report of that incident. UM DD said she would interview both residents. On 7/30/21 at 9:21 AM, Social Service Director was asked if she had any concern forms or information on R 30 wandering into resident rooms. SSD was informed residents are reporting stolen items, fear and sleep being disturbed. SSD said she would look for concern forms and talk to the Social Workers. Upon exit SSD did not provide any documentation of addressing wandering residents or concern forms. During an interview with UM DD on 8/3/21 at 11:40 AM, this Surveyor followed up on the concerns she had discussed with her on 7/30/21 at 8:21 AM about R 23 and R 142 about wandering residents frightening them, waking them up and stealing from them. UM DD confirmed R 23 was still missing a shirt and the Social Work Director was following up on that concern. UM DD was asked what interventions she implemented to prevent residents from wandering into other residents' rooms after she confirmed the concerns. UM DD said she notified administration. The surveyor asked if the facility had notified the State Agency about the stolen items and Residents being fearful of wandering into her room and UM DD said she would have to check with administration. No report to the State Agency was located upon exit. R 62 Review of R 62's face sheet dated 7/28/21 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R 62 was her own responsible party. Review of R 62's Brief Interview of Mental Status (BIMS) date 7/30/21 at 5:46 PM revealed a score of 14/15 (normal cognition). Review of R 62's Kardex (caregiver instructions) dated 729/21 revealed, toilet on request. Do not leave alone in the bathroom. Transferring: Limited assist x 1 with walker. Review of R 62's mobility care plan dated 2/12/21 revealed, Toilet Schedule: Toilet on request. Do not leave alone in bathroom, initiated 2/12/21. On 7/28/21 at 2:21 PM, R 62 was observed sitting on the toilet in her room, call light on in bathroom and phone in her hand. R 62 said she had called the nurses station to get help. Within a minute Certified Nurse Aide (CNA) X arrived to assist R 62 out of the bathroom and back into her recliner. The Surveyor did not hear a call alarm and asked CNA X how she knew R 62 needed help in the bathroom. CNA X demonstrated the call light in the bathroom turns on a light in the hall. CNA X said she put R 62 on the toilet and had to leave the unit so when she returned to the unit, she checked on R 62 first. CNA X was not sure what time it was when she assisted R 62 to the bathroom. CNA X was asked about the call light pager to see how long the call light had been on and CNA X said her pager battery was dead, so she did not know how long R 62 had been waiting for help. R 62 complained of diarrhea and upset stomach. CNA X went to get Licensed Practical Nurse (LPN) JJJ to address R 62's medical concerns. (CNA X did not remain in the bathroom after she transferred R 62 to the toilet as instructed on R 62's Kardex). During an interview with R 62 on 7/28/21 at 2:25 PM., R 62 said the Nursing Home Administrator (NHA) and Chief Executive Officer (CEO) talked to her in February 2021 about moving to the nursing home because she needed more care. R 62 said the care was not better. R 62 said she was left sitting in her recliner for 14 days. R 62 said she was not put in bed for 14 days. R 62 said she was on the 2 nd floor and residents would wander in and out. R 62 said she complained about the care and the wandering residents, but no one cares. R 62 said she was so up set by the care that one day she took a razor to her wrist and tried to kill herself. R 62 said 2 nights ago she had a resident come in this room (R 62 currently is on the 1st floor). R 62 said the resident came in her room and sat on her legs in bed causing excruciating pain in her legs. R 62 said she was so upset now she wanted to start taking her [MEDICATION(S)] so she would die. Licensed Practical Nurse (LPN) JJJ was in the room. When R 62 reported the issue with a wandering resident last night LPN JJJ said they had put an alarm on the other resident so staff would hear when she got out of her room at night. When R 62 said she wanted to die because of the care the Surveyor asked LPN JJJ to get R 62's Unit Manager and her Social Worker. JJJ came back with Unit Manager UM) KKK and Social Worker (SW) LLL. R 62 told UM KKK and SW LLL she wanted to die because of the care and questioned them about watching the video camera from the other night to see who came into her room. The NHA joined the conversation and reported the video camera did not show anyone entering R 62's room between 2:00 AM and 3:00 AM like R 62 reported. R 62 spoke to UM KKK, SW LLL and the NHA for a while. R 62 stressed the main thing she wanted was tender loving care for everyone. R 62 explained when they do not have enough staff or agency, they are not able to meet her needs. She said she knows she should not take herself to the bathroom but when they do not come, she takes herself. R 62 said one nurse and two caregivers is not enough help at night. The NHA said she recently increased staffing to 2 nurses at night but can not do it every night. During an interview with the NHA on 7/29/21 at 1:05 PM, the NHA said she had not watched the video from R 62 hall the night of 7/27/21 prior to meeting with her on 7/28/21. The NHA said staff that watch the video must not have reviewed the correct night because the video did show a resident enter R 62's room the night of 7/27/21. The Surveyor reviewed the video with the NHA, and the video did show a resident in the room next door enter R 62's room at 2:24 AM and exit at 2:28 AM. The resident that entered the room was not assisted by staff and staff were not present to see the resident enter or exit. A Certified Nurse Aide (CNA) was observed entering R 62 room at 2:37 AM (13 minutes after a resident wandered into her room. The NHA was asked for all documentation related to the incident on 7/27/21 at 2:24 AM. The NHA said staff met with the resident and documented the meeting in the medical record. No other documentation was located. Review of R 62's Psychosocial note dated 7/19/21 at 3:48 PM revealed, Resident indicated she became upset and transferred herself to the bathroom this morning to have BM (bowel movement) without waiting for staff assistance. SS talked with resident and educated her about waiting for staff assistance when needing to transfer. Resident voiced understanding and acknowledged the possible outcomes of self-transferring. Resident continued to talk about call light times and SS reassured resident and offered to print off call light report 7/20/21 resident and SS will review call light times and discuss resident's expectations for call light time. Review of R 62's Psychosocial note dated 7/20/21 at 4:49 PM revealed, Resident and SS reviewed call light report and resident was appreciative of follow up. Resident and SS agreed to review again next week and compare results. Review of R 62's Psychosocial note dated 7/24/21 at 3:20 PM revealed, During meeting resident shared frustrations and feelings with nursing staff. SS (Social Services) suggested to schedule meeting with DON (Director of Nursing) and unit manager to discuss these concerns and resident was agreeable to this. SS scheduled meeting for 7/2621 at 2:00 pm with also inviting friend (friend name) for additional support per resident request. Review of R 62's Plan of Care Note dated 7/26/21 at 2:58 PM revealed, Care conference completed with resident, unit manager, DON, resident and resident's friend. During meeting resident discussed her frustrations and nursing concerns. Medications reviewed and discussed changing medication times to meet resident's preference; unit manager will be contacting PCP (primary care physician) to change orders. Resident shared her love for the facility and her history helping with various parts of the organization. Resident talked about her past suicide attempt/self-harm and shared it was the wrong decision. Discussed resident not consistently accepting antidepressant medication and will review times medication is given. Resident expressed multiple times about advocating for herself and other residents receiving tender loving care. At the end of the visit resident voiced appreciation for the meeting and listening to her concerns. SS will print off call light report 7/27/21. Review of R 62's progress note dated 7/27/21 at 3:34 PM revealed, Spoke with resident this am resident stated that another resident had come into her room last night and sat on her bed. Resident stated that she felt safe, and she just wanted someone to be aware. Social services to follow up. This writer to follow up as well. Per social services resident did agree to have a stop sign on her door at night. Review of R 62's Hospice Note dated 7/27/21 at 3:57 PM revealed, pt (patient) express concern over resident coming in her room, pt reassured that she was safe, and staff is aware. Review of R 62's Psychosocial Note dated 7/27/21 at 5:32 PM revealed, Resident expressed that she had and unexpected visit from a co-resident over the night while she was sleeping. Resident stated that staff was able to redirect co-resident out of her room and she was not harmed. Resident indicated she continues to feel safe in the facility and concerned for co-resident. SS reassured resident that IDT (interdisciplinary team) will be working on interventions for co-resident and that SS could not provide additional information d/t (due to) HIPPAA; Resident agreed to having stop sign placed across doorway after going to bed, as for she does not wish to have door closed. Resident asked to review call light times and was ok with unit manager reviewing with her tomorrow. Resident desired to file a grievance, which SS started. No grievance was provided to the State. All documentation related to this incident was requested when the Surveyor met with the NHA on 7/29/21 at 1:05 PM. Review of R 62's Social Service Note dated 7/28/21 at 5:56 PM revealed, SSD (Social Services Director) and Unit Manager spoke with resident about residents' concerns. Resident made statements about self-harm. Resident stated that she wanted to take medication to die. As SSD and Unit Manager talked with resident, she then stated, She has a lot of things to do. Resident was asked if she had a plan to hurt herself and resident noted that she did not. R4 Screen was completed indicating minimal risks. Residents room was searc [TRUNCATED]

Based on interview and record review, the facility failed to report allegations of abuse to the State Agency for 4 Residents ( R 23, R 142, R 119, and R 86), resulting a failure to thoroughly identify, protect residents, investigate, and report to the state agency and law enforcement allegations of abuse. This deficient practice has the potential to affect all vulnerable residents in this facility. Findings include: R 23 Review of R 23's face sheet dated, 7/30/21 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R 23 was her own responsible party. Review of R 23's Brief Interview of Mental Status (BIMS) score dated 4/27/21 was 15/15 (normal cognition). During an interview with R 23 on 7/27/21 at 10:46 AM, R 23 complained about residents wandering into her room. R 23 said R 30 wanders into her room and takes things and has a mean look on her face. R 23 said residents had stolen her remote control, a shirt and slippers. R 23 said the facility replaced the remote control and slippers. R 23 said one resident comes in and pees in her trash can. R 23 reported the wandering residents become more active after 5:00 PM and they come in and wake her up. R 23 said when she complained they gave her a half door but that does not keep them out. R 23 complained about having to move to the floor with the wandering residents and her over all care. R 23 said she has asked to have the facility find an apartment for her because she is so unhappy with the care. On 7/30/21 UM at 10:14 AM, DD was informed R 23 was upset with residents wandering into her room and made that allegation that they steal things and all items had not been replace. UM was informed that the wandering residents wake R 23 up and that the half door was not effective at keeping residents out. On 8/4/21 at 2:46 PM, the Nursing Home Administrator (NHA) emailed the Surveyor and indicated R 23 wanted to talk to the Surveyor. At this time the Surveyor went to R 23's room and R 23 said she just wanted to let me know she did not have any problems sleeping. R 23 said she does get awakened when residents wander into her room and confirmed the facility had asked her about her missing items and the shirt, she reported stolen 2 months ago was not located or replaced. R 23 said she is not afraid of the wandering residents, but she did slap one in the hand when she tried to take her water one time. R 23 said R 142 is across the hall from her and when they wander in her room, she yells really loud. Review of R 23's progress note dated 7/28/21 at 10:19 revealed R 23 stated, she didn't like the way agency people treat her. When Social Worker came in to do a depression assessment R 23 told the Social Worker she wanted to harm herself and had a plan. She was going to jump out the window. R 23 was started on 1:1 but when the 1:1 started R 23 began to cry and scream. R 23 said, I should never said anything. Review of R 23's progress note dated 7/30/21 at 10:06 AM revealed R 23 was asked about missing items and she stated she was missing a striped blue/green and white shirt. R 23 said she had told laundry about the missing shirt. R 23 said it came up missing the first week she came in this room. The missing shirt was reported to the Social Services Director. R 23 also reported R 30 took her remote and they gave her another one. When R 23 reported her slippers missing the Certified Nurse Aide (CNA) told her she knew where they were, and the CNA went and got them. R 23 was asked if she was fearful and she said, just a little. She said R 30 has a scary look on her face. Review of R 23's progress note dated 7/29/21 at 9:16 PM revealed R 23 responded to a survey, indicated feeling caregivers provide compassionately but not always timely. R 142 Review of R 142's face sheet dated 7/30/21 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R 142 was her own responsible party. Review of R 142's Brief Interview of Mental Status (BIMS) score dated 7/11/21 was 15/15 (normal cognition). During an interview with R 142 on 7/27/21 at 10:49 AM, R 142 said R 30 wandered into her room on Sunday 7/25/21 and she is afraid of her because people have reported she hits people. R 142 said staff are slow to respond to the call lights at night, so she yells until they come. R 142 said Sunday she was afraid staff would not get there in time, so she held up her assistive device she uses to reach things to defend herself. R 142 said staff did get R 30 out of her room before she could get close. R 142 said she would not want to hit R 30 but felt she needed to protect herself. R 142 said she complains to the nurses about residents wandering into her room, but they do not do anything. On 7/30/21 UM at 10:14 AM, DD said she was aware residents were wandering into R 142's room. UM DD said she was not aware of the incident Sunday night 7/25/21 or that R 142 was afraid of R 142. UM DD said she did not implement any new intervention when she became aware R 142 did not like residents wandering into her room. UM DD said we all try to watch for the wandering residents and guide them back out of rooms when we see them go in. UM DD said she did not have any documentation on R 142's concerns about wandering residents. UM DD said R 142 moved to her unit on 6/8/21 and the unit she came from did not have wandering residents. UM DD said she would look for documentation related to R 142's concerns about wandering residents. Upon exit no information related to R 142's concerns about wandering residents were provided. Review of R 142's note dated 7/30/21 at 10:47 AM revealed R 142 was questioned after the state person brought concerns forward, R 142 reported, the stop sign on the door does help, they just walk underneath it. She stated 2 come in her room and the one just watches TV for the most part. The other one has taken my walker one and my over the bed table. I got up and told her to get out of my room and was stern with her. I asked if she thought of any other way to keep other residents out of her room and she stated she wondered about a half door. Will make administration aware. When asked if she was fearful, she stated, not of unknown resident first name, the other one has a ornery look on her face. [Name of R 30] might hit me, but she hasn't. Review of R 132's progress noted date 7/30/21 at 10:43 AM revealed R 142 was questioned about residents entering her room. R 132 denied being fearful or losing sleep. R 142 said she had to be stern with R 30 entering her room. R 142 reported R 30 tried to take her walker, coffee table. On 7/30/21 at 8:21 AM, Unit Manager (UM) DD was asked about R 23 and R 142's concerns about residents wandering into their room. UM DD was informed both residents provided a resident first name. UM DD said she had two residents with that first name. UM DD said R 30 wanders into other residents' rooms daily and so it was most likely R 30. UM DD said she was aware R 23 and 142 were concerned about other residents wandering into their rooms. UM DD was unable to locate any paperwork or documentation in R 23 or R 142's medical record that indicated they had concerns about wandering residents. UM DD was informed R 23 had complained of Residents stealing items from her when they wander into her room, and they wake her up at night. UM DD denied any knowledge of stolen items or problems with being awaken at night. UM DD was informed R 142 was very frightened over the weekend when a resident came in her room at night, she held up her assistive device she uses to reach items to defend herself and yelled until staff came to get the resident out of her room. UM DD said she did not get a report of that incident. UM DD said she would interview both residents. On 7/30/21 at 9:21 AM Social Service Director was asked if she had any concern forms or information on R 30 wandering into resident rooms. SSD was informed residents are reporting stolen items, fear and sleep being disturbed. SSD said she would look for concern forms and talk to the Social Workers. Upon exit SSD did not provide any documentation of addressing wandering residents or concern forms. During an interview with UM DD on 8/3/21 at 11:40 AM, this Surveyor followed up on the concerns she had discussed with her on 7/30/21 at 8:21 AM about R 23 and R 142 about wandering residents frightening them, waking them up and stealing from them. UM DD confirmed R 23 was still missing a shirt and the Social Work Director was following up on that concern. UM DD was asked what interventions she implemented to prevent residents from wandering into other residents' rooms after she confirmed the concerns. UM DD said she notified administration. The surveyor asked if the facility had notified the State Agency about the stolen items and Residents being fearful of wandering into her room and UM DD said she would have to check with administration. No report to the State Agency was located upon exit. Resident #119 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], revealed R 119 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 4 out of 15 which represents R 119 had severe cognitive impairment. R 119 did not reside at the facility during the onsite survey and was not available for interview. The facility provided a copy of a letter signed by CNA E and CNA BBB (undated) for review. The letter reflected, Specifically, (name of CNA L) will be unnecessarily aggressive, physically and verbally (sp) with (name of R 119). She will hold her arms and legs beyond the behavior-control needed to perform cares. She will actively spray her in the face in the shower when (name of R 119) yells, whines, or tries to hit. The facility provided a typed interview for CNA E, completed by the ADON A, and dated 5/12/21 at 9:15 AM. The record reflected, (Name of R 119) will hit, scratch and bite staff. Staff will tell (name of R 119) to stand there, we are taking a shower. They will tell (name of R 119) to shut up. (Name of R 119) tries to shut the water off during the shower and will move her arms around while they are washing her. (Name of R 119) spit at staff and got sprayed in the face. (Name of CNA E) feels that (name of CNA L) purposefully put water in (name of R 119's) face. During an interview and record review on 7/30/21 at 11:00 AM, CNA E demonstrated how she observed R 119 as she stood at the grab bar in the shower while CNA E and CNA BBB washed and CNA L rinsed R 119. CNA E then demonstrated how CNA L held the shower head directly in front of R 119's face and told her to shut up. CNA L stated, It appeared to me as waterboarding. When asked what that looked like, CNA E stated, She (CNA L) sprayed it so long it was hard for her (R 119) to breath. When asked if the police ever interviewed her about the incident, CNA E stated, No, I didn't even know if they were called. According to the Abuse Policy the facility failed to ensure that reporters are free from retaliation or reprisal. The facility provided a typed interview for CNA BBB and completed by the ADON A, dated 5/12/21 at 10:30 AM. The record reflected, I have worked with (name of CNA L) for two years. Since she came back from (name of leave taken from work) she has become like she is burnt out. She always works down the same hall. Her tone is loud and gruff. She is rude. She will push residents back down into their chairs at lunch. She doesn't have compassion or patience. I am uncomfortable working with her. (Name of R 119) is a handful during cares. It is very hard to approach (Name of R 119). (Name of CNA L) sprayed (name of R 119) in the shower in her face multiple times. This happened within a month ago, but I can't give an exact date. I think she did it as a reaction because (name of R 119) was hitting and trying to bite. (Name of CNA L) will say knock it off to (name of R 119). During a telephone interview on 7/30/21 at 11:30 AM and on 8/3/21 at 2:30 PM, the typed statement was read to CNA BBB. CNA BBB stated that the statement was correct. CNA BBB stated that she felt that CNA L intentionally and repeatedly sprayed R 119 in the face as a result of R 119's behaviors in the shower. CNA BBB stated that she has observed CNA L push R 9 down by the shoulder and back into her chair in the dining room when R119 attempted to stand and leave after finishing her meal. During an interview and record review on 8/3/21 at 1:00 PM, ADON A stated Unit Manager (UM) DD noticed a letter under her office door on 5/12/21 about 8:30 AM and gave it to her. She said she was unable to determine the exact date of the shower incident. ADON A stated she removed CNA L from their shift on 5/12/21 at approximately 10:30 AM, and brought CNA L back to work on 5/18/21, after the investigation was completed. According to the facility 5-day report, abuse was not substantiated. When asked if the police were notified of the allegation, ADON A stated, Yes, on May 19th at 5:03 PM (7 days after learning of the allegation). When asked if the allegation of CNA L pushing R 9 down in a chair in the dining room was investigated or if CNA L was interviewed regarding the alleged witnessed incident, ADON A stated that the facility did not, and was not, able to provide the survey team with an investigation for the allegation. During an interview and record review on 8/4/21 at approximately 10:00 AM, the NHA stated that she was the Abuse Coordinator at the facility and had reviewed the investigation. The NHA stated that what she had heard and was explained to her was not considered abuse because it was not purposeful or willful. The NHA stated that all reports of abuse allegations should be brought straight to the NHA and the police should be called right away. When asked if there were any reason that CNA E and CNA BBB would bring false allegations against CNA L, the NHA stated, No. According to the Abuse Policy the staff failed to identify abuse and understand behavioral symptoms of residents that may increase the risk of abuse and neglect such as aggressive and/or catastrophic reactions of residents. The NHA stated that all staff were educated because the allegations were not immediately reported when the incidents occurred. R 86 According to the MDS assessment, dated 5/25/21, R 86 had multiple diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This same assessment indicated that R 86 used a walker and wheelchair and required extensive assistance of one staff member for transferring as R 86 had limited range of motion to both upper and lower extremities. Staff assessed R 86 as cognitively intact. During an interview on 7/28/21 at 10:30 AM, R 86 reported that staff had left him sitting in a chair for 12 and a half hours. A follow up interview that same day at 3:40 PM, R 86 reported that staff were well aware of what had happened and stated that Licensed Practical Nurse (LPN) P was aware of the situation when he was left in his chair. During an interview on 8/4/21 at 8:12 AM, LPN P stated that R 86 had reported to them that he was left in his chair for over 12 hours about four weeks prior. LPN P then entered R 86's room and R 86 stated that he was left in his chair for 12 and a half hours, that he was still angry, and that he did not want to talk about it because it makes him so angry. LPN P stated a grievance form/investigation was not completed regarding this situation. At 9:00 AM LPN P reported that they had talked with Unit Manager (UM) EEE and Social Services FFF and verified that no grievance/investigation was completed. On 8/4/21 at 2:42 PM, the DON reported per email that R 86 was interviewed and that he does not want to file a grievance. When asked if being left in a chair for over 12 hours was an allegation of neglect, the DON asked which staff members were aware of the allegation. That same day at 5:23 PM an email reply from the DON reported an allegation of abuse was reported for R 86. A facility investigation was started on 8/4/21 for an allegation that occurred at least four weeks prior.

