Every finding on record at Notting Hill of West Bloomfield

This citation pertains to intake #3066174 Based on observation, interview, and record review, the facility failed to ensure appropriate kitchen sanitation with regards to the dish room, and the use of hair nets and beard restraints. This deficient practice had the potential to affect all residents who eat from the kitchen. Findings include: On 8/4/26 at 9:00 AM, staff were observed opening the door from the dish washing room leading to the hallway. At that time, a foul, putrid, rotten smell wafted out of the dish washing room and permeated the hallway. On 8/4/26 at 12:23 PM, Dietary Staff 'F' was observed entering and exiting the kitchen serving meals in the dining room. Dietary Staff 'F' was not observed to be wearing a hair net or a beard restraint. On 8/4/26 at 12:38 PM, an observation of the kitchen was conducted with Dietary Manager 'E'. At that time, Dietary Staff 'G' and 'H' were not observed to be wearing beard restraints. On 8/4/26 at 12:40 PM, an observation of the dish room adjacent to the kitchen was conducted. A strong, foul, putrid, rotten smell permeated the dish room. The floor drain from the three-compartment sink appeared soiled with stuck on food debris. Behind the dishwasher several kitchen utensils were observed on the floor. A mop bucket with gray water sat near the three-compartment sink. At that time, Dietary Manager 'E' was asked about the pervasive, foul smell in the dish room. They said they were aware of the smell, and the cause were the floor tiles and the grout. On 8/5/26 at 9:20 AM, a second tour of the dish room was conducted with Dietary Manager 'E' and the facility's Administrator. It was noted the foul smell persisted. It was also observed a plastic moving dolly holding the clean plastic dish racks used in the dish machine were soiled with a brown, slimy appearing substance. At that time, the Administrator acknowledged the odor, citing the floor tiles with cracked grout as the source of the odor. They were asked how long it had been going on and said approximately six months. They were asked what the plan was to address it and said they had been working on it, and the tile company was in the process of making the new tiles to replace the entire floor in the dish room. A review of a facility policy titled, Food Handling and Production revised 3/2026 was conducted and read, .1. The kitchen and equipment will be maintained in a clean, neat, and orderly manner to minimize bacteria formation and food contamination .2. Practice good personal hygiene: .Wear hair nets and beard guards .

This citation pertains to intake #3105200. Based on interview and record review, the facility failed to ensure treatment in a dignified manner for one resident, (R905) of three residents reviewed for resident rights, resulting in R905's dissatisfaction with treatment. Findings include: On 8/5/26 at 9:30 AM, R905 was asked if they had an altercation with the facility's contracted hairdresser 'I'. R905 said they recalled the incident. They said they were not happy with the way hairdresser 'I' was cutting their hair and began yelling at them. They said hairdresser 'I' continued to cut their hair despite their objections. They said they got madder and madder and eventually took a swing at hairdresser 'I' to get them to stop. They said they were exchanging words and while R905 admitted to swinging at and swearing at hairdresser 'I' they went on to say hairdresser 'I' was calling them names and using profane language in retaliation. They were asked if they were afraid of hairdresser 'I' and said they were not, they just wanted them to stop the haircut and leave them alone. On 8/5/26 at 9:48 AM, an interview was conducted with Social Worker 'J'. They were asked about their knowledge of the altercation between R905 and hairdresser 'I' and said R905 did not like the way their hair was being cut and hairdresser 'I' did not respond to R905's objections appropriately. Social Worker 'I' reported R905 was swinging their arms and calling hairdresser 'I' names and hairdresser 'I' was calling R905 names and using profane language back at R905. A review of R905's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: schizophrenia, anxiety disorder, and bipolar disorder. Continued review of the record revealed R905 had intact cognition and exhibited numerous inappropriate behaviors. A review of a facility provided investigation file was conducted and indicated there was a verbal altercation that occurred between R905 and hairdresser 'I'. Hairdresser 'I' did not respond appropriately to R905's escalated objections with the haircut and as a result of the incident hairdresser 'I' would no longer be permitted to provide hairdressing services in the facility. On 8/5/26 at 12:08 PM, an interview was conducted with the facility's Administrator. They were asked about the incident and said they could not substantiate abuse, but hairdresser 'I's behavior regarding the incident was inappropriate and their services were terminated. A review of a facility provided policy titled, Resident Dignity & Personal Privacy revised 3/2024 was conducted and read, The facility provides care for residents in a manner that respects and enhances each resident's dignity, individuality, and right to personal privacy . During the onsite survey, past noncompliance was cited after the facility implemented actions to correct the noncompliance which included: terminating hairdresser 'I's contract with the facility, identification of other residents with the potential to be affected by the deficient practice, review of the facility policy for resident rights and dignity, re-education of staff, and audits of residents weekly to ensure residents were treated in a dignified manner. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation relates to Intake 2806062 and Intake 2807263. Based on observation, interview, and record review, the facility failed to prevent an injury of unknown origin for one Resident (R65) of four residents reviewed for accidents, resulting in R65 sustaining a right arm fracture during care, with increased pain and discomfort. Findings include:A Facility Reported Incident (FRI), dated 3/08/26 at 4:01 p.m., revealed, The nurse on duty was informed by a nurse aide that the resident appeared to be in pain and that her arm locked abnormally while care was being performed. The nurse assessed the resident and contacted the physician. The physician advised that the resident be sent to ER (Emergency Room) for further evaluation. At the hospital, it was confirmed that the resident had a fracture. The family was notified. The facility will conduct a complete investigation to determine the cause.Investigation Summary:.According to the physician's note and hospital records, the resident was diagnosed with a right humerus (upper arm bone between the shoulder and elbow) angulated fracture (a type of fracture where a bone is broken but not perfectly aligned, which may require surgical intervention for proper healing) of unknown origin. Hospital radiology report confirmed osteoarthritis degenerative joint disease. A complaint received by the State Agency on 3/18/26, related to this incident, alleged on 3/08/26 between 11:00 a.m. and 6:00 a.m., an incident occurred when someone pulled R65's arm during care or did a lack of care, because R65's arm was swollen and broken. This investigation further revealed regarding: .Staff Interviews and Findings: Staff who worked with the resident during the night shift reported no falls or incidents involving the resident. Staff stated that the resident slept through the night without any signs of distress. (Certified Nurse Aide -CNA BB) reported that she entered the resident's room at approximately 5:15 a.m. on March 8, 2026, to provide morning care and change the resident. (CNA BB) stated that the resident (R65) was wearing a white, pink, and blue pajama top that pulls over the head. During care, she changed the resident into a gray shirt that also pulls over the head. While assisting the resident with getting dressed, (CNA BB) noticed that (R65's) right arm appeared swollen and limp. (CNA BB) stated that while putting the shirt on, the resident attempted to help by pushing her right arm through the sleeve, and at that time the resident expressed pain. (CNA BB) reported that the resident's arm then became limp, which prompted her to immediately notify the nurse of what she observed.Additional Findings: The resident (R65) was interviewed but was unable to express or explain what may have happened due to her cognitive impairment. Camera footage reviewed during the timeframe did not show any falls or incidents involving the resident. Staff interviews were consistent and did not identify any witnessed injury event. Residents who receive care from CNA ( BB) were interviewed and no concerns or complaints of abuse, neglect, or mistreatment were reported. The residents care plan was reviewed, and it was confirmed that CNA ( BB) was providing care appropriately and following the residents plan of care at the time of the incident. Conclusion: Based on the information gathered, the exact cause of the injury remains unknown. The investigation did not identify any evidence of abuse, neglect, or misappropriation of resident. Due to the residents' existing conditions of degenerative joint disease, osteoarthritis, and overall medical condition, the injury appears to be an unfortunate accident that may have occurred while the resident was assisting with movement during dressing. Although the injury appears accidental, the facility will reinforce safe care practices. CNA ( BB) will receive one-on-one education on proper range of motion (ROM) techniques and the importance of immediately stopping care and notifying the nurse if a resident expresses pain during care. The facility will continue to monitor the residents' condition and reinforce safe care practices to help prevent future injuries. Based on the investigation findings, the allegation of abuse or neglect is unsubstantiated. The report also showed local law enforcement was contacted about the incident, per facility policy. Review of R65's Minimum Data Set (MDS) assessment, dated 2/01/26, revealed R65 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, dementia, kidney disease, anxiety, and depression. The assessment showed that R65 was dependent for dressing, bed mobility, toileting, and transfers, and required maximal assistance with eating. The cognitive assessment showed that R65 was severely cognitively impaired and was rarely or never understood or could understand others. The assessment revealed no pain and R65 was receiving an antipsychotic medication and an antidepressant medication, with no pain medications noted. On 3/23/26 at 5:32 p.m., R65's Family Member (FM) AA reported during a phone interview R65 received a phone call from the facility, reported R65's arm was broken. FM AA said where the fracture was located on R65's arm was a place hard to break, and per the hospital physicians R65's arm must have been twisted hard, or there was an unwitnessed fall. FM AA reported R65 was not on pain medication prior to their fall and required Oxycodone (a narcotic controlled pain medication) after their fall. FM AA said R65 fed themselves with their right arm before their fall. FM AA said they were concerned about the possibility that abuse occurred, only because of the unusual nature of the injury, per the hospital physician team. FM AA said R65 had dementia and could not describe what had occurred when the injury happened, or after the incident. On 3/24/26 at approximately 10:30 a.m., R65 was observed seated in a padded Geri Chair, smiling and talking in another language, as English was their second language. R65 did not demonstrate any grimacing or expressions which indicated pain or discomfort. R65's right arm was in a sling, with a long hard cast, with their fingers partly exposed. R65 was observed wiggling their fingers in the cast. The hard cast with a padded underlayer extended from their mid-fingers to above their right elbow. On 3/24/26 at 10:40 a.m., Staff L, was asked to interpret for R65, per facility designation. R65 was asked questions through Staff L, such as what happened to their right arm, did they have any pain, or if they had a fall. R65 answered nonsensically per Staff LL. R65 was lastly asked if they felt safe in the facility and could not respond per Staff LL. Staff LL had interpreted for the facility when the incident occurred on 3/08/26 and could not describe what occurred at that time either. Review of R65's nursing progress note, dated 3/08/26 at 7:11 p.m., confirmed CNA BB reported during care they noted R65's right arm was not moving, and when their arm was gently lifted, R65 expressed pain. The nurse noted R65's upper arm was swollen, was abnormal in appearance and was misaligned at the elbow joint, appearing suspicious for a fracture. R65 reported pain with minimal movement of their right arm, the medical director was contacted and instructed the nurse to call 911, and R65 was sent to the emergency room via EMS (Emergency Medical Services). R65's family member was notified and was with the resident at the time of the transfer. Review of a nursing progress note dated 3/08/26 at 13:47 (1:47 p.m.) showed a law enforcement officer arrived and was informed R65's right arm was fractured and asked about a possible fall and events during the night. They noted a suspicious circumstances event per this note. On 3/24/26 at 12:45 p.m., R65's family member notified Surveyor during a phone call R65 would be seeing their orthopedic physician on this date for follow-up of their injury. On 3/24/26 at approximately 1:00 p.m., CNA BB was asked about the 3/08/26 incident during R65's care during a phone interview. CNA BB described they were providing care to R65 around 5:00 a.m., as R65 was scheduled to be gotten up and dressed on the midnight shift, which they typically worked. CNA BB said R65 was known to them and they had provided morning care for them prior, for about six months. CNA BB said they were alone with R65 when they were providing care and R65 was not agitated or screaming, and it was not until they were performing care that R65 began to show signs of pain. R65 denied being made aware R65 fell although said they had heard they may have fallen (after the incident). R65 said the day shift nurse, and CNA S may be aware, as they had R65 on the earlier day shift. CNA BB said they asked R65 if their arm was hurting and R65 could not tell them, and this would have been typical for R65. CNA BB said they saw R65's arm was swollen and then lifted their arm to put it in their shirt on and after that they realized R65's arm was hurting. CNA BB said normally R65 could have lifted their arms and placed them in their shirt. CNA BB was asked if they twisted R65's arm and denied this but said R65's arms were contracted and they kept them on their chest. CNA BB was asked how they dressed R65 and put their shirt on them. CNA BB said they put the left side on R65 first, their weaker side, and lifted R65's arm overhead and said it was more of a stretch shirt than a regular shirt. CNA BB said R65's arm was already swollen and they didn't believe it was from dressing them. During the care, CNA BB said R65 was wincing, not exactly crying, but waving for them to stop. R65 said they didn't know anything was wrong with her arm as she had sometimes resisted care prior so they continued to get her dressed and noted R65 was a little bit more verbal than usual. When asked if they could have done anything differently, CNA BB said, I should have stopped care. CNA BB said they were suspended from work pending the investigation and given an education and told they should have stopped care when R65 showed pain and increased resistance to care. CNA BB denied seeing or hearing any fracture occurred, and believed it was possible they had fallen prior to the incident since R65's arm was swollen, but no one told them when they asked. CNA BB said they also did not stop care to determine why R65's right arm was reportedly swollen prior to dressing them. CNA BB further described once they saw R65 had increased pain, they stepped out to get R65's nurse, Licensed Practical Nurse (LPN) CC, who looked at R65's arm with them. They both noticed R65's arm dropped when lifted and LPN CC said they had to immediately send R65 out to the hospital. It was noted CNA BB reported they did not observe something being wrong with R65's arm until after they donned R65's shirt. CNA BB said, The nurse learned about it when I did. as they had noticed pain and swelling, and said, Her arm was already big and swollen. when they began dressing R65. CNA BB denied anything intentional occurred, although they were inconsistent in reporting when they observed R65's arm was swollen. Review of CNA BB's witness statement denied a fall or any abuse had occurred. Review of R65's investigation file revealed CNA BB passed their background check upon hire and had a current license when the incident occurred an at present. The investigation showed CNA BB received a reeducation from the Director of Nursing (DON) which showed they were providing care and did not stop at the point of resistance when changing R65's clothing during care. The education included providing proper range of motion and pain management of residents and stopping during the point of resistance when changing a resident's clothing. There was no abuse or intent found. Review of R65's ER report, dated 3/08/26, showed R65 had dementia and was assessed for right arm pain, swelling, and deformity, and per the facility did not fall. R65's daughter was with R65 and reported R65 was at her mental baseline and could not report to them (either) what occurred. The x-ray report showed a displaced and angulated fracture of the distal humeral meta diaphysis (area where the wide part and shaft of bone met, which is an atypical humeral fracture presentation, often from a significant trauma, a fall, or a hard twisting motion). The orthopedic team placed a long arm splint on R65's right arm and planned for R65 to follow up with them shortly to be considered for surgery. R65 was newly prescribed Oxycodone, a narcotic pain medication, for pain. Review of R65's hospital orthopedic report, dated 3/08/26, showed R65 was presumed to have had an unwitnessed fall, as the fracture appeared to be a spiral (severe) fracture of the distal (lower) humeral presumed and noted the fracture was unstable. The report revealed R65 needed to be non-weightbearing on their right arm, with follow-up recommended in one week to discuss operative verses non operative management of the fracture. On 3/24/26 at approximately 3:40 p.m., CNA S was asked what occurred on 3/08/26, as they had worked on the earlier shift and cared for R65. CNA S said R65 had not fallen to their awareness, and said no staff told them R65 had fallen. CNA S said when they arrived on their shift on 3/08/26 in the morning, R65 was not in their room and the nurse told them R65 was at the hospital. CNA S then asked the question, and no one told me she fell. CNA S said they worked with R65 almost every day and were concerned about the fracture but did not know how it had occurred. On 3/24/26 at approximately 3:51 p.m. and 3:52 p.m., R65's day shift nurse was called, LPN EE, who worked a 12-hour shift on 3/07/26 and 3/08/26, with no answer. On 3/24/26 at 4:17 p.m., the Medical Director, Physician DD was called at 4:17 p.m., and asked about R65's right arm fracture, what had occurred, and the cause. Physician DD reported while they were not their regular medical provider, they came to see R65 shortly after the incident, on 3/10/26. Physician DD said they saw R65 because the injury (fracture) had occurred. Physician DD said based on their understanding R65's fracture presented as an unwitnessed fall, and they understood R65 needed dressing assistance, and said it was brought to their attention the fracture could occurred from whoever dressed R65 yet said the logistics of what exactly occurred were unclear. Physician DD said they did not have anything else to add, and acknowledged R65 was at risk for falls, and had osteoarthritis, which may have contributed. Physician DD indicated osteoarthritis could predispose a resident with comorbidities to a fracture due to decreased joint integrity. Surveyor asked Physician DD if R65 had osteoporosis or osteopenia (weakened or fragile bones), which Physician DD denied, as both conditions may predispose a resident to a fracture. Physician DD indicated R65's internal regular medical provider would be providing a follow up visit on 3/25/26. Review of Physician DDs progress note on 3/10/26 at 8:00 a.m. revealed, .3/10/26. Visit Type: Acute.Status post hospitalization secondary acute injury.of humeral fracture.(R65) with advance dementia. Long term care residents under care of (R65's physician) evaluated status post recent emergency visit secondary to acute injury.of right humeral angulated fracture of unknown origin.pt (patient) seen bedside with use of global interpreter and later with daughter (FM AA), for interpreter to whom she (was) more responsive during encounter.patient alert and oriented to family only, appropriately answering some questions, complaint of symptoms of dizziness and uncontrolled pain she attributes to acute injury. (FM AA) concern(ed) with acuity of injury and control of patient pain.Notes: Limited range of motion with fixed casting of RUE (right upper extremity).Unspecified fx (fracture) shaft of [NAME] (humerus), right arm.Unspecified : unknown acute injurious event, clinical suspicious concerning for mech fall (mechanic fall) given past history significant for recurrent mechanical falls as well as increased risk for injury.dependent ADLs (activities of daily living) and generalized osteoarthritis.Will continue to monitor / optimize pain control with analgesic (pain management) therapy continue fall precautions.Continue: oxycodone.5 MG.Continue Acetaminophen (over the counter pain medication) 650 MG.Follow up with scheduled orthopedic outpatient appointment. On 3/24/26 at 4:51 p.m., the Director of Nursing (DON) was interviewed about the incident, as Surveyor was unable to reach both the day shift nurse (LPN EE) on 3/07/26 and 3/08/26, or LPN CC, who worked when R65 was sent out emergently on 3/08/26. It was noted there was no witness statement for LPN EE in lieu of a phone call. The DON was asked why there was no witness statement in the investigation for LPN EE. The DON said they didn't think I needed a witness statement for LPN EE as they denied a fall had occurred. The DON confirmed CNA S had also reported no fall had occurred on their shifts, as well as another CNA, CNA FF, who shared the night shift with CNA BB on 3/08/26, who Surveyor was also unable to reach with an earlier call. The DON said they did not feel the need to suspect anything suspicious because the family had provided evidence they had been with R65 during the day prior and evening, so they found no fall had occurred prior to the night shift, and their interviews and witness statements showed no falls or unusual incidents had occurred. The DON said the only aides who worked with R65 on the night shift on 3/08/26 were CNA FF and CNA BB, who had both denied R65 fell. Review of the scheduled staff's witness statements all showed no falls had occurred, and the source of the injury was unknown. Review of R65's medical record with the DON revealed no nursing assessments, including pain or skin, a change of condition assessment, or a transfer form on 3/08/26, showing R65's medical status at the time of R65's transfer. The DON observed the medical record with Surveyor and reported they understood the concern and would have expected a transfer form to be completed, per facility process. The DON concurred the 3/08/26 nursing progress note was not a full assessment, and they would have expected the assessment to have at least included which doctor they spoke with. The DON continued to attempt to contact LPN CC during the interview, who was unable to be reached by phone by this Surveyor, again at 5:15 p.m. Review of R65's orthopedic consult, dated 3/12/26, revealed, R (right) distal (lower) humerus shaft (mid bone) fracture (typically occurring from a direct blow, fall, trauma, or twist). Must keep splint on (cast). Recheck on 3/24/26. An appointment reminder was attached, which showed an appointment on 3/24/26 at 10:30 a.m. On 3/24/26 at 5:00 p.m., the DON acknowledged they were the primary investigator of the incident and summarized their findings. The DON reported that the family had been with the resident and proven this which gave a specific time stamp to what had occurred and who to interview. The DON said they spoke to another resident across the hall, who had confirmed with them and the family that nothing had occurred that night out of the ordinary, as they had good cognition and were observant. The DON said Resident from across the hall told them R65 had a quiet night and did not start yelling out until the early morning, when R65's right arm injury was discovered and R65 was sent out emergently after. The DON denied having a witness statement from R46 when asked. The DON further conveyed their investigation determined given the other Resident's report, family observations, staff interviews, and their own investigation, they believed the chances R65 fell and injured their right arm were unlikely. The DON said Physician DD indicated R65 could have sustained the fracture from a plethora of things, as she was [AGE] years old, not walking, had limited range of motion, osteoarthritis, functional quadriplegia (inability to move), and muscle atrophy (muscle wasting away from lack of use). The DON was asked what they determined was the root cause of the fracture. The DON said when they interviewed CNA BB, she said R65 was hollering while being dressed and it escalated from her normal hollering and R65 became more resistant to care and the aide, CNA BB, did not stop when she felt resistance. The DON said, When it had changed.that is when CNA BB should have stopped. Given this and their investigation findings, the DON was asked if this was an avoidable incident/accident. The DON denied the incident being avoidable, given R65's comorbidities and arthritis, and said they were just educating CNA BB, not acknowledging wrongdoing. The DON confirmed CNA BB was suspended and had no other disciplinary action. CNA BB's date of hire was on 9/23/25. Surveyor asked for their orientation and abuse and dementia training. Review of CNA BB's orientation showed they received training in resident care and had completed their abuse and dementia training since their date of hire. On 3/24/26 at 6:30 p.m., LPN CC returned call and described the incident occurred per their progress note. LPN CC added CNA BB came and got them and they saw R65's hand was not moving and the upper part of her hand was not straight and R65 was shouting and screaming when they tried to assess her arm, which was not normal for R65. LPN CC said they saw the joint was not connected and when they lifted R65's hand, it fell back. LPN CC said they immediately called the on-call facility physician team, who wanted them to wait for an x-ray, and LPN CC told them she needed an ambulance, and the physician then agreed. LPN CC acknowledged they did not do a nursing assessment form. LPN CC said they asked staff and there was no report of R65 falling by staff, and said, Nobody told me a fall happened . LPN CC said R65 was not in pain unless their arm was moved so they did not complete a pain assessment. LPN CC said they did not know how the incident occurred. The DON confirmed afterwards LPN CC should have known to complete a transfer form. Review of R65's Accident and Incident report, dated 3/08/26, showed a similar description of the incident. No fall was mentioned. Review of R65's Physical Therapy evaluation from June 2025, showed R65's upper extremity range of motion was within normal range. Occupational therapy records showed R65 had not been on caseload seen since 2023. Quarterly therapy screenings since that time showed R65 had no change in status, with the last one completed in January 2026. There was no documentation found of contractures for this resident. Review of R65's Care Plan, accessed 3/24/26, showed R65 was dependent for feeding since 2024, and was dependent for all care for an extensive time prior to their injury. Review of R65's March (2026) medication administration treatment record showed they received three doses of Oxycodone pain medication after the incident on 3/08/26. Review of the facility investigation showed abuse was not substantiated. Review of facility documentation of R65's hallway camera footage from 3/07/26 and 3/08/26, completed by the Administrator, showed no evidence of staff entering R65's room with a mechanical lift or any concerns with additional observations. On 3/25/26 at 10:12 a.m., the Unit Manager, Licensed Practical Nurse (LPN) C, was asked about R65's injury on 3/08/26. The LPN reported they checked and R65 had not fallen per their awareness and said they had checked facility documentation and found no falls at or near that time and said they believed the fracture occurred from their disease process. LPN C said they had no evidence of abuse or had found any abuse concerns on R65's hall. Review of R65's pain log was reviewed and noted R65 had 8/10 pain on 3/08/26 at 16:05 (4:05 p.m.), upon return to the facility after the incident. On 3/25/26 at 10:43 a.m., another attempt was made to reach LPN EE by phone. No call was returned by survey exit. On 3/25/26 at 10:45 a.m., a telephone call was placed to the local police department. It was learned the report could not be accessed as the investigation remained open. A message was left for the police officer assigned; a call was not returned. On 3/25/26 at 11:00 a.m., R65 was observed in their room, up in their Geri chair, with the cast remaining on their right arm and their right arm supported. R65 was smiling. On 3/25/26 at 11:05 a.m, R65's aide, CNA S, was asked about R65's right arm use before their fall. CNA S said R65 required extensive assistance with feeding prior to their injury using their right arm and hand, and denied she had any arm contractures. CNA S described R65 could assist only when something was placed into their hand, such as a sandwich or a drink. CNA S said R65 communicated little and could only sometimes answer yes/no or say a few words but not consistently. CNA S was asked if R65 went to their follow-up orthopedic appointment on 3/24/26, as scheduled, and said they missed it. CNA S said according to R65's daughter, transportation was late. On 3/25/26 at 11:39 a.m., Occupational Therapist (OT) H confirmed they were covering the department in lieu of the Rehabilitation Director being out of the country and was unavailable for phone interview, despite being most familiar with R65. OT H reviewed R65's physical therapy and occupational therapy records with Surveyor and confirmed R65 had last been seen by occupational therapy on 2/03/23. R65's records at that time showed R65 was dependent for feeding and had diminished arm strength. OT H said they were unfamiliar with this resident, other than record review. OT H was asked about R65's fracture and if it could have occurred while being dressed. OT H said a spiral twisting fracture could have happened with any twisting movement and it was possible from getting dressed. OT H confirmed if R65 had weakness then the most impaired arm would get dressed first. When asked if CNA BB should have continued dressing R65 when they resisted, OT H said one should never dress someone who is resisting or make them get dressed. OT H clarified since R65 had Alzheimer's dementia she may not have wanted to get dressed due to her cognition and said if a resident did not want someone touching their arm they would guard it and resist. OT H clarified a resident including R65 should never be dressed if they were resisting in any way, and then said they did not know R65 broke their arm during care. On 3/25/26 at 12:15 p.m., FM AA was asked to clarify about R65 feeding themselves and said they could only feed themselves if something was placed in R65's hand and they were assisted. FM AA said at that time R65 had good range of motion in both arms prior to their injury and denied contractures being present. On 3/25/26 at 2:13 p.m, the DON was asked about R65's missed orthopedic appointment yesterday. The DON said the transportation company was late and the orthopedic surgeon could not see R65 after their appointment time. The DON said they were using a newer transportation company. Review of R65's tasks tab in the medical record for transfers showed there was no lift transfer completed at or near the time of R65's injury, on 3/08/26. On 3/25/26 at approximately 3:50 p.m., the concerns regarding R65's avoidable injury were shared with the Nursing Home Administrator (NHA) during the Quality Assurance and Performance and Improvement interview. The NHA said they understood the concerns, denied any intentional abuse had occurred from their own investigation, and conveyed they had personally reviewed the video footage from the date of the incident, 3/08/26, and had found no lifts going in or out of R65's room, no fall had occurred and there were no unusual observations. On 3/25/26 at 4:00 p.m., the NHA shared the facility had a Past Non-Compliance (PNC), when a deficient practice was identified on 3/08/26, related to R65's fractured right arm, which had occurred during care. The PNC was received just prior to survey exit. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included identification of the deficiency, review of the facility residents for similar concerns, staff education, one-to-one education for CNA BB, and appropriate monitoring. The facility was able to demonstrate monitoring of the corrective action and maintained compliance during the survey.Review of CNA BB's reeducation, dated 3/16/26, revealed, During routine care on 3/09/26, the resident (R65) sustained a fracture to the right arm; the care was consistent with the resident's needs at that time. Reeducated on safe handling and transfer techniques including use of slow, controlled movements, cues of pain or discomfort. Recognize that residents with osteoporosis, contractures, or frailty are at increased risk for injury even with appropriate care. Anticipate fragility. Adjust care techniques in real time. Review of the policy, Pain Management, revised 4/01/24, revealed, The policy will evaluate and identify residents for pain, determine the type, location, and severity and develop a care plan for pain management.Acute pain refers to pain that is usually sudden in onset and time limited with duration of less than 1 month and often is caused by injury, trauma, or medical treatments such as surgery. Review of the policy, Incidents and Accidents, revised 7/08/25, revealed, Policy; Incident or Accidents involving a resident will be documented and reported so as to meet regulatory requirements. The Administrator and the Director of Nursing will be notified as outlined in this policy. Definitions: Incidents Requiring Further Investigation - Injuries of Unknown Origin.8. All Incident and Accident reports are reviewed by the Administrator or Director of Nursing. There was nothing about prevention of injuries of unknown origin. This policy focused on documentation requirements and how to investigate the incidents.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread foodborne illness to all residents that consume food from the kitchen. Findings Include:On 03/23/2026 at 9:00 AM observed a food item discard date schedule posted on the walk-in cooler (WIC) door which included a 14-day discard for cheeses and pepperoni. During this observation when asked about this policy, the Dietary Manager (DM) L said this is a corporate policy. On 03/23/2026 at 9:06 AM observed a facility container of shredded mozzarella cheese with an attached facility provided date marking sticker indicating prep/open date of 3/21/26 and a use by date of 4/4/26. During this observation when asked about the facility provided use by date, DM L referred to the corporate policy of 14-days use and indicated that this product was typically used within 7 days. DM L also indicated that the product would be re-labeled with a 7-day use by/discard date.On 03/23/2026 at 9:59 AM observed in the 2nd floor nourishment room an opened container of fortified nutritional shake with no facility marked open or discard date. DM L removed the shake and discarded it to the garbage. An interview with DM L at this time found that the policy is to discard this product 3 days after opening.According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety .On 03/23/2026 at 9:25 AM observed kitchen ice bin drain line terminating below the flood rim of the floor drain. When queried during this observation, DM L viewed the drain line and indicated that a maintenance request would be entered for the air gap to be provided. On 03/23/2026 at 10:05 AM observed the 2nd floor nourishment room ice bin drain line terminating below the rim of the drain opening. Both the drain cup and the end of the drain line were soiled with a green and black substance. When shown to DM L they confirmed seeing it soiled and the drain line ending below the edge of the drain cup. According to the 2022 FDA Food Code section 5-402.11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed.On 03/23/2026 at 9:27 AM observed two juice nozzles with colored build up on the inside edges of the nozzles. When queried at this time DM L said the juice guns are cleaned daily by soaking in warm water and the company comes out and cleans and services this unit weekly.According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. On 03/23/2026 at 9:30 AM observed the Delfield upright 2-door cooler with the unit temperature displayed as 45 F. When a probe thermometer was placed in this unit and checked after several minutes of time to verify the air temperature, the thermometer read 50 F. A temperature of yogurt in this cooler was taken at this time and found with an internal food temperature of 52 F. When queried at this time, DM L said this unit is used for day storage of individual yogurts, nutritional shakes, juices and that no items are stored in the unit overnight. DM L said these items got moved into this unit after breakfast service which begins at 7:15 AM and they would return these items to the Walk-in cooler for cold holding and contact the service company for a check of the unit. According to the 2022 FDA Food Code section 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2.According to the 2022 FDA Food Code section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) .TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57C (135F) or above; or (2) At 5C (41F) or less.On 03/23/2026 at 9:43 AM observed in the clean utensil storage area 4 of 5 plastic spatulas that were chipped, stained, damaged on the food contact portion of the spatulas. When queried during this observation about when equipment is taken out of use, DM L indicated 4 of the 5 were damaged to the point of removing and that there are new spatulas that can be put into use. According to the 2022 FDA Food Code section 4-202.11 Food-Contact Surfaces (A) Multiuse FOOD-CONTACT SURFACES shall be: (1) Smooth; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections.On 03/23/2026 at 9:48 AM observed dining room tables pre-set with place settings including utensils stored on top of napkins and exposed to potential contamination. The dining room is open and available to staff, residents and guests passing through this area. When queried at this time, DM L indicated the settings were out and ready for lunch service. Record review of the facility policy Fine Dining/Casual Dining with a last revised date of 8/12/2024 found that in section titled Pre-setting of Tables Procedure: 4. Place setting guidelines: Napkin- folded with the eating surfaces of the flatware covered.According to the 2022 FDA Food Code section 4-904.13 Preset Tableware.TABLEWARE that is preset shall be protected from contamination by being wrapped, covered, or inverted.On 03/23/2026 at 9:50 AM observed the 1st floor nourishment room handsink with the water service line off and a sign posted do not turn on water. In this room, the ice machine was not currently connected to the water supply or power supply. During this observation when queried, DM L indicated that the sink water is off temporarily while service is provided to this newly installed ice machine that started leaking after installation. According to the 2022 FDA Food Code section 5-205.15 System Maintained in Good Repair. A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; and (B) Maintained in good repair.

