Every finding on record at Mission Point Nursing & Physical Rehabilitation Ce

This citation pertains to intake 3135345. Based on interview and record review, the facility failed to respect the dignity of one (R1) of three residents reviewed for dignity. Findings include: Review of the face sheet showed the facility admitted R1 on 7/16/26 with pertinent diagnoses of traumatic brain injury and vascular dementia.During an interview on 8/13/26 at 12:00 PM, the Durable Power of Attorney (DPOA) for R1 stated that an incident occurred at the facility in which R1 alleged a Certified Nursing Assistant (CNA) threw a pillow at him during a bed transfer.During an interview on 8/17/26 at 11:24 AM, R1 stated he did not remember any incident involving a staff member throwing a pillow at him and denied any concerns with staff. He stated he felt safe at the facility and had no concerns about his care.Review of the Police Report dated 8/2/26 showed the Police Officer spoke with R1, who alleged CNA I became angry with him during a bed transfer. R1 told the officer that CNA I was going to punch him in the face, and R1 replied he would punch CNA I back. R1 reported that CNA I stated he would hit R1 again and threw a pillow at R1.Review of the same Police Report showed the Police Officer spoke with CNA I, who reported R1 was unwilling to receive help during the bed transfer and threatened to punch CNA I in the face. CNA I told R1 that if R1 hit him, he would hit R1 back. CNA I denied throwing a pillow at R1.During an interview on 8/19/26 at 2:46 PM, staff questioned CNA I about the information in the Police Report regarding R1's allegations. CNA I stated R1 threatened him first, so he told R1 he would give it right back. CNA I stated, He threatened me and I didn't want to just not say anything to make it not happen. In retrospect I wouldn't have done it. I could see the look on his face. I obviously wasn't going to do it.During an interview on 8/19/26 at 3:00 PM, the Nursing Home Administrator (NHA) stated she was disappointed that CNA I responded to R1 in that manner. She stated she instructs staff that if a resident is in a safe position, they should walk away. The NHA stated CNA I should have walked away.

Based on observation, interview and record review, the facility failed to maintain dishwashing equipment resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings include: On 07/27/2026 at 9:20 AM, during an observation of operation of the dish machine, a plate simulating dishwasher tester was sent through the wash, rinse and sanitizing cycle. The plate simulator was observed registering a maximum heat temperature of 158 degrees Fahrenheit (F). During the same dish machine cycle, the final rinse gauge, that is part of the dishmachine, was observed to have registered a temperature of 190F. During the discussion regarding maintenance of the dishmachine, with Certified Dietary Manager (CDM) L, it was disclosed that the dishmachine had been installed in the facility for less than a year and that the [NAME] also provides routine maintenance of the dishmachine and the [NAME] comes out quarterly. On 07/27/2026 at 9:22 AM, the final rinse gauge was observed registering a final rinse temperature of 192F and the plate simulator registered a maximum surface temperature of 155F. CDM L also ran the facility's irreversible registering temperature indicator, and the indicator did show that plate surface had not reached 160F. On 07/27/2026 at 9:28 AM, the dishmachine temperature log was reviewed and found to support the gauge readings, at time of observation, from the dishmachine.On 07/27/2026 at 10:58 AM, CDM L was asked how often they use the dishmachine temperature strips to check the operation of the dishmachine, CDM L responded that the temperatures were taken several times a day, from the gauges of the dishmachine, and did not use the dishmachine temperature strips, because the gauges were registering temperatures within the dishmachine operating range requirement to properly wash, rinse and sanitize. On 07/27/2026 a review of the Dish machine usage Policy, Master Policy #: 2615, policy states Dietary staff will check for calibration of gauge temperatures by: Running a secondary thermometer through the machine to compare temperatures or Use a commercial test strip following manufacturer instructions g Inadequate temperatures will be reported to the dietary manager or Maintenance immediately before continuing use.According to the 2022 FDA Food Code Annex 3. Public Health Reasons/Administrative Guidelines section 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. The temperature of hot water delivered from a warewasher sanitizing rinse manifold must be maintained according to the equipment manufacturer's specifications and temperature limits specified in this section to ensure surfaces of multiuse utensils such as kitchenware and tableware accumulate enough heat to destroy pathogens that may remain on such surfaces after cleaning. The surface temperature must reach at least 71 C (160 F) as measured by an irreversible registering temperature measuring device to affect sanitization. When the sanitizing rinse temperature exceeds 90 C (194 F) at the manifold, the water becomes volatile and begins to vaporize reducing its ability to convey sufficient heat to utensil surfaces. The lower temperature limits of 74 C (165 F) for a stationary rack, single temperature machine, and 82 C (180 F) for other machines are based on the sanitizing rinse contact time required to achieve the 71 C (160 F) utensil surface temperature. According to the 2022 FDA Food Code section 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) Except as specified in (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90C (194F), or less than: (1)For a stationary rack, single temperature machine, 74C (165F); or (2) For all other machines, 82C (180F).According to the 2022 FDA Food Code, Annex 3 Public Health Reasons/Administrative Guidelines, section 4-302.13 Temperature Measuring Devices, Manual Warewashing. Water temperature is critical to sanitization in warewashing operations. This is particularly true if the sanitizer being used is hot water. The effectiveness of cleaners and chemical sanitizers is also determined by the temperature of the water used. A temperature measuring device is essential to monitor manual warewashing and ensure sanitization. Effective mechanical hot water sanitization occurs when the surface temperatures of utensils passing through the warewashing machine meet or exceed the required 71 C(160 F). Parameters such as water temperature, rinse pressure, and time determine whether the appropriate surface temperature is achieved. Although the Food Code requires integral temperature measuring devices and a pressure gauge for hot water mechanical warewashers, the measurements displayed by these devices may not always be sufficient to determine that the surface temperatures of utensils are reaching 71 C(160 F). The regular use of irreversible registering temperature indicators provides a simple method to verify that the hot water mechanical sanitizing operation is effective in achieving a utensil surface temperature of 71 C (160 F). According to the 2022 FDA Food Code section 4-302.13 Temperature Measuring Devices, Manual and Mechanical Warewashing. (A) In manual WAREWASHING operations, a TEMPERATURE MEASURING DEVICE shall be provided and readily accessible for frequently measuring the washing and SANITIZING temperatures. (B) In hot water mechanical WAREWASHING operations, an irreversible registering temperature indicator shall be provided and readily accessible for measuring the UTENSIL surface temperature.

Based on observation, interview and record review, the facility failed to maintain general cleanliness of the exterior of the building and repair of shared furniture. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living. Findings include: On 07/27/2026 at 11:11 AM, a chair in the hallway of the 300-hall was observed to have creasing and several worn spots that were exposing the portions of the under cloth of the original surface material.On 07/28/2026 at 10:45 AM, approximately 24 cigarette butts were observed on the ground under a tree by the beginning of the sidewalk, where it meets the driveway. The facility is a smoke-free facility, and no cigarette trash receptacles were observed in areas around the sidewalk, where cigarette butts were found. On 07/28/2026 at 11:07 AM, during discussion with Housekeeping Supervisor (HS) M regarding the cleaning of areas on the exterior of the building and the cigarette butts; it was stated that Maintenance Director (MD) N, would walk the exterior of the building and would alert staff when cleaning needed to occur. Staff that would be responsible for cleaning up the exterior of the building would be from the housekeeping department and the maintenance technician. On 07/28/2026 at 4:10 PM, Nursing Home Administrator (NHA) stated the facility and exterior was smoke-free, residents who do smoke are required to leave the facility premises to smoke. NHA disclosed that the facility has provided trash cans and personal containers to encourage resident smokers to throw away their cigarette butts instead of throwing them on the ground, but the facility staff are still working to prevent the used cigarettes being thrown on the ground. Record review of the Smoke Free Environment policy last revised 9/24, Guideline 5., Smoking is prohibited in all outdoor areas of the facility which includes but is not limited to the sidewalks, decks, parking lots, and back service driveway, as applicable to the facility.; confirmed the surrounding exterior premises of the facility are considered smoke-free.

Based on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) for one Resident (R82) out of 1 resident reviewed for EBP; and failed to implement a process to ensure reusable resident drinking vessels were routinely cleaned for every resident who drank from personal drinkware. Findings include:R82 Review of a Face Sheet reflected R82 admitted to the facility with diagnoses of sepsis, acute osteomyelitis of the right ankle and foot, non-pressure chronic ulcer of left heel and midfoot with fat layer exposed. Review of the July 2026 Medication Administration Record/Treatment Administration Record (MAR/TAR) reflected the order, Enhanced Barrier Precautions (EBP) while performing high-contact care activities every shift for infection control. During an observation on 07/27/2026 at 2:23 PM, Registered Nurse (RN) A was observed entering R82's room, sat on the bed occupied by R82 and handled R82's Peripherally Inserted Central Catheter (PICC) line dressing to assess the date on the transparent dressing. RN A continued to touch the PICC catheter and surrounding skin with ungloved hands as she assessed the area. R82 had bilateral foot wounds and a foley catheter in addition to the PICC line and required EBP. Signage posted on the door indicated EBP was required, and Personal Protective Equipment (PPE) was available outside the room. During an interview on 07/28/2026 at 2:46 PM, Infection Control Nurse (ICN) B reported that the expectation is that whenever a staff person has extensive contact with a resident, especially to do with a PICC line, linens, etc. the staff implement EBP. Review of a policy Enhanced Barrier Precautions last reviewed 3/2024 reflected It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO. ii. Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. During an interview on 07/29/2026 at 8:19 AM, Certified Nurse's Aide (CNA) O stated she was not sure how often or when resident's personal cups (vessels) are washed. CNA O further stated I do not clean them, but I think one of the other shifts do. During an interview on 07/29/2026 at 8:31 AM, Licensed Practical Nurse (LPN) P revealed she was not sure what the procedure was for cleaning resident personal mugs. LPN P stated, I believe it probably is a 3rd shift thing. Like the aides on 3rd I believe they take them down and wash them in the kitchen. LPN P further revealed she did not get complaints about resident personal cups (vessels) being lost or misplaced even though many of them were not labeled/identified as to which resident they belonged to. During a breakfast interview on 7/29/2026 at 8:35 AM, with R79 (room [ROOM NUMBER]-1) it was observed the resident did not have any facility provided beverages alongside his breakfast. However, there was a large personal drinking vessel. Resident stated, I stopped drinking out of facility provided cups/mugs because I was grossed out. My former roommate would [NAME] loogies into them, and I did not like the idea of possibly drinking from one of his mugs/cups. R79 further revealed he was unable to get up and clean his mug (vessel) and was not sure how often it was cleaned. R79 stated, It's probably not cleaned very often because when I have things like pop in it they (staff) never empty/rinse it out. They will just put more ice/water in top of it, and I can taste the diluted pop flavored water. The vessel was not observed to have the residents' name on it. During an interview on 07/29/2026 at 8:47 AM, Certified Dietary Manager (CDM) L revealed she did not know which residents have personal mugs(vessels) and who doesn't. CDM L stated she knows 3rd shift CNAs are not cleaning resident personal mugs (vessels) in the kitchen because, My staff take apart the dish machine before they leave for the night, and my staff puts it back together the next morning. During the interview CDM L revealed her staff do not go and pick up resident's personal mugs (drinking vessels) but will wash them if staff bring them down. On 7/29/2026 at 9:08 AM, the resident in room [ROOM NUMBER]-1 was observed to have a non-labeled personalized drinking vessel on his bedside table. The resident stated, I do not know when the last time it was cleaned. When this surveyor asked if it (drinking vessel) was usually cleaned on certain shifts or by dietary staff, or his aides he stated No. During an interview on 07/29/2026 at 9:13 AM, Certified Nurse's Aide (CNA) Q stated, I'm not sure what the policy is for cleaning resident personal cups (drinking vessels). I believe dietary comes and gets them. When this surveyor asked CNA Q if she washed/cleaned them for the residents she stated, Not usually. During an observation of room [ROOM NUMBER] on 07/29/2026 at approximately 9:50 AM, the resident stated, the staff never clean my cup (drinking vessel) and I've been here several months. During an interview on 07/29/2026 at 12:45 PM, Infection Control (IC) Nurse B revealed the facility changes out the facility provided drinking mugs/cups every shift and with their meals. This surveyor asked what do they do with resident's personal mugs/cups (drinking vessels)? IC Nurse B stated, I don't know. When asked when do they get washed? IC Nurse B stated, I don't know. We don't let our cups go at home; we wash them. We will have to get a policy/procedure for this. When IC Nurse B was asked why she stated, Not washing the cups (Resident's personal drinking vessels) could lead to infection control issues. Review of current facility policy/procedures revealed, the facility did not have a policy/procedure in place for washing/cleaning Resident's personal drinking vessels. A quick tour of resident rooms with open doors was conducted on 07/29/2026 from approximately 12:55 PM to 1:20PM. The tour revealed 25 rooms contained personal drinking vessels for 26 different residents. Several residents had multiple drinking vessels in their rooms that they used daily/frequently. During the tour five additional residents revealed that staff do not clean their cups/mugs (personal drinking vessels) and could not remember the last time they were cleaned.

Based on observation, interview, and record review, the facility failed to ensure hearing aids were being put on one resident (R18) of 1 resident reviewed for hearing and vision, per the resident's plan of care for effective communication. Findings include:Review of the Electronic Medical Record (EMR) reflected R18 admitted to the facility 6/8/2024 with pertinent diagnoses that included severe intellectual disabilities, legal blindness and hearing loss in both ears. Review of the Minimum Data Set (MDS) for R18 dated 5/19/2026 reflected R18 was sometimes able to understand verbal content with the use of hearing aids.Review of the Activities for Daily Living (ADL) Self Care Performance Deficit Care Plan for R18 reflected Hearing Aid(s) I require hearing aid(s) to assist my hearing. Please make sure they are in and functioning daily.Review of the Doctor's Orders for R18 reflected an active order to Please ensure hearing aids are in, one time a day for verbal hearing with a start date of 4/3/2026.Review of R18's July 2026 Medication Administration Record (MAR) reflected Please ensure hearing aids are in, one time a day for hearing Start Date 4/3/2026 0630. The documentation on 7/28/2026 reflected the initials of Registered Nurse (RN) I that this was completed.On 7/28/2026 at 10:39 AM, R18 was observed in her room sitting in a chair with a television on low volume. No hearing aids were observed in the Resident's left or right ear. On a dresser in the Resident's area was small case, assumed to be a case for hearing aids, that was empty. At this time Certified Nurse Aide (CNA) J was in called into the room and verified that R18 did not have hearing aids in place. CNA J checked the small case for the hearing aids, looked around the R18's area and acknowledged she did not know where R18's hearing aids were. CNA J reported that the nurse probably knows where the hearing aids were.On 7/28/2026 at 12:34 PM, R18 was observed eating lunch in a common room on the 200 hall. R18 did not have hearing aids in place. At this time an interview was conducted with RN I outside the common room. RN I reported that the CNAs fit R18 with the hearing aids in the morning and that the hearing aids were kept in the nurses' cart when not in use. RN I observed R18 in the common room and acknowledged that the hearing aids were not in place. RN I went into R18's room, checked the empty hearing aid case, and began looking in the Resident's dresser drawers but was unable to locate the hearing aids.On 7/29/2026 at 8:50 AM, R18 was observed in the common room on the 200 hall. It was observed that R18 did not have hearing aids in place.Review of the July 2026 MAR for R18 reflected documentation on 7/29/2026 by nursing that R18 had hearing aids put in place, despite the observation showing R18 did not have hearing aids in place.On 7/29/2026 at 9:06 AM, RN I reported that R18s hearing aids not found on 7/28/2026 were located in the nurses' cart in a different case. Returning to the common room on the 200 hall R18 remained in the room, and it was again noted that the hearing aids were not in place at this time.Review of the EMR Progress Notes revealed a Psychiatry entry dated 6/16/2026 at 1:15 PM which reflected Progress note review shows on 6/12/2026 she (R18) was yelling out frequently but would calm down when her meals came or when someone was sitting with her. Her hearing aids were not able to be located so she did not have these in, possibly a contributing factor to increase in behaviors. The entry indicated not having the hearing aids in place raised the potential for a detrimental effect on the Resident.

Based on observation, interview, and record review, the facility failed to provide appropriate wound care for one of two residents (Resident #4) reviewed for quality of care. Findings: Resident #4 (R4)Review of a Face Sheet revealed R4 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses of morbid obesity, chronic obstructive pulmonary disease, diabetes mellitus, congestive heart failure, peripheral vascular disease, and chronic kidney disease-stage 3. During an observation on 07/27/26 at 10:48 AM, Licensed Practical Nurse (LPN) K entered R4's room to complete physician ordered daily wound care and dressing changes. Two Certified Nurse Aides (CNA's) assisted R4 to roll over onto her right side to provide access to the two wounds: one on the back of each thigh. Two 4x4 border dressings, dated 7/26, covered the back of the left thigh and there was not a dressing on the back of the right thigh. LPN K removed the two dressings and then left the room to gather more supplies. LPN K returned to the room, took a spray bottle of wound cleanser and sprayed the solution on the dime sized open area on the back of R4's left thigh. LPN K did not have any 4x4 gauze to pat the wound dry and gathered a handful of paper towel from the bathroom and used it to pat dry the open wound. LPN K applied the physician ordered wound care ointment into the wound and then spread zinc oxide around the periphery of the area that had been covered by the two previous 4X4 border dressings. LPN K applied two new 4x4 border dressings over the same area on the left thigh that the previous dressings were placed. The two dressings had adhesive borders and did not stick to the skin due to the zinc oxide that had been spread around the periphery of the left thigh. LPN K asked the CNA's to place a second brief on R4 if needed to hold the dressings in place. No wound care was completed on the back of the right thigh. LPN K stated that the wound care was done and that R4 could roll back and lay flat. R4 asked LPN K to make sure that some cream was put on the back of her right thigh. LPN K stated that she would have to get more wound cream and left the room. LPN K returned with more zinc oxide, applied it to the back of the right thigh without assessing the skin, then noted aloud that R4 was having a bowel movement, that the two CNA's would need to clean up R4, and the LPN would return to start over on the back of the right thigh. LPN K left the room a third time to gather more supplies. At 11:20 AM LPN K had not yet returned to the room and R4 stated that she could not wait any longer because her back hurt from laying on her side for so long. LPN K returned to the room and stated that she had to beg, steal, and borrow wound cream. LPN K spread zinc oxide on the back of the right thigh without assessing the skin. During an interview on 07/27/26 at 12:03 PM Wound Care Nurse/Unit Manager C indicated the following: (a) that paper towel from the bathroom should absolutely not be used during wound care, (b) a review of physician orders for R4 showed two separate dressing changes were ordered, one on the back of each thigh, (c) the expectation for all nurses performing wound care was to have all needed supplies with them when they enter a resident's room to avoid unnecessary delays in care, and (d) applying zinc oxide under the adhesive dressing for R4 was not only not ordered but made no sense.

Based on observation, interview and record review, the facility failed to implement its infection prevention and control policies and procedures for glucometer cleaning, equipment cleaning and Management of C. Difficile Infection for two residents (R16 & R39) out of a total sample of 18 residents reviewed. Findings: Resident #39 (R39) Review of an Admission Record reflected R39 admitted to the facility on [DATE] with diagnoses that included encounter for surgical aftercare following surgery on the digestive system, contact with and (suspected) exposure to other viral communicable diseases, ventral hernia without obstruction or gangrene, disruption or dehiscence of closure of internal operation (surgical) wound of abdominal wall muscle or fascia, sequela and enterocolitis due to clostridium difficile (c. diff), not specified as recurrent. Review of a Nursing Progress Note dated 5/9/2025 reflects C. Diff test positive, contact precautions in place from time suspected and on-going, call placed to on-call NP (nurse practitioner) regarding, she states she will review lab and enter an order, Pt. (patient) notified of results, also (name of hospice provider) notified. Review of a Care Plan initiated on 5/9/2025 reflected I (R39) have an active infection: C-diff; Interventions on the care plan specified Administer anti-viral as per MD orders (clostridium difficile is a bacterium, not a virus and can cause severe diarrhea and colitis, which are inflammation of the colon.) The care plan also specified R39 was to be on CONTACT precautions. No further interventions were noted on the care plan. Review of a Kardex (a quick reference guide used by nurse aides to provide instruction for care) printed on 5/22/2025 reflected R39 required CONTACT precautions when providing care. No further information pertaining to c. diff was provided. Resident #16 (R16) Review of an Admission Record reflected R16 was admitted to the facility on [DATE] with diagnoses that included bipolar II disorder, vascular dementia, & muscle weakness. Review of a Care Plan initiated on 3/14/2022 indicated R16 had generalized weakness and required Supervision assist with 4WW (Four wheeled walker) and Personal Hygiene: Supervision. Further review of the entire care plan also reflected that R16 sometimes wander in the hallways or into other residents room . Further review of the entire care plan and Kardex did not reveal any indication R16 was sharing a room with a resident who was infected with C. diff. During an interview on 5/22/2025 at 9:02 AM, Registered Nurse (RN) B indicated she was the Infection Control Nurse (IC) Nurse at the facility. RN B said that R39 was placed in contact precautions as soon as it was suspected that she may have C. diff. RN B indicated that staff were instructed to don personal protective equipment (PPE) when entering R39's room and all trash and/or linens were to be removed from the room in red bio-hazard bags and that staff were to wash their hand with soap and water because alcohol-based hand rub was ineffective against the C. diff spores. RN B reported that R39 did not use the shared bathroom, and a private room was not available, so staff were instructed to treat both residents in the room as if they were both in contact precautions. RN B reported that R16 (R39's roommate) was able to transfer independently and used a 4WW with supervision. RN B said that no interventions such as assisting/ensuring R16 wash their hands with soap and water prior to leaving the room or cleaning the walker had been added to factor in R16's likelihood of touching contaminated surfaces and leaving the room to ambulate around the facility. During an observation on 5/22/2025 at 12:17 PM, RN B donned PPE and entered R39's room as Certified Nurse Aide (CNA) C was exiting R39's room with two clear plastic bags of soiled materials. CNA C was not observed washing her hands with soap and water. A red biohazard bin was a few feet away from the head of the bed against a partially drawn privacy curtain separating R39's side of the room from R16's side of the room. A clear plastic trash bag was inside the red biohazard bin. R39 reported the bin had just been placed in her room. During an interview on 5/22/2025 at 12:33 PM, CNA C reported she had just been educated by RN B who had observed her leaving R39's room without washing her hands with soap and water after providing care to R39. CNA C reported she did not know hand sanitizer was ineffective against C. diff. Review of a policy Management of C. Difficile Infection last revised 1/24 reflected This facility implements facility-wide strategies for the prevention and spread of Clostridioides difficile (C. difficile) infections. Clostridioides difficile, formerly known as Clostridium difficile and often-called C. diff, is a bacterium that causes diarrhea and colitis (an inflammation of the colon). It is shed in feces and is spread by direct contact with contaminated objects or the hands of persons who have touched a contaminated object. 2. Potential complications and risks associated with C. difficile include: a. hospitalization b. Pseudomembranous colitis c. Toxic megacolon d. Sepsis e. Death . General principles related to contact precautions for C. difficile: All staff are to wear gloves and a gown while providing care for the resident with C. difficile infection or having direct contact with items in their environment. Hand hygiene shall be performed by handwashing with soap and water in accordance with facility policy for hand hygiene. Maintain contact precautions for the duration of illness per CDC Isolation Precautions Appendix A. Encourage/assist residents to wash hands frequently. Use disposable equipment whenever possible. Thoroughly clean and disinfect reusable equipment with a sporicidal disinfectant that is compatible with the equipment. Disinfected items with fecal soiling (i.e. bedpans, commode chairs, bedrails, etc.). A private room with a dedicated toilet is preferred. If a private room is not available: i. Prioritize residents with bowel incontinence for placement in private room. ii. If cohorting (i.e. room sharing) is required, cohort residents with the same organism, with a dedicated toilet. Treatment for C. difficile infection will be in accordance with physician orders, current treatment guidelines, and local sensitivity/susceptibility data. Environmental infection control: Housekeeping staff shall adhere to standard and contact precautions. Perform daily cleaning of the resident's room and high touch surfaces using a C. difficile sporicidal agent (EPA List K agent). Perform terminal cleaning after the resident is transferred/discharged with a C. difficile sporicidal agent (EPA List K agent). 37872 During an interview on 05/22/25 at 11:40 AM, Laundry Aide (LA) O revealed she has never been educated on the procedure for handling clothing/linens contaminated with C-Diff. LA O further revealed, I sometimes will separate residents' load (in the red bio-hazardous bags) because I do not want to wreck their personal clothing in bleach, but I will wash all the other items in a bleach load. LA O further revealed R39's laundry, usually comes down in regular (clear) bags. During an interview on 5/22/25 at 11:55 AM, Registered Nurse (RN) B revealed R39's soiled lines are supposed to be placed in the red (biohazardous) bags and/or bags that dissolve in the wash. Aides grab the new bags from the PPE bins (located outside of residents' room) when going in to provide care. RN B further revealed laundry is supposed to wash them separately. During an observation on 5/22/25 at approximately 12:06 PM, Certified Nurse's Aide (CNA) Q and Certified Nurse's Aide (CNA) C were observed gowning up to enter R39's room. (No red or dissolvable bags observed in Personal Protection Equipment (PPE) bins located outside room.) CNA Q further revealed they did not have any red bags located in the residents' room and would have housekeeping get more. 37573 Glucometer and Blood Pressure Cuff Cleaning During an observation on 5/21/25 at 8:12 AM, Licensed Practical Nurse (LPN) G went to room [ROOM NUMBER]-1 to check a blood pressure with a blood pressure cuff and check a blood sugar level with a glucometer for that resident. When LPN G was done, she left the room without cleaning the equipment and sat the devices on top of the medication cart. At 8:56 AM, LPN G went to room [ROOM NUMBER]-1 to check a resident's blood sugar with the same uncleaned blood pressure cuff and glucometer. After leaving room [ROOM NUMBER]-1, LPN G took the devices out of the room and sat them on the medication cart in the hallway without appropriately cleaning them. During an observation on 5/21/25 at 12:03 PM, LPN G took the same uncleaned glucometer that was sitting on top of the medication cart into room [ROOM NUMBER]-1 to check a blood sugar and left the room with the device and sat it on top of the medication cart without cleaning it. In an interview on 5/21/25 at 1:50 PM, LPN G reported she already knew she was supposed to clean the glucometer after each resident with sanitizing wipe with a purple top called Micro Kill Sanitizer Wipes for one minute and admitted she did not do that. At this time the glucometer and the blood pressure cuff were still sitting on top of the medication cart and LPN G reported she still did not clean them. LPN G did not know where the sanitizing wipes were and then searched the medication cart and found them. LPN G reported she had a total of 4 residents she had to use the glucometer for. LPN G reported she uses her own personal blood pressure cuff for resident care because she likes it better and realized she should have cleaned that as well after each resident. Hoyer lifts During an observation and an interview on 5/20/25 at 3:30 PM, two Hoyer lifts (mechanical lifts), numbered 203 and 309, were in the hallway of the 300 hall. Both lifts had empty plastic bags hanging from them. The base of one Hoyer lift was covered with a large amount of sticky and rough substance that did not rub off, while the upper bar where the slings attach was covered with fingerprints and grime. Certified Nursing Assistant (CNA) J stated that the empty bags were meant to hold sanitizing wipes for cleaning the lifts but acknowledged that there were none inside them. CNA J also noted that the feet of one Hoyer lift resembled tape. When I inquired about the bar above where the slings attach, CNA J indicated it appeared not to have been cleaned in a considerable time. Review of a policy titled Cleaning and Disinfection of Resident-Care Equipment last revised 8/24 revealed: Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC (Centers for Disease Control) recommendations to break the chain of infection. 2. d. Multiple-resident use equipment shall be cleaned and disinfected after each use.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment, and ensure proper cooling of food affecting 75 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. On 05/22/25 between 9:10 AM and 10:05 AM during the initial tour with Certified Dietary Manager (CDM) A the following concerns were observed: Observation of the cookline revealed the Accutemp Steamer had one end of a drain line directly connected to the bottom of the steamer. The other end of the drain line went down through the grated floor drain and was submerged directly into the sewer drainpipe. Review of the FDA 2017 Food Code Section, 5-402.11 Backflow Prevention. Reflects the following, .a direct connection may not exist between SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. Further observation of the cookline revealed a build-up of grease, grime and food debris behind/under the cooking equipment. Review of the FDA 2017 Food Code Section, 6-501.12 Cleaning, Frequency and Restrictions. Reflects the following, (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. Observation of the Kelvinator 3 door line cooler was observed to be empty and had orange sticky not posted on a door of the cooler that stated, breakers Not working everything moved to [NAME] The unit is needed for cold holding food storage and ensuring safe food service operations. Review of the FDA 2017 Food Code Section, 4-501.11 Good Repair and Proper Adjustment. Reflects the following, (A) Equipment shall be maintained in a state of repair and condition that meets the requirements under 4-1 and 4-2. Review of the FDA 2017 Food Code Section, 4-301.11 Cooling, Heating, and Holding Capacities. Reflects the following, EQUIPMENT for cooling and heating FOOD, and holding cold and hot FOOD, shall be sufficient in number and capacity to provide FOOD temperatures as specified under Chapter 3. Observation of the can opener blade reflected stuck on food residue and debris. Observation of the clean pan storage shelving on the cook line revealed a few pans were soiled with stuck on food residues and debris. Review of the FDA 2017 Food Code Section, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces and Utensils. Reflects the following, (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean sight to touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. Observation of [NAME] 3-Door-Cooler revealed a burnt-out light bulb. Review of the FDA 2017 Food Code Section, 6-303.11 Intensity. Reflects the following, The light intensity shall be: .(B) At least 215 lux (20-foot candles): . (2) Inside EQUIPMENT such as a reach-in and under-counter refrigerators; . Observation of the ice machine revealed no date mark on the filter. During the interview the CDM A stated she was unsure when it was last replaced. Review of the FDA 2017 Food Code Section, 5-205.13 Scheduling Inspection and Service for a Water System Device. A device such as a water treatment device or backflow preventer shall be scheduled for inspection and service, in accordance with manufacturer's instructions and as necessary to prevent device failure based on local water conditions, and records demonstrating inspection and service shall be maintained by the PERSON IN CHARGE. Observation of the Walk In Freezer and Walk In Cooler revealed food residue and debris on flooring. Further observation of the Walk in Cooler revealed containers of Sloppy [NAME] & Ravioli both had a date mark of 5/19/25. Condensation droplets were observed on the underside of both lids indicating a possible cooling concern. Review of the FDA 2017 Food Code Section, 6-501.12 Cleaning, Frequency and Restrictions. Reflects the following, (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. Review of the FDA 2017 Food Code Section, 3-501.14 Cooling. Reflects the following, (A) Cooked POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR FOOD SAFETY) shall be cooled: (1) Within 2 hours from 57 degrees Celsius (135 degrees Fahrenheit) to 21 degrees Celsius (70 degrees Fahrenheit), and (2) Within a total of 6 hours from 57 degrees Celsius (135 degrees Fahrenheit) to 5 degrees Celsius (41 degrees Fahrenheit) or less. During observation of Walk In Cooler CDM A was asked how they were cooling and if they had a cooling log. CDM A revealed their cooling logs were marked/monitored on their daily temp log sheets. Review of the 5/19/25 temp log reflected that staff had failed to document cooling for both the Sloppy Joes & the Ravioli. An obaervation 05/20/25 11:26 AM, of the locked Nutritional Refigerator (located in dining room on 300 hall) revealed soiled/sticky shelving. Review of the FDA 2017 Food Code Section, 4-602.13 Nonfood- Contact Surfaces. Reflects the following, NonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumualtion of soil residues. During and interview on 5/20/25 at 11:52 AM, CDM stated she had an in-service on cooling policy and procedures with two of my cooks. CDM A revealed her last cook is off and will be educated when they get back. During the kitchen observation on 5/20/25 at 11:53 AM, NHA revealed a new ice machine filter had been ordered and would be here tomorrow.