This citation pertains to MI 676 and MI 732 Based on interview and record review, the facility failed to accurately assess a resident upon admission, identify care concerns, and or implement interventions, resulting in unidentified pressure ulcers and or skin alterations for 2 residents (R547 and R 53) and falls with serious injury for one resident (R 129). This deficient practice has resulted in repeated falls and the potential for serious, avoidable complications. Findings include: Resident #547 (R 547) Review of a facility Admission Record reflected R 547 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Braden Scale for Predicting Pressure Sore Risk completed on the day R 547 admitted to the facility (7/14/21) reflected she scored a 19 (low risk), at risk for developing a pressure sore, as opposed to having a moderate, high, or very high risk of developing a pressure sore. Review of R 547's Admission Assessment locked on 7/15/21, reflected R 547 admitted to the facility on [DATE]. Section L of the assessment for SKIN reflected only two areas of concern were identified: Right Trochanter (surgical incision) measuring 10.5 centimeters (cm) and the Right thigh lateral (surgical incision) measuring 5.5 cm. A note at the end of the section for skin assessment reflected R547's BUE (Bilateral upper extremity) extremely bruised, tried to take photos to monitor and was not able to label photos. No other areas on R 547's skin was identified as having an issue on the admission assessment. Review of a PCC Skin & Wound - Total Body Skin assessment dated [DATE] at 17:42 (5:42 p.m.) reflected no wounds were present on R 547's body. Review of a PCC Skin & Wound - Total Body Skin assessment dated [DATE] at 11:13 a.m. reflected no wounds were present on R 547's body. Review of a Skin/Wound Note dated 7/17/21 at 12:47 p.m. reflected This nurse called into res (R 547's) room, staff providing am (morning) cares, repositioning, Dark purple discoloration noted to res right heel. No open areas noted at this time, res admitted to facility on 7/14/21, skin prep applied to area, purple heel protectors to be worn, heels to be offloaded using pillows, air mattress to be placed, dietary to consult for possible supplements to enhance wound healing. Review of a Skin/Wound Note dated 7/17/21 at 12:56 p.m. reflected this nurse called in to assess res (R 547) during am (morning) cares, small pustule like areas noted to coccyx/sacrum area as well as dark red discoloration, air mattress to be placed and dietary to consult for possible supplements to promote wound healing . res recently admitted to facility on 7/14/21 after right hip fx (fracture) and repair, staff to assist res to turn q (every) 2 hours in bed to offload pressure. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . No specific treatments were referenced in the progress note to address the [CONDITION(S)] on R 547's back and no mention of the heel sore was found. Review of a Wound Evaluation dated 7-17-2021 reflected R 547 had an area on her heel that measured 9.98 cm squared and had not been evaluated by staff for three days since her admission to the facility. Review of a Wound Evaluation dated 7/17/21 reflected an area on her sacral-coccygeal region measuring 7.46 cm squared and had not been evaluated by staff for three days since her admission to the facility. Review of a Baseline Care Plan signed on 7/16/2021 reflected R 547 had current skin integrity issues related to surgical incisions, a cancerous labial mass and bruising to bilateral upper extremities but did not reference any areas of pressure sores. Review of a Care Plan Report reflected R547 had Actual impairments to skin integrity. I have right hip incision. I have a mass to my left labia related to vaginal [CONDITION(S)]. I have pain with movement to my right hip area and discomfort in my vaginal area. I have limited mobility to lower extremities. I am 75% weight bearing to right lower extremity. I am a full lift and not able to ambulate at this time. The care plan report identified R 547 as at a moderate risk for pressure sores and reflected that on admission R 547 was identified with a Deep Tissue Injury (DTI) to the left heel and sacrum, however, interventions to treat and prevent the worsening of the wounds allegedly present on admission were not implemented until 7/17/21, three days after admission. During an interview on 8/4/21 at 4:24 p.m., wound care nurse, Registered Nurse (RN) P reported that the expectation is for a full body skin assessment to be completed on newly admitted residents within four hours of admission, ideally within two hours of admission. RN P explained that a pressure ulcer can develop within hours and any wound that is not identified upon admission or within a short timeframe, would have to be assumed to be a facility acquired pressure ulcer. R 53 According to the MDS assessment, dated 5/11/21, R 53 had multiple diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff assessed R 53 as cognitively intact. An observation on 7/27/21 at 10:30 AM revealed R 53 had a dark purple discoloration on the backside of their left arm. The discoloration extended from the elbow to wrist. When asked, R 53 looked at his arm and stated that he did not know how it occurred and denied recently falling. Review of R 53's electronic medical record (EMR) revealed no documentation of the observed discoloration. According to the Skin care planned interventions, initiated 7/11/19, R 53 was to have weekly skin checks by a licensed nurse and the weekly treatment documentation is to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. The skin assessment found in R 53's EMR, dated 7/23/21, indicated no new wounds. A skin assessment performed on 7/31/21, and four days after the discoloration was noted by this surveyor, indicated no new wounds. On 8/3/21 at 4:40 PM, R 53's discolored right arm was visible from the doorway of the room. The discoloration was faded and receded in size when compared to the observation made on 7/27/21. At this time the Unit Manager EEE, Licensed Practical Nurse EE, and Registered Nurse (RN) HH was asked about the discoloration, all verbalized they were unaware of any discoloration resembling a bruise on R 53. RN HH accompanied this surveyor back to R 53's room to assess the discoloration. After assessing R 53, RN HH stated that the discoloration was a bruise and should have been documented. During an interview on 8/4/21 at 2:46 PM, Wound Nurse P stated that all residents have a weekly skin assessment completed and any alteration, such as a bruise, should be assessed and documented. During an interview on 8/6/21 at 7:45 AM the Nursing Home Administrator (NHA), Director of Nursing (DON), and UM EEE reported that R 53 has a history of discoloration on his arm and that it was care planned. When asked to provide care planned documentation, it was noted that the care plan was updated with the discoloration and initiated on 8/3/21. The facility was asked for any documentation regarding R 53's bruised arm prior to 8/3/21 and when this surveyor reported the concern to staff. The facility provided additional documentation indicating that R 53's bruise was caused from the transfer device used in his room and that it was not a long-term skin condition as previously reported. An Incident Report and Skin and Wound Evaluation was completed on 8/3/21. There was no indication that staff was aware of R 53's bruise, no investigation, no assessment, and no protection from additional harm was provided for R 53 until the concern was identified by this surveyor. The facility Skin Assessment Policy, issued 1/29/19, read, A full body, or head to toe, skin assessment will be conducted by nurse upon admission/readmission, or after extended overnight LOA (leave of absence) visit. The assessment may also be performed after a change of condition or after any newly identified pressure injury, Note any skin conditions such as redness, bruising, rashes, blisters, skin tears, open areas, ulcers, and [CONDITION(S)], Documentation of skin assessment: a. Include date and time of the assessment, your name, and position title, b. Document observations in EMR (electronic medical record) (measurements, color, type of tissue in wound bed, drainage, odor, pain), c. document type of wound, d. describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain), e. Document if resident refused assessment and why, f. Document other information as indicated or appropriate. R129 Review of R 129's face sheet and electronic medical record revealed she was an [AGE] year old resident initially admitted to the facility on [DATE] and most recently admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/11/2021 a right humerus fracture and on 7/22/21 a neck of right femur fracture was added to R 129's diagnoses. Review of R 129's baseline care indicated she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R 129's incident/accident history revealed she sustained 8 falls since her admission to the facility on [DATE]. On 3/8/21 a witnessed fall occurred when R 129 was self-propelling in a wheelchair and she attempted to stand up. On 3/10/21 a witnessed fall occurred when R 129 self-transferred out of her wheelchair and tripped, falling and hitting her head causing a skin tear to the eyebrow. On 4/3/21 an unwitnessed fall occurred when R 129 was observed sitting in a doorway on her right side. On 4/10/21 an unwitnessed fall occurred when R 129 was found in her room laying on her right side at the foot of the bed. R 129 fractured her right humerus as a result of the 4/10/21 fall. On 05/1/21 an unwitnessed fall occurred when R 129 was ambulating without assistance and found laying on her stomach at the end of the bed. The incident report indicated the resident had taken themselves to the bathroom and her pajama bottoms were not fully pulled up. On 5/25/21 an unwitnessed fall occurred when R 129 was found on her floor at the end of the bed. R 129 sustained an abrasion to her right arm. On 07/14/21 an witnessed fall occurred when R 129 self-transferred out of a recliner in the common area, the resident was incontinent at the time of her fall and staff documented that resident did not ask for any help from staff. On 7/21/21 an unwitnessed fall occurred when R129 was found sitting on the floor of her bathroom in front of her toilet behind her wheelchair .Resident's brief and pants were at her knees/calves and she was sitting on the floor. Per witness statements CNA (Certified Nursing Assistant) D had put resident on the toilet and then went and assisted another resident. The resident was crying out in pain and had a pain assessment of 10/10. R 129 sustained a right hip fracture as a result of the 7/21/21 fall. Review of R 129's care plan revealed she was on BEDREST AT THIS TIME related to falls and a newly added intervention Do not allow me to use the restroom unattended added on 07/21/21. Other interventions to prevent falls also included Anticipate and meet my needs. Under ADL care focus area, interventions included TOILET USE: TOTAL assist x 1 check and change every two hours staff to provide toilet hygiene, revised on 7/28/21, the previous intervention initiated on 03/12/21 was: TOILET USE: Extensive assist x 1 staff to provide toilet hygiene. Review of a hospice Visit Note Report for R 129 dated 7/15/21 revealed she was Dependent on caregiver for all ADL's including toileting. On 07/27/21 at 11:37 AM, R 129 was observed asleep in room and her husband was visiting her. R 129's husband stated R 129 has had a lot of falls, and one of the reasons she admitted to the facility was due to her frequent falls at home and dementia. He stated that R 129 had been weak on her right side for a long time. R 129's husband stated that since being in the facility R 129 had fallen several times including a fall where she broke a shoulder and then broke her hip about a week ago. R 129's husband stated she has declined since the last fall and is less alert. Staff have discussed interventions to reduce falls with him and he thought staff were waking her up and taking to bathroom, his understanding was staff would assist her while going to the bathroom at all times. R 129's husband stated she has been in a lot of pain due to the two fractures and is no longer getting out of bed since the last fracture. A follow up interview was completed with R 129's husband on 8/3/21 at approximately 1:30 PM. He stated R 129 had not woken up at all yesterday and had been awake for a short time today. He stated R 129 had stopped speaking and was continuing to decline. R 129's husband was told the details regarding her most recent fall and he stated I don't think she would do well if left alone. When asked why he stated she would get impatient sitting and waiting and a lot of her previous falls were due to her impatiently self-transferring. On 7/29/21 at approximately 2:35 PM, an interview was completed with Hospice Nurse B, who was in R 129's room. R 129 was viewed to be asleep. Nurse B stated that R 129 is normally awake and communicative but stated staff have informed her she had been unusually lethargic lately. On 07/29/21 at approximately 2:50 PM, an interview was completed with CNA C who stated she cares for R 129 often. CNA C was asked about R 129's condition and she stated R 129 had fell and fractured a hip about a week ago and had been declining since the fall. CNA C stated at R 129's baseline functioning, she was alert and able to communicate some needs to you. R 129 would have to be reminded often to use her call light and was frequently self-transferring. Per CNA C R 129 was generally kept in the common area due to her impulsive transferring and frequent falls. CNA C was asked what R 129's bathroom assistance needs were and she stated R 129 previously needed the assistance of one person in the bathroom. CNA C asked if R 129 was able to be left alone in the bathroom and she replied no, fall risks are never left alone in the bathroom. CNA C was asked if she considered R 129 a fall risk and she stated yes, since she has admitted , you can't turn your back on her for two seconds, even in a common area. CNA C was asked what the coding extensive assist in the bathroom meant to her and she replied it depends on the resident, but it generally means they need help wiping, getting dressed and undressed and transferring. CNA C asked if residents requiring extensive assist should be left alone in the bathroom and she stated: no. On 07/29/21 at approximately 4:15 PM, an interview was completed with CNA D. CNA D confirmed she had been caring for R 129 on 7/21/21 when she fell in the bathroom. CNA D stated that on 7/21/21 she assisted R 129 to the bathroom, gave her the call light and left the room. CNA D stated all of a sudden there was screaming and her and a couple other staff responded to see R 129 on the floor. CNA D stated R 129 was not able to verbalize how it happened, so she wasn't sure how she fell . CNA D stated she worked with R 129 often and generally worked on the floor R 129 resided on. CNA D stated R 129 has always told me when she needs to go to the bathroom or when she is hungry. CNA D was asked if R 129 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . CNA D was questioned further about R 129 being a fall risk and she stated I think she may have fell a couple months ago and broke her shoulder, but I can't be sure. CNA D was asked what the coding extensive assist in the bathroom meant to her and she replied they need help washing their bottom. CNA D was asked if it meant anything else and she said I'm not sure, maybe they can't walk to the bathroom, I can't explain it. CNA D revealed she had worked for the facility for four years, and was not sure what the different ADL assistance level codes meant. CNA D stated she would ask a resident's regular aide on shift change if she was unsure of what assistance they needed. CNA D was asked if she would consider herself R 129's regular aide if she worked with her often and she did not answer. On 07/29/21 at 5:20 PM, CNA H was interviewed regarding assisting residents in the bathroom. CNA H was asked what the coding extensive assist in the bathroom meant to her and she replied that it depends on the resident but meaning at least helping with wiping, pulling up pants and doing most of the work with transferring. CNA H stated they generally would not leave a resident alone who required extensive assistance but it would depend on other factors. CNA H was asked if a resident at risk for falls could be left alone in the bathroom and she stated absolutely not. CNA H continued that if a resident had self-transferring history, fall history, or impaired cognition they would be considered at risk to fall in the bathroom. CNA H stated the fall risk should be in the resident's care plan and that staff discuss this at shift change when giving report. During the conversation on 08/04/21 at 11:30 AM, R 129's care plan was discussed with the DON and NHA. The NHA and DON clarified that the intervention do not leave resident alone in the bathroom was not in the plan of care prior to the 7/21/21 fall, and that it was an added intervention after the fall. It was discussed this intervention should have specifically been in the care plan prior to this fall due to the behaviors and risk factors displayed by R 129 and staff report that she should not have been left alone in the bathroom. There was discussion that R 129's previous intervention of needing extensive assist in the bathroom some staff interpreted as she could not be left alone and the staff member who left her alone when she fell and fractured her hip did not interpret extensive assist the same way. The review of all resident care plans to ensure complete and clear care plans for R 129 and other residents was discussed.

Based on interview, and record review, the facility failed to complete and revise accurate and comprehensive care plan for six residents (R 23, R 32, R 142, R 30, R 114, and R 129) reviewed for care plans, resulting in unmet needs, increased risk of accidents/falls, actual falls with injury (R 129), abusive behaviors (R30), skin integrity (R 114) and decreased quality of life. Findings include: R 129 Review of R 129's face sheet and electronic medical record revealed she was an [AGE] year old resident initially admitted to the facility on [DATE] and most recently admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/11/2021 a right humerus fracture and on 7/22/21 a neck of right femur fracture was added to R 129's diagnoses. Review of R 129's baseline care indicated she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R 129's incident/accident history revealed she sustained eight falls since her admission to the facility on [DATE]. On 3/8/21 a witnessed fall occurred when R 129 was self-propelling in a wheelchair and she attempted to stand up. On 3/10/21 a witnessed fall occurred when R 129 self-transferred out of her wheelchair and tripped, falling and hitting her head causing a skin tear to the eyebrow. On 4/3/21 an unwitnessed fall occurred when R 129 was observed sitting in a doorway on her right side. On 4/10/21 an unwitnessed fall occurred when R 129 was found in her room laying on her right side at the foot of the bed. R 129 fractured her right humerus as a result of the 4/10/21 fall. On 05/1/21 an unwitnessed fall occurred when R 129 was ambulating without assistance and found laying on her stomach at the end of the bed. The incident report indicated the resident had taken themselves to the bathroom and her pajama bottoms were not fully pulled up. On 5/25/21 an unwitnessed fall occurred when R 129 was found on her floor at the end of the bed. R 129 sustained an abrasion to her right arm. On 07/14/21 an witnessed fall occurred when R 129 self-transferred out of a recliner in the common area, the resident was incontinent at the time of her fall and resident did not ask for any help from staff. On 7/21/21 an unwitnessed fall occurred when R129 was found sitting on the floor of her bathroom in front of her toilet behind her wheelchair .Resident's brief and pants were at her knees/calves and she was sitting on the floor. Per witness statements CNA (Certified Nursing Assistant) D had put resident on the toilet and then went and assisted another resident. The resident was crying out in pain and had a pain assessment of 10/10. R 129 sustained a right hip fracture as a result of the 7/21/21 fall. Review of R 129's care plan revealed she was on BEDREST AT THIS TIME related to falls and a newly added intervention Do not allow me to use the restroom unattended added on 07/21/21. Other interventions to prevent falls also included Anticipate and meet my needs. Under ADL care focus area, interventions included TOILET USE: TOTAL assist x 1 check and change every two hours staff to provide toilet hygiene, revised on 7/28/21, the previous intervention initiated on 03/12/21 was: TOILET USE: Extensive assist x 1 staff to provide toilet hygiene. Review of a hospice Visit Note Report for R 129 dated 7/15/21 revealed she was Dependent on caregiver for all ADL's including toileting. On 07/27/21 at 11:37 AM R 129 was observed asleep in room and her husband was visiting her. R 129's husband stated R 129 has had a lot of falls, and one of the reasons she admitted to the facility was due to her frequent falls at home and dementia. He stated that R 129 had been weak on her right side for a long time. R 129's husband stated since being in the facility R 129 had fallen several times including a fall where she broke shoulder and then broke her hip about a week ago. R 129's husband stated she has declined since the last fall and is less alert. Staff have discussed interventions to reduce falls with him and he thought staff were waking her up and taking to bathroom, his understanding was staff would assist her while going to the bathroom at all times. R 129's husband stated she has been in a lot of pain due to the two fractures and is no longer getting out of bed after the last fracture. A follow up interview was completed with R 129's husband on 8/3/21 at approximately 1:30 PM. He stated R 129 had not woken up at all yesterday and had been awake for a short time today. He stated R 129 had stopped speaking and was continuing to decline. R 129's husband was told the details regarding her most recent fall and he stated I don't think she would do well if left alone. When asked why he stated she would get impatient sitting and waiting and a lot of her previous falls were due to her impatiently self-transferring. On 7/29/21 at approximately 2:35 PM an interview was completed with Hospice Nurse B, who was in R 129's room. R 129 was viewed to be asleep. Nurse B stated that R 129 is normally awake and communicative but stated staff have informed her she had been unusually lethargic lately. On 07/29/21 at approximately 2:50 PM an interview was completed with CNA C who stated she cares for R 129 often. CNA C was asked about R 129's condition and she stated R 129 had fell and fractured a hip about a week ago and had been declining since the fall. CNA C stated at R 129's baseline functioning, she was alert and able to communicate some needs to you. R 129 would have to be reminded often to use her call light and was frequently self-transferring. Per CNA C R 129 was generally kept in the common area due to her impulsive transferring and frequent falls. CNA C was asked what R 129's bathroom assistance needs were and she stated R 129 previously needed the assistance of one person in the bathroom. CNA C asked if R 129 was able to be left alone in the bathroom and she replied no, fall risks are never left alone in the bathroom. CNA C was asked if she considered R 129 a fall risk and she stated yes, since she has admitted , you can't turn your back on her for two seconds, even in a common area. CNA C was asked what the coding extensive assist in the bathroom meant to her and she replied it depends on the resident, but it generally means they need help wiping, getting dressed and undressed and transferring. CNA C asked if residents requiring extensive assist should be left alone in the bathroom and she stated: no. On 07/29/21 at approximately 4:15 PM an interview was completed with CNA D. CNA D confirmed she had been caring for R 129 on 7/21/21 when she fell in the bathroom. CNA D stated that on 7/21/21 she assisted R 129 to the bathroom, gave her the call light and left the room. CNA D stated all of a sudden there was screaming and her and a couple other staff responded to see R 129 on the floor. CNA D stated R 129 was not able to verbalize how it happened, so she wasn't sure how she fell . CNA D stated she worked with R 129 often and generally worked on the floor R 129 resided on. CNA D stated R 129 has always told me when she needs to go to the bathroom or when she is hungry CNA D was asked if R 129 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . CNA D was questioned further about R 129 being a fall risk and she stated I think she may have fell a couple months ago and broke her shoulder, but I can't be sure. CNA D was asked what the coding extensive assist in the bathroom meant to her and she replied they need help washing their bottom. CNA D was asked if it meant anything else and she said I'm not sure, maybe they can't walk to the bathroom, I can't explain it. CNA D revealed she had worked for the facility for 4 years, and was not sure what the different ADL assistance level codes meant. CNA D stated she would ask a resident's regular aide on shift change if she was unsure of what assistance they needed. CNA D was asked if she would consider herself R 129's regular aide if she worked with her often and she did not answer. On 07/29/21 at 5:20 PM, CNA H was interviewed regarding assisting residents in the bathroom. CNA H was asked what the coding extensive assist in the bathroom meant to her and she replied that it depends on the resident but meaning at least helping with wiping, pulling up pants and doing most of the work with transferring. CNA H stated they generally would not leave a resident alone who required extensive assistance but it would depend on other factors. CNA H was asked if a resident at risk for falls could be left alone in the bathroom and she stated absolutely not. CNA H continued that if a resident had self-transferring history, fall history or impaired cognition they would be considered at risk to fall in the bathroom. CNA H stated the fall risk should be in the resident's care plan and staff discuss this at shift change when giving report. During the conversation on 08/04/21 at 11:30 AM R 129's care plan was discussed with the DON and NHA. The NHA and DON clarified that the intervention do not leave resident alone in the bathroom was not in the plan of care prior to the 7/21/21 fall, it was an added intervention after the fall. It was discussed this intervention should have specifically been in the care plan prior to this fall due to the behaviors and risk factors displayed by R 129 and staff report that she should not have been left alone in the bathroom. There was discussion that R 129's previous intervention of needing extensive assist in the bathroom some staff interpreted as she could not be left alone and the staff member who left her alone when she fell and fractured her hip did not interpret extensive assist the same way. The review of all resident care plans to ensure complete and clear care plans for R 129 and other residents was discussed. R 30 Review of R 30's face sheet dated 8/3/21 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R 30 was not her own responsible party. Review of R 30's cognitive assessment completed for her Minimum Data Set (MDS) dated [DATE] revealed she was unable to answer any of the cognitive questions and was marked as severely cognitively impaired. Review of R 30's mood/behavioral care plan initiated on 7/11/19 and revised on 5/19/21 revealed, wanders among the unit in and out of co-resident's rooms to seek comfort. -noted paranoia at times. -offered change of room to husband on 6/29/20 r/t (related to) embracing male co-resident, however husband declined to move, -I was involved in a peer-to-peer interaction 5/18/21. Review of R 30's progress note dated, 5/24/21 at 11:33 revealed, IDT met to review resident in EWBT (unknown) r/t (related to) indicating for behavioral symptom on the [NAME] report, for psych medications, and recent altercation. Noted behaviors include hitting, kicking, pushing, grabbing, pinching, and wandering over the last 30 days. Resident has dx of dementia. If [R30] is attempting to assist co-residents among the unit, thank her for her help, offer to trade places and complete task, as for [R30] enjoys helping others; If [R30] is entering co-resident's rooms, redirect to alternate activity and provide supplies as needed.; If observing exit seeking behavior, offer to walk with [R30] among the unit and attempt to redirect to alternate topic or task; Increase supervision when [R30] is moving independently on the unit; Monitor for tearfulness, agitation, anxiousness, changes in sleep patterns, mood, thoughts of death. Review of R 30's care plan revealed no interventions were placed that prevented R 30 from continuing to entered other residents rooms. R 32 Review of R 32's face sheet and electronic medical record revealed she was an [AGE] year old female who admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility reported incident revealed R 23 and R 32 had an altercation on 5/18/21 where R 32 reported R 30 came into her room and pulled her blankets up over her head and pushed down. Review of R 32's resident progress notes revealed a note by Nurse K for 5/18/21 at 8:30 PM: Upon entering residents room to pass meds to her, resident was found up out of bed and walking towards the door to find someone to help her. Resident was teary eyed and looked upset. When asked what was wrong she stated that women was in here again and this time she put my blankets over my face and I couldn't breathe. Resident stated that nobody here cares because they keep coming in the room. I assured the resident that staff definitely does care. Resident was asked to sit down and that we could talk about it. Resident than stated that that would be fine and she sat down. Resident stated that she was asleep lying in bed and was awoken by [R 30] pulling her blankets up over her face and she was suffocating me. She then proceeded to show me with her hands to her face how she was pressing. She stated that she was terrified. She stated that she was trapped in her blankets or she would have half killed her. She said, I may be small, but I am not weak. Residents roommate than walked out of bathroom with [CNA CCC] who stated I am praying for us. They come in here all the time and do whatever they want. For residents feelings of being safe, this nurse pulled the UA to come and sit in their room with them until I could get a hold of the DON. [Nurse DD] unit manager and [Name of DON], DON was notified. DON placed [R 30] on a one on one for all of the residents safety and a full head to toe skin assessment was done on residents with no issues found. Resident denied pain and stated that she felt safer after talking to this nurse. [CNA CCC] was also in residents room the entire time that this situation was brought to my attention and stayed until this nurse left room to make phone call to managers. A progress note entered by Nurse DDD on 5/20/21 at 3:04 PM revealed: Resident speaking with CNA reported to have asked when co-resident's court date would be r/t recent altercation. Resident also stated she did not have to put up with people trying to kill her. Staff redirected conversation and stated that resident is safe and that staff are keeping close eye on co-resident. Resident participating in bingo today with activity staff. Resident did not report any concerns directly to this nurse when asked. Stop sign remains in place in doorway of resident's room. Social work follow up notes on 5/19/21 and 5/20/21 indicated R 32 was having trouble sleeping. A follow up note was written by the Assistant Director of Nursing (ADON) on 6/1/21 at 11:18 AM: Follow up to incident: On 5/18/21 at approximately 1930, CNA entered resident's room to assist her roommate to use the restroom. At that time, resident was ambulating from her bed to the doorway. resident stated that she was upset. resident stated that a woman came in her room as she was in bed and pulled her blankets up over her head and pushed the blankets down. resident stated that she was able to move her blankets in a short time, she estimated less than a minute that the blankets were on her head. resident stated that the woman did not talk to her. resident roommate, was in her recliner at the time. She stated that the woman walked into their room with an empty cup. She brought the cup to [Roommate of R 32] and attempted to hand it to her. Co-resident stated to the woman that she could not get her anything to drink as she could not get up out of her chair by herself. Co-resident stated that the woman took the cup and ambulated to resident's side of the room and attempted to take resident's cup. Co-resident then heard resident state to the woman to get out of her room. Co-resident stated she noted the woman to touch resident's blankets, but was not able to see what occurred after that as the privacy curtain was pulled blocking her vision. RN was entering the room at the same time that resident reported this to CNA as she was completing medication pass for resident. She was able to provide reassurance to both resident and co-resident. A skin and pain assessment was performed with resident and there were no significant findings. Following resident's statement, it was verified that a different co-resident was the woman that entered their room and she did indeed have a Styrofoam cup with her. UA was able to provide reassurance to resident and co-resident throughout the evening and stayed in their room. Another staff member guided co-resident to her room and provided increased supervision for her. Following the incident, a half door was installed on residents' room to deter others from entering their room. On 5/25/21, resident and co-resident moved to a different unit per their preference. Co-resident had labs and a urinalysis obtained. There were no significant findings with her labs and the urinalysis was negative for infection. The psychiatric nurse practitioner reviewed co-resident and made medication adjustments. Co-resident has received increased supervision from staff following the incident. A sleep study has been initiated for co-resident to assess her sleeping pattern. On 08/04/21 at 09:45 AM an interview was completed with R 32. R 32 stated at least twice someone came into my old room. Someone held me down. R 32 put her hand close to her face and made a pushing motion when talking about being held down. Then, R 32 went from siting up in bed to collapsing down on her elbow and sighed, her voice broke and her face appeared distressed as she said I don't want to talk about it anymore, I just want to forget it. I'm glad got through it and was able to hit them away. On 08/04/21 at 9:55 AM an interview was completed with R 32's roommate (who was also her roommate at the time of the 5/18/21 incident): She stated there were 2 or 3 of them that would come into the room all the time in their old room, she stated they usually they would eat food off their trays. But one time think they physical with her roommate, but she couldn't remember all the details An email was sent to the DON questioning why the incident with R 30 and 32 was not substantiated and the DON responded on 08/03/21 at 12:48 PM Per our understanding, the substantiated tab reflects if the facility feels that abuse was purposeful/willful and verified. Based on the resident's cognitive status, the facility does not feel that it was purposeful/willful, therefore indicating it was unsubstantiated. A follow up email asked if the police department was contacted regarding the incident and the DON responded on 08/05/21 at 8:47 AM: Police were not notified. R 23 Review of R 23's face sheet dated, 7/30/21 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R 23 was her own responsible party. Review of R 23's Brief Interview of Mental Status (BIMS) score dated 4/27/21 was 15/15 (normal cognition). During an interview with R 23 on 7/27/21 at 10:46 AM, R 23 complained about residents wandering into her room. R 23 said R 30 wanders into her room and takes things and has a mean look on her face. R 23 said residents had stolen her remote control, a shirt and slippers. R 23 said the facility replaced the remote control and slippers. R 23 said one resident comes in and pees in her trash can. R 23 reported the wandering residents become more active after 5:00 PM and they come in and wake her up. R 23 said when she complained they gave her a half door but that does not keep them out. R 23 complained about having to move to the floor with the wandering residents and her over all care. R 23 said she has asked to have the facility find an apartment for her because she is so unhappy with the care. On 7/30/21 UM DD was informed R 23 was upset with residents wandering into her room and made that allegation that they steal things and all items had not been replace. UM was informed that the wandering residents wake R 23 up and that the half door was not effective at keeping residents out. On 8/4/21 at 2:46 PM the Nursing Home Administrator (NHA) emailed the Surveyor and indicated R 23 wanted to talk to the Surveyor. At this time the Surveyor went to R 23's room and R 23 said she just wanted to let me know she did not have any problems sleeping. R 23 said she does get awakened when residents wander into her room and confirmed the facility had asked her about her missing items and the shirt, she reported stolen 2 months ago was not located or replaced. R 23 said she is not afraid of the wandering residents, but she did slap one in the hand when she tried to take her water one time. R 23 said R 142 is across the hall from her and when they wander in her room, she yells really loud. Review of R 23's progress note dated 7/28/21 at 10:19 revealed R 23 stated, she didn't like the way agency people treat her. When Social Worker came in to do a depression assessment R 23 told the Social Worker she wanted to harm herself and had a plan. She was going to jump out the window. R 23 was started on 1:1 but when the 1:1 started R 23 began to cry and scream. R 23 said, I should never said anything. Review of R 23's progress note dated 7/30/21 at 10:06 revealed R 23 was asked about missing items and she stated she was missing a striped blue/green and white shirt. R 23 said she had told laundry about the missing shirt. R 23 said it came up missing the first week she came in this room. The missing shirt was reported to the Social Services Director. R 23 also reported R 30 took her remote and they gave her another one. When R 23 reported her slippers missing the Certified Nurse Aide (CNA) told her she knew where they were, and the CNA went and got them. R 23 was asked if she was fearful and she said, just a little. She said R 30 has a scary look on her face. Review of R 23's progress note dated 7/29/21 at 9:16 PM revealed R 23 responded to a survey, indicated feeling caregivers provide compassionately but not always timely. R 142 Review of R 142's face sheet dated 7/30/21 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R 142 was her own responsible party. Review of R 142's Brief Interview of Mental Status (BIMS) score dated 7/11/21 was 15/15 (normal cognition). During an interview with R 142 on 7/27/21 at 10:49 AM, R 142 said R 30 wandered into her room on Sunday 7/25/21 and she is afraid of her because people have reported she hits people. R 142 said staff are slow to respond to the call lights at night, so she yells until they come. R 142 said Sunday she was afraid staff would not get there in time, so she held up her assistive device she uses to reach things to defend herself. R 142 said staff did get R 30 out of her room before she could get close. R 142 said she would not want to hit R 30 but felt she needed to protect herself. R 142 said she complains to the nurses about residents wandering into her room, but they do not do anything. On 7/30/21 UM DD said she was aware residents were wandering into R 142's room. UM DD said she was not aware of the incident Sunday night 7/25/21 or that R 142 was afraid of R 142. UM DD said she did not implement any new intervention when she became aware R 142 did not like residents wandering into her room. UM DD said we all try to watch for the wandering residents and guide them back out of rooms when we see them go in. UM DD said she did not have any documentation on R 142's concerns about wandering residents. UM DD said R 142 moved to her unit on 6/8/21 and the unit she came from did not have wandering residents. UM DD said she would look for documentation related to R 142's concerns about wandering residents. Upon exit no information related to R 142's concerns about wandering residents were provided. Review of R 142's note dated 7/30/21 at 10:47 AM revealed R 142 was questioned after the state person brought concerns forward, R 142 reported, the stop sign on the door does help, they just walk underneath it. She stated 2 come in her room and the one just watches TV for the most part. The other one has taken my walker one and my over the bed table. I got up and told her to get out of my room and was stern with her. I asked if she thought of any other way to keep other residents out of her room and she stated she wondered about a half door. Will make administration aware. When asked if she was fearful, she stated, not of unknown resident first name, the other one has a ornery look on her face. [Name of R 30] might hit me, but she hasn't. Review of R 142's progress noted date 7/30/21 at 10:43 AM revealed R 142 was questioned about residents entering her room. R 132 denied being fearful or losing sleep. R 142 said she had to be stern with R 30 entering her room. R 142 reported R 30 tried to take her walker, coffee table. On 7/30/21 at 8:21 AM, Unit Manager (UM) DD was asked about R 23 and R 142's concerns about residents wandering into their room. UM DD was informed both residents provided a resident first name. UM DD said she had two residents with that first name. UM DD said R 30 wanders into other residents' rooms daily and so it was most likely R 30. UM DD said she was aware R 23 and 142 were concerned about other residents wandering into their rooms. UM DD was unable to locate any paperwork or documentation in R 23 or R 142's medical record that indicated they had concerns about wandering residents. UM DD was informed R 23 had complained of Residents stealing items from her when they wander into her room, and they wake her up at night. UM DD denied any knowledge of stolen items or problems with being awaken at night. UM DD was informed R 142 was very frightened over the weekend when a resident came in her room at night, she held up her assistive device she uses to reach items to defend herself and yelled until staff came to get the resident out of her room. UM DD said she did not get a report of that incident. UM DD said she would interview both residents. On 7/30/21 at 9:21 AM Social Service Director was asked if she had any concern forms or information on R 30 wandering into resident rooms. SSD was informed residents are reporting stolen items, fear and sleep being disturbed. SSD said she would look for concern forms and talk to the Social Workers. Upon exit SSD did not provide any documentation of addressing wandering residents or concern forms. During an interview with UM DD on 8/3/21 at 11:40 AM, this Surveyor followed up on the concerns she had discussed with her on 7/30/21 at 8:21 AM about R 23 and R 142 about wandering residents frightening them, waking them up and stealing from them. UM DD confirmed R 23 was still missing a shirt and the Social Work Director was following up on that concern. UM DD was asked what interventions she implemented to prevent residents from wandering into other residents' rooms after she confirmed the concerns. UM DD said she notified administration. The surveyor asked if the facility had notified the State Agency about the stolen items and Residents being fearful of wandering into her room and UM DD said she would have to check with administration. No report to the State Agency was located upon exit. Resident #114 Resident #114 was originally admitted to the facility 3/11/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] reflected the Resident was cognitively intact, was ventilator dependent and had received nutrition and fluids through a feeding tube since admission. Section M of this MDS reflected the Resident was admitted with one unhealed Stage four pressure ulcers and Moisture Associated Skin Damage (MASD). Review of the Discharge assessment MDS dated [DATE] reflected Resident #114 had two Stage two pressure ulcers. The MDS of 3/18/21 reflected that no stage two pressure ulcers were present on admission which indicated that the pressure ulcers were acquired while admitted at the facility. Review of the EMR weekly Wound Evaluation documents for wound #5 that have photographs, measurement, and Progress are summarized as: 3/29/21 #5 In-house acquired measures 3.22cm by 4.85cm. Progress: New 4/26/21 #5 Resolved. 5/10/21 #5 measuring 0.5 cm by 1.27 cm. Progress: Improving 5/17/21 #5 measuring 2.86 cm by 3.5 cm. The documentation reflected the area of the wound increased to 7.18 cm2 and identified this as a 2362% increase in size. 7/5/21 #5 measuring 4.36 cm by 9.03 cm. The photograph revealed one deep wound with a pronounced area of degradation superior to the wound without documentation. Progress Stalled' . 7/12/21 #5 measuring 4.36 cm by 7.45 cm. While the measurement documented reflects a decrease of total area of the wound the photograph reveals marked degradation of the surrounding area. Progress is documented as Deteriorating. 7/19/21 #5 5.18 cm by 12.12 cm, an increase in size from 7/12/21 but documented as Progress Improving and the degradation of the perimeter as previously mentioned. 7/26/21 #5 2.57 cm by 4.65 cm with Progress of Stable. The photograph displays overall degradation of the surrounding area with three areas separate from the measured wound oozing blood and other areas with defined borders not measured or documented. 8/2/21 #5 measures 1.57cm by 3.33 cm with Progress of Improving. However, the photograph revealed severe degradation of the entire surrounding area that appears to extend beyond the edges of the photograph. 8/2/21 Wound #8 is listed as present on admission at the right Ischial Tuberosity but listed under Progress as New. The documentation reflected measurements of 5.33 cm by 4.92 cm. The severity of change to this area is evident when compared to the photograph of the same area captured on 3/29/21. Review of the Care Plan for Resident #114 reflected on page 28 of 44 pages the focus of Skin Integrity I have actual impairment to skin of the buttocks (related to (r/t)) immobility, incontinency. I am at risk for further skin issues. The Focus areas continue with description of concerns of, I am able to, and do, remove pillows after repositioning. Listed under Actual are the current wounds of the Resident and include: The Stage 4 wound the Resident admitted to the facility with on 3/11/21, MASD to the scrotum Additional wounds listed are stage 1 lateral left ischial tuberosity, stage 2 (right) ischial tub (sic) area (right) trochanter, and coccyx Stage 2. Review of the Care Plan for Resident #114 revealed on page 14 a Focus of Infection I am using antifungal magic butt paste to treat worsening MASD to scrotum and coccyx. Date initiated 7/15/21. Revision on 7/15/21. The interventions documented were to administer medication as ordered and to follow facility procedure to report infection. No other revisions or new interventions were implemented after 7/15/21. In an interview conducted 7/30/21 at 12:18 PM Unit Manager (UM) JJ reported that Resident #114 is non-compliant with repositioning. UM JJ indicated the Resident will move pillows that had been placed to position off wounds. UM JJ reported facility efforts on repositioning are documented. Review of the Assisted Breath Unit Progress Notes revealed an entry by UM JJ dated 4/12/21 at 4:23 PM reflected a Manager Skin Summary, Risk for Impaired Skin Integrity: Resident is dependent for cares and repositioning. He has limited mobility of upper body and no mobility to lower body. <br [TRUNCATED]

Based on interview and record review, the facility failed to fully assess and implement interventions to prevent and treat pressure sores for three residents (R 54, R 141, and R 114) resulting in the delay of diagnosing two unstageable pressure ulcers for R 547 and an avoidable pressure ulcer for R 114. Findings: Resident #547 (R 547) Review of a facility Admission Record reflected R 547 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Braden Scale for Predicting Pressure Sore Risk completed on the day R 547 admitted to the facility (7/14/21) reflected she scored a 19 (low risk), at risk for developing a pressure sore, as opposed to having a moderate, high, or very high risk of developing a pressure sore. Review of R 547's Admission Assessment locked on 7/15/21 reflected R 547 admitted to the facility on [DATE]. Section L of the assessment for SKIN reflected only two areas of concern were identified: Right Trochanter (surgical incision) measuring 10.5 centimeters (cm) and the Right thigh lateral (surgical incision) measuring 5.5 cm. A note at the end of the section for skin assessment reflected R 547's BUE (Bilateral upper extremity) extremely bruised, tried to take photos to monitor and was not able to label photos. No other areas on R 547's skin was identified as having an issue on the admission assessment. Review of a PCC Skin & Wound - Total Body Skin assessment dated [DATE] at 17:42 (5:42 p.m.) reflected no wounds were present on R 547's body. Review of a PCC Skin & Wound - Total Body Skin assessment dated [DATE] at 11:13 a.m. reflected no wounds were present on R 547's body. Review of a Skin/Wound Note dated 7/17/21 at 12:47 p.m. reflected This nurse called into res (R 547's) room, staff providing am (morning) cares, repositioning, Dark purple discoloration noted to res right heel. No open areas noted at this time, res admitted to facility on 7/14/21, skin prep applied to area, purple heel protectors to be worn, heels to be offloaded using pillows, air mattress to be placed, dietary to consult for possible supplements to enhance wound healing. Review of a Skin/Wound Note dated 7/17/21 at 12:56 p.m. reflected this nurse called in to assess res (R 547) during am (morning) cares, small pustule like areas noted to coccyx/sacrum area as well as dark red discoloration, air mattress to be placed and dietary to consult for possible supplements to promote wound healing . res recently admitted to facility on 7/14/21 after right hip fx (fracture) and repair, staff to assist res to turn q (every) 2 hours in bed to offload pressure. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . No specific treatments were referenced in the progress note to address the [CONDITION(S)] on R 547's back and no mention of the heel sore was found. Review of a Wound Evaluation dated 7/17/2021 reflected R 547 had an area on her heel that measured 9.98 cm squared and had not been evaluated by staff for three days since her admission to the facility. Review of a Wound Evaluation dated 7/17/21 reflected an area on her sacral-coccygeal region measuring 7.46 cm squared and had not been evaluated by staff for three days since her admission to the facility. Review of a Baseline Care Plan signed on 7/16/2021 reflected R 547 had current skin integrity issues related to surgical incisions, a cancerous labial mass and bruising to bilateral upper extremities but did not reference any areas of pressure sores. Review of a Care Plan Report reflected R 547 had Actual impairments to skin integrity. I have right hip incision. I have a mass to my left labia related to vaginal [CONDITION(S)]. I have pain with movement to my right hip area and discomfort in my vaginal area. I have limited mobility to lower extremities. I am 75% weight bearing to right lower extremity. I am a full lift and not able to ambulate at this time. The care plan report identified R 547 as at a moderate risk for pressure sores and reflected that on admission was identified with a Deep Tissue Injury (DTI) to the left heel and sacrum, however, interventions to treat and prevent the worsening of the wounds allegedly present on admission were not implemented until 7/17/21, three days after admission. During an interview on 8/4/21 at 4:24 p.m., wound care nurse, Registered Nurse (RN) P reported that the expectation is for a full body skin assessment to be completed on newly admitted residents within four hours of admission, ideally within two hours of admission. RN P explained that a pressure ulcer can develop within hours and any wound that is not identified upon admission or within a short time-frame, would have to be assumed to be a facility acquired pressure ulcer. Resident #114 Resident #114 was originally admitted to the facility 3/11/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] reflected the Resident was cognitively intact, ventilator dependent, and had received nutrition and fluids through a feeding tube since admission. Section M of this MDS reflected the Resident was admitted with one unhealed Stage 4 pressure ulcer and Moisture Associated Skin Damage (MASD). Review of the Discharge assessment MDS dated [DATE] reflected Resident #114 had two Stage 2 pressure ulcers. The MDS of 3/18/21 reflected that no Stage 2 pressure ulcers were present on admission which indicated that the Stage 2 pressure ulcers were acquired while admitted at the facility. Review of the EMR weekly wound assessment documentation for 3/29/21 reflected a New, healable #5 Pressure stage 2 wound on the coccyx of Resident #2 that was in-house acquired. The documentation reflected the measurements of this new wound to be 3.22 centimeters (cm) by 4.85 cm. The photograph of the wound revealed an irregularly shaped open area on the coccyx of the Resident with mild to moderate redness extending superiorly several inches with the same redness extendedly laterally and inferiorly beyond the area captured in the photo. The surrounding skin appears intact with flaking of the skin noted. The pain level of the Resident was documented as 2 (on the 1 to 10 pain scale). Review of the EMR weekly Wound Evaluation documentation for 7/19/ 21 revealed the same #5 coccyx wound with measurements of 5.18 cm by 12.12 cm. Despite the measurement that implied one wound, the photograph of the wound reflected two open areas with no less than eight smaller questionable open areas scattered outside the wound borders that were not identified or described in the documentation. The documentation of the assessment reflected the wound bed was bleeding and the wound exudate (fluid) was sanguineous/bloody, and pain to the Resident was 10. The Progress was documented as improving. Review of the EMR weekly Wound Evaluation documents for wound #5 that have photographs, measurements, and Progress are summarized as follows: 3/29/21 #5 In-house acquired measures 3.22cm by 4.85cm. Progress: New 4/26/21 #5 Resolved. 5/10/21 #5 measuring 0.5 cm by 1.27 cm. Progress: Improving 5/17/21 #5 measuring 2.86 cm by 3.5 cm. The documentation reflected the area of the wound increased to 7.18 cm2 and identified this as a 2362% increase in size. 7/5/21 #5 measuring 4.36 cm by 9.03 cm. The photograph revealed one notable wound with a pronounced area of degradation superior to the wound without documentation of this. Progress Stalled. 7/12/21 #5 measuring 4.36 cm by 7.45 cm. While the measurement documented reflected a decrease in area the photograph revealed marked degradation of the surrounding area. Progress is documented as Deteriorating. 7/19/21 #5 5.18 cm by 12.12 cm with Progress Improving and the degradation of the perimeter as previously mentioned. 7/26/21 #5 2.57 cm by 4.65 cm with Progress of Stable. The photograph displays overall degradation of the surrounding area with three areas separate from the measured wound oozing blood and other areas with defined borders not measured or documented. 8/2/21 #5 measures 1.57cm by 3.33 with Progress of Improving. However, the photograph revealed severe degradation of the entire surrounding area that appears to extend beyond the edge of the photograph. 8/2/21 Wound #8 is listed as present on admission at the right Ischial Tuberosity but listed under Progress as New. The documentation reflected measurements of 5.33 cm by 4.92 cm. The severity of change is evident when compared to the photograph of the same area captured on 3/29/21. Review of the Care Plan for Resident #114 reflected on page 28 of 44 pages the focus of Skin Integrity I have actual impairment to skin of the buttocks (related to (r/t)) immobility, incontinency. I am at risk for further skin issues. The Focus areas continue with description of concerns of, I am able to, and do, remove pillows after repositioning. Listed under Actual are the current wounds of the Resident and include: The Stage 4 wound the Resident admitted to the facility with on 3/11/21, MASD to the scrotum Additional wounds listed are stage 1 lateral left ischial tuberosity, stage 2 (right) ischial tub (sic) area (right) trochanter, and coccyx Stage 2. Review of the Care Plan for Resident #114 reveal on page 14 a Focus of Infection I am using antifungal magic butt paste to treat worsening MASD to scrotum and coccyx. Date initiated 7/15/21. Revision on 7/15/21. The interventions documented were to administer medication as ordered and to follow facility procedure to report infection. No other revisions or new interventions were implemented after 7/15/21. In an interview conducted 7/30/21 at 12:18 PM, Unit Manager (UM) JJ reported that Resident #114 is non-compliant with repositioning. UM JJ indicated the Resident will move pillows that had been placed to position off wounds. UM JJ reported facility efforts on repositioning are documented. Review of the Assisted Breath Unit Progress Notes revealed an entry by UM JJ dated 4/12/21 at 4:23 PM reflected a Manager Skin Summary, Risk for Impaired Skin Integrity: Resident is dependent for cares and repositioning. He has limited mobility of upper body and no mobility to lower body. Review of the Assisted Breath Unit Progress Notes revealed an entry by UM JJ dated 7/5/21 at 3:15 PM. The entry reflected .new area noted to right ischial tuberosity ., . Other wounds noted to be deteriorated ., and Resident is non-compliant with re-positioning and off-loading. Review of the Care Plan reflected the minimum industry standard of care for repositioning for all residents of every two hours while in bed was implemented as an intervention on admission on 3/11/21. The Care Plan did not reflect an increased frequency change to repositioning/off-loading despite the existence of new, acquired, and deteriorating skin integrity and a known concern of compliance with repositioning. New interventions were documented for a change of air mattress settings on 7/5/21 and transfer method on 7/20/21 but no consideration is documented in the Care Plan to address positioning. In an interview conducted 7/30/21 at 12:18 PM, UM JJ reported that Resident #114 was followed by the Veterans Affairs Wound Clinic prior to admission. UM JJ reported a wound specialist was providing weekly assessments until about the beginning of June 2021. UM JJ reported she now does the weekly evaluations and/or reviews and documents in the EMR for review by the medical provider. UM JJ indicated a when wound treatment does not show improvement within two weeks, the treatment is changed. On 8/5/21 at 10:26 AM an interview was conducted with IM JJ. UM JJ reported that the Assisted Breathing Unit has a camera designated for wound documentation. UM JJ acknowledge that, although staff are trained in using this camera and the associated computer application, inconsistencies in photographing, and measuring of the wounds does occur. The photograph of the weekly Wound Evaluation of 7/26/21 was discussed with UM JJ. UM JJ indicated that it can be difficult to decide what to measure in a fluctuating area. UM JJ reported, I don't know if it is more appropriate to call it a 10 by 10 area or small with fluctuating larger areas and 20 different assessment measuring all of the areas from one common cause. When reviewing the documentation of the 7/26/21 wound evaluation UM JJ stated I don't trust those measurements and acknowledged that the wound area was deteriorating. Resident #141 Resident #141 was originally admitted to the facility 1/16/14 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) of 1 which indicated the Resident was severely cognitively impaired. Review of the Care Plan for Resident #141 reflected a Skin Integrity Care Plan implemented 7/17/19. The Care Plan revealed an intervention implemented 7/17/19 documented as, I have blue boots to wear. No documentation was found that indicated Resident #141 was to wear purple boots. On 8/5/21 at 2:34 PM8:39 AM RN MMM reported that Resident #141 had two blisters on the tops of his feet and compromised skin on his right heel. RN MMM reported that the Resident had on purple boots when he was supposed to have blue boot on. RN MMM reported that the purple boots have straps, but the blue boots do not have straps. RN MMM indicated that the straps from the purple boots caused blisters on the feet of Resident #141. Review of the Nurse Practitioner's (NP) note of 7/27/21 reflected an evaluation of a fluid filled blister on the top of the Residents left foot and on the Resident's left heel. The documentation reflected Resident #141 had a doctor's order for blue boots, but purple been had been applied. Review of the documentation by the NP revealed, The Resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The documentation reflected that due to the straps from the purple boots the Resident is now requiring medical treatment.

This citation pertains to intakes: MI 332 and MI 344: Based on interview and record review, the facility failed to develop and implement policies and procedures to prevent abuse and neglect and report the reasonable suspicion of a crime according the the Elder Justice Act (EJA) for 2 residents (R 32 and R 119) reviewed for abuse, resulting a failure to thoroughly identify, protect residents, investigate, and report to the state agency and law enforcement allegations of abuse. This deficient practice has the potential to affect all vulnerable residents in this facility. Findings include: According to the facility Abuse, Neglect and Exploitation Policy with a revision date 10/8/2019, read, in part, Abuse: means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical. Mental, and psychosocial well-being, The home will provide ongoing oversight and supervision of staff in order to assure that is (sic) policies are implemented as written, The home will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: . B Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed and certified staff on each shift, Possible Indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse 2. Physical marks such as bruises or patterned appearances such as a hand print, belt or ring mark on a resident's body, 3. Physical injury of a resident, of unknown source, 4. Resident reports of theft of property, or missing property, 5. Verbal abuse of a resident overheard, 6. Physical abuse of a resident observed, 7. Psychological abuse of a resident observed, 8. Failure to provide care needs such as feeding, bathing, dressing, turning, and repositioning, A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedure for investigation include: 1. Identifying staff responsible for the investigation, 2. Exercising caution in handling evidence that could be used in a criminal investigation, 3. Investigation different types of alleged violations, 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation, The home will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation, B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed, C. Increased supervision of the alleged victim and residents, D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator, E. Protection from retaliation, F. Providing emotional support and counseling to the resident during and after the investigation, as needed, and The home will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g law enforcement when applicable) within specified timeframes: a. 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 b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 2. Assuring that reporters are free from retaliation or reprisal .4. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following: a. analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences, b. defining how care provision will be changed and /or improved to protect residents receiving services, c. training of staff on changes made and demonstration of staff competency after training is implanted (sic), d. Identification of staff responsible for implantation (sic) of corrective actions, e. the expected date for implementation, and f. Identification of staff responsible for monitoring the implementation of the plan. R 30 Review of R 30's face sheet dated 8/3/21 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R 30 was not her own responsible party. Review of R 30's cognitive assessment completed for her Minimum Data Set (MDS) dated [DATE] revealed she was unable to answer any of the cognitive questions and was marked as severely cognitively impaired. Review of R 30's mood/behavioral care plan initiated on 7/11/19 and revised on 5/19/21 revealed, wanders among the unit in and out of co-resident's rooms to seek comfort. -noted paranoia at times. -offered change of room to husband on 6/29/20 r/t (related to) embracing male co-resident, however husband declined to move, -I was involved in a peer-to-peer interaction 5/18/21. Review of R 30's progress note dated, 5/24/21 at 11:33 revealed, IDT met to review resident in EWBT (unknown) r/t (related to) indicating for behavioral symptom on the [NAME] report, for psych medications, and recent altercation. Noted behaviors include hitting, kicking, pushing, grabbing, pinching, and wandering over the last 30 days. Resident has dx of dementia. If [R30] is attempting to assist co-residents among the unit, thank her for her help, offer to trade places and complete task, as for [R30] enjoys helping others; If [R30] is entering co-resident's rooms, redirect to alternate activity and provide supplies as needed.; If observing exit seeking behavior, offer to walk with [R30] among the unit and attempt to redirect to alternate topic or task; Increase supervision when [R30] is moving independently on the unit; Monitor for tearfulness, agitation, anxiousness, changes in sleep patterns, mood, thoughts of death. R 32 Review of R 32's face sheet and electronic medical record revealed she was an [AGE] year old female who admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility reported incident revealed R 32 and R 30 had an altercation on 5/18/21 where R 32 reported R 30 came into her room and pulled her blankets up over her head and pushed down. Review of R 32's resident progress notes revealed a note by Nurse K for 5/18/21 at 8:30 PM: Upon entering residents room to pass meds to her, resident was found up out of bed and walking towards the door to find someone to help her. Resident was teary eyed and looked upset. When asked what was wrong she stated that women was in here again and this time she put my blankets over my face and I couldn't breathe. Resident stated that nobody here cares because they keep coming in the room. I assured the resident that staff definitely does care. Resident was asked to sit down and that we could talk about it. Resident than stated that that would be fine and she sat down. Resident stated that she was asleep lying in bed and was awoken by [R 30] pulling her blankets up over her face and she was suffocating me. She then proceeded to show me with her hands to her face how she was pressing. She stated that she was terrified. She stated that she was trapped in her blankets or she would have half killed her. She said, I may be small, but I am not weak. Residents roommate than walked out of bathroom with [CNA CCC] who stated I am praying for us. They come in here all the time and do whatever they want. For residents feelings of being safe, this nurse pulled the UA to come and sit in their room with them until I could get a hold of the DON. [Nurse DD] unit manager and [Name of DON], DON was notified. DON placed [R 30] on a one on one for all of the residents safety and a full head to toe skin assessment was done on residents with no issues found. Resident denied pain and stated that she felt safer after talking to this nurse. [CNA CCC] was also in residents room the entire time that this situation was brought to my attention and stayed until this nurse left room to make phone call to managers. A progress note entered by Nurse DDD on 5/20/21 at 3:04 PM revealed: Resident speaking with CNA reported to have asked when co-resident's court date would be r/t (related to) recent altercation. Resident also stated she did not have to put up with people trying to kill her. Staff redirected conversation and stated that resident is safe and that staff are keeping close eye on co-resident. Resident participating in bingo today with activity staff. Resident did not report any concerns directly to this nurse when asked. Stop sign remains in place in doorway of resident's room. Social work follow up notes on 5/19/21 and 5/20/21 indicated R 32 was having trouble sleeping. A follow up note was written by the Assistant Director of Nursing (ADON) on 6/1/21 at 11:18 AM: Follow up to incident: On 5/18/21 at approximately 1930, CNA entered resident's room to assist her roommate to use the restroom. At that time, resident was ambulating from her bed to the doorway. resident stated that she was upset. resident stated that a woman came in her room as she was in bed and pulled her blankets up over her head and pushed the blankets down. resident stated that she was able to move her blankets in a short time, she estimated less than a minute that the blankets were on her head. resident stated that the woman did not talk to her. resident roommate, was in her recliner at the time. She stated that the woman walked into their room with an empty cup. She brought the cup to [Roommate of R 32] and attempted to hand it to her. Co-resident stated to the woman that she could not get her anything to drink as she could not get up out of her chair by herself. Co-resident stated that the woman took the cup and ambulated to resident's side of the room and attempted to take resident's cup. Co-resident then heard resident state to the woman to get out of her room. Co-resident stated she noted the woman to touch resident's blankets, but was not able to see what occurred after that as the privacy curtain was pulled blocking her vision. RN was entering the room at the same time that resident reported this to CNA as she was completing medication pass for resident. She was able to provide reassurance to both resident and co-resident. A skin and pain assessment was performed with resident and there were no significant findings. Following resident's statement, it was verified that a different co-resident was the woman that entered their room and she did indeed have a Styrofoam cup with her. UA was able to provide reassurance to resident and co-resident throughout the evening and stayed in their room. Another staff member guided co-resident to her room and provided increased supervision for her. Following the incident, a half door was installed on residents' room to deter others from entering their room. On 5/25/21, resident and co-resident moved to a different unit per their preference. Co-resident had labs and a urinalysis obtained. There were no significant findings with her labs and the urinalysis was negative for infection. The psychiatric nurse practitioner reviewed co-resident and made medication adjustments. Co-resident has received increased supervision from staff following the incident. A sleep study has been initiated for co-resident to assess her sleeping pattern. On 08/04/21 at 09:45 AM, an interview was completed with R 32. R 32 stated at least twice someone came into my old room. Someone held me down. R 32 put her hand close to her face and made a pushing motion when talking about being held down. Then, R 32 went from siting up in bed to collapsing down on her elbow and sighed, her voice broke and her face appeared distressed as she said I don't want to talk about it anymore, I just want to forget it. I'm glad got through it and was able to hit them away. On 08/04/21 at 9:55 AM, an interview was completed with R 32's roommate (who was also her roommate at the time of the 5/18/21 incident): She stated there were 2 or 3 of them that would come into the room all the time in their old room, she stated they usually they would eat food off their trays. But one time thought they got physical with her roommate, but she couldn't remember all the details An email was sent to the DON questioning why the incident with R 30 and 32 was not substantiated and the DON responded on 08/03/21 at 12:48 PM Per our understanding, the substantiated tab reflects if the facility feels that abuse was purposeful/willful and verified. Based on the resident's cognitive status, the facility does not feel that it was purposeful/willful, therefore indicating it was unsubstantiated. A follow up email asked if the police department was contacted regarding the incident and the DON responded on 08/05/21 at 8:47 AM: Police were not notified. Resident #119 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R 119 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 4 out of 15 which represents R 119 had severe cognitive impairment. R 119 did not reside at the facility during the onsite survey and was not available for interview. The facility provided a copy of a letter signed by CNA E and CNA BBB (undated) for review. The letter reflected, Specifically, (name of CNA L) will be unnecessarily aggressive, physically and verbally (sp) with (name of R 119). She will hold her arms and legs beyond the behavior-control needed to perform cares. She will actively spray her in the face in the shower when (name of R 119) yells, whines, or tries to hit . The facility provided a typed interview for CNA E completed by the ADON A dated 5/12/21 at 9:15 AM. The record reflected, (Name of R 119) will hit, scratch and bite staff. Staff will tell (name of R 119) to stand there, we are taking a shower. They will tell (name of R 119) to shut up. (Name of R 119) tries to shut the water off during the shower and will move her arms around while they are washing her. (Name of R 119) spit at staff and got sprayed in the face. (Name of CNA E) feels that (name of CNA L) purposefully put water in (name of R 119's) face. During an interview and record review on 7/30/21 at 11:00 AM, CNA E demonstrated how she observed R 119 as she stood at the grab bar in the shower while CNA E and CNA BBB washed and CNA L rinsed R 119. CNA E then demonstrated how CNA L held the shower head directly in front of R 119's face and told her to shut up. CNA L stated, It appeared to me as waterboarding. When asked what that looked like, CNA E stated, She (CNA L) sprayed it so long it was hard for her (R 119) to breath. When asked if the police ever interviewed her about the incident, CNA E stated, No, I didn't even know if they were called. According to the Abuse Policy the facility failed to ensure that reporters are free from retaliation or reprisal. The facility provided a typed interview for CNA BBB completed by the ADON A dated 5/12/21 at 10:30 AM. The record reflected, I have worked with (name of CNA L) for two years. Since she came back from (name of leave taken from work) she has become like she is burnt out. She always works down the same hall. Her tone is loud and gruff. She is rude. She will push residents back down into their chairs at lunch. She doesn't have compassion or patience. I am uncomfortable working with her. (Name of R 119) is a handful during cares. It is very hard to approach (Name of R 119). (Name of CNA L) sprayed (name of R 119) in the shower in her face multiple times. This happened within a month ago, but I can't give an exact date. I think she did it as a reaction because (name of R 119) was hitting and trying to bite. (Name of CNA L) will say knock it off to (name of R 119). During a telephone interview on 7/30/21 at 11:30 AM and 8/3/21 at 2:30 PM, the typed statement was read to CNA BBB. CNA BBB stated that the statement was correct. CNA BBB stated that she felt that CNA L intentionally and repeatedly sprayed R 119 in the face as a result of R 119's behaviors in the shower. CNA BBB stated that she has observed CNA L push R 9 down by the shoulder back into her chair in the dining room when she attempted to stand and leave after finishing her meal. During an interview and record review on 8/3/21 at 1:00 PM, ADON A stated Unit Manager (UM) DD noticed a letter under her office door on 5/12/21 about 8:30 AM and gave it to her. She said she was unable to determine the exact date of the shower incident. ADON A stated she removed CNA L from shift on 5/12/21 at approximately 10:30 AM and brought CNA L back to work on 5/18/21 after the investigation was completed. According to the facility 5-day report, abuse was not substantiated. When asked if the police were notified of the allegation, ADON A stated, Yes, on May 19th at 5:03 PM (7 days after learning of the allegation). When asked if the allegation of CNA L pushing R 9 down in a chair in the dining room was investigated or if CNA L was interviewed regarding the alleged witnessed incident, ADON A stated that the facility did not and was not able to provide the survey team with an investigation for the allegation. During an interview and record review on 8/4/21 at approximately 10:00 AM, the NHA stated she was the Abuse Coordinator at the facility and had reviewed the investigation. The NHA stated that what she had heard and was explained to her was not considered abuse because it was not purposeful or willful. The NHA stated that all reports of abuse allegations should be brought straight to the NHA and the police should be called right away. When asked if there were any reason that CNA E and CNA BBB would bring false allegations against CNA L, the NHA stated, No. According to the Abuse Policy the staff failed to identify abuse and understand behavioral symptoms of residents that may increase the risk of abuse and neglect such as aggressive and/or catastrophic reactions of residents.

This citation pertains to intake number MI 716. Based on observation, interview and record review the facility failed to adequately supervise 1 Resident (R 8) of 3 residents reviewed for falls resulting in R 8 falling and sustaining a [CONDITION(S)]. Findings include: Review of R 8's face sheet dated 3/31/21 revealed she was an [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: fractured left femur (left hip), [CONDITION(S)], fractured left humerus (left arm), weakness, cognitive communication deficit, and difficulty walking. She was listed as her own responsible party. Review of R 8's Physician assessment dated [DATE] revealed she was admitted with a left humerus fracture secondary to fall. She had a urinary tract infection, [CONDITION(S)] (stroke), left [CONDITION(S)] (left sided weakness) and senile [CONDITION(S)] brain disease. She was having severe significant [CONDITION(S)] with lying down blood pressure of 139/62 and standing blood pressure of 80/61 with symptoms. R 8 was very impulsive and was continued on multiple supervisions for safety. R 8 had a tendency to walk and had increased risk of falling. According to the plan the [CONDITION(S)] was most likely due to poor oral intake. R 8's urinary tract infection was already treated and stable. R 8 was to be evaluated by physical therapy, occupational therapy and to stay on one-to-one supervision to prevent falls. R 8 was to be seen by neurology due to her recent stroke, have a dietary consult due to poor oral intake and a psych consultation related to her senile [CONDITION(S)] brain disease with impulsive behavior. Review of R 8's Nurse Practitioner visit note dated 1/25/21 revealed she continued to have positive orthostatic blood pressures and was receiving IV fluids. R 8 was confused and disoriented. Review of R 8's Nurse Practitioner visit note dated 1/26/21 revealed she was being seen due to a fall and positive [CONDITION(S)]. R 8 was agitated and having increased behaviors. R 8 had another fall within the last 48 hours, she had been self-transferring and continued to have dropping blood pressures. She was to remain on one-to-one supervision. The plan revealed she had a normal urinalysis. R 8 was to have a psychiatrist evaluation and remain on one-to-one supervision. Review of R 8's Nurse Practitioner visit note dated 2/23/21 revealed under assessment and plan: 5. Behaviors. The patient has been stable. Will trial one-on-one supervision and the patient will be encouraged to participate in activities and will continue to monitor. Did explain to the nurses to have the midnight staff keep a close eye on her and see how she will respond to that change. At this time, she appears to be doing much better, has improved. Her orthostatic blood pressures are better, and she has no dizziness. There was no indication she had improved in mental status, impulsivity, or self-transfers. The note indicated 1:1 was going to continue while R 8 started activities. Review of R 8's ADL (activity of daily living) care plan dated 1/20/21 revealed she had a left arm sling to be worn at all times, she required extensive assistance of 1-2 people for bed mobility and dressing. She was to transfer with a mechanical lift and be assisted by 2-3 people. She was to walk with therapy. There was no mention of one-on-one care as noted in the physician and nurse practitioner notes. Review of R 8's fall care plan dated 1/20/21 revealed she had a stroke 2 years ago that left her with left sided weakness. She had a history of compression fractures, rib fractures and an ankle fracture. She had fallen in the facility on 1/22/21, 1/23/21 and 2/25/21. Interventions included 1:1 care initiated on 3/5/21 and resolved on 3/18/21, and 1:1 was initiated again on 3/18/21 and resolved on 3/19/21, bed and chair alarm, initiated on 1/22/21, increased supervision for safety was initiated on 1/23/21. 1:1 was not care planned as the Physician assessment dated [DATE] indicated was in place or as indicated in the Nurse Practitioner notes dated 1/26/21 and 2/23/21. Review of R 8's Baseline Care Plan revealed it was completed by a Registered Nurse on 1/21/21. There was no indication R 8's resident advocate was involved or any other facility staff. According to the assessment she had history of falls, she had fallen at home and fractured her arm, she required a walker to walk. She was assessed as cognitively intact and alert. Social Service worker signed the Baseline Care Plan on 1/26/21 and there was no indication R 8's resident advocate was involved in the care planning. There was no indication R 8 was assessed to need in any increased safety precautions. Review of R 8's progress note dated 1/20/21 at 5:39 PM revealed she was admitted from the hospital after a fall resulting in a left should fracture. R 8 had mild confusion. She had completed her antibiotics in the hospital for her urinary tract infection. She required assistance of 2 people for transfers. Review of R 8's COMS-Skilled Evaluation dated 1/20/21 at 10:09 PM, revealed R 8 was confused and disoriented. She was only oriented to person. R 8's confusion was a new onset. Review of R 8's COMS - Skilled Evaluation date 1/21/21 at 9:59 AM, revealed R 8 was confused and disoriented. Review of R 8's COMS - Skilled Evaluation date 1/22/21 at 2:19 AM, revealed R 8 was confused and disoriented, oriented to person only. Review of R 8's progress note dated 1/22/21 at 11:17 AM revealed the nurse contacted R 8's Nurse Practitioner (NP) about her orthostatic blood pressure readings and was waiting for a response. Review of R 8's progress note dated 1/22/21 at 11:58 AM revealed the NP ordered orthostatic blood pressures for 2 days. Review of R 8's progress note dated 1/22/21 at 2:50 PM (late entry) revealed R 8 had wandered into the hallway and fell backwards hitting her head on a wall. The fall was witnessed by staff. R 8 was not able to explain to staff where she was going or what she was doing. (There was no indication of any added supervision placed after this fall). R 8's care plan indicated a bed and chair alarm was placed on 1/22/21. Review of R 8's COMS - Skilled Evaluation dated 1/23/21 at 10:28 AM, revealed she was confused and disoriented. She did not wander at night and was sleeping at night. She was unaware of her safety needs. She was being checked frequently for safety and fall alarms were in place. Review of R 8's progress noted dated 1/23/21 at 2:49 PM revealed Resident was observed standing from her recliner in her room and slid to the floor. The RN that observed the fall was standing at her medication cart during the observation. Resident was not on 1:1 prior to the fall. There was no indication if fall alarm was on or sounded. 1:1 care was started after the fall. R 8's care plan did not indicate 1:1 care started on 1/23/21. Review of R 8's COMS - Skilled Evaluation dated 1/24/21 at 2:22 PM revealed she was confused and disoriented. She was unaware of safety needs. She was on frequent checks for safety and alarms were in place. Physician note indicated she was on 1:1 care but 1:1 care was not on the care plan. Review of R 8's COMS -Skilled Evaluations from 1/24/21 to 1/30/21 indicated R 8 remained mentally impaired and did not have safety awareness. There was no indication she was on 1:1 care as Physician and NP notes indicated. Review of R 8's COMS - Skilled Evaluation dated 1/31/21 at 9:37 AM, revealed her mental status was cognitively impaired some forgetfulness. R 8 was on 1:1 for safety and was able to walk with therapy in the hall with a hemi walker (one handed walker). Review of R 8's notes from 2/1/21 to 2/2/21 do not indicate she is on 1:1 care. Review of R 8's COMS - Skilled Evaluation dated 2/3/21 at 9:49 AM, revealed she was cognitively impaired and continued on 1:1 for safety. Review of R 8's progress notes from 2/4/21 to 2/5/21 at 12:37 PM revealed she remained cognitively impaired, had no change in behaviors and remained on 1:1 care for safety. Review of R 8's progress noted dated 2/26/21 at 5:41 AM revealed R 8's had a fall. The note did not indicate the date or time of the fall. The note revealed R 8 was found in her room flat on her back. R 8 said someone in the hall said something to her. There was no indication R 8 was on 1:1 care at the time of the fall. R 8 was sent to the emergency room at 11:30 PM. Review of R 8's progress noted dated 2/26/21 at 10:58 AM, revealed Clarification incident happened at 7:33 PM on 2/25/21 not 7:33 AM. Review of R 8's narrative noted dated 3/4/21 at 3:27 PM revealed the note was an investigative summary of the fall on 2/25/21. A Certified Nurse Aide (CNA) found R 8 on the floor in the doorway of her room. R 8's call light was on. Staff said they had taken R 8 to the bathroom at 5:45 PM. There was no indication why she was not on 1:1 as documented in the note 2/25/21 at 12:37 PM. There was no indication what her behaviors and activity level had been prior to the fall. There was no indication if she had continued to self-transfer or attempt to when she was on 1:1 care. Review of R 8's Admission Summary dated 3/5/21 at 4:55 PM revealed R 8 returned from the hospital at 4:50 PM and was placed on 1:1 care until she could be safe in her room alone. Review of R 8's notes on 3/6/21 to 3/13/21 did not indicate R 8 was on 1:1 care. Review of R 8's noted on 3/14/21 at 9:35 revealed she was on 1:1 care and was attempting to stand and self-transfer. Review of R 8's notes 3/15/21 to 3/16/21 did not indicate she is on 1:1 care. Note dated 3/17/21 at 6:20 PM indicated she was on 1:1 care and self-transferring. Review of R 8's notes 3/18/21 to 3/23/21 did not indicate she is on 1:1 care. Review of R 8's note dated 3/24/21 at 4:50 PM indicated she was on 1:1 care for safety. R 8 was observed on 3/30/21 at 2:10 PM sitting in her when near the nurse's station on the nursing unit. RN N said when R 8 is out of bed she is placed out by the nurse's station or in an area staff can monitor her for safety due to her fall history. R 8's was not oriented to place or time. R 8 had no memory of falls and said she had lived in this place her whole life and her son lived out back. She was able to carry on a pleasant conversation and was agreeable to care when staff assisted her to the bathroom. Two staff assisted her onto the toilet with a mechanical lift. Review of R 8's care plan revealed she was not care planned to be in site when she was out of bed. During a telephone interview with the Director of Nursing (DON) on 4/1/21 at 10:52 AM, R 8's medical record and care plan were reviewed. The DON confirmed the nurse's notes, physician notes and fall summaries did not match the R 8 fall care plan. The DON confirmed R 8 was not on 1:1 care on 2/25/21 as indicated in the progress note on 2/25/21 at 12:37 PM and she was not on 1:1 care when she fell on [DATE]. The DON said the NP discontinued R 8's 1:1 care because she was moving to the dementia unit where she would have activities. The DON confirmed the care plan did not reflect times for activities or times supervision was required and R 8 had been on 1:1 care 24 hours a day prior to 2/23/21. The DON was asked if the staff had monitored how often R 8 had been attempting to self-transfer while she was on 1:1 and the DON said they did not monitor that behavior. The DON was asked how they assessed and monitored if the safety interventions were effective. The DON said they did not have any system in place to assess and monitor safety interventions. The DON was asked if they had specific criteria for initiating and discontinuing 1:1 care and the DON said they did not.

This citation pertains to intake number MI 716. Based on observation, interview and record review the facility failed to implement fall interventions to provide adequate supervision and assistance for 1 Resident (R 8 ) of 3 Residents reviewed for baseline care plans resulting in R 8 safety needs not being care planned and R 8 having multiple falls and one fall that resulted in a left [CONDITION(S)]. Findings include: Findings include: Review of R 8's face sheet dated 3/31/21 revealed she was an [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was listed as her own responsible party. Review of R 8's Baseline Care Plan revealed it was completed by a Registered Nurse on 1/21/21. There was no indication R 8's resident advocate was involved or any other facility staff. According to the assessment she had history of falls, she had fallen at home and fractured her arm, she required a walker to walk. She was assessed as cognitively intact and alert. Social Service worker signed the Baseline Care Plan on 1/26/21 and there was no indication R 8's resident advocate was involved in the care planning. There was no indication R 8 was assessed to need in any increased safety precautions. Review of R 8's Physician assessment dated [DATE] revealed she was admitted with a left humerus fracture secondary to fall. She had a urinary tract infection, [CONDITION(S)] (stroke), left [CONDITION(S)] (left sided weakness) and senile [CONDITION(S)] brain disease. She was having severe significant [CONDITION(S)] with lying down blood pressure of 139/62 and standing blood pressure of 80/61 with symptoms. R 8 was very impulsive and was continued on multiple supervisions for safety. R 8 had a tendency to walk and had increased risk of falling. According to the plan the [CONDITION(S)] was most likely due to poor oral intake. R 8's urinary tract infection was already treated and stable. R 8 was to be evaluated by physical therapy, occupational therapy and to stay on one-to-one supervision to prevent falls. R 8 was to be seen by neurology due to her recent stroke, have a dietary consult due to poor oral intake and a psych consultation related to her senile [CONDITION(S)] brain disease with impulsive behavior. Review of R 8's Nurse Practitioner visit note dated 1/25/21 revealed she continued to have positive orthostatic blood pressures and was receiving IV fluids. R 8 was confused and disoriented. Review of R 8's Nurse Practitioner visit note dated 1/26/21 revealed she was being seen due to a fall and positive [CONDITION(S)]. R 8 was agitated and having increased behaviors. R 8 had another fall within the last 48 hours, she had been self-transferring and continued to have dropping blood pressures. She was to remain on one-to-one supervision. The plan revealed she had a normal urinalysis. R 8 was to have a psychiatrist evaluation and remain on one-to-one supervision. Review of R 8's Nurse Practitioner visit note dated 2/23/21 revealed under assessment and plan: 5. Behaviors. The patient has been stable. Will trial one-on-one supervision and the patient will be encouraged to participate in activities and will continue to monitor. Did explain to the nurses to have the midnight staff keep a close eye on her and see how she will respond to that change. At this time, she appears to be doing much better, has improved. Her orthostatic blood pressures are better, and she has no dizziness. There was no indication she had improved in mental status, impulsivity, or self-transfers. The note indicated 1:1 was going to continue while R 8 started activities. Review of R 8's ADL (activity of daily living) care plan dated 1/20/21 revealed she had a left arm sling to be worn at all times, she required extensive assistance of 1-2 people for bed mobility and dressing. She was to transfer with a mechanical lift and be assisted by 2-3 people. She was to walk with therapy. There was no mention of one-on-one care as noted in the physician and nurse practitioner notes. Review of R 8's fall care plan dated 1/20/21 revealed she had a stroke 2 years ago that left her with left sided weakness. She had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She had fallen in the facility on 1/22/21, 1/23/21 and 2/25/21. Interventions included 1:1 care initiated on 3/5/21 and resolved on 3/18/21, and 1:1 was initiated again on 3/18/21 and resolved on 3/19/21, bed and chair alarm, initiated on 1/22/21, increased supervision for safety was initiated on 1/23/21. 1:1 was not care planned as the Physician assessment dated [DATE] indicated was in place or as indicated in the Nurse Practitioner notes dated 1/26/21 and 2/23/21. Review of R 8's progress note dated 1/20/21 at 5:39 PM revealed she was admitted from the hospital after a fall resulting in a left should fracture. R 8 had mild confusion. She had completed her antibiotics in the hospital for her urinary tract infection. She required assistance of 2 people for transfers. Review of R 8's COMS-Skilled Evaluation dated 1/20/21 at 10:09 PM, revealed R 8 was confused and disoriented. She was only oriented to person. R 8's confusion was a new onset. Review of R 8's COMS - Skilled Evaluation date 1/21/21 at 9:59 AM, revealed R 8 was confused and disoriented. Review of R 8's COMS - Skilled Evaluation date 1/22/21 at 2:19 AM, revealed R 8 was confused and disoriented, oriented to person only. Review of R 8's progress note dated 1/22/21 at 11:17 AM revealed the nurse contacted R 8's Nurse Practitioner (NP) about her orthostatic blood pressure readings and was waiting for a response. Review of R 8's progress note dated 1/22/21 at 11:58 AM revealed the NP ordered orthostatic blood pressures for 2 days. Review of R 8's progress note dated 1/22/21 at 2:50 PM (late entry) revealed R 8 had wandered into the hallway and fell backwards hitting her head on a wall. The fall was witnessed by staff. R 8 was not able to explain to staff where she was going or what she was doing. (There was no indication of any added supervision placed after this fall). R 8's care plan indicated a bed and chair alarm was placed on 1/22/21. Review of R 8's COMS - Skilled Evaluation dated 1/23/21 at 10:28 AM, revealed she was confused and disoriented. She did not wander at night and was sleeping at night. She was unaware of her safety needs. She was being checked frequently for safety and fall alarms were in place. Review of R 8's progress noted dated 1/23/21 at 2:49 PM revealed Resident was observed standing from her recliner in her room and slid to the floor. The RN that observed the fall was standing at her medication cart during the observation. Resident was not on 1:1 prior to the fall. There was no indication if fall alarm was on or sounded. 1:1 care was started after the fall. R 8's care plan did not indicate 1:1 care started on 1/23/21. Review of R 8's COMS - Skilled Evaluation dated 1/24/21 at 2:22 PM revealed she was confused and disoriented. She was unaware of safety needs. She was on frequent checks for safety and alarms were in place. Physician note indicated she was on 1:1 care but 1:1 care was not on the care plan. Review of R 8's COMS -Skilled Evaluations from 1/24/21 to 1/30/21 indicated R 8 remained mentally impaired and did not have safety awareness. There was no indication she was on 1:1 care as Physician and NP notes indicated. Review of R 8's COMS - Skilled Evaluation dated 1/31/21 at 9:37 AM, revealed her mental status was cognitively impaired some forgetfulness. R 8 was on 1:1 for safety and was able to walk with therapy in the hall with a hemi walker (one handed walker). Review of R 8's notes from 2/1/21 to 2/2/21 do not indicate she is on 1:1 care. Review of R 8's COMS - Skilled Evaluation dated 2/3/21 at 9:49 AM, revealed she was cognitively impaired and continued on 1:1 for safety. Review of R 8's progress notes from 2/4/21 to 2/5/21 at 12:37 PM revealed she remained cognitively impaired, had no change in behaviors and remained on 1:1 care for safety. Review of R 8's progress noted dated 2/26/21 at 5:41 AM revealed R 8's had a fall. The note did not indicate the date or time of the fall. The note revealed R 8 was found in her room flat on her back. R 8 said someone in the hall said something to her. There was no indication R 8 was on 1:1 care at the time of the fall. R 8 was sent to the emergency room at 11:30 PM. Review of R 8's progress noted dated 2/26/21 at 10:58 AM, revealed Clarification incident happened at 7:33 PM on 2/25/21 not 7:33 AM. Review of R 8's narrative noted dated 3/4/21 at 3:27 PM revealed the note was an investigative summary of the fall on 2/25/21. A Certified Nurse Aide (CNA) found R 8 on the floor in the doorway of her room. R 8's call light was on. Staff said they had taken R 8 to the bathroom at 5:45 PM. There was no indication why she was not on 1:1 as documented in the note 2/25/21 at 12:37 PM. There was no indication what her behaviors and activity level had been prior to the fall. There was no indication if she had continued to self-transfer or attempt to when she was on 1:1 care. Review of R 8's Admission Summary dated 3/5/21 at 4:55 PM revealed R 8 returned from the hospital at 4:50 PM and was placed on 1:1 care until she could be safe in her room alone. Review of R 8's notes on 3/6/21 to 3/13/21 did not indicate R 8 was on 1:1 care. Review of R 8's noted on 3/14/21 at 9:35 revealed she was on 1:1 care and was attempting to stand and self-transfer. Review of R 8's notes 3/15/21 to 3/16/21 did not indicate she is on 1:1 care. Note dated 3/17/21 at 6:20 PM indicated she was on 1:1 care and self-transferring. Review of R 8's notes 3/18/21 to 3/23/21 did not indicate she is on 1:1 care. Review of R 8's note dated 3/24/21 at 4:50 PM indicated she was on 1:1 care for safety. R 8 was observed on 3/30/21 at 2:10 PM sitting in her when near the nurse's station on the nursing unit. RN N said when R 8 is out of bed she is placed out by the nurse's station or in an area staff can monitor her for safety due to her fall history. R 8's was not oriented to place or time. R 8 had no memory of falls and said she had lived in this place her whole life and her son lived out back. She was able to carry on a pleasant conversation and was agreeable to care when staff assisted her to the bathroom. Two staff assisted her onto the toilet with a mechanical lift. Review of R 8's care plan revealed she was not care planned to be in site when she was out of bed. During a telephone interview with the Nursing Home Administrator (NHA) on 4/1/21 at 7:33 AM, the NHA confirmed R 8's advocate and care team was not involved in her baseline care plan. She said the facility had recently identified the need for improvement in baseline care planning and she had implemented a process improvement plan. The NHA was asked if R 8's physician had assessed her competency to make medical decisions and the NHA said R 8 had not been assessed. She said R 8 was seen by a Psychiatrist in February and after review of the Psychiatrist note said R 8 competency was not assessed by the Psychiatrist. The NHA confirmed R 8's mental status fluctuated from day today and they had ongoing safety concerns related to R 8's falls. During a telephone interview with the Director of Nursing (DON) on 4/1/21 at 10:42 AM, R 8's medical record and care plan were reviewed. The DON confirmed the nurse's notes, physician notes and fall summaries did not match the R 8 fall care plan. The DON confirmed R 8 was not on 1:1 care on 2/25/21 as indicated in the progress note on 2/25/21 at 12:37 PM and she was not on 1:1 care when she fell on [DATE]. The DON said the NP discontinued R 8's 1:1 care because she was moving to the dementia unit where she would have activities. The DON confirmed the care plan did not reflect times for activities or times supervision was required and R 8 had been on 1:1 care 24 hours a day prior to 2/23/21. The DON was asked if the staff had monitored how often R 8 had been attempting to self-transfer while she was on 1:1 and the DON said they did not monitor that behavior. The DON was asked how they assessed and monitored if the safety interventions were effective. The DON said they did not have any system in place to assess and monitor safety interventions. The DON was asked if they had specific criteria for initiating and discontinuing 1:1 care and the DON said they did not.

This citation pertains to intakes: MI 128, MI 614 and MI 481 Based on observation, interview and record review the facility failed to provide adequate supervision and assistance to prevent fall for 3 Residents (Resident #1, #2 #4) of 4 residents reviewed for falls, resulting in Resident #1 /#2 falling and sustaining fractures and Resident #4 falling an sustaining injuries to her face. Findings include: Resident #1 According to the face sheet dated 12/10/19, Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Resident #1 was not his own responsible party. According to the Minimum Data Set (MDS), nursing assessment tool, dated 9/24/19, Resident #1 had Brief Interview of Mental Status (BIMS) score of 3/15 (severe cognitive impairment). He required extensive assistance of 1 person for bed mobility, toilet use, and hygiene. He required limited assistance of 1 person for transfers and supervision assistance of 1 for walking. According to the ADL (activity of daily living) care plan dated initiated 7/31/19 and revision on 11/20/19, Resident #1 was to be encouraged to use a call light (People with BIMS score of 3, severe cognitive impairment generally lacks the ability to remember). No indication of assistance required for walking or transfers was noted. According to the mobility deficits care plan dated initiated 7/31/19 and revision on 11/20/19, Resident #1 had dementia with behavioral disturbance and required extensive assistance with bed mobility, floor staff to ambulate with wheel chair to and from dining room at meals and to sit in common areas, transfers with extensive assistance with a SARA lift, he was only able (no information on wake/sleep or frequency of toilet needs) to walk with therapy. According to the fall care plan dated 7/31/19 and revision on 10/2/19, Resident #1's needs were to be anticipated as of 10/2/19, auto lock brakes 10/2/19, he was to be encouraged to walk in main areas of activity room. If able guide away from close areas of furniture, upon readmission from hospital bowel and bladder evaluation, bladder scans initiated 11/13/19. (no information on wake/sleep cycle or when to anticipate needs). Review of Residents #1's fall for the last 6 months revealed he had 3 falls. The fall on 11/8/19 at 15:41 (3:41 PM) was witness. Resident #1 was in the activity room and the nurse heard a crash and found Resident #1 on the floor in front of a recliner. Life enrichment staff were next to Resident #1. No details or witness statements were located for this fall. No analysis of the fall or new interventions to prevent the fall were located. According to the incident report dated 11/13/19 at 3:30 AM, Resident #1 had an un-witnessed fall in his bathroom. Resident was found with a wet brief around his ankles, no witness statements or analysis of the fall were found and no intervention to prevent falls was located. Resident #1 was sent to the emergency room for treatment. According to the facility 5-day report, Resident #1 had a fall on 11/13/19 that resulted in increased pain, noted with fracture of right femoral neck. 8 staff were named as Involved/Witness to the incident. No witness statements were found. The summary of the investigation indicated Resident #1 was assisted to the bathroom at 1:30 AM (no indication which staff took him or his condition at that time). It was noted that someone rounded on Resident #1 hall 10 minutes to finding him on the floor (he was not on the floor at that time). There was no indication were Resident #1 was at that time or if he was awake or asleep. There was no indication of his normal toilet needs at the time of the fall. According to the incident report dated 11/24/19 at 15:37 (3:37 PM), Resident #1 was found on the floor in the activity room. There was no indication of staff, residents or visitors present at the time of the fall. There was no witness statement. No analysis of the fall or interventions placed to prevent falls. According to the x-ray report dated 11/13/19 at 12:38 PM, Resident #1 had a nonspecific fracture through the right femoral neck. According to a post fall-72-hour monitoring report dated 11/24/19 at 22:03, 22:08, 20:46, 18:44. Resident #1's vital signs were within normal limits. There were no details or information located in the progress notes about the fall on 11/24/19. According to a progress note dated 11/13/19 at 5:39 AM, Resident #1 Durable Power of Attorney (DPOA) was notified of an incident. There was no indication of what the incident was or any details. Just that the DPOA agreed to x-rays. According to the post fall 72-hour monitoring report dated 11/13/19 at 3:30 AM. Resident #1 had a swollen right lower leg and it was painful when pressure was applied. No details of the fall were documented. Review of Resident #1's Kardex dated 12/10/19 gave no indication as to how he should be supervised or how staff were to anticipate his needs. Under safety it did not list he was a fall risk. There was no indication of the findings of the bowel and bladder evaluation that was to be done on hospital readmission 11/20/19. Under bladder/bowel was noted, Toilet at 1:45, 0300, 0500, 0630, 0900, 1300, 1500, 1800, 2000, 2100, 2300 and upon request for bladder incontinence. (There was no indication if they should wake him up or if he used a urinal or the toilet). During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on 12/10/19 at 2:10 PM, Resident #1's falls for the last 6 months including the facility reported fall 11/13/19 that resulted in a [MEDICAL CONDITION] were reviewed. They did not have witness statements, analysis of the falls or documentation of implementation of new interventions being placed after falls. The Surveyor was unable to determine Resident #1's condition just prior to the fall that resulted in fracture on 11/13/19 as there were no witness statement or questions asked of staff at the time of fall or prior to the fall located. The DON was not sure if Resident #1 had a history of [REDACTED].#1's wake/sleep cycle was not known prior to the fall. The facility did not have a plan in place to determine when Resident #1 needed supervision. The DON and NHA said they had been working on improving there fall investigations and implemented a new process on 11/27/19. Resident #2 According to the face sheet dated 12/10/19, Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Resident #2 was not her own responsible party. According to the Minimum Data Set (MDS), nursing assessment tool, dated 9/4/19, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 7/15 (moderate cognitive impairment). Resident #2 required supervision and set up with bed mobility, transfers, walking in her room and for toilet use. She required limited assistance of 1 person to walk on the unit and for personal hygiene. She required extensive assistance of 1 person for dressing. Review of Resident #2's Mobility care plan dated 8/29/19 and revision on 10/28/19 revealed it did not match the MDS assessment dated [DATE] and these interventions were not resolved until 10/28/19 after Resident #2 fell and fractured her hip. Dressing indicated she was limited assistance/one person, locomotion on unit - Independent/no set up or physical help wheelchair assist and walking in the corridor (unit) Independent/set-up help. Review of Resident #2's fall for the last 6 months revealed she had 3 falls. The incident report for the fall on 9/29/19 at 20:40 (8:40) PM, Resident had previously been walking in hallways without walker so helped to a chair in common area, upon walking into the common area the nurse observed resident on floor beside chair. (Un-witnessed) No supervision at the time of the fall in a common area. According to notes Resident #2 was discharged from therapy on 9/27/19 and was determined to be independent with transfers and ambulation. Resident #2 typically walked throughout the unit during the day. There was no witness statement, no indication how Resident #2 had been doing that day prior to the fall and no intervention to prevent falls were located. Review of the incident report dated 10/21/19 at 17:19 (5:19 PM) for Resident #2, Staff was in room [ROOM NUMBER] and heard the door of room [ROOM NUMBER] open. She quickly ran next door to see this resident stumble and land o her buttock. She didn't appear to have any injury and denied. Resident already had gotten herself up by the time nurse went to assess her. She denies any pain. ROM WNL for resident. No injuries noted. Residents description varied wildly. Not able to give exact description. Under Other Info, Resident entered co residents' room and was unfamiliar with the setup of the room and stumbled back on her buttock. She is legally blind. (no indication if Resident was using her walker). Under notes, 'name of resident typically walks the unit throughout the day. name of resident received therapy services and was discharged on [DATE] as independent with transfers and ambulation. Staff observed the incident. Resident is independent with ambulation at this time and had parked her walker in the hallway and then attempted to open the door. Resident had proper footwear on. Resident remained independent with ambulation following this incident as she was witnessed walking backward and fell . This is an isolated occurrence. Resident got herself up from the floor and was observed returning to her usual state and balance. (This was the second fall were Resident #2 was noted to not be using her walker. Her MDS evaluation determined she needed supervision with transfer and ambulation, the therapy evaluation 9/27/19 made her independent. Therapy evaluations were not repeated after these falls). No witness statements were located, and no analysis of the fall or interventions were located. Review of the incident report dated 10/22/19 at 20:20 (8:20) PM for Resident #2, Un-witnessed. Resident observed lying on her back on the floor in front of her recliner, Resident assessed with [REDACTED]. Left hip with external rotation and visible shortening. Resident with c/o pain, unable to rate pain on 1 to 10 scale. Resident guarding her left leg and hip, has facial grimacing, and verbal statements of pain. Vs 103/57, 77, 17, 95. Resident stated she fell with c/o (complaint of) left hip pain. Resident alert and oriented to person and confusion. No witness statement or information of Resident #2's condition, care provided prior to the fall was located. No analysis of the fall was located. Review of the facility report to the State Agency dated 10/23/19 at 1:05 AM, Incident Summary: Resident had a change in elevation which resulted in a [MEDICAL CONDITION] femur. Resident care plan was being followed as resident is independent with transfers and ambulation. Resident is currently at the hospital. 8 staff were listed as Involved/Witness with knowledge of Incident. No statements were located from any of the staff listed in the report. The conclusion to the report, Resident, was noted to be in a sitting position on her floor in front of her bed and recliner. Resident stated she was trying to help her daughter who was calling out for help. Residents roommate had called out. Based on investigation and interviews, adequate supervision was provided with last observation 20 minutes prior to the incident, resident was noted in bed resting. Residents plan of care is independent with transfer and mobility. Upon interview, resident expressed she was trying to assist her daughter. The appropriate care and services were provided, and no evidence of an altercation exits as a factor related to this fall. It has been determined that resident independently transferred from her bed to assist her roommate that she perceived as her daughter secondary to her Dementia. Residents plan of care has been reviewed & updated upon return to the facility. (The Surveyor could not verify this information as there were no witness statement or documented information from staff describing Resident #2 normal condition and what her condition was prior to the fall. The MDS assessment of needs did not match the therapy assessment for mobility. Resident had 2 falls prior this fall and there was no assessment documented that verified Resident #2 should be independent with walking or transfers). Resident #2 was sent to the emergency room and admitted to the hospital for surgery due to a [MEDICAL CONDITION]. Resident #2 was observed on 11/11/19 at 8:48 AM being assisted by two Certified Nurse Aides (CNA), they used a mechanical device to get Resident #2 on and off the toilet. When care was completed the Surveyor asked CNA H if she had worked with Resident #2 prior to the fall when she fractured her hip and what was she like. CNA H said she would frequently get up and walk without her walker, she was very unsteady when she did not use her walker. We had to do 1:1 with her many times because she was not safe. The Surveyor asked where the 1:1 care was documented, and CNA H was not sure. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on 12/10/19 at 2:10 PM, Resident #1's falls for the last 6 months including the facility reported fall 10/22/19 that resulted in a [MEDICAL CONDITION] were reviewed. The DON verified that therapy did not assess Resident #2's transfer or ambulation status after the last two falls. They were not sure why the MDS assessment did not match or what Resident assessment tools therapy used to determine Resident #2 was independent. They had Physical Therapist (PT) J come to the conference room to discuss the therapy assessment. PT J explained they use the Tinetti Balance Assessment Tool and Resident #2 did score in the risk of fall area. PT J was asked why she would document Resident #2 was independent with ambulation when she scored at risk. PT J said she watches to see if they lock their brakes and use their walker. If they lock, there brakes and uses their walker she makes them independent. The Surveyor asked for a copy of the Tinetti and upon exit a copy was not provided. The DON and NHA said they did not know Resident #2 was ever on 1:1 and they would check the records. Upon exit no 1:1 documentation for Resident #2 was provided. The DON and NHA said they had been working on improving there fall investigations and implemented a new process on 11/27/19. Resident #4 According to the face sheet dated 12/12/19, Resident #4 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Resident #4 was her own responsible party. According to the Minimum Data Set (MDS), nursing assessment tool, dated 10/22/19 for Resident #4, she scored a one (modified independence) for cognitive skills for daily living. This indicated she has some difficulty in new situations. She required total assistance of 2 people for transfers, required extensive assistance of 2 people for bed mobility and dressing, could not walk, and was totally dependent for transport in a wheelchair. She was incontinent of bowel and bladder. Section P entered 0for all restraints. (indicating no restraints were used). According to the incident report dated 10/21/19 at 02:10 AM, Resident #4 had an un-witnessed fall in her room at 19:10. Resident #4 was sitting straight in her chair and reached out to get a blanket and fell out of the chair. Resident #4's care plan was updated to recline wheelchair when not at meals related to leaning. Therapy evaled (sic) to evaluate appropriateness of tilt and space chair. Broda chair was indicated and ordered. Seat belt to be on resident when sitting up at the table for meals and when in the tilt in space wheelchair for transporting to outside appointments. Resident has worked with therapy and demonstrated the ability to remove the seat belt. No witness statements were located, and no analysis of the fall was located. According to the care plan for mobility/falls/restraints, dated 7/22/19 and revision on 11/4/19 for Resident #4, Interventions included: Ensure WC (wheelchair) is reclined back so name of resident is not leaning forward when in tilt and space. Monitor name of resident every 30 minute while in chair with self-releasing seat belt in Broda wheelchair when upright at meals. Soft Velcro seat belt to aid with positioning while in tilt in space w/c initiated 10/21/19. On 12/11/19 at 9:20 AM, Resident #4 was observed sitting in the unit dining room eating independently. Resident #4 had a blanked over her. She was sitting in a geriatric style chair (the chair reclined and tilted in space). A belt could be seen from the side view (blue padded area over Resident #4's stomach/diaphragm area and white belts on the back portion were tied to the frame of the chair). No staff were observed in the dining room at this time. Resident #4 did not know what the device was called or anything about it. Resident #4 did not indicate she could remove it. During an interview with RN K on 12/10/19 at 3:35 PM, RN K said she was working when Resident #4 fell out of her wheelchair. RN K said she was in the room next to Resident #4 and heard Resident #4 call for help. Resident #4 was face down and her glasses were broken and had facial injuries. Resident #4 w/c back was straight. RN K said the CNA at the time did not know Resident #4 could not be left upright in her wheelchair after meals. She was only to be upright at meals. (care plan was not update until after the fall. Staff familiar with the resident knew she did was not safe when the wheelchair was up right. (This information was not on the incident report or acknowledged in the medical record). Resident #4 was sent to the hospital for evaluation of her head and facial injuries. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on 12/10/19 at 2:10 PM, Resident #4 fall on 10/21/19 was reviewed. They were not able to locate witness statements or an analysis of the fall. The DON and NHA said they had been working on improving there fall investigations and implemented a new process on 11/27/19.

Based on observation, interview, and record review, the facility failed to provide physician supervision of care for 3 (Resident #91, Resident #121, and Resident #169), of three reviewed for physician services, resulting in unsupervised care by an attending physician for medical care, pressure ulcers, and significant weight loss. Findings include: Resident #91 Review of a Face Sheet for Resident #91 revealed an [AGE] year-old female admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] for Resident #91 revealed she had Brief Interview for Mental Status (BIMS) that indicated she was cognitively intact and was totally dependent on two staff for transfers, no pressure ulcers, and weighed 112 pounds. During an observation and an interview on [DATE] at 1:36 p.m., Resident #91 was asleep in bed laying on her back with her arms and legs elevated on pillows. Her husband was sitting in the chair in her room and reported that his wife (Resident #91) had a very sore hind end and received ointment. He said he was frustrated with her care and felt the facility was not doing much for her. He reported she was not eating well and felt the facility was not doing much to assist with her meals. In an interview on [DATE] at 1:23 p.m., the Registered Dietician (RD) CC reported Resident #91 was recently admitted from the Assisted Living facility and had always had a decreased appetite. Resident #91 was getting weighed weekly and was getting fortified foods. RD CC reported the resident was getting a supplemental Med Pass (dietary supplement) and had increased her Mighty Shakes (dietary supplement) to three times a day because the resident preferred liquids. RD CC reported Resident #91 was started on fortified foods but did not eat much solid food. RD CC was aware that upon admission on [DATE], Resident #91 weighed 112.2 pounds on [DATE], and on [DATE] she weighed 103.4 pounds which indicated a 7.84% weight loss. RD CC reported that she would communicate with physicians about a residents' weight loss by using an electronic tool and the last time it triggered a weight gain. RD CC reported that the physician was not aware of the weight loss for Resident #91 at the time of this interview because the tool used did not trigger for a weight loss yet. RD CC reported she did not ask the physician for any medication that would help stimulate her appetite. During an observation and an interview on [DATE] at 3:21 p.m., Resident #91 was in bed laying on her back when CNA AAA and CNA BBB started to provide incontinence care for the resident. When the soiled brief was removed, Resident #91 had an area of redness on her coccyx, and a pencil eraser sized wound that was past the second layer of skin that was beefy red in color, and the edges were approximated no drainage noted. The CNA put a cream over the residents' buttocks and the open wound. Review of Resident #91's weekly weights revealed: XXX[DATE]-112.20 pounds, [DATE]-110.20 pounds, [DATE]- 110.0 pounds, [DATE]-109.4 pounds, [DATE]-107.4 pounds, [DATE]-106.8 pounds, [DATE]- 104.6 pounds, and [DATE]-103.40 pounds. In an interview and record review on [DATE] at 4:13 p.m., RD CC reported she had completed a Physician Told communication form this day regarding Resident #91's weight loss. RD CC then reported the residents' goal weight was 110 pounds plus or minus 3 pounds and had a history of [REDACTED]. RD CC reported she would usually notify a physician if the weight change were>5% in 1 month, >7.5% in 3 months, or > 10% in 6 months. RD CC reported that on [DATE] the Mighty Shakes were changed to three times a day and put it on the meal ticket right away even though the physician signed for it on [DATE] and put it on the Care Plan right away. In an Interview on [DATE] at 4:30 p.m., a Timeline of Resident #91's skin assessment was requested from the Director of Nursing (DON) who reported there was not a timeline for Resident #91 because there were no wounds. This surveyor suggested the facility may want to assess the residents' skin. Review of a Timeline received on [DATE] for Resident #91 revealed: Resident admitted on [DATE] skin assessment showed no areas to buttocks. Skin check on [DATE] buttocks was noted to have slight excoriation. 2 nurses completed skin check on [DATE] and noted 2 scar tissue areas. (1) Noted to be red and blanchable on the right buttock. And (1) noted to the coccyx to be red and blanchable. Coccyx does have to small areas of excoriation noted. Cleansing with cares and applying caldazine. (sic) Review of a Skin assessment dated [DATE] for Resident #91 revealed: .Document Location of Wound and other treatment provided: right arm into hand remains an old yellow bruise color. Buttocks is slightly escoriated (sic) Review of a Non-Pressure Ulcer Skin Condition assessment for Resident #91 dated [DATE] revealed: .Initial Assessment: Date of Onset: [DATE], Location: Coccyx, Description: slight excoriation, Treatment: Bamer cream Weekly Evaluation: [DATE], Progress/treatment: #1 Top most area 0.2 cm (centimeters) x 0.2 cm superficial open area. #2, 0.1 cm x 0.1 cm superficial open area. Area pink and blanchable. cleanse with cares. Apply Caldazine. (sic) Review of a Physician order [REDACTED].# 91 revealed: Caldazinc to be applied to coccyx area with cares . During an observation and an interview on [DATE] at 10:13 a.m., Unit Manager/Registered Nurse (UM) HH reported Resident #91 had excoriation on her buttocks and described excoriation as not open but could be an opened superficial layer if it was blanchable. UM HH reported she did not diagnose wounds and did not have an answer as to why the physician did not diagnose Resident #91's wound. UM HH and this surveyor went to Resident #91's room together to look at the wound. The CNA's were in the room starting morning care and removed the residents brief. The wound looked the same as this surveyor observed the day before. UM HH reported it had gotten worse since yesterday and this surveyor told her it looked the same yesterday. UM HH insisted it was worse this day. UM HH reported she was going to notify the physician. Review of an Interim Orders document dated [DATE] for Resident #91 revealed: Based on exam of wound Kennedy Ulcer- r/t (related to) rapid onset worsening .Cleanse, cover dressing- comfort care . (sic) The State Operations Manual states: The Kennedy Terminal Ulcer (KTU) The facility is responsible for accurately assessing and classifying an ulcer as a KTU or other type of PU/PI and demonstrate that appropriate preventative measures were in place to prevent non-KTU pressure ulcers. KTUs have certain characteristics which differentiate them from pressure ulcers such as the following: o KTUs appear suddenly and within hours; o Usually appear on the sacrum and coccyx but can appear on the heels, posterior calf muscles, arms and elbows; o Edges are usually irregular and are red, yellow, and black as the ulcer progresses, often described as pear, butterfly or horseshoe shaped; and o Often appear as an abrasion, blister, or darkened area and may develop rapidly to a Stage 2, Stage 3, or Stage 4 injury. The last two physician progress notes [REDACTED].#91 and received as follows: Physician Note dated [DATE] for Resident #91 revealed: . Reason for visit: . very frail lady who has a past medical history of [REDACTED]. Physician Note dated [DATE] for Resident #91 revealed: . Reason for visit: The patient is seen today at the request of nursing staff. She is noted to have crackles in her bilateral lungs . Resident #121 Review of a Face Sheet revealed Resident #121 was a [AGE] year-old male was originally admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] for Resident #121 revealed a Brief Interview for Mental Status (BIMS) indicated he was severely cognitively impaired and required extensive assistance of 1 staff for transfers, totally dependent on two staff for toileting and no pressure ulcers. During an observation and an interview on [DATE] at 10:21 a.m., Resident #121 was in bed, and 2 Certified Nursing Assistants (CNA) were in the room and started his morning care. The staff removed the resident's brief, and his coccyx had some thick white cream that covered an area that was dark purple/black appearance (like a Kennedy Ulcer) that was unable to size due to the cream, and there was a half dollar sized wound that had active serosanguinous drainage with no dressing covering the wound. The staff did not remove the old cream during his peri care, and did not apply new cream before applying a new brief on the resident. CNA I reported not knowing what kind of wound Resident #121 had and did not remove the old cream because the nurse was in the room earlier and put it on the resident and it looked fresh. CNA I also reported that Resident #121 was on hospice and did not recall the hospice staff coming in much to see the resident. The CNA's positioned the resident on his left side with pillows on his right side and propped his arms and legs with pillows. Review of a document titled Non-Pressure Ulcer Skin Conditions for Resident #121 revealed: Date of Onset: [DATE] (Admission), Location . Right buttock, Description: 1 cm (centimeter) X 3 cm area of excoriation. Treatment: Caldazine with cares. Physician Notified? Yes. Date and time: [DATE] . Weekly Evaluation: Date: [DATE], Progress/treatment: 1X2 cm excoriation, [MEDICATION NAME] with cares, [MEDICATION NAME] as needed. Date: [DATE]. Progress/treatment: 2 cm X 2 cm area of excoriation, Caldazine cream applied with cares. [DATE], Progress/treatment: 2 cm X 2 cm excorital area, no drainage noted, applied Caldazine covered with [MEDICATION NAME]. [DATE], 2 cm X 2 cm excoriated area noted. No drainage noted. Covered with [MEDICATION NAME]. Will cont. to monitor . [DATE], Progress/treatment 2 cm X 1 cm excoriated area noted. No drainage noted. Covered with [MEDICATION NAME]. Will cont. [DATE], Progress/treatment: 1.9 X 0.7 cm Excoriated . drain, cover with [MEDICATION NAME]. [DATE], Progress/treatment resident expired . (sic) Review of a handwritten Progress Note dated [DATE] for Resident #121 revealed: 1 cm X 3 cm excoriation to R (right) buttock Review of a physician progress notes [REDACTED].#121 revealed: . Physical exam . Extremities with non-healing ulcer on the dorsum of the right leg. Impression/Plan: 1. Right leg ischemic ulcer . 2. [MEDICAL CONDITION] . 3. Hypertensive [MEDICAL CONDITION] . No wound assessment or [DIAGNOSES REDACTED]. Review of Physician order [REDACTED].#121 revealed: Admit to hospice . Review of Resident #121's Medication Profile active orders prior to [DATE] revealed: Start Date: [DATE], [MEDICATION NAME] 0.44%-20.6% topical ointment, Notes: Apply thin layer coccyx. Do not scrub off excess. Frequency: By shift. Review of a Nurse Practitioner Progress Note dated [DATE] for Resident #121 revealed: Reason for visit . Right shin intact scab, right buttock excoriation. Right foot has an open area .Physical examination .Skin is warm, pale, and dry. Assessment and Plan: 1. Dementia with behaviors . 2. [MEDICAL CONDITION] ([MEDICAL CONDITIONS]) . 3. Chronic pain management 4. Constipation . 5. Will continue current plan of care . No wound assessment or [DIAGNOSES REDACTED]. Review of Treatment Administration Records (TAR) for Resident #121 revealed: (MONTH) 2019: .Orders: Two Times Weekly Starting [DATE], Notes: Cleanse area just above the coccyx with NS (normal saline), pat dry, apply skin prep to surrounding and apply a [MEDICATION NAME] weekly and PRN (as needed) if soiled (sic) Resident #169 Review of a Face Sheet for Resident #169 revealed an [AGE] year old female originally admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #169 had a Brief Interview for Mental Status (BIMS) that indicated she was cognitively intact and was totally dependent on two staff for transfers, and a stage 4 pressure ulcer. In an interview on [DATE] at 1:41 p.m., Licensed Practical Nurse (LPN) SS reported Resident #169 was actively dying and did not want anyone to turn her right now. LPN SS was the day shift nurse and did not know if her dressing was changed yet this day but was going to ask. LPN SS reported it was to be done twice a day. During an observation and an interview on [DATE] at 2:56 p.m., Certified Nursing Assistant (CNA) I and CNA YY were in Resident #169's room for incontinence care. Resident #169 still had her lunch tray in front of her and barely ate any food. CNA I reported she was not feeling well this day and had some nausea and vomiting. Resident #169's brief was soaked with urine and had a large amount of light brown liquid stool. The pressure ulcer on her coccyx had no dressing in place and was not in brief. The runny stool seeped into the wound. Both CNA's cleaned the resident and wiped over the pressure ulcer that appeared to be small, about the size of a pencil width, and deep. Resident #169 moaned in pain when the pressure ulcer was touched. A new brief was put on, and the nurse did not place a new dressing on the resident. In an interview on [DATE] at 10:56 a.m., Registered Nurse/Unit Manager HH reported Resident #169 used to go to the wound clinic and stopped a couple of years ago. They had tried different dressings, but they would just fall off. The facility had to get prior authorization for the Renegrex Gel because it was expensive. The facility was just to rinse the wound and apply the Renegrex to the pressure ulcer and not use a cover because it would just fall off because of her loose stools. The family did not want the resident to have debridement done anymore to the because it was painful and did not feel it was necessary to put her through that treatment. RN HH reported the family was very involved and even though the Resident was her own person, the resident wanted to do whatever the family recommended. Dr. OO was following the resident because she was a family friend of theirs. The family only wanted to do what this physician recommended for Resident #169. Requested Physician Notes for Resident #169 for the last two visits and received the following: Review of a Physician note revealed at the time of this survey; Resident #169 was last seen on [DATE] by a Physician. The Physician Note revealed: [DATE] (Resident #169) - NCC? Physician visit- Reason for visit: Ms. (Resident #169) is an [AGE] year-old very pleasant lady who has a past medical history of [REDACTED]. She is in her usual state of health. She has been evaluated for follow-up of chronic medical problems. At the time of examination, the patient denies any shortness of breath, chest pain, palpitations, lightheadedness or dizziness. Current meds: Reviewed . Impression: . 4. Decubitus ulcer Stage 2, continue the patient on local skin care and follow-up with the dietitian to maintain the nutrition and continue the patient on local skin care . (sic) Review of a Nurse Practitioner Progress note dated [DATE] for Resident #169 revealed: [DATE] (Resident #169) - NCC?? Physician Visi??? . Reason for visit: (Resident #169) is seen today on request of the nursing staff. She is a patient of (Dr. OO) who is unavailable to see the patient today. Nursing staff report concern over the patient recently reporting abdominal pain. This started earlier this morning. The patient has a history of constipation and has had a GI (gastrointestinal) bleed in the past. The patient denies associated nausea or vomiting. Her stools are soft, and because of her debility and incontinence, the patient has frequent output of stooling with repositioning. This happened during the counter today. Stool is light yellow to brown in color, and there is no visualized mucus or dark tarry substance. The patient is also known to have a decubitus ulcer to her coccyx. The patient is afebrile, and nursing staff deny any changes in during characteristics . Physical exam . The patient has an area suspicious for a hernia near the left upper quadrant .The patient has pain with deep palpation of the right and left upper quadrant . Impression/Plan: 1. Abdominal pain. Recommend a flat plate of the abdomen, and we will also obtain a (labs). 2. Decubitus ulcer of the coccyx. Continue with current wound care as completed by staff at the nursing facility. (sic) Review of a Nursing Progress Note dated [DATE] for Resident #169 revealed: Per (FNP NN), res (resident) is to have an abdominal flat plate d/t abd (abdominal) pain. (sic) Review of a Nursing Progress Note dated [DATE] for Resident #169 revealed: Received results of abd flat plate. Suggestive of mild adynamic ileus. (On call doctor for Dr. OO notified. Res. continues to have c/o (complaints of) abd pain and hard lump to abd. N.O. (new orders) to send to ER (emergency room ) for eval . (sic) Review of a Nursing Progress Note dated [DATE] for Resident #169 revealed: . N.O. for [MEDICATION NAME] (antibiotic) . for UTI (urinary tract infection) . Review of a Nursing Progress Note dated [DATE] for Resident #169 revealed: N.O. per pharmacy recommendation. resident receives two routine opioids [MEDICATION NAME] and Tylenol, re-evaluate use of these therapies perhaps d/cing (discontinuing) the [MEDICATION NAME]. Per (Dr. OO ) I decline this recommendation d/t (due to) it has been tried before, patients' pain is not controlled on just one. (sic) Review of a Pharmacy Consultation Report dated [DATE] for Resident #169 revealed: . Comment: (Resident #169) has received Regranex (gel that medical staff uses for the treatment of [REDACTED].) since [DATE]. Recommendation: Please re-evaluate the continued need for Regranex, perhaps discontinuing its use . Physicians response: I accept the recommendation(s) above, please implement as written was checked with a check mark, then below a box marked with an X next to I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below. Rationale: per Dr. OO wound is stable continue medication was handwritten on the line below and signed by the physician on [DATE]. Review of an undated and handwritten note by Dr. OO given to this surveyor on [DATE] revealed: (Resident #169), Pt (patient) has a non-healing wound sacral/coccyx area. She has had a number of surgical consultations in the past at which time surgeon felt that nothing else would be offered. She also saw the wound clinic and treatment options were exhausted. At present although wound is not completely healed, it is stable on current therapy/treatment and has not worsened. Have discussed with family and they are in agreement with treatment plan . Review of a Nursing Progress Note dated [DATE] for Resident #169 revealed: Resident has an unstageable ulcer to her coccyx that has been present for years. Recent measurements suggested that the wound is stable at this time. Current treatment is cleanse with NS (normal saline) and pat dry. Apply regranex to the wound bed in AM (morning) and cover with ABD (abdominal pad) and cleanse with NS and pat dry and apply ABD pad. Current treatment is in place due to family request, and they will not allow the physician to change the orders, despite education from the wound nurse, nurse manager, and physician. Resident currently has an alternating air mattress in place, a Roho cushion to her wheelchair when she is up, an every 2 hour turning schedule as the resident allows the staff to turn her to her side d/t (due to) her being uncomfortable . Physician and family are aware of wound and current treatments at this time. No recommendations at this time. (sic) Review of a Resident Medication Profile order form for Resident #169 revealed: . Medication/Dose: Regranex 0.1 % topical gel . Notes: Cleanse sacral wound with dial soap and rinse with NS. Pat dry. Apply regranex to wound and cover with [MEDICATION NAME] (absorbent foam dressing with adhesive borders). Apply at 08:00 and then at 20:00 (8:00 p.m.) remove dressing and rinse with NS, pat dry and apply [MEDICATION NAME] . Start Date: [DATE], Status: Active . Review of a Nursing Progress Note dated [DATE] at 2:33 p.m. for Resident #169 revealed: Resident having stomach pain and emesis X3. Ginger ale given and pain medicine given and effective . Review of a Nursing Progress Note dated [DATE] at 11:42 a.m. for Resident #169 revealed: res c/o nausea and upset stomach . Review of a Nursing Progress Note dated [DATE] at 2:33 p.m. for Resident #169 revealed: . c/o of upset stomach . Review of a Dietician Progress Note dated [DATE] at 2:44 p.m. for Resident #169 revealed: . Resident typically has good fluid acceptance and was enjoying Ginger Ale r/t (related to) nausea . Review of a Nursing Progress Note dated [DATE] at 10:17 a.m. for Resident #169 revealed: . resident has not eaten breakfast today or lunch or dinner yesterday . resident appears gray in color - called and spoke with residents daughter - she stated Mom was sick all weekend . nurse manager aware of resident situation and states that resident has blotching to bilateral legs- . Dr. OO office was informed of residents situation and will call back should doctor need us to draw labs or change medication . After review of all documentation, no indication of a physician assessing the resident regarding wound care, medication review, post emergency room visit, and complaints of abdominal pain and nausea and vomiting.

Based on observation, interview and record review, the facility failed to assess, monitor, and treat pressure ulcers in 3 (Resident #91, Resident #121, Resident #169) reviewed for pressure ulcers, resulting in the development and worsening of pressure ulcers. Findings include: Resident #91 Review of a Face Sheet for Resident #91 revealed an [AGE] year-old female admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] for Resident #91 revealed she had Brief Interview for Mental Status (BIMS) that indicated she was cognitively intact and was totally dependent on two staff for transfers, no pressure ulcers, and weighed 112 pounds. During an observation and an interview on [DATE] at 1:36 p.m., Resident #91 was asleep in bed laying on her back with her arms and legs elevated on pillows. Her husband was sitting in the chair in her room and reported that his wife (Resident #91) had a very sore hind end and received ointment. He reported he was frustrated with her care and felt the facility was not doing much for her. He also said she was not eating well and felt the facility was not doing much to assist with her meals. During an observation on [DATE] at 4:,[DATE] at 4:24 p.m., Resident #91 was observed laying on her back sleeping, and without the pillows used to relieve pressure from her arms and legs. During an observation on [DATE] at 8:17 a.m., Resident #91 was in bed laying on her back with pillows under both of her arms. She had a cup of pineapple on her bedside table with a Mighty Shake. Both were untouched. During an observation and an interview on [DATE] at 1:53 p.m., Resident #91 was in bed laying on her back, and her husband was sitting in the chair in her room. One of the Certified Nursing Assistants reported they had changed Resident #91's brief around ,[DATE]:00 p.m. and she was due again soon. The CNA was to get this surveyor for the next brief change. During an observation and an interview on [DATE] at 3:21 p.m., Resident #91 was in bed laying on her back when CNA AAA and CNA BBB provided incontinence care for the resident. When staff removed the soiled brief, Resident #91 had an area of redness on her coccyx, and a pencil eraser sized wound that was past the second layer of skin that was beefy red in color, and the edges were approximated no drainage noted. The CNA put a cream over the resident's buttocks and the open wound. In an Interview on [DATE] at 4:30 p.m., a Timeline of Resident #91's skin assessment was requested from the Director of Nursing (DON) who reported Resident #91 did not have a timeline because there were not any wounds. This surveyor suggested the facility may want to assess the resident's skin. Review of a Timeline received on [DATE] for Resident #91 revealed: Resident admitted on [DATE] skin assessment showed no areas to buttocks. Skin check on [DATE] buttocks was noted to have slight excoriation. 2 nurses completed skin check on [DATE] and noted 2 scar tissue areas. (1) Noted to be red and blanchable on the right buttock. And (1) noted to the coccyx to be red and blanchable. Coccyx does have to small areas of excoriation noted. Cleansing with cares and applying caldazine. (sic) Review of Nursing Progress Notes dated [DATE] to [DATE] revealed no documentation regarding wound on buttocks. Review of a Skin assessment dated [DATE] for Resident #91 revealed: .Document Location of Wound and other treatment provided: right arm into hand remains a old yellow bruise color. Buttocks is slightly escoriated . (sic) Review of a Non-Pressure Ulcer Skin Condition assessment for Resident #91 date [DATE] revealed: .Initial Assessment: Date of Onset: [DATE], Location: Coccyx, Description: slight excoriation, Treatment: Bamer cream .Weekly Evaluation: [DATE], Progress/treatment: #1 Top most area 0.2 cm (centimeters) x 0.2 cm superficial open area. #2, 0.1 cm x 0.1 cm superficial open area. Area pink and blanchable. cleanse with cares. Apply Caldazine. (sic) Review of a Physician order [REDACTED].# 91 revealed: Caldazinc to be applied to coccyx area with cares . Review of the Resident Care Guide for Resident #91 revealed: .Skin and Positioning: Turn Every 2 hours Prop with Pillows .Transfer: Extensive Assist x 1 .(sic) Review of a Care Plan for Resident #91 revealed: .Skin Integrity: (Resident #91) is at risk for skin breakdown .Goals: .will not have any open areas over the next 90 days .Interventions: Turn and reposition . every two hours to bed and one hour in chair .(if indicated: state any focus areas for skin checks for this resident . (sic) During an observation and an interview on [DATE] at 10:13 a.m., Unit Manager/Registered Nurse (UM) HH reported Resident #91 had excoriation on her buttocks and described excoriation as not open but could be an opened superficial layer if it was blanchable. UM HH reported she did not diagnose wounds and did not have an answer as to why the physician did not diagnose Resident #91's wound. UM HH and this surveyor went to Resident #91's room together to look at the wound. The CNA's were in the room and started morning care for Resident #91 and removed the residents brief. The wound on the residents' coccyx looked the same as the day before when this surveyor observed it. UM HH reported it had gotten worse since yesterday when she reported she observed it. This surveyor told UM HH that it looked the same yesterday, but UM HH insisted it was worse this day. Review of an Interim Orders document dated [DATE] for Resident #91 revealed: Based on exam .of wound .Kennedy Ulcer- r/t (related to) rapid onset worsening .Cleanse, cover dressing- comfort care . (sic) The State Operations Manual states: The Kennedy Terminal Ulcer (KTU) The facility is responsible for accurately assessing and classifying an ulcer as a KTU or other type of PU/PI and demonstrate that appropriate preventative measures were in place to prevent non-KTU pressure ulcers. KTUs have certain characteristics which differentiate them from pressure ulcers such as the following: o KTUs appear suddenly and within hours; o Usually appear on the sacrum and coccyx but can appear on the heels, posterior calf muscles, arms and elbows; o Edges are usually irregular and are red, yellow, and black as the ulcer progresses, often described as pear, butterfly or horseshoe shaped; and o Often appear as an abrasion, blister, or darkened area and may develop rapidly to a Stage 2, Stage 3, or Stage 4 injury. Resident #121 Review of a Face Sheet revealed Resident #121 was a [AGE] year-old male was originally admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] for Resident #121 revealed a Brief Interview for Mental Status (BIMS) indicated he was severely cognitively impaired and required extensive assistance of 1 staff for transfers, totally dependent on two staff for toileting and no pressure ulcers. Review of the MDS dated [DATE] for Resident #121 revealed Entry date (date of this admission/reentry into the facility) [DATE]. During an observation and an interview on [DATE] at 10:21 a.m., Resident #121 was in bed, and two Certified Nursing Assistants (CNA) were in the room and started his morning care. Staff removed the resident's brief, and his coccyx had some thick white cream that covered an area on his coccyx that was dark purple/black appearance (like a Kennedy Ulcer) that was unable to size due to the cream, and there was a half dollar sized wound that had active serosanguinous drainage with no dressing covering the wound. The staff did not remove the old cream during his peri care, and they did not apply new cream before putting a new brief on the resident. CNA I reported not knowing what kind of wound Resident #121 had and did not remove the old cream because the nurse put the cream on the resident earlier while she was in the room and it looked fresh. CNA I also reported that Resident #121 was on hospice and did not recall the hospice staff coming in much to see the resident. The CNA's positioned the resident on his left side with pillows on his right side and propped his arms and legs with pillows. During an observation on [DATE] at 1:42 p.m., Resident #121 was in the same position in bed with pillows on his right side. In an interview on [DATE] at 7:51 a.m., the facility staff reported Resident #121 passed away the night before. In an interview on [DATE] at 2:10 p.m., Registered Nurse (RN) II reported he took care of Resident #121 and said that the resident did not have any wounds or dressings on his buttocks. RN II reported that the hospice nurse would come in sometimes and help assist him with the bandages on his legs, and the hospice CNA's would to general care like baths. Review of a timeline requested for Resident #121 revealed: Resident was admitted to the facility on [DATE] skin check was completed, and nurse noted: Right foot 2nd digit 1.8 cm stasis ulcer with granulated tissue with serosanguinous drainage at the top of the 2nd digit at knuckle. (sic) There was no documentation of a wound on the resident's coccyx on this timeline. Review of a handwritten Progress Note dated [DATE] for Resident #121 revealed: 1 cm X 3 cm excoriation to R (right) buttock Review of Resident #121's Medication Profile active orders prior to [DATE] revealed: Start Date: [DATE], [MEDICATION NAME] 0.44%-20.6% topical ointment, Notes: Apply thin layer coccyx. Do not scrub off excess. Frequency: By shift. Review of a physician progress notes [REDACTED].#121 revealed: .Physical exam .Extremities with non-healing ulcer on the dorsum of the right leg. Impression/Plan: 1. Right leg ischemic ulcer .2. [MEDICAL CONDITION] .3. Hypertensive [MEDICAL CONDITION] . No wound assessment or [DIAGNOSES REDACTED]. Review of the Braden Scale for Predicting Pressure Sore Risk dated [DATE] for Resident #121 revealed: .Moisture Degree to which skin is exposed to moisture: Very moist .Total Score: 12, Risk Level: High Risk (sic) Review of a document titled Non-Pressure Ulcer Skin Conditions for Resident #121 revealed: Date of Onset: [DATE] (Admission), Location .Right buttock, Description: 1 cm (centimeter) X 3 cm area of excoriation. Treatment: Caldazine with cares. Physician Notified? Yes. Date and time: [DATE] .Weekly Evaluation: Date: [DATE], Progress/treatment: 1X2 cm excoriation, [MEDICATION NAME] with cares, [MEDICATION NAME] as needed. Date: [DATE]. Progress/treatment: 2 cm X 2 cm area of excoriation, Caldazine cream applied with cares. [DATE], Progress/treatment: 2 cm X 2 cm excorital area, no drainage noted, applied Caldazine covered with [MEDICATION NAME]. [DATE], 2 cm X 2 cm excoriated area noted. No drainage noted. Covered with [MEDICATION NAME]. Will cont. to monitor . [DATE], Progress/treatment 2 cm X 1 cm excoriated area noted. No drainage noted. Covered with [MEDICATION NAME]. Will cont. [DATE], Progress/treatment: 1.9 X 0.7 cm Excoriated .drain, cover with [MEDICATION NAME]. [DATE], Progress/treatment resident expired . (sic) Review of Treatment Administration Records (TAR) for Resident #121 revealed: (MONTH) 2019: .Orders: Two Times Weekly Starting [DATE], Notes: Cleanse area just above the coccyx with NS (normal saline), pat dry, apply skin prep to surrounding and apply a [MEDICATION NAME] weekly and PRN (as needed) if soiled Review of a Nurse Practitioner Progress Note dated [DATE] for Resident #121 revealed: Reason for visit .Right shin intact scab, right buttock excoriation. Right foot has an open area .Physical examination .Skin is warm, pale, and dry. Assessment and Plan: 1. Dementia with behaviors .2. [MEDICAL CONDITION] ([MEDICAL CONDITIONS]) .3. Chronic pain management .4. Constipation .5. Will continue current plan of care . No wound assessment or [DIAGNOSES REDACTED]. Review of the resident Resident Care Guide for Resident #121 revealed: .Skin and Positioning: Turn Every 2 Hours, air mattress, avoid wearing shoes when possible per wound clinic . Review of a Care Plan Report for Resident #121 revealed: .Problem: [DATE] .Risk for skin breakdown .(two open areas on right foot) .Goals: Will reduce the risk for skin breakdown over the next 90 days .Interventions: .Reposition every two hours in bed .Apply appropriate devices to prevent bony prominences from rubbing together, provide comfort, and/or reduce friction and shearing sheepskin, elbow or heel protectors, pillows, foam wedges .Apply moisture barrier creams as warranted to protect skin integrity .Complete dressing change per physician order [REDACTED].>In an interview on [DATE] at 2:10 p.m., Registered Nurse (RN) II reported Resident #169 did not have any wounds or dressings on his buttocks, only on his shins. Resident #169 Review of a Face Sheet for Resident #169 revealed an [AGE] year-old female originally admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #169 had a Brief Interview for Mental Status (BIMS) that indicated she was cognitively intact and was totally dependent on two staff for transfers, and a stage 4 pressure ulcer. In an interview on [DATE] at 1:41 p.m., Licensed Practical Nurse (LPN) SS reported Resident #169 was actively dying and did not want anyone to turn her right now. LPN SS was the day shift nurse and did not know if her dressing was changed yet this day but was going to ask. LPN SS reported it was to be done twice a day. During an observation and an interview on [DATE] at 2:56 p.m., Certified Nursing Assistant (CNA) I and CNA YY were in Resident #169's room for incontinence care. Resident #169 still had her lunch tray in front of her and barely ate any food. CNA I reported she was not feeling well this day and had some nausea and vomiting. Resident #169's brief was soaked with urine and had a large amount of light brown liquid stool. There was no dressing on the pressure ulcer on her coccyx or in her brief. The runny stool seeped into the wound. Both CNA's clean the resident and wiped over the pressure ulcer that appeared to be small, about the size of a pencil width, and deep. Resident #169 moaned in pain when the pressure ulcer was touched. A new brief was put on, without the nurse putting a new dressing on the resident. In an interview on [DATE] at 10:56 a.m., Registered Nurse/Unit Manager HH reported Resident #169 used to go to the wound clinic and stopped a couple of years ago. They had tried different dressings, but they would fall off. The facility had to get prior authorization for the Renegrex Gel because it was expensive. The facility was to rinse the wound and apply the Renegrex to the pressure ulcer and not use a cover because it would just fall off due to her loose stools. The family did not want the resident to have debridement done anymore because it was painful and did not feel it was necessary to put her through that treatment. RN HH reported the family was very involved and even though the Resident was her own person, the resident wanted to do whatever the family recommended. Dr. OO followed the resident because she was a family friend of theirs. The family only wanted to do what this physician recommended for Resident #169. Review of a Resident Medication Profile order form for Resident #169 revealed: .Medication/Dose: Regranex 0.1 % topical gel .Notes: Cleanse sacral wound with dial soap and rinse with NS. Pat dry. Apply regranex to wound and cover with [MEDICATION NAME] (absorbent foam dressing with adhesive borders). Apply at 08:00 and then at 20:00 (8:00 p.m.) remove dressing and rinse with NS, pat dry and apply [MEDICATION NAME] .Start Date: [DATE], Status: Active (sic) Review of a timeline provided by RN HH for Resident #169 regarding the care of her pressure ulcer revealed: (Resident #169 was admitted to (facility) on [DATE]. The Resident admitted with a stage IV coccyx wound measuring 12 x 5 x 4.8 with tunneling. The Resident followed in a wound clinic .Resident d/c (discontinued) wound clinic services d/t (due to) family and resident were told wound would never close and it was stable . On [DATE], New Order per Risk Manager to change treatment to coccyx: Cleanse with dial soap, rinse with NS (normal saline), pat dry, apply collage rope to wound bed and cover with [MEDICATION NAME] Q (every) 3 days. [DATE], This nurse and associate director of preventative health had a conversation with the daughter and the resident concerning the condition of the wound to sacral area. Regranex treatment had been stopped on [DATE] and solosite had been started to debride the wound. Debridement was successful, and blood flow had returned to the wound, and associated director of preventative health had reassessed the wound and ordered [MEDICATION NAME] to be packed in the wound and covered with [MEDICATION NAME] or press and seal. Resident #169's daughter declines the need for treatment and does not care if her mother's wound condition improves. Resident #169's daughter states, my mom is in pain from debridement, and it is more important for her to be comfortable than the wound to heal. I want that regranex back because that worked previously, she had had this for [AGE] years and has been to wound clinic, and we know that it will never heal. Despite education from both parties the daughter and resident still would like to continue with the regranex. (Dr. OO) faxed for new orders. [DATE], Dr. OO ordered regranex to be applied to sacral wound at 08:00 and to be washed out at 20:00. Use [MEDICATION NAME] 5% BID (twice daily). [DATE] Wound notes: Resident has an unstageable ulcer to her coccyx that has been present for years. Recent measurements suggest that the wound is stable at this time. Current treatment is, cleanse with NS (normal saline) and pat dry. Apply regranex to the wound bed in AM (a.m.) and cover with ABD (abdominal dressing) pad and cleanse with NS and pat dry and apply ABD pad. Current treatment is in place due to family request, and they will not allow the physician to change the orders, despite education from the wound nurse, nurse manager, and physician. Resident currently has an alternating air mattress in place, a Roho cushion to her wheelchair when she is up, an every 2-hour turning schedule as the resident allows and use of a maxislide when repositioning resident in bed. Resident does choose not to turn, allow the staff to turn her side d/t (due to) her being uncomfortable. Nutrition status weights have been stable for the past three months; resident is on [MEDICATION NAME] (nutrition supplement) BID (twice a day) and Prostat (liquid protein supplement) 30 cc (cubic centimeters) BID for supplements. Physician and family are aware of the wound and current treatments at this time. No recommendations at this time. The progress notes for Resident #169 dated ([DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] reveal the same progress note verbatim as the one provided by staff on the timeline for [DATE].) Resident #169 's current treatment is; cleanse with dial soap and rinse, place reganex to wound bed and cover with [MEDICATION NAME] in AM. In the PM rinse and cover with [MEDICATION NAME]. Resident has a very long history of constant leaking of bowel, [MEDICATION NAME] does not stay on, throughout admission wound clinic and (Dr. OO) have trial several coverings with none being adequate to cover the wound d/t bowel leakage. Resident has used press and seal, [MEDICATION NAME], ABD, non-stick [MEDICATION NAME]. [MEDICATION NAME] is placed with A dressing change but does not stay intact d/t constant bowel leakage. Regranex gel is applied in am and wound is cleansed. At night wound is cleansed, and [MEDICATION NAME] is applied. (sic) Review of Weekly Wound Progress Notes for Resident #169 as follows revealed: (Stage of pressure ulcer not indicated on any of the assessments.) [DATE], size 1.2 [MEDICAL CONDITION] x 2 .current treatment: cleanse with dial soap, rinse with normal saline, pat dry, Regranex to wound. [DATE], size 1.2 [MEDICAL CONDITION] x 2 .current treatment: cleanse with dial soap, rinse with normal saline, pat dry, Regranex to wound. [DATE], size 1.2 [MEDICAL CONDITION] x 2 .current treatment: cleanse with dial soap, rinse with normal saline, pat dry, Regranex to wound. [DATE], size 1.2 [MEDICAL CONDITION] x 2.1 .current treatment: cleanse with dial soap, rinse with normal saline, pat dry, Regranex to wound, cover with [MEDICATION NAME]. [DATE], size 1.2 [MEDICAL CONDITION] x 2 .current treatment: cleanse with dial soap, rinse with normal saline, pat dry, Regranex to wound. [DATE], size 1.2 [MEDICAL CONDITION] x 2.1 .current treatment: cleansed with dial soap, rinse with normal saline, pat dry, Regranex to wound and cover. [DATE], size 1.2 [MEDICAL CONDITION] x 2.1 .current treatment: cleanse with dial soap, rinse with normal saline, pat dry, Regranex to wound. [DATE], size 1.2 [MEDICAL CONDITION] x 2 .current treatment: cleanse with dial soap, rinse with normal saline, pat dry, Regranex. [DATE], size 1.2 [MEDICAL CONDITION] x 2 .current treatment: cleanse with dial soap, rinse with normal saline, pat dry, Regranex. [DATE], size 1.2 [MEDICAL CONDITION] x 2 .current treatment: (no entry). [DATE], size 1.2 [MEDICAL CONDITION] x 2 .current treatment: cleanse with dial soap, rinse with normal saline, pat dry, [MEDICAL CONDITION][DATE], size 1.2 [MEDICAL CONDITION] x 2 .current treatment: cleanse with dial soap, rinse with normal saline, pat dry, Regranex to wound. During an interview on [DATE] at 11:11 a.m., Unit Manager (UM) HH reported Resident #121 was on hospice, and when the staff came to do care for the resident, they had their own system of charting. When queried about what the definition of excoriation was regarding the wounds on the coccyx/buttocks for Resident #91, Resident #121, and Resident # 169, UM HH reported it could be redness or the first or second layer of skin not intact but could not identify a pressure ulcer. UM HH reported she did not diagnose the resident's wounds and could not answer why a physician had not diagnosed or monitored the wounds.

This citation pertains to intake #MI 416 Based on observation, interview and record review the facility failed to ensure adequate supervision to prevent accidents in 1 of 3 sampled residents (Resident #102), from a total sample of 3 residents, resulting in Resident #102 having a fall with a hip fracture. Findings include: Review of Resident #102's Admission Record revealed Resident #102 was a [AGE] year old male admitted on [DATE] and had a [DIAGNOSES REDACTED]. 3-6-12 revealed he had a score of 4/15 which indicated severe cognitive impairment. Review of Resident #102's Minimum Data Set ((MDS) dated [DATE] revealed he required extensive assistance of 1 person for transfers and walking. Review of the Physical Mobility/Falls/Restraints Care Plan dated 3-17-11 revealed Resident #102 was at risk for falls due to an "unsteady gait at times, poor safety awareness and with transfer without benefit of staff, will not use call bell to alert staff to needs and forgetfulness." Under approach the care plan documented, "Transfers with extensive assist 1-2 with 4 wheeled walker, Ambulate with extensive assist 1-2 in room and in hallway with 4 wheeled walker, Ensure resident has safety equipment in place: bed and chair sensors, non-skid foot wear on when up." (no new interventions were added after falls on 12-4-11, 12-19-11 and 4-11-12) Review of the Incident/Accident Report dated 12-4-11 at 1:00 PM revealed Resident #102 had an unwitnessed fall. The report indicated, "Patient stated he was sitting in his chair and went to get up for something on his TV stand, he fumbled and fell ." Next to Measures to prevent future incidents was documented, "Call light in reach. Teaching done with resident to use call light with getting up." There were no further interventions documented to prevent Resident #102 from falling. During an interview on 4/20/12 at 3:30 PM, Social Worker (SW) #1 this Surveyor showed SW #1 the intervention listed on Resident #102's incident/accident report dated 12-4-11, 1:00 PM where the documented intervention was "Call light in reach. Teaching done with resident to use call light with getting up." and asked if this is an appropriate intervention for Resident #102 and she replied, "no, not with a Brief Interview for Mental Status (BIM'S) of 4." SW #1 stated she was not involved in making recommendations for fall interventions. Review of the Incident/Accident Report dated 12-19-11 at 3:00 AM, revealed Resident #102 had an unwitnessed fall. The report documented, "Heard resident (Resident #102) yelling 'help' - found lying on floor on his right side in front of bathroom. 2.6 cm x 2.5 cm abrasion right knee, reddened area right shoulder and right buttock." Review of the Incident/Accident Report for Resident #102 dated 4-11-12, 8:50 PM, revealed Resident #102 was found on the floor after a nurse heard a "thud" while in another residents room. The report indicated Resident #102 stated, "I really bumped my head" and had a 1.5 cm round raised area on the left sided of his head. Review of the Physical Mobility/Falls/Restraints Care Plan dated 3-17-11 revealed there were no new interventions were added after Resident #102's falls on 12-4-11 or 12-19-11 and 4-11-12. Review of the Nurses notes dated 4-12-12 at 12:04 AM documented, "Resident (Resident #102) complained of pain to left hip. Staff continue to transfer with assist of 2 and non weight bearing to left hip." Review of the Nurses notes dated 4-12-12 at 3:30 PM documented, "Resident (Resident #102) complained of pain to left hip. Decreased range of motion (ROM) to left lower extremity (LLE)." Review of the Nurses Nurses notes dated 4-12-12 at 4:56 PM for Resident #102 documented, "X-ray results to left hip called to doctor with new orders to send resident to (name of hospital) for evaluation and treatment." Review of Emergency Department Summary, Physician Documentation for Resident #102, dated 4-13-12, documented, "The patient was suspected to have severe excruciating pain and patient was unable to bear weight. An x-ray has been obtained which has revealed impacted acetabular fracture for which the patient was brought to the emergency room and the patient was evaluated and was admitted to the hospital for pain control." Resident #102 was observed sitting in his wheelchair is his room on 4-20-12 at 9:50 AM. The Surveyor asked Resident #102 if he remembered falling and he replied his daughter was in and turned off the light, I got up to turn the light on and off and fell right straight down." During an interview on 4-20-12 at 2:40 PM, Licensed Practical Nurse (LPN) #1 stated she was working on 4-11-12 when she heard a "thud" went to Resident #102's room and found him on the floor. The Surveyor asked LPN #1 if her pager (used to alert staff of fall alarm sounding) went off before or after she heard the "thud", notifying her that Resident #102 was out of bed. LPN #1 responded she did not think it went off before she heard the thud because she thought her pager had a 2 minute delay. (Sensor alarms do not sound in the room or hall, sensors send a message to staff pagers and turns the light on out side of the Residents room). When asked if Resident #102 was known to get out of bed without help< LPN #1 responded that he would get up daily without help, he was very quick, she would see his light on because the sensor pad was connected to the call system and she would see him up walking without assistance. The Surveyor asked LPN #1 if is able to initiate another safety intervention when they were not able to get to a resident in time with the alarms and she said no it would have to come from the Director of Nursing or Program Manager. During an interview on 4-20-12 at 3:10 PM, Certified Nurses Assistant (CNA) #8 stated she was assigned to Resident #102 when he was found on the floor on 4-11-12. The Surveyor reviewed the VisionLink Call Data (computerized read out of bed sensor page and light notification) for Resident #102 on 4-11-12. CNA #8 said she must have been working with Resident #102 at 8:19 PM because the sensor responded for 25 seconds at that time, CNA #8 said she probably set something on Resident #102's bed which would alert the sensor to page. According to the VisionLink Call Data the sensor went off at 8:35 PM and 8:36 PM. CNA #8 said Resident #102 stood up at his bed when getting his pajamas on and sometimes just stands a few times before she can get him into bed (this makes the sensor send a page). CNA #8 said once Resident #102 was in bed she went to assist another Resident and was not able to respond at 8:44 PM when the sensor sent a page for 5 minutes and 16 seconds. CNA #8 explained that Resident #102 never used his call light and it was not unusual for Resident #102 to be up walking before she could respond to his call system. Review of the the VisionLink Call Data for Resident #102 from 4-2-12 through 4-11-12 revealed Resident #102's bed sensor would go off multiple times a day and nurse response times varied from a few seconds to as long as 15 minutes. Observations made during the initial tour on 4/20/12 from 8:35 AM - 10:15 AM with Unit Manager #1 included non sampled Resident #104, had wires exposed on sensor box and sensor was not functioning, non sampled resident #105 had wires exposed on sensor box and no date written on sensor pad. (sensor pads are good for 1 year), non sampled Resident #106's alarm sensor box blinked a few times than stopped, no nurses responded to Resident #106's sensor, non sampled Resident #107 did not have any date on her sensor pad. Resident #102's sensor pad was past the one year date. Resident #103's sensor box wires were exposed and it did not respond to the first test. ( ) & ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ADMINISTER MEDICATION WITHOUT DELAY FOR AN INFECTED WOUND, FAILED TO APPROPRIATELY CHANGE THE DRESSINGS, AND FAILED TO ASSESS AND MONITOR A WOUND FOR HEALING OR DECLINE FOR THE ONLY RESIDENT (#12) WITH A NON-PRESSURE RELATED WOUND OF 30 RESIDENTS REVIEWED, RESULTING IN AN INFECTED, PAINFUL, NON-HEALING WOUND. FINDINGS INCLUDE: ACCORDING TO THE ADMISSION RECORD, DATED 2-21-2011, RESIDENT #12 WAS [AGE] year-old FEMALE ORIGINALLY admitted to the facility on [DATE]. THE PHYSICIAN ORDER [REDACTED]. ON 4-20-2011 AT ABOUT 12:45 PM, RESIDENT #12 WAS VISITED IN HER ROOM. DURING THE CONVERSATION, RESIDENT #12 REPORTED THAT SHE WAS "STILL WAITING" FOR THE MEDICINE FOR THE WOUND ON HER ARM. ON 4-20-2011 AT ABOUT 1:00 PM, STAFF "D", A UNIT NURSE, STATED THAT THE INFECTIOUS DISEASE DOCTOR HAD VISITED RESIDENT #12 ON 4-18-2011 AT ABOUT 10:00 PM AND HAD PRESCRIBED THE ANTIBIOTIC [MEDICATION NAME] TO BE GIVEN INTRAVENOUSLY (IV) ONCE DAILY. ON 4-20-2011 AT ABOUT 1:00 PM, STAFF "D" CONFIRMED THAT RESIDENT #12 HAD NOT YET RECEIVED ANY DOSE OF THE [MEDICATION NAME] THAT SHE SAID HAD BEEN DELIVERED to the facility on [DATE] AT ABOUT 2:00 AM (MORE THAN 24 HOURS AFTER THE MEDICATION WAS PRESCRIBED BY THE PHYSICIAN). THE [MEDICATION NAME] FOR RESIDENT #12 WAS OBSERVED TO BE IN THE MEDICATION ROOM REFRIGERATOR ON 4-20-2011 AT ABOUT 1:15 PM. THE INTERDISCIPLINARY NOTES DATED, 4-18-2011 AT 1:30 PM, REFLECTED THAT AN IV LINE WAS PLACED IN RESIDENT #12'S RIGHT FOREARM. THE INTERDISCIPLINARY NOTES DATED 4-19-2011 REFLECTED THAT THIS IV WAS FUNCTIONING ON 4-19-2-11 AT 9:00 AM. ADDITIONALLY, THE INTERDISCIPLINARY NOTES REFLECTED THAT RESIDENT #12 HAD A PERIPHERALLY INSERTED CENTRAL CATHETER (USED TO ADMINISTER IV MEDICATIONS) PLACED ON 4-19-2011 THAT WAS OKAY TO USE AT 12:40 PM. THIS SURVEYOR QUESTIONED WHY THE PHYSICIan order for [REDACTED]. STAFF "D" STATED AT 3:40 PM ON 4-20-2011 THAT THE MEDICATION HAD BEEN ADMINISTERED AT 2:58 PM ON 4-20-2011, WHICH WAS ALMOST 41 HOURS AFTER THE PHYSICIAN HAD PRESCRIBED IT. ON 4-20-2011, THE UNIT MANAGER, STAFF "E" STATED THAT THE WOUND WAS INFECTED WITH [MEDICAL CONDITION] (A PATHOGENIC BACTERIA). ON 4-21-2011 AT ABOUT 11:30 AM, STAFF NURSE "F" WAS OBSERVED IN RESIDENT #12'S ROOM WHILE CHANGING THE DRESSING ON RESIDENT #12'S LEFT ARM. TWO WOUNDS WERE NOTED ON RESIDENT #12'S LEFT ARM. THE WOUND ON THE OUTSIDE OF THE UPPER LEFT ARM WAS ABOUT THE SAME DIAMETER AS A BASEBALL. THE OUTSIDE EDGE OF THE WOUND WAS BRIGHT RED AND THE CENTER WAS WHITE. THE OTHER WOUND WAS JUST ABOVE THE BEND OF THE ELBOW, WAS DIME SIZED, SCABBED, AND HAD A RED OUTER EDGE. DURING THE DRESSING CHANGE PROCEDURE, STAFF NURSE "F" WAS OBSERVED TO CONTAMINATE BOTH WOUNDS BY WIPING THE WOUNDS WITH A NORMAL SALINE SOAKED GAUZE, THEN FOLDING THE GAUZE AND WIPING THE WOUND AGAIN WITH THE SIDE SHE HAD BEEN TOUCHING WITH HER GLOVED HANDS. STAFF "F" FOLDED THE GAUZE ONCE MORE AND AGAIN CONTAMINATED THE WOUND BY WIPING WITH THE GAUZE SURFACE THAT SHE HAD TOUCHED. ON 4-21-2011 AT ABOUT 11:40 AM, THE UNIT MANAGER, STAFF "E" WAS ASKED FOR THE MEASUREMENTS OF THE WOUND. STAFF "E" RESPONDED THAT THE WOUND HAD NOT BEEN MEASURED. WHEN ASKED HOW THE PROGRESS OR DECLINE OF THE WOUND WAS MONITORED WITHOUT MEASUREMENTS, STAFF "E" HAD NO RESPONSE. THE INTERDISCIPLINARY NOTES REFLECTED THAT ON 3-15-2011 A "RED/DRY PATCH" WAS NOTED ON RESIDENT #12 ' S LEFT ARM. THE NOTE WAS NOT SPECIFIC AS TO WHERE ON THE ARM THE "PATCH" WAS, OR HOW LARGE IT WAS. THE NEXT NOTE ABOUT THE AREA WAS RECORDED ON THE INTERDISCIPLINARY NOTES ON 3-23-2011 AT 4:16 AM WHEN THE AREA WAS DESCRIBED AS A "LESION" AND "BACTRACIN" (SIC) OINTMENT WAS PRESCRIBED TO BE APPLIED TWICE A DAY AND THE ANTIBIOTIC [MEDICATION NAME] WAS PRESCRIBED. ON 3-23-2011 AT 12:00 PM, AN AREA ON THE LEFT UPPER ARM WAS DESCRIBED AS "QUARTER SIZED AREA, RED IN COLOR, NO DRAINAGE". ON 3-25-2011 AT 11:04 AM, A NOTE REFLECTED THAT THE LESION ON THE LEFT UPPER EXTREMITY HAD A RED RING AROUND A BLISTERED AREA. AN INTERDISCIPLINARY NOTE ON 3-26-2011 REFLECTED, "SMALL REDDENED AREA NOTED" WITH NO DESCRIPTION OF THE AREA OR LOCATION ON THE BODY OF THE AREA. ON 3-28-2011 AT 2:00 PM, AN INTERDISCIPLINARY NOTE REFLECTED THAT A BIOPSY OF THE LEFT ARM LESION WAS SCHEDULED. THERE WAS NO FURTHER DESCRIPTION OR MEASUREMENT OF THE LESION IN THE NOTE. ON 4-5-2011, AN INTERDISCIPLINARY NOTE REFLECTED THAT THE [MEDICATION NAME] PRESCRIBED FOR A "CUTANEOUS INFECTION" TO THE LEFT UPPER ARM OF RESIDENT #12. THERE WAS NO FURTHER DESCRIPTION OR MEASUREMENT IN THE NOTE ABOUT THE AREA THAT WAS NOW INFECTED. ON 4-6-2011 AT 4:35 AM, THE INTERDISCIPLINARY NOTE REFLECTED THAT RESIDENT #12 COMPLAINED OF ITCHING AND THE AREA ON THE LEFT ARM WAS REDDENED. AN INTERDISCIPLINARY NOTE ON 4-8-2011 AT 12:40 PM REFLECTED THAT THERE WAS A SMALL AMOUNT OF CLEAR DRAINAGE FROM THE LESION ON THE LEFT UPPER EXTREMITY. ON 4-11-2011 AT 1:50 PM AN INTERDISCIPLINARY NOTE RECORDED THAT THE ANTIBIOTIC [MEDICATION NAME] WAS PRESCRIBED FOR [MEDICAL CONDITION] IN THE LEFT ARM WOUND. THERE WAS NO DESCRIPTION OR MEASUREMENT OF THE WOUND IN THAT NOTE. ON 4-12-2011 AT 3:00 AM, AN INTERDISCIPLINARY NOTE REFLECTED THAT THERE WAS GREEN DRAINAGE FROM THE LEFT ARM WOUND AND THE AREA AROUND THE WOUND WAS REDDENED. THE NOTE ALSO REFLECTED THAT RESIDENT #12 COMPLAINED OF PAIN WHEN THE ARM WAS TOUCHED. THE INTERDISCIPLINARY NOTE OF 4-13-2011 AT 1:00 PM REFLECTED THAT THE RESIDENT COMPLAINED OF ITCHING OF THE LESION ON THE LEFT ARM AND THERE WAS A SMALL AMOUNT OF GREEN/YELLOW DRAINAGE ON THE DRESSING. AGAIN, THERE WAS NO FURTHER DESCRIPTION OR MEASUREMENT OF THE AREA. AN INTERDISCIPLINARY NOTE ON 4-15-2011 AT 1:00 PM REFLECTED THAT A PHYSICIAN'S ASSISTANT OBSERVED THE "[MEDICAL CONDITION]" ON RESIDENT #12'S LEFT ARM. THERE WAS NO DESCRIPTION OR MEASUREMENT OF ANY LESION IN THAT NOTE AND NOW THE NOTE REFLECTED THAT THERE WAS MORE THAN ONE "LESION". ACCORDING TO THAT NOTE, THE PHYSICIAN'S ASSISTANT PRESCRIBED THE ANTIBIOTIC [MEDICATION NAME] TO BE GIVEN INTRAVENOUSLY TO TREAT THE LESION. THE NOTE ALSO REFLECTED THAT THE PHARMACY WAS TO DELIVER THE MEDICATION LATER ON THAT DAY. THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. THE INTERDISCIPLINARY NOTE OF 4-17-2011 AT 12:00 PM REFLECTED THAT "GREEN DRAINAGE AND REDNESS" WAS NOTED TO "SITES" ON THE LEFT UPPER EXTREMITY. THERE WAS STILL NO DESCRIPTION OR MEASUREMENT OF THE NOW MULTIPLE AREAS. THE INTERDISCIPLINARY NOTE OF 4-17-2011 AT 12:00 PM REFLECTED THAT THERE WAS "GREEN DRAINAGE AND REDNESS NOTED TO SITES" ON THE LEFT UPPER EXTREMITY. AN INTERDISCIPLINARY NOTE ON 4-17-2011 AT 6:00 PM REFLECTED THAT THE LEFT UPPER EXTREMITY WOUND WAS DRAINING "GREEN MODERATE DRAINAGE SLIGHT ODOR". THE INTERDISCIPLINARY NOTE OF 4-18-2011 AT 1:30 PM REFLECTED THAT RESIDENT #12 HAD A LESION ON THE LEFT ARM WITH LARGE RED SURROUNDING AREA AND A SMALL AMOUNT OF CLEAR DRAINAGE. THERE WAS NO DESCRIPTION OR MEASUREMENT OF THE AREA AND NO NOTE ABOUT ANY OTHER "[MEDICAL CONDITION]". AN INTERDISCIPLINARY NOTE OF 4-19-2011 AT 10:30 PM REFLECTED THAT THE "SORES" ON THE LEFT UPPER EXTREMITY ARE RED ON THE OUTSIDE OF THE "WOUND" AND WHITE IN THE CENTER. ON 4-21-2011 AT ABOUT 11:40 AM, THE UNIT MANAGER, STAFF "E", STATED THAT THE [MEDICAL CONDITION] WOULD BE MEASURED IN THE EVENING ON 4-21-2011. THE MEASUREMENTS AND DESCRIPTIONS OF THE [MEDICAL CONDITION] RECORDED ON THE INTERDISCIPLINARY NOTES DATED 4-21-2011 AT 9:45 PM WERE "UPPER ARM LESION MEASURES 5 CENTIMETERS (CM) X (BY) 5 CM (WITH) AREA WHITE IN APPEARANCE INSIDE MEASURING 3 CM X 3.2 AND INSIDE THE INNER PART MEASURES 2.5 X2 0 DRAINAGE NOTED. LESION TO ELBOW AREA MEASURING 1.8 CM X 1.8 CM OUTSIDE. REDENNED (SIC) AREA INSIDE AREA NOTED SCABBED AND MEASURING 1.2 CM X 1.3 CM". IN SUMMARY, RESIDENT #12 DEVELOPED TWO WOUNDS ON HER LEFT UPPER ARM. FIVE ANTIBIOTICS WERE PRESCRIBED TO TREAT THE INFECTED [MEDICAL CONDITION], CULMINATING WITH TWO INTRAVENOUS ANTIBIOTICS ORDERED IN RESPONSE TO A CULTURE ON 4-11-2011 THAT REVEALED AN INFECTION WITH THE ANTIBIOTIC RESISTANT BACTERIA, [MEDICAL CONDITION]. THERE WAS A DELAY BETWEEN THE TIME OF THE PRESCRIPTION AND ADMINISTRATION OF BOTH INTRAVENOUS MEDICATIONS [MEDICATION NAME] AND [MEDICATION NAME]. CONTAMINATION OF THE WOUNDS WAS OBSERVED DURING A DRESSING CHANGE ON 4-21-2011. NO PRECISE DESCRIPTION OR MEASUREMENT OF THE [MEDICAL CONDITION] WAS NOTED IN THE CLINICAL RECORD UNTIL 4-21-2011 SO THE PROGRESS OR DECLINE OF THE [MEDICAL CONDITION] COULD NOT BE ACCURATELY ASSESSED FROM THE DATE THAT THE PROBLEM WAS NOTED, 3-15-2011, AS A "RED PATCH". ( )