Based on observation, interview, and record review the facility failed to properly dispose of waste and maintain dumpster area to mitigate the presence of pests, potentially affecting all residents in the facility. Findings include:On 3/23/2026 at 12:31 PM observed two overfilled wheeled trash bins and a foul odor present in the 1st floor soiled linen/trash collection room.On 03/23/2026 at 2:00 PM observed two outdoor waste receptacles located in separate enclosures adjacent to each other. The first waste receptacle was observed with both the top lid and sliding access door left open with scattered debris present around the enclosure. The second waste receptacle was observed with the top lid in the open position, and an accumulation of cardboard, plastic bags, gloves, wrappers and other debris scattered along the side and in a matted pile behind the unit. On 03/23/2026 at 2:18 PM an interview with Assistant Maintenance Supervisor (AMS) A found that housekeeping staff are responsible for maintaining the outdoor waste receptacle area and small objects that may surround it, while maintenance handles larger discard items. When asked about frequency of pickups, AMS A indicated trash is picked up daily, and stated that staff try to keep the receptacle lids closed between use.On 03/23/2026 at 2:20 PM observed the top lid in the open position on both outdoor waste receptacles. AMS A acknowledged the lids were open.On 3/23/2026 at 2:45 PM interviewed the Nursing Home Administrator (NHA) related to general physical environment concerns and policies. When asked about departmental responsibility for maintaining the outdoor garbage storage area, the NHA indicated that was shared responsibility among staff to ensure it stays cleaned. A record review of the facility provided policy entitled Housekeeping Services last revised 7/8/2025 includes the following: Trash will be removed from all areas on a specific schedule to prevent spillage and odors . The area surrounding the dumpster will be kept free of debris. When transporting garbage to the dumpster staff will ensure the area is clean and free of debris.

This citation pertains to Intake #2694463. Based on observation, interview and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), failed to ensure infection control standards and practices were consistently implemented by the facility staff and failed to implement an effective infection control surveillance program. This deficient practice has the increased potential to result the in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility and the spread of infection to residents. Findings Include:On 03/23/26 at 11:50 AM observed a functional hopper in soiled laundry sorting room. When the hopper faucet was turned on, discolored water ran for a few seconds before running clear. On 03/23/2026 at 2:05 PM an interview with Assistant Maintenance Supervisor (AMS) A found the Maintenance Director left suddenly two weeks ago. On 03/23/2026 at 2:06 PM observed one boiler at 128 degrees F and the second boiler at 122 degrees F in the boiler room. On 03/23/2026 at 2:09 PM an interview with AMS A found there is no water management team to their knowledge, and they were not involved in the water management plan as the assistant and were unsure of the maintenance director's responsibilities regarding the plan. When asked about flushing, AMS A indicated they flushed tubs, hoppers, and eyewash stations once a week. When asked about the hopper in the laundry room, AMS A indicated that was not a part of their flushing routine. On 03/23/2026 at 2:39 PM an interview with AMS A regarding documentation of flushing found they do not keep logs, and flushing is done weekly when it notifies them on their maintenance system TELS. On 03/23/2026 at 3:26 PM an interview with Nursing Home Administrator (NHA) found the water management team previously consisted of the NHA, Director of Nursing, Infection Preventionist and Maintenance Director. The NHA stated that the AMS A was now assuming those responsibilities. NHA stated they had recently sent out a legionella training resource to the team to get them up to date. When asked when the last time was that they had a formal meeting to discuss water management, NHA stated that they need to meet. It was noted that the last minutes were dated 2024 and no documentation of a 2025 meeting, NHA did not dispute. When quired about additional documentation related to water management, NHA indicated they had no other documentation. Record review of a facility provided binder entitled Legionella Environmental Plan included a document Legionella Environmental Assessment Form with a date of assessment marked 9-1-2025. Question 18 asked Does the facility have a water management program (WMP)? The box was checked yes, and the form states: If YES, please describe the program briefly here (does it include clinical disease surveillance and/or environmental Legionella surveillance?) and obtain a written copy of the program policy: with a response marked See attached copy of policy. Question 28 asked How is the hot water system configured to deliver hot water to each building? Below usual temperature setting, 150 degrees F was written indicating the temperature each boiler is set to. Record review of a facility provided binder entitled Legionella Environmental Plan included a map titled Notting Hill Evacuation Routes including Green dot water/showers sinks indicated at various points in the map. A flow diagram of water and description of water traveling through the facility was not present in the binder. Record review of a facility provided binder entitled Legionella Environmental Plan included a policy titled Water Management Program last revised 2/1/2024. Including: Developing and maintaining a water management program is a multi-step process that requires continuous review. Seven key activities are routinely performed in a Legionella water management program: Establish a water management program team Describe the building water systems using flow diagrams and a written description Identify areas where Legionella could grow and spread Decide where control measures should be applied and how to monitor them Establish ways to intervene when control limits are not met Make sure the program is running as designed (verification) and is effective (validation) Document and communicate all the activities The general principles of an effective water management program include: Maintaining water temperatures outside of ideal range for Legionella growth Preventing water stagnation Ensuring adequate disinfection Maintaining devices to prevent sediment, scale, corrosion and biofilm, all of which provide habitat and nutrient for Legionella growth. The water management program team will meet quarterly in conjunction with the infection control committee to validate and verify the water management program utilizing the meeting minutes for the water management program. According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, Hot water: Store hot water at temperatures above 140 degrees F (60 degrees C). Ensure hot water in circulation does not fall below 120 degrees F (49 degrees C). Recirculate hot water continuously, if possible. On 3/23/26, the infection control preventionist (ICP) JJ was interviewed to review the facility's Infection Control and Surveillance program. When asked if the facility had any recent outbreaks or any trending infections, ICP JJ reported that the facility did not have any recent out breaks. A review of the facility's infection control surveillance program revealed that the program was not on-going/continuous and was a month behind. ICP JJ was asked about the line listing and how did they follow trends if the list was not completed. The type of infection, duration of treatment, and location was not provided on the line list. McGreer's criteria was not provided/implemented. ICP JJ reported that the facility had completed a Past noncompliance for December 2025 and January 2026. A review of the infection control books was conducted and ICP JJ was asked for several residents, where the laboratory results could be found, the clinician's rationale for the use of antibiotics were and where could the McGeer's criteria be found for the use of antibiotics. The material requested was not available for review. ICP JJ reported that they had worked on the books and tried to keep them up to date however, by them working as a floor nurse (due to staffing shortages) the program was still non compliant except for the month of February when the staff was not challenged and they were able to do their hired job. ICP JJ stated they were not offered any assistance or support to complete their job responsibilities. ICP JJ also reported that they had reached out to corporate staff to get additional help and training but was denied due to them being done with orientation. ICP JJ reported that since the time of hire they had been more of a floor nurse than an ICP. There was no additional information provided by the exit of survey.

This citation pertains to intake 2793611.Based on observation, interview and record review, the facility failed to honor mealtime preferences for six of eight confidential residents that attended the resident council meeting, resulting in expressed feelings of discontent, isolation from peers and loss of autonomy. Findings include:Review of allegations reported to the State Agency included concerns that the resident was given the incorrect diet.On 3/23/26 at 12:27 PM, observation of the facility's main dining room revealed there were nine residents present. Residents were observed interacting with one another and staff were observed obtaining orders for the meal from each resident (Restaurant-like style).On 3/24/26 at 11:00 AM, a confidential meeting was held with eight residents that usually attended the facility's resident council meetings. When asked about how they felt the facility's dining/meal process was, six of the eight residents voiced concerns that the dining room was closed frequently, including not open at all on the weekends. The residents reported they enjoyed getting out of their rooms and socializing in the dining room during meals, and that when they ate in the dining room their meals were warm and they received all of the food items on the menu.Several residents reported that when they received meal trays to their room when the dining room was closed, they were often missing items despite what they pre-filled out on the menu selections for the week.Several other residents reported they were always offered soup and salad when they went to the dining room but that did not occur when they ate in their rooms.The residents reported the dining restrictions had been in place for a long time and expressed their frustration over their loss of choice to eat their meals in the main dining room. Several residents also reported their perceptions were the dining room was opened this week due to the State Agency being in the building.On 3/24/26 at 12:38 PM, an interview was conducted with the Director of Nursing (DON). When asked about who determines when the main dining room is open or not, the DON reported that was up to the Dining Manager (DM 'L').On 3/25/26 at 4:20 PM, an interview was conducted with DM 'L'. When asked about how it was determined the main dining room stayed open or closed, DM 'L' reported the dining room would only close if there was an emergency. When asked what they would classify as an emergency, DM 'L' reported that would be if there was an issue like an outbreak (infection control). DM 'L' further reported they had recently closed the dining room due to a fuse box issue with the dish machine and the main dining room had been closed for about four or five days. When asked when this occurred, DM 'L' reported earlier this month.When asked about the closure of the dining room on the weekends, DM 'L' reported the main dining room was not open on the weekends. When asked for the reason it was closed on weekends, DM 'L' reported that was just their plan and since covid when all the dining rooms were shut down. DM 'L' further reported their plan was to slowly open the dining room and that it was now open Monday - Friday for all three meals. DM 'L' was requested to provide the facility's plan for the re-opening of the main dining room and reported there was no official plan to provide.According to the facility's policy titled, Meal Service dated 1/9/2025: .It is the policy of this facility to provide a dining experience that is conducive to meal acceptance, which includes a quiet, pleasant room, positive staff attitudes, and attractive meal presentation.Residents will be interviewed at the time of admission and thereafter, as needed, as to their preference to eat in the Dining Room or their room.According to the facility's policy titled, Resident Rights dated 5/14/2024: .Residents have freedom of choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care.

This citation pertains to intake 2741968.Based on observation, interview, and record review, the facility failed to provide a safe, clean, homelike environment throughout multiple resident rooms and hallways affecting multiple residents including R17, R31, R87, R91, R100, R110, R125 and eight of eight residents that attended the confidential group interview. Findings include: Observations that were conducted from 3/23/26 - 3/24/26 identified the following environmental concerns: The inner bottom portion of the handrails throughout the second-floor west hallway were observed to have food and debris (potato chips, pink and white popcorn, straw wrappers and used tissues) items that were not cleaned/maintained. Additionally, there were multiple resident room doors that were observed heavily soiled with dirt, debris and unknown substances. The private dining room doors were observed to be heavily soiled with dirt and debris and what appeared to be a liquid that had splattered and dried. On 3/24/26 at 7:56 AM, R17's room was observed to have the entire corner wall with missing drywall that was crumbled on the flooring. Additionally, the dresser was observed to have a thick layer of dust across the entire top. Resident Council Interview: On 3/24/26 at 11:00 AM, a confidential resident council interview was conducted with eight residents that normally attend the resident council meetings. When asked about if there were any concerns regarding the facility's housekeeping or maintenance concerns, multiple residents verbalized concerns. Their responses included: Been waiting to wash my carpet. It's pitch back and when I drive over it in my wheelchair, my whole hand is black from touching the wheel to move. Only in my room twice a week. My roommate uses a urinal and when he misses the urine goes on the floor and between the room divider. It will sit there for long time. It smells so bad like urine. Feel like our room should be cleaned every day. My heater filter is real thick and it stinks. They (Housekeeping Department) lost some staff. Don't see them on the weekends. Got a leak in the back of my toilet. I dump it everynight. Maintenance says he's too busy. Our toilet seat is broken. We asked him (unsure of name) last month. Can you please help us with that. It's been over a month. On 3/24/26 at 3:00 PM, an interview was conducted with the Director of Housekeeping and Laundry (Staff 'P'). When asked about their housekeeping staff and whether there were any openings, Staff 'P' reported there were no current openings for housekeeping. When asked what hours the housekeeping staff worked, Staff 'P reported they worked day shift from 8:00 AM to 4:30 PM and afternoons from 3:00 PM to 11:00 PM. At this time, Staff 'P' was requested to observe the environment. Upon observation of the environment, Staff 'P' confirmed the same findings identified above and reported the process was once the housekeeping staff were done in the rooms, they should work on the hallways and take the vacuum and go along the handrails. Staff 'P' confirmed the same food and debris remained throughout the hallway in R17's room. They also confirmed the corner metal brace was exposed and had sharp edges. The drywall pieces observed on 3/24/26 were mostly gone, however there were several large pieces of drywall under the bed. Staff 'P' reported there had been some staffing issues and they didn't work the weekends so sometimes when they came in on Monday there were housekeeping concerns that needed to be followed up on. On 3/24/26 at 4:48 PM, an interview was conducted with the Administrator. When asked about their Maintenance Staff, they reported their Maintenance Director abruptly left their position on 3/2/26 and there was a maintenance assistant that had been stepping in. The Administrator was requested to provide the electronic reporting documentation for the past three months (concerns reported by staff that needed follow up). On 3/24/26 at 5:21 PM, the Administrator was requested to observe several of the resident rooms. Observations included: At 5:21 PM, the room occupied by R17 was observed to have the broken drywall and exposed sharp metal. The Administrator reported the facility had previously had that area fixed and was not aware it was still in need of repair. At 5:25 PM, the room occupied by R87 and R110 was observed to have a loose toilet seat that was not secured and able to easily slide left to right. The Administrator reported that would be addressed and was not aware of that before now. R110 stated to the Administrator it had been like that for three weeks now and they had told a male staff about it but have not had any follow-up. At 5:30 PM, the room occupied by R31 was observed to have a small plastic basin on the floor under the pipes under the back of the toilet that was almost completely filled with water. The toilet was visibly leaking water and when the Administrator flushed the toilet, the leaking water worsened. The Administrator reported they were not aware of that. On 3/25/26 at 10:11 AM, the facility was requested for a second time to provide the electronic documentation of environmental reports from staff. Review of the documentation provided by the facility revealed a work order log from 12/1/25 – 3/25/26 that had been completed already. There was no documentation provided of existing concerns. Additionally, this documentation did not include any specific details of what date these were reported and when they were corrected. There was no documentation included for the above resident concerns. According to the facility's policy titled, Housekeeping Services dated 7/8/25: .In resident care areas, cleaning of non-carpeted floors and other horizontal surfaces will be done daily and more frequently if spillage or visible soiling occurs.Carpeting will be vacuumed regularly, cleaned promptly if spills occur and shampooed every 3 to 6 months or when indicated by appearance. R125 On 03/23/2026 at approximately 9:19 a.m., R125 was observed in room, lying in bed. R125 was asked if they had any concerns and they indicated they have not had any toilet paper in their restroom to wipe their bottom since the previous night. R125 indicated that they had informed two Certified Nursing Assistants (CNA's) to refill their toilet paper, and nobody had done it. R125 reported they had to clean their self with paper towel which hurt. R125's restroom was observed to not contain any toilet paper. R91 On 03/23/2026 at approximately 9:46 a.m., R91 was observed in their room, lying in bed. R91's restroom was observed to have their Call button (a system used to notify facility staff of assistance needs) pull cord wrapped around the grab bar in bathroom rendering it non-functional for R91 to use. R100 On 03/23/2026 at approximately 10:41 a.m., R100 was observed in their room, lying in their bed. R91's room was observed to have their drywall peeling away from the walls in their room exposing the cardboard drywall underneath. R100's Call button was observed on the floor, out of reach of R100. On 3/25/26 at approximately 12:05 pm., a follow-up observation of R100's room was conducted and was observed to still have five areas of peeling drywall that was exposing the brown cardboard underneath. On 3/25/26 at approximately 12:12 p.m., R100's room was observed with Maintenance Worker A (MW A). MW A reported that R100's drywall would need to be repaired and painted. MW A was queried if they had been made aware of R100's walls needing repair and they reported they had not but that the facility used a system of notification that should have utilized and was not. MW A indicated they would have to find some time to work on R100's room because they were the only Maintenance Worker that was employed at that time as the Director had recently resigned. On 3/23/26 at 11:40 AM observed both (two) washers and dryers running and a large bin of clean linens to be folded/delivered. At this time when asked about laundry procedures, Housekeeping (HK) staff V indicated knowing basic laundry tasks, but that she was filling in to provide coverage and help catch up the laundry and her normal work is housekeeping tasks for unit/rooms. On 3/23/26 at 12:25 PM interview with Certified Nursing Assistant (CNA) GG regarding availability of clean linens, they said this is a constant issue and there are often not enough clean linens for their shower schedule. CNA GG said there were not enough earlier today, but now supply has been restocked, but it can disrupt the showering schedule. On 3/23/26 at 12:30 PM observed the 1st floor clean linen/supply room with approximately 20 wash cloths and 20 bath towels. Disposable briefs storage shelves appear low on supplies; there were 2 packages each of sizes M, L, 2XL. No packages of size XL. On 3/23/26 at 12:31 PM observed 1st floor soiled linen/utility room with 2 overly full garbage bins, not yet emptied. On 3/23/26 at 12:55 PM observed the 2nd floor central shower full of several pieces of stored equipment limiting the ability to move in this room: 4 shower chairs, 1 shower bed, and the therapy tub. During this observation when queried, CNA X indicated that most residents use the showers available in their rooms, there is limited but routine use of the central shower. CNA X then said that when using the central shower room, the extra items are placed into the hall temporarily. On 3/23/26 at 1:05 PM observed the 2nd floor soiled linen room with heaping full tub of bagged soiled linens and a full blue hamper with bagged soiled personal laundry items. On 3/23/26 at 1:10 PM observed the 2nd floor clean linen room with a limited supply of clean linens and disposable briefs: 1 open package size L, 4 packages size M, no packages of XL or 2XL, a stack of about 20 clean washcloths and 0 (no) clean bath towels. When asked at this time about availability of supplies, CNA W indicated that if they were short on anything they could contact Central Supply (CS) staff to re-stock. On 3/23/26 at 1:50 PM observed both washing machines running, a bin of clean linens and partially full stocked transfer cart of folded linens. During this observation, when asked, staff Z indicated they had come in early to help provide coverage. When asked about linen supply, staff Z said keeping clean towels stocked are the biggest problem and they often go missing. On 3/23/26 at 2:10 PM observed housekeeping (HK) staff Y with a wheeled bin full of toilet paper (TP) rolls, restocking the common bathrooms near service hallway. During this observation when asked if there was a TP supply issue, HK Y indicated no, there is plenty and they were trying to get the restrooms restocked. On 3/23/26 at 2:20 PM Interview with staff N to ask about any issues with supplies of linens, briefs, TP. Staff N indicated there were plenty of supplies available and that housekeeping staff are responsible for restocking TP to public restrooms and resident rooms, including on weekends. When asked about the low supply of briefs she indicated she was aware and was about to restock this afternoon that there was ample supply in central supply area. Related to staffing, when asked if that may be an issue with getting supplies to residents, staff N indicated being aware of new hires onboarding with housekeeping department. On 3/23/26 at 2:45 PM interview with the Nursing Home Administrator (NHA) regarding availability of supplies to residents. When asked about provision of TP/tissue to resident rooms on weekends, NHA indicated that housekeeping staff would provide those items, including on weekends. When asked about housekeeping staffing levels, it was indicated that there are new housekeeping staff coming to orientation. Record Review of the Notting Hill Facility Assessment 25-26 document indicated the following: page 44 Section D.1. Cultural – Sufficiency Analysis Summary: . The Housekeeping/Laundry Supervisor in conjunction with Central Supply Coordinator maintains a supply of above-mentioned supplies and products and replaces items as needed.

This citation pertains to Intake 2741968. Based on interview and record review, the facility failed to protect the resident's right to be free from neglect for 18 residents (R25, R41, R123, R46, R61, R65, R72, R78, R81, R87, R90, R91, R93 and R109) of 19 residents reviewed for abuse/neglect/mistreatment, resulting in pain, missed medication administration, treatments and assessments. Findings include: On 03/23/2026 a concern submitted to the State Agency was reviewed that alleged the facility failed to ensure a Nurse was assigned to a block of resident rooms (Rooms 125-147) on 12/28/25. On 3/24/26 at approximately 10:08 a.m., Family member Q (FM Q) was interviewed via phone pertaining to allegations that the facility did not have a Nurse assigned to the Orchard Lake block of rooms on 12/28/25. FM Q reported that R123 not receive any of their day shift medications on 12/28/25 until approximately 9:00 PM. FM Q indicated they drove up to the facility in the afternoon and addressed the concern with Nurse J who informed them that no Nurses were assigned to the Orchard Lake hallway, and none of the Nurses in the facility could take on the hall due to them putting their license at risk in caring for so many residents. R123 On 3/24/26 the medical record for R123 was reviewed and revealed the following: R123 was initially admitted to the facility on [DATE], discharged on 1/8/26 and had diagnoses including Congestive heart failure and Atrial Fibrillation. A review of R123's MDS (minimum data set) with an ARD (assessment reference date) of 11/14/25 revealed R123 needed assistance with most of their activities of daily living. A review of R123's December 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed R123 was not administered approximately 16 doses of medications/supplements and had three treatment opportunities for their urostomy not completed. Further review of the MAR and TAR for the other 17 residents on the unit revealed the following number of Medications/supplements and treatments were not administered or completed during the day shift on 12/28/25. R25-six medications, R41-10 medications, R46-six medications and 8 treatments, R61-17 medications, R65-three medications, R72-six medications, R78-15 medications and one treatment, R81-11 medications, R87-18 medications and one treatment, R90-five medications and one treatment, R91-12 medications and four treatments, R93-13 medications, R109-nine medications and two treatments, R127-seven medications, R128-11 medications, R129-five medications and one treatment, R130-nine medications and two treatments. On 3/24/26 a copy of the facility Nurse staffing assignment was reviewed and revealed no Nurse (Nurse J) was scheduled to work the first floor that had a census of 38 residents on the floor and Certified Nursing Assistants S and T (CNA) were assigned to the Orchard Lake rooms (125-147) during the day shift on 12/28/25. On 3/24/26 at approximately 12:35 p.m., Certified Nursing Assistant S (CNA S) was queried regarding the allegation of no Nurse being present for the 125-147 rooms on 12/28/25 during the day shift. CNA S reported they were one of the CNA's for the Orchard Lake rooms that day and they remembered that day and there was no Nurse for those rooms. CNA S reported that occasionally the other Nurse from the other hallway on the first floor would come over to the unit, but they believed that nobody was given any medications, but the Nurse had their own hall to give medications. On 3/24/26 at approximately 12:45 p.m., CNA T was interviewed pertaining to the allegation of no Nurse being assigned to the 125-147 room on 12/28/25. They reported they were assigned to the unit that day and there was no Nurse during the day shift, and they remembered many of the residents were in pain because they had to be changed without any pain medications. On 3/24/26 at approximately 3:01 p.m. The Director of Nursing (DON) was queried regarding the 18 residents that had resided on rooms 125-147 on 12/28/25. The DON indicated they were unaware of the hallway not having an assigned Nurse. The DON reported that if the facility has a low census, they schedule three Nurses who are to divide up the facility, and one Nurse will have to do a split floor. The DON was queried if they were made aware of any Nursing shortages on 12/28/25 and they indicated they were not. On 3/25/26 at approximately 8:15 a.m., during a follow up conversation with the DON, the DON indicated that the census on 12/28/25 was 86 so the facility would have three Nurses, and they should have spit up the building between the three of them with one of the Nurses on the second floor having to have a split set between the first and second floors. The DON indicated that there may have been a miscommunication regarding Nursing assignments. The DON indicated they ran a missed medication report for that day which resulted in 15 pages of residents with missed medications. On 3/25/26 at approximately 10:01 a.m., Nurse J was interviewed by phone and asked about staffing in the facility. Nurse J explained staffing had been poor lately. Nurse J was asked how many nurses were usually scheduled. Nurse j explained usually there were four nurses scheduled, two for each floor. Nurse J was asked if there were ever only three nurses scheduled. Nurse J explained it had happened a couple of times, but she had told them she could not split the building like that, with the nurses covering two floors. On 3/25/26 at approximately a facility document titled Abuse Prohibition Policy was reviewed and revealed the following: Policy-Each guest/resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Abuse shall include freedom from verbal, mental, sexual, physical abuse, corporal punishment, involuntary seclusion and any physical or chemical restraint imposed for purposes of discipline or convenience that are not required to treat the guests/resident's medical symptoms To assure guests/residents are free from abuse, neglect, exploitation, or mistreatment, the facility shall monitor guest/resident care and treatments on an ongoing basis. It is the responsibility of all staff to provide a safe environment for the guests/residents Neglect is the failure of the facility, its employees or service providers to provide goods and services to a guest/resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect occurs when the facility is aware, or should have been aware of, goods or services that a guest/ resident(s) requires but the facility fails to provide them to the guest(s)/resident(s), resulting in physical harm, pain, mental anguish or emotional distress. Alleged violations of neglect include cases where the facility demonstrates indifference or disregard for guest/resident care, comfort or safety, resulting in physical harm, pain, mental anguish or emotional distress .

This citation pertains to intake 2679285 and 2741968.Based on observation, interview and record review, the facility failed to ensure medications were administered in accordance with physician orders for four (R43, R44, R87 and R110) of four residents reviewed for medication administration, and five of eight residents that attended the confidential group interview; And the facility failed to ensure wound dressings were identified, assessed, changed per physician orders and/or dated for two (R13 and R112) of three residents reviewed for skin conditions. Findings include:Review of multiple complaints reported to the State Agency included allegations that medications were not being administered per physician orders. On 3/24/26 at 11:00 AM, a confidential resident council interview with conducted with eight residents that normally attend the resident council meetings. When asked if anyone had concerns with their medication administration, five residents verbalized concerns. Their responses included: Last night in our wing, we didn't have a Nurse until 12:00 AM. The day nurse was here all day. So when they are late with medication, what are we supposed to do? Double up? That's a big problem. They sit and talk at the nursing station I know cause I have to find the nurse to pass the medications. They will be there yapping away. I haven't had my morning meds yet. My pain patch is supposed to be given between 9:00 AM and 10:00 AM. Three additional residents reported they also had not received their 9:00 AM medication as of now. Review of the following Medication Administration Records (MARs) for the following residents revealed as of this review on 3/24/26 at 12:40 PM, none had received their scheduled 9:00 AM medications/treatments. Additionally, there was no documentation such as progress notes, physician notification of missed/late administration and/or further directions to hold or continue with administration for any of the above residents. R43 Review of the clinical record revealed R43 was admitted into the facility on 8/9/22 with diagnoses that included: unspecified atrial fibrillation, other symptoms and signs involving the musculoskeletal system, muscle wasting and atrophy, iron deficiency anemia, primary insomnia, mild cognitive impairment of uncertain or unknown etiology, generalized anxiety disorder, dysthymic disorder, other specific arthropathies, unspecified systolic (congestive) heart failure, major depressive disorder recurrent mild, hyperlipidemia, GERD, depression, type 2 diabetes mellitus without complications, orthostatic hypotension, and hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease. Current medications included: Cholecalciferol Tablet 1000 UNIT Give 1 tablet by mouth one time a day for Supplement. Famotidine Tablet 20 MG (Milligrams) Give 1 tablet by mouth one time a day for GERD (Gastroesophageal reflux disease). Ferrous Sulfate Oral Tablet 325 MG Give 1 tablet by mouth on time a day every other day for iron deficiency. Folate Oral Tablet 400 MCG (Folic Acid) Give 400 mcg (Micrograms) by mouth one time a day for Folate deficiency with anemia. Furosemide (Lasix – a diuretic) Oral Tablet 40 MG Give 1 tablet by mouth one time a day for chf (Congestive Heart Failure). Lidocaine External patch Apply to Right shoulder topically one time a day for Right shoulder pain Keep on for 12 hours then remove. Lisinopril (for blood pressure) Oral Tablet 10 MG Give 1 tablet by mouth one time a day for Hypertension HOLD SBP (Systolic Blood Pressure) <100mgHg (millimeters of mercury). Potassium Chloride ER (Extended Release) Oral Tablet Extended Release 20 MEQ (Milliequivalent) Give 2 tablet by mouth one time a day for hypokalemia. Eliquis Tablet 5 MG (Apixaban) (An anticoagulant/blood thinner) Give 1 tablet by mouth every 12 hours for A-fib (Atrial Fibrillation). R44 Review of the clinical record revealed R44 was initially admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: acute and chronic respiratory failure with hypoxia, streptococcal infection (2/26/26), chronic obstructive pulmonary disease, chronic right heart failure, pseudomonas, injury of right quadriceps muscle, fascia and tendon, morbid obesity due to excess calories, other depressive episodes, other iron deficiency anemias, hyperlipidemia, Von Willebrand disease type 1, acute on chronic systolic (congestive) heart failure, generalized anxiety disorder, adjustment disorder with mixed anxiety and depressed mood, primary insomnia, essential hypertension, hereditary factor IX deficiency, unspecified atrial fibrillation, and muscle wasting and atrophy. Current medications included: Amiodarone HCl Oral Tablet 200 MG Give 1 tablet by mouth one time a day for atrial fibrillation. Fluticasone Propionate Nasal Suspension 50 MCG/ACT (Actuation) 1 spray in both nostrils one time a day for allergy symptoms. Folic Acid Oral Tablet 1 MG Give 1 tablet by mouth one time a day for supplement. Jardiance Oral Tablet 25 MG (Empagliflozin) (a diabetes medication) Give 1 tablet by mouth one time a day for DM2 (Diabetes Mellitus Type 2). Spironolactone Oral Tablet 50 MG Give 1 tablet by mouth one time a day for DIURETIC. Apixaban (an anticoagulant/blood thinner) Oral Tablet 5 MG Give 1 tablet my mouth two times a day for DVT. This was to be given scheduled at 9:00 AM and 9:00 PM. Bumex Oral Tablet 0.5 MG (Bumetanide) Give 3 tablet by mouth two times a day for DIURETIC. Carvedilol Oral Tablet 25 MG Give 1 tablet by mouth two times a day for HTN (Hypertension). Guaifenesin ER Tablet Extended Release 12 Hour 600 MG Give 1 tablet by mouth every 12 hours for cough. Hydralazine HCl Oral Tablet 50 MG Give 1 tablet by mouth every 12 hours for HTN. This was to be given scheduled at 9:00 AM and 9:00 PM. Sacubitril-Valsartan Oral Tablet 97-103 MG Give 1 tablet by mouth two times a day for HEART FAILURE. This was to be given scheduled at 9:00 AM and 9:00 PM. Isosorbide Dinitrate Oral Tablet 20 MG Give 1 tablet by mouth three times a day for HTN. This was to be given scheduled at 9:00 AM, 1:00 PM, and 9:00 PM. R87 Review of the clinical record revealed R87 was initially admitted into the facility on 6/10/25 and readmitted on [DATE] with diagnoses that included: acute on chronic systolic (congestive) heart failure, chronic obstructive pulmonary disease, heart failure, obstructive sleep apnea, obesity due to excess calories, other instability left hip, fracture of unspecified part of left femur, essential hypertension, hyperlipidemia, anxiety disorder, anemia, GERD, vitamin D deficiency, chronic viral hepatitis C, gout, type 2 diabetes mellitus with diabetic neuropathy, other abnormalities of gait and mobility. Current medications included: Aldactone Oral Tablet 25 MG (Spironolactone) Give 1 tablet by mouth one time a day for Fluid Retention. Bumetanide Tablet 2 MG Give 1 tablet by mouth one time a day for fluid retention. Ferrous Sulfate Oral Tablet Delayed Release 324 (65 Fe) MG Give 1 tablet by mouth one time a day for Anemia. Jardiance Oral Tablet 10 MG (Empagliflozin) Give 1 tablet by mouth one time a day for Diabetes Mellitus. Lidocan [sic] External Patch 5% (Lidocaine) Apply to skin topically one time a day for pain and remove per schedule. Pantoprazole Sodium Oral Tablet Delayed Release 40 MG Give 1 tablet by mouth in the morning of GERD. Toprol XL Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate) Give 11 tablet by mouth one time a day for Hypertension. Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 MCG/ACT (Fluticasone-Umeclidinium-Vilanterol) 1 inhalation inhale orally one time a day for COPD. Ammonium Lactate Solution Apply to affected areas topically two times a day for dry skin apply to affected areas. Scheduled to be administered at 9:00 AM and 5:00 PM. Entresto Oral Tablet 24-26 MG Give 1 tablet by mouth two times a day for Heart Failure. Scheduled to be given at 9:00 AM and 5:00 PM. Gabapentin Oral Tablet 600 MG Give 1 tablet by mouth three times a day for neuropathy. Scheduled to be given at 9:00 AM, 1:00 PM, and 9:00 PM. Insulin Lispro Injection Solution 100 UNIT/ML Inject as per sliding scale: If 70 - 150 = 0 units; 151 - 200 = 1 unit; 201 - 250 = 2 units; 251 - 300 = 3 units; 301 - 350 = 4 units; 351 - 400 = 5 units IF BLOOD SUGAR GREATER THAN 400, GIVE 6 UNITS AND CONTACT MD, subcutaneously before meals and at bedtime for DM2. As of this record review on 3/24/26 at 12:40 PM, this was last documented as completed on 3/24/26 at 7:00 AM. R87 was already observed in the dining room at this time and there was no documentation their blood sugar had been checked. Additionally, the MAR documentation revealed R87 frequently received sliding scale insulin coverage before meals. R110 Review of the clinical record revealed R110 was admitted into the facility on 3/4/25 with diagnoses that included: unspecified dementia unspecified severity with other behavioral disturbance, dysthymic disorder, essential hypertension, GERD, obesity, hyperlipidemia, type 2 diabetes mellitus without complications, vitamin D deficiency, other specified arthritis right and left hand, carpal tunnel syndrome left upper limb, anemia, acquired absence of right leg below knee and unspecified urinary incontinence. Current medications included: Bupropion HCl (Hydrochloride) ER (XL) Tablet Extended Release 24 Hour 150 MG Give 1 tablet by mouth one time a day for depression. Claritin Oral Tablet 10 MG (Loratadine) Give 1 tablet by mouth one time a day for itching for 14 Days. This was started on 3/13/26. Clopidogrel Bisulfate Oral Tablet 75 MG (Clopidogrel Bisulfate) Give 75 mg by mouth one time a day for DVT (Deep Vein Thrombosis – Blood Clot) Prevention. Eucerin External Lotion (Emollient) Apply to bilat (bilateral) dry skin topically one time a day for Xerosis cutis (dry, rough, scaly skin). Ezetimibe Oral Tablet 10 MG Give 10 mg by mouth one time a day for Hyperlipidemia. Active Liquid Protein two times a day Active Liquid protein 30 mL (milliliters) BID (twice a day) or any available nutritional supplement. Nursing to provide. Ordered to be given scheduled at 9:00 AM and 5:00 PM. Diclofenac Sodium External Gel 1 % Apply to Hands bilaterally 2gm (Grams) topically every morning and at bedtime for arthritis pain. On 3/24/26 at 12:30 PM, Nurse 'R' who was assigned to the 2 East unit was asked about their morning medication pass and if they were completed with their morning medication administration. Nurse 'R' reported they were not because it was a heavy med pass and they had the back half to finish. When asked if they had notified anyone from Administration or the Physician that the medication administration was delayed, Nurse 'R' reported they did not. On 3/25/26 at 1:24 PM, an interview was conducted with the DON. When asked about what their policy was regarding late and/or missed medications and treatments, the DON did not offer any explanation but reported they could pull up the facility's Medication Administration policy for review. Review of the policy with the DON revealed this policy did not address late/missed medications and treatments and when asked for further explanation, the DON offered no further response. Further review of R43's MAR with the DON on 3/25/26 at 2:03 PM revealed R43's MARs had no documentation for the above medication/treatments documented as administered today. The MAR remained blank for all 9:00 AM medication. When asked if they had been notified of any concerns with late medication administration today, the DON reported they had not and was unable to offer any further explanation. According to the facility's policy titled, Medication Administration dated 10/17/2023: .Medications are administered in accordance with written orders of the attending physician .Document the interaction with the physician in the progress notes and elsewhere in the medical record, as appropriate .Administer medications within 60 minutes of the scheduled time. Unless otherwise specified by the physician, routine medications are administered according to the established medication administration schedule for the facility. For example, if the medication is ordered for 8:00 a.m., it must be given between 7:00 a.m. and 9:00 a.m. in order to be considered timely . R112 On 3/23/26 at 11:01 AM, R112 was observed seated on the side of bed. Their pant legs were above their knees and the right leg was observed with two red ribbons tied around a white bandage that was visibly soiled (grey in appearance in some areas with visible saturation) that was dated 3/17. When asked about the bandage, R112 reported they had fallen down a while ago but were feeling better now. When asked if anyone had offered to change the dressing (since date of 3/17 on bandage) and resident stated no. On 3/23/26 at 1:37 PM, an interview was conducted with R112's Nurse (Nurse 'U') who reported they were in training with Nurse Manager (NM 'M'). Nurse 'U' was asked about R112's bandage to the right knee and at that time, Nurse 'U' observed R112's dressing, confirmed the date of 3/17 and the condition of the bandage was soiled and saturated and reported they would have to change that. Nurse 'U' then requested NM 'M' come to review and when asked about the treatment and conflicting documentation on the TAR that the resident's treatment had been completed on 3/18 and 3/20, NM 'M' offered no further explanation. Review of the clinical record revealed R112 was admitted into the facility on 4/26/23 with diagnoses that included: acute systolic heart failure, anxiety disorder, major depressive disorder recurrent, insomnia, peripheral vascular disease, abdominal aortic aneurysm without rupture, and type 2 diabetes mellitus with other circulatory complications. According to the Minimum Data Set (MDS) assessment dated [DATE], R112 had intact cognition and had no skin concerns. Review of the care plans included: (R112) has Actual impairment to skin integrity r/t (related to) abrasion of right knee. Date initiated: 3/17/26. Interventions included: Treatment to skin impairment per order. Physician orders included: An order started on 3/17/26 read, Cleanse right knee abrasion with normal saline pat dry apply triple antibiotic ointment cover with border gauze Monday Wednesday Friday and prn (as needed). Review of the corresponding Treatment Administration Record (TAR) revealed the treatment for the abrasion was documented as completed by Nurse Manager (NM 'M') on 3/18 and 3/20 via a check mark. On 3/24/26 at 12:34 PM, the Director of Nursing (DON) was requested to confirm the Nurse's initials on the TAR from 3/18 and 3/20 and reported those were NM 'M's initials. When asked about why NM 'M' documented that had been completed when it wasn't, the DON reported they would have to follow up. On 3/24/26 at 12:38 PM, the DON reported they had spoken to NM 'M' and when asked if they provided an explanation, the DON declined to offer their response but acknowledged that was a concern and further reported they were going to issue a write up and It's not tolerated or acceptable. The DON later reported they also had further concerns and would be suspending NM 'M' pending further investigation. R13 On 3/23/26 at 10:10 AM, R13 was observed lying in bed. A bandage was observed wrapped around R13's right hand, both ends of the dressing were taped to the palm of the hand and the dressing wrapped around the right thumb. The dressing was undated, and appeared worn and had a fringe of lint from the fleece blanket R13 had on his bed along the edge of the dressing nearest R13's fingers. R13 was asked how long the dressing had been on their hand. R13 explained he had gone to an appointment on 3/17/26 and his hand had started bleeding at the appointment, so they had put that dressing on his hand to stop the bleeding. R13 was asked if anyone at the facility had looked at the dressing or his hand. R13 explained no one had asked him anything about the dressing. An undated foam border dressing was observed on R13's left outer arm under the elbow. R13 was asked about the dressing on his left arm. R13 explained that dressing had been changed a couple days ago. Review of the clinical record revealed R13 was admitted into the facility on 2/11/26 with diagnoses that included: pleural effusion [fluid around lungs], sepsis and malnutrition. According to the MDS assessment dated [DATE], R13 was cognitively intact. Review of R13's skin impairment care plan initiated 2/11/26 read in part, .Conduct weekly head to toe skin assessments, document and report abnormal findings to the physician. Review of a Skin Check dated 3/21/26 revealed no skin issues. Review of R13's March 2026 Treatment Administration Record (TAR) revealed no physician order for a dressing on R13's left arm. However, there was a physician order with a start date 2/25/26 that read, Cleanse right arm abrasion with normal saline pat dry apply triple antibiotic ointment cover with border gauze every Monday Wednesday and Friday and prn [as needed]. The TAR was marked as completed on 3/20/26 and left blank [indicating not done] on 3/23/26. On 3/24/26 at 10:23 AM, R13 was observed lying in bed. The same soiled bandage was observed wrapped around R13's right hand. The undated dressing under R13's left elbow appeared to be unchanged. R13 was asked if the left arm dressing had been changed. R13 explained it had not been changed for a couple of days. On 3/24/26 at 2:07 PM, R13's dressings were observed with the DON. The DON asked R13 who had put the dressing on his hand. R13 explained it was put on when he went out to an appointment. The DON removed the soiled dressing around R13's right hand to reveal a crescent shaped raised black scab approximately ¾ inch x 1/4 inch on the outside of the hand between the thumb and the index finger. The DON was asked to verify there was no date written on the dressing on R13's left arm. On 3/24/26 at approximately 2:15 PM, the DON was asked if the dressing she removed from R13's right had appeared to have been old and soiled. The DON agreed the dressing was not a new dressing. The DON was asked what the proper procedure was if a resident had a dressing that there were no orders for. The DON explained she expected the nurse to do exactly what she did, remove the bandage to see what was under there, then if there was a wound to obtain orders from the physician for wound care. The DON was asked about the undated dressing. The DON explained all dressings should be dated when they were applied. Review of a facility policy titled, Skin Management revised 1/28/26 read in part, .The licensed nurse will monitor, evaluate and document changes regarding skin condition (to include: dressing, surrounding skin, possible complications and pain) in the medical record. If a new area of skin impairment is identified, notify the resident, responsible party, practitioner, DON/designee and treatment team, if appliable.

This citation pertains to intake #'s 2741968, 2679285 and 2694463. Based on observation, interview and record review, the facility failed to ensure sufficient Nurse staffing levels to meet resident needs for three residents (R13, R48, R74 and R102) and multiple anonymous residents that participated in the group meeting of a total census of 106, resulting in long wait times for staff assistance and delay in medication administration and treatments. Findings include: Resident Group Interview: On 3/24/26 at 11:00 AM, a confidential resident council interview was conducted with eight residents that normally attend the resident council meetings. When asked about if they got the help and care they needed without having to wait a long time and if staff responded to their call light timely, eight of eight residents verbalized concerns. Their responses included: Last night in our wing, we didn't have a Nurse until 12:00 AM. The day nurse was here all day. So when they are late with medication, what are we supposed to do? Double up? That's a big problem. They sit and talk at nursing station I know cause I have to find the nurse to pass the medications. They will be there yapping away. I haven't had my morning meds yet. My pain patch is supposed to be given between 9:00 AM and 10:00 AM. Three additional residents reported they also had not received their 9:00 AM medication. It's an issue for both floors. Had to wait over two hours. When I ask why they waiting so long and they give me attitude back. Wait sometimes 20, 30, 40 or 50 minutes at times. I have to tell my roommate hit your button and I'm going to grab someone. They say I'm coming but it's not for 30 more minutes. When I say my buttons been on for two hours, it's been on for two hours. Why would I lie? The clock is right in front of my face. I can go up across the hall and up to nursing station and they are talking and laughing and ignoring. That's after waiting an hour. On 3/23/26 at 9:12 AM, R48 was observed sitting in a wheelchair in his room. R48 was asked about care at the facility. R48 explained there was not enough staff. R48 was asked what happened when there was not enough staff. R48 explained there was long call light response times, averaging 1 to 1 1/2 hours due to not enough staff, housekeeping only cleaning his room every other day, or every third day due to not enough housekeeping staff, laundry was supposed to be delivered the next day after being sent down, but he still did not have his laundry he had sent down on 3/20/23 due to not enough laundry staff. On 3/24/26 at 10:18 AM, R48 explained the day shift nurse had to stay to pass the evening medications the night before because there was no one to relieve her. When asked how often that happened, R48 explained a couple times a month the residents do not get their night medications until morning due to there being no nurse on the unit. On 3/25/26 at 10:25 AM, LPN 'E' was interviewed and asked about staffing in the facility. LPN 'E' explained it had not been good lately, there used to be three nurses on the 1st floor, now there were only two nurses and four to five CNA's. LPN 'E' was asked if two nurses and four to five CNA's was enough staff to care for the residents' needs. LPN 'E' explained she did not think it was. LPN 'E' was asked what did not get done. LPN 'E' explained treatments get done late, if at all, because the floor nurse had to do them all, there used to be a treatment nurse that did the treatments, but now the floor nurses had to do the treatments. When asked if there were Unit Managers, LPN 'E' explained there was one for the 1st floor and one for the 2nd floor, but they often had to work on the floor so they could not help if they were working on the floor themselves. On 3/25/26 at 10:01 AM, LPN 'J' was interviewed by phone and asked about staffing in the facility. LPN 'J' explained staffing had been poor lately. LPN 'J' was asked how many nurses were usually scheduled. LPN 'J' explained usually there were four nurses scheduled, two for each floor. LPN 'J' was asked if there were ever only three nurses scheduled. LPN 'J' explained it had happened a couple of times, but she had told them she could not split the building like that, with the nurses covering two floors. Cross Reference: F600 R48 On 03/23/2026 at approximately 9:12 a.m., R48 was observed sitting in their wheelchair. R48 was asked if they had any concerns and reported there are not enough staff and it takes tong for staff to answer the call button. R48 indicated it takes 1 to 1.5 hours average for staff to respond and provide assistance. R74 On 03/23/2026 at approximately 11:07 a.m., R74 was asked if they had any concerns regarding their care and they reported that did not have a Nurse the previous day (Sunday-3/22/26) until 11:00 AM. R74 indicated there was confusion about what Nurse who was supposed to have been coming in and they missed their morning medications. R74 indicated that staffing has gotten worse since the beginning of the year as they indicated they thought that management was sending staff home that are needed to help the residents. R74 reported that one Nursing aide for the whole hall was not enough. R13 On 03/23/2026 at approximately 10:10 a.m., R13 was observed in their room, lying in their bed, R13 was asked if they had any concerns regarding the staffing levels in the facility and they reported they need more staff because they experienced long call light response times, especially in the afternoon shift. R102 On 03/23/2026 at approximately 12:52 p.m., R102's family member was asked if they had any concerns regarding the care of their loved one and they reported that R102 did not use the call light anymore because there are not enough staff to answer it. They reported that R102 had fallen over the weekend in attempting go to the bathroom. On 03/25/2026 at approximately 1:59 p.m., Staffing Coordinator B (SC B) was queried regarding staffing levels in the facility. SC B indicated that they staff the building according to the PPD (patients per day) levels set by their corporate office. SC B reported indicated that the facility has been short staffed and they were aware of staffing shortages. SC B reported they had about five Nurses recently resign and were trying to hire more but the facility does not permit them to use agency Nurses or hire PRN (contingent/as needed) Nurses to fill the shortages. SC B reported that when multiple Nurses take leave, it is difficult to staff Nurses appropriately. SC B reported they utilize an application to notify all staff of open shifts. SC B was asked if they take into consideration the acuity levels of the facility residents and they reported they do not and that the Nursing mangers are supposed to adjust for acuity levels. SC B was asked if they were aware of the issues that being short staffed had affected the residents and they indicated that they were aware of meal tray passes being late due to staffing problems. SC B reported that hiring more Nurses will help with the staffing difficulties the facility had been experiencing. On 3/25/26 a facility document titled Nursing Staffing was reviewed and revealed the following: Policy-The nursing services department provides 24-hour nursing services.The facility ensure sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well* being of each resident, as determined by resident evaluations and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Information Nursing service is provided by number and type of personnel to ensure that each resident: Receives treatments* medications, and diets as prescribed; Receives rehabilitative nursing care as needed; Receives proper care to maintain their highest level of functioning (prevent decline in function or poor clinical outcomes); Is kept clean, comfortable, and well-groomed. Is protected from accidents, injury, and infection; and is encouraged* assisted and trained in self-care and group therapy 4. A licensed nurse (RN or LPN/LVN) is on duty for each shift (tour of duty) and is responsible for providing direct nursing care as well as supervising non-licensed nursing personnel. A person shall not be assigned to duty on the night shift if that person has been on duty either in the home or any other place of business during the preceding 8 hours, but may assume temporary duty on the night shift if the facility has made every reasonable effort to otherwise eliminate a staffing emergency, 5. Work assignments are prepared by the nursing supervisor or charge nurse and issued on a daily basis. 6. Nursing assistants are expected to carry out their daily assignments in a professional manner and in accordance with established nursing procedures. 7.The nursing supervisor or charge nurse must approve all changes in work assignments. 8. Nursing staff will meet competency requirements based on the number of residents, resident acuity, range of diagnoses, and the content of the individual care plan. 9.The facility will staff to meet the needs of the residents at the facility. 10. Refer inquiries concerning nursing services to the Director of Nursing

Based on interview and record review, the facility failed to develop an antibiotic stewardship program that promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance. Findings include:On 3/23/26 an interview was conducted with Infection control preventionist (ICP) JJ. They were asked to explain the facility's antibiotic stewardship program. ICP JJ reported that they make sure that residents meet McGeer's criteria, make sure staff are following protocol and procedures, educate staff on the importance of following infection control policies, and utilize audits and an infection screening tool that they use to interview patients to see if they meet criteria. ICP JJ was asked when they started in their position and reported that they started in November of 2025 and was hired for strictly Infection control, but the staffing was not the best at the facility so they had been working as a floor nurse and doing infection control when they could or had time. ICP JJ also reported that the facility had completed a Past noncompliance for December 2025 and January 2026. A review of the infection control books was conducted and ICP JJ was asked for specific resident laboratory results could be found, the clinicians rational for the use of antibiotics and where could the McGeer's criteria be found for the use of antibiotics they were prescribed. The material requested was not available for review. ICP JJ reported that, they had worked on the books and tried to keep them updated however, by them working as floor nurse due to staffing shortages, the program was still not compliant except for the month of February when staffing was not challenged, and they were able to do their hired job. ICP JJ also reported that they had reached out to corporate staff to get additional help and training but was denied due to them being done with orientation. ICP JJ reported that since the time of hire they had been more of a floor nurse than an ICP.A request for the antibiotic stewardship policy was requested, and no additional information was provided.

Based on observation, interview and record review, the facility failed to ensure a resident was assessed for the safe self-administration of medication and to have medication kept at bedside for one (R105) of one resident reviewed for self-administration of medication. Findings include:On 3/23/26 at 9:50 AM, during an interview with R105 there was a large oblong cream-colored pill observed in the top bedside dresser drawer that was opened. When asked about the pill, R105 reported, Yeah that's my gabapentin (pain medication) they (Nurse) left me that the other day. I took it cause they double dosed my one dose and there were two in there. I said to them here I'm taking this and saving for when I'm in pain. It's for nerve pains in my leg, they feel like bee stings and hurt like hell. So, I just took it and saved it.On 3/23/26 at 10:13 AM, Nurse Manager (NM 'M') was asked about the facility's process for residents keeping medication at bedside. NM 'M' reported the only time should be if they are assessed to self-administer and I only have one. When asked if R105 was the one, NM 'M' reported, He's not one of those ones.Review of the clinical record revealed R105 was admitted into the facility on 2/10/26 with diagnoses that included: spinal stenosis lumbar region with neurogenic claudication and altered mental status unspecified.According to the Minimum Data Set (MDS) assessment dated [DATE], R105 had intact cognition, and required supervision or touching assistance for eating and oral hygiene, and required partial/moderate assistance with toilet hygiene, and shower/bath.There was no documentation in R105's clinical record of any assessment, physician order or care plan that indicated R105 had been assessed to be able to have medication kept at bedside to self-administer.According to the facility's policy titled, Medication Administration dated 10/17/2023: .Self-Administration - residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with the guideline for self-administration of medication. A self-administration evaluation will be completed prior to the resident starting the self-administering process. Self-administration of medication will be reflected in the resident care plan along with any special considerations.

Based on observation, interview and record review the facility failed to ensure acceptable standards of nursing care and services were provided for one (R14) out of six residents reviewed for medication administration. Findings include:A review of R14's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: bipolar disorder, schizophrenia and anxiety disorder. A review of the residents Minimum Data Set (MDS) revealed R14 had a Brief Interview for Mental Status (BIMS) score of 13/15 (intact cognition).Continued review of R14's clinical record, documented, in part, the following:2/2/26: Administration Note: .appears she is spitting out the medication in her room, under the bed. (Authored by Registered Nurse (RN) HH)3/22/26: Administration Note : .Patient appears to have been hoarding all of her medications and throwing them away under the bed. It appears to be several days of medication found. (Authored By RN HH)Care Plan: Focus: (R14) is at risk for adverse reactions.r/t (related to)receiving multiple psychotropic medications.takes antianxiety and antidepressant.Interventions: Administer medications per orders. *There were no interventions pertaining to the refusal of medications found in R14's care plan.On 3/25/26 at approximately 2:07 PM, R14 was observed lying in bed. The resident was alert and able to answer most questions asked. The resident was asked if they were taking the medication that was provided by nursing staff. R14 noted that most times they do not want to take their medication because the staff try to poison them. R14 was asked what they do with the medication given by staff and they reported that sometimes they refuse it, sometimes staff just leave it in the room and sometimes they will spit the medication out and put it under their bed.On 3/25/26 at approximately 2:15 PM a phone interview was conducted with RN HH. RN HH was asked about the medication found under R14's bed and reported at times the resident refuses their medication and, on a few occasions, they went to provide the medication and noted several pills under the residents bed. RN HH noted that the concern was reported to Unit Manager.On 3/25/26 at approximately 3:02 PM an interview was conducted with Social Worker (SW) II. SW II was asked if they were familiar with R14 and their refusal to take their medication. SW II reported that they were aware of R14's refusal to take their medication and the medication that was found underneath their bed on 3/22/26. SW II provided a picture that showed approximately 20 pills found underneath R14's bed. They were not aware that it had happened prior to 3/22/26.On 3/25/26 at approximately 3:29 PM, the Director of Nursing (DON) was queried about R14 hoarding medication under their bed. The DON noted they were aware Nurse HH found the medication under the bed on 3/22/26, but not familiar about the concern in February 2026. The DON was asked as to how nursing staff should ensure the administration of residents' medication. The DON reported that staff should remain in the room to ensure the residents take their medication and correctly mark if the resident refused.

This citation pertains to Intake 2793611Based on interview and record review, the facility failed to ensure pressure ulcer treatments were ordered, completed as ordered, wound care was provided timely, and accurate skin assessments were completed for two (R2 and R115) of three residents reviewed for pressure ulcers. Findings include:R2 Review of R2's MDS assessment, dated 3/08/26, revealed they were admitted to the facility on [DATE], with diagnoses including spinal stenosis (narrowing of spine), polyneuropathy (nerve impingement), kidney disease, and urinary retention. The skin assessment showed R2 was admitted with one stage 3 pressure ulcer (the wound dept extends beyond the skin layers) and a surgical wound. On 3/23/26 at 2:16 p.m., R2 confirmed their right foot pressure injury was on their heel, and said the wound developed at home and at the hospital, when they pushed into their mattress too hard in bed repeatedly due to back pain. R2 said their wound care at this facility was supposed to be completed every other day, without exception, and felt frustrated that their wound care was getting missed at times, or their wound was not getting wrapped correctly, as it was often too tight. R2 showed surveyor a wrap around his leg and said it hurt them. R2 said they had their wound care completed Saturday, and stated, I missed Friday.It should be done every second day no matter what. R2's nurse was notified after the interview R2 said their wound was wrapped too tightly. On 3/24/26 at 11:10 a.m., LPN C was asked about R2's wound care after review of R2's physician orders. LPN C confirmed R2 was scheduled to have wound care every Monday, Wednesday, and Friday during the Day shift. LPN C said their wound improved slightly and showed Surveyor three weeks of wound pictures since admission. LPN C said R2's wound was appropriately offloaded, per physician orders. Review of the wound pictures and measurements with Surveyor revealed the following wound description and measurements, showing L = length, W = width, and D= depth: 3/03 4.86 cm2 (1.78 L x 3.78 W x 0.1 D) – Stable, previously deteriorating. 3/11 5.9 cm 2 (3.22 L x 2.39 W x 0.0 D) – Improving (unclear as wound larger). 3/18 4.29 cm 2 (3.98 L x 1.53 W x 0.1 D) – Stable, previously deteriorating. Review of R2's March (2026) Treatment Administration Record (TAR), revealed, Cleanse right heel with normal saline (rinse), pat dry, apply collagen (wound treatment), cover border gauze (a rectangular flat clear bandage with a gauze center and adhesive border) Monday, Wednesday, Friday and prn (as needed) every day shift everyday shift Mon, Wed, and Fri. Start date 3/20/26 0700 (7:00 a.m.). Further review of R2's March (2026) TAR on 3/24/26 revealed a missing wound treatment, noted on 3/20/26, the past Friday (which was the start date). Review of R2's March (2026) TAR reviewed an earlier physician order, dated 3/06/26, which revealed, Cleanse right heel with normal saline, pat dry, apply collagen, cover with ABD pad, wrap with Kerlix (gauze rolled wound wrap), Monday, Wednesday, Friday, and prn everyday shift Mon, Wed, Fri. Start date: 3/06/26 and D/C (discharge date ) 3/18/26. Further review of R2's TAR (earlier wound order) revealed a missing wound treatment on Wednesday, 3/11/26, which showed as a blank box, with no explanation. The treatment on 3/20/26 was blank too; it was noted the order was discharged on this same date. Wound treatment was not initialized again until Friday, 3/13/26. Review of R2's TAR revealed another active order, which read, Cleanse right heel with normal saline, pat dry, apply collagen, cover with border gaze, Monday, Wednesday, Friday, and prn as needed. Start date: 3/18/26 1315 (1:15 p.m.). Further review of this order showed missing wound treatments on Wednesday, 3/18/26 and Friday, 3/20/26, with Saturday, 3/21/26 initialed by a nurse as provided. Further TAR review showed there was a second active order which appeared to read the same, started on 3/18/26. Regardless, neither order reflected wound care being done on 3/18/26 or 3/20/26, and the wound treatment on 3/11/26 was clearly missed. Review of R2's March (2026) TAR's in their entirety showed no other entries reviewed reflected missing wound treatments on 3/11/26, 3/18/26, and 3/20/26. Review of R2's current physician order, dated 3/25/26, showed the latest treatment for R2's Stage 3 pressure injury was to clean the wound with normal saline, pat dry, apply collagen, and then cover in border gauze, Monday, Wednesday, and Friday and as needed. On 3/24/26, at approximately 5:15 p.m., Surveyor asked the Nursing Home Administrator (NHA) to observe R2's wound care on 3/25/26. The NHA said they would have wound care held for surveyor observation, as it could be completed anytime during the day. On 3/25/26 at approximately 8:10 a.m, Surveyor asked about observing R2's wound care, as scheduled and was told it had been completed already by nursing staff for the day. Surveyor had not been asked to arrive at any earlier time on this date. On 3/25/26 at approximately 11:00 a.m., R2 stopped Surveyor in the hallway, while propelling their wheelchair, and stated, My wound got worse; they used the wrong dressing. (Registered Nurse -RN K) and the doctor (unnamed) both said they (the nurses) should not have used gauze but (instead) a bandage. I am worried it (the pressure injury wound) is getting worse. R2 described to Surveyor a wrap was used instead of a bandage, so when the nurse and physician removed the dressing this morning, their wound seemed to bleed more than usual, was larger, and had worsened. On 3/25/26 at 11:07 a.m., RN K was asked about R2's report of the wrong wound care treatment being applied earlier on 3/25/26, their wound bleeding and worsening, and why this Surveyor was unable to observe R2's wound care, as scheduled. RN K shared they had been off work a week, and upon return they and the physician had begun wound care, as scheduled, and had not received a message to wait for Surveyor. RN K was asked if they had a picture of the wound, as had been noted in prior wound documentation. RN K responded when they were off, no staff had charged the camera battery, so they could not get a picture of the R2's heel wound. RN K explained their standard of wound care when asked was to get a picture of the wound every seven days, and for the camera to be charged. RN K said given the collagen wound treatment was applied, it would not be ideal to open the wound bandage again, as the wound treatment would have to be redone. During further interview on 3/25/26, RN K was asked about R2 reporting on this date the wrong wound care treatment being applied, and their wound worsening. RN K reviewed their documentation and reported R2's right heel Stage 3 pressure ulcer had 20% granulation tissue, 80% epithelization tissue, had serosanguineous (non-infectious) drainage, and was healing. The measurements were described by RN K as 3.0 L, 1.0 W, and 0.1 D, with no tunneling or undermining, and said they did not have the area. Upon further documentation review with Surveyor, RN K said the wound was healing, decreasing in size, and clarified R2's wound should have had a border foam dressing applied, not a Kelex wrap, which was confirmed by current physician orders. When asked to describe the difference as a certified wound care nurse, RN K said the Kerlex wraps were for cushioning and support and sometimes used for compression and was a rolled gauze type bandage and showed surveyor the same. RN K said border gauze was an actual bandage over the wound and did not circle the wound or leg and showed surveyor a large rectangular bandage with a foam border, which they said was most appropriate for R2's heel wound. Surveyor described how R2 had reported their bandage being tight (around their leg) on 3/23/26 and their nurse being made aware. RN K said no circulatory problems had been noted for R2. RN K was asked to review R2's TAR with Surveyor and understood the concerns with the missed treatments. RN K said they did the wound care treatment on the missing Wednesday treatment and said they should have marked the TAR, as that was their responsibility. Regarding the other missing dates, RN K noted the orders had changed, however understood the concern despite orders changing with missed treatments, and could not explain why the treatments were missed on the other dates. This included review of the medical record, including R2's progress notes and all wound documentation notes. Review of R2's wound care provider documentation, dated 3/25/26, confirmed RN K's wound measurements were reflected as noted in earlier interview, and the wound was described the same, and reflected as improved, with the treatment reflected as a border foam bandage (not Kerlex wrap) to be completed on Mondays, Wednesdays, and Fridays, and said R2 was using pillows for offloading. On 3/25/26 at 3:08 p.m., the concerns related to R2's missing wound care documentation and treatments per the TAR were reviewed with the DON, the missed observation, and no picture being available, per their wound care standards. The DON conveyed they understood the concerns and would be following up with RN K. The DON was given the opportunity to respond further by survey exit and did not reapproach surveyor with additional feedback. On 3/25/26 at approximately 3:45 p.m, the NHA was asked about the missing wound care observation during the Quality Assurance and Performance Improvement (QAPI) interview, and the concerns were reviewed, including R2's reporting of their wound care treatments being missed and the wrong wound treatment being applied, as confirmed by RN K. The NHA said they took responsibility for the missed wound care observation, as they did not realize the wound care team was starting treatment so early in the morning, and understood this Surveyor's described concerns. Review of a policy, Skin Management, revised 1/28/26, revealed, The policy that the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries. Overview: Residents with wounds and/ or pressure injury and those at risk for skin compromise are identified, evaluated, and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes. Practice Guidelines.3. Appropriate preventative measures will be implemented on residents identified on residents identified at risk and the interventions are documented on the care plan. 4. Residents admitted with any skin impairment will have appropriate interventions implemented to promote healing, a physician order for treatment, and skin impairment location, measurements, and characteristics documented. 5.Photos will be taken unless refused by the resident. R115 A complaint was filed with the State Agency [SA] that alleged in part, .[R115] has a bed sore. that is supposed to be cleaned and a topical ointment is supposed to be applied. he was to be laid [sic] on his side and turned from side to side which did not occur. Review of the closed record revealed R115 was admitted into the facility on 2/14/26 with diagnoses that included: sepsis, atrial fibrillation and chronic kidney disease. According to the Minimum Data Set [MDS] assessment dated [DATE], R115 had intact cognition, and had one Stage 4 [full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone] and one Unstageable [obscured full-thickness skin and tissue loss] pressure ulcers on admission. Review of a Nursing Comprehensive Evaluation dated 2/14/26 revealed R115 had skin impairment to the right heel, left heel and sacrum. There was no description of what the skin impairment was. Review of an admission Nurses Note for R115 dated 2/14/26 at 8:29 PM read in part, .Wounds noted to both left and right heels. Open wound present to coccyx. Measurement to be obtained/documented per wound care protocol, dressing in place per discharge order. Review of R115's hospital discharge paperwork dated 2/14/25 revealed detailed orders for wound care to the left buttock, coccyx to right buttock, left heel and right heel. All the wound orders included the treatments to be completed twice daily. Review of R115's physician orders revealed no wound treatments were ordered until 2/17/26 to be started on 2/18/26. Review of R115's February 2026 Treatment Administration Record [TAR] revealed no documentation of wound care until 2/18/26. Review of a SW [skin and wound] - Skin Check for R115 dated 2/17/26 at 5:57 AM documented No skin issues. Review of a SW – Skin Issues for R115 dated 2/17/26 at 8:27 AM revealed a left heel Unstageable pressure ulcer measuring 4.9 centimeters [cm] x 3.44 cm and a coccyx Stage 4 pressure ulcer measuring 4.25 cm x 3.64 cm x 1.5 cm. On 3/25/26 at 10:25 AM, the Assistant Director of Nursing [ADON] was interviewed and asked if she was the Wound Care Coordinator. The ADON explained she had been the Wound Care Coordinator and still aided with wound care. The ADON was asked about R115 being admitted on [DATE] with wounds, but not documented wound care provided until 2/18/26. The ADON explained R115 was admitted on a Saturday, she worked Monday thru Friday, and the admitting nurse did not put wound treatment orders in. The ADON was asked if the wound care orders on the hospital discharge paperwork were any different than the medication orders when admitting a resident. The ADON explained there was no difference, the admitting nurse was expected to enter the wound care orders the same as the medication orders. The ADON was asked why there was no documentation of wound care until 2/18/26 if the order was entered 2/17/26. The ADON explained it was her practice to put the orders into the computer and provide the wound care that day, but the TAR documentation would start on the next day. When asked if there was any documentation that wound care had been provided prior to 2/18/26, the ADON explained there was not. Review of a facility policy titled, Skin Management revised 1/28/26 read in part, .Residents admitted with any skin impairment will have: Appropriate interventions implemented to promote healing, A physician's order for treatment, and Skin impairment location, measurements and characteristics documented.

Based on interview and record review, the facility failed to ensure irregularities identified by the consultant pharmacist and signed by the physician were completed for two (R9 and R19) of five residents reviewed for monthly medication regimen reviews [MMR's]. Findings include: R19 Review of the clinical record revealed R19 was admitted into the facility on 3/19/21 and readmitted [DATE] with diagnoses that included: Parkinson's Disease, dementia and hallucinations. According to the Minimum Data Set [MDS] assessment dated [DATE], R19 had severely impaired cognition. Review of monthly pharmacist medication reviews revealed there were irregularities with R19's medication on 8/15/25. No documentation of what the irregularities were, or what the physician's response to the irregularity was found in R19's clinical record. An email was sent to the facility requesting the pharmacist recommendation and the physician response for R19 on 8/15/25 on 3/25/26 at 8:50 AM. No documentation was provided prior to the end of the survey. On 3/25/26 at 11:07 AM, the Director of Nursing [DON] was interviewed and asked about R19's MRR dated 8/15/25. The DON explained she could find no documentation in the chart and had the pharmacy resend the MRR's, but there was no physician response on the MRR's the pharmacy had sent. The DON was asked to provide R19's MRR the pharmacy had resent. No MRR was received prior to the end of the survey. Bottom of Form R9 A review of R65's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: traumatic ischemia, schizoaffective disorder and Alzheimer's. According to the MDS assessment the resident had a Brief Interview for Mental Status (BIMS) score of 3/15 (severely impaired cognition). Review of the monthly medication reviews revealed there were irregularities with R9's medication as follows: 6/16/25: .MRR-Pharmacy: See report. Report to 6/16/25: Pharmacist Recommendation to Prescriber: .This resident is currently receiving Ferrous Sulfate 325 mg (milligrams) qd (every day) for an iron supplement.Recommendation: Please consider changing Ferrous sulfate dose to 325 mg qd on Monday-Wednesday-Friday to optimize iron absorption.Agree. (signed by Physician on 7/2/25). 7/2025: No MRR was located in R9's clinical record. 8/15/25: .MRR-Pharmacy: See report. Report to 6/16/25: Pharmacist Recommendation to Prescriber: .This resident is currently receiving Ferrous Sulfate 325 mg (milligrams) qd (every day) for an iron supplement.Recommendation: Please consider changing Ferrous sulfate dose to 325 mg qd on Monday-Wednesday-Friday to optimize iron absorption.Agree. (signed by Physician on 9/4/25). A review of the residents Orders and Medication Administration Record (MAR) for the months of July, August and September 2025 documented the resident received Ferrous Sulfate 325 mg daily despite the physicians Agreement to changing the dose to 325 mg Monday-Wednesday-Friday. Continued review of the MRR, noted recommendations were made 9/16/25, 11/14/25, 12/9/25, 1/16/26, 2/11/26. There were no responses in the resident electronic record. R19 Review of the clinical record revealed R19 was admitted into the facility on 3/19/21 and readmitted [DATE] with diagnoses that included: Parkinson's Disease, dementia and hallucinations. According to the Minimum Data Set [MDS] assessment dated [DATE], R19 had severely impaired cognition. Review of monthly pharmacist medication reviews revealed there were irregularities with R19's medication on 8/15/25. No documentation of what the irregularities was, or what the physician's response to the irregularity was found in R19 clinical record. An email was sent to the facility requesting the pharmacist recommendation and the physician response for R19 on 8/15/25 on 3/25/26 at 8:50 AM. No documentation was provided prior to the end of the survey. On 3/25/26 at 11:07 AM, The Director of Nursing [DON] was interviewed and asked about R19's MRR dated 8/15/25. The DON explained she could find no documentation in the chart and had the pharmacy resend the MRR's, but there was no physician response on the MRR's the pharmacy had sent. The DON was asked to provide R19's MRR the pharmacy had resent. No MRR was received prior to the end of the survey.

Based on observations, interview and record review the facility failed to ensure that the medication error rate was less than five percent with a percentage of 6.45. Findings include: On 3/23/26 at 9:18 AM, a medication administration pass was completed with Registered Nurse (RNHH). RNHH was observed pulling medications from the pack and administered Lasix 20mg(milligrams), multivitamin, MiraLAX 17 g(grams) Duloxetine 60 mg, allopurinol 100 mg, carvedilol 3.125, vitamin B12 and lisinopril 5 mg.On 3/23/26 at 12:38 PM, a review of the medical administration record was made and the following errors were discovered. Duloxetine 60 mg was ordered as DULoxetine HCl Capsule Delayed Release Particles 60 MG Give 1 capsule by mouth at bedtime for depression. It was ordered to be given at bedtime and was giving during the morning medication pass. There was also an order for Famotidine Oral Tablet 20 MG Give 1 tablet by mouth one time a day for GERD (Gastro Esophageal Reflux Disease) IN THE MORNING and it was not observed being given but was signed off on the medication administration record as being administered.On 3/23/26 at 1:10 PM an interview with the Director of Nursing (DON) and she was made aware of the medication observation pass and the errors that were made. The DON reported that she would follow up with the nurse and have them fix the situation.There was no additional information provided.

Based on interview and record review, the facility failed to maintain complete and accurate medical records for two (R9 and R19) of five residents reviewed for monthly regimen reviews [MRR's]. Findings include: R9 A review of R9's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: traumatic ischemia, schizoaffective disorder and Alzheimer's. According to the MDS assessment the resident had a Brief Interview for Mental Status (BIMS) score of 3/15 (severely impaired cognition). Review of the monthly medication reviews revealed there were irregularities with R9's medication as follows: 9/16/25, 11/14/25, 12/9/25, 1/16/26, 2/11/26. No documentation of the physician response to the irregularities was in R9's clinical record. On 3/25/26 at 11:07 AM, the Director of Nursing [DON] was interviewed and asked about R9's MRR dated 9/16/25, 11/14/25, 12/9/25, 1/16/26, 2/11/26. The DON explained she could find no documentation in the chart, so she had asked Unit Clerk [UC] 'P', who worked in Medical Records, where they were, and UC 'P' had told her she had shredded the MRR's. On 3/25/26 at approximately 2:24 PM, UC P was interviewed about the pharmacy recommendations and physician responses. UC P reported that the facility changed pharmacy services in July 2025 and after the change they did not scan the documents into the record and shredded the paper documents. R19 Review of the clinical record revealed R19 was admitted into the facility on 3/19/21 and readmitted [DATE] with diagnoses that included: Parkinson's Disease, dementia and hallucinations. According to the Minimum Data Set [MDS] assessment dated [DATE], R19 had severely impaired cognition. Review of monthly pharmacist medication reviews revealed there were irregularities with R19's medication on 8/15/25. No documentation of what the irregularity was, or what the physician's response to the irregularity was found in R19's clinical record. On 3/25/26 at 11:07 AM, the Director of Nursing [DON] was interviewed and asked about R19's MRR dated 8/15/25. The DON explained she could find no documentation in the chart, so she had asked Unit Clerk [UC] 'P', who worked in Medical Records, where they were, and UC 'P' had told her she had shredded the MRR's. The DON was asked why the MRR's were being shredded. The DON explained she had asked UC 'P' that and UC 'P' had told her she did not know why she had shredded them.

Based on observation, interview and record review, the facility failed to ensure the daily nurse staffing information was accurately posted and updated for each shift. This deficient practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's current staffing levels.Findings include:On 03/23/2026 at approximately 8:33 a.m., upon entrance to the facility, a review of the displayed daily staffing posting was observed and the posting that was displayed was for 3/21/26 indicating it was approximately two days old and not reflecting the current census of the day (106) or any staffing changes of the active shift. On 03/25/2026 at approximately 1:59 p.m., during a conversation with Staffing Coordinator B (SC B), SC B was asked who was responsible for ensuring the Nurse staffing posting was accurate and up to date. SC B reported they were responsible for updating the staffing posting. SC B reported that when they leave the facility for the weekend, they will provide the following staffing postings for the Saturday, Sunday and Monday. SC B was queried how the posting is updated on each of the weekend days to reflect staffing and census changes and SC B reported they were not updated. SC B informed of the observation of the staffing posting being dated for 3/21/26 (Saturday) upon entrance to the facility on 3/23/26 and they reported the front receptionist is responsible for changing the staffing posting on the weekends and must have forgotten. SC B indicated they would try to develop a method of updating the staffing posting daily to reflect changes for each shift pertaining to changes in staffing levels and census. On 3/25/26 a facility document titled Required Regulatory Postings was reviewed and revealed the following: Policy-The facility posts the total number and actual hours worked of licensed and unlicensed nursing staff directly responsible for guest/resident care for each shift. The information will be displayed in a prominent location that is clearly visible and accessible by guests/residents family and staff. The facility will provide a posting of names, addresses, and telephone numbers of all pertinent State client advocacy groups, per regulatory guidelines .Process for Staffing Postings: The following information will be posted on a daily basis by the facility: 1. Data Requirements-Facility Name. The current date. iii. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for guest/resident care per shift: 1. Registered Nurses 2. Licensed Practical Nurses 3. Certified Nurse aides or State Tested Nursing Assistants 4. Medication Aides iv. Guest/Resident census .2 Posting Requirements i, the facility will post the data specified above on a daily basis at the beginning of each shift. ii. Data must be posted as follows: 1. Clear and readable format 2. In a prominent place readily accessible to guests/residents and visitors. 3. Data retention requirements i. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by state law, whichever is greater, 4. Public Access to posted nurse staffing data i. The facility must, upon request, make nurse staffing data available to the public for review at a cost not to exceed the community standard .

This citation pertains to intake #2574455Based on interview and record review the facility failed to thoroughly investigate an injury of unknown origin for one resident (R701), of two residents reviewed for abuse, resulting in the potential for undetected incidences of abuse. Findings include: A complaint received by the State Agency alleged R701 was intentionally handled roughly causing a skin tear to their forearm.On 11/25/25 at 9:40 AM, an interview was conducted with the complainant, and they alleged a facility staff member intentionally caused a skin tear to R701's during a transfer from the toilet to their wheelchair. They reported R701 told the staff member they were hurting them, and rather than stop grabbing them by their forearm the staff member grabbed it tighter causing a skin tear.On 11/25/25 at 9:53 AM, a review of R701's clinical record revealed they admitted to the facility on [DATE] and discharged to the emergency room on [DATE]. R701's diagnoses included: left pubis fracture, heart failure, falls, diabetes, and heart disease.A review of a progress note entered into the record on 11/17/25 at 8:34 PM by Nurse 'I' read, .Writer observed resident with a skin [NAME] [sic] to left forearm after being transferred from toilet to w/c (wheelchair) by two staff members .Drssing [sic] applied to left forearm .On 11/25/24 at 12:24 PM, an interview was conducted with Nurse 'I' regarding their progress note entered into the record on 11/17/25. They were asked to describe the incident and said Certified Nurse Aide (CNA) 'J' needed assistance transferring R701 off the toilet and Unit Manager 'K' went to assist them. They said they did not witness the transfer but after it occurred, they noticed a skin tear to the resident's forearm. Nurse 'I' said Unit Manager 'K' instructed them not to do an incident report, but they did one anyway as they felt it was the facility's policy. They further said they reported the incident to another Unit Manager, Unit Manager 'L' who agreed an incident report should be done. They then went on to say a nurse orientee they were working with applied a dressing to the wound. They were asked if anyone from the facility interviewed them or investigated the incident. They said they were not interviewed and they were unsure whether anyone else investigated the incident. On 11/25/25 at 12:45 PM, a telephone interview was conducted with CNA 'J'. They were asked about the incident and denied any knowledge of the transfer or the skin tear sustained by R701.On 11/25/25 at 12:49 PM, a phone call was placed to Unit Manager 'K' (who assisted with the transfer), and a voicemail was left. On 11/25/25 at 12:50 PM, a phone call was placed to Unit Manager 'L' (who agreed with Nurse 'I' on doing an incident report), however their phone was not able to receive calls at the time the call was placed. On 11/25/25 at 2:31 PM, an interview was conducted with the facility's Director of Nursing (DON) regarding R701 sustaining a skin tear. They were asked if they had any additional information such as an interview with the resident, interviews with the two staff members who transferred R701, or interviews with Nurse 'I' and Unit Manager 'K' and they said they were going to look for additional information. No additional information regarding the incident was provided by the end of the survey. On 11/25/25 at 3:24 PM, an interview was conducted with the facility's Administrator/Abuse Coordinator. They said they did not have any additional information regarding the skin tear and also volunteered knowledge of Unit Manager 'J' turning in their two-week notice saying their last day of work was coming up. A review of a facility provided policy titled, Abuse Prohibition Policy revised 9/2022 was conducted and defined Injuries of unknown source, however; the policy did not address investigating, Injuries of unknown source.

This citation pertains to Intake Number(s): MI00151142, MI00152404 and MI00151259. Based on observation, interview, and record review, the facility failed to provide adequate supervision and implement effective interventions to prevent falls and accidents for three of three residents (R804, R806, and R807) reviewed for accidents, resulting in R806 falling and fracturing both legs, R804 sucking on a bleach sheet, and R807 exiting an alarmed door and going down a flight of stairs. Findings include: A complaint received by the State Agency alleged a resident sustained an avoidable fall. R806 On 5/14/25 at 12:45 PM, a review of a facility provided document titled, FACILITY PAST NON-COMPLIANCE/QAPI (Quality Assurance and Performance Improvement) PLAN was conducted and read, .The plan of care was not implemented while preparing the resident (R806) for transfer to shower chair. The CENA (Certified Nurse Aide 'G') was preparing the resident to be transferred into shower chair and waiting on the second person to assist with the transfer, the CENA sat the resident up on the side of the bed with a 2WW (two wheeled walker) in place. As the CNA (Certified Nurse Aide) was awaiting the second person to assist with the transfer the resident's roommate asked the CENA a question. The CENA turned her back to speak with the resident and during this time resident slid to floor . On 5/14/25 at 12:55 PM, a review of R806's progress notes was conducted and revealed the following: A late entry progress note for 3/7/25 at 1:30 PM, entered into the record by Assistant Director of Nursing 'C' that read, Resident slid out of bed onto the floor, fell on the right side .Resident unable to say what happened .Therapy called to bedside to help with transfer, noticed right leg a little more swollen than usually .EMS (Emergency Medical Services) called, sent out to hospital for further evaluation . A progress note dated 3/8/25 at 12:50 AM, entered into the record by Nurse 'D' that read, .resident returned to facility with dx (diagnoses) of right tibial <sic> (shin bone) fracture . A progress note dated 3/10/25 at 7:05 PM, entered into the record by Dr. 'E' that read, .Note Text: chief complaint: fall .called this weekend for fall- sent to ER (Emergency Room) and returned din <sic> splint for fx (fracture) R LE (Right Lower Extremity). increased <sic> pain in left leg and we ordered an xray <sic> at the facility showing a periprosthetic (around a prosthetic joint or implant) femur fx. son <sic> at bedsid, <sic> made son aware of findings and plan to transfer to hospital immediately . A progress note dated 3/17/25 at 4:52 PM, entered into the record by Nurse 'F' that read, .Resident has Broken LT (left) femur, RT (right) tibia/fibula . On 5/14/25 at 2:07 PM, an interview was conducted with CNA 'G' regarding R806's fall. They explained they assisted R806 to sit at the side of the bed waiting for a second CNA to assist with a transfer to the shower chair. At that time R806's roommate asked them a question from the other side of the privacy curtain. They said they took their eyes off R806, opened the curtain to acknowledge the roommate and R806 fell forward off the side of the bed. They said R806 did not complain of any pain after the fall but they could tell something was wrong with their right leg. On 5/14/25 at approximately 2:30 PM an interview was conducted with the facility's Director of Nursing (DON). They acknowledged the deficient practice that resulted in R806's femur and tibia fractures. A review of a complaint submitted to the State Agency revealed an allegation that the facility was not providing adequate supervision for residents on one-to-one (1:1) supervision and utilized unqualified staff to supervise them. On 5/14/25 at 11:20 AM, R804 was observed lying in bed, half sitting up. His pants were down to his knees and his incontinence brief was exposed. Certified Nursing Assistant (CNA) 'B' was observed getting their own food from a lunch cooler. When queried about R804, CNA 'B' reported they were assigned to be R804's sitter because he required 1:1 supervision. When queried about why R804 required that level of supervision, CNA 'B reported the resident was a fall risk, wandered into other residents' rooms, and was at risk of eating non-food items, such as foam. R804's dresser was observed with the drawers facing the wall. R804's roommate (R807) was not observed in the room at that time. On 5/14/25 at 1:36 PM, R804 was observed eating lunch with CNA 'B's assistance. CNA 'B' reported both R804 and R807 were assigned to her for 1:1 supervision. When queried about how she provided 1:1 supervision for two residents at once, CNA 'B' reported they could usually redirect R807 by verbally telling him to come back into the room. A review of R804's clinical record revealed R804 was admitted into the facility on 1/29/25 with diagnoses that included: dementia, severe; adjustment disorder, insomnia, and anxiety disorder. A review of MDS assessments dated 2/5/25 and 5/5/25 revealed R804 had severely impaired cognition, physical, wandering, and other behaviors, and was dependent on staff for assistance with all activities of daily living, except walking, which he was able to do with supervision. A review of R804's progress notes revealed the following: On 2/7/25, it was documented in a Behavior Note that R804 was ambulating in other resident rooms, ambulating within his room, pulling the dresser drawers of his and his roommate out and placing them on the floor, consuming his roommate personal snacks, utilizing his roommate personal hygiene supply . It was documented R804 was unable to be redirected. On 2/12/25, it was documented in a Nurses Note that R804 wandered into another resident's room and the facility placed a mesh stop sign to discourage R804 from entering. On 2/13/25, it was documented in a Nurses Note that R804 was going in and out of multiple residents' rooms and was observed standing over another resident's bed. That same day, it was alleged R804 hit that same resident. It was noted R804 was placed on one on one (1:1 supervision - one staff person to supervised one resident). On 2/22/25, it was documented in a Nurses Note that R804 was found by his sitter (1:1) sucking on bleach sheet. Poison control was contacted by the nurse and they instructed the facility to administer water to the resident and monitor him. On 5/14/25 at 10:15 AM, all incident reports and investigations conducted by the facility for R804 since February 2025 were requested from the Director of Nursing (DON). A review of an incident report dated 2/22/25 revealed no additional information than what was documented in the progress note mentioned above. No investigation was provided by the facility. A review of R804's care plans revealed an active care plan initiated on 2/13/25 that noted, (R804) currently 1:1, until further evaluation . Further review of R804's care plans revealed R804 was incontinent of bladder and bowel, had severely impaired cognition, a language barrier, difficulty communicating and following simple direction, wandered into other residents' rooms, and was a fall risk. A review of the nursing staff assignment sheets revealed on 2/22/25 CNA 'A' was assigned to provide one on one to R804. A review of the nursing staff assignment sheets for May 2025 revealed from 5/1/25 through 5/13/25, had one staff member assigned each shift for 1:1 assigned to both R804 and R807, who shared a room. During the above observations of R804, R807 was not observed in the room. At 1:36 PM, CNA 'B' reported R807 was either in therapy or in the dining room. At approximately 1:40 PM, R807 was observed in the therapy room and at approximately 2:30 PM, R807 was observed with family in the dining room. A review of R807's clinical record revealed R807 was admitted into the facility on 4/18/25 with diagnoses that included: dementia. A review of R807's MDS assessment dated [DATE] revealed R807 had severely impaired cognition, physical and other behaviors, wandering behaviors, and was independent with bed mobility, required supervision for transfers, and was able to walk up to 50 feet with supervision. A review of a MDS assessment dated [DATE] revealed R807 required partial/moderate assistance from staff to walk up to 50 feet. Both assessment noted R807 used a wheelchair. A review of a Nurses Note documented on 3/27/25, revealed, Writer noticed the alarm was going off on (unit) exit door, at that time writer went downstairs to observe if resident was down the stairs, resident located at bottom of staircase, resident was assisted back to his room and designated sitter was to remain doing 1:1 . Further review of R807's progress notes revealed the following: On 1/28/25, it was documented in a Behavior Note that R807 attempted to elope out of the (unit) door. On 2/15/25, it was documented in a Nurses Note that R807 won't stay in his room .also tried pushing through the fire exit doors and saying that he was looking for his keys and car . On 2/16/25, it was documented in a Nurses Note that R807 tried multiple times to exit room to get his car and leave the facility . On 2/18/25, it was documented in a Nurses Note that R807 got out of his room and began to wander . On 3/13/25, it was documented R807 had a fall in his room. On 3/20/25, it was documented R807 had unsteady gait when walking to the bathroom. A review of R807's care plans revealed R807 had a hearing impairment, cognitive impairment, vision impairment, was at risk for elopement and/or wandering (initiated on 6/6/24), and was at risk for falls. On 5/14/25 at 1:46 PM, the nursing assignment sheets for 3/27/25 were requested from the DON. On 5/14/25 at 1:52 PM, all incident reports with associated investigations for R807 for the past three months were requested from the DON. No incident report regarding the incident where R807 was found to exit through the door on the unit and go down a flight of stairs was provided. On 5/14/25 at 3:15 PM, an interview was conducted with the DON. When queried about the assignment sheets that indicate one staff member assigned 1:1 to both R804 and R807, the DON reported R807 was not actually on 1:1 and we call them resident companions, not 1:1. When queried about whether it was possible to provided supervision to both residents at one time, if they required more consistent supervision and redirection, the DON reported R807 was able to be redirected verbally. When queried about what was done to look into how R807 made it out an alarmed door on the unit and down a flight on stairs on 3/27/25, the DON reported it was not investigated because it was not an elopement. The DON reported R807 did not require 1:1 supervision on that date and it was implemented as needed. When queried about how the root cause was determined to ensure effective interventions were implemented after the incident on 3/27/25, since R807 had a history of exit seeking, the DON did not offer a response. When queried about R804 and how he managed to suck on a bleach sheet on 2/22/25 when he was assigned a staff member for 1:1 supervision, the DON reported she did not now how he got a hold of it. The DON reported it was investigated. When queried about why the investigation was not provided with the incident report, the DON said she must have missed it and said it would be provided. On 5/14/25 at approximately 3:25 PM, an interview was conducted with CNA 'A'. When queried about the protocols when assigned to R804 and R807's room for 1:1, CNA 'A' reported the 1:1 supervision was for both residents. When queried about how that worked if both residents required supervision, CNA 'A' reported it was very difficult. CNA 'A' explained R807 had dementia and wandered out of the room often looking for his car, house, and children. He required assistance to make sure he did not wander out of the room. He also required assistance with eating at times and going to the bathroom. CNA 'A' further explained R804 required total supervision and care assistance. CNA 'A' reported the aides had to do all the care for him, he frequently gets into things, pulls out the drawers. CNA 'A' stated, It is very challenging to watch both of them. One could be walking out of the room and the other one is trying to stand up. We just learn how to do it, but it's hard. When queried about how R804 got a hold of the bleach sheet on 2/22/25, CNA 'A' explained the bleach sheet was a wipe used to disinfect surfaces. CNA 'A' further explained that the nurse stepped out of the room, CNA 'A' was talking with R807 and by the time she got back over to R804, he had a bleach wipe in his mouth. CNA 'A reported there was another CNA in the room at the time but must not have been paying attention. CNA 'A' did not notice the bleach wipes in the room and thought they were in the drawer and was not sure if it was a new one or one that was sitting on the dresser, but smelled the strong bleach smell and removed it from the resident and notified the nurse. When queried about whether anyone interviewed her about what happened with R804 on 2/22/25, CNA 'A' reported nobody talked to her about it, she just notified the nurse. On 5/14/25 at 3:48 PM, the DON confirmed she did not have an investigation for the incident with the bleach wipes on 2/22/25 for R804. No additional information was provided prior to the end of the survey.

This citation pertains to intake #' MI00149666, MI00149701, MI00149703 and MI00149863. Based on observation, interviews and record review, the facility failed to protect the resident's right to be free from physical abuse and neglect by facility staff for two residents (R901 and R902) of five residents reviewed for abuse/neglect/mistreatment resulting in R901 being forcefully slapped in the face by a staff member and R902's lower extremities being wheeled into a medication cart and a metal doorframe. Findings include: R901 On 2/12/25 a facility reported incident (FRI) that was submitted to the State Agency was reviewed which indicated R901 was slapped in the face by Certified Nursing Assistant A (CNA A) on the morning of 1/18/25. On 2/12/25 at approximately 8:56 a.m., R901 was observed in their room, laying in their bed. R901 was observed to have a low bed with their wheelchair against the wall. R901 was observed to be confused and unable to follow specific conversation pertaining to the allegation. On 2/12/25 the medical record for R901 was reviewed and revealed the following: R901 was initially admitted to the facility on [DATE] and had diagnoses including Adjustment disorder, Anxiety and Dementia. A review of R901's MDS (minimum data set) with an ARD (assessment reference date) of 1/15/25 revealed R901 needed assistance from facility staff with most of their activities of daily living. R901's BIMS score (brief interview of mental status) was four indicating severely impaired cognition. On 2/12/25 at approximately 9:59 a.m., during a conversation with the facility Administrator (Abuse Coordinator), the Administrator was queried regarding the abuse allegation between R901 and CNA A. The Administrator reported that the CNAA was terminated after the incident had been reviewed from a video recording and that the allegation was substantiated. The Administrator indicated that in the video recording of the incident, CNA A was observed slapping R901's face while Nurse B was having their hair pulled. At that time, the facility investigation was requested along with the recorded video for review. On 2/12/25 at approximately 11:19 a.m., The recorded video of the incident between R901 and CNA A was reviewed and it showed CNA A and Nurse B were in an altercation with R901 in which they were trying to wheel R901 in their wheelchair down the hallway but R901 was resistive. Nurse B was observed to try and maneuver R901's legs in the wheelchair in which R901 was then observed to pull their hair. At approximately the 05:30 time mark in the video, CNA A was observed forcefully slapping R901 with open hand using an extended arm and a voice reviewing the video stating D**. On 2/12/25 a review of the facility investigation pertaining to CNA A hitting R901 on 1/18/25 was reviewed and revealed the following: This writer was alerted by Maintenance Director that the Nurse [Nurse B] asked to review footage in regards to the resident pulling her hair off. Upon review of camera footage it as noted that the CNA [CNA A] placed hand on residents face. Maintenance Director alerted writer immediately after review at 9:50 AM., Writer notified Administrator immediately. Writer reviewed assignment sheets dated for Friday 17, 2025 for midnight shift CNA [CNA A] was assigned to [R901]. Writer immediately called [CNA A] to alert her that she was suspended immediately pending investigation .[Local Police Department] notified .At this time the facility is able to validate alleged concern due to CNA (CNA A) stating that she did make contact with resident On 2/12/25 at approximately 11:54 a.m., Maintenance Director E (MD E) was queried regarding the incident between R901 and CNA A on 1/18/25. MD E reported they were made aware of the incident by Nurse B on 1/21/25 and that Nurse B had asked them if they had seen the video and the Maintenance Director E indicated they had not. MDE then reviewed the video, and reported they saw CNA A hit R901. At that time, they reported the allegation the facility management. On 2/12/25 at approximately 1:12 p.m., Detective I (DI) was queried regarding their investigation of the incident and they reported that the police department had issued a warrant for CNA A's arrest and that the department will be pressing charges for assault and battery and the process was currently with the court. DI indicated that in their observation of the incident on the recorded video, CNA A slapped R901 in the face even though they were not the staff member being threatened by R901's behavior. On 2/12/25 a facility document titled Separation of Employment Form with an effective date of separation of 1/21/25 was reviewed and documented that CNA A was terminated from employment at the facility for resident abuse and that it was signed by the facility Administrator on 1/28/25. 30675 R902 On 2/12/25 at 9:13 AM, Nurse 'D' was observed pushing a resident (R902) who was seated in a wheelchair towards the medication cart across from room [ROOM NUMBER]. R902's wheelchair was observed to hit into the medication cart. Nurse 'D' was not observed to say anything to the resident and proceeded to access the cart. Nurse 'D' then proceeded to quickly turn the resident's wheelchair to the right, to turn around in the hallway. While being turned around, R902's bilateral bare feet were observed to hit into the metal doorframe of room [ROOM NUMBER]. The resident flinched and Nurse 'D' did not appear to identify what had occurred. Nurse 'D' proceeded to push R902 in their wheelchair in a forward motion, letting go of the wheelchair and returned to the medication cart. R902 continued to propel forward for several feet while Nurse 'D' was at the cart. At 9:15 AM, Nurse 'D' was then observed to push R902 in their wheelchair towards the nursing station and making an overhead page to ask for staffing to call them back. This occurred several times. Nurse 'D' then attempted to make another call and was heard stating they needed someone to sit with [Room number of R902] as he was going in other doors. Nurse 'D' was asked to identify the resident's name and they reported they didn't know, only knew his room number (Nurse 'D' was R902's assigned nurse). Throughout the discussion with Nurse 'D', Nurse Practitioner (NP 'H') was observed a few feet away at a counter next to the nursing station and offered if they could help. Nurse 'D' was asked to speak with them to further discuss what had just been observed in the hallway and they reported, I'm a little busy, can we talk later. They were informed that would not be possible and would like to discuss the concerns immediately and was asked to have another staff come stay with the resident before they proceeded with anything else. Nurse 'D' was then observed to make another phone call to the Human Resource (HR) Manager and stated, She said she's from the State, wants to talk, and doesn't understand that I'm busy. Nurse 'D' was asked to have the Director of Nursing (DON) come to the area and Nurse 'D' reported, She's not here. When asked to have the Administrator come up, Nurse 'D' reported She's not here. At that point, Nurse 'D' was asked to have the HR Manager come up and they proceeded to call and request they come up to the area. At that time, NP 'H' reported they would stay with R902. Nurse 'D' was then observed to walk off the unit and towards the east side of the hallway, towards the elevator and when asked where they were going, Nurse 'D' reported You're really, like . and did not finish speaking. They were asked to accompany to the HR office. At 9:19 AM, the HR Manager was informed of the specific observations of Nurse 'D' with R902 and the HR Manager directed Nurse 'D' to punch out and go home. Review of the clinical record revealed R902 was admitted into the facility on [DATE] with diagnoses that included: unspecified dementia, severe, with agitation, adjustment disorder with mixed anxiety and depressed mood, and dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, and generalized anxiety disorder. According to the Minimum Data Set (MDS) assessment dated [DATE], R902 had severely impaired cognitive skills for daily decision making, had long and short term memory problems, had physical and other behavioral symptoms directed towards others which occurred one to three days, which significantly interfered with the resident's participation in activities or social interactions, and had wandering behaviors which occurred one to three days. Review of the progress notes identified concerns with R902 wandering throughout the facility and other resident rooms. An entry on 2/12/25 at 10:47 AM by NP 'H' documented in part, .demented male seen today for wondering <sic> . Patient was found in neighbors <sic> room. Patient is alert and oriented x 0 .Patient is easily redirectable, but spontaneous. Patient is able to get up out of bed or chair easily and walk around independently. Patient appears in no acute physical or mental distress. Discussed with staff and social work importance of patient being monitored while awake. Patient has wander guard on. Will continue to monitor .ASSESSMENTS AND PLANS .UNSPECIFIED DEMENTIA, SEVERE, WITH AGITATION: Unstable. A&O x 0 at baseline. Easily redirectable but spontaneous, patient needs 1:1 monitoring . There was no identification of any follow-up based on the observations that were reported to the HR Manager earlier. Further review of the clinical record revealed there was no social service assessment completed yet for review. On 2/12/25 at 11:10 AM, the Administrator (also the facility's Abuse Coordinator) requested to meet with this surveyor to review the incident from earlier. They were provided with the same events as documented above and the Administrator further reported Nurse 'D' had been suspended and they were working on reporting to the State Agency. On 2/12/25 a facility document titled Abuse Prohibition Policy was reviewed and revealed the following: Each guest/resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Abuse shall include freedom from verbal, mental, sexual, physical abuse, corporal punishment, involuntary seclusion and any physical or chemical restraint imposed for purposes of discipline or convenience that are not required to treat the guests/resident's medical symptoms Physical Abuse includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment Neglect is the failure of the facility, its employees or service providers to provide goods and services to a guest/resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect occurs when the facility is aware, or should have been aware of, goods or services that a guest/ resident(s) requires but the facility fails to provide them to the resulting in physical harm, pain, mental anguish or emotional distress. Alleged violations of neglect include cases where the facility demonstrates indifference or disregard for guest/resident care comfort or safety, resulting in physical harm, pain, mental anguish or emotional distress .

This citation pertains to Intake Number(s): MI00147948. Based on interview and record review, the facility failed to accurately assess, timely treat, and identify the worsening of a diabetic ulcer for one (R801) of two residents reviewed for wounds, resulting in a hospital transfer facilitated by an outside provider which resulted in an amputation of R801's left great toe. Findings include: A review of a complaint submitted to the State Agency (SA) revealed an allegation R801 was not assessed for a change in condition. On 11/18/24, an unannounced, onsite investigation was conducted. A review of R801's clinical record revealed R801 was admitted into the facility on [DATE], had readmissions on 6/21/24 and 9/5/24, and discharged on [DATE] with diagnoses that included: acute osteomyelitis (bone infection) right ankle and foot, acquired absence of right toes, peripheral vascular disease, and type 2 diabetes mellitus. A review of a Minimum Data Set (MDS) assessment revealed R801 had moderately impaired cognition, was dependent on staff for activities of daily living and transfers, required substantial/maximum assistance from staff for bed mobility, and had diabetic ulcers. A review of R801's progress notes revealed on 5/22/24, R801 was diagnosed with osteomyelitis in the right foot. They were admitted into the hospital on 5/29/24 and required amputation of the third toe on their right foot and were readmitted to the facility on [DATE]. A review of a Nursing Comprehensive Evaluation dated 6/22/24 revealed R801 was readmitted with, amputation of the 3rd right toe. No other skin impairments were documented on the evaluation. A review of a Total Body Skin Assessment progress note dated 6/22/24 revealed R801 refused to allow the nurse to complete a full body skin assessment at that time. A review of a Total Body Skin Assessment form dated 6/22/24 revealed R801 had one new wound (which was likely the site of the toe amputation on the right foot). A review of R801's Total Body Skin Assessment forms revealed the next assessment was dated 9/5/24, approximately two and a half months after R801 was readmitted into the facility from the hospital. A review of R801's progress notes revealed the following documentation: On 8/23/24, a Dietary Note documented R801 had a [NAME] grade 1 diabetic ulcer (superficial ulcer on the outer layer of the skin) to the left great toe. At that time it was recommended to add active liquid protein to support wound healing. It should be noted that there were no progress notes prior to the dietary note that mentioned a wound to R801's left great toe. A review of a Skin & Wound Evaluation for R801 dated 8/5/24 (the assessment was not locked until 9/5/24) revealed R801 was assessed to have a diabetic ulcer to the Left Dorsum - 1st Digit (Hallux) (top of the great toe) that was present on admission. The measurements of the ulcer were 1.5 centimeters (cm) by 0.7 cm. It was documented the wound bed was bleeding and pink or red in color with light sanguineous (bloody) exudate (drainage). It was documented the ulcer was healable and stable. The photo included as part of the assessment did not show an ulcer to the dorsum of the left great toe, but a bloody area to the tip of the left great toe and an open area on the second digit. A review of a consultation report written by the facility's contracted wound Physician Assistant (PA 'B') on 8/5/24 revealed R801 had a [NAME] Grade 1 Diabetic Ulcer to the left great toe that measured 0.6 cm by 0.9 cm with no drainage and a wound bed with one hundred percent eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like). The treatment plan documented, .Cleanse wound with Normal Saline (NS) .Betadine wipe to all scabs on R (right) and L (left) feet (protectively) . A review of R801's physician's orders revealed no treatment orders to address the left great toe until 8/26/24 at which time, the ordered treatment was Cleanse left foot (first, second digit) with NS, pat dry, apply Betadine moistened gauze to wound bed, and cover with ABD (abdominal pad), and kerlix (bulky dressing) QD (every day) and PRN (as needed) .for diabetic ulcer . Further review of R801's physician's orders revealed the active liquid protein recommended per the dietary note written on 8/12/24 was not ordered until 9/9/24. Further review of R801's Skin & Wound Evaluations and consultations completed by PA 'B' revealed the following: On 8/12/24, it was documented on a Skin & Wound Evaluation R801 had a diabetic ulcer to the left dorsum great toe that measured 2.8 cm x 2.0 cm with a wound bed covered with 60% slough (non-viable yellow, tan, gray, green or brown tissue). In the section that assessed if there was evidence of infection, Warmth was documented. It was noted there was a moderate amount of serosanguineous (serum mixed with blood) drainage. It was documented the wound was slow to heal and the progress was stalled. The attached photograph revealed a black area on the tip of R801's great toe and an open area to the top of R801's great toe that was pink with an area of yellow. On 8/12/24, it was documented by PA 'B' R801's left great toe diabetic ulcer increased in size to 4 cm x 3 cm and was 100% eschar with no slough. That was not consistent with the facility assessment and photograph from the same date. The treatment recommendation remained the same as 8/5/24. It should be noted that there was no treatment ordered for that wound as of 8/12/24. On 8/19/24, a Skin & Wound Evaluation of R801's Left dorsum great toe diabetic ulcer did not include any measurements and noted the wound was slow to heal and stable. The attached photograph revealed a blurry, far away photograph that showed a large dark area at the tip of the toe, but was not clear. On 8/19/24, it was documented by PA 'B' that R801's left great toe diabetic ulcer measured the exact same as the week prior at 4 cm x 3 cm with 100 % eschar. The treatment recommendation remained the same as 8/5/24. It was noted as of 8/19/24, there were no treatment orders for the left great toe. On 8/26/24, a Skin & Wound Evaluation of R801's Left dorsum great toe diabetic ulcer noted measurements of 3.8 cm x 2.5 cm with 100% eschar in the wound bed. It was documented the wound was healable and improving. The attached photograph revealed a black area on the tip of the left great toe and multiple black areas on the top of the toe. On 8/26/24, it was documented by PA 'B' that the diabetic ulcer to R801's great toe measured the exact same as on 8/19/24 (4 cm x 3 cm) with 100% eschar. It was unspecified if the area evaluated was the tip of the toe or the top of the toe. The treatment included additional instructions to wrap the toes individually with Betadine gauze to help dry off the toes. It was also recommended for R801 to have a vascular consult for severe PVD (peripheral vascular disease). A review of a Nurses Note dated 8/27/24 revealed R801's family member requested R801 was transferred to the hospital due to the, healing progress of bilateral feet. R801 was sent to the hospital on that date. A review of a Skin/Wound Progress Note dated 8/30/24 documented the wound to R801's left great toe was acquired on 6/21/24 and remained 4 cm x 3 cm with 100 % eschar. However, R801 was at the hospital on that date (8/30/24). A review of the hospital records from R801's 8/27/24 through 9/5/24 hospital stay revealed the following: Results from an X-ray to R801's left foot revealed the following, .Clinical date: Pain, gangrene .Possible erosions of the [NAME] (tips) of the first and second distal phalanges (bones of the toes). Osteomyelitis is not excluded. MRI could be considered to further evaluate . An Infectious Disease Consultation dated 8/28/24 read, .He has 2 open wounds with minimal drainage affecting the dorsal aspect of the left great toe and left 2nd toe .Ulcers involving left great toe and left 2nd toe with probable ischemic component. Ulcers have progressed in the last few months .Cellulitis of the left foot . A Cardiovascular Medicine and Vascular Medicine Consultation dated 8/28/24 revealed, .Sores on left 1st and 2nd toes, necrotic appearing distal (end) 1st toe . A Cardiovascular Medicine and Vascular Medicine Consultation dated 9/3/24 revealed results from an angiogram that showed 99% occluded left anterior tibial artery (blocked blood flow to the left lower extremity). R801 was readmitted to the facility on [DATE]. A review of a Nursing Comprehensive Evaluation dated 9/5/24 revealed R801 did not have any skin conditions (indicated by checking 'no' in the section that asked if the resident had any skin conditions). There was no mention of R801's left great toe diabetic wound in the section for potential for skin breakdown care plan. A review of a Physician Note dated 9/6/24 revealed, H&P (History & Physical): re-admit .was sent back to the hospital for Left foot worsening wound .worsening diabetic ulceration . A review of a wound consultation completed by PA 'B' on 10/28/24 noted R801's diabetic ulcer to the left great toe was resolved. A review of the facility's Skin & Wound Evaluations revealed on 10/21/24, a week prior to the wound being resolved, the wound measured 5.6 cm x 4.6 cm with fragile surrounding skin. The assessment did not include an assessment of the wound bed tissue. The photograph taken as part of the assessment revealed black areas on the top of the left great toe and at the tip. The skin above the ulcer appeared black/brown, thick, dry and cracked. There was no wound consult by PA 'B' on 10/21/24 included in the medical record. Further review of R801's physician's orders revealed the treatment to the left great toe was discontinued on 10/28/24. Continued review of R801's progress notes revealed on 11/5/24 R801 was transferred to (hospital) 11/02/24 from podiatrist appointment . Review of R801's hospital records dated 11/5/24 revealed the following: It was documented in an ED (emergency department) Notes dated 11/5/24 that .concern of worsening ulcer in left great toe .evaluated by his podiatrist who sent him to ED for admission and left great toe amputation tomorrow. Patient said he has been feeling feverish .gangrene of left great toe .concerning for underlying osteomyelitis . A consultation by the podiatrist on 11/6/24 revealed, .presents with a diabetic foot infection and worsening foot wounds bilaterally. He was noted to have a significant infection yesterday during his outpatient podiatry evaluation and reported fevers, chills, pain, and general malaise. He also reports that the facility where he has been staying was not taking care of him or performing dressing changes or wound exams as advised. He is requiring a left great toe amputation for source control .Necrotic and gangrenous tissue appreciated to the left hallux to the level of IPJ (interphalangeal joint) and slightly proximal to this. Malodor and drainage noted .Positive probe to bone with concern for underlying osteomyelitis .OR (operating room) today for left hallux amputation . On 11/18/24 at approximately 1:35 PM, an interview was conducted with the facility's Wound Care Coordinator, Licensed Practical Nurse (LPN) 'A'. LPN 'A' reported her job responsibilities included updating care plans, ensuring physician's orders were transcribed appropriately, ensuring treatments were changed per physician's orders, assuring preventative measured were in place, and conducting assessments along with the facility's contracted wound provider, PA 'B' who came to the facility on e time per week. LPN 'A' explained PA 'B' was responsible for diagnosing residents' wounds and determining treatments. LPN 'A' entered assessments of residents' wounds into the Skin & Wound Evaluation in the clinical record by taking a photograph of the wound which calculated the measurements. LPN 'A' reported her assessment was based off of the wound providers and she transcribed it into the record. LPN 'A reported she started working as the Wound Care Coordinator in August 2024. When queried about when R801's diabetic wound to the left great toe was first identified, LPN 'A' reported it was first assessed on 8/5/24. LPN 'A' acknowledged that PA 'B' documented it was acquired on 6/21/24, but did not know when it was first identified prior to her working in that position. LPN 'A' reported the wound was resolved by PA 'B' on 10/28/24 and treatment was discontinued. LPN 'A' did not know why there was no photograph of the wound from 10/28/24. LPN 'A' reported her assessment of R801's left great toe wound was based off of the photograph and PA 'B's evaluation, including the documentation that the wound was healable. LPN 'A' did not offer a response as to why the treatment to R801's left great toe was not ordered until 8/26/24, On 11/18/24 at 1:50 PM, an interview was conducted with PA 'B'. PA 'B' reported R801 had severe PVD and previous history of other amputations and therefore an amputation of R801's left great toe was unavoidable. When queried about the documentation that the wound was resolved on 10/28/24, PA 'B' reported she resolved it because, there was nothing open to the eye and there was some eschar and no drainage. When queried about the delay in treatment to R801's left great toe between 8/5/24 and 8/28/24, PA 'B' reported it would not have made any difference if it was treated sooner. On 11/18/24 at 2:53 PM, an interview was conducted with the Director of Nursing (DON) and LPN 'A'. The DON reported prior to August 2024, the previous Wound Care Coordinator was not doing what she was supposed to be doing and was terminated. When queried about the delay in treatment to R801's left great toe diabetic wound, the DON reported R801 had multiple areas that were all treated at once. A review of a physician's order the DON provided for reference was specific to the left heel. When queried about PA 'B's documentation that did not correspond with the photographs and documented R801's wound to the great left toe was acquired on 6/21/24, the DON reported she would look into it. On 11/18/24 at 3:30 PM, the DON followed up and reported that she did not think the wound consults were accurate and the great toe wound was identified on 8/5/24, not 6/21/24. On 11/28/24 at 4:28 PM, the DON reported she had PA 'B' change her assessments to document R801's left great toe diabetic ulcer was acquired on 8/5/24 instead of 6/21/24 because, There's no way it was there on 6/21/24 and we didn't do anything about it. When queried about the lack of Total Body Skin Assessments between 6/22/24 and 9/5/24 and whether they were documented anywhere else, the DON reported she was unable to locate skin assessments for that time frame. When queried about how it was known the wound was acquired on 8/5/24 when there were no weekly skin assessments prior to that, the DON did not offer a response. A review of a facility policy titled, Skin Management revised 8/14/24 revealed, in part, the following, Resident with wounds .are identified, evaluated and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal guest/resident outcomes .

This citation pertains to intake(s): MI00141604 & MI00142153. Based on interviews and record reviews the facility failed to accurately complete Braden assessments, implement preventive/effective interventions for pressure wounds, Implement wound treatments timely or at all, accurately implement Dietician orders to aide in wound healing, and consistently identified worsening of the wounds for two (R's 502 & 504) of two residents reviewed for wounds, resulting in R502 to have developed multiple wounds which included a Stage 4 sacrum pressure ulcer and a Stage 3 right ear pressure ulcer and for R504 to have developed a Stage 4 coccyx pressure ulcer that contributed to their hospitalization , severe sepsis and death. Findings include: R502 Review of a complaint submitted to the State Agency (SA) documented concerns of the facility's failure to prevent the development and worsening of a pressure ulcer for R502. Review of the medical record revealed R502 was admitted to the facility on [DATE] with diagnoses that included: dementia and neurocognitive disorder with lewy bodies. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 3, which indicated severely impaired cognition and required staff assistance for all Activities of Daily Living (ADLs). Review of an admission Nursing Comprehensive Evaluation dated [DATE], documented in part . Skin . Does the resident have any skin conditions- No . Review of an admission Braden Scale For Predicting Pressure Sore Risk dated [DATE], documented a Low Risk and a score of 15. The Mobility section documented the resident to have Slightly Limited ability to change and control body position. Further review of the Braden assessment documented in the Friction & Shear section, the Potential Problem: Moves feebly or requires minimum assistance . Review of an admission Interdisciplinary Therapy Screen dated [DATE] at 12:08 PM, documented in part . Pt (patient) is a New admit . presented with Bilateral Knees contractures which are fixed . Pt attempted to sit at the EOB (edge of the bed), and she was unsuccessful . Pt also was unable to use her hands to self feed herself, has lack of hand to mouth coordination and position in space. Pt is AXOX1 (alert and oriented times one), confused. Pt will be a Hoyer lift with Transfers. Pt also has right Elbow flexion contractures and limited left elbow ROM (range of motion) has limited B (bilateral) shoulder ROM . Review of an admission Interdisciplinary Therapy Screen (Occupational Therapy- OT) dated [DATE], documented in part, . Patient is dependent with self feeding and is unsafe with hot liquids . Patient is dependent with all self care . reported to speech patient unable to feed herself . Patient has dementia . Review of a care plan titled . at risk for impaired skin integrity/pressure injury R/T (related to): decreased mobility, need for assist with adls, incont (incontinence care) . Initiated [DATE], documented the Goal to Minimize risk in an effort to reduce likelihood of pressure injury development . The care plan documented one intervention Braden scale per protocol. Review of the [DATE] Medication Administration Record (MAR) and Treatment Administration Record (TAR), documented the following order: Start date [DATE], . Sacrum. Cleanse sacrum with NS (normal saline), pat dry apply triad paste. One time a day for redness . Review of the medical record contained no documentation of the characteristics of the skin impairment identified on R502's sacrum. Review of a late entry Nursing note dated [DATE] at 8:37 AM, documented in part . Resident has buttock wound not responding to treatment, new treatment order put into place . Review of the [DATE] MAR and TAR documented the following order: Start dated [DATE], . Cleanse left buttock with wound cleanser, pat dry. Apply Plurogel to wound bed and cover with dry dressing. Apply thin layer of Calmoseptine to surrounding tissues every day and prn (as needed) every day shift for wound . Review of the medical record revealed no documentation of a physician, nurse practitioner or clinician to have assessed the sacrum/buttock area from August when the triad paste was initially implemented until October, to ensure the initial treatment was appropriate and effective. Review of a Nursing note dated [DATE] at 4:26 PM, documented in part . while the aide was doing residents care, he brought to writers attention that resident had a wound to her right ear. Writer went into residents room and saw a small open wound to residents right ear. Writer contacted the physician and told him about it and he told writer to cleanse the ear with normal saline, pat dry, apply triple antibiotic . Review of a Nurse Practitioner (NP) note dated [DATE], documented in part . Noted right ear wound, which is bleeding. Appears infected. Pt reports pain at site . New ear wound noted on ,d+[DATE]. Discussed with wound care RN (Registered Nurse). Topical abx (antibiotic) ordered. Start course of Keflex (oral antibiotic) . Further review of the progress notes revealed no documentation of the wound to have been initially identified to the right ear on ,d+[DATE]. Review of a wound consult dated [DATE], documented in part . Wound #1 Sacrococcyx is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurement are 5.8 cm (centimeters) length x 3 cm width, with an area of 17.4 sq (square) cm. There is a small amount of serous drainage noted which has no odor. The wound margin is well defined wound bed has 30% pink, granulation, 70% slough . Wound #2 Right Ear is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 1.5 cm length x 1cm width, with an area of 1.5 sq cm. There is a small amount of serous drainage noted which has no odor. The wound margin is well defined Wound bed has 100% slough . Plan . Cleanse wound with Normal Saline . Apply Medihoney Gel QDay (every day)/PRN (as needed) - Sacrococcyx, R (right) Ear . Cover with secondary dressing . Turn/reposition every 2 hours. Avoid direct pressure to wound site, Facility pressure injury prevention/relief protocol, Low Air Loss Mattress or Low Air Loss Bed, Roho Cushion for wheelchair, Elevate BLE (bilateral lower extremities) above the level of the heart, Soft Heel protector boots . Please note change in treatment - Sacrococcyx . Review of the October and [DATE] Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed the wound orders for the Sacrococcyx and right ear as documented by the wound practitioner was not implemented until [DATE], a week after the wound physician consult. Review of the medical record revealed no documentation of the Dietician to have been notified of the wounds in October or November. Review of a Dietician Late entry note created [DATE] at 12:52 PM, documented in part . Resident w (with)/unstageable PU (pressure ulcer) to Sacral region/Coccyx per wound care notes . Goal is to support wound healing and increase calorie protein intake. Will provide ACTIVE LIQUID PROTEIN 30 ml (milliters) QID (four times a day) to speed wound healing . This was documented by Registered Dietician (RD) A. Review of the physician orders and MARs/TARs revealed the Active Liquid Protein was implemented once a day instead of four times a day by RD A. Review of a wound consultation dated [DATE], documented in part . Cleanse wound with Normal Saline . Apply Dakins moist gauze (,d+[DATE] strength) QDay (everyday)/PRN (as needed) x 7 days - Sacrococcyx, Apply Triad Paste QDay/ PRN - R (right) Ear . Apply Foam Dressing QWeek (every week)/PRN to R Forearm . Cover with secondary dressing(s) . Please note change in treatment - Sacrococcyx . Review of the [DATE] MAR and TAR revealed the wound physician orders were not implemented until [DATE], three days later. This treatment was never applied to the resident due to R502 to have been transferred to the hospital on [DATE] for a change in condition. Review of the hospital records documented the following in part . Wound Ostomy Evaluation And Treatment Note . Braden Score: 10 . Sacrum . Staging . 4 . Wound Length (cm- centimeters) 11 cm, Wound Width (cm) 10 cm, Wound Surface Area (cm2- centimeters squared), Wound Depth (cm) 1 cm . left hip and left heel DTI's (Deep Tissue Injuries) . left shoulder, right shoulder, right ear, left ear . wounds . The mid sacral wound is malodorous and fluctuant inside of the wound . This indicated additional wounds were identified by the hospital staff as well as worsening of the sacral wound. On [DATE] at 11:33 AM, the Director of Nursing (DON) was interviewed and asked about the inaccurate Braden score, the lack of preventative interventions implemented to prevent a pressure ulcer, the delayed implementation of the ordered wound treatments and the delay in the collaboration with the Dietician for R502's wounds. The DON explained they were not the DON at the time of R502's inpatient care at the facility, however, would look into it and follow back up. On [DATE] at 12:19 PM, RD A was interviewed and asked when they were first notified of R502's wounds and RD A explained there was a lot of miscommunications with the previous nursing staff, and they could not remember the exact date. When asked about the Active Liquid Protein order and if it was meant for once a day or supposed to be four times a day, RD A stated it was supposed to be four times a day and at the time they were newly employed with the facility, and they couldn't discontinue the order to implement the correct order, so they asked the nursing staff to fix the order. When asked RD A could not remember the name of the nursing staff they asked to fix the order. RD A stated they did not realize that the order was never fixed to reflect the four times a day administration. On [DATE] at 1:26 PM, the DON returned and stated they could not provide any further explanation or documentation to address any of the identified concerns. R504 Review of a complaint submitted to the State Agency (SA) documented concerns of the facility's failure to prevent the development and worsening of a pressure ulcer. Review of the medical record revealed R504 was initially admitted to the facility on [DATE] with diagnoses that included: dementia, muscle wasting and atrophy and intervertebral disc degeneration in the lumbar region and required staff assistance with all ADLs. Review of an admission Nursing Comprehensive Evaluation dated [DATE] at 3:02 PM, documented in part . Does the resident have any skin conditions- Yes . Site . Coccyx . Groin . Left buttock . The Description section for the skin impairments was left blank. Further review of the evaluation contained no documentation of the characteristics of the wounds identified. Review of the medical record revealed no characteristics documented of the wounds identified on admission. Review of the [DATE] MAR and TAR revealed no treatment implemented for either of the skin impairments identified. Review of the admission Braden scale for Predicting Pressure Sore Risk dated [DATE], documented a score of 16 Low Risk. Review of a care plan titled . at risk for impaired skin integrity/pressure injury implemented on [DATE], documented no interventions to prevent the development of pressure ulcers. On [DATE] the facility initiated interventions for this care plan. Review of the [DATE] MAR and TAR documented the following orders: [DATE] (start date) cleanse buttock, coccyx, groin, perineal and apply barrier cream every shift for wound care. [DATE] (start date) cleanse coccyx with normal saline and apply adherent foam dressing every shift. This order stopped on [DATE] and was changed to every day shift instead of every shift. Review of a Nursing note dated [DATE] at 12:49 PM, documented in part . Coccyx redden with a small open area, excoriation groin, buttock and peroneal <sic> area . Further review of the [DATE] MAR and TAR documented the following order: [DATE] (start date) Calmoseptine External Ointment 0XXX,d+[DATE].6% (Menthol-Zinc Oxide) Apply to coccyx, buttocks topically one time a day for Moisture associated excoriation for 21 Days. This order was implemented two days after the identification of the skin impairment to the coccyx and buttocks. Review of a Physician Note dated [DATE] at 3:30 AM, documented in part . Late Entry . PATIENT SEEN AND EXAMINED . C/O (COMPLAINTS OF) LOWER BACK PAIN/TAIL BONE PAIN . PATIENT HAS A ST (STAGE) 2 PRESSURE DECUB ON THE COCCYX. EXPLAINED TO THE STAFF TO TURN THE PATIENT ON HER SIDE EVERY 2 HRS (HOURS) . CLEAN AREA WITH NS (NORMAL SALINE), APPLY TRIAD DAILY AND PRN . Review of the medical record revealed no documentation of the identification of the worsening of the coccyx area prior to the physician consultation on [DATE]. Review of a wound consultation dated [DATE], documented a Stage 3 sacral pressure ulcer. A New order to cleanse wound with NS (normal saline), apply medihoney gel everyday and prn to wound base, apply triad paste every day/prn to periwound and to cover with a secondary dressing was ordered. This order was not implemented until [DATE], four days later. Review of a wound consultation dated [DATE], documented in part . Sacrum, R (right) Parasacral . Wound #1 Sacral is a Stage 3 Pressure injury Pressure Ulcer . 1 cm length x 0.3 cm width x0.2 cm depth Scant amount of sero-sanguineous drainage . 50% slough . Wound #2 Right Parasacral is a Stage 3 Pressure Injury Pressure Ulcer . Initial wound encounter measurements are 4 cm length x 1.5 cm width, with an area of 6 sq (square) cm . small amount of sero-sanguineous drainage . 50% slough . Review of the medical record revealed no documentation of the staff to have identified the Parasacral wound prior to the wound practitioner visit on [DATE] or identify worsening of the sacral wound. Review of a wound consultation dated [DATE], documented in part . Wound #1 Sacral is a chronic Stage 3 Pressure Injury . 3.5 cm length x 3.5 cm width x 0.8 cm depth, with an area of 12.25 sq cm . Tendon is exposed . Undermining has been noted at 6:00 and ends at 3:00 with a maximum distance of 1.5 cm . Moderate amount of sero-sanguineous drainage . Wound bed has 100% slough. The wound is deteriorating . Apply Santyl (a nickel thick layer) + Calcium Alginate QDay/ PRN - to wound base Sacral, Apply Silvadene (thin layer) Qday/ PRN - to periwound Sacral . Cover with secondary dressing(s) . Review of the medical record revealed the above order was never implemented as documented by the wound practitioner. Review of a Nursing note dated [DATE] at 6:51 PM, documented in part . Patient transferred to (hospital initials) for AMS (altered mental status) and unstable VS (vital signs) BP (blood pressure) ,d+[DATE] . Patient was given 2L (liters) of oxygen for labored breathing. Patient has had progressive decrease in appetite and fluid intake over the last 24 hrs (hours) . Review Of the hospital records revealed the following: ED (emergency department) Provider Notes dated [DATE] at 11:33 PM, documented in part . Leukocytosis of 33.9 (elevated white blood cell count) . Severe sepsis . Has chronic wounds which also could be a source. CT (Cat Scan) concerning for stercoral colitis . She is on Vanc/Cefepime/Flagyl (antibiotics) . Wound Ostomy Evaluation And Treatment Note dated [DATE] at 3:49 PM, documented in part . Pressure Injury Coccyx . Sloughing;Moist;Necrotic . Drainage Description Foul purulent . PI (pressure injury) Staging . 4 . Exposed Bone(s) . Length (cm) 4 cm . Width (cm) 5 cm . Depth (cm) 1 cm . Undermining (cm) 3.5 cm . Patient is not oriented and is unable to self protect. There is a stage 4 pressure injury on the coccyx. Wound bed is tan and grey slough with purulent drainage. There is undermining around the clock with deepest depth of 3.5 cm. Wound has foul odor. Culture taken at request of ID (Infectious Disease) . Bone is palpable . Review of the wound culture results revealed abnormal findings, which indicated a wound infection. Review of a Physician Assistant note dated [DATE] at 2:55 AM, documented in part . Pt (patient) declared expired on [DATE] at 2:30 am . Review of a Certificate Of Death for R504 documented in part, . CAUSE OF DEATH . a. Ventricular tachycardia, Approximate Interval Between Onset and Death - minutes, b. Sepsis- days, c. stercoral colitis, skin infection- weeks/months . On [DATE] at 2:34 PM, the DON and Administrator was interviewed and asked about the admission skin assessment and the characteristics of the skin impairments identified, the lack of initial interventions implemented to prevent the development of pressure ulcers, the braden score, and the delayed and/or failure to implement the wound treatments as ordered by the wound practitioner, the DON explained they were not the DON at the time of the residents inpatient care but would look into it and follow back up. The DON returned at 3:47 PM and stated they could not provide additional information or documentation for the concerns asked but explained when they first took over the position as the DON the wound care system was not organized, and they have been in the process since the start of their employment to implement a system.

This citation pertains to Intake Number(s): MI00139564. This citation has two deficient practice statements (DPS). DPS #1 Based on observation, interview, and record review, the facility failed to determine the root cause of falls and implement effective interventions to prevent falls for two (R26 and R90) of four residents reviewed for accidents, resulting in R26 sustaining a closed right hip fracture femur fracture that required Open Reduction Internal Fixation surgery (a surgery used to stabilize and heal a broken bone) which caused subsequent pain and thoughts of being better off if she was dead. Findings include: On 12/13/23 at 12:13 PM, R26 was observed in their room seated in a wheelchair. R26's call light was activated at that time, as indicated by a light that was lit outside their door. When interviewed, R26 reported they wanted to get into bed. R26 stated, I want to do it myself, but I'm too scared. But I am so tired. R26 was unable to say how long ago they activated their call light. At approximately 12:30 PM, R26 was observed seated in a wheelchair in their room. The call light was no longer lit outside of the room. When queried about why they remained in their wheelchair, R26 stated, They said they would come back to put me in the bed. Review of R26's clinical record revealed the following: A Nurses Note dated 8/21/23 that documented, At approx (approximately) 0540 (5:40 AM), cna (Certified Nursing Assistant) reported to writer pt (patient) was on the floor. Writer observed pt sitting on the floor in an upright position with both legs stretched out in front of her sitting by her toilet in the bathroom, with wheelchair in front of her. Pt states 'I was trying to get ready for my appointment'. Pt complains of pain upon ROM (range of motion) on RLE (right lower extremity) .Md (doctor) notified .x-ray ordered . A Nurses Note dated 8/21/23 at 11:21 AM documented, MD order transfer to (hospital name) due to fall resulting in R (right) femoral (thigh) fracture. Review of a Nursing Summary progress note dated 8/26/23 revealed, Patient .admitted to the facility from (hospital) .femur fx (fracture) .Skin assessment completed: Right Leg bruising and two surgical incisions .Patient is currently having pain . Review of a Social Services Note dated 8/28/23 revealed, SW (social work) was notified by therapy that she has thoughts that it would be better off if she were dead. SW meet w/ (with) resident and she states she feels this way 2nd (secondary to) recent condition and pain relating to this . Review of an incident report dated 8/21/23 at 5:40 AM revealed documentation of R26's fall mentioned in the above progress note. The incident report noted R26 had pain at a level five out of 10 with 10 being the worst level of pain. It was documented R26 was oriented to person only. Predisposing factors were identified as impaired memory, gait imbalance, incontinent, and ambulating without assistance. The following was documented, Encourage non-skid footwear. Requires assistance with ADL (activities of daily living) but chooses to do it herself . Review of a Post Fall Evaluation completed on 8/21/23 revealed R26 was trying to get ready for an appointment according to the resident and fell while attempting to self transfer. It was documented R26 was alert and oriented times two and had bare feet at the time of the fall. It was documented R26 was last toileted and/or changed at 5:00 AM and that was the last time R26 was observed. It was documented a CNA assisted R26 back to bed at 5:00 AM after incontinence care. In the section for re-enactment of fall the following was documented, Resident does not ask for assistance. She is alert oriented x 4. Wants to be independent and chooses (not) to ask staff to assist her. The root cause of the fall was noted to be footwear and the initial intervention to prevent future falls was assisted resident to finish dressing. New interventions after interdisciplinary team (IDT) review was encourage non-skid foot wear. The post fall evaluation did not document whether R26 activated their call light or if they had an appointment to get ready for. There was no documentation that indicated R26 refused assistance for non-skid footwear when the CNA took them to the bathroom at 5:00 AM. Further review of R26's clinical record revealed R26 was initially admitted into the facility on [DATE], and most recently readmitted on [DATE] with diagnoses that included: fracture of right femur (8/26/23), Parkinson's Disease, and Alzheimer's Disease. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed R26 had intact cognition, no behaviors including rejection of care, and required the following assistance: R26 required substantial/maximal assistance (Helper does more than half the effort) for lower body dressing, putting on and taking off footwear, sit to stand (The ability to safely come to a standing position from sitting in a chair or on the side of the bed), and chair/bed to chair transfers (The ability to safely come to a standing position from sitting in a chair or on the side of the bed). The MDS indicated R26 required partial/moderate assistance to walk 10 feet and was not assessed to walk more than that due to medical condition or safety concerns. It was noted that R26 did not use a wheelchair. According to the MDS assessment, R26 had one fall with no injury during the assessment period. Review of R26's care plans revealed the following: A care plan initiated on 8/10/22 and revised on 11/28/22 that read, (R26) has an ADL Self Care Performance Deficit and requires assistance with ADL's and mobility r/t (related to): Decreased mobility, multiple co-morbidities, has dx (diagnosis) of Parkinson .and has times when she is weaker. The care plan indicated at that time of R26's fall on 8/21/23 they required two person assist for bed mobility and transfers; and requires assistance with ambulation. An intervention initiated on 7/3/21 documented, Encourage resident to use bell/call light to call for assistance. There were no care plans that indicated R26 refused to request assistance from the staff, was unable or unwilling to use the call light, or had a history of self transferring. Further review of R26's incident reports and Post Fall Evaluations revealed R26 had falls on 8/8/23 and 8/12/23, in addition to the fall on 8/21/23 mentioned above. The following was documented: An incident report completed on 8/8/23 at 9:45 AM documented, (R26) was attempting to self ambulate, to get dressing and changed. Patient was on her buttocks with her back against the nightstand with her wheelchair within reach .does have an abrasion on her back on the right side .Patient stated she was trying to get in her wheelchair, in order to self dress . It was documented R26 was oriented to person and situation (x 2). The predisposing factors identified were Wheelchair/bed brakes unlocked, gait imbalance, incontinent, ambulating without assist. The report documented, Re-educate resident to wait for staff assistance. A Post Fall Evaluation completed on 8/8/23 revealed R26 was trying to self ambulate to get dressed and the wheelchair brakes were unlocked. The fall was unwitnessed and R26 was observed on the floor. It was documented that R26's was alert and oriented times two with some confusion, had bare feet, and was incontinent at the time of the fall. It was documented R26 was last observed at 9:20 AM at which time she was notified that she would be next to be changed. (It should be noted that R26 was found on the ground 25 minutes later). The new intervention documented on the evaluation was Encourage to wait for staff assistance. There was no documentation of what was done to determine when R26 typically liked to be up and dressed or why they had to wait 25 minutes for help. Review of R26's care plans revealed a care plan initiated on 7/3/21 that read, (R26) is at risk for fall r/t: h/o (history of) fell at home has dx: of Parkinson . After R26's fall on 8/8/23, an intervention to Encourage resident to wait for staff for assistance was initiated on 8/9/23 and a previous intervention that was initiated on 7/4/23 was revised but the intervention did not change, only the date (Provide resident with activities that minimize the potential for falls while providing diversion and distraction). It should be noted that at the time of R26's fall on 8/8/23, they were attempting to dress them self and they were incontinent. An incident report completed on 8/12/23 at 4:50 PM revealed R26 was observed sitting on their bottom and reported they were trying to make their bed. The following was documented, Resident is impatient. Wants to be independent but is no longer. Review of a Nurses Note dated 8/14/23, revealed, IDT Post Fall Review: Resident still chooses not to use call light. Continues to think she is independent but she is not. Plan is to encourage resident to ask for staff assistance . Review of R26's falls care plan revealed the following interventions after the 8/12/23 fall: Continue to encourage resident to use call light for assistance (It should be noted that the intervention for the 8/8/23 fall was to encourage resident to wait for staff for assistance). There was no care plan that indicated R26 was impatient or struggled with their lack of independence. On 12/14/23 at 2:29 PM, an interview was conducted with interim Director of Nursing (DON) 'B' (as of 12/7/23) and Regional Nurse 'X'. At that time, R26's incident reports, post fall evaluations, and care planned interventions were reviewed. When queried, DON 'B' and Regional Nurse 'X' reported after each fall, a root cause analysis should be determined in order to implement effective interventions to prevent future falls. At that time, DON 'B' and Regional Nurse 'X' were given the opportunity to provide any additional information regarding R26's falls on 8/8/23, 8/12/23, and 8/21/23. No additional information was provided prior to the end of the survey. Review of a facility policy titled, Fall Management, revised on 9/22/23, revealed, in part, the following: The facility will identify .resident risk factors and implement interventions to minimize falls and risk of injury related to falls .If a fall occurs, the interdisciplinary team conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls . DPS #2 Based on observation, interview, and record review, the facility failed to follow the plan of care for bed mobility for one (R55) of four residents reviewed for accidents, resulting in a nondisplaced fracture of the proximal humerus (upper part of the upper arm bone) and abrasions to knees and nose and a bruised eye and pain (using the reasonable person concept). Findings include: On 12/12/23 at 11:53 AM, R55 was observed lying in bed. R55 appeared to have limited mobility of their left hand. When spoken to, R55 was unable to answer questions coherently. R55 repeatedly reported feeling angry and that they had demons inside of them. R55's bed had a perimeter mattress and was not in the lowest position. Review of a Facility Reported Incident (FRI) submitted to the State Agency on 8/23/23 revealed R55 had a fracture of unknown origin. Review of an investigation conducted by the facility revealed the following: An incident summary completed by former Administrator 'D' documented, .On 8/23/23 (R55) complained of left arm pain and was sent to hospital for CT (computed tomography - an imaging technique used to obtain detailed internal images of the body) with results being nondisplaced fracture of the proximal humerus (upper part of the upper arm bone) with involvement of the greater and lesser tuberosities . .On 8/22/23 resident with noted red area to the right side of forehead, resident verbalized that she accidentally hit her head with her remote control. On 8/23/23 she told the day shift nurse .that she fell . .Interview (R55) .stated to the SWD (Social Work Director) that 'I just hit myself in the face'. Earlier (R55) had also told her assigned nurse .I decked myself when asked how resident replied, I don't know . .Interview (Certified Nursing Assistant - CNA 'G') .was assigned to (R55) on midnight shift on 8/21/23 into the morning of 8/22/23. (CNA 'G') says resident did not fall out of bed during her shift. She indicates that on last rounds she changed (R55) briefs and had rolled resident towards her (so resident was facing the window in the room) and after changing her briefs she rolled the resident onto her back in the center of the bed. 'I put my left hand on the top of resident shoulder/left arm and my right arm on her hips and turned the resident onto her back'. (CNA 'G') states after completion of the peri care/brief change (R55) stated to her 'my face hurts' . .On 8/23/23 residents PCP (primary care physician) .documented that the resident had a nondisplaced [NAME] type (a classification system used for proximal humeral fractures) fracture of the proximal humerus with involvement of the greater and lesser tuberosities. 'These fractures are common in elderly caused by trauma during turning and repositioning' . On 12/13/23 at 1:49 PM, a telephone interview was attempted with CNA 'G'. CNA 'G' was not available for interview prior to the end of the survey. Review of R55's clinical record revealed R55 was admitted into the facility on [DATE] and most recently readmitted on [DATE]. Review of the Minimum Data Set (MDS) assessment dated [DATE] and 8/13/23 revealed R55 was dependent on staff for toileting hygiene and rolling from left to right. The MDS assessment on 5/13/23 indicated R55 required physical assistance of at least two staff members for bed mobility and toilet use. Review of a In-Service One on One form that was signed by CNA 'G' and former Director of Nursing (DON) 'C' on 8/29/23 revealed, Concern: CNA was assigned to (R55) on (8/21/23) midnight shift. CNA failed to follow resident Kardex regarding bed mobility with turning and repositioning, which states resident requires assistance of two staff. Because CNA failed to follow the care plan and performed bed mobility without a second staff, that resulted in the resident receiving a major injury . Review of R55's care plans revealed, (R55) has an ADL (activities of daily living) Self Care Performance Deficit and requires assistance with ADL's and mobility r/t (related to): decreased mobility and weakness. On 9/2/21, an intervention was initiated that read, BED MOBILITY: Resident requires assistance of two staff to reposition and turn in bed . On 12/13/23 at 2:00 PM, an interview was conducted with Unit Manager, Licensed Practical Nurse (LPN) 'Y'. When queried about how the CNAs knew what level of assistance was required for each resident, LPN 'Y' reported the protocol was for CNAs to check the residents' Kardex before providing care. When queried about R55's humerus fracture sustained on 8/21/23 and whether CNA 'G' provided care appropriately, LPN 'Y' reported R55 required two staff to assist with bed mobility and brief changes and CNA 'G' did not follow the plan of care. Review of an incident report for R55 dated 7/11/23 at 2:42 AM revealed, Writer called to residents room at (11:00 PM) resident was observed on the floor to the right side of the bed. Residents CNA stated to writer that while changing resident and turning resident she lost her grip causing resident to roll out of the bed .Resident has bruising to the right side of her face and her nose. Bilateral knee scrape observed. Resident has c/o (complained of) all over pain .Order received to send resident to ER (emergency room ) for Observation .Resident stated, 'I was turning' . R55's pain level was documented as 5 (out of 10, with 10 being the worst level of pain). Injuries post incident were documented as an abrasion to the right knee, left knee, and nose; and bruise to the right eye. Review of a Post Fall Evaluation signed by LPN 'AA' on 7/10/23 revealed, CNA providing resident care and while rolling her she lost her grip on resident and resident fell out of the bed onto the floor. It was documented the CNA was educated on fall safety and a new intervention for a wide bed with perimeter mattress was initiated. The CNA who provided care at the time of the fall was identified as CNA 'I'. Review of a handwritten statement given by CNA 'I' on 7/10/23 revealed, I (CNA 'I) was changing (R55). She was sleeping when I did my rounds and woke her up and was talking to her and let her know she was wet and I needed to change her. She was talking as I was explaining to her what I was doing as I was changing her and she was responding to me and she rolled over toward to me and she rolled over toward the chair and I caught her and brought her back. Started cleaning her again asked her if she was alright she said yes. Then she started to go over again this time I caught her by her hip not realizing she was sweaty there and she slipped off of my glove and fell to the floor on her stomach . Review of a Separation of Employment Form for CNA 'I' revealed their last day worked was 7/14/23 due to violation of company policy. Review of a Disciplinary Action Record for CNA 'I' revealed they were terminated from employment for the following reason: CNA failed to follow care plan for resident in (R55's room number) while providing care. Resident is a 2 person assist with bed mobility. This CNA performed bed mobility alone, resulting in resident falling from the bed to the floor. The safety of the resident was not maintained . Review of R55's Kardex as of 7/11/23 revealed, BED MOBILITY: Resident requires assistance of two staff to reposition and turn in bed. On 12/14/23, an interview was conducted with DON 'B'. DON 'B' did not work in the facility at the time of the incident. DON 'B' reported staff should follow the Kardex when providing care to residents. 47283 R90 A record review of the Electronic Medical Record (EMR) revealed that R90 was a long-term resident of the facility. R90 was recently readmitted to the facility on [DATE] after recent hospitalization . R90's diagnoses included right Femur fracture due to a fall at the facility on 5/9/23, dementia, stroke, and hemiplegia. R90 had history of multiple falls since admission to the facility. R90's Brief Interview for Mental Status (BIMS) score of 5/15, indicative of severe cognitive impairment, based on the Minimum Data Set (MDS) assessment dated [DATE]. An initial observation was completed on 12/12/2, at approximately 11:30 AM. R90 was observed in their bed. R90 had a wheelchair parked on the left side of the bed, near the wardrobe. The wheel had an anti-roll back device. Antiroll back device is a mechanism that stopped the wheels of the chair from rolling back and minimized the fall risk when the resident failed to engage the wheelchair brakes while attempting to transfer or stand up. The device would stay in an unlocked position while the resident was sitting in a wheelchair so the resident can move in their wheelchair. During this observation, this surveyor checked the wheelchair. The wheelchair was freely moving when touched. The wheelchair locks were not engaged i.e., the anti-roll back mechanism was not working. R90's bathroom had a urinal sitting on top the toilet tank. Later that day a second observation was completed at approximately 1:15 PM. During this observation R90 was observed in their bed. The wheelchair was parked was next to the bed on the left side. The locks were not engaged i.e., the antiroll back device was not working. During part of this observation R90's family member was present in the room. R90's family member reported that R90 had attempted to get out of bed and attempted to use the bathroom and showed the bathroom. The surveyor observed the urinal on top the toilet tank. R90 was observed in their room throughout the day. On 12/13/23, at approximately 8:20 AM, another observation was completed. R90 was observed in their bed, lying on their left side with eyes closed. R90's wheelchair was parked next to bed, near wardrobe. The surveyor checked the antiroll back device. The device was not working, and the brakes were not engaged. The surveyor checked the bathroom and the observed the urinal on top of the toilet tank, in the same location. A review of R90's Electronic Medical Record (EMR) revealed a care plan that revealed multiple interventions for the fall risk which included: Anti-roll back device to wheelchair initiated on 7/11/23, have urinal at bedside and attempt to have resident utilize the urinal initiated on 7/27/23. A review of the incident and accident reports provided by the facility revealed that the above interventions were initiated after R90 had falls on 7/10/23 and 7/26/23. An interview with the Nurse (staff member K) and Certified Nursing Assistant (CNA - Staff member AA) were interviewed on 12/13/23, at approximately 11:05 AM. Staff members K and AA were queried on the anti-roll back device on the wheelchair. Staff members K and AA explained the purpose of the device. When showed the device did not engage to the lock the wheels, staff member K checked and agreed that they would notify their maintenance team via their electronic notification system. An interview with demonstration was completed with the Therapy Program Manager (Staff member U) on 12/13/23, at approximately 11:20 AM. During the interview it was observed that the maintenance worker was observed pushing R90's wheelchair in the hallway. Staff member U explained the purpose of the device and confirmed that device was not functional and maintenance staff member reported that they were taking the wheelchair to fix the anti-roll back device. An interview with interim Director of Nursing (DON) (DON B) was completed on 12/13/23, at approximately 12:00 PM. Interim DON was queried about the ant-roll back device that was not functioning, and the urinal that was not placed at bedside during multiple observations. DON B reported that they understood the concern and would follow up with their team.

This citation pertains to intake MI 042. Based on interview and record review the facility failed to provide safe bed mobility assistance during a brief change per the residents assessed care needs for one (R604) of three residents reviewed for accidents resulting in R604 rolling out of bed and sustaining a [CONDITION(S)]. Findings include: A complaint was filed with the State Agency that alleged, .the resident is paralyzed on one side and the staff member rolled her to that side without another staff member being in place . the resident rolled out of bed and fell . causing her to have a broken femur and hip . Review of the closed record revealed R604 was originally admitted into the facility on [DATE] and readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) assessment dated [DATE], R604 scored 15 on the Brief Interview for Mental Status (BIMS) exam, indicating intact cognition. The MDS assessment also indicated R604 required the extensive assistance of two staff member for bed mobility and toileting. Review of R604's 30 day look back for bed mobility revealed out of the 57 times documented, there were 31times the support provided was, Two + persons physical assist Review of R604's progress notes revealed a Nursing note dated 8/14/21 at 11:13 AM that read in part, .cena (Certified Nursing Assistant - CNA E) was changing resident's brief when she turned resident to [sic] far and she fell out of bed. Nurse writer assessed resident and resident complained of pain in her lefr [sic] arm and left leg . Nurse writer educated cena . Review of an Incident and Accident Report (I&A) for R604 revealed on 8/14/21 at 10:30 AM, Resident was in the process of getting cleaned up and cena turned resident and she fell out of bed. For INTERVENTIONS IMPLEMENTED it read in part, Educate cena . Review of X-ray results dated 8/14/21 read in part, .There is a fracture involving the left femoral trochanteric region with minimal displacement . There is a fracture involving proximal femur with displacement . On 9/1/21 at 1:25 PM, CNA E was interviewed and asked about R604's fall. CNA E explained she was new and had only worked at the facility for approximately ten weeks. CNA E further explained she was changing R604's brief and had turned R604 to their side so she could clean their bottom and R604 rolled off the bed and she could not prevent R604 from falling off the bed. When asked if she rolled R604 towards herself or away from herself, CNA E explained she had rolled R604 away from her. On 9/1/21 at 1:33 PM, the Director of Nursing (DON) was interviewed and asked which way a resident should be rolled when only one staff member is present. The DON explained a resident should be turned toward the person assisting the resident. On 9/1/21 at 2:06 PM, Registered Nurse (RN) G, who served as the Staff Development Nurse, was interviewed, and asked if a resident should be turned toward or away from one staff member assisting with bed mobility. RN G explained that it was common sense, a resident should always be rolled toward the staff member, never away unless there was another staff member on the other side of the bed. When asked if CNA E was trained on bed mobility, RN G explained he had checked off her competencies and they had practiced on a mannequin. Review of the education provided to CNA E after R604's fall read in part, .You may request assistance with performing bed mobility if you feel it will not be safe to perform with one person and inform your nurse that additional assistance was needed. When performing bed mobility with 1 person, you are to roll the resident towards you. Never roll the resident away from you unless there are 2 people performing bed mobility . Make sure the residents [sic] has enough room to roll on the side you [sic] turning them to. You may have to reposition them in bed prior to rolling them on their side. Review of a facility policy titled, Perineal care of the female patient undated did not address the direction to roll a resident when one staff member was present.

This citation pertains to intake: MI 825 Based on interview and record review the facility failed to ensure consistent and accurate skin assessments, ensure an antidepressant medication that aided in resident's compliance with wound care was reordered upon readmission and prevent worsening of skin condition on the extremities for one (R#700) of three residents reviewed for quality of care, resulting in worsening of skin conditions, multiple refusals of care, lack of coordinated care amongst the wound nurse practitioner, consulted behavioral group and medical physician and resulting in a consultation that documented the need for bilateral (below the knee) major amputations. Findings include: A complaint was submitted to the State Agency on 3/6/20 at 16:39 (4:39 pm) which documented in part, . Patient's skin is extremely dry, appearing to not have been cleansed in a long time, and has gangrene (a lack of oxygen rich blood causes tissue to die) with (sic) on feet and hands (contracted) with ischemic black tissue . after viewing the patient, feels that he has been grossly neglected . On 3/10/20 to 3/12/20 an onsite investigation into the complainant's allegations was conducted. A review of R#700's clinical record revealed the following: R#700 was admitted into the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating severely impaired cognition. R#700 was dependent on staff for all activities of daily living. A Nursing Comprehensive Evaluation- admitted d 1/16/19 at 19:01 (7:05 pm) documented in part . Right lower leg (front)- Scrapings and dark bruises present, Left lower leg (front)- scrapings, and scars. Dark discolored dry skin, Right lower leg (rear)- Right lower leg small open wound, Right toe(s)- Dark discolored right toes and foot with dry skin, Left toe(s)- Toes dark, discolored and dry, Other (specify)- Fingers on left hand noted abnormalities, Other (specify)- Fingers on right hand without function on movement with abnormalities present . A Wound Consultation with Wound Nurse Practitioner (WNP D) dated 1/22/19 documented in part, . Chief Complaint: regarding this patient's feet . At the time of admission, he was noted to have some discoloration on his toes . He does state that his feet hurt . On his toes and his feet, he is found to have numerous scattered darkened ischemic (poor blood flow to an area, which causes cells to die and damages to tissue) patches. Again, these are scattered amongst his toes and his dorsal lateral feet. Currently there are no open areas, no drainage, no [MEDICAL CONDITION], borders are closed, no fluctuance noted . There are no treatments necessary to the ischemic areas on his feet since there are no openings drainage or [MEDICAL CONDITION] . A Wound Consultation with WNP D dated 1/29/19 documented in part, . On his toes and his feet he is found to have numerous scattered darkened ischemic patches. Again, these are scattered amongst his toes and his dorsal lateral feet. Currently there are no open areas no drainage, no [MEDICAL CONDITION] borders are closed, no fluctuance noted . There are no treatments necessary to the ischemic areas on his feet since there are no openings, drainage or [MEDICAL CONDITION] . A Social Services Note dated 1/30/19 documented in part, Resident seen by psychiatrist . on this date for evaluation/behaviors, confusion, depression . A Wound Consultation with WNP D dated 2/5/19 and 2/13/19 were identical and documented in part, . On his toes and his feet he is found to have numerous scattered darkened ischemic patches. Again, these are scattered amongst his toes and his dorsal lateral feet. Currently there are no open areas no drainage, no [MEDICAL CONDITION] borders are closed, no fluctuance noted . There are no treatments necessary to the ischemic areas on his feet since there are no openings, drainage or [MEDICAL CONDITION] . A Social Services Note dated 3/9/19 at 20:03 (8:03 pm) documented in part, . Resident has episodes of refusing care and treatment, presents with signs/symptoms of depression including sleep/appetite disturbance, increased fatigue. Resident referred for psych support services . A Total Body Skin assessment dated [DATE] at 16:45 (4:45 pm) completed weekly by the facility nursing staff documented, Skin Assessment- 1. Turgor- Good Elasticity, 2. Skin Color- Normal for ethnic group, 3. Temperature- Cool, 4. Moisture- Normal, 5. Condition- Extremely Dry, 6. New Wounds- 0. A Wound Consultation with WNP D dated 3/12/19 documented in part, . At the time of admission he was noted to have some discoloration on his toes . I was told that (R#700 name redacted) can be very resistive to care . Left heel darkened non-blanchable area 5.3 x 3.3 cm (centimeter) currently no open, Right heel wound 0.5 x 0.5 x 0.2 cm minimal amount of drainage no clinical evidence of infection surrounding tissue is intact the base is granular with some scattered coagulum (mass/clump/clot) . His toes and fingers have scattered stable ischemia no drainage no [MEDICAL CONDITION] . Discontinue treatment to his toes and his fingers. The areas can be left open to air. Monitor regions for further ischemia, drainage, [MEDICAL CONDITION] . It should be noted that the total body skin assessment on 3/11/19 did not identify the new left and right heel wounds documented on the next day (3/12/19) by the Wound Nurse Practitioner (WNP) D. A behavioral consultation dated 3/12/19, documented in part, . no noted behaviors by staff . he reports pain in his back . discussed starting an antidepressant that could also help with pain . [MEDICATION NAME] 30mg capsule, delayed release, take 1 capsule by oral route, QAM (every morning) . Patient seen and evaluated. Patient admitted he was feeling depressed . A behavioral consultation dated 3/21/19, documented in part, . Resident has episodes of refusing care and treatment and presents with signs/symptoms of depression. Resident reports feeling down/depressed, fatigued, and having sleep/appetite disturbance . Nursing staff reports depression as evidence by patient refusing care, tube feeds, etc. [MEDICATION NAME] was recently started to help with depression (3/12/19) therefore writer is not making any changes today and will give time for medication to take effect . A Wound Consultation with WNP D dated 3/26/19 documented in part, . Left heel darkened non-blanchable area 4.2 x 3.5 cm currently not open, Right heel wound 0.5 x 0.4 x 0.1 scant drainage no clinical evidence of infection surrounding tissue is intact the base is scab with opening granular . His toes and fingers have scattered stable ischemia no drainage no [MEDICAL CONDITION] . Treat left heel, right heel areas wipe with skin prep apply dry bulky wrap 3 time a week and as needed . Discontinue treatment to his toes and his fingers. These areas can be left open to air. Monitor regions for further ischemia, drainage, [MEDICAL CONDITION] . A Wound Consultation with WNP D dated 4/2/19 documented in part, . I continue to see this patient for his . heel . He continues to be very resistant to care . Left heel darkened non-blanchable area resolved, Right heel wound resolved . His toes and fingers have scattered stable ischemia, no drainage, no [MEDICAL CONDITION] . D/C (discontinue) Treatment to left heel, right heel areas. D/C treatment to his toes and his fingers. These areas can be left open to air. Monitor regions for further ischemia, drainage, [MEDICAL CONDITION] . A Wound Consultation with WNP D dated 4/9/19 documented in part, . His toes and fingers have scattered stable ischemia no drainage, no [MEDICAL CONDITION] . Discontinue treatment to his toes and his fingers. These areas can be left open to air. Monitor regions for further ischemia, drainage, [MEDICAL CONDITION] . A Wound Consultation with WNP D dated 4/16/19 documented in part, . His toes and fingers have scattered stable ischemia no drainage, no [MEDICAL CONDITION] . Discontinue treatment to his toes and his fingers. These areas can be left open to air. Monitor regions for further ischemia, drainage, [MEDICAL CONDITION] . A Total Body Skin assessment dated [DATE] at 13:45 (1:45 pm) completed weekly by the facility nursing staff documented, Skin Assessment- 1. Turgor- Good Elasticity, 2. Skin Color- Normal for ethnic group, 3. Temperature- Warm (normal), 4. Moisture- Normal, 5. Condition- Normal, 6. New Wounds- 0 A Wound Consultation with WNP D dated 4/23/19 documented in part, . Unfortunately the treatment nurse states that yesterday she noted some turbid (cloudy) drainage coming from his right toe and I have been asked to evaluate the area . His right great toe ischemic cap is significantly destabilized. My concern is that this toe is going to Autolytically amputate (spontaneuous detachment) without mummifying, there is minimal drainage currently no [MEDICAL CONDITION]. His remaining toes and fingers have scattered stable ischemia, no drainage, no [MEDICAL CONDITION] . Treat right great toe wound with [MEDICATION NAME] gauze covered with dry gauze change daily and as needed. His remaining toes and his fingers can be left open to air. Monitor regions for further ischemia, drainage, [MEDICAL CONDITION] . The total body skin assessment completed on 4/22/19 did not identify the new right great toe wound and drainage documented on the next day (4/23/19) by the WNP D. A Wound Consultation with WNP D dated 4/30/19 documented in part, . His right great toe ischemic cap is significantly destabilized. There is minimal drainage currently, no [MEDICAL CONDITION]. There is a rim of granular tissue, the rest still has the darkened Ischemic cap. His remaining toes and fingers have scattered stable ischemia, no drainage, no [MEDICAL CONDITION] . Treat right great toe wound with [MEDICATION NAME] gauze covered with dry gauze change daily and as needed. His remaining toes and his fingers can be left open to air. Monitor regions for further ischemia, drainage, [MEDICAL CONDITION] . A behavioral consultation dated 5/2/19, documented in part, . Patient presents as calm and cooperative. Patient denies mood or anxiety sx. (symptoms) Patient denies issues with sleep or appetite. Continue [MEDICATION NAME] as described . It appears that the benefit resident is getting from the residents medication regimen is outweighing the risk of potential side effects . A Wound Consultation with WNP D dated 5/7/19 documented in part, . His right great toe ischemic cap is significantly destabilized. There is minimal drainage currently, no [MEDICAL CONDITION]. There is a rim of granular tissue, the rest still has the darkened Ischemic cap. His remaining toes and fingers have scattered stable ischemia, no drainage, no [MEDICAL CONDITION] . Treat right great toe wound with [MEDICATION NAME] gauze covered with dry gauze change daily and as needed. His remaining toes and his fingers can be left open to air. Monitor regions for further ischemia, drainage, [MEDICAL CONDITION] . A Total Body Skin assessment dated [DATE] at 9:45 am) completed weekly by the facility nursing staff documented, Skin Assessment- 1. Turgor- Good Elasticity, 2. Skin Color- Normal for ethnic group, 3. Temperature- Warm (normal), 4. Moisture- Normal, 5. Condition- Normal, 6. New Wounds- 0 A Wound Consultation with WNP D dated 5/21/19 documented in part, . I have been seeing this patient for his . toe and finger wounds. They were all responding favorably to treatment. Unfortunately, the ischemic on his left third fourth and fifth fingers prematurely separated and we now have open areas . His right great toe ischemic cap is restabilizing , there is minimal drainage currently no [MEDICAL CONDITION]. There is a rim of granular tissue. The rest still has the darkened ischemic cap . his left third fourth and fifth fingers have open areas 1.0 x 0.8 x 0.1 cm minimal amount of serous sinus drainage no clinical evidence of infection surrounding tissue is intact bases are granular . Treat right great toe wound with [MEDICATION NAME] gauze change daily and as needed. His remaining toes can be left open to air. Single layer Xeroform gauze cut to fit applied to open areas on his left third, fourth and fifth fingers cover with gauze change daily and as needed. Monitor regions for further ischemia, drainage, [MEDICAL CONDITION] . The total body skin assessment completed on 5/20/19 did not identify the new open areas to the left third, fourth and fifth fingers and drainage as documented on the next day (5/21/19) by the WNP D. A Wound Care Consultation with WNP D dated 5/28/19 documented in part . His right great toe ischemic cap is restabilizing , there is minimal drainage currently no [MEDICAL CONDITION]. There is a rim of granular tissue. The rest still has the darkened ischemic cap . his left third fourth and fifth fingers have open areas 1.0 x 0.8 x 0.1 cm minimal amount of serous sinus drainage no clinical evidence of infection surrounding tissue is intact bases are granular . Treat right great toe wound with [MEDICATION NAME] gauze change daily and as needed. His remaining toes can be left open to air. Single layer Xeroform gauze cut to fit applied to open areas on his left third, fourth and fifth fingers cover with gauze change daily and as needed. Monitor regions for further ischemia, drainage, [MEDICAL CONDITION] . A Wound Care Consultation with WNP D dated 6/4/19 documented in part, . His right great toe ischemic cap is restabilizing. There is minimal drainage currently no [MEDICAL CONDITION]. There is a rim of granular tissue the rest still has the darkened ischemic cap . his left, third, fourth and fifth fingers are beginning to cover over with ischemic caps. There is still some scattered open areas with granular tissue. Scant drainage no [MEDICAL CONDITION] . Treat right great toe wound with [MEDICATION NAME] gauze change daily and as needed. His remaining toes can be left open to air. Single layer Xeroform gauze cut to fit applied to open areas on his left third, fourth and fifth fingers cover with gauze change daily and as needed. Monitor regions for further ischemia, drainage, [MEDICAL CONDITION] . A behavioral consultation dated 6/5/19, documented in part, . Patient was seen and evaluated. Patient presents as calm and cooperative. Patient denies issues with sleep or appetite. Patient denies mood or anxiety sx. Continue [MEDICATION NAME] at current dose . A Wound Consultation with WNP D dated 6/11/19 documented in part, . His right great toe ischemic cap is restabilizing, there is minimal drainage, currently no [MEDICAL CONDITION]. There is a rim of granular tissue is drying out the rest still has the darkened Ischemic cap . His left third, fourth and fifth fingers are beginning to cover over with ischemic caps. There is still some scattered open areas with granular tissue. Scant drainage no [MEDICAL CONDITION] . Treat right great toe wound with [MEDICATION NAME] gauze covered with dry gauze change daily and as needed. His remaining toes can be left open to air. Single layer Xeroform gauze cut to fit applied to open areas on his left third, fourth and fifth fingers cover with gauze change daily and as needed. Monitor regions for further ischemia, drainage, [MEDICAL CONDITION] . A Nurses Note dated 6/13/19 at 22:15 (10:15 pm), documented in part Pt was sent out to (hospital name redacted) via ambulance. Pt BP (blood pressure) was 121/94 and HR (heart rate) 115. These are abnormal vitals for the pt baseline . The resident returned on 6/17/19, however their [MEDICATION NAME] medication was not restarted upon admission. The Director of Nursing (DON) was asked to confirm the discontinuation of R#700 [MEDICATION NAME] upon readmission on 6/17/19 and confirmed that the medication was not restarted. A Social Services Note on 6/20/19 at 16:07 (4:07 pm) documented in part, Resident seen by psychiatrist . on this date for follow up, medication review . [MEDICATION NAME]. Risks vs benefits of continued medication use reviewed . (It was noted the resident was not on [MEDICATION NAME] at this time, as indicated by the Social Worker.) On 3/11/20 at 3:49 pm, the DON and Corporate Staff Member (CSM) A were queried on why R#700's [MEDICATION NAME] was not restarted upon admission back into the facility on [DATE], considering the facility's documentation noted improvement and the decrease in refusals of care while on the medication. The DON and CSM A were unable to provide any further explanation or documentation on why the [MEDICATION NAME] was discontinued. When queried on why the Interdisciplinary team didn't address or consult with the medical physician and consulted behavior group regarding the discontinuation of the [MEDICATION NAME] medication, no further explanation or documentation was provided. A Wound Consultation with WNP D dated 6/18/19 documented in part, . His right great toe ischemic cap is restabilizing, there is minimal drainage, currently no [MEDICAL CONDITION]. There is a rim of granular tissue is drying out the rest still has the darkened Ischemic cap . His left third, fourth and fifth fingers are beginning to cover over with ischemic caps. There is still some scattered open areas with granular tissue. Scant drainage no [MEDICAL CONDITION] . Treat right great toe wound with [MEDICATION NAME] gauze covered with dry gauze change daily and as needed. His remaining toes can be left open to air. Single layer Xeroform gauze cut to fit applied to open areas on his left third, fourth and fifth fingers cover with gauze change daily and as needed. Monitor regions for further ischemia, drainage, [MEDICAL CONDITION] . A Wound Consultation with WNP D dated 6/25/19 documented in part, . His right great toe ischemic cap is stable currently no [MEDICAL CONDITION]. There is a rim has dried out the rest still has the darkened Ischemic cap . his left, third, fourth and fifth fingers are covered over with ischemic caps. No [MEDICAL CONDITION] . Treat right great toe wound wipe [MEDICATION NAME] QD (every day) can be left open to air. Left third, fourth and fifth fingers wipe with [MEDICATION NAME] QD can be left open to air. Monitor regions for further ischemia, drainage, [MEDICAL CONDITION] . A Social Services Note on 6/27/19 at 15:23 (3:23 pm), documented in part . Resident continues to have fewer episodes of refusing care/treatment. Resident reports feeling down/depressed, fatigued, and having sleep/appetite disturbance. Resident has rx (prescription) antidepressant and is followed by psych support services . (It was noted the resident was not on [MEDICATION NAME] at this time, as indicated by the Social Worker.) A Wound Consultation with WNP D dated 7/2/19 documented in part, . Right great toe ischemic is stable, left third, fourth and fifth fingers are stable . Treat right great toe wound wipe [MEDICATION NAME] QD can be left open to air. Left third, fourth and fifth fingers wipe with [MEDICATION NAME] QD (everyday) can be left open to air. Monitor regions for further ischemia, drainage, [MEDICAL CONDITION] . On 3/11/20 at 8:34 AM, the Director of Nursing (DON) was queried and asked to provide the Wound Care Consults from July of 2019 until November of 2019. Originally all Wound consultations was requested regarding R#700 on 3/10/20 at 3:04 pm. A Progress note sheet documented the dates of: 10/15/19, 10/9/19, 10/1/19, 9/24/19, 9/17/19 and 9/10/19 as a refusal of assessment by the resident from the wound nurse practitioner. By the end of survey, no further wound care consultations from the months of July 2019 to November 2019 was provided. On 3/11/20 at 11:40 AM, Wound Care Licensed Practical Nurse (WCLPN) C (the facility wound nurse) was queried and asked to provide R#700's wound consultations from July 2019 to November of 2019 and nothing was provided by the end of survey. A behavioral consultation dated 9/11/19, documented in part, . Resident continues to have fewer episodes of refusing care/treatment . presents as calm and cooperative. Resident states he is doing alright . Unable to determine level of competency . A behavioral consultation dated 10/2/19, documented in part, . Patient noted with multiple med (medication) refusals and refusals of care . Continue to document changes in bx (behavior)/mood . A Social Services Note dated 11/20/19 at 18:44 (6:44 pm), documented in part . Resident has episodes of refusing care and treatment including skin checks and wound care. Resident presents with signs/symptoms of depression including sleep disturbance. Resident has recently started asking staff to cover his feet with pillowcases and making statements that he is putting them to sleep. Resident is followed by psych support services . A behavioral consultation dated 11/20/19, documented in part, . Patient noted with refusal of care multiple times. Pt is noted with confusion on numerous occasions. 11/15/19: skin care note pt (patient) is refusing changing of dressings . Pt states that he wants to go home. Pt denies pain. Pt states that he is being mistreated and states they are doing everything- pt states he doesn't want to explain . Pt is angry, agitated, and continues to be uncooperative . was previously on [MEDICATION NAME] which was discontinued by PCP (primary care physician) for unknown reasons . Pt has been noted to refuse meds, was previously on [MEDICATION NAME] which was later discontinued for unknown reasons . Will continue to monitor . A Wound Consultation with WNP D signed on 11/26/19 at 9:53 am documented in part, . (R#700 name redacted) is a long-term resident of this facility. He has been refusing almost anything related to his care including bathing, taking medications, staff to perform his treatments. He has not allowed me to assess his wound since always (sic) back here except for right (sic) 8/27. Staff is (sic) been attempting to do his treatments with him refusing most times . significant ischemia on his fingers and toes. He will allow me to look at the areas however he will not allow me to do a thorough assessment or touch him. Most of his toes are mummified and stable except the right great toe. At the proximal, and there is an open area that is granular minimal drainage no [MEDICAL CONDITION]. His left heel also has an open area he will not allow me to measure the region has been 0.1 depth minimal drainage the base is granular. He will not allow me to assess his fingers . Right great toe: Xeroform gauze to open area cover with dry gauze change twice a week and as needed, left heel: Silver impregnated calcium alginate covered with foam dressing change twice a week and as needed . His left heel was previously covered with ischemic eschar. This has destabilized. There is minimal slightly turbid drainage. No [MEDICAL CONDITION] right and left toes are slowly modifying. On his right plantar foot there are scattered open areas there is turbid drainage noted. There is the underlying fluctuance noted. He would not allow me to thoroughly cleanse the area provide the care that is necessary. His right lateral leg is now open there was turbid drainage the base is granular . I have asked the treatment nurse to contact his medical doctor and update her regarding her findings . A Nurses Note dated 11/26/2019 at 14:15 (2:15 pm) documented in part, Resident allowed writer and wound NP (Nurse Practitioner) to assess BLE (Bilateral lower extremities) gangrene. His left heel was previously covered with ischemic eschar. This has destabilized. There is minimal slightly turbid (cloudy) drainage. Right and left toes are slowly modifying. On his right plantar foot there are scattered open areas there is turbid drainage noted. There is the underlying fluctuance noted. He would not allow to thoroughly cleanse the area provide the care that is necessary . Discussed with MD (Medical Doctor) and guardian and new order to send to (hospital name redacted) for destabilization of gangrene. A hospital Discharge Summary (admitted : November 27, 2019, discharge date : December 2, 2019) documented in part, . patient presented to emergency department [MEDICAL CONDITION] to 118, with leukocytosis of 17 . Additionally patient has potential sources on scan due to wounds on lower extremities with evidence of osteo[DIAGNOSES REDACTED] in bilateral feet with concern of dry gangrene as well as right index finger concerning for dry gangrene . patient is [MEDICAL CONDITION] as well as hypotensive . dry gangrene seen on bilateral lower extremities on toes, right foot as well as left foot x-ray well emergency department were concerning for chronic osteo[DIAGNOSES REDACTED], suspicion for dry gangrene versus osteo[DIAGNOSES REDACTED] in right index finger . recommended [MEDICATION NAME] dressing changes . no acute surgical intervention . A Physician Note dated 12/6/2019 at 15:41 (3:41 pm), documented in part . C/O (complaints of) LE (lower extremity) pain, wants an appointment with vascular surgery for [REDACTED]. A Wound Consultation with WNP D signed 12/17/19 at 9:33 PM, documented in part, . I have not seen his wounds since 29 October. Today he is finally agreeing to allow us to assess his foot wounds. Not surprisingly, due to his refusals these areas have deteriorated . We have more than adequately documented his refusals and noncompliance regarding his wound care and treatments. He recently went out to the hospital and was treated for [REDACTED]. He was seen by plastic surgery. Patient had requested an amputation however he is too high of a risk secondary to his [DIAGNOSES REDACTED] . Plantar feet, toes on bilateral feet all stable gangrene in the process of mummifying (skin becomes dry, shriveled, dark in color and cold to touch). There is scant drainage no [MEDICAL CONDITION] . right and left plantar foot, left and right toes: Wipe areas with [MEDICATION NAME] cover with ABD (abdominal) pad change 3x/week (three times a week) and as needed . A Wound Consultation with WNP D signed 1/7/20 at 11:06 AM, documented in part . Gangrenous areas on his toes and his feet are stable. There is no drainage no [MEDICAL CONDITION]. He would not allow assessment of his hands . right and left plantar foot, left and right toes: Wipe areas with [MEDICATION NAME] cover with ABD pad change 3x/week and as needed . A Wound Consultation with WNP D signed 1/14/20 at 11:21 AM, documented in part . I am seeing this patient again today regarding his right leg foot toe and hand wounds. I been told by the treatment nurse that he is become much more cooperative with allowing dressing changes to be performed to his legs. He still is refusing to allow treatments to be performed as ordered to his hands . Recommend: right and left plantar foot, left and right toes: Wipe areas with [MEDICATION NAME] cover with ABD pad change 3x/week and as needed . A Wound Consultation with WNP D signed 1/21/20 at 12:03 PM, documented in part, . I am seeing this patient again today regarding his right leg, foot toe and hand wounds. I been told by the treatment nurse that he is become much more cooperative with allowing dressing changes to be performed to his feet and to his hands. He does not appear to be in any pain. He has developed significant finger contractures to the point where his nails are starting to digging (sic) into his palms of his hands . Gangrenous areas on his toes and his feet and his fingers are stable . There is no drainage, no [MEDICAL CONDITION] . A Wound Consultation with WNP D signed 1/28/20 at 11:52 AM, documented in part, . I am seeing this patient again today regarding his right leg, foot, toe and hand wounds. He is much more cooperative with allowing dressing changes to be performed to his feet and to his hands. He does not appear to be in any pain. He has significant finger contractures to the point where his nails are starting to digging (sic) into the palms of his hands . Recommend: right and left plantar foot, left and right toes: Wipe areas with [MEDICATION NAME] cover with ABD pad change 3x/week and as needed . A Wound Consultation with WNP D signed 2/4/20 at 9:19 PM, documented in part, . Chief Complaint/Nature of Presenting Problem: Finger toe foot right leg and left heel wounds . Recommend: right and left plantar foot, left and right toes: Wipe areas with [MEDICATION NAME] cover with ABD pad change 3x/week and as needed . Hand Surgeon Consult . A Wound Consultation with WNP D signed 2/26/20 at 2:56 PM, documented in part, I am seeing this patient again today regarding his right left foot toe and hand wounds. He is much more cooperative with allowing dressing changes to be performed to his feet and to his hands. He does not appear to be in any pain. He has significant finger contractures to the point where his nails are starting to digging (sic) into the palms of his hands . Hand surgeon consult/vascular surgery consult- I will leave the decisions regarding his request for amputations to his medical team . A Wound Consultation with WNP D signed 3/05/20 at 7:05 PM, documented in part, . I am Seeing this patient again today regarding his gangrenous toes and fingers . We have been documenting the issues regarding his refusals for almost every aspect of his care. He has finally been allowing staff to treat his toes, however he is still rarely allowing any treatments or interventions to his fingers . Most recently he has been requesting a vascular surgery consult so he can get his feet and fingers amputated . Gangrenous areas on his toes and his feet and his fingers are stable. There is scant drainage. From his right gt (great) toe. No [MEDICAL CONDITION]. The blister on his abdomen has resolved . Recommend: right and left plantar foot, left and right toes: Wipe areas with [MEDICATION NAME] cover with ABD pad change 2x/week and as needed . A Nurses Note dated 3/5/20 at 17:28 (5:28 pm) documented R#700 was transferred to the hospital for other medical concerns. A (hospital name redacted) consultation dated 3/6/20 at 16:57 (4:57 pm) documented in part, .Patient with bilateral dry gangrene of the forefeet and the lateral portion of the plantar surface up to mid foot level patient does have good perfusion into the foot palpable DP's (Dorsalis Pedis) bilaterally. Going by how the feet affected by gangrene, limb salvage is probably not an option and he (sic) need bilateral major amputations . A hospital Palliative Medicine Consult filed on 3/9/20 at 11:53 am, documented in part . Vascular consulted for gangrene of bilateral feet and recommend bilateral BKA ([MEDICAL CONDITION]) . Vascular team will contact patient's legal guardian to discuss further regarding procedure . On 3/11/20 at 11:40 am, Wound Care Licensed Practical Nurse (WCLPN) C was queried on the inaccurate weekly nursing skin assessments (on 3/11/19, 4/22/19 and 5/20/19) and explained the wound may not have been present when the skin assessment was performed and may have developed the next day. WCLPN C was further queried on the worsening of R#700's skin condition and stated the resident had so many refusals of care. When asked what the facility was doing about the constant refusals of care and why wound care staff didn't take advantage of completing the wound assessments during the weekly nursing skin assessments or bath days since the resident allowed the staff to complete these tasks weekly, WCLPN C did not offer any further explanation. On 3/12/20 at 9:55 am, WNP D was queried regarding R#700's worsening of skin condition and stated in part . we have more than enough documentation of his refusals. When asked about the coordination of care with the medical physician (MP B) and the WNP D stated in part the doctors have access to my notes in the system . On 3/12/20 at 10:01 am, Medical Physician (MP) B was queried regarding R#700's wound care and stated in part, . There was a communication problem when it came to his care . No, (Wound Nurse Practitioner name redact(TRUNCATED)

This citation pertains to intake: MI 825 Based on interview and record review the facility failed to follow up with the urologist after the insertion of a left [MEDICAL CONDITION] stent (a soft tube about 10-12 inches long, used to hold ureter open and maintain drainage of urine) and monitor for renal/[MEDICAL CONDITION] calculous/calculus (stones) obstructions for one (R#700) of three residents reviewed for a urinary catheter, resulting in the lack of coordination of care with the urologist, a missed urology appointment, the lack of straining/collecting stone fragments from urine,[MEDICAL CONDITION], pain and resulting in a transfer to the hospital for a surgical consultation to remove a urinary catheter. Findings Include: A complaint was submitted to the State Agency on 3/6/20 at 16:39 (4:39 pm) which documented in part, . Patient arrived at (hospital name redacted) . because the staff at (facility name redacted) was attempting to take out his foley, but it got stuck. Urology was consulted and they were unable to remove the foley, even after flushing it. Patient was admitted for a Cystoscopy (a procedure that allows a urologist to view the inside of the bladder and urethra). Foley was removed and found to be severely encrusted . A review of R#700's clinical record revealed the following: R#700 was admitted into the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 5 out of 15, indicating severely impaired cognition. R#700 was dependent on staff for all activities of daily living. R#700 was not admitted with a urinary catheter. Continued review of R#700's clincial record revealed the following: A Nurses Note dated 9/3/19 at 5:20 AM, documented in part . Resident observed during care rounds to be diaphoretic (excessive sweating). VS (vital signs) obtained T (temperature)-103.1, BP (blood pressure) 112/81, P (pulse)-163 R (respiration)-22. Attempted to give Tylenol peg tube clogged. Cold cloths placed on resident forehead. MD (Medical Doctor) notified of condition and ordered to send out 911 . A hospital discharge summary (admitted date: September 3,2019, discharge date : September 6, 2019), documented in part, . Insertion of [MEDICAL CONDITION] stent (left) . [MEDICAL CONDITION] stone with hydro[DIAGNOSES REDACTED] . [MEDICAL CONDITION] with a 8mm (millimeter) calculus in the distal L (left) ureter . 1.1 x1.9 cm (centimeter) rim-enhancing collection . which may represent a psoas muscle abscess . f/u (follow up) in 4 weeks with low dose CT scan prior to f/u with (urologist doctor name redacted) .[MEDICAL CONDITION] . On admission febrile (fever) 103.1 and [MEDICAL CONDITION] (110) .Continue to strain all urine with strainer to collect any stone fragments . Collect the stone and bring to your appointment if you pass them . Stent MUST be removed after stone is resolved. Please ensure follow-up with (Urologist name redacted) . A review of R#700's clinical chart revealed no follow up outpatient consultations completed with the urologist, Per R#700 discharged paperwork which documented in part to follow up on [DATE] 10:00 AM. A Nurses Note dated 11/26/2019 at 15:45 (3:45 PM) documented the resident was transferred to the hospital. A hospital Discharge Summary (admitted date: November 27, 2019, discharge date : December 3, 2019) documented in part, . Foley replaced on admission . presented with [MEDICAL CONDITION] 2/2 (secondary to) [MEDICATION NAME] bacteremia with source likely being GU ([MEDICAL CONDITION]- genital and urinary organs) . UC (urinary catheter) showing gross contamination . patient presented to emergency department [MEDICAL CONDITION] (fast heart rate) to 118, with leukocytosis (high white blood cell count) of 17 with likely source urinary tract . It was noted the resident was readmitted on [DATE] with a foley catheter and remained at the facility until March 5, 2020, when the resident was transferred back into the hospital. Per the DON, 11/27/19 was the last time R#700's foley [MEDICATION NAME] was documented as changed (by the hospital.) A Nurses Note dated 3/5/20 at 17:28 (5:28 pm) documented in part, . Resident's foley balloon was deflated and foley unable to be removed. B/P (Blood Pressure) 102/64, HR (heart rate) 52 . MD (Medical Doctor) notified: and ordered to send resident to the hospital . A (hospital name redacted) urology surgery consult dated 3/5/20 documented in part, . Stuck foley . he has complaints of urethral pain when catheter is manipulated. Once in the ED (emergency room department), the foley was attempted removal without success. Urology surgery is consulted to assess the removal and replacement of the foley . Patient has suprapubic (lower abdomen) pain when catheter being flushed . presented today from his nursing facility due to inability to remove his foley cath . Case has been reviewed and discussed in detail with supervising physician . for surgical consultation . purulent (milky) drainage out of foley . Urology consulted and they were also unable to remove the foley despite flushing. Urology requests CT (computed tomography) pelvis for better imaging. They request the patient be placed in observation with plan for possible cystoscopy (a procedure that allows a urologist to view the inside of the bladder and urethra) in a.m . A (hospital name redacted) CT of pelvis report dated 3/6/20 at 12:14 AM, documented in part . The tip of the patient's foley catheter is located within the urinary bladder with multiple coarse calcifications (accumulation of calcium salts) seen along the course of the foley catheter, most prominent near the foley catheter tip . additional layering calcifications within the urinary bladder . A hospital Palliative Medicine Consult filed on 3/9/20 at 11:53 am, documented in part, . Pt (patient) had foley catheter removed 3/6/20 with Urology and did not replace foley catheter. Urology recommending to leave foley catheter out with checks PVRs (post-void residual) . A review of R#700's care plans revealed one urinary care plan titled R#700 has an Indwelling Catheter d/t (due to) [MEDICAL CONDITION] (Date Initiated and Revised on 1/28/20). Is at risk for urinary tract infection and catheter related trauma R/T (related to) Indwelling Catheter . Goal- Catheter will remain patent and without complications through the review date . Interventions- Change R#700 catheter and tubing per facility policy, Foley catheter securement device in place every shift, Observe and document output every shift, Position catheter bag and tubing below the level of the bladder. Check tubing for kinks each shift, Privacy bag to foley drainage bag every shift, provide catheter care every shift and as needed . This care plan did not inform the staff to monitor for the signs and symptoms of renal/[MEDICAL CONDITION] calculous (calculus), pain or straining the urine to collect stone fragments for the urologist as the physician documented. On 3/11/20 at 8:32 AM, the DON was asked to provide the facility policy on changing catheter and tubing (as documented in R#700's care plan) and stated the facility did not currently have a policy for the changing of a resident's urinary catheter and tubing. On 3/11/20 at 9:51 AM, the Director of Nursing (DON) and Corporate Staff Member (CSM) A was queried about R#700's urology appointments and provided an appointment reminder from R#700 discharged paperwork which documented in part . Follow up in 1 week(s) . [DATE] 10:00 AM . Follow-Up Visit with (Urologist name redacted) . When queried on why the facility did not ensure that R#700 made it to the appointment, both the DON and CSM A could not provide an explanation. The DON and CSM A were queried further on why the low dose CT scan was not completed as directed by the Urologist and no further explanation was given. On 3/12/20 at 10:02 AM, Medical Physician (MP) B (R#700's attending physician at the facility) was interviewed via telephone. When asked if the Urologist follow up would have been beneficial to R#700's care, MP B stated in part . Yes, if they would have followed up with the Urologist it would have equipped the facility to be able to better monitor him and his urological condition . There was a big miscommunication with his care . We all need to have a meeting about this and work on improving the communication there (at the facility) . On 3/12/20 at 12:02 PM, the DON and CSM A was asked to provide any additional documentation regarding R#700's urological care and no additional documentation or information was provided by the end of survey. The DON and CSM A were asked to provide any policies on following up on appointments after a hospital discharge and implementing a physician directive. The DON and CSM A provided policies on physician's orders [REDACTED]. All policies were reviewed, however contained no relevant information to the above deficient practice.

This citation refers to Intake #s: MI 566 and MI 632. Based on interview and record review, the facility failed to identify new and worsening wounds and implement interventions upon development of a total of 16 pressure ulcers for one (R#72) of six residents reviewed for pressure ulcers, resulting in an unstageable pressure ulcer to the sacrum worsening with a bone infection, development of a deep tissue injury to the left ishium, and the potential for further worsening of other pressure ulcers. Findings include: The State Agency received complaints regarding R#72 that alleged the facility was not providing appropriate pressure ulcer care and R#72 developed pressure ulcers at the facility. The complainants' concerns were investigated during an onsite, unannounced annual recertification survey conducted between 7/22/19 and 7/29/19. R#72's clinical record was reviewed and revealed the following: R#72 was originally admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. R#72 was discharged to the hospital on [DATE] and readmitted on [DATE], discharged on [DATE] and readmitted on [DATE], discharged on [DATE] and readmitted on [DATE] (with a [DIAGNOSES REDACTED]. A 5-Day Minimum Data Set (MDS) assessment dated [DATE] 5 documented R#72 had one stage 4 pressure ulcer (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough - Dried [MEDICAL CONDITION] fluids that are moist, stringy; and yellow, tan, gray, green or brown and/or eschar - Necrotic tissue that is leathery or thick; and black, brown or tan may be visible). An Admission MDS dated [DATE] documented R#72 had severely impaired cognition, required extensive to total two person assistance for bed mobility and transfers, did not walk, and required extensive assistance for all activities of daily living (ADLs), including eating, had an indwelling urinary catheter, was frequently incontinent of stool, and had nine pressure ulcers that included: One Stage 2 pressure ulcer (Partial-thickness skin loss with exposed dermis), two unstageable pressure ulcers (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed), and six unstageable pressure ulcers presenting as deep tissue injuries (DTIs - Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister). The MDS documented all but one DTI was present upon admission into the facility. On 7/24/19 at 1:24 P.M., Wound Care Nurse X was interviewed regarding the facility's protocol for monitoring residents' skin. Wound Care Nurse X stated, Do a skin assessment in 24 hours of admission. If I found any wounds, initiate treatment, take a picture, do an assessment, and call the doctor. Wound Care Nurse X