Based on interview and record review, the facility failed to follow professional standards of nursing practice for medication administration for 4 residents (Residents #11, #50, #7, and #28) out of 18 residents and residents receiving controlled medications on the Garden Unit, reviewed for the provision of nursing services. Findings: On 05/20/25 at 09:43 AM, the Garden Unit Narcotic Book was reviewed. There were 9 residents that did not have their scheduled morning controlled medications (narcotics) documented as dispensed since 5/19/25. Review of the Garden Unit Medication Administration Record revealed there were no medications documented as not administered at the time of the Narcotic Book review. On 05/21/25 at 02:01 PM, the Garden Unit Narcotic Book was reviewed. The previous 9 residents' medications were documented as dispensed the morning of 05/20/25 with the times the medications were dispensed documented prior to 09:43 AM. Confirming the licensed nurse did not document the date and time at the time the controlled medications were dispensed. Resident #11 Review of an Admission Record revealed R11 was an [AGE] year-old female, admitted to the facility on [DATE]. Review of R11's Order Summary dated 4/25/25 revealed, CloNIDine HCl Tablet 0.1 MG Give 0.1 mg by mouth every shift for HTN (hypertension) ONLY GIVE MEDICATION IF SBP (systolic [top number] blood pressure) is GREATER than 160 or DBP (diastolic [bottom number] blood pressure) is GREATER than 90. HOLD MEDICATION IF OUTSIDE OF THESE PARAMETERS! To be administered on day shift if needed and night shift if needed. Review of R11's May Medication Administration Record revealed: *On 5/2/25 R11's blood pressure was 135/69 and the clonidine was administered on day shift. *On 5/2/25 R11's blood pressure was 128/61 and the clonidine was administered on night shift. *On 5/3/25 R11's blood pressure was 148/76 and the clonidine was administered on night shift. *On 5/4/25 R11's blood pressure was 142/77 and the clonidine was administered on day shift. *On 5/5/25 R11's blood pressure was 151/67 and the clonidine was administered on day shift. *On 5/6/25 R11's blood pressure was 160/68 and the clonidine was administered on night shift. *On 5/7/25 R11's blood pressure was 133/71 and the clonidine was administered on night shift. *On 5/8/25 R11's blood pressure was 140/71 and the clonidine was administered on day shift. *On 5/8/25 R11's blood pressure was 159/83 and the clonidine was administered on day shift. *On 5/9/25 R11's blood pressure was 159/83 and the clonidine was administered on night shift. Resident #50 (R50) Review of an Admission Record revealed R50 was a [AGE] year-old male, admitted to the facility on [DATE]. Review of R50's Order Summary dated 4/27/25 revealed, Lisinopril Oral Tablet 5 MG (Lisinopril) Give 1 tablet by mouth one time a day for htn HOLD if SBP < (less than) 100, Pulse < (less than) 60. Review of R50's Blood Pressure Summary and Pulse Summary revealed there were no blood pressure or heart rate assessments documented on 5/2/25, 5/7/25, 5/9/25, 5/13/25, or 5/19/25. Review of R50's May Medication Administration Record revealed: *On 5/2/25 R50's lisinopril was administered. The blood pressure and heart rate from the previous shift was documented. *On 5/7/25 R50's lisinopril was administered. The blood pressure and heart rate from the previous shift was documented. *On 5/9/25 R50's lisinopril was administered. The blood pressure and heart rate from the previous shift was documented. *On 5/13/25 R50's lisinopril was administered. The blood pressure and heart rate from the previous shift was documented. *On 5/19/25 R50's lisinopril was administered. The blood pressure and heart rate from the previous shift was documented. Resident #7 (R7) Review of an Admission Record revealed R7 was a [AGE] year-old male, admitted to the facility on [DATE]. Review of R7's Order Summary dated 4/29/25 revealed, Lisinopril Oral Tablet 10 MG (Lisinopril) Give 1 tablet by mouth two times a day for HTN Hold if Systolic < 90. Notify physician if SBP is greater than 165 or DBP is greater than 95. Review of R7's Blood Pressure Summary and Pulse Summary revealed there were no morning blood pressure or heart rate assessments documented on 5/2/25, 5/7/25, 5/9/25, 5/13/25, or 5/19/25. Review of R7's May Medication Administration Record revealed: *On 5/2/25 R7's morning lisinopril was administered. The blood pressure and heart rate from the previous shift was documented. *On 5/7/25 R7's morning lisinopril was administered. The blood pressure and heart rate from the previous shift was documented. *On 5/9/25 R7's morning lisinopril was administered. The blood pressure and heart rate from the previous shift was documented. *On 5/13/25 R7's morning lisinopril was administered. The blood pressure and heart rate from the previous shift was documented. *On 5/19/25 R7's morning lisinopril was administered. The blood pressure and heart rate from the previous shift was documented. During an interview on 05/21/25 at 03:57 PM, Licensed Practical Nurse (LPN) M reported that some resident medications have parameters ordered and those parameters are expected to be followed. During an interview on 5/22/25 at 10:33 AM, Nurse Practitioner (NP) N reported it was expected that medications were administered following the provider order which including obtaining and assessing vital signs prior to the administration of medications. During an interview on 05/22/25 at 11:14 AM, Nursing Home Administrator (NHA) and DON (Director of Nursing) reported that they had identified concerns with licensed nurses following ordered parameters. Nurse education and audits were conducted beginning in February to ensure medications were administered within the ordered parameters. NHA reported they had not identified concerns with nursing staff utilizing previous shift vital signs (blood pressures and heart rates) when administering medications and the expectation was for vitals to be assessed immediately prior to the administration of medications. During an interview on 05/22/25 at 12:16 PM, DON and NHA confirmed that R7 and R50 had not had vital signs assessed prior to the lisinopril administration on the dates listed above. NHA reported they identified that it had been 1 nurse that administered the medications, and she was immediately educated. Review of the licensed nurse's education revealed, .It can be observed in the MAR (medication administration record) for more than one resident this nurse copying vitals last collected prior to administering medications, this creates potential for safety risk to resident as vitals should be obtained within window of med pass so parameters can be followed. Review of the facility policy Controlled Substances last revised January 2018 revealed, .D. Accurate accountability of the inventory of all controlled substances is maintained at all times. When a controlled substance is administered, the nurse administering the medication immediately enters the following information on the controlled substance count sheet and on the Medication Administration Record (MAR): 1) Date and time of administration (MAR, controlled substance count sheet) 2) Amount administered (controlled substance count sheet) 3) Remaining quantity (controlled substance count sheet) 4) Initials of the nurse administering the dose (MAR, controlled substance count sheet) . Review of the facility policy Medication Administration-General Guidelines last revised June 2019 revealed, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system. The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions.2) Medications are administered in accordance with written orders of the prescriber . Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, (Nurses) are also responsible for documenting any preassessment data required with certain medications such as a blood pressure measurement for antihypertensive medications or laboratory values, as in the case of warfarin, before giving the medication. After administering a medication, immediately document which medication was given on a patient's MAR per agency policy to verify that it was given as ordered. Inaccurate documentation, such as failing to document giving a medication or documenting an incorrect dose, leads to errors in subsequent decisions about patient care. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (pp. 643-644). Elsevier Health Sciences. Kindle Edition. 29073 Resident #28 (R28) Review of an Admission Record reflected R28 admitted to the facility on [DATE] with diagnoses that included congestive heart failure, atherosclerotic heart disease, atrial fibrillation, hypertensive heart disease with heart failure, ischemic cardiomyopathy and a history of other venous thrombosis and embolism. Review of a Follow-up visit note, documented by Nurse Practitioner (NP) N on 4/29/2025, indicated R28's PT/INR was 3.6/43.7 (Prothrombin Time/International Normalization Ratio, a blood test that measures how quickly blood clots). Will hold coumadin (a blood thinning medication) x one dose and repeat PT/INR on Friday. Review of a Follow-up visit note, documented by Nurse Practitioner (NP) N on 4/30/2025 reflected R28's coumadin was not held as intended and his PT/INR was 5.0/60.00. Will hold coumadin x 2 days, then re-check pt/inr on Friday. He denies any unusual bruising or bleeding. He has 2+ non-pitting edema to LLE (left lower extremity, 1+ non pitting edema to RLE (right lower extremity. He is resting with eyes closed but awakens to verbal stimuli. He denies any new or uncontrolled pain. He reports stable mood, sleep, appetite patterns. Review of a Nursing Incident Note dated 5/1/2025 reflected the medication error and indicated order was not held or discontinued, and warfarin was administered. Immediate intervention implemented: educated staff r/t (related to discontinuing and putting orders on hold in (electronic medical record). Review of Coagucheck: PT/INR Test Log for R28 reflected 11 entries from dates 4/3/2025-5/21/2025. An entry on 4/29/2025 at 0630 (6:30 AM) indicated R28's PT/INR was 3.6/43.7 without a Current Coumadin Dose recorded. The next entry recorded on the log was dated 5/6/2025. The PT/INR of 5.0/60.00 was not entered onto the log. No diagnosis was included on the log indicating the reason R28 required the anticoagulant and an INR Goal Range was also NOT specified. Review of a Physician Progress Note dated 5/3/2025 reflected the Physician, DO P saw R28 for a Regulatory Visit and noted This [AGE] year-old male was seen for a regulatory visit. He transferred to (name of facility) on 7/29/24 after a hospitalization for UTI/septic shock. He uses a wheelchair now and can propel it himself according to a PT (physical therapy) note. He has memory loss. He has a history of DVT/embolism. His LLE is more swollen than his RLE. A recent ultrasound showed peroneal DVT which is chronic. He is on coumadin. His LLE is not tender when I palpate it. His INR is in the appropriate range. Further review of the clinical record did not reflect evidence that a PT/INR had been obtained prior to the next recorded value on the PT/INR log. The progress note was not electronically signed by the DO P until 5/7/2025, making it unclear if DO P saw R28 on 5/3/2025. During an interview on 5/21/2025 at 3:03 PM, Licensed Practical Nurse (LPN) L reported that she was a brand new nurse and just off orientation at the facility. When asked about the facility procedures for PT/INR monitoring, reporting and documentation, LPN L said she had no idea and would have to ask someone to help her learn the process. During an interview on 5/21/2025 at 3:04 PM, LPN G reported that she had no idea what the PT/INR protocols at the facility are and that it differs on each unit. LPN G said there are logs in the med books and in progress notes. During an interview on 5/21/2025 at 3:09 PM, LPN H reported that PT/INR is obtained with a machine in the facility via test strips. The results are recorded on a log maintained in the narcotic book on the med cart and noted in the computer charting, the physician/provider is notified, and orders are updated. Side effect monitoring is completed daily for any resident who is on an anticoagulant. During an interview on 5/22/2025 at 10:31 AM, NP N reported that she was educated about how to enter orders into the electronic medical record to prevent medication errors in the future. NP N reported the therapeutic range for R28's PT/INR was 2.5-3.5. NP N reviewed the progress note written by DO P and stated that based on the information available in the clinical record and the PT/INR Test Log, the PT/INR for R28 at that time was not in the therapeutic range for DVT or atrial fibrillation. An attempt to contact DO P via telephone was made on 5/22/2025 at 12:07 PM. A voice message was left requesting a return call. During a telephone interview with DO P on 5/23/2025 at 4:17 PM, DO P was not able to locate the PT/INR value used to determine that as of 5/3/2025 R28's INR was in the appropriate range. According to DO P, he wasn't sure where nursing staff recorded the PT/INR readings measured at the facility. DO P said the therapeutic PT/INR goal for R28 was 2.0-3.0, unless he had a heart valve issue. The health care record provides a way for members of the interprofessional health care team to communicate about multiple aspects of patient care, including patient needs and response to care and therapies; clinical decision making; and the content and outcomes of consultations, patient education, and discharge planning. Information communicated in the health care record allows health care providers to know a patient thoroughly, facilitating safe, effective, timely, and patient-centered clinical decision making. The health care record is the most current and accurate, continuous source of information about a patient's health care status, allowing the plan of care to be clear to anyone who accesses the record. To enhance communication and promote safe patient care, you document assessment findings and patient information as soon as possible after you provide care (e.g., immediately after providing a nursing intervention or completing a patient assessment). The quality of patient care depends on your ability to communicate with other members of the health care team (see Chapter 24). When a plan is not communicated to all members of the health care team, care becomes fragmented, tasks are repeated, and delays or omissions in care often occur. The health record is an important means of communication because it is a confidential, permanent, legal documentation of information relevant to a patient's health care. The record is an ongoing current and accurate account of a patient's health care status and is available to all members of the health care team. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 366). Elsevier Health Sciences. Kindle Edition. Legal Guidelines for Documentation . Errors in recording can lead to errors in treatment or may imply an attempt to mislead or hide evidence . Record must be accurate, factual, and objective. Be certain that each entry is thorough. A person reading your documentation needs to be able to determine that a patient received adequate care. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 366). Elsevier Health Sciences. Kindle Edition.

Based on observation, interview and record review, the facility failed to assist in finding an appropriate fitting wheelchair for one (R44) of one resident reviewed for wheelchair needs. Findings include: Resident #44 (R44) Review of a Face Sheet revealed R44 originally admitted to the facility on [DATE] and has pertinent diagnoses of lack of coordination, spinal stenosis in lumbar region with neurogenic claudication (nerve pain typically in both legs), morbid obesity, and limitation of activities due to disability and osteoporosis. Review of the Minimum Data Set (MDS) dated [DATE] for R44 revealed she was cognitively intact and utilizes a manual wheelchair. In an interview on 5/20/25 at 9:31 AM, R44 was in bed and reported the facility took her electric wheelchair away from her because they were concerned about her safety due to her high ammonia levels and some components of her electric wheelchair were broken so they were concerned about the steering mechanisms. R44 reported that she no longer has control over going outside and navigating the facility independently. R44 stated that she transitioned from having some independence to none at all. She now uses a manual wheelchair, which she finds difficult to self-propel. She pointed out areas of discoloration and bruising on her legs caused by bumps against the sharp edges of the wheelchair, which sometimes breaks the skin. Additionally, she complained that the wheelchair wobbles when she attempts to transfer into it. During an observation and an interview on 5/20/25 at 10:26 AM, R44 reported her feet could not reach the floor to self-propel in her wheelchair. At this time, she transferred from her bed to her wheelchair and once she sat down, her feet were in the air approximately 3 inches off the floor. R44 reported she will scoot to the middle of the seat so her toes can touch floor and move the wheelchair, but staff will tell her she needs to sit back in the wheelchair, so she does not fall. R44 reported sometimes she will push backwards in her wheelchair because it is easier, or she will use the rails on the side of the walls to help pull herself along. R44 complained her shoulder was sore from trying to pull herself along the wall the day before. R44 reported that losing her independence does not do well for her mind. In an interview on 5/21/25 at 11:14 AM, the Rehabilitation Director (RD) D reported R44 was deemed unsafe in her electric wheelchair before her admission to the hospital and agreed her current wheelchair does not fit R44 appropriately, but they do not make a wheelchair that sits low enough for her. In an interview on 5/21/25 at 11:23 AM, the Nursing Home Administrator (NHA) reported that R44 is not safe in an electric wheelchair and was told last year that the manual wheelchair R44 is in now meets her needs. At this time documentation was requested to show that R44 was properly fitted for her current wheelchair and any attempts made to find an appropriate fitting wheelchair. The NHA later reported that the current wheelchair R44 is 17-inch height and that is the lowest one they (the facility) have and could not find a lower sitting wheelchair. When questioned about how shorter people, including children, are accommodated for smaller wheelchairs and the fact that they exist, the NHA reported she would look into that. Later the NHA reported that the 17-inch wheelchair is the shortest one they make. No documentation provided by the end of this survey to show there is any correspondence or documentation to show there is no other wheelchair options for R44 that will fit her appropriately and safely. Review of Physical Therapy Treatment Encounter notes for R44 revealed the following: 3/18/25- WC (wheelchair) mobility performed in facility with bilateral UE's (upper extremities) long distances with intermittent cueing for safety negotiating obstacles. Pain: . Patient noting some bilateral knee soreness. 3/19/25- W/C mobility included turning around in narrow spaces, turning corners, passing through doorways, forward propelling and backward propelling. Pt (patient) prefers backward d/t (due to) short LE's (lower extremities) able to push self, otherwise using B UE (bilateral upper extremities) when going forward. Pain: . Pt stated having some pain in B knees d/t bone on bone and some pain in R (right) ankle). 4/9/25: Patient noting problem with wc catching during mobility. Noted screws on wheel rims loosened and hitting arm rest panel. Tightened screws and problem resolved. Patient also c/o (complains of) discomfort sitting in wc due to patient removing wc cushion secondary to being too high to reach floor with feet. Replaced wc cushion with lower profile cushion to trial. Patient able to perform WC mobility with lower extremities without assistance with some continued difficulty with foot contact on floor. Patient noted she would consider alternative footwear to improve contact and traction. In an interview on 5/22/25 at 8:56 AM, Physical Therapy Assistant (PTA) F reported he measured R44 this morning and her feet are 4 inches short from reaching the floor. R44 will push herself backwards which is not safe since she cannot see behind her. PTA F reported R44 will also pull herself down the hall using the wall rails. When questioned about the progress note on 4/9/25 regarding R44 considering alternative footwear to improve contact and traction, PTA F reported that would be helpful for anyone in general when self-propelling in a wheelchair. Review of an ADL (Activities of Daily Living) Care Plan for R44 revealed: Focus: . I am able to meet my SAFEST and highest functional level of independence with use of my manual wheelchair. My guardian and physician have agreed that the electric wheelchair is a hazard to my safety and providing me with it as a tool I use to harm myself DOES NOT promote independence nor physical or mental wellness, last revised 4/24/25. Interventions included, but not limited to: I propel myself with a w/c (wheelchair). I have a seatbelt. I am able to unfasten my seatbelt independently. I often choose to remove seatbelt. I use a pommel style cushion provided by therapy, last revised 3/19/25. Review of a fall prevention Care Plan for R44 revealed: Intervention: . I have been evaluated by a physical therapist in the facility who states the manual w/c is able to meet my needs. I am able to utilize a manual wheelchair as designed with my upper body strength only. Despite being educated I choose to utilize my feet because it's easier. I do this knowing it increased my potential for falls. Initiated 10/28/24.

Based on observation, interview, and record review, the facility failed to assess and address edema, significant weight gain, and follow through with physician orders for one (R44) who was reviewed for quality of care. Findings include: Resident #44 (R44) Review of a Face Sheet revealed R44 originally admitted to the facility on [DATE] and has pertinent diagnoses of stage III chronic kidney disease, diabetes, morbid obesity, and cardiac murmur. Review of the Minimum Data Set (MDS) dated [DATE] for R44 revealed she was cognitively intact. During an observation and an interview on 5/20/25 at 9:31 AM, R44 was laying down in bed with her legs horizontal. She reported that she had to go to the hospital a couple months ago because she had high ammonia levels, which resulted in her experiencing some psychiatric issues. R44 was unhappy because she felt the facility could have caught it earlier. R44 reported having a fall when her ammonia levels were high and was accused of throwing herself on the floor. R44 stated Who does that? R44 reported the facility was to recheck her ammonia levels since she came back from the hospital a couple months ago and they still have not done it. Review of the Electronic Medical Record (EMR) for R44 revealed no laboratory results or hospital records indicating abnormal ammonia level concerns or any labs with resulting ammonia levels. Review of an Order Summary for R44 revealed on 4/24/25 there was an order for Lab: Ammonia one time only for psychotic features/confusion for 1 Day. During an observation and an interview on 5/20/25 at 10:26 AM, R44 was still lying in bed with her legs horizontal and uncovered. R44 was able to reach her shin to push in on her skin when a 2+ pitting edema was noticed. Review of R44's weight history in the electronic medical records (EMR) revealed some of the following weights: 3/14/25- 231.7 Lbs (pounds) Floor Scale 4/10/25- 248.2 Lbs Wheelchair (A 16.5-pound weight gain since 3/14/25) 4/11/25- 248 Lbs Floor Scale 4/22/25- 237 Lbs Floor Scale (An 11-pound weight loss from 4/11/25) 4/23/25-244.3 Lbs Floor Scale (A 7.3-pound weight gain from the day before) 5/4/25- 246.6 Lbs Floor Scale 5/8/25- 254 Lbs Wheelchair 5/9/25- 254.3 Lbs Wheelchair (A 22.6-pound weight gain since 3/14/25) In an interview on 5/22/25 at 9:41 AM, Registered Nurse (RN) E reported she would assess residents if they prompted for skilled charting. RN E was not aware of R44's weight gain or her edema. RN E went to R44's room at this time to do an assessment and reported R44 did have 1-2 + pitting edema in her bilateral lower extremities and her hands were swollen and rings on her fingers were tight and indented. RN E' reported R44 does like to eat a lot of unhealthy foods and lots of soda. RN E did confirm R44 was not on any diuretics now and will reweigh R44 to make sure they have an accurate weight. RN E reported that a weight fluctuation like this would usually trigger dietary as well to question the change. In an interview on 5/22/25 at 9:57 AM, Unit Manager (UM)/Licensed Practical Nurse (LPN) B reported she would expect staff to recheck the weight for R44. UM B did not know of any ammonia labs ordered for R44. In an interview on 5/22/25 at 12:24 PM, the Director of Nursing (DON) reported if a resident has a big fluctuation in weights like R44, she expects staff to reweigh residents for accuracy, then notify the provider and educate the resident on food and fluid intake and confirmed that it was not done. When queried about the ammonia lab orders for R44, the DON could not find that it was completed and later reported it was never done. The DON reported the physician put the orders in the EMR but it did not prompt the nursing staff to make sure it was done. Review of Care Plan interventions for R44 revealed the following: -Inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness. Initiated 9/16/24. -Draw labs as needed to monitor for electrolytes imbalances when needed. Initiated 11/5/24.

Based on observation, interview, and record review, the facility failed to implement preventative care and services of pressure injuries for one (R15) of two residents reviewed for pressure injuries. Findings include: Review of a Face Sheet for R15 revealed she originally admitted to the facility on [DATE] and has pertinent diagnoses of Parkinsonism, scoliosis (irregular curvature of the spine), and spondylosis with myelopathy in the cervical region (neurological deficit related to the spinal cord). Review of the Minimum Data Set (MDS) dated [DATE] for R15 revealed she is severely cognitively impaired and has bilateral limited range of motion on her upper and lower extremities and requires substantial/maximal assistance for bed mobility. R15 is documented as not being a high risk for pressure ulcers which conflict with the Braden Scale Assessment done on 3/1/25. During an observation on 5/20/25 at 9:48 AM, R15 is in bed lying on her back, eyes closed, neck resting on a neck pillow, and bilateral legs resting on two pillows and the left foot appears to be contracted in a forward position (plantar flexion). Review of a Braden Scale for Determining Pressure Ulcer Risk for R15 dated 3/1/25 revealed she is at high risk for developing pressure ulcers. During an observation and an interview on 5/20/25 at 11:08 AM, R15 was observed in bed on her back with her neck resting on a neck pillow and her legs resting on 2 pillows with her heels over them. R15 reported she used to have a pressure ulcer on her back but not anymore. R15 reported staff are to reposition her often but she must put the call light on for them to come to her room to do anything. R15 reported she is uncomfortable. During an observation on 5/20/25 at 2:06 PM, R44 was still in bed lying on her back in the same position as the last observation with her legs elevated on pillows. During an observation and an interview on 5/20/25 at 3:40 PM, R15 was in bed in the same position as the previous observation. Certified Nursing Assistant (CNA) J went into R15's room for incontinence care. R15 had a large tennis ball sized reddened/purple area on her coccyx that was blanchable and rated pain in that area at a 7 out of a 10-point scale. When asked if R15 hurts when she changes positions, R15 reported it hurt more to just lay there in that same position. At this time CNA J place a pillow on her left side to offload her weight. During an observation on 5/21/25 at 8:50 AM and 10:54 AM, R15 was observed on her back with her neck resting in a neck pillow and her legs elevated on two pillows. During an observation on 5/21/25 at 12:30 PM, R15 just received her lunch tray and was sitting up more in her bed at a 45 degree angle eating her meal. During an observation and an interview on 5/21/25 at 1:47 PM, R15 was lying in bed on her back with her legs elevated on 2 pillows. R15 reported she had pain on her backside/buttocks and knees and rated the pain at 7/10 scale. During an observation and interview on 5/21/25 at 2:25 PM, CNA K reported she did not recall seeing any redness or discoloration on R15 when she provided incontinence care earlier. When asked why R15 was not repositioned all day, CNA K reported there were no orders for R15 to be repositioned. During an observation and an interview on 5/21/25 PM at 4:04 PM, Licensed Practical Nurse (LPN) L assisted R15 with incontinence care and observed a large reddened/purple area on her coccyx that was blanchable. R15 reported she was uncomfortable. In an interview on 5/22/25 at 10:26 AM, Unit Manager (UM)/LPN B reported R15 has a history of refusing care. Staff should attempt to reposition R15 and inform the nurse if she refuses to be repositioned. Staff should also reapproach the resident if she refuses. In an interview on 5/22/25 at 12:38 PM, the Director of Nursing (DON) stated she expects all CNAs to reposition residents who are in bed all day, every 2 hours. Review of the Care Plan revealed: I am at risk for impaired skin integrity r/t weakness/debility, COPD, polyneuropathy, incontinence, Vit B12 deficiency, scoliosis, hypothyroidism, chronic pain syndrome. I often refuse to get out of bed, sit in w/c, and be turned. (last revised 5/13/25) Interventions included: - Assess and monitor me for pain Initiate my preferred non-pharmacological interventions prior to initiating medication, as applicable. Follow-up as indicated. -If I decline treatment, confer with me, IDT and my representative, as applicable, to determine why and try alternative methods to gain compliance. -Pressure reduction support surface in bed, type: APM, date applied: 3/21/25 No high risk for pressure ulcers is focused on the care plan with meaningful interventions to drive a personalized plan of care for R15. Review of a policy titled Skin and Pressure Injury Risk Assessment and Prevention last revised 2/24 revealed: 12. Interventions for Prevention and to Promote Healing a. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. b. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). c. Evidence-based interventions for prevention will be implemented for residents who are assessed at risk and/or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: i. Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.); ii. Minimize exposure to moisture and keep skin clean, especially of fecal contamination; iii. Provide appropriate, pressure-redistributing, support surfaces; iv. Maintain or improve nutrition and hydration status, where feasible.

Based on observation, interview, and record review, the facility failed to identify and implement measures to prevent foot drop for one (R15) of one resident reviewed for positioning. Findings include: Review of a Face Sheet for R15 revealed she originally admitted to the facility on [DATE] and has pertinent diagnoses of Parkinsonism, scoliosis (irregular curvature of the spine), and spondylosis with myelopathy in the cervical region (neurological deficit related to the spinal cord). Review of the Minimum Data Set (MDS) dated [DATE] revealed she is severely cognitively impaired and has bilateral limited range of motion on her upper and lower extremities and requires substantial/maximal assistance for bed mobility. Review of the Electronic Medical Records for R15 revealed she had no diagnosis of contractures or foot drop. During an observation on 5/20/25 at 9:48 AM, R15 is in bed lying on her back, eyes closed, neck resting on a neck pillow, and bilateral legs resting on two pillows and the left foot appears to be contracted in a forward position (plantar flexion/foot drop). During an observation and an interview on 5/20/25 at 11:08 AM, R15 was observed in bed on her back with her neck resting on a neck pillow and her legs resting on 2 pillows with her heels over them. Her left foot is resting over the pillows in a plantar flexion position. During an observation on 5/20/25 at 2:06 PM, R44 was still in bed lying on her back in the same position as the last observation with her legs elevated on pillows and her left foot is still in a plantar flexion position. During an observation and an interview on 5/20/25 at 3:40 PM, R15 was in bed in the same position as the previous observation. During an observation on 5/21/25 at 8:50 AM and 10:54 AM, R15 was observed on her back with her neck resting in a neck pillow and her legs elevated on two pillows and her left foot in a plantar flexion position. During an observation and an interview on 5/21/25 at 1:47 PM, R15 was lying in bed on her back with her legs elevated on two pillows with her left foot in a plantar flexion position. During an observation and interview on 5/21/25 at 2:25 PM, CNA K was asked why R15 was not repositioned all day, CNA K reported there were no orders for R15 to be repositioned. During an observation and an interview on 5/21/25 PM at 4:04 PM, Licensed Practical Nurse (LPN) L assisted R15 with incontinence care and observed a large reddened/purple area on her coccyx that was blanchable. R15 reported she was uncomfortable. In an interview on 5/22/25 at 10:26 AM, Unit Manager (UM)/LPN B reported she was not aware of R15 having any contractures in her left foot and not sure if she would benefit from any active or passive range of motion (ROM) care. If R15 would benefit from any ROM care, it would be ordered by hospice or therapy. In an interview on 5/22/25 at 12:38 PM, the Director of Nursing reported that R15 had foot drop in her left leg and that hospice confirmed it and documented it this day. Review of a Hospice Nursing progress note dated 5/22/25 for R15 revealed: While at facility was requested to assess foot drop which is present to left foot. Review of the Care Plan for R15 revealed no focus for positioning for limited ROM on the bilateral upper and lower extremities.

Based on interview and record review, the facility failed to notify the provider of abnormal vital signs for 1 of 6 residents (Resident #11) reviewed for notification of change. Findings: Resident #11 Review of an Admission Record revealed R11 was an [AGE] year-old female, admitted to the facility on [DATE]. Review of R11's Blood Pressure Summary revealed: *On 4/8/2025 9:00 PM R11's blood pressure was 209/92 no reassessment until 4/9/2025 at 9:27 AM. *On 5/12/2025 9:35 AM R11's blood pressure was 236/104 no reassessment until 8:40 PM. *On 5/20/2025 8:48 AM R11's blood pressure was 213/102 no reassessment until 7:12 PM. Review of R11's Provider Note dated 5/12/25 revealed, .Blood Pressure: 236/104 mmHg .BP recorded this morning quite high in the 200s systolic. Has previously been quite stable. Would like to recheck. If staying persistently elevated will adjust BP meds . Confirming the provider had not been notified of the elevated blood pressure but observed it in R11's Electronic Health Record. Review of R11's Electronic Health Record revealed no documentation that the providers were notified of the above elevated blood pressures. During an interview on 05/21/25 at 03:57 PM, LPN M reported that if a residents blood pressure was as high as R11's then a manual assessment should be completed. If the resident's blood pressure was out of range the provider would be notified. LPN M reported that any provider communication should be documented in the progress notes. During an interview on 5/22/25 at 10:33 AM, Nurse Practitioner (NP) N reported it was expected that the provider would be notified for blood pressures that were out of range and would have expected the licensed nurses to notify the provider of R11's blood pressures listed above and to reassess as well. During an interview on 05/22/25 at 11:14 AM, Nursing Home Administrator (NHA) and DON (Director of Nursing) reported that they had identified concerns with licensed nurses following notifying providers of abnormal vital signs. Nurse education and audits had been conducted beginning in February. On 05/22/25 at 11:50 AM any additional documentation regarding R11's elevated blood pressures and treatment/notification was requested. There was no additional documentation received prior to survey exit. Review of the facility policy dated 7/24 revealed, It is the policy of this facility to inform residents/legal representative, attending physician or designee of a change in the resident's condition . 2. The facility will inform the resident, consult with the resident's provider, and notify, consistent with his or her authority, the resident representative(s) when there is . b. A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); c. A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) .

This citation pertains to MI00147646 Past Non-Compliance was determined appropriate by the state agency for this citation. Plan outlined below. Based on interview and record review the facility failed to protect the resident's right to be free of Abuse from physical restraints for one resident (R101) of six residents reviewed for abuse. Findings: Review of the Facility Reported Incident (FRI) revealed on the morning of 10/15/24 in the Garden Unit R101 was discovered by oncoming staff to be tightly wrapped in a blanket from the waist down preventing freedom of movement. The FRI reflected the assigned staff member had left the facility without notifying the nurse on duty and before the oncoming shift had arrived. Review of the medical record reflected R101 admitted to the facility 2/19/18 with pertinent diagnoses that included Alzheimer's Disease, Dementia, and Anxiety. Review of the Minimum Data Set (MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 5 indicating R101 is severely cognitively impaired. This MDS also reflected R101 was incontinent and had displayed rejection of care and behaviors toward others. The Care Plan for R101 reflected one to two staff are required to check and change (incontinence briefs). On 10/29/24 at 9:25 AM an interview was conducted with Certified Nurse Aide (CNA) G in a Conference room. CNA G reported when she arrived for her shift on 10/15/24 at approximately 6:00 AM she went to the Garden unit to get report from CNA D who was assigned the night shift. CNA G reported she learned the previous CNA had left early so she began resident rounds. CNA G reported when she checked R101 she lifted the top blanket to discover the Resident was wrapped tightly in a blanket from the waist down. CNA G reported she could not get her fingers between the blanket and the Resident's skin without causing pain. CNA G reported that R101 cannot communicate well but she recognizes pain. CNA G reported she summoned Licensed Practical Nurse (LPN) C before removing the blanket. CNA G reported she had to roll R101 side to side to get the blanket from around her without causing pain. CNA G reported R101 was wet, and the incontinence brief was on backwards. CNA G reported R101 has a history of being a digger on her brief and will dig out the brief lining. CNA G reported that R101 was not able to say how she ended up with the blanket wrapped tightly around her. On 10/29/24 at 9:59 AM a telephone interview was conducted with LPN C. LPN C acknowledged being called to the room of R101 by CNA G. LPN C reported that R101's arms were free but that her lower body was wrapped in a blanket like when you swaddle a baby really tight. LPN C reported after ensuring R101 was not injured she informed the Nursing Home Administrator (NHA) and the Director of Nursing (DON) of the findings. LPN C reported R101 is a regular check and change and, in her experience, R101 has never used the call light. On 10/29/24 at 10:13 AM a telephone interview was conducted with LPN B. LPN B reported she was in an all-staff meeting following her night shift that included covering the Garden Unit and another hall. LPN B reported she had been in the room of R101 between 4:00 and 5:00 AM and that R101 was sleeping and covered with a blanket. LPN B reported that CNA D did not inform her she was leaving before the end of her shift. On 10/29/24 at 10:25 AM an interview was conducted with the DON. The DON reported she was in an all-staff meeting when LPN C informed her that R101 was found in bed restrained by a blanket. The DON reported staff interviews began immediately. The DON reported that staff training on Abuse and Restraints were added to the all-staff meeting in progress and added to the other all-staff meetings slated for later that day. On 10/29/24 at 10:36 AM an interview was conducted with the NHA. The NHA reported on the morning of 10/15/24 she was informed by LPN C about how R101 was found that morning. The NHA reported an investigation was immediately started, staff were interviewed, and all notifications were made including to the state agency. The NHA reported staff education began that morning and continued until all staff received the education. The NHA reported CNA D left her assignment without the knowledge or permission of her immediate superior:the nurse on duty. The NHA reported that proper CNA shift change resident to resident rounds were not completed. The NHA explained that oncoming and off going CNA's are to round with each other room to room and resident to resident to ensure all tasks had been completed and observations and report on the status of each resident is conveyed to the next shift. The NHA reported CNA D, newly hired, was suspended pending investigation and was ultimately terminated from the facility and reported to the state agency. Review of the facility report of the incident submitted to the state agency reflected a description of the incident and a telephone interview with CNA D by the NHA. The report reflected CNA D asserted R101 may have gotten herself tangled up in that (blanket) because she was not wrapped up in that when I left, she just had it on top of her like a lap blanket. She might have been rolling around and got herself that way because she kept trying to get out of the bed. On 10/29/24 at 11:23 AM an telephone interview was conducted with CNA D. CNA D reported on the morning of 10/15/24 she had left the facility early due to a personal matter. CNA D reported she had completed rounds by herself and had informed the nurse she was leaving. CNA D reported during the night she had checked the brief of R101 by lifting the blanket that was covering her. CNA D reported she did not have to remove it completely because R101 was dry all night. CNA D reported she was later told how the blanket had been found on R101 and that it was considered a restraint. CNA D reported she did not think the blanket was a restraint because the Resident could move her arms. CNA D reported R101 was dry all night and that the CNA from the previous shift must have wrapped the Resident in the blanket. CNA D reported she did not complete shift to shift resident rounds with the off going CNA at the start of her shift. CNA D did not explain how she could check the Resident's brief during her shift if the Resident had been wrapped tightly in a blanket from the hips down since the previous shift. On 10/29/24 at 4:25 PM an interview was conducted in the conference room with CNA H. CNA H reported she was assigned the Garden Unit on the afternoon shift of 10/14/24 and was relieved by CNA D who arrived about 1000 PM. CNA H reported shift to shirt resident rounds are to be conducted with the oncoming staff at shift change bur that CNA D refused to do the rounds. CNA H stated you can't make them do them (shift to shift rounds). CNA H reported she had last checked on R101 about 9:30 PM and that the Resident was sleeping on her side facing the wall. CNA H reported the brief was dry and that one indicator of a wet brief is that there will be a blue line on the brief when you look under the blanket. Review of the Employee file for CNA D revealed a background check had been completed on 9/5/24, Elder Abuse training completed on 9/12/24, and Abuse training completed on 9/19/24. On 10/29/24 the surveyor verified the following interventions were put into place and were effective to bring the facility into compliance: - All staff were educated on the facility policy for Abuse and Abuse Reporting beginning 10/15/24. - All residents affected and/or potentially affected were assessed and no negative outcomes were noted. - The facility had been conducting random weekly resident audits to screen for signs/symptoms/or self-reports of abuse or neglect. Process to ensure it was being properly followed and no concerns were noted. - Process reviewed at QA meeting. During this survey, this surveyor reviewed documentation, conducted interviews, and made observations the preceding interventions were completed prior to the abbreviated survey and no continuing issues related to this citation were noted. A determination of past non-compliance was approved by the state agency as of 10/15/24.

Based on observation, interview, and record review, the facility failed to maintain an environment that was free from potential accidents and hazards for 7 of 7 residents (Resident #23, Resident #37, Resident #4, Resident#42, Resident #6, Resident #46, and Resident #58 ) reviewed for accidents and hazards. Findings: Resident #23 (R23) Review of an Admission Record revealed R23 was a [AGE] year old female, admitted to the facility on [DATE], with pertinent diagnoses of Huntington's disease, she received all nutrition and hydration via tube feeding, and cognitive communication deficit. R23 had severe cognitive impairment, depended on staff to meet all her needs, and was Spanish speaking. During an observation on 07/15/24 at 11:51 AM, R23 laid in bed with eyes open. The blue fall mat sat folded up on the floor at the foot of the bed. The call light touch pad was clipped to the top of the mattress over R23's left shoulder, out of sight and out of reach of the resident. During an observation on 07/16/24 at 12:55 PM, R23 laid in bed with eyes open and the tube feed running. The call light touch pad was draped over the top of the mattress, with the touch pad hanging off the mattress, out of sight and out of reach of R23. During an interview on 07/17/24 at 2:20 PM, the Administrator indicated that R23 was capable of using the touch light call pad. Review of the facility policy Call Light System, last reviewed 06/2023, reflected: (5) with each interaction in the resident's room, staff will ensure the call light is within reach of the resident. Resident #37 (R37) Review of an Admission Record revealed R37 was an [AGE] year old female, admitted to the facility on [DATE], with pertinent diagnoses of Dementia, fall with hip fracture just prior to admission to the skilled nursing facility, difficulty walking, and unsteadiness on feet. During an observation on 07/15/24 at 9:24 AM, R37 laid in bed resting with eyes closed. The call light touch pad laid at the foot of the bed out of reach of the resident. A sign posted on the wall near R37 read: STOP use call light and wait for assistance. R37's wheelchair was placed next to the bed and the wheels were not locked. During an observation on 07/16/24 at 8:14 AM, R37 laid in bed resting with eyes closed. The call light touch pad and cord were curled up at the foot of the bed, out of reach of R37. The wheelchair was placed near the middle of the bed and was not locked. During an observation on 07/17/24 at 7:48 AM, R37 laid in bed resting with eyes closed. The call light touch pad sat at the end of the bed under the covers, out of sight and out of the reach of R37. The wheelchair sat bed side and was not locked. Review of the EHR (electronic health record) for R37 revealed the resident sustained a fall with wrist fracture on 02/22/24 and a self-reported unwitnessed fall on 03/10/24. Review of a Care Plan for R37 related to safety interventions to prevent falls indicated: Be sure my call light is within reach. Resident #4 (R4) Review of an Admission Record revealed R4 was an [AGE] year old female, admitted to the facility on [DATE], with pertinent diagnoses of Alzheimer's, glaucoma, and disorientation. R4 had severe cognitive impairment. During an observation on 07/15/24 at 9:21 AM, R37 self propelled in her wheel chair out of the common area, near the nurses offices, toward the hallway away from the dining area. On the right side of the hall was a hoyer lift and on the left side of the hall was a housekeeping cart, narrowing the area in which any resident could pass. The right front wheel of R37's wheelchair got caught on the long arm of the hoyer lift closest to her. R37 made several attempts to free her wheelchair from the hoyer lift, including bending over and leaning forward out of the wheelchair. Three staff persons walked past R37 and did not assist her free the wheelchair from the leg of the hoyer lift. Out of concern for the resident's safety, this surveyor alerted staff to the situation and staff assisted R37. Review of the EHR for R37 reflected an unwitnessed fall on 06/14/24. 31771 Resident #42 (R42) Review of the Electronic Medical Record (EMR) Admission Record reflected R42 originally admitted to the facility 3/6/23 with pertinent diagnoses that include Repeated Falls, Unsteadiness on Feet, and Morbid Obesity. Review of the MDS dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R42 is cognitively intact. Review of the Care Plan for R42 revealed a Focus area of I am at increased risk for falls (related to) decreased mobility and multiple comorbidities initiated 3/7/23. Review of the interventions to prevent falls included Grip strips to floor by bed to increase to traction with transfers initiated 12/27/23. Review of the Kardex (a summary of a resident's care needs) for R42 reflected the intervention of Grip strips to floor by bed . as also indicated in the Care Plan. Review of the Incident Report dated 7/15/24 at 7:05 AM reflected R42 was found on the floor by her bed. The report indicated R42 did not have any footwear on at the time. The report did not indicate a review to ensure all Care Planned interventions were in place at the time of the fall. On 7/16/24 at 11:56 AM an interview was conducted with R42 in her room. R42 reported she fell the previous morning getting out of her bed. It was observed that there were no grip strips next to the bed of R42 as indicated on the Care Plan and Kardex. The room of R42 was observed to have extensive clutter mostly on flat raised surfaces but many personal items and possible trip hazards were observed to be on the floor along edges of and under furniture. Grip strips were observed to be on floor near an adjacent wall appearing that the bed may have been moved to the current location without relocating the grip strips. On 7/17/25 at 10:26 AM The Nursing Home Administrator (NHA) reported that the previous week the Environmental Services Director had moved the furniture in the room of R42 and failed to relocate the grip strips at the bed's new location. The NHA was asked if staff were expected to regularly ensure fall precautions were in place. The NHA indicated all staff are expected to always follow the Care Plan. 28101 Resident #6 (R6) Review of R6's face sheet dated 7/15/24, revealed she was admitted on [DATE] and had diagnoses that included: Hemiplegia and hemiparesis (paralyzed one side of body) following unspecified cerebrovascular disease affecting left non-dominant side, moderate protein-calorie malnutrition, diabetes mellitus with diabetic neuropathy (affection nerves), and unspecified symptoms and signs involving cognitive functions following unspecified cerebrovascular disease. R6 was not her own responsible party. R6 was observed on 7/16/24 at 8:20 AM, receiving morning care from Certified Nurse Aide (CNA) E. CNA E raised R6's bed to waist height to provide care and then discovered she did not have all the supplies she needed to do care. CNA E left the bed at waist height and left the room to gather supplies (no other staff in the room). When CNA E returned to do care, she independently turned R6 on her left side. Review of R6's fall care plan revealed and intervention for bed height, low as I allow dated 1/5/22. Review of R6's ADL (Activities of Daily Living) care plan dated, 6/5/24 revealed R6 required extensive assistance of 1-2 person for bed mobility. During an interview with Registered Nurse (RN) F on 7/17/24 at 9:15 AM, the observation of R6 being left unattended while her bed was waist high and the CNA rolling the resident away from her without staff being on the other side of bed was share. RN F reviewed the facility nursing procedure guidebook and verified residents that are dependent for bed mobility require another person on the opposite side of the bed when rolling the resident away from them for safety reasons. RN F all said it was not safe to walk away from R6's bed when it was in a high position. RN F said she would start staff education. Resident #46 (R46) Review of R46's face sheet dated 7/17/24 revealed she was admitted to the facility on [DATE] and had diagnoses that included: Alzheimer's disease, and muscle weakness. She was not her own responsible party. R46 was observed on the 300-nursing unit, in the main dining room on 7/15/24 at 12:30 PM eating independently. No staff were in the room. Review of R46's progress note dated 4/14/24 at 2:11 PM revealed, Residents diet downgraded to minced and moist. Noted coughing at mealtime. Review of R46's ADL (Activities of Daily Living) care plan last revised on 11/13/23 (not up to date) revealed she required set up supervision with eating. Resident #58 (R58) Review of R58's face sheet dated 7/17/24 revealed she was admitted to the facility on [DATE] and had diagnoses that included: Anoxic brain damage and dysphagia (difficulty swallowing). She was not her own responsible party. R58 was observed on the 300-nursing unit, in the main dining room on 7/15/24 at 12:30 PM eating independently. No staff were in the room. Review of R58's Kardex (nursing care guide) dated 7/17/24 revealed that R58 required 1:1 feeding assistance, she required minced and moist textured foods. On 7/15/24 at 12:43 PM, the Activity Director (AD) I was assisting pass meal trays to the residents in 300 halls. AD I was asked if staff are to be supervising residents eating in the main dining area. AD I said she was not certified in doing the Heimlich maneuver (first aid used to dislodge food or objects in a person's airway), residents are to be supervised by the certified nurse aides. AD I went looking for staff and returned with CNA C. CNA C was asked if she was assigned supervise residents in the 300-hall main dining room today and CNA C was not aware of anyone having an assignment to supervise residents in the main dining room. During an interview with the Nursing Home Administrator (NHA) on 7/17/24 at 9:00 AM the observations of resident not being supervised while eating on 7/15/24. The NHA said she was not aware if the facility dining policy included supervision or the status of residents needed to be supervised in the main dining room. Review of the facility Dining Service policy dated revised 1/05/21 revealed, 3. Necessary staff will be available to assist in passing out meals either in rooms or dining areas. There was no indication of a need to supervise residents at risk for choking or special needs, or assigning staff to remain in the dining room when residents are eating.

Based on observation and interview, the facility failed to maintain general cleanliness and repair. This resulted in the potential for contamination of linens and domestic water. Findings Include: During a tour of the facility, with Maintenance Director (MD) G, starting at 12:23 PM on 7/15/24, the following environmental concerns were noted: Observation of the Beauty shop hair wash sink was found to not have proper backflow prevention on the hose for the hair sprayer. The hose was able to drop below the overflow rim of the sink and be a submerged inlet with no inline atmospheric vacuum breaker. Observation of the 200 Hall linen closet found an open wire rack shelving with no bottom barrier on the bottom rack to protect against contamination from cleaning or accumulation of debris on the floor. At this time the floor underneath the clean linen was found with a heavy accumulation of dust and paper trash debris. During a tour of the Garden utility room it was found that underneath rack storage shelving found accumulation of dust along with paper and packaging debris. During a tour of the Garden janitors closet it was found that the chemical pre-dispense system was installed on a cold water line with no wasting tee to help maintain the integrity of the hose bib vacuum breaker. During a tour of the 300 shower room it was found that three slings were stored on the back wall floor with numerous slings hung up but also having dangling portions on the floor. An interview with MD G at 2:52 PM found that the slings shouldn't be touching or on the floor and he was unsure why there were so many at that location. During a tour of the 300 clean linen closet it was found that no bottom barriers were present on the bottom portion of the wire rack and an accumulation of dust and debris was evident on the floor of the unit. Observation of the lakeshore dining room found a large hole under the sink counter that leads plumbing lines into the wall. The size of the hole was roughly 10x8. At 3:10 PM an interview with MD G stated he was new to the facility and was not familiar with the hole under the sink.

Based on observations, interviews, and record review, the facility failed to implement care to prevent skin break down and maintain range of motion related to a severe contracture for 1 Resident (R6), resulting in R6 having intermittent skin irritation and the potential for skin breakdown. Findings included: Review of R6's face sheet dated 7/15/24, revealed she was admitted on [DATE] and had diagnoses that included: Hemiplegia and hemiparesis (paralyzed one side of body) following unspecified cerebrovascular disease affecting left non-dominant side, moderate protein-calorie malnutrition, diabetes mellitus with diabetic neuropathy (affection nerves), and unspecified symptoms and signs involving cognitive functions following unspecified cerebrovascular disease. R6 was not her own responsible party. R6 was observed in bed on 7/15/24 at 9:54 AM. R6's left hand was in a fist position. (no air space between finger or palm of her hand). R6 was observed in bed on 7/16/24 at 1:48 PM. R6's left hand was in a fist position. (no air space between finger or palm of her hand). During an interview with R6's Certified Nurse Aide (CNA) C on 7/16/24 was asked how she cares for R6's left hand. CNA C said R6 used to have a splint but since her splint was discontinued R6 has had some issues with the hand getting pink. CNA C said she charted in the electronic medical record today that R6 had pink skin in her left hand and reported this to Registered Nurse (RN) A. During an interview with Unit Manager (UM) B and RN A on 7/16/24 the surveyor confirmed that CNA C had reported R6's hand concern to RN A. UM B said she would contact R6 physician about the concern. On 7/17/24 at 8:30 AM R6's left hand was in a fist position. (no air space between finger or palm of her hand). CNA D and E came in to provide morning care. CNA D was able to do range of motion with R6's left hand. R6's hand could be opened to about a 1/4 fist size (open 1 to 1 and 1/2 inches. The palm was pink and moist. One fingernail stuck out about 1/4 from the end of R6's finger. When asked what could be done to prevent R6's fingernails to be away from R6's palm of her hand and to keep it dry, CNA D took a clean washcloth, rolled it up and placed in in the open space between R6's fingers and palm of her hand. R6 remained comfortable throughout the care. Review of R6's nursing progress note dated 7/16/24 at 4:31 PM revealed UM B, Made (name of R6's nurse practitioner (NP)) aware of L (left) palm redness, increased pain and contracture. During an interview with UM B on 7/17/24 at 11:15 AM, UM B said R6's NP would be addressing R6 left hand concerns today. Review of R6's Caregiver Education Tracking dated 4/18/24 revealed the following education was provided: please provide hand hygiene daily and keep fingernails short. Please provide PROM (passive range of motion) to LUE (left upper extremity) as tolerated 1 - 2 x daily. Check skin integrity issues and report to nurse. (see observation 7/16/24 at 8:30 AM, one fingernail was 1/4 inch long). Review of R6's care plan revealed an impaired skin integrity related to impaired mobility dated 6/4/24. None of the active interventions included interventions for the care of R6' left hand. Review of R6's ADL (activities of daily living) care plan initiated on 6//5/24 revealed no active interventions in place to maintain R6 left hand range of motion, keep her nails trimmed or promote skin integrity.

Based on observation, interview, and record review, the facility failed to maintain a safe and clean homelike environment for two facility Residents (R42 and R23). R42 Review of the Electronic Medical Record (EMR) Admission Record reflected R42 originally admitted to the facility 3/6/23 with pertinent diagnoses that include Repeated Falls, Unsteadiness on Feet, and Morbid Obesity. Review of the MDS dated [DATE] reflected R42 requires partial/moderate assistance with transfers but is non-ambulatory and is confined to a motorized wheelchair for mobility. The medical record reflected R42 is cognitively intact and is her own responsible party. On 7/15/24 at 10:42 AM in the room of R42 it was observed that all flat surfaces to include over the bed table, dresser/ nightstand and counter tops were full and stacked in an unorganized manner with the resident's belongings. An observation and interview were conducted on 7/15/24 at 3:18 PM with R42 in her room. It was observed that the room remained cluttered on all surfaces to include the second unoccupied bed in the room. R42 indicated she had to get her things organized and indicated staff had not offered to assist her with this. On 7/15/24 at 3:47 PM an interview was conducted with the Director of Nursing (DON). The DON reported R42 is very particular about her things but she noticed last week that R42 was spreading out with her belongings onto the other bed in the room. The DON reported that she was told R42 had been educated about the ongoing clutter issue in her room. The DON reported she is not aware if anyone has offered to help the Resident to organize her personal belongings and doesn't know if the current state of her room is Care Planned. Review of the Care Plan for R42 reflected an intervention of Respect my personal space without any further direction or information. However, this intervention was implemented by Social Services under the Focus title of I have a history of trauma . and not by care staff. No Care Plan Focus or interventions were found regarding maintaining a home-like room environment or the desire of R42 to protect the cluttered state of her room. Review of the EMR Progress Notes, to include Care Conference Summaries, did not reveal any documentation on the cluttered condition of the Resident's room, that this is a preference for R42, or that staff had educated or offered to help organize the belongings. On 7/16/24 at 11:56 AM an interview was conducted with R42 in her room. The Resident's clutter remained throughout the room. The Resident again indicated an intention to organize her belongings. R42 reported that Housekeeping does come into her room but that they do not clean, really. On 7/17/24 at 10:35 AM an observation was noted on the condition of R42's room. The clutter persists as previously observed despite the discussion with the DON on 7/15/24 at 3:47 PM. 37577 Resident #23 (R23) Review of an Admission Record revealed R23 was a [AGE] year old female, admitted to the facility on [DATE], with pertinent diagnoses of Huntington's disease, she received all nutrition and hydration via tube feeding, and cognitive communication deficit. R23 had severe cognitive impairment, depended on staff to meet all her needs, and was Spanish speaking. During an observation on 07/15/24 at 9:48 AM, R23 had a laminated communication board that sat on the overbed table. The board was coated in a light brown sticky substance, similar to tube feed formula. Upon further exam, there was a second laminated communication board but it was stuck to the top board. The two communication boards were pulled apart and the second communication board was also coated in the light brown sticky substance. During the following additional observations, the laminated communication boards were found to be covered with a light brown sticky substance: 07/15/24 at 2:26 PM, 07/15/24 at 4:35 PM, 07/16/24 at 8:04 AM, 07/16/24 at 12:55 PM, and on 07/17/24 at 7:54 AM. Review of a Kardex for R23 (a quick reference guide for staff to utilize that lists a resident's care needs) reflected: I am able to communicate by use of the picture boards and my family when they are in the building.

This citation pertains to Intake # MI00145106 Based on observation, interview, and record review, the facility failed to facilitate administration of, and monitor, a bowel preparation protocol for one Resident (R30) and get him to an appointment for a scheduled colonoscopy, resulting in the resident becoming distraught due to lack of staff assistance to meet his medical needs. Findings: Review of the Minimum Data Set (MDS) dated [DATE] reflected R30 admitted to the facility 3/2/23 and had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the Resident was cognitively intact. Section E of the MDS, which reviews Behavior, reflected R30 had displayed verbal behaviors toward others less than daily. Review the Electronic Medical Record (EMR) Admission Record reflected R30 has pertinent diagnoses that include Schizoaffective Disorder and Irritable Bowel Syndrome. The EMR also reflected that R30 can make his own decisions. On 7/16/24 at 11:19 AM an observation and interview were conducted with R30 in his room. R30 reported on 6/14/24 he was scheduled to have a colonoscopy at 1:30 PM transported by the facility bus at 1:00 PM. R30 reported he had completed most of the bowel cleaning preparation that began with timed administration by a second shift nurse the previous day. R30 reported early on the morning of 6/14/24 the night shift nurse handed to him a bottle of pills he was to self-administer to complete the preparation. R30 reported he took nine of the twelve pills with the expected effect but fell asleep before completing the regimen. R30 reported he woke up on his own at 12:30 PM soiled in stool and in a state of panic because he was to leave shortly for the procedure. R30 reported no nurse had returned to monitor his physical status or to ensure proper self-administration of the preparation. R30 reported no staff awakened him to ensure he was dressed and ready to leave for the appointment. Using his walker, R30 reported he then went to the hall and asked for help from two Certified Nurse Aides (CNA) who told him they were busy with routine tasks. R30 acknowledged he verbalized unkind words and walked toward the front entrance of the building leaking stool and shoeless. R30 reported at the front counter he verbalized more unkind words to the receptionist and the bus driver who were at the counter, left the building and sat on a bench by the transport bus. R30 reported the police subsequently arrived and talked to him. R30 reported he told the police he was upset the facility did not wake up in time for an important procedure. R30 reported he told the police he was soiled and shoeless because no one would help him get cleaned up and ready. R30 reported the police eventually left and he returned to his room missing the appointment. R30 reported no staff, nurses, Medical Providers, or Administration, has discussed the incident with him or informed him if the procedure had been rescheduled stating It's like all this never happened. R30 reported he had to clean himself up and that staff did not offer to assist. R30 stated I was totally on my own, that was so upsetting that they would leave me like that. R30 reported he was not aware of ever being assessed for self-administration of medication and produced an empty bottle of medication. This bottle (image retained) reflected that it had contained sodium sulfate, magnesium sulfate and potassium chloride tablets a common bowel-cleansing agent. R30 further reported that shortly after the incident of 6/14/24 he was informed he was being involuntarily discharged which he felt was related to the incident. R30 reported this has since been reversed. Review of the EMR for R30 reflected Doctor's Orders which confirmed R30 was to board the facility bus on 6/14/24 at 12:45 PM for a 1:30 PM for a colonoscopy and endoscopy, and a staff member was to remain with the resident during the procedure. The Doctors Orders also reflected R30 was placed on a clear liquid diet and begin a bowel preparation protocol beginning 6/13/24 and ending on 6/14/24. Review of the Medication Administration Record (MAR) for R30 for June 2024 reflected nurse documentation the bowel preparation medication had been administered. Review of the EMR did not reveal an assessment for self-administration of medication had been completed for R30. Review of the EMR Progress Notes for R30 did not reveal any documentation on 6/13/24 or 6/14/24 prior to the scheduled appointment time of monitoring during the bowel preparation, the Resident's physical status, or reminders to the Resident of readiness for impending procedure. Review of the EMR Progress Notes revealed an administrative entry dated 6/14/24 at 3:13 PM. The entry reflected R30 was reported to have been kicking and throwing items in the hall and yelling and swearing making other residents fearful. The entry reflected staff were unable to de-escalate the Resident's behavior. The entry reflected the police responded and were also unable to redirect the Resident's behavior. Review of the police report dated 6/14/24 at 12:47 PM reflected a complaint of a resident Currently in hallway cussing and throwing things. The responding police officer's documentation reflected Subject calm on arrival. Disagreement over transport for procedure at hospital. The police report reflected the officer then spoke with staff and left the facility approximately twenty minutes after arriving. After the entry of 6/14/24 at 3:38 PM the EMR Progress Notes reflected no further entries until 6/17/24 at 4:45 PM by Social Services. The entry reflected Resident served a 30-day involuntary discharge notice today due to history and recent events of violent outbursts . The entry reflected R30 acknowledged his actions and was tearful and apologetic. The entry reflected a possible path to a resolution of the issue. Review of the Doctor's Orders for R30 reflected a future colonoscopy/ endoscopy procedure scheduled for 9/3/24. Review of the Progress Notes for R30 from 6/17/24 to 7/16/24 did not reflect any documentation that the incident of 6/14/24 had been reviewed, investigated, or discussed with staff or R30. The Progress Notes did not reflect efforts to determine the root cause or what preventative measures were missed. The Progress Notes also did not reflect that R30 was aware the appointment had been rescheduled. On 7/16/24 at 4:30 PM an interview was conducted in the conference room with the Director of Nursing (DON) Nursing Home Administrator (NHA) regarding the incident of 6/14/24 with R30. The DON and the NHA were informed of the Resident's version of the incident. That a bowel preparation had been initiated and evidence had been provided that R30 was expected to self-administer the second half of the protocol. Additionally, that the medical record did not reflect any staff monitoring or reminders to the Resident. Furthermore, that R30 reported he had awakened on his own to find himself incontinent of stool in his clothes, short on time, and unable to obtain assistance to get ready. Also, that R30 reported following the incident, he remained soiled, and no one offered to assist with care. The medical record Progress Notes did not provide any documentation why R30 did not make it to a procedure he had completed a preparation for, was offered help by care staff when soiled, or if R30 was informed the procedure was rescheduled. The NHA reported that R30 is independent, but that care would be provided to any resident if they asked. Both the DON and the NHA reported that R30 is known to not be awakened in the morning. The NHA reported she does not know if this is Care Planned but was told this by a long time CNA. The NHA reported R30 was approached by staff 15 minutes before the time to leave for the appointment. The NHA reported R30 did not feel he had time to get cleaned up and he became aggressive. The NHA stated a lot of things went wrong prior to the appointment that resulted in R30 becoming upset. The NHA reported that staff are informed when a resident's has an appointment. The NHA reported in the past R30 has either refused the prep or had the procedure canceled. The NHA also reported that discharging the Resident had been discussed but since that time there has been a big shift in his demeanor and R30 is more gentle. The Care Plan for R30 was reviewed. No Care Plan Focus or Intervention was found that reflected R30 was not to be awakened in the morning.

This Citation pertains to Intake Number MI00142207. Based on interview and record review, the facility failed to protect Resident #103's (R103) right to be free from neglect, which resulted in R103's physical deterioration and subsequent death. Immediate Jeopardy: The Immediate Jeopardy began on [DATE] when Resident #103 (R103) was admitted to the facility from the hospital for short-term rehab following a left arm fracture and a Urinary Tract Infection (UTI). An admission nursing assessment identified only a pressure injury on the right heel. The facility failed to follow hospital discharge instructions, physician's orders, and did not obtain follow-up consults for wound care which resulted in the worsening of and development of wounds on the right 5th toe, right heel, right lateral foot, right lateral lower leg, sacrum, coccyx and thoracic spine. The facility failed to ensure hydration and nutrition were accessible, and provide needed assistance to drink and eat. The facility left the resident in the wheelchair for an extended period of time and the resident fell and hit his head. Multiple staff were made aware of concerns related to R103's care and overall decline and failed to act, including but not limited to, being made aware: that the resident could not call for help if needed, that the resident was found sitting in urine soaked bedding, the resident's broken arm was not cared to facilitate healing, and pain and swelling reduction. The resident was placed in a room with a Covid-positive resident and subsequently developed Covid 19. R103 was admitted to the hospital on [DATE] with septic shock, malnutrition, a 25-pound weight loss since admission on [DATE], a Stage 3 thoracic injury, a Stage 4 sacrococcygeal injury, unstageable pressure injuries to the right leg, right heel, and right 5th toe and deep tissue injuries to the left leg and left heel. On [DATE] R103 was placed on hospice care and died on [DATE]. The death certificate stated that R103 died of sepsis. Findings: Resident #103 (R103): Review of an Admission Record revealed R103 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: left arm fracture, acute cystitis with hematuria (a bladder infection with blood in the urine), diabetes, and heart disease. Review of a Minimum Data Set (MDS) assessment for R103, with a reference date of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated R103 was cognitively intact. Review of a hospital discharge summary reflected R103 was discharged to the facility on [DATE] in the following condition .confusion improved and back to baseline .follow up with orthopedics in ,d+[DATE] weeks for left arm fracture . wound care: buttocks-liberally apply Desitin twice per day and PRN (as needed) until skin is healed. Right heel-paint with betadine and cover with dry gauze daily .follow up with wound healing center within 7 days. Review of R103's Hospital Medical Nutrition Therapy - RD Chart Review note dated [DATE] revealed, No weight loss seen in chart during these visits . R103's weight had remained stable. Review of R103's facility Admission assessment dated [DATE] revealed: (a) R103 was alert and oriented to person, place, and time (no cognitive impairments), had no behavioral symptoms, and had no diagnoses affecting his cognitive status or memory, (b) admission weight-178.9, (c) R103 had a right heel pressure injury measuring 3 cm x 6.5 cm and was staged as unstageable, (d) R103 had an abrasion on his left gluteal fold measuring 6 cm by 3.5 cm with a depth of 0.1 cm, (e) R103's pedal pulses were palpable, equal, and weak/thready, indicating R103 had poor/impaired blood flow to bilateral feet. (Impairments in blood flow to the feet increase the risk for heel pressure injuries). Review of R103's Electronic Health Record revealed no documentation that the provider was notified of R103's wounds identified on the admission assessment. Review of R103's Order Summary revealed the wound care treatment for R103's right heel was not ordered, initiated, or completed upon admission to the facility per the hospital discharge orders. (An order for wound treatment for R103's right heel was not ordered until [DATE].) Review of R103's Order Summary revealed the wound care treatment for R103's buttocks was not ordered, initiated, or completed upon admission to the facility per the hospital discharge orders. (An order for wound treatment for R103's buttocks was not ordered until [DATE].) Review of R103's Electronic Health Record revealed no order and/or appointment scheduled for a wound consult following his admission to the facility per the hospital discharge orders. (A wound care consult was not initiated until [DATE] and he was not evaluated by the wound consultant until [DATE]). Review of R103's Care Plan for skin integrity revealed, I have actual impairment to skin integrity r/t left buttock abrasion and right cheek abrasion Date Initiated: [DATE] .Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs and symptoms) of infection, maceration etc. to MD (physician). Date Initiated: [DATE]. It was identified that R103 had poor BLE perfusion (pedal pulse assessment-weak/thready) during the admission assessment which increased R103's risk for the worsening of the right heel pressure injury and the development of additional wounds on R103's feet. There were no interventions implemented in R103's Care Plan to prevent the worsening of R103's right heel pressure injury and/or the development of new pressure injuries to R103's feet. Review of R103's Social Service Admission Note dated [DATE] revealed, .Resident was admitted from hospital for a fall that resulted in a broken shoulder .Resident plans to gain strength and heal through P/T (physical therapy), O/T (occupational therapy) and S/T (speech therapy) .Resident is able to communicate verbally and answer questions .Resident is their own person .BIMS-14. The admission note revealed R103 did not have any behavioral concern or a history of trauma requiring follow-up. Review of R103's Social Work Discharge assessment dated [DATE] revealed, 1. Resident's Discharge Plan: Gain strength in order to safely discharge home .Prior to coming to the SNF (skilled nursing facility), where was he/she living? Independent living .is this living arrangement still available to them? Yes .Discharge Potential: Fair. Review of R103's Care Conference Summary dated [DATE] at 10:04 AM revealed, IDT (interdisciplinary team) met with resident to discuss resident's stay at the facility. Resident is hopeful about gaining strength and healing in order to safely discharge back home. Resident does live alone and is open to home health care needs, if necessary, upon discharge .Discharge Potential: Fair. Confirming R103 was admitted to the facility for rehab services and had the potential to return to his home. Review of R103's Care Plan revealed, I am here for a short term stay and will be offered therapeutic activities that support my rehab goals. Date Initiated: [DATE]. Confirming R103 was expected to return home following the completion of therapy. Review of R103's Occupational Therapy Treatment Encounter Note dated [DATE] at 6:23 PM revealed, Pt (patient) supine needed full bed change and to be changed, pt in room for Covid precautions and door is shut. Nursing notified of pt needing full bed change. Review of R103's Practitioner Progress Note completed by Nurse Practitioner (NP) B and dated [DATE] at 9:00 PM revealed, (R103) is discharged to (facility) for SAR (subacute rehab) [DATE]. Today he is seen in his room in no apparent distress, endorses minimal use of left arm with significant swelling .Is hoping for therapy evaluation today so he can get out bed. A/O x 4 (alert and oriented to person, place, time, and situation). R103's wounds identified during the admission assessment were not addressed confirming the provider was not notified at the time the wounds were identified. Review of R103's Physical Therapy Treatment Encounter Note(s) dated [DATE] at 8:30 AM revealed, .rolling two assist to max assist to get changed and new sheets as current sheets were soiled, patient declined to sit up, stated he was too fatigued. Review of R103's Nursing Progress Note dated [DATE] at 9:21 AM revealed, Called and spoke to RN on the ER operating line to give nurse to nurse report. I stated the following. Upon entering the room the author noticed that (R103) was acting strange unable to speak, labored breathing diaphoretic and lethargic. He was responding inappropriately and BGL (blood glucose level) at 9:04 was 40 and received 1 mg IM (intramuscular) of glucagon and at 9:12 am his BGL was retested and was at 42 he was unable to swallow the oral Glucose 15. Review of R103's Hospital Discharge Documents dated [DATE] at 10:06 AM revealed, Patient seen and examined by myself for a chief complaint hypoglycemia prior to arrival . Patient states he felt okay and does not know exactly why his blood sugar went down but that he thinks maybe he had missed a meal. Review of R103's Practitioner Progress Note completed by NP B and dated [DATE] at 8:26 PM revealed, Today he is seen in his room in no apparent distress, endorses minimal use of left arm with significant swelling secondary to non-surgical fracture of left arm .He was sent to ED (emergency department) yesterday am by facility staff for hypoglycemic episode, bg (blood glucose) 40 per EMR (electronic medical record), apparently facility did not administer glucagon, EMS did upon arrival. He was evaluated in ED, he said he had not been getting food or much to drink the day prior, suspect hypoglycemia secondary to poor intake. Today he has no fluids at his bedside, states has not had anything to drink since yesterday. I did discuss this with his nurse and unit manager .He thanked me and states I just want to go home. NP B documented that at the time of the assessment R103 was alert and oriented x 4. Review of R103's Care Plans revealed there were no new interventions initiated to ensure R103 had water/fluids and adequate food/snacks to prevent hypoglycemic events following NP B's discussion with the nurse and unit manager. Review of R103's Skilled assessment dated [DATE] revealed no assessment of R103's pedal pulses. Review of R103's Nutrition Summary Note dated [DATE] revealed, (R103's) nutritional status was evaluated and food preferences were obtained. My appetite is good. My nutrition goals while here are: maintain weight. Met with resident, who reports an okay appetite. Denies issues with chewing or swallowing. Review of R103's Occupational Therapy Treatment Encounter Note dated [DATE] revealed, Pt (patient) found with LUE (left upper extremity) thumb and palm under leg, LUE elevated and STM (soft tissue mobilization) to shoulder joint to open lymph pathway. Review of R103's Care Plans revealed no interventions for elevating R103's left upper extremity to reduce swelling. Review of R103's Occupational Therapy Treatment Encounter Note dated [DATE] revealed, OTA (Occupational Therapy Assistant) observed blisters on Pt's back and had DON (Director of Nursing) assess. OTA and DON coordinated to have pt (patient) get air mattress .OTA directed pt in brief change, noting pt soiled upon arrival. Review of R103's Nursing Progress Note completed by DON and dated [DATE] at 7:19 PM revealed, This nurse was called to room by therapy to assess resident's skin. Therapist had noted areas of concern. Resident found to have blisters on his back, a DTI (deep tissue injury) to thoracic spine and stage 2 pressure injury to his coccyx. Care plan updated and order for air mattress. Maintenance care submission to switch out mattress. Please see detailed wound assessment for measurements. Review of R103's Wound Assessment completed by the DON and dated [DATE] revealed: Wound #1: right heel suspected deep tissue injury measuring 5 cm x 2.5 cm. Treatment/Changes/Notifications: Continue current treatment. Wound #2: vertebrae (upper-mid) suspected deep tissue injury measuring 1.5 cm x 1 cm. Acquired in-house. Treatment/Changes/Notifications: Air mattress ordered. Wound #3: left scapula blister measuring 4 cm x 0.5 cm. This was not documented as a pressure injury. Acquired in-house. Treatment/Changes/Notifications: Air mattress ordered. Wound #4: right scapula blister measuring 16.5 cm x 4.0 cm. This was not documented as a pressure injury. Acquired in-house. Treatment/Changes/Notifications: Air mattress ordered. Wound #5: coccyx Stage II pressure injury measuring 7 cm x 4.5 cm with a depth of 0.1 cm. Acquired in-house. Note: hospital discharge order dated [DATE] for liberally apply Desitin twice per day and PRN (as needed) until skin is healed which had not been initiated since R103's admission. Review of R103's Care Plan revealed new interventions to prevent the worsening of R103's pressure injuries discovered on [DATE]. Encourage good nutrition and hydration in order to promote healthier skin and I need air mattress and pressure relieving boots to protect the skin while in bed. The intervention to apply house barrier cream was not included until [DATE]. Review of R103's Order Summary revealed: No order for the treatment of Wound #1: right heel suspected deep tissue injury measuring 5 cm x 2.5 cm. (An order for wound care for R103's right heel was not ordered until [DATE].) No order for the treatment of Wound #2: vertebrae (upper-mid) suspected deep tissue injury measuring 1.5 cm x 1 cm. (An order for wound care for R103's vertebrae was not ordered until [DATE].) Wound #3 and #4: WOUND CARE: Blisters bilateral back. Cleanse gently with soap and water or house wound cleanser. Apply skin prep BID (twice a day) if blisters are intact. Cover with non-adherent dressing ONLY if blisters are open. Change dressing BID. two times a day- Start Date [DATE]. Wound #5: WOUND CARE STAGE II - until healed Cleanse the area with soap and water or saline and dry. Apply hydrocolloid dressing, change q 3d (every 3 days) and prn if dressing soiled or for accidental removal. one time a day every 3 day(s) for Stage II Coccyx -Start Date [DATE]. Review of R103's Occupational Therapy Treatment Encounter Note dated [DATE] at 9:52 AM revealed, Pt with increased edema on this date due to sitting in wc (wheelchair) for extended amount of time without arm elevated. Review of R103's Practitioner Progress Note completed by NP B and dated [DATE] at 12:51 PM revealed . resident had appointment with Ortho today who gave orders for PT/OT and reinforced elevation of LUE (left upper extremity) to decrease swelling. He is observed laying in bed, states he has not gotten up for meals since arrival to facility. NP B documented that at the time of the assessment R103 was alert and oriented x 4. R103's 5 pressure injuries/wounds were not addressed during NP B's assessment. Review of R103's Order Summary revealed, Orthopedic follow-up recommendation- Encourage patient to elevate left arm above the level of the heart ,d+[DATE]x/day for ,d+[DATE] minutes order date [DATE]. Review of R103's Care Plans revealed no intervention to elevate R103's left upper extremity to decrease swelling recommended by the facility provider and orthopedic provider. R103 did not have a Weekly Skin Sweep completed on [DATE] following the facility's policy and procedure Skin and Pressure Injury Risk Assessment and Prevention for a skin assessment to be completed upon admission and weekly thereafter. Review of R103's Care Plan revealed no intervention for timed (every 2 hour) repositioning. Noting only Assist me to turn &/or reposition routinely during CNA (Certified Nursing Assistant) rounds while in bed and frequently redistribute my weight if/when I am up in my chair, (not initiated until [DATE]). Review of R103's Practitioner Progress Note completed by NP B and dated [DATE] at 3:03 PM revealed, resident is seen in his room in no apparent distress, unfortunately he tested + (positive) for COVID yesterday, of note this pt. was tested during recent ED visit with negative results, he was placed in room in facility with COVID + roommate upon return from ED. He reports frustration with this and states I just want to go back to my home .He is here for SAR (subacute rehab), he states he is almost always in bed and wishes to be up for meals, this is communicated verbally to facility staff. R103's pressure injuries were not addressed during NP B's assessment. Review of R103's Care Plans revealed there were no new interventions initiated to ensure R103 was assisted out of bed for meals. Review of the COVID outbreak Line List confirmed R103's roommate tested positive for COVID with the 1st COVID test obtained on [DATE]. R103 received treatment for hypoglycemia in the emergency department on [DATE] and per the Hospital Discharge Summary tested negative for both COVID. Upon return to the facility, R103 returned to his room (where his COVID positive roommate continued to reside) and tested positive for COVID on [DATE]. Review of R103's Occupational Therapy Treatment Encounter Note dated [DATE] revealed, OTA provided positioning in bed to elevate LUE to decrease edema. Patient not feeling well. Patient with change in medical status with new illness and demonstrating fatigue and decreased alertness during session on this date .Upon arrival pt with soiled brief and bed pad .Pt with blood in brief and visible wound on bottom, noting OTA updated DON on visual appearance of wound. OTA inquired with contract wound nurse if pt was on her schedule for this date and he was not .Complexities/Barriers Impacting Session: Change in medical status, pain from wound. Confirming DON was notified of a change in R103's medical status change and the need for a wound consult. Review of R103's Wound assessment dated [DATE] revealed: Wound #1: sacrum Stage II pressure injury measuring 8 cm x 3 cm. Documented as a new skin condition. No other wounds were addressed in the wound assessment (previous assessment on [DATE] included 5 pressure injuries/wounds.) Review of R103's Care Plans revealed the intervention/education notified aides to have more frequent turning and cleaning was not added to R103's Care Plan until [DATE]. Review of R103's Skilled assessment dated [DATE] revealed no assessment of R103's pedal pulses. Review of R103's Weekly Skin Sweep dated [DATE] revealed, sacrum-open area, treatment in place for pt. The documentation of the areas of impairment did not include the type of wound, measurements, color, type of tissue in wound bed, drainage, odor, and/or pain (as required in the facility policy Skin and Pressure Injury Risk Assessment and Prevention.) Review of R103's Weekly Skin Sweep dated [DATE] revealed: Sacrum-open area noted to sacrum. Macerated edges discolored .Discoloration noted to BLE (bilateral lower extremities).Left arm swollen and discolored. The documentation of the areas of impairment did not include a pedal pulse assessment (pertinent assessment with the discoloration of BLE), the type of wound, measurements, color, type of tissue in wound bed, drainage, odor, and/or pain (as required in the facility policy Skin and Pressure Injury Risk Assessment and Prevention.) Review of R103's Electronic Health Record revealed no documentation that the provider was notified of the deterioration of the sacral wound (macerated edges) or the discoloration of R103's BLE, left arm, or sacrum which was a change from R103's baseline. There was no follow up from the DON/Wound Team following the [DATE] Weekly Skin Sweep and no follow up from the facility providers. Review of R103's Behavior Management Program Review and Symptom Analysis dated [DATE] revealed, Resident is not showing any behaviors at this time. IDT (interdisciplinary team) will continue to monitor this resident. Confirming R103 did not have a history of refusing care and/or treatment. R103 did not have a Wound Assessment completed on [DATE] following the facility's policy and procedure Wound Treatment Management and Documentation (last wound assessment was on [DATE]). Review of R103's Skilled assessment dated [DATE] revealed no assessment of R103's pedal pulses. Review of R103's Skilled assessment dated [DATE] revealed R103's left pedal pulse was weak and thready and his right pedal pulse was normal. Review of R103's Nursing Progress Note dated [DATE] at 5:03 PM revealed, Event occurred on [DATE] 4:30 PM. author alerted that patient slid out of his wheelchair and stated that he hit his head. DON came and got nurse assigned to patient, but cena's (Certified Nursing Assistants) on hall placed patient back in bed prior to a nursing assessment. Order from (NP B) to send patient out for eval and CT of head. Review of R103's Care Plan did not reflect the use of a high back/reclining wheelchair or resident focused interventions for the use of the high back/reclining wheelchair to ensure resident safety and prevent falls. Review of R103's Antigravity Team Note dated [DATE] revealed, Date of Fall: [DATE]. Root Cause(s) of Fall: Resident was up in wheelchair for an extended period of time upon returning from an appointment. During an interview on [DATE] at 2:32 PM, Director of Therapy (DT) J reported that R103 required extensive assistance with sitting up because he was non weight bearing to his left arm and was receiving therapy services for weakness. DT J reported that a high back wheelchair was obtained for R103 due to his weakness and fractured left arm. DT J reported that R103 fell from his chair because staff left him sitting straight up and down at a 90-degree angle for an extensive period of time following his appointment. DT J reported staff should have reclined the high back wheelchair for his safety and comfort. Review of R103's Practitioner Progress Note completed by NP B dated [DATE] at 7:13 PM revealed, Patient seen today in his room for fall occurring 1 day ago in facility. NN reviewed, per NN patient slid out of his wheelchair and stated that he hit his head. Today he is observed laying in his bed, appears uncomfortable. He states he is thirsty, breakfast tray noted to be on table untouched, patient is laying down in bed unable to reach call light. He states his head hurts, facility nurse manager notified. R103's wounds were not addressed during the provider assessment. Review of R103's Care Plan revealed, Offer resident fluids with every interaction was not initiated until [DATE]. The nurse manager did not update the care plan to reflect that R103 required meal set-up. Review of R103's Wound Assessment completed by DON dated [DATE] at 9:21 PM revealed: Wound #1: sacrum suspected deep tissue injury measuring 14 cm x 12 cm x 0.2 cm depth. Treatment/Changes/Notifications- Tx (treatment) in place. Referral to (contracted wound consulting company) sent [DATE]. R103's sacral pressure injury had a significant increase in size from previous assessment on [DATE]. There was no documentation that the provider was notified of the worsening of the wound. Wound #2: vertebrae (upper-mid) suspected deep tissue injury measuring 5.5 cm x 5.0 cm. Treatment/Changes/Notifications- Tx (treatment) in place. Referral to (contracted wound consulting company) sent [DATE]. R103's vertebral pressure injury had a significant increase in size from previous assessment on [DATE]. No other pressure injuries/wounds were addressed in the wound assessment. There was no documentation that the provider was notified of the worsening of the wound. Review of R103's Electronic Health Record revealed no documentation that the provider was notified that R103 was too weak to sign his own name which was a deviation from his baseline. Review of R103's Weekly Skin Sweep dated [DATE] revealed: Hydration Screen .Mucous membranes-Dry. Mucous Membrane color-Pale. Indicating R103 was exhibiting signs of dehydration. Review of R103's Electronic Health Record revealed no documentation that the provider was notified that R103 was exhibiting signs of dehydration (dry and pale mucous membranes) or the nursing management team to ensure appropriate on-going assessments. Review of R103's Care Plans revealed the care planned intervention initiated on [DATE] to Offer resident fluids with every interaction was ineffective. There were no new interventions initiated to prevent continued and/or worsening dehydration. Review of R103's Order Summary revealed, Elevate left arm d/t (due to) edema in left hand/ arm every shift for swelling order date [DATE]. This order was not reflected in R103's Care Plans. Review of R103's Physical Therapy Treatment Encounter Note dated [DATE] revealed, Left UE (upper extremity) very swollen and hanging off bed. Review of R103's Dietary Note dated [DATE] at 12:50 PM revealed, Following resident r/t new wound. Resident with stage II open wound on coccyx. Wound developed in LTC (long term care). The dietary assessment did not include R103's multiple new facility acquired pressure injuries, weight loss/weight assessment, or his dehydration. Review of R103's IDT Review Note completed by DON and dated [DATE] at 4:14 PM revealed, Note: Resident was seen in consultation with (contracted wound consulting company) (Wound Consultant Physician assistant (WCPA) D on [DATE] and the following 6 wounds were noted: Wound #1: R (right) Upper Back Stage II Pressure Ulcer. Initial measurements were 2.9 x 4.1 x 0.1 cm. Wound #2: Unstageable Pressure Injury with full thickness skin and tissue loss. Initial measurements were 22 x 15 x 0.1 cm. WCPA D opted not to perform debridement due to evolving status of the wound, eschar was not amenable to debridement (sacrococcygeal area). Wound #3: R Lateral Lower Leg Unstageable Pressure Injury. Initial measurements were 2.5 x 4.2 x 0 cm. Wound #4: R heel DTI (deep tissue injury). Initial measurements 2.54.2. Wound #5: R Lateral foot Unstageable Pressure injury. Initial measurements 4.8 x 1.5 x 0.1 cm Wound #6: R fifth toe DTI. Initial measurements 1.1 x 1 cm. Mechanical debridement was performed to wound #5 with a blade and forceps. Pain control was achieved with 4% lidocaine spray. Post debridement measurements were 5.8 x 1.5 x 0.2 cm Note: R103 received a surgical debridement and not a mechanical debridement (surgical debridement uses a scalpel/blade where mechanical debridement uses moist to wet dressings and/or hydrotherapy). Review of R103's IDT Review Note dated [DATE] at 4:37 PM revealed, Note: Correction: Measurements to wound #3, R lateral lower leg are 22.3 x 3.9 cm. Review of R103's Contracted Wound Consultants Progress Note Detail completed by WCPA D and dated [DATE] revealed, Associated Signs and Symptoms: Complains of pain and drainage. Patient admitted with a pressure injury of his right heel. Patient has developed several additional wounds. Patient is non-ambulatory and incontinent of bowel and bladder. Facility DON reports patient has been overall declining with poor appetite, little PO (oral) intake, and increased weakness .Physical Exam .Cardiovascular: the DP (dorsalis pedis) and PT (posterior tibial) pedal pulses are not palpable bilaterally (indicating significantly diminished and/or absent blood flow to feet) (last pedal pulse assessment was completed on [DATE] with noted irregularities).Wound #1 Right Upper Back is a Stage 2 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 2.9 cm length x 4.1 cm width x 0.1 cm depth, with an area of 11.89 sq cm (square centimeters) and a volume of 1.189 cubic cm. There is a small amount of serous drainage noted which has no odor. Wound#2 Sacral is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 22 cm length x 15 cm width x 0.1 cm depth, with an area of 330 sq cm and a volume of 33 cubic cm. There is a small amount of serosanguineous drainage noted which has no odor. General Notes: Extensive sacral wound extending to the bilateral buttocks and lower back. Debridement not performed due to: Wound is still evolving, and eschar is not amenable to debridement at this time. Wound #3 Right, Lateral Lower Leg is an Unstageable Pressure Injury, Obscured full-thickness skin and tissue loss pressure ulcer and has received a status of Not Healed. Initial wound encounter measurements are 22.3 cm length x 3.9 cm width with no measurable depth, with an area of 86.97 sq cm. There was no drainage noted. General Notes: Wound along the fibula. Small area of dry, stable eschar distally. Superior area with deep tissue pressure injury. Wound #4 Right Heel is a Deep Tissue Pressure Injury Persistent non-blanchable deep red, maroon or purple discoloration, Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 2.5 cm length x 4.2 cm width with no measurable depth, with an area of 10.5 sq cm. There was no drainage noted. Wound #5 Right, Lateral Foot is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 5.8 cm length x 1.5 cm width x 0.1 cm depth, with an area of 8.7 sq cm and a volume of 0.87 cubic cm. There is a Scant amount of serous drainage noted which has no odor. Wound #6 Right Fifth Toe is a Deep Tissue Pressure Injury Persistent non-blanchable deep red, maroon or purple discoloration Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 1.1 cm length x 1 cm width with no measurable depth, with an area of 1.1 sq cm. There was no drainage noted. Additional Orders .Turn in bed at least once every 2 hours if able (specific turn schedule of every 2 hours was not initiated on care plan during entire length of stay). During an interview on [DATE] at 2:35 PM, WCPA D reported she was consulted to assess R103 due to multiple wounds. WCPA D reported that she had not been consulted on R103 until the week before and he was not on my radar. WCPA D reported that per her company's policy the wound care providers cannot perform wound assessments and treatment recommendations on a resident until a consult order is received and the resident becomes an established patient by their office. WCPA D reported that R103 had multiple extensive wounds and was told by DON that R103 wasn't eating or drinking, had increased weakness, and had a sudden decline medical status. WCPA D reported that based on the DON's report of R103's condition she believed R103's wounds were a result of end of life skin failure. WCPA D only had 1 appointment with R103 on [DATE] before he passed away and was unable to provide any additional information related to his wound care/treatments. WCPA D reported that from [DATE]-[DATE] she did not receive any calls with concerns, or requests for treatment changes on R103. R103's wound clinic consult was not initiated until [DATE]. R103's Hospital Discharge Documentation dated [DATE] recommended a wound care consult to be completed within 7 days of discharge. During an interview via email on [DATE] at 3:32 PM, Nursing Home Administrator (NHA) confirmed that R103 did not have any wound appointments or wound consults before the WCPA D's evaluation on [DATE].(30 days after admission to the facility). Review of R103's Nursing Progress Note dated [DATE] 11:41 AM revealed, Upon assessment, this RN (Registered Nurse) noted resident had decreased LOC (level of consciousness), resident pale and lethargic. NP (Nurs[TRUNCATED]

This citation pertains to Intake Numbers: MI00-141372, MI00-141306, MI00-142123, MI00142-230, and MI00142-016 This citation has two DPS statements. Statement #1 Based on interview and record review, the facility failed to provide adequate supervision based on current medical concerns for 2 of 2 residents (Resident #107 and Resident #104) reviewed for falls, and failed to communicate the falls to therapy staff for 1 of 1 residents (Resident #107), resulting in fractures for both Resident #107 and Resident #104. Findings: Resident #107 (R107) Review of a an admission record revealed R107 was an [AGE] year old male, admitted to the facility on [DATE], following a 2 day hospital stay, after presenting to the emergency department (ED) with increased weakness in the lower extremities and multiple falls at home. Relevant diagnoses at admission included weakness, falls sequela (a condition resulting from a previous injury), and insomnia. Review of hospital notes for R107, dated 11-23-23 through 11-25-23 , reflected the following information: (a) Physician note dated 11-24-23: patient had multiple new falls over last 1-2 weeks, x3 this week, family reported progressive lower extremity weakness that is worse in the morning, urinary frequency, monitor PVR (post void residual) for incomplete emptying, (b) OT (occupational therapy) treatment note dated 11-24-23 recorded: patient demonstrating minimum to moderate assist needed for ambulation, needs constant assistance with walker as patient tends to keep walker way out in front of him, (c) PT (physical therapy) treatment note dated 11-24-23 reflected: patient requiring increased level of assist to minimum of 1 assist for transfer and gait, fatigued significantly with only 35 feet of ambulation, patient with moderate forward flexion posture and difficulty maintaining walker at appropriate distance as patient tends to push the walker too far forward, and (d) nursing note dated 11-25-23 patient up to the bathroom x 2, unsteady gait, PVR (the amount of urine left in the bladder after a person urinates) indicated a need for straight cath x1 (nursing used a catheter to drain the rest of the urine from the bladder due to incomplete emptying). Review of a facility nursing admission assessment, dated 11-25-23, documented the following assessment of R107: (a) uses glasses to aid vision, (b) temperature 99.4 and respirations 22, (c) devices used for mobility-wheelchair, (d) recent and frequent falls, (e) orthostatic blood pressures not obtained, (f) not independent with mobility with or without an assistive device, (g) currently taking an anticoagulant, (h) and last bowel movement 11-24-23, reported normal bowel movement frequency was daily. The assessment did not include any concerns with PVR and R107 being straight cathed that morning at the hospital, nor any interventions to monitor for PVR. Review of Care Plans for R107 revealed that interventions to prevent falls were initiated 11/26/23. No care plan was developed regarding R107's urinary frequency, inability to completely empty the bladder, and potential need for straight cath. Review of an Incident Report that documented an unwitnessed R107 fall on 11-25-23 at approximately 7:20 PM revealed the resident was trying to go to the bathroom with the use of a wheeled walker. R107 was put back into bed by staff, without assisting the resident to go to the bathroom. The incident report did not implement a new intervention to help ensure the residents safety. Review of an :Incident Report that documented a witnessed R107 fall on 11-25-23 at approximately 9:45 PM revealed the resident was assisted to the bathroom by certified nurse aide (CNA) FF and was using a 4 wheeled walker. R107 became weak and the right leg buckled. The incident report did not implement a new intervention to help ensure the residents safety. Review of a statement given by CNA FF on 11/28/23, pointed out that CNA FF had obtained a 4 wheeled walker for R107 and placed it in his room, the evening of 11-25-23, without the resident assessed first by therapy to ensure that the resident could use the walker safely. Review of a Occupational Therapy Eval for R107, dated 11-26-23, revealed COTA (certified occupational therapy assistant) W met with R107 the morning of 11-26-23 to complete an evaluation, and was not notified by nursing that the resident had 2 falls the evening before. Pain assessment at rest was 5/10 constant in right hip, and with movement was 9/10 constant in right hip. COTA W alerted nursing of R107's pain assessment and at that time nursing made therapy aware of the two falls from the previous evening. R107 was sent back to the ED for further evaluation of right hip pain. Review of a physician hospital note for R107, dated 11-26-23, revealed: discharged to skilled rehab less than 24 hours ago, last night patient got up to go to the bathroom unsupervised, fell and experienced hip pain, patient was put back into bed and this morning complained of severe hip pain, and was brought back to the ED for evaluation. X-rays show a right femoral neck fracture. Resident #104 (R104) Review of an admission record reflected R104 was a [AGE] year old female, originally admitted to the facility on [DATE], with pertinent diagnoses of Alzheimer's, high blood pressure, and chronic obstructive pulmonary disease. Review of a BIMS dated 12/20/23 revealed a score of 4 out of 15, which indicated R104 had severe cognitive impairment. Review of a Fall Risk Assessment completed on 12/19/23 for R104, revealed the resident was a high risk for falls due to inpart .easily distracted/short attention span .altered perception/awareness of surroundings .periods of restlessness and/or impulsivity .decreased level of consciousness (sleepy, lethargic) .mental function varies over the course of the day .incontinent of bowel and bladder .unsteady gait .and wanders. Review of a facility Incident Summary revealed R104 sustained an unwitnessed fall, in her room on 01/05/24, at approximately 8:15 PM. The summary further revealed that R104 had a significant history of falls, had been out with family earlier that day, and had been restless upon returning to the facility on [DATE]. Certified Nurse Aide (CNA) Fs written statement reflected the following: (a) heard a loud crash and responded to it, (b) observed R104 laying on the floor on her left side near the bathroom door with the wheelchair positioned behind the resident, (c) called for nursing assistance, (d) noted R104 was very confused, (e) resident was assisted by CNA F and Licensed Practical Nurse (LPN) CC back into the wheelchair, (f) resident was then moved to the recliner, (g) R107 was holding her left arm close to her body and had a bump on the left side of her head, and (h) R107 was left in the recliner unattended when staff left the room. The written statement by LPN CC confirmed that once R107 was in the recliner, both staff exited the room leaving the resident unattended, despite documented reports of confusion. R107 was sent to the ED for further evaluation. Review of Nursing Progress Notes for R104 reflected resident returned from the ED on 01/06/24 around 5:00 AM, with diagnoses of fractured distal left radius (wrist), a contusion to the head, and a neck sprain due to the fall. 39056 Statement #2 Based on observation and record review, the facility failed to implement documented care interventions for 1 resident (Resident #116) out of 3 residents reviewed for accidents and hazards. Findings: Resident #116 (R116) Review of an Admission Record revealed R116 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: muscle weakness, chronic pain, and dysphagia (difficulty swallowing). Review of R116's Care Plan revealed: Feeding Techniques I require: Safe-swallowing strategies: alternate liquids and solids, small bites/sips, double swallow, and slow rate of intake. Date Initiated: 04/18/2022 .My diet orders are: general, soft and bite sized textures, thin liquids. No straws . Revision on: 11/21/23 .EATING- encouragement, cues as needed after set up .Revision on: 9/27/23 . Bed: I need the following room accommodations: Low Bed, Mats on the Floor, Bed against the wall. Date Initiated: 01/03/2024. Be sure my call light is within reach and encourage me to use it for assistance as needed. I need prompt response to all requests for assistance. Date Initiated: 04/12/2022. Review of R116's Nutrition Summary Note dated 10/31/23 revealed, .Currently on a general diet .no straws . Review of R116's Meal Ticket placed on meal trays revealed, .Alerts: NO STRAWS . Review of R116's Nursing: Antigravity Team Note dated 1/3/24 at 9:56 AM revealed, Date of Fall: 1/3/24 .Root Cause(s) of Fall: Resident was confused and attempted to transfer out of bed without asking for assistance .Prior Interventions: Call light within reach .New Interventions: Low bed. Fall mat beside bed while resident is in bed . Review of R116's Speech Therapy Evaluation and Plan of Treatment note (evaluation date 5/15/23-6/13/23) revealed Recommendations .Liquids-Nectar thick liquids, cup drinking (Okay to have thin water, NO straws per informed consent . Review of R116's Informed Consent dated 6/2/23 and signed by R116 revealed, It is understood that (R116) has a swallowing problem that puts him/her at risk for medical complication .The recommended diet is: IDDSI 6-soft and bit size/IDDSI 2-mildly thick liquids. IT is understood that the following diet will be given despite the risks explained below: Regular solids/thin liquids . The Informed Consent did not include the use of straws. Review of R116's Statement of Ability/Inability for Decision Making dated 6/5/23 deemed R116 unable to make his/her own decisions. (R116 was her own person at the time the Informed Consent was signed. During an observation on 01/30/2024 at 9:10 AM, R116 was lying in bed, there was no fall mat in place on the right side of her bed (the left side of R116's bed against the wall), and her bed was not in the low position (close to the ground). During an observation on 01/30/2024 at 11:17 AM, R116 was lying in bed, there was no fall mat in place on the right side of her bed, and her bed was not in the low position. During an observation on 01/30/2024 at 11:37 AM, R116 was lying in bed, there was a mug of water with a straw on her tray table within arm's reach (R116 able to independently drink from the mug). There was an additional unused (wrapped) disposable straw on R116's tray table. During an observation on 01/30/2024 at 12:36 PM, R116 was sitting up in bed eating lunch. R116 had a mug of water with a straw on her tray table and there was a drink with a straw that was on her lunch tray. There was no fall mat in place on the right side of her bed, and her bed was not in the low position. During an observation on 01/31/2024 at 9:13 AM, R116 was lying in bed, there was a mug of water with a straw on her tray table within arm's reach and there was no fall mat in place on the right side of her bed. During an observation on 01/31/2024 at 11:45 AM, R116 was lying in bed, there was a mug of water with a straw on her tray table within arm's reach and there was no fall mat in place on the right side of her bed. During an observation on 02/05/2024 at 10:10 AM, R116 was lying in bed, there were 2 mugs of water with straws on her tray table within arm's reach and there was no fall mat in place on the right side of her bed. During an observation on 02/05/2024 at 12:37 PM, R116 was lying in bed, there was a mug of water with a straw on her tray table within arm's reach and there was no fall mat in place on the right side of her bed. During an interview on 01/31/2024 at 10:10 AM, Licensed Practical Nurse (LPN) GG reported the kitchen would provide residents straws on their meal trays even when it is care planned and on their meal ticket that they are not to use straws. LPN GG reported the floor CNAs (Certified Nursing Assistants) would put the straws in the drinks without double checking the meal ticket or care plan assuming that since a straw arrived on the meal tray the resident could use it. LPN GG reported when the CNAs pass waters to the residents on the units, they do not check the care plans or the resident guides for the residents that are to have thickened liquids or no straws, they just fill them (the cups) all up, put straws in, and go room to room. Review of the Resident Assistance Form completed following the Resident Council Group Meeting dated 1/17/24 revealed, .Summary of Findings or Conclusions regarding the concerns: educated staff on importance of reading tray card correctly (and) giving residents what is ordered .Any Corrective Action taken or to be taken: more tray line audits to ensure accuracy signed by the grievance officer 1/22/24.

This Citation is related to Intake Number MI00141306 Based on observation, interview, and record review, the facility failed to provide quality care to 3 of 5 residents (Resident #17, Resident #101, and Resident #126) reviewed for quality of care, resulting in untreated sepsis and septic shock for R17. Findings include: Resident #17 (R17) Review of an admission record showed R17 was a [AGE] year old female, originally admitted to the facility on [DATE], with pertinent diagnoses of Huntington's disease, diabetes mellitus, gastrostomy with tube feed for hydration and nutrition. R17 was completely dependent on staff for all activities of daily living. Review of a Nursing Progress Note (NPN) for R17 dated 09/05/23 revealed .resident with dyspnea (difficulty breathing). Oxygen saturation (02 sat) on 2 liters 85%, provider notified, stat chest x-ray ordered as well as labs in the am. Chest x-ray showed no acute disease process. Review of a NPN for R17, dated 09/07/23, indicated Bowel Movement Protocol was initiated due to no bowel movement or only small bowel movement for past 3 days. Nursing to assess for bowel sounds, distention, complaints of pain, nausea and vomiting. Only the bowel sounds assessment was noted in the NPN. No additional notes described if and or when the bowel situation was resolved. The next NPN located in R17 EHR (electronic health record), that described R17's physical well being was dated 09/11/23, ( 4 days later) and revealed R17 was .clean, and appropriate. Physical assessment WNL (within normal limits) lung sounds clear and bowel sounds active x 4. The next NPN to document a physical assessment of R17 was dated 09/18/23 ( 7 days since the last assessment) .diarrhea alert-there were 3 or more loose stools in 24 hours recorded. If continues, notify provider. Review of a NPN for R17, dated 09/19/23, reflected .PULSE WARNING, value-111, high of 100 exceeded. No documentation found that stated the provider was notified. The next NPN to document a physical assessment for R17 was dated 09/22/23 (3 days later) and revealed .diarrhea alert-there were 3 or more loose stools in 24 hours recorded. No documentation found that the provider was notified. Review of a NPN dated 09/27/23 (5 days after the last nursing note that described any assessment of R17, recorded .(R17) found with vomit all over her this am. Pharmacy was contacted about delivery of famotidine (a medication that reduces the amount of acid that the stomach produces) and physician aware that resident did not receive one dose on 09/26. The NPN did not indicate that lung sounds were assessed nor was a residual from the tube feed checked. Review of R17's Electronic Medication Administration Record (Emar) for September 2023 revealed R17 missed prescribed doses of famotidine on 9/3, 9/4, 9/5, 9/6, 9/7, 9/8, 9/11, and 9/26. No documentation found that indicated the physician was made aware of the missed doses 9/3 through 9/11. Review of a NPN for R17 dated 09/28/23 reiterated that the resident had a large emesis (vomit) yesterday and a chest X-ray was done and was negative for disease process. The NPN did not indicate that lung sounds were assessed nor was a residual from the tube feed checked. Review of a NPN for R17 dated 10/01/23 indicated that the tube feed was clogged, multiple attempts were made to unclog it and eventually resident was sent to the Emergency Department (ED) to have the tube feed unclogged. R17 returned to the facility later that afternoon. Review of a NPN for R17 dated 10/03/23 at 1:37 PM revealed .BLOOD PRESSURE WARNING, value 129/58, low of 60 exceeded. Review of a NPN for R17 dated 10/04/23 at 12:48 AM specified .nursing noticed resident vomited and had watery bowel movement. Review of a Discharge Emergent Nursing Note, dated 10/04/23 at 8:34 AM, reflected R17 was sent to the ED for possible ileus (bowel blockage) no bowel sounds. Review of an eINTERACT Transfer Form (used to communicate to the hospital recent and relevant information related to the need for emergency care) dated 10/04/23 at 8:30 AM, listed most recent blood pressure, pulse, temperature, and respirations were from 09/29/23. The oxygen saturation listed was obtained at 4:45 AM that morning. Review of an ambulance run sheet for R17, dated 10/04/23 reflected: (a) patient (PT) was reported to have had uncontrollable diarrhea and vomiting, possibly aspirating, (b) PT was pale, hot and sweaty and had some vomit around her bottom lip-attempted suctioning, (c) staff was unsure of her baseline orientation, (d) PT had copious amounts of feces noted when moving her over from their bed to the stretcher, it appeared dark with a green tinge and liquid, (e) PT legs were very wet, unsure if it was sweat or urine, and (f) placed on 4 liters of oxygen, pulse ox 89% (amount of oxygen in the blood). Review of ED physician notes for R17, dated 10/04 23, revealed R17: (a) had a temperature of 102.6, (b) blood pressure was 108/60, (c) pulse was 115, (d) respirations were 25, (e) white blood count of 27.6, (f) CT scab found bibasilar pneumonia worse on the right side, (f) was sent to the ED for 1 1/2 days of uncontrollable diarrhea, some vomiting, lethargy, and possible dehydration, (g) was diagnosed with sepsis due to a urinary tract infection and found to be in septic shock. The Professional Standards of Quality for Staff Roles and Responsibilities in Monitoring Patients with Acute Changes of Condition for the nurse includes recognizing condition change early and assessing the patient's symptoms and physical function and document detailed description of observations and symptoms. (Process Guidelines for Acute Change of Condition, AMDA Clinical Process Guidelines, 2013). Resident #101(R101) Review of an admission record revealed R101 was a [AGE] year old male, originally admitted to the facility on [DATE], with pertinent diagnosis of cerebral palsy, epilepsy, paraplegia, gastrostomy with tube feed for hydration and nutrition, and non dominant side monoplegia of upper limb (cannot use his left arm). Review of a Brief Interview for Mental Status (BIMS) dated 01/03/24, revealed a score of 4 out of 15 which indicated R101 had severe cognitive impairment. R101 is dependent on staff to meet all of his needs. Review of a Nursing Progress Note for R101, dated 01/14/24, revealed .Upon dressing change writer observed green, yellowish secretion coming form penis .physician notified and will send of prescription for an antibiotic. Will continue to monitor closely. Review of an Electronic Medication Administration Record (Emar) for R101, dated January 1 2024 through January 31 2024, showed an order for Diflucan (fluconazole) an antifungal medication, 150 milligrams give one tab one time. The medication was documented as given on 01/15/24. Diflucan's common side effects include headache, nausea, abdominal pain, diarrhea, and indigestion. The Emar did not list any instructions or orders for the monitoring of side effects. Review of the Nursing progress Notes for R101 showed no documentation of nursing follow up regarding the penile infection (had the penile discharge continued, was the medication effective, etc) for 01/15/24 through 01/17/24. Review of a Nursing Progress Note for R101, dated 01/18/24, reflected .aide reported while doing cares that resident had a green milky discharge coming out of the penis. Reported to oncoming nurse and Director of Nursing (DON). Review of a Nursing Progress Note for R101, dated 01/19/24, revealed .this nurse called provider to notify of penile discharge, orders to monitor resident and have resident seen by in-house Nurse Practitioner. Review of all progress notes for R101, completed on 01/30/24, showed no follow up notes documenting any assessments or findings regarding the penile discharge. A provider note dated 01/19/24 to 1/30/24 could not be located in the EHR (electronic health record). According to The Legal and Ethical Issues In Nursing, Sixth Edition, By [NAME] (2019), Standards of care must have and use the knowledge and skill ordinarily possessed and used by nurses actively practicing in the nurses's specialty area. 39056 Resident #126 (R126) Review of an Admission Record revealed R126 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: urinary retention. Review of R126's Physician Order with a start date of 2/2/24 revealed, Bladder scan every 6 hours. Straight cath (catheterization) if >350ml (greater than 350 milliliters of urine in the bladder) every 6 hours for Urinary Retention. Review of R126's February Treatment Administration Record revealed: On 2/3/24 at 12:00 PM-bladder scan result of 446 ml On 2/3/24 at 6:00 PM-bladder scan result of 500 ml On 2/4/24 at 6:00 AM-bladder scan result of 927 ml Review of R126's Electronic Health Record revealed no documentation that R126 received a straight catheterization and/or the results of the straight catheterization on the above dates. During an interview via email on 2/5/24 at 2:26 PM, Nursing Home Administer (NHA) confirmed there was no documentation for when R126 was catheterized and the output resulting from the catheterization. It should have been part of the administration note. We have updated the order to include if he was cathed, and if so, how much so this doesn't happen again.

Based on observation and record review, the facility failed to implement documented care interventions for 1 of 3 residents (Resident #17) reviewed for accidents and hazards, resulting in the potential for choking, and injuries sustained during bed mobility or a fall from the bed. Findings: Resident #17(R17) Review of an admission record revealed R17 was a [AGE] year old female, originally admitted to the facility on [DATE], with pertinent diagnoses of Huntington's Disease and dysphasia (difficulty swallowing). R17 had severe cognitive impairment and relied totally on staff for all activities of daily living. Review of a physician order summary for R17 revealed an order for NPO (nothing by mouth). During an observation on 11/30/23 at 7:15 AM, a handled drinking cup of water, with a lid and straw, sat on R17's over bed table within reach of the resident. During an observation on 11/30/23 at 9:15 AM, Certified Nurse Aide (CNA) S entered R17's room to provide incontinence care and the following was observed: (a) CNA S repositioned R17 by rolling the resident side to side 5 times without a second staff person assisting and (b) CNA S left R17 unattended in the bed, with the bed in a high position, while CNA S exited the room to gather additional supplies. The call light was not in reach of R17 when CNA S exited the room to gather supplies. Review of R17's care plans reflected the following information: (a) I will frequently reposition myself to laying on my left side, (b) I tend to move myself around in my bed, and (c) I require two person assist for bed mobility.

This citation pertains to intakes M100140527 and M100141143. Based on observation, interview, and record review, the facility failed to provide care and implement interventions related to pressure ulcers for 2 (Resident #10 and Resident #13) of 4 residents reviewed for pressure ulcers. Findings include: Review of concerns reported to the State Agency were allegations of pressure ulcer dressing changes not being completed and repositioning/offloading weight off wounds were not being done timely. Resident #13 (R13) Review of the Face Sheet revealed R13 admitted [DATE] with pertinent diagnoses of stage 4 pressure ulcer, diabetes, and paraplegia. Review of the Minimum Data Set (MDS) revealed R13 is cognitively intact and has limited range of motion on bilateral lower extremities and needs substantial/maximal assistance to roll left to right. R13 In an interview on 11/29/23 at 8:10 AM, R13 was in bed and reported he had a shower on Monday (11/27/23) and his pressure ulcer dressing came off and it was not put back on him until the following day. He reported the staff had not done his dressing this morning at 5:00 AM and feared he probably would not get it done this day now. R13 reported the staff will wake him up at 5:00 AM to do his dressing changes when he is trying to sleep and complained that he has a hard time falling asleep at night because of his sleep apnea and narcolepsy. He reported he has 3 pressure ulcers on his buttocks and the staff miss many days of dressing changes and denies refusing any of them. There is always a new nurse who does not seem to know how to do his dressings and not sure if they are using the right supplies. He is only supposed to be up one hour a day and needs assistance to rotate the pillows on his sides and his feet. He reported he had told Administration about his concerns with no follow up. He reported that he will turn on his call light for help to get repositioned and staff will come in and turn off his call light without meeting his needs. In an interview on 11/29/23 at approximately 8:30 AM, Licensed Practical Nurse (LPN) G reported she had not been on this unit with R13 in about 3 weeks and the night shift reported to her that he did not get his dressing changed the night before. When asked to see his dressing change when its time, LPN G reported she had many dressing changes to do this day and not sure if his would be done before her shift is over. In an interview on 11/29/23 at 9:20 AM, the Nursing Home Administrator reported she did not have any concern forms from R13. In an Interview on 11/29/23 at 10:00 AM, Social Worker (SW) I reported the main reason R13 is at the facility is for wound care. He is non-compliant with staying in bed which is not helping with his wound healing. He likes to sit up and will be seen sitting on the edge of his bed when he needs to be reclined and alternating his weight. The facility has weekly care conferences with him and talked to him about compliance verses hospice. SW I reported she is unaware of any dressing changes not being done. The Interdisciplinary Team (IDT) is involved in the discussions of the resident not being compliant with care but could not provide any documentation of his refusals to care, behaviors or documented concerns with follow up. In an interview on 11/29/23 at 10:22 AM, Unit Manager/LPN J reported R13 does not always tell her of his concerns but 2 weeks ago was informed that R13 reported his dressing changes were not getting done. He had one small wound when he came in and the Wound Care provider noticed he recently had another one. His dressings get done while he is still in bed at 5:00 AM by the third shift staff. Dressing changes can be done anywhere between 6:00 PM to 6:00 AM. R13 has one border dressing to cover all wounds. His dressing supplies should be in his room, and he knows where they are. If the staff do not know where his supplies are, he can tell them where they are in his room. R13 is also able to reposition himself and received therapy for trunk support. Review of the October Treatment Administration Record (TAR) for R13 revealed 11 pressure ulcer dressing changes were not done between 10/12/23 and 10/31/23, and no documentation or rationale explaining why treatments were missed and no documentation indicating the physician was notified. Review of the November TAR with UM J revealed several dates that R13 did not get treatments and was coded to see nurses' notes or resident refused with no follow up progress notes. No documentation indicating the resident was reapproached when refused. UM J acknowledged he did not get a dressing change on 11/28/23 and reported she will have a talk with that nurse. The resident missed 8 pressure ulcer treatments from 11/1/23 to 11/29/23. The Wound Care Provider did treatments on 11/2/23 and 11/9/23. He was out to an appointment on 11/6/23 with no documentation indicating dressing changes were done before or after his appointment. No physician notification of missed dressing changes is documented. Review of the Order in the MAR for R13 revealed a start date of 11/10/23 to cleanse wounds to sacrum, bilateral buttocks with wound wash or normal saline, pat dry, apply medihoney hydrogel sheets to each wound, then apply skin prep around them, then apply silicone barrier and cover with mepilex silicone dressing daily, every night shift. During an observation on 11/29/23 at 11:07 AM, UM J went to R13s room to provide dressing changes for the resident. Checked his room for supplies and asked the resident where his dressing supplies were. The resident reported he thinks there are some things in his bedside nightstand. UM J left the room several times gathering missing dressing supplies in his room. Once the old dressing was removed, R13 had one small deep wound on his sacrum and reddened area on both sides of his buttocks and scrotum and no evidence of silicone cream as ordered. UM J reported his clothing removes the cream when they pull up his pants. UM J cleansed wound and applied a small piece of the Hydrofera blue (not in the order) into the sacral wound and the medihoney gel (not sheets). Skin prep was applied to the reddened areas of buttocks and then the silicone cream was applied to the sacral peri wound and buttocks, then the silicone border foam dressing was dressed over the sacral wound and did not cover the buttocks. The UM J then asked the resident when he would like to have his dressings changed and he clarified he would like it done during the day before 11:00 PM. In an interview on 11/29/23 at 11:45 AM, UM J reported the medihoney sheets are sheets you can just stick in the wound verses using the gel. When queried about the Hydrofera blue treatment not matching the orders, UM J reported that was her boo boo. Review of Nursing Progress notes dated 11/4/23 at 2:15 PM for R13 revealed: Patient up in his wheelchair since before breakfast. Will do when patient lays down later. Review of Nursing Progress notes dated 11/5/23 at 2:34 PM for R13 revealed: Resident has been in (wheelchair) since 0600, offered dressing refused. Review of a Behavior Note for R13 dated 11/9/23 revealed the writer went to R13s room to explain the new Wound Care orders and he became agitated yelling at staff and using foul language about only being able to be up for one hour a day due to the two new pressure wounds and not being compliant with previous orders for his up/down schedule and refusing treatment changes. Review of a Nursing Progress note dated 11/14/23 at 5:51 AM for R13 revealed he refused to turn for the nurse and wanted to be left alone to sleep. Review of a Nursing Progress note dated 11/15/23 at 5:53 AM revealed R13 refused his dressing change and stated he does not want it done at night but during the day. Explained the importance of it being changed and he refused. Notified next shift nurse. Review of Wound Care Progress notes/orders for R13 dated 11/9/23 revealed 3 pressure injuries. Nursing reported the resident has a new pressure injury to both his left and right buttock. He is documented as being non-compliant with up and down schedule, offloading and refusing dressing changes. Wound #1: Sacrum which was present upon admission is a stage 4 pressure ulcer with measurements of 2 cm (centimeters) x 2 cm x 0.3 cm with an area of 4 square cm and a volume of 1.2 cubic cm and is deteriorating. Wound #2: Left buttock deep tissue pressure injury measured 5.5 cm x 5 cm x 0.1 cm, with an area of 27.5 square cm and a volume of 2.75 cubic cm. Wound is still evolving with an area of necrosis. Unstageable pressure injury of at least stage 3. Wound #3: Right buttock is an unstageable pressure injury obscured full-thickness and tissue loss pressure ulcer with measurements of 7cm x 5 cm x 0.1 cm with an area of 35 square cm and a volume of 3.5 cubic cm and identified as an unstageable pressure injury of at least stage 3. Review of Wound Care Orders for R13 dated 11/9/23 revealed orders for Wound #1 sacral, wound #2 left buttock (new), wound #3 right buttock (new) to cleans wound with normal saline or wound cleanser, apply leptospermum honey to promote autolytic debridement, cover with silicone bordered foam to promote autolytic debridement- sacral dressing change daily. Change dressing as needed for soiling, saturation, or accidental removal. Apply Silicone cream to peri-wound. Additional orders included but not limited to: Facility pressure ulcer prevention protocol, limit sitting to 60 minutes a day, turn in bed at least once every 2 hours if able. Apply Silicone cream to posterior thighs every shift and as needed. Review of Wound Care Progress Notes for R13 dated 11/16/23 revealed the resident was seen for wounds to sacrum, left buttock, right buttock and the left fifth toe (new). During wound rounds, the resident noticed he had blood on his socks and questioned if he had a new wound. Assessments: Wound #1 is a sacral stage 4 pressure ulcer measuring 1.6cm x 0.6cm x 0.1cm, 0.96 square cm and a volume of 0.096 cubic cm and is improving. Wound #2 on left buttock is an unstageable pressure injury obscured full-thickness skin and tissue loss pressure ulcer measuring 6.4 cm x 4.3 cm x 0.1 cm with an area of 27.52 square cm and a volume of 2.752 cubic cm. After debridement determined to be a stage III pressure injury. Wound #3 on the right buttock is a stage 3 pressure injury pressure ulcer and measures 0.9 cm x 0.7 cm x 0.1 cm with an area of 0.63 square cm and a volume of 0.063 cubic cm. Wound #4 left fifth toe is a full thickness blister and measures 1.2 cm x 1.3 cm with no measurable depth. Treatment orders are the same as 11/9/23 with the addition of applying skin prep to Wound #4 after cleaning with normal saline. Review of a Physical Therapy (PT) discharge summary for R13 for services dated 10/18/23 to 11/14/23 revealed upon discharge, the resident has ROM (range of motion) and core strengthening HEP (home exercise program) that staff is to assist with ROM daily during self-cares. Patient will be turned in bed by staff every two hours, assisted by patient as he is able to help improve pressure relief and prevent further skin breakdown. He is a moderate assist with transfers with total dependence with attempt to initiate (Sara lift). (Repositioning every 2 hours is not in the care plan.) Review of the Care Plan for R13 revealed: I have actual impairment to skin integrity (related to) PARAPLEGIA, INCOMPLETE, TYPE 2 DIABETES MELLITUS WITH DIABETIC POLYNEUROPATHY, Stage 4 pressure ulcer Coccyx. Date last revised is 10/19/23. No meaningful interventions for healing or prevention. Review of the Activities of Daily Living (ADL) Care Plan for R13 last revised 10/19/23 revealed he has a saskapole assistive device to both sides of his bed for transfers. He uses the transfer bars to help reposition himself in bed and assist staff with turning side to side. Review of the Stage 4 pressure ulcer on coccyx Care Plan for R13 last revised on 10/19/23 revealed to turn side to side while in bed to prevention of skin integrity. (No frequency provided.) Administer wound and skin treatments as ordered and monitor for effectiveness. Notify physician if wound stalls (no change in 2 weeks) or worsens. Avoid positioning me on my (left buttocks and coccyx.) Continue with preventative care plan measures. No up/down schedule is in the care plan and no intervention for being up for one hour a day. Review of the Care Plan for R13 revealed to document behaviors and attempted interventions on the POC (plan of care) and to offer choices regularly, last revised on 11/7/23. Review of the Certified Nursing Assistants (CNA) task charting for R13 to Turn side to side while in bed to prevention of skin integrity from 10/30/23 to 11/28/23 revealed he is repositioned 2 to 4 times a day. Review of the electronic medical records (EMR) for R13 revealed no documentation of R13 refusing care with a reapproach by another staff member or another attempt at another time and no physician notification of missed treatments, In an interview on 11/30/23 at 9:35 AM, the Director of Nursing (DON) reported that her expectation of staff when residents are refusing care is to reapproach them at least twice at different times or ask the resident if a different time would work better for them. The DON acknowledges the residents have rights to participate with decisions in their care. The DON verified that R13 did have some dressing changes not done and lacked follow up. The DON reported the staff needed to communicate with each other better and each resident may need a different approach to care. When queried if a resident would be considered non-compliant when refusing care while he is sleeping or engaging in other activities, the DON reported they would not and that they would need to be reapproached. Resident #10 (R10) Review of the Minimum Data Set (MDS) revealed R10 admitted to the facility on [DATE] and discharged on [DATE]. In an interview on 11/28/23 at 9:11 AM, R10 reported she came to the facility from the hospital for wound care and therapy. She was only at the facility for a few days and staff did not know how to do her pressure ulcer dressing changes and did not do them every day. R10 reported she called the ambulance to come and take her back to the hospital. Review of a Hospital Discharge Summary dated 10/26/23 for R10 revealed she had diagnoses that included a stage III pressure injury of contiguous region involving right buttock and hip, and an unstageable pressure injury of right leg. Review of an Admission Skin assessment dated [DATE] for R10 revealed unspecified wounds as follows: 1. Coccyx 3 x 1, right buttocks 2x2 open, right lower thigh 4 x 2, right thigh 4.5 x 2, right thigh 5 x 4, left lower thigh-pressure (no measurements). Pressure Ulcer Care plan was initiated. Review of the October TAR for R10 revealed an order for daily cleanse with skin integrity wound spray and gently pat dry. Cover with single layer of xeroform to wound base and apply silicone-border mepilex post op bordered foam. This does not say for which wound. She did not get a dressing change on 10/27/23. In an interview on 11/30/23 at 9:35 AM, the DON reported there was a lack of follow up with her transfer of care to the facility and should have had more orders for her wounds. The DON reported the documentation does not show a dressing was completed on 10/27/23 which means if it is not documented it was not done. Review of a policy titled Skin and Pressure Injury Risk Assessment and Prevention last revised on 3/23 revealed: It is our policy to perform a skin assessment and pressure injury risk assessment as part of our systematic approach to pressure injury prevention and management. [Facility] utilizes the [NAME] & [NAME] clinical Nursing Skills/Techniques and National Pressure Ulcer Advisory Panel for procedural guidance.

This citation pertains to intake # MI00139197, MI000136833, MI000137737. This citation has multiple Deficient Practice Statements (DPS), A & B. DPS A Based on interview and record review, the facility failed to acknowledge, identify, and provide adequate supervision to prevent an elopement and ensure the safety of 1 resident (Resident #66), reviewed for risk of elopement, placing all residents with a history of wandering and/or elopement behavior at risk of serious harm and/or death. This deficient practice resulted in an Immediate Jeopardy beginning on 8/29/23 at 2:40 PM, when R66, a known elopement risk, eloped from the facility after Receptionist F allowed him to leave the building unattended. Receptionist F did not immediately recognize R66 as a resident and R66 was not included in the elopement risk binder. Receptionist F eventually identified R66 as a resident but had lost sight of him, adjacent to a 35 MPH 4 lane, high traffic volume road nearby a moving water source. Furthermore, Receptionist F did not follow the policy and activate an internal alert notifying all staff of a missing resident. Receptionist F sent out an email at 2:51 PM notifying management staff that R66 had eloped which was not seen by a member of management until 2:56 PM. At 3:24 PM (44 minutes after his elopement) R66 was located by facility staff approximately 0.25 miles from the facility. R66 arrived back to the facility at 3:30 PM. Findings: Resident #66 (R66) Review of an Admission Record revealed R66 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: mild cognitive impairment, major depressive disorder, alcohol abuse, epilepsy, and stroke. R66 had an activated DPOA (Durable Power of Attorney)/decision maker. Review of a Minimum Data Set (MDS) assessment for R66, with a reference date of 6/21/23 revealed a Brief Interview for Mental Status (BIMS) score of 8, out of a total possible score of 15, which indicated R66 was moderately cognitively impaired. Review of R66's Hospital Records dated 6/14/23 (prior to admission to the facility) revealed, .Reviewed neuro-psychology consult which indicates an impaired cognitive profile, marked by his verbal and visual learning and memory and information processing speed. Executive functioning is notably variable. With functional declines reported by (R66), his updated cognitive profile now meets criteria for the diagnosis of Major Neurocognitive Disorder .Cognitively, his memory functioning has progressively worsened since 2020. He acknowledged that he most likely would not remember important information over time. Decreased information processing speed and attention and intermittent word finding difficulties were also endorsed . Review of R66's Admission/Readmission assessment dated [DATE] revealed R66 was identified as at risk for elopement. Review of R66's Care Plan dated 6/15/23 revealed, I am at risk for elopement r/t (related to): confusion secondary to a hx (history) of ETOH (alcohol) usage and cardiac insufficiency, dizziness, dx (diagnosis) of depression, incontinence, and forgetfulness .I need direct supervision while outside the facility . Place information in the elopement book per policy . During an interview on 08/30/2023 at 2:59 PM, Licensed Practical Nurse (LPN) V reported that she was working on 8/29/23 when she heard an overhead page of a code search which indicated a resident was missing. LPN V reported that she was not working on R66's unit at the time but reported that he had since been moved to her unit (dementia unit) and now had a wander-guard (alarm bracelet) because of his elopement and his continued risk for elopement. Review of the Witness Statement written by Receptionist F and dated 8/29/23 revealed, FOLLOWING IS MY STATEMENT REGARDING THE ELOPEMENT OF (R66) WHICH OCCURRED TUESDAY, AUGUST 29, 2023, AT 2:40 PM. THIS STATEMENT SUPERCEDES THE INCOMPLETE HANDWRITTEN STATEMENT I PROVIDED EARLIER TODAY WHEN I WAS UNABLE TO CLEARLY UNDERSTAND WHAT WAS BEING ASKED OF ME. On Tuesday, August 29, 2023, (R66) a resident at (facility), approached the front desk and asked me for directions to (shopping center). I did not recognize (R66) as a resident as I was unfamiliar with him, and he was not in the elopement binder (there are 86 residents at (facility) and I know about 30 of them by name and by sight.) Additionally, he was not in a wheelchair or using a walker or cane; he was appropriately dressed and appeared coherent to me. After I gave him directions, he went to look for (R66) sign out page. Again, I did not know he was (R66). He then signed out. I didn't think this was strange as I thought he was signing out the resident, (R66), and then going to go get him and take him to (shopping center). When he finished signing out and walked out without going to get the resident was when I thought something was wrong. I went to look at the page where he signed out and saw that (R66) was supposed to be accompanied when going outside the facility. I then realized that the person I was talking to was in fact (R66). I attempted to chase after him for five minutes. He walked very quickly, and I realized I wasn't going to be able to catch up to him. I also knew I needed to get back to my station at the facility as I'm not supposed to leave it for very long. I spent the next five minutes looking for the administrator. I could not locate her down the hallways nor did I see any other managers. I was unable to call the administrator's cell phone on (sic) it was not at the desk at the time and there isn't anything else at the front desk that might have the number. Because I thought this was an emergency situation, I sent an email to the leadership team explaining what happened because that was the best thing I could think of to do, and there was no one to speak with in person. I sent the email as a last resort. I was never instructed on elopement procedures; I was only instructed what to do during a Code Search. No one ever gave me the specific protocol as to what I was supposed to do if a resident actually eloped. No one ever specifically told me that elopement falls under abuse and neglect. During this entire time, I was unsure what I needed to do because of the lack of training (Do A; if not A, then B; if not B, then C). At this point after I sent the email the phone started ringing and I answered it. While I was on the phone, I noticed that the managers were up and about looking for the resident so at that point I stopped looking for someone to help. Very shortly after that, as I was sitting at the desk I overheard a nurse or aide say that she knew that (R66) was going to (shopping center). At this time the Code Search was initiated. Review of the Witness Statement written by Nursing Home Administrator in Training (NHAIT) Z and dated 8/29/23 revealed, (name omitted) the recreation director told me in the lobby area the (sic) (R66) had left the faciity on foot and the receptionist sent an email out about it. The administrator was also in the lobby and staff members began to disperse in searching. I was told by another resident that (R66) left the parking lot and went left on (facility road). I walked a few streets down to the right on (facility road) and did not see (R66). I came back to the facility where I met back up with (name omitted) who had walked to the left on (facility road). (name omitted) and I searched the creek and did a full perimeter of the outside of the facility .I saw a man in the distance that looked like (R66) and I ran to him (R66) returned safely to the facility where I stayed with him until we relocated him to the memory care unit and placed a wander guard on him with guardians permission. Review of the R66's elopement investigation revealed: Timeline of Events (8/29/23) 2:40 pm- Resident, (R66) signed himself out of the facility and was witnessed leaving the facility by (Receptionist F). Once [Name of Receptionist] realized he was not allowed out of the facility by himself, (Receptionist F) followed him into the parking lot. 2:50 pm- (Receptionist F) came back inside the facility to locate Administrator to inform them of the eloped resident. 2:51 pm- (Receptionist F) sent an email to (facility) Leadership Team informing them of the elopement. 2:56 pm- the email was read, and Code Search Drill was initiated, and members of the management team were dispatched into the surrounding area to locate the resident. 3:01 pm- (Nursing Home Administrator) called (name omitted) Police Department with description of resident to aide in community search for him. 3:09 pm- DPOA (name omitted) was notified by the administrator that (R66) had eloped from the facility and asked her if there were any locations in the immediate area that he would know to go to. (name omitted) said there was not. 3:24 pm- Resident was located on the corner of [NAME] Ave and [NAME] St by (NHAIT Z) and escorted back to the facility on foot. He was safe and assessed with no concerns noted . Root Cause Analysis It was determined that the facility mechanisms/ emergency door alarms were functioning properly and were sounding properly. Staff executed the process appropriately. Resident was found safe and immediately brought back into the facility with no concerns. The resident was identified as an elopement risk upon signing out and exiting the facility, and the staff member did initially follow him out into the parking lot. After determining she could not keep up with him the staff member returned to the building but did take several minutes to notify the team and have the Code Search Drill initiated. The receptionist on duty failed to follow through and initiate the drill in a timely manner. Once the drill was initiated, the procedure was followed correctly. Investigation Summary Upon review of staff, resident interviews, and investigation the facility confirms that resident exited the facility and was unsupervised for approximately 30 minutes. The facility does substantiate neglect. Although the receptionist, (Receptionist F), initially responded to the elopement, she failed to continue to follow the resident and initiate the missing resident procedure immediately. (Receptionist F) has been terminated as a result of this investigation due to substantiated neglect. Once Code Search was called the staff executed looking for the resident according to procedure. Staff successfully redirected resident (R66) back into the facility. He currently resides in our memory care unit and has decreased risk of being able to exit the facility without supervision . Review of the facility policy Elopements and Wandering Residents last reviewed/revised 4/23 revealed, Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .5. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 6. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay. b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements. e. Staff will monitor the implementation of interventions, response to interventions, and document accordingly. f. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. 7. Procedure for Locating Missing Resident a. Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (e.g. internal alert code). b. The designated facility staff will look for the resident. c. If the resident is not located in the building or on the grounds, Administrator or designee will notify the police department and serve as the designated liaison between the facility and the police department. The administrator or designee should also notify the company's corporate office . The Immediate Jeopardy began on 8/29/23 when the facility failed to provide adequate supervision for a resident at risk of elopement and follow the facility elopement procedure. The Director of Nursing and the Nursing Home Administrator were notified of the Immediate Jeopardy on 8/31/23 at 4:45 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 8/31/23, but noncompliance remains at isolated with the likelihood of serious injury, harm, impairment, or death due to sustained compliance has not been verified by the State Agency. The Immediate Jeopardy that began on 8/29/23 was removed on 8/31/23 when the facility took the following actions to remove the immediacy: Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the deficient practice and prevent any additional residents from a potential adverse outcome. Completion Date: 8/31/2023. *During investigation of elopement on 8/29/2023 the facility identified that the resident did not have proper interventions in place to reduce risk of elopement for a resident identified as an elopement risk upon admission. *The facility identified that residents residing in the facility were determined to be at risk. On 8/31/2023, the facility assessed all residents for elopement risk and implementation of elopement care plans with appropriate interventions; proper assessments and care plans were implemented if applicable. *The elopement binder was updated on 8/31/2023. *Education of elopement policy and care planning of elopement with proper interventions was initiated on 8/29/2023, given by the administrator and administrator in training; any facility staff member and agency staff member who did not receive education by 8/29/2023 will receive education prior to the start of their next shift. All facility staff and agency staff who were present at the time of the incident were immediately educated. Education is completed for all new hires prior to their first shift. *The EVS (Environmental Services) Director assessed the facility doors for proper function of the alarm system on 8/29/2023; deemed to be functioning appropriately. *The Administrator notified the DPOA of the incident and discussed proper interventions, she agreed with the implementation of the interventions including relocation to the memory care unit. Law Enforcement, Physician and Director of Nursing also notified. Law enforcement promptly dispatched two units to assist staff in the search for the resident after receiving the resident description. *Resident was placed on 1:1 supervision immediately after return to the facility until further interventions could be implemented. *Resident received a wander guard and was relocated to the memory care unit on 8/29/2023 where 1:1 supervision was later deemed unnecessary, and resident was put on frequent checks. *Assessments were completed on the resident to ensure the resident did not experience any adverse effects of the elopement, including skin assessment, nursing assessment and vitals signs were obtained. *On 8/29/23, the care plan for the resident was reviewed and updated with proper interventions to reduce future risk of elopement. *Risk Management report was completed on 8/29/2023. *Witness statements were obtained by primary care staff on 8/29/2023. Actions to Prevent Occurrence/Reoccurrence: *The Elopement and Wandering Policy was reviewed by the facility Administrator and deemed appropriate. *Staff member responsible for deficiency removed from facility and terminated as result of the investigation. *Beginning on 8/29/2023, education with facility staff and agency staff was initiated on the Elopement and Wandering Policy. Any facility staff and agency staff who did not receive the education by 8/29/2023 will be educated prior to the start of their next shift. All facility staff and agency staff who were present at the time of the incident were immediately educated. Education is completed for all new hires prior to their first shift. This was completed by administrator and the administrator in training. *Beginning on 8/29/2023, education with licensed nurses was initiated on proper implementation of elopement care plans and interventions. Any facility staff and agency staff who did not receive the education by 8/29/2023 were educated prior to the start of their next shift. All facility staff or agency staff who were present at the time of the incident were immediately educated. Education is completed for all new hires prior to their first shift. *Director of Nursing/designee will conduct an audit with three licensed nurses weekly for four weeks and then monthly for three months to ensure understanding of proper implementation of care planning and interventions for resident at risk of elopement, until substantial compliance has been maintained. Results of these audits will be submitted to the QAA committee for review and any further recommendations. *Director of Nursing/designee will conduct an audit with five random staff members once a week for four weeks and monthly for three months to ensure understanding of elopement and wandering policy, until substantial compliance has been maintained. Results of the audits will be submitted to the QAA committee for review and any further recommendations. *Residents will be evaluated for elopement risk quarterly beginning 8/29/2023, and as needed, new residents will be assessed for elopement risk upon admission. The initial assessment and reassessment for all residents is deemed appropriate to capture any other residents that could potentially be at risk for elopement; implementation of possible interventions to reduce occurrence. All licensed nursing staff have begun receiving education on completing the elopement assessment with proper implementation of interventions. *Results of audits will be reviewed with the QAA committee to ensure compliance and any further recommendations. Areas identified requiring quality improvement: Failure to implement appropriate interventions for a resident at risk of elopement. How facility identified resident affected and residents with potential to be affected: *All residents currently residing in the facility reviewed for appropriate elopement assessments and appropriate care plans implemented with immediate correction if applicable. How the facility monitors the effectiveness of its quality improvement measures (sustained compliance): *Director of Nursing/designee will conduct an audit with three licensed nurses weekly for four weeks and then monthly for three months to ensure understanding of proper implementation of care planning and interventions for resident at risk of elopement, until substantial compliance has been maintained. Results of these audits will be submitted to the QAA committee for review and any further recommendations. *Director of Nursing/designee will conduct an audit with five random staff members once a week for four weeks and monthly for three months to ensure understanding of elopement and wandering policy, until substantial compliance has been maintained. Results of the audits will be submitted to the QAA committee for review and any further recommendations. *The Administrator will be responsible for maintaining compliance with this plan of correction. The facility asserts the likelihood of immediate harm has been mitigated since 8/31/2023. *The facility is alleging compliance of 8/31/23 29073 DPS B Based on interview and record review the facility failed to implement effective interventions to prevent accidents and hazards for 1 resident (Resident #58) resulting in harm from a fall and serious injury. Findings: Resident #58 Review of an Admission Record reflected R58 originally admitted to the facility on [DATE] with diagnoses that included dementia, atrial fibrillation, syncope and collapse, difficulty in walking, unsteadiness on feet, peripheral vascular disease, a history of falling and muscle weakness. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected R58's cognitive status was not assessed. R58 required extensive assistance from one person for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use and personal hygiene. The assessment did not indicate R58 had any falls since the previous assessment. Review of a Brief Interview for Mental Status (BIMS) assessment dated [DATE] (not included in the MDS) reflected R58 was severely cognitively impaired as evidenced by a BIMS score of 4/15. Review of a Care Plan initiated on 1/4/2022 reflected R58 was on anticoagulant (blood thinner) therapy related to atrial fibrillation and had the potential for bruising. The goal of the care plan was that R58 would be free from discomfort or adverse reactions related to anticoagulant use. Interventions to meet that goal included Monitor/document/report to MD (doctor) PRN (as needed) signs of anticoagulant complications: blood tinged or [NAME] (obvious) blood in urine, black tarry stools, dark or bright red blood in stools, coffee ground emesis, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB (short of breath), loss of appetite, sudden mental changes in mental status, significant or sudden changes in v/s (vital signs). Review of a Nursing Progress Note dated 6/6/23 at 9:47 AM revealed Nurse was notified the Pt (patient, R58) has bruises on her right lower extremity and 4th digit toe right foot, Pt occasionally moaning in pain, restless and trying to get up without assist. Pt is unable to communicate effectively if she is having pain. Provider (name omitted) was notified and x-rays ordered. The progress note did not indicate a medication review was ordered or conducted. Review of an Other-Injury incident report dated 6/6/23 at 11:04 AM reflected Resident (R58) presents with swelling and discoloration to RLE (right lower extremity), tender to touch, denies pain at rest. The Resident Description reflected R58 said I really don't know (what happened). The injuries documented on the incident report indicated R58 had bruises to the front of her right lower leg. No further information was documented. Review of a Nursing Progress Note dated 6/6/23 at 1:06 PM reflected Observation of resident complete with discoloration to RLE (right lower extremity), denies pain at rest, ROM (range of motion) intact without indicators of pain but does tense during palpation of discoloration, resident unable to describe what happened, when asked if resident fell she stated I don't think so when asked if anyone injured her she stated No not at all and confirms feeling safe in the facility, message left for (name of Power of Attorney for Healthcare (POA) EE) requesting call back with phone number provided, awaiting STAT (right away) X-ray results. Review of a Nursing Progress Note dated 6/7/23 at 9:26 AM reflected the x-ray taken on 6/6/2023 was negative. Review of a Nursing Progress Note dated 6/7/23 at 3:34 PM, documented by the Director of Nursing (DON) reflected Resident stated to nurse that she had fallen a few days ago and hurt her leg. Responsible party notified, Physician notified, Administrator notified, DON notified. It was not clear from the progress note if R58's report of falling a few days ago was in any way related to the bruising on the right lower extremity. Review of a Fall incident report dated 6/10/23 at 7:31 PM reflected R58 had an unwitnessed fall without injury related to an attempt by R58 to transfer herself to bed from her wheelchair. Review of a Care Plan initiated on 1/4/2022 reflected R58 was at risk for falls related to problems with mobility and a history of falling. The goal of the care plan was that R58 would be free from injury from falls. No new interventions were added to the care plan to increase supervision or prevent injury from falling after R58's alleged reported fall a few days before as mentioned in the nurse progress note written on 6/7/23. An intervention to add anti-rollback device to the wheelchair was added after R58's unwitnessed fall on 6/10/23. During a telephone interview on 9/6/23 at 11:15 AM, POA EE reported that R58 had lived at the facility for 5 years and had not previously had issues with falling. POA EE said that she first learned about R58's bruised legs after her sister had visited her and had NOT been informed by the facility of R58's bruising. POA EE said the family didn't know what happened. POA EE said that R58 could not walk on her own and that if she had fallen in the facility, she would not be able to get herself back up again. During an interview on 9/6/23 at 12:15 PM, the Nursing Home Administrator (NHA) reported that she did not report R58's injury of unknown origin identified on 6/6/23 to the State Agency because the resident said she had fallen. The NHA said that she asked the DON to create a soft file investigation into the bruising injury. When asked, the NHA said that a soft file is an internal investigation that is not reported to the State Agency and would include a review of staffing and staff interviews. During a telephone interview on 9/6/23 at 1:30 PM, the DON reported she was familiar with R58 but could not recall the name of the nurse she referred to in the progress note she had written in R58's record on 6/7/23 (stating 'resident told the nurse' that she fell a few days ago). The DON said that she would typically do an investigation into the bruising identified on R58 on 6/6/23 and that all the documentation would be at the facility. Review of an Order Details report dated 6/19/23 reflected a doppler venous ultrasound of RLE had been ordered to rule out a deep vein thrombosis, edema (swelling). Review of a Physician Assessment reflected a Comprehensive Follow-up was conducted on 6/20/2023. The Chief Complaint was a Resident oriented review. The vital signs included a weight taken on 5/1/2023, blood pressure, pulse, temperature and oxygen saturations measured on 4/19/2023 (two months prior) and a blood glucose reading obtained on 5/31/23. The Exam reflected R58 had no edema in her extremities. The Assessment & Plan indicated R58 had Atrial Fibrillation . -continue Eliquis 5 mg twice daily. No reference to R58's recently identified injury of unknown origin/bruising or fall was made. No discussion related to the R58's injury of unknown origin/possible fall, R58's fall on 6/10/23 or order for a doppler venous ultrasound of the RLE was mentioned. Review of a Fall incident report dated 6/21/23 at 4:45 PM revealed (R58) was observed on the floor next to bed. Resident had a laceration to right leg noted after fall. The report indicated R58 was not able to give a description of the event. The physical assessment noted a deep laceration noted to lower right leg. Discoloration noted to bilateral toes and feet. Review of hospital records, including ED (Emergency Department) Provider Notes reflected that on 6/21/23 R58 was transferred to the hospital via ambulance after falling at the facility and sustaining a deep laceration with extensive bleeding. The Laceration Repair note written on 6/21/23 at 7:21 PM reflected R58 has a laceration to her right lower leg that was 15 centimeters long and to the bone. The records indicated that R58 was admitted to the hospital for monitoring due to the laceration and bleeding that was difficult to control. During a follow-up interview on 9/6/23 at 2:45 PM, the NHA reported she did not have an investigation/soft file into the injury of unknown origin sustained by R58 on 6/6/23. The NHA also reported there was no record any neurological assessments were completed on R58 after the unwitnessed fall on 6/10/2023. The NHA said there was no additional assessment documentation or provider progress notes in the clinical record to explain why a doppler scan had been ordered to rule out a DVT on R58 prior to her being transferred to the hospital on 6/21/23.

This citation pertains to intake #: MI00135410 Based on interview and record review, the facility failed to ensure staff initiated timely and appropriate Cardiopulmonary Resuscitation (CPR) per standards of care, federal regulation, and their own facility policy and procedures, resulting in an immediate jeopardy when 1 resident (Resident #103), who was a full code (desired full life saving measures), was found unresponsive in respiratory distress and subsequently cardiac arrest. Licensed nursing staff did not know how to appropriately respond causing a delay in rescue attempts and R103's death. This deficient practice placed all residents, who are designated as a Full Code and who suffer cardiac arrest, or are found unresponsive, at risk for serious harm and/or death. Resident #103 (R103) Review of an Admission Record revealed R103 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: diabetes and heart disease. Review of R103's Physician Order dated [DATE] revealed R103 code status was CPR-Full Resuscitation. Review of R103's Nursing Progress Note dated [DATE] at 8:40 PM revealed, Entered residents room and observed that she was non-responsive, (blood pressure) ,d+[DATE]-(heartrate) 43-(respirations) 8-(temperature) 96.3 O2 sat (oxygen saturation) 80% on room air. O2 started at 5L/m. Call placed to NP (Nurse Practitioner) (name omitted), order to send to ER (emergency room ), called daughter and informed her, and called (ambulance service name omitted). Within a few minutes (ambulance service) and Fire dept. were here. (Respiration range for adults ,d+[DATE], pulse range for adults ,d+[DATE], Oxygen saturation range ,d+[DATE]%). During an interview on [DATE] at 8:53 AM, Licensed Practical Nurse (LPN) Q was asked to describe the events that led to R103's cardiac arrest. LPN Q reported that she was R103's nurse at the time R103 coded (respiratory/cardiac arrest). LPN Q reported R103's blood sugar level was assessed around 4:00 PM which was the last time LPN Q had observed R103. LPN Q reported she returned to R103's room to administer evening medications around ,d+[DATE]:15 PM and found R103 sitting in her chair and unresponsive. LPN Q reported 2 Certified Nursing Assistant (CNAs) assisted with getting R103 back to bed and placed a backboard behind R103 in the event she would require CPR. LPN Q reported vital signs were obtained and R103 was breathing (8 respirations a minute) but did not describe ventilatory depth or rhythm (deep, shallow, normal, labored, regular, irregular). LPN Q reported R103's oxygen level and heart rate were assessed via pulse oximeter and identified R103's pulse in the 40's and oxygen level at 80%. LPN Q was asked if she assessed R103's pulse other than by the pulse oximeter and she reported that she had palpated R103's pulse via radial and carotid. LPN Q was unable to recall the pulse (rate, rhythm, force) or the frequency it was assessed and confirmed that subsequent pulse assessments were not documented. LPN Q reported that she had continued to assess R103's pulse until EMS arrived but did not report that R103 had additional oxygen saturation or respiration assessments. LPN Q reported LPN HH was assisting with R103's care and the crash cart (cart containing medications and equipment used for emergency resuscitation) and the ambu bag (device used for manual ventilation) were brought to R103's room. Although the facility was equipped with an AED (automated external defibrillator portable machine that automatically diagnoses the heart rhythm and determines if a shock or CPR is needed) it was not applied to R103. LPN Q reported that she had not identified asystole and CPR had not been initiated prior to EMS arrival. LPN Q reported that once EMS arrived, EMS identified that R103 was in asystole and directed her to begin CPR. Review of R103's Ambulance Report dated [DATE] revealed the ambulance dispatcher received a call for emergency service at 9:02 PM. At 9:10 PM the paramedics made contact with R103. Narrative History Text: EVENTS LEADING TO ILLNESS/INJURY: staff states Pt (patient) was steadily declining for several hours and complaining of difficulty breathing. POSITION PT FOUND/INITIAL SCENE FINDINGS: pt lying supine on her bed with a backboard under her. Agonal respirations, no pulses, staff was not performing CPR. (Agonal breathing is characterized by slow, very shallow irregular respirations that result from anoxic brain injury. This will often progress to apnea (absence of breath) depending on the underlying cause NIH 2023). PT LAST SEEN AT AND BY: (Staff at the nursing facility throughout the evening) COMPLAINT(S) PRIOR TO ARREST: (Dyspnea) . CHECK THE FOLLOWING CONDITIONS CONSIDERED AS THE CAUSE OF THE CARDIAC ARREST .hypoxia (low oxygen level) ADDITIONAL ASSESSMENT NOTES (IF APPLICABLE): Prior to arrival, the call came across as a cardiac arrest. On arrival, Pt (patient) was lying in her bed unresponsive with agonal respirations and secretions coming out of her mouth. Staff were not performing CPR. no pulses were found. CPR was initiated by ALS. ALS directed available staff to assist in chest compressions and ventilations. Staff needed constant coaching on compression rate and depth and were unable to complete two minute cycles of compressions. Average time of compressions was about 30 seconds and then they were too tired and would switch out. Staff also needed constant coaching on mask seal, respiration rate and amount of oxygen per breath. Initial pulse and rhythm check showed asystole with no pulses . Review of R103's Emergency Department Hospital Records dated [DATE] at 10:38 PM revealed This is a [AGE] year-old female with unknown past medical history presenting after cardiac arrest. On arrival, the patient is pulseless. CPR is initiated . After 2 rounds of CPR and 1 dose of epinephrine, the patient regained pulses .Based on the degree of anasarca (fluid accumulation), as well as pulmonary edema, suspect this was likely a respiratory arrest at this time . This is a [AGE] year-old female with unknown past medical history presenting after cardiac arrest. Per EMS, patient was declining at his care facility for 3 hours. When EMS arrived, she was agonal breathing and was pulseless. They started CPR . Review of R103's Emergency Department Hospital Records dated [DATE] at 11:04 PM revealed, This is a 85 y.o. female who presents today as a post arrest. Patient reportedly per EMS had been going downhill for 3 hours before she went down in front of staff. They did not start CPR on the patient. EMS found her to be agonal with PA .She got 5 rounds of epinephrine from EMS and they did get a pulse back. As they were wheeling her into the Trauma Bay, patient lost her pulse and she have CPR started by us. She did get a dose of epinephrine and her pulse came back .Patient was found to be hypoglycemic (low blood sugar) and was given D50 .Patient was admitted to the intensive care unit. The resident did update the family and family wants to pursue all aggressive measures. R103's blood sugar level was 45 (normal range ,d+[DATE]). Review of R103's Inpatient Hospital Records dated [DATE] at 3:34 AM revealed, Pt (patient) is an 85 y/o female with history of DM (diabetes mellitus), PVD (peripheral vascular disease), s/p right BKA (status post right below knee amputation), dementia admitted after cardiac arrest. By report, she was having respiratory distress at her facility and EMS was called. On EMS arrival, she was agonally breathing and found to be in PEA (pulseless electrical activity) arrest. CPR initiated. She received 5 doses of epinephrine prior to ROSC (return of spontaneous circulation). On arrival to the ER, she again was found pulseless and received 2 more rounds of CPR .Her daughter (DPOA) arrived shortly after admission and the patient's grave prognosis was discussed. The patient had escalating presssor (raises blood pressure) requirements and remained unresponsive throughout her stay. Her daughter opted to transition to comfort care after having her pastor come to the bedside. Her high dose pressors were discontinued, a morphine drip started and she was extubated. On ,d+[DATE] at 0330 she was found without spontaneous pulses or respirations. She was unresponsive to any stimuli and her pupils were fixed and dilated. She was pronounced deceased at that time. On [DATE] the Nursing Home Administrator was verbally notified and received written notification of the immediate jeopardy identified on [DATE] that began on [DATE] due to the facility's failure to immediately perform Cardiopulmonary Resuscitation on a Full Code resident. A written plan for removal for the immediate jeopardy was received on [DATE] and the following was verified on [DATE]: 1. Identification of Residents Affected or Likely to be Affected: *On [DATE], the facility completed a root cause analysis of the event and determined the licensed nurse did not identify the immediate need to initiate CPR on the resident. The licensed nurse was provided education by the facility Director of Nursing/designee on the BLS guidelines for the initiation of CPR with return demonstration. *The facility determined all other FULL CODE residents are at risk. On [DATE], the facility audited all resident deaths in the last 30 days via review of their electronic health record. The audit results showed that there were no other FULL CODE residents who had a medical emergency who did not receive CPR per current standards of practice. Current residents were assessed for an acute change in condition on [DATE] with no notable deviation from baseline or medical emergency requiring CPR. *Facility Medical Director was notified of the incident on [DATE]. *The DON/designee completed a chart audit on current residents and compared the Medical Treatment Decision Forms to the physician order for accuracy on [DATE]. Identified discrepancies were addressed at the time of the event. *On [DATE], the emergency carts at the facility were audited by the DON/designee to ensure all necessary items are present - no concerns were identified. *On [DATE], all current residents were assessed by a licensed nurse for an acute change in condition. *On [DATE], the Administrator and DON were provided counseling by the Regional Director of Operations on the Mission Point expectations related to investigations and the systemic reporting of adverse events to ensure appropriate personnel are notified of such matters. 2. Actions to Prevent Occurrence/Recurrence: *The Cardiopulmonary Resuscitation Policy was reviewed by the facility Administrator, DON and Medical Director and deemed appropriate. *Beginning on [DATE], the DON/designee educated the licensed nurses on the Cardiopulmonary Resuscitation Policy, including how to assess the need, monitor and perform CPR. *On [DATE], the facility Human Resources Business Partner performed an audit of all licensed nurses CPR certifications - all licensed nurses are up to date with certification. *Beginning on [DATE], DON/designee performed a Code Blue drill and/or return demonstration on all shifts until every nurse had participated at least once. This will continue until all nurses have been educated. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: [DATE] Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and severity of actual harm due the fact that not all facility staff have received education and sustained compliance has not been verified by the State Agency. Review of the facility policy Cardiopulmonary Resuscitation (CPR) - Adult dated ,d+[DATE] revealed, Appropriate cardiac and respiratory function will be maintained until a definitive treatment can be given. CPR will be initiated on all residents with an Advanced Directive stating CPR-Full Resuscitation except in circumstances where you are responding to an emergency (drowning, choking, or electrocution). It is the policy of this facility to respect each resident's individual, informed decision regarding advance directives and code status. Cardiopulmonary Resuscitation (CPR) will be initiated for residents who have requested CPR, for residents who have not formulated an advance directive and for residents who do not have a valid DNR order. To provide Basic Life Support (BLS) to residents with absence of respirations and pulse, as designated by resident or legal guardian except in circumstances listed above. Policy Explanation and Compliance Guidelines: 1. In the event a resident is identified unresponsive and upon a thorough assessment determines that there is no pulse or respiratory activity and the resident has declared a full-code status, a BLS certified staff member will: a. Simultaneously with the initiation of chest compressions direct a staff member to immediately retrieve the emergency cart. b. Continue to administer chest compressions and rescue respirations per the American Heart Association recommendations. c. Direct a staff member to contact the Emergency Response Team (911) immediately to inform them of a full code requiring life support interventions and possible transportation to the emergency department. d. Direct a member of the response team to contact the attending physician and responsible party/DPOA/guardian. This staff member shall also complete a hospital transfer sheet including a copy of advance directives/code status and make these documents available to Emergency Response Personnel. e. Identify a member of the response team to be responsible for documenting the time of each intervention and resulting response. Documentation should include but not limited to: 1) Date and time of arrest and name(s) of person(s) assisting with CPR, including the recorder. 2) Medications given. 3) Treatments performed. 4) Results of resuscitation. 5) Time AED was placed and whether or not shock advised if available. 6) Date and time family and doctor notified. 7) Assessment done. 8) Where resident was transferred to (i.e., EMS Agency or Mortuary). Mission Point Healthcare Systems 9) A debriefing with staff involved in the code response as needed. f. Facility staff shall defer all resuscitation efforts to Emergency Response Personnel once they arrive at the location and declare that they will assume the responsibility of maintaining life support interventions. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, A saturation greater than 93% is acceptable while a saturation of less than 90% is a clinical emergency. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 483). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Hypoxia is inadequate tissue oxygenation at the cellular level. It results from a deficiency in oxygen delivery or oxygen use at the cellular level. It is a life-threatening condition. Untreated, it has the potential to produce fatal cardiac dysrhythmias ([NAME] and [NAME], 2019). [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 917). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Patients with sudden changes in their vital signs, LOC (level of consciousness), or behavior may be experiencing profound hypoxia .If a patient's hypoxia is severe and prolonged, cardiac arrest results. A cardiac arrest is a sudden cessation of cardiac output and circulation. When this occurs, oxygen is not delivered to tissues, carbon dioxide is not transported from tissues, tissue metabolism becomes anaerobic, and metabolic and respiratory acidosis occur. Permanent damage to the heart, brain, and other tissue occurs within 4 to 6 minutes. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. ,d+[DATE]). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Cardiopulmonary Resuscitation During cardiac arrest there is an absence of pulse and respiration. Patients in cardiac arrest require immediate cardiopulmonary resuscitation (CPR), a basic emergency procedure of artificial respiration and manual external cardiac massage. The sequence for CPR is C-A-B: chest compression, early defibrillation, establishing an airway, and rescue breathing (Link et al., 2015). The American Heart Association (AHA, 2015) continues to research cardiac arrest treatment and outcomes. In adults (the majority of cardiac arrests) the critical initial elements found to be essential for survival were adequate chest compressions and early defibrillation. Adequate compressions in adults need to occur at a rate of 100 to 120/ minute with a depth of at least 2 inches and allowance for time for the chest to recoil. Passive ventilation is no longer recommended in patients undergoing conventional CPR in the community setting, although it may be used in emergency medical service settings (Neumar et al., 2015). Defibrillation delivers an electrical current to the myocardium that stops all electrical activity and allows the heart's normal pacemaker to resume its normal activity ([NAME], 2017). It is recommended that defibrillation occur within 5 minutes for an out-of-hospital sudden cardiac arrest and within 3 minutes for a patient in a hospital. An automated external defibrillator (AED) (Box 41.10), available in many public places, such as schools, airports, and workplaces, can be used by health care providers and lay individuals alike to defibrillate people with cardiac arrest (AHA, 2018; Neumar et al., 2015). [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 944). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Automated External Defibrillator o The automated external defibrillator (AED) is a device used to administer an electrical shock through the chest wall to the heart to stop the abnormal rhythm and restore a normal heart rhythm. The AED has built-in computers that assess a patient's heart rhythm and determine whether defibrillation is necessary. New technology has made them user friendly, with audio and visual cues telling users what to do when using them. The AED delivers a shock to the patient after announcing, Everyone stand clear of patient. A shock is delivered only if the patient needs it (NHLBI, n.d.b). Lay rescuer AED programs train lay personnel on the use of the AED (AHA, 2018). The AED is used to strengthen the chain of survival. Patients who received a shock from an AED available in the public had a higher survival rate and rate of discharge from the hospital than those who did not (AHA, 2018). For witnessed ventricular fibrillation, early cardiopulmonary resuscitation with defibrillation within the first 3 to 5 minutes results in greater survival rates ([NAME] et al., 2017). [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 944). Elsevier Health Sciences. Kindle Edition.

This citation pertains to intake #: MI00135410 Based on observation, interview, and record review the facility failed to 1.) stock or re-stock medication carts with necessary medications for residents and 2.) ensure that all on-duty nurses had access to the pyxis (medication dispensing system) in the event of a medical emergency resulting in an immediate jeopardy when, beginning on [DATE], the facility licensed nurses did not have access to and were unable to administer emergency/life-saving medication to a resident in hypoglycemic crisis (R102) resulting in her death. This deficient practice places all diabetic residents at risk for serious harm, injury and/or death. Findings: Resident #102 (R102) Review of an Admission Record revealed R102 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: Type 2 Diabetes. Review of the Standing Orders revealed that Glucose Gel (Hypoglycemic event-Conscious), Glucose IM (Hypoglycemic event-Unconscious), and Hypoglycemic Crisis-May follow facility policy were available to order as an order set by nursing staff. Review of R102's Order Summary revealed no Standing Orders for hypoglycemic event medications. Review of R102's Blood Sugar Log revealed on [DATE] at 7:23 AM R102's blood sugar was 49 (blood sugar range ,d+[DATE]). Review of R102's Electronic Health Record (EHR) revealed the provider was not notified of the critical low blood sugar result. Review of R102's Nursing Progress Note dated [DATE] at 10:15 AM revealed, Called to residents room- resident with garbled speech and drooling. - Accucheck (blood sugar check) completed- was 37. Pudding , OJ (orange juice), 1 tube glucose, Accucheck 45-provider called- new order for glucagon given. and a repeat glucagon given. Accucheck 123- Resident groggy but beginning to answer questions. 11am blood sugar 210. Provider notified. Will continue to offer fluids and food. Review of R102's EHR revealed the 2 doses of glucagon was not documented as ordered and was not documented as administered. On [DATE] at 7:53 AM, Nursing Home Administrator (NHA) verified R102's glucagon was not ordered in the EMR and was not documented as administered. Review of R102's Nursing Progress Note dated [DATE] at 6:23 AM revealed, During am (morning) med (medication) pass this nurse entered resident's room to give her am medication and noted resident had small emesis on pillowcase and on shoulder. Resident not arousable. Resident breathing, R18 (respirations 18). Blood sugar checked immediately, 27. Checked unit for Glucagon and/or Glutose gel. None found. Requested assistance from other LPN (Licensed Practical Nurse). Called NP (Nurse Practitioner) on call, ordered to send patient to ER (emergency room ). Called 911 at 0503. Glucose tab crushed and administered while waiting for EMS. Daughter notified of situation. Reentered room and found resident was no longer breathing, EMS (Emergency Medical Services) arrived and took over care. Resident DNR (Do Not Resuscitate), no CPR (Cardiopulmonary Resuscitation) provided. EMS called time of death at 0529 (5:29 AM). Notified daughter that resident had passed away. Other LPN notified DON (Director of Nursing). RN (Registered Nurse) arrived at shift changed and notified administrator. Review of R102's Emergency Medical Services Report (company name omitted) dated [DATE] revealed the 911 call was received at 5:05 AM and the paramedics/EMTs made contact with R102 at 5:18 AM. Patient is a nursing home resident was last spoken to at 0300 HRS (3:00 AM). Staff now found unresponsive patient and suspecting a diabetic issue. They called 911. ATF (arrived to find) unresponsive/apneic/pulseless patient in semi-fowlers (inclined position ,d+[DATE] degrees on back) position in bed. EKG (electrocardiogram) rhythm is asystole (no heartbeat). Pupils dilated/non-reactive .Time of death 0529 HRS (5:29 AM) . During an interview on [DATE] at 9:41 AM, Confidential Informant (CI) A reported that R102 had an incident of hypoglycemic crisis on [DATE] where she required glucagon which resolved her symptoms and raised her blood sugar. On [DATE] in the early morning, R102 was found unresponsive with a blood sugar of 27 and the nursing staff on duty did not have access to glucagon resulting in R102's death. CI A reported R102 was admitted to the facility for short term rehab and was to be discharged home on [DATE]. CI A reported that R102's death was avoidable and felt that facility management did not appropriately handle R102's death, investigate the incident, or put a system in place to ensure this could not happen again. During an interview on [DATE] at 5:35 AM, Licensed Practical Nurse (LPN) E reported that during his shift ([DATE]-[DATE] night shift) R102 had been stable throughout the night. LPN E reported that during morning medication pass around 5:00 AM, R102 would not wake up. LPN E reported he assessed her blood sugar level, and it was incredibly low. LPN E immediately accessed the medication cart to obtain a glucagon IM (intramuscular) injection or gel (emergency medication used to treat severe hypoglycemia) and there was no glucagon available to administer. LPN E reported that he ran to the other units to obtain glucagon and assistance from the only other scheduled nurse in the facility (LPN L). LPN E reported that there was no glucagon available in the medication carts on the other units (4 units in the facility). LPN E and LPN L then attempted to gain access to the facility's pyxis (medication storage unit that requires login and password) but both had not been given access. LPN E reported that because he was unable to obtain the glucagon, he crushed glucose tabs and placed it in R102's mouth in an attempt to raise her blood sugar and save her life. LPN E reported that at that point R102 did have a pulse or respirations and he called 911. LPN E reported that by the time EMS arrived to the facility R102 was without a pulse and/or respirations. LPN E reported that glucagon IM, gel, and tabs were to be available in the medication cart on the unit in case of an emergency. LPN E reported that he had not been told in nurse-to-nurse report of R102's low blood sugar levels on [DATE] or [DATE] and was unaware that she had required glucagon x2 on [DATE] as it was not reflected in the EHR. LPN E reported that had he been aware of R102's hypoglycemic emergencies he would have ensure he had glucagon available in the case of an emergency. LPN E reported that had he had access to the emergency medication, glucagon, R102's would likely have had a different outcome (R102 would have survived). LPN E reported R102 was scheduled to discharge home in the next couple days. During an interview on [DATE] at 1:06 PM, LPN J reported that she did not have access to the facility pyxis until after R102 died on [DATE]. LPN J reported that prior to the incident that occurred on [DATE] R102 had had critically low blood sugar and required glucagon. LPN J reported that only an agency nurse had access to the pyxis to pull the glucagon during that incident. LPN J reported that nursing management (Unit Managers and DON) were notified at that time that the facility nurses needed to pull glucagon from the facility pyxis but were unable to because the facility nurses did not have access. LPN J stated, the DON knew we didn't have access to the pyxis prior to the incident. It wasn't a secret. LPN J reported that had the DON ensured all licensed nurses had access to the pyxis when they were made aware, LPN E would have had the ability to obtain the glucagon from the pyxis and administer it to R102. LPN J reported that the facility nurses were upset about R102's death because it was preventable and told the DON that all of the medication carts needed an emergency glucagon IM to ensure this didn't happen again, but the DON reported that glucagon IM expires and therefore it would be kept in the pyxis. LPN J reported R102 was to be discharged home on [DATE] but because the licensed nurses did not have access to emergency medication she died . During an observation and interview on [DATE] at 11:37 AM, the medication carts on the 100 Unit and 200 Unit were reviewed with Registered Nurse (RN) B. The 200 Unit medication cart did not contain glucagon IM or Gel and the 100 Unit medication cart contained 1 glucagon IM injection assigned to 1 resident. The 100 Unit medication cart did not contain glucagon gel. RN B reported concerns that in the case of a hypoglycemic emergency there would be no way to quickly administer glucagon and reported the 100 Unit and 200 Unit had multiple residents on insulin. During an observation and interview on [DATE] at 11:57 AM, the medication cart on the 300 Unit was reviewed with Licensed Practical Nurse (LPN) C. The 300 Unit medication cart contained 1 glucagon IM injection assigned to a resident. LPN C reported that if a resident required glucagon, it would be located in the facility pyxis if there was not one assigned to them in the medication cart. LPN C reported any resident that receives insulin should have an order for glucagon IM and Gel and it should be located on their unit medication cart. During an interview on [DATE] at 11:20 AM, LPN Y reported that at the time the Immediate Jeopardy was served, she had not had access to the facility pyxis. During an interview on [DATE] at 9:38 AM, LPN U reported that at the time the Immediate Jeopardy was served, she had not had access to the facility pyxis. During an interview on [DATE] at 8:00 AM, NHA reported that R102's hypoglycemic crisis/death and was identified and reviewed on [DATE]. NHA reported that the root cause for the incident was lack of access to the pyxis and it was identified as a widespread issue. NHA reported that beginning on [DATE] the Director of Nursing (DON) was completing an audit to ensure all licensed nursing staff, including agency nurses, had access to the pyxis as well as ensuring all diabetic residents had blood sugar parameters and appropriate medications ordered in the Electronic Health Record following the facility hypoglycemia policy and standing orders. On [DATE] the Nursing Home Administrator was verbally notified and received written notification of the immediate jeopardy identified on [DATE] that began on [DATE] due to the facility's failure to ensure that all on-duty nurses had access to the pyxis in the event of a medical emergency. A written plan for removal for the immediate jeopardy was received on [DATE] and the following was verified on [DATE]: 1. Identification of Residents Affected or Likely to be Affected: *Facility Medical Director was notified of the incident on [DATE]. *All diabetic residents are at risk and are considered like residents. *On [DATE] the DON/designee began an audit of all residents with a diabetes diagnosis for blood sugar parameters, and to ensure orders for glucagon gel/tabs in place. *On [DATE] the DON/designee performed an audit for glucagon gel/tabs available in carts - glucagon available on cart. *On [DATE] current residents were assessed by a licensed nurse for an acute change in condition. Two LOA residents on [DATE] were assessed by a licensed nurse on [DATE]. *On [DATE] the Administrator and DON were provided counseling by the Regional Director of Operations on the Mission Point expectations related to investigations and the systemic reporting of adverse events to ensure appropriate personnel are notified. Actions to Prevent Occurrence/Recurrence: *On [DATE] nursing staff audited for log-in access to backup device of medications. On [DATE] all facility licensed nurses and Agency nurses who did not have access to the backup device were entered and provided access to emergency use medications. The staffing roster is reviewed daily to monitor for Agency nurses who need access. The DON or designee will assign log in and provide training prior to shift start time. *On [DATE] the Diabetes Management policy was reviewed and deemed appropriate by the facility Administrator, DON and Medical Director. *Beginning on [DATE], the DON/designee educated the licensed nurses on the Diabetes Management Policy. Facility licensed nurses and Agency nurses will be educated prior to working their next scheduled shift. *On [DATE] the facility completed an Ad Hoc QAPI and will continue to review for continued monitoring and compliance during monthly QAPI. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: [DATE] Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and severity of actual harm due the fact that not all facility staff have received education and sustained compliance has not been verified by the State Agency. Review of the facility policy Diabetic Management: Hyper/Hypoglycemic Events last revised ,d+[DATE] revealed, .Residents with diabetes mellitus will be monitored and treated for hypoglycemia and/or hyperglycemia according to Clinical Practice Guidelines and per physician orders .1. Hypoglycemic Event: A hypoglycemic event is defined by a blood sugar less than 70 mg/dl or markedly less than usual for a resident who is exhibiting symptoms .2. Hypoglycemic Event Protocol: If blood sugar is less than 70 mg/dl or markedly less than usual for an individual resident who is exhibiting symptoms, suspect a hypoglycemic event and begin treatment as follows .b. PROTOCOL B - for Unconscious Resident: i. Administer one of the following: 1 mg or 1 unit of Glucagon subcutaneous or IM 50 ml of IV 50% Dextrose. ii. Recheck blood sugar in 30 minutes and if blood sugar remains under 100 or if resident is still unconscious or unresponsive phone emergency services .

Based on observation, interview, and record review, the facility failed to ensure residents were engaged in dignified and meaningful activities for 2 Residents (Resident #3 and #6) of 18 residents reviewed for activities, from a total sample of 21 residents, resulting in boredom, and the potential for feelings of worthlessness and the promotion of loneliness. Findings include: Resident #3 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) score indicated Resident #3 was moderately cognitively impaired and required extensive assistance for activities of daily life (ADLs). Resident #3 was viewed to be asleep or watching television in his reclining chair in his room on multiple occasions on 8/1/2017 at 7:35 AM and 2:45 PM and at 7:40 AM and 9:20 AM on 8/2/2017. An interview was completed with Resident #3 on 8/2/2017 at 9:30 AM. When asked about activities, Resident #3 stated that all I can do is watch television. Resident #3 stated he does not like group activities and there is not much he can do in his room. He stated I don't like bingo and all of that. Resident #3 stated he hoped his family could get him a Playstation so he could at least watch some movies or play a game. Resident #3 advised that it was frustrating to be there with nothing to do. Resident #3 stated he leaves the room for about an hour and a half whenever they clean his room but other than that he stays in his room all day. Resident #3 stated that my sister committed suicide with my gun and if I had it, I would do it myself. Resident #3 confirmed he was not saying this out of frustration, it's the truth. Resident #3 denied having any weapons in the facility or another plan to harm himself but stated eventually I will figure something else out. Resident #3 denied talking to anyone at the facility about how he was feeling and stated I don't think there is anyone here you can talk to. An interview was completed with Director of Nursing (DON) B at 10:00 AM regarding Resident #3. DON B was not aware of any suicidal concerns with Resident #3. DON B immediately started the process to implement a safety plan regarding Resident #3's suicidal statements. DON B was informed that Resident #3 had mentioned he was interested in playing video games and she stated they have a Wii system in the building and could see if Resident #3 would be interested in using that. A review of Resident #3's care plan dated reveals the focus area with initiation date of 1/30/2017 limited activity involvement the intervention is noted at Try and encourage me to activities outside of my room; my only leisure activities are to watch TV and socialize with my family. Another noted focus area with initiation date 1/30/2017 reads I have mood problems r/t (related to) Depression with medications given. The interventions listed include assist me, my family and caregivers to identify strengths, positive coping skills and reinforce these, offer alternatives to me if I am unhappy with something, and provide me with reassurance that you will listen to my concerns and that you will attempt to help me resolve any concerns that I have. Resident #6 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #6 was a [AGE] year old female readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) score indicated Resident #6 was moderately cognitively impaired and required extensive assistance for activities of daily life (ADLs). An interview was completed with Resident #6 on 8/1/2017 at 7:30 AM. Upon entering Resident #6's room she was viewed to be singing and facing the wall looking at herself in the mirror. Resident #6 stated singing in her room is how she spends most of her time. An interview was completed with Resident #6 on 8/2/2017 at 11:40 AM in her room. Resident #6 was viewed to be facing the window and singing. Resident #6 stated she was bored. She stated that she had gotten her hair done that day and missed the activity, which was bible study. Resident #6 again stated that she spends most of her time singing songs to my roommate or sleeping. Resident #6 stated she doesn't see well, so there isn't much to do. Resident #6 stated she would like to go outside more and feed the ducks. A review of Resident #6's care plan dated reveals the focus area with initiation date of 12/13/16 I am dependent on staff for activities, cognitive stimulation, social interaction r/t (related to) Cognitive deficits. A focus area initiated on 12/12/16 reveals I have mood problem r/t (related to) adjusting to a new living environment, Depression . A listed intervention is encourage me to attend activities of interest to promote socialization with others.

This citation pertains to MI 412 Based on interview and record review, the facility failed to prevent a fall with injury for 1 (Resident #11) of 4 reviewed for falls, from a total sample of 19, resulting in Resident #11 falling and sustaining a hip fracture. The facility submitted past non-compliance and was in compliance at the time of investigation. Findings include: Review of the Face Sheet and quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #11 was a [AGE] year old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS reveled Resident #11 was moderately cognitively impaired, transferred and ambulated with extensive assistance of 2 staff members, and had a history of [REDACTED]. Review of the Fall Risk assessment dated [DATE], revealed Resident #11 was at high risk for falls. Review of Resident #11's Fall Investigation Reports, revealed Resident #11 sustained falls on the following dates and times: [DATE] at 2:00 pm [DATE] at 1:00 pm [DATE] at 1:30 pm [DATE] at 7:30 pm [DATE] at 7:35 pm [DATE] at 1:45 pm [DATE] at 10:45 am [DATE] at 2:35 pm [DATE] at 10:50 am [DATE] at 4:00 am Review of Resident #11's History of Falling Care Plan created on [DATE], revealed Staff to provide 1:1 when resident is restless/delusional created on [DATE]. The intervention was revised on [DATE] to include If I appear awake and anxious during 10p-6a shift, encourage me to come to a common area that is populated for safety and sensor alarm to bed and chair was initiated on [DATE]. Review of the eMAR (electronic Medication Administration Record) note dated [DATE] at 3:38 am, revealed Resident #11 received Ativan (anti-anxiety medication) 0.5 mg (milligrams) at 3:35 am for anxiety, agitation, upset thinking her mother just died . Crying, yelling. Review of Resident #11's Fall Investigation Report dated [DATE] at 4:00am, revealed Resident #11 was heard yelling for help and fell in her bedroom doorway. The Fall Investigation Report revealed Resident #11's alarm was not sounding, Resident #11 was last toileted at 9:30 pm, and last observed at 3:55 am talking and sitting. The Intervention & Root Cause Analysis revealed attempting to ambulate unassisted. Decreased safety awareness, confusion, agitation, anxiety, dementia-thinking her mother just died . The root cause analysis statement revealed 1.) Resident awake in room talking noted by staff to be anxious. 2.) Resident transferred independently + fell when ambulating. 3.) Resident delusional thought mother had just died . Review of Resident #11's Behavior to Monitor:Sleep Pattern (30 minute checks) revealed Resident #11 was asleep in bed on [DATE] from 2:30 am until 7:00 am. The 30 minute checks from 2:30 am until 5:30 am, were initialed by CNA F Review of Resident #11's Radiology Report dated [DATE], revealed Modestly displaced right hip fracture . In a telephone interview on [DATE] at 8:39 am, Certified Nursing Assistant (CNA) F reported she was the only CNA scheduled to work on Resident #11's hall the night of [DATE]-[DATE]. CNA F reported she was in a room with another resident when she heard Resident #11 yell for help. CNA F reported she came out of the other resident's room, observed Resident #11 standing in the doorway of her room, and then Resident #11 fell as CNA F was running toward her. CNA F reported Resident #11's alarm was not sounding. CNA F also reported Resident #11 had been anxious the whole night and was trying to get up. CNA F reported Resident #11 was not placed on 1:1 supervision. When queried why the alarm was not functioning, CNA F reported she thought the batteries were not working. CNA F reported CNA Y (who was assigned on another hall) was in Resident #11's room 5 to 7 minutes prior to the fall. CNA F reported she did not complete 30 minute checks on Resident #11 and did not document 30 minute checks. CNA F reported another staff member must have initialed the form for her. The surveyor attempted to contact CNA Y via telephone twice on [DATE], with no response to voicemail or e-mail request to return the call. CNA Y was the staff who performed the 30 minute checks on Resident #11 up until 2:00 am on [DATE], at which point CNA F's initials appeared on the form. In a telephone interview on [DATE] at 9:34 am, Licensed Practical Nurse (LPN) C reported on the night of [DATE]-[DATE], Resident #11 was agitated. LPN C stated eventually she started crying, upset her mother died , her family wouldn't know, and nobody would go to the funeral. LPN C reported he attempted to administer Ativan to Resident #11 for an hour before she was willing to take the medication. LPN C reported he last observed Resident #11 sitting on the edge of her bed eating a snack. LPN C reported Resident #11 fell and then she was placed on 1:1 supervision. LPN C reported Resident #11 was not placed on 1:1 supervision prior to the fall on [DATE] at 4:00 am, but that he knew she was care planned for 1:1 supervision if she was anxious/delusional. When asked why Resident #1 was not placed on 1:1 supervision, LPN C reported staff was trying to keep an eye on Resident #11 from the hall, but reported no staff were in her room for 1:1 supervision. LPN C did not have a reason why. LPN C reported he believed Resident #11's alarm did not function because she had books and other belongings on top of the sensor pad in her bed, which may have been enough weight to keep the alarm silenced. In an interview on [DATE] at 8:25 am, Director of Nursing (DON) B stated Resident #11 was definitely confused a lot of the time. DON B reported the root cause of Resident #11's fall was anxiety and restlessness related to delusions DON B agreed, that according to documentation, Ativan was administered to Resident #11, 22 minutes prior to her fall. When asked what staff should have done, per the care plan, if Resident #11 was anxious, restless, or delusional, DON B stated they were to provide 1:1 .they (staff) did not follow the care plan. Review of CNA F's Employee Conference Record dated [DATE] (2 months prior to Resident #11's fall and fracture), revealed CNA F was educated to include .when a resident is appearing to be anxious, do not leave them unattended. Past non-compliance was submitted to surveyor on [DATE] and accepted on [DATE] once reviewed. The following was done to correct the deficient practice: * Resident #11 was assessed by the physician on [DATE] with an x-ray ordered. X-ray determined fracture with new orders for pain medications ordered. * Staff educated regarding proper monitoring of those residents who exhibit anxious behaviors in order to prevent falls. * Residents identified as being high risk for falls will had care plans reviewed to ensure safety interventions appropriate. * Facility nursing staff educated regarding properly following resident care plans and in identification of resident change of condition as related to falls. * Audits started to determine root cause of falls. Audits also conducted on appropriate treatement following a fall. * Falls reviewed by QAPI committee. Substantial compliance achieved on [DATE]. (,[DATE])

This citation pertains to intake#MI 645 Based on observation, interview and record review, the Facility failed to provided adequate supervision and assistive devices (care plan intervention required constant supervision during personal hygiene), for 1 of 4 total sampled Residents (#102), resulting in a fractured hip and head injuries from a fall while left unattended in the bathroom. Findings include: Review of the clinical record face sheet revealed Resident #102 was a [AGE] year old man admitted to the facility on [DATE]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #102 had [DIAGNOSES REDACTED]. Review of the fall risk assessment dated [DATE] revealed Resident #102 was rated a "high risk for falls" Review of the plan of care for Resident #102 under the problem titled "falls" dated 3/25/13, revealed instructions for nursing to provide the call light within reach. Review of the plan of care under the problem titled, "I require assistance of 1 for personal hygiene(shaving, mouth care, daily maintaining of appearance...etc.), related to fatigue/lethargy, weakness, cognitive impairment, impaired mobility, dated 8/15/2010 revealed instructions for nursing to have 1 assist to provide constant supervision with physical assistance. Review of the Facility incident report dated 5/9/13 at 9:00 PM revealed Resident #102 "was observed on the floor of his bathroom with 3 lacerations to his forehead and one skin tear to his left hand. Resident #102 complained of a lot of pain to his left hip. Resident #102 said he was finished brushing his teeth and went to pull the call light in the bathroom and fell out of his chair and hit his head." Review of the Facility Fall investigation report dated 5/9/13 at 9:00 PM under the section titled "environmental", revealed the call light was not within reach for Resident #102 when he fell as he tried to reach for it,in the bathroom. He was sent to the hospital emergency room for a Fractured Left Hip. Review of the Facility investigation report witness statement dated 5/14/13 revealed Certified Nurse Assistant (CNA#5), had written "I was named Resident #102)'s aide the night he fell ....He wanted to go to activities after dinner. When he came back, I was with another Resident. Another aide set him up with his supplies in front of the sink...he rings the bathroom call bell when he is done. I was in the hall and saw his light go off. i immediately began walking to his room ..when I was 5-10 feet from his room I heard him hollering ("help me") and ran in. He was on his side on the floor and the chair had rolled back against the wall. I saw blood by his head-immediately called for a nurse, and knelt with him-not moving him, until a nurse reached us. He said"I pulled the light and fell ".". Review of the Hospital Emergency Department records dated 5/9/13 at 11:13 PM, revealed the following was written regarding Resident #102, "[AGE] year old male who presents to the emergency department with complaint of fall. Patient was in the bathroom fell struck his left forehead and injured his left hip. He arrives awake alert, orientated and complained of left hip pain. Patient has had a stroke and has left-sided hemiparesis...There is no evidence of acute intracranial insult. Left hip findings;Acute intertrochanteric fracture of the proximal left femur with avulsion of the lesser trochanter. Scalp abrasion." An observation on 7/5/13 at 9:58 AM revealed Resident #102, in his bed. There was a faded bruise above his forehead on the left side and on his left hip. In an interview, at the time of the observation, when asked how he fractured his hip, Resident #102 said, "I was in the bathroom, alone, trying to adjust the wheelchair footpedal's so I could reach the the call button because I was done brushing my teeth. I was bent over too far trying to reach the string to pull the call light and fell on my face." In an interview on 7/5/13 at 10:15 AM Registered Nurse (RN#4), the Unit Manager, said she thought he could be left alone in the bathroom before his fall, for personal hygiene. When asked didn't the care plan instruct constant supervision for Resident #102 while performing personal hygiene, prior to the fall, RN#4 looked on the computer and said, "well yeah, I can't argue with that." when asked if Resident #102 should have had someone with him while he brushed his teeth on 5/9/13 at approximately 9:00 PM RN#4 responded, "yes." #

This citation pertains to MI 8534. Based on interview and record review, the facility failed to properly utilize assistive devices to prevent injury in 1 of 10 Sampled Residents (Resident #104) who required assistance with transfers, from a total of 10 Sampled Residents, resulting in a fractured rib for Resident #104. Findings include: Per Resident #104's MDS/Minimum Data Set, dated dated [DATE], Resident #104 scored 14/15 for "Cognitive Patterns", and had [DIAGNOSES REDACTED]. Per the facility's "Investigation" documentation, dated 6/09/12, "In the evening of June 8, 2012, as (physician # 33) was examining (Resident #104) he was complaining of increased shortness of breath and some discomfort. (Physician #33) ordered him sent to ER (emergency room ) to evaluate for a possible PE (blood clot in the lungs). In the course of his ER evaluation he had a chest x-ray done which revealed a mildly displaced fracture of the anterior 9 th rib...(Resident #104) stated he was transferred from his chair to the bed about 5 days ago by (nurse aide #9). (Resident #104) stated that (nurse aide #9) transferred him without the Sara lift and the transfer was difficult...He felt that this transfer was the cause of his rib fracture..." Per a witness statement, signed by SW/Social Worker #17, "On June 1, 2012 (Resident #104) reported to me that a (nurse aide) had thrown him in bed. (Resident #104) stated it was (nurse aide #9) ... (Resident #104) continued to be upset stating he felt he was thrown in bed. He did not complain of pain ...it was agreed (nurse aide #9) would no longer take care of (Resident #104)". In a telephone interview, on 6/27/12 at 11:08 AM, Resident #104's son #19 told this Surveyor that he could not remember who, but somebody at the facility told him that Resident #104's rib fracture was incurred when, "The fell ow ...nurse aide (nurse aide #9) was trying to get (Resident #104) back to bed and (Resident #104) slipped out of the lift, so (nurse aide #9) grabbed (Resident #104) around the waist". Per the "Fall Risk Assessment", dated 5/02/12, Resident #104 was at "High Risk for Falls" because Resident #104 was receiving blood pressure and narcotic pain medication, had a history of [REDACTED]. Per Resident #104's ADL (Activities of Daily Living) Care Plan, initiated 5/02/12 and Revised on 5/21/12, "Transfer: I require assist of 2 with staff participation with transfers using SARA (mechanical sit-to-stand) lift; please monitor for dizziness". Per Resident #104's Communication Care Plan, dated 5/03/12, "I have a communication problem r/t (related to) Slurring, Stroke, Expressive Aphasia (difficulty getting words out) ...Allow adequate time to respond, repeat as necessary, do not rush ...". Per a "Rehab Conference", dated 5/24/12, Resident #104 was admitted to the facility on [DATE], and "Attendees" included PT/Physical Therapist #18 and SW/Social Worker #17. Per the "Rehab Conference" notes, "...(Resident #104) continues to experience dizziness and weakness ...He is unable to sit in w/c (wheelchair) for any length of time ...He was recently diagnosed with [REDACTED]. He was started on Cipro (antibiotic) on 5/29/(12) ...Decreased ability to work on standing task due to dizziness, decreased ability to be out of bed, decreased transfers to SARA lift. Max (maximum) assist with all cares. Education Goals: Improved transfers and ability to assist with ADL (Activities of Daily Living) as well as tolerate being up in chair for longer periods of time ..." Per "ED (Emergency Department) Notes", dated 6/08/12, "...Chest x-ray was obtained there is evidence for a ninth rib fracture on the right consistent with his pain ... " Per a witness statement, signed by PT/Physical Therapist 18, "...I was informed by (nurse aide #9) that (Resident #104's) care plan reflected use of SARA lift. (PTA/Physical Therapy Assistant #10) noted telling (nurse aide #9) to use samhall turner/EAC Turner (dolly type device used to pivot standing residents) for the transfer ... (PTA #10) stated, I thought (Resident #104) was using the samhall turner since it was in the room. Samhall turner was being utilized for patient in bed #1 (another resident)". In an interview, on 6/25 12, nurse aide #8 stated she assisted nurse aide #9, with the use of the samhall turner, attempt to move Resident #104 from his chair to his bed on 6/01/12. Nurse aide #8 stated, "(Resident #104) wouldn't stand. The gait belt was on. We quick sat him in the recliner wheelchair. We couldn't move him up. He wasn't sitting well; was sliding out. We 2-person'd him to the bed". Nurse aide #8 accompanied Surveyor to Room 105-2 and reenacted the incident. Nurse aide #8 said, "It was kind of quick. We had to use all of our strength. (Nurse aide #9) is really tall and strong. (Resident #104) was frazzled ... (Resident #104) was such a big guy, we had to exert all our energy. I don't know of any other way we could of done it ..." Nurse aide #8 stated that she and nurse aide #9 lifted Resident #104 with the gait belt from the recliner chair to his bed, without Resident #104's assistance. During a telephone interview on 6/27/12 at 11:24 AM, nurse aide #9 stated that on 6/01/12, Resident #104 did not bear any weight during the transfer performed with nurse aide #8. Nurse aide #9 stated, "(Resident #104) got weak, his knees buckled; slouched. We sat him in the recliner but he was slipping out. We lifted him up using the gait belt ... I'm a pretty big guy; never had any reason to lower him to the floor ... A 2-person (transfer) is designed so that you can do it (perform the transfer) all for them (without assistance from the resident)". "The nurse should recognize personal strength...Transfer of a client from a bed to a chair... requires assistance from the client and should not be attempted with a client who cannot help... Often a hydraulic lift can be used to transfer clients...An immobilized client who must be transferred from a bed to a stretcher or from a bed to another bed often requires a three-person carry...Another way to transfer a client is by using a lift sheet or a quilted transfer pad placed under the client. The lift sheet serves as a cradle while the client is being transferred..." (Fundamentals of Nursing 6 th Edition, Potter and Perry, Mosby 2005). In an interview on 6/27/12 at 1:05 AM, PTA #10 stated when asked if she uses the gait belt to lift residents, PTA #10 paused and then stated, "Yes, I use the gait belt to lift them." When asked if the facility had a written Policy and Procedure for safe gait belt use, PTA #10 stated, "I don't think so". Per the facility's "Resident Lifting and Transfers" in-service, "A gait belt...should only be used when moving residents who are partially dependent, can bear some weight, and are cooperative...It should NOT be used for lifting residents." In an interview, on 6/27/12 at 1:40 PM, this Surveyor asked PT #18 to describe a 2-person transfer. PT #18 stated, "We (therapists) are trained differently than the (facility nurse aides) are in nurse aide training school". PT #18 stated she had recommended the SARA lift for transferring Resident #104 at the Care Conference on 5/28/12 and had not changed her mind as of 6/01/12; she had not approved of the use of the samhall turner for the nurse aides to use with Resident #104. PT#18 said, "The samhall turner was in the room for the roommate, and I believe PTA/Physical Therapist Assistant #10 thought the Care Plan reflected the samhall turner for Resident #104". In an interview, on 6/28/12 at 12:10 PM, Assistant Director of Nursing (ADON) #29 stated she taught the nurse aides to give the resident a bear hug and help them slide down on the nurse aide's leg if a resident loses strength in their legs. ADON #29 said she had not reeducated nurse aide #9 regarding the incident with Resident #104 on 6/08/12, and commented, "I can teach them (nurse aides) how to reposition in the recliner chair (demonstrated with positioning hands as if they were under a residents' back and legs, without using a gait belt). I don't think I've done that". In an interview, on 6/27/12 at 9:50 AM, DON/Director of Nursing #20 stated she believed that Resident #104 sustained a fractured rib during the transfer done by nurse aide #8 and nurse aide #9 on 6/01/12. DON #20 stated that she did not believe that nurse aide #8 and nurse aide #9 had any other options than to transfer Resident #104 the way they did. ( )

This citation pertains to intake number MI 521. Based on observation, interview, and record review the facility failed to adequately implement a care planned safety device to prevent falls in 1 of 4 sampled residents (Resident #104), who were identified as at risk for falls, resulting in Resident #104 sustaining a hip fracture from a fall. Findings include: Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #104 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #104 had severe cognitive impairments and a history of falls. During the onsite investigation Resident #104 did not reside at the facility. Review of the Fall Risk assessment dated [DATE] revealed Resident #104 was identified as a "high risk for falls". Review of the Fall Care Plan dated 10/31/11, updated 11/8/11 and 11/14/11, revealed interventions to prevent falls for Resident #104, including hourly safety rounds, an extra low bed, chair/bed sensor alarms, Posey roll guards (foam rolls placed on each side of bed to prevent rolling out of bed) when in bed, and non-skid footwear. Review of the "Incident Note" dated 12/5/11 at 11:42 PM, revealed Resident #104 was "found laying on the floor, after hearing the alarm going off..." Review of the "Resident Fall Investigation Report" dated 12/5/11 at 10:30 PM revealed Resident #104's Posey roll was not in place at the time of the fall. Review of the Progress Notes dated 12/5/11 at 11:01 PM with a revision on 12/5/11 at 11:50 PM revealed Resident #104 was found lying on the floor on her right side with her hand under her head. The Note documented Resident #104 had a right hip fracture and a skin tear on her right elbow. The Note revealed Resident #104 was transferred to the hospital for possible fracture of the right hip with external rotation, shortening, and continued pain. In an interview on 1/3/12 at 4:07 PM, Certified Nurses Aide (CNA) # 15 stated sometime during the 2nd shift on 12/5/11 he heard an alarm sounding from (Resident #104's) room and responded to the alarm. CNA #15 stated he was the first to respond to the alarm and found Resident #104 on the floor approximately 2-3 feet away from the bathroom on her right side. CNA #15 stated he "wasn't paying much attention to where the Posey rolls were, but the one for where she could get out, was out...after the fall when talking with the other aides we remembered it (Posey roll guard) was up in the chair". Review of the Facility Witness Statement dated 12/5/11, revealed a written statement completed by CNA #15 detailing the sequential events regarding the fall with Resident #104. As documented by CNA #15, "At 10:15 PM I heard (Resident #104's) alarm going off and, when I approached her room she was found lying on her right side on floor about 2 feet from bathroom door. Her bed was in a low position but her Posey roll was not on it. Her Posey roll was found in resident's chair". In an interview on 1/4/12 at 3:15 PM, CNA #14 stated during her shift on 12/5/11 she heard an alarm sounding and followed after another aide (CNA #15) who had already responded to the alarm, upon entering (Resident #104's) room, CNA #14 said she "saw (Resident #104) on the floor, and noticed the Posey Roll was in the chair". CNA #14 stated "there is no way she (Resident #014) could have put it there, it was straight up, vertical not horizontal in the chair, it looked like we had done it (referring to the placement of the Posey Roll Guard in Resident #104's chair)". CNA #14 reported Resident #104 stated her right leg hurt and it was turned in. Review of the Facility "Final Investigation" Report for Resident #104 dated 12/5/11 revealed "...one side of the Posey roll guard was sitting in her (Resident #104's) bedside chair next to the bed. (CNA #17) also stated that the Posey roll guard was setting on the chair after (Resident #104) fell . (CNA #17) is certain she had put it in place on the bed when she assisted (Resident #104) into bed. (CNA #17) is unsure how the Posey roll guard came to be in (Resident #104's) chair but it is possible that (Resident #104) unzipped it from the covering and removed it herself..." In an interview on 1/4/12 at 11:45 AM, CNA #17 stated as she was assigned to (Resident #104) on 12/5/11 she had placed all safety devices in place as care planned, prior to leaving (Resident #104's) room, including "both Posey Rolls, lowered the bed, and made sure the alarm was on". When CNA #17 was asked by the Surveyor if she had put the Posey Roll Guards in place after laying Resident #104 in bed, CNA #17 stated "like my statement said I am positive that I put them (Posey Roll Guards) both on". CNA #17 stated after she was alerted that (Resident #104) had fallen, she entered the room and "one of them (Posey Roll Guard) was out, on the ground or something", and then stated to this Surveyor "which I don't understand" (referring to how one Posey Roll was out of place). In an interview on 1/4/12 at 12:01 PM, Licensed Practical Nurse (LPN) #9 stated upon being notified (Resident #104) had fallen, she entered the room and noted (Resident #104) to be laying on her right side near the bathroom. LPN #9 stated Resident #104 had pain in her right hip and shoulder and was unable to move her let without pain in her right hip. LPN #9 reported Resident #104 was transferred to the hospital for evaluation. LPN #9 stated, "the one Posey Roll that's suppose to be on the right side of the bed was in the chair. I don't think she (Resident #104) could remove it, she (Resident #104) is pretty confused", when the Surveyor asked about Resident #104's cognitive status. During the onsite investigation, 1/3/12 through 1/4/12, observations were made of safety devices in place as care planned for residents requiring the need of safety devices. ( )

This citation pertains to intake #MI 823 Based on observation, interview and record review, the Facility failed to provide adequate supervision and assistive devices (monitoring to assure the implementation of personal alarms), resulting in 3 of 4 sampled Residents (#302, #303 and #304) assessed as high risk for falls, not being provided the assistive devices as an intervention for fall prevention, resulting in Resident #302 falling, requiring emergency hospital services due to fractured ribs, Resident #304 falling and sustaining a skin tear and the potential for serious harm or death due to falls. Findings include: Resident #302: An observation on 11/30/10 at 9:05 AM, revealed Resident #302 in bed, on her left side sleeping. Resident #302's bed was in a low position, a blue mat was on the floor on the left side of her bed. Her bed was close to the wall on the right side. A tab alarm was attached to Resident #302 and was tested and sounded adequately. A sensor pad alarm was observed on her chair. Resident #302 was not able to be interviewed at the time of the observation. Review of the clinical record face sheet revealed Resident #302 was a [AGE] year old woman admitted to the facility on [DATE]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #302 had [DIAGNOSES REDACTED]. Review of the falls Resident Assessment Protocol Summary for the MDS dated [DATE] revealed Resident #302 was highly at risk for falls related to her blindness, decreased cognition, UTI, and history of back pain and weakness. Review of the care plan under problem of falls initiated 10/21/10 and revised on 11/13/10 revealed interventions to use a sensor alarm in bed and chair as well as a tab alarm in bed and in the chair. Staff are not to leave her in the bathroom or on the commode unattended, the care plan instructed. . According to the Facility incident reports dated 10/21/10 and 11/10/10, Resident #302 fell and sustained a fractured Clavicle on 10/21/10 and 2 fractured ribs and a possible fractured knee on 11/10/10. (Review of the X-Ray report dated 11/12/10 under "impression" revealed "extensive osteopenia which limits assessment for nondisplaced fractures", of the right knee.) Review of the Facility's investigation report dated 11/10/10 at 4:15 PM, revealed Certified Nurse Assistant (CNA "G") was passing out drinking water and assisted Resident #302 to the bathroom because she needed help. CNA "G" left Resident #302 unattended in the bathroom and went to CNA "H" (who had been assigned to care for Resident #302), and told her that she took Resident #302 to the bathroom. CNA "G" then delivered drinking water to other Residents. Approximately 15 minutes later Licensed Practical Nurse (LPN "E"), heard Resident #302 call out for help and when she entered the room she saw Resident #302 on the floor in the bathroom. Resident #302 told LPN "E" she tried to get off the toilet and back into her wheelchair but fell . Resident #302 complained of pain in her right side and right knee. According to the report she was sent to a Hospital at 5:00 PM and returned at 9:30 PM on 11/10/10 with a [DIAGNOSES REDACTED]. There were no new orders for pain medication because she was already on Narcotic Analgesics for her Fractured Clavicle. She was prescribed an antibiotic for her UTI. The Director of Nursing (DON) said, in an interview on 11/30/10 at 10:30 AM that CNA "G" was disciplined for leaving Resident #302 on the toilet unattended without detaching the personal alarm. CNA "H" was disciplined for not informing CNA "G" that Resident #302 could not be left unattended and for not checking Resident #302 as soon as she was notified by CNA "G" that she left her in the bathroom alone. CNA "G", in an interview on 11/30/10 at 3:05 PM, said she was not assigned to Resident #302 on 11/10/10 and was passing water when Resident #302 needed help to go to the bathroom. CNA"G" said she had a sensor pad on her wheelchair that she turned off and assisted Resident #302 onto the toilet and then left her unattended. CNA "G" said she went across the hall to tell CNA "H", who was assigned to Resident #302, what she did and then continued on to pass water out to other Residents. CNA "H", in an interview on 11/30/10 at 3:20 PM, said CNA "G", came into the room where she was helping a Resident (not on the sample), and told her she took Resident #302 to the bathroom and put her on the toilet. CNA "H" said she replied, "OK", to CNA "G". CNA "H" said, "it didn't really phase me because the last I knew she could be by herself." CNA "H" said she was not aware Resident #302 had personal alarms for fall prevention. CNA "H" said, "we don't know pretty much anything until it's too late! We never get report." LPN "E", in an interview on 11/30/10 at 1:15 PM, said that on 11/10/10 at approximately 4:14 PM, she heard someone call "help" and started looking in rooms and then heard someone again call "help" and saw Resident #302 alone in her bathroom, on the floor, in front of her wheelchair, "kinda propped up against it". When asked if her personal alarm was sounding LPN "E" said, "no because she was sitting on the toilet before that happened. I guess no one has the alarm on when they are on the toilet. They take it off if it's on the wheelchair." LPN "E" said, "she was in so much pain I grabbed a pillow and laid her down on the floor (she had been sitting on the floor) and got another Nurse." LPN "E" said she assessed her and assisted her to her bed with the other nurse and then called the Supervisor and the Doctor who ordered X-Rays. "We sent her to the Hospital", said LPN "E". Review of the physician progress notes [REDACTED]. Sustained left rib fractures times 2; reports pain controlled; nursing reports cough, wet sounding; patient denies feeling tired, confused with her med's." Resident #304: Review of the Facility's Incident report dated 11/29/10 at 7:15 PM revealed Resident #304 was observed on the floor, in her room. A skin tear was noted on Resident #304's right elbow that measured 0.5 cm by 0.25 cm and was steristripped and then covered with Shursite. The instructions written were;"do not leave Resident in room until she is ready to go to bed." Review of the clinical record face sheet revealed Resident #304 was a [AGE] year old woman admitted to the facility on [DATE]. Resident #304 had [DIAGNOSES REDACTED]. Review of the care plan under problem of falls initiated 8/16/10 and revised on 9/20/10 revealed interventions to use a sensor alarm in bed and chair . Staff are not to leave her in the bathroom or on the commode unattended. It also alerts staff to not leave Resident #304 alone in her room while in the wheelchair. Review of the nurse's notes dated 11/29/10 at 7:15 PM revealed Resident #304 was observed on the floor, in her room, sitting in front of her wheelchair. Under "new intervention implemented" was written "do not leave Resident in room until she is ready to go to bed." However, this intervention was already in place according to the care plan. In a phone interview, on 11/30/10 at 2:50 PM, when asked if Resident #304's alarm was sounding on 11/29/10 at approximately 7:15 PM when she found her on the floor, CNA "I" said, "No it wasn't. We are supposed to check and see if the alarms are on at the beginning of the shift." When asked if she checked to see if the alarm was on and functioning for Resident #304 on 11/30/10 prior to 7:15 PM CNA "I" said, "No I didn't." CNA "I" said, "the alarm didn't go off because we didn't hook it." Resident #303: Review of the clinical record face sheet revealed Resident #303 was a [AGE] year old woman admitted to the facility on [DATE]. Resident #303 had [DIAGNOSES REDACTED]. An observation, during the tour on 11/30/10 at 8:55 AM, revealed Resident #303 sitting in a wheelchair, in her room with no tab or sensor alarm on and activated. The sensor alarm was not activated. LPN "D", who assisted with the tour, pressed the re-set button on the sensor alarm and asked Resident #303 if she was sitting on a sensor pad. Resident #303 responded no. LPN "D" then went to check the Kardex for Resident #303, which was located in a 3 ring binder, in her room. LPN "D" said, "the Kardex said she's supposed to have a tab alarm on when she's in her wheelchair and a sensor pad alarm in bed". LPN "D" left the room and went into the hall to find her CNA. LPN "B" (the Charge Nurse for Resident #303), entered the room and was about to leave because she didn't see the tab alarm, so the Surveyor informed her that the tab alarm was on the small chest of drawers across the bed from Resident #303. LPN "B" took the tab alarm and attached it to Resident #303. the Surveyor requested that it be tested and LPN "B" tested the alarm and it sounded appropriately. CNA "C", in an interview on 11/30/10 at 9:00 AM, when asked if she was aware that Resident #303 was supposed to have a personal alarm on said, "Yes and no. I'm an on-call person and it slipped right past me. I'm sorry" as she apologized for not placing the personal alarm on Resident #303 as an intervention for fall prevention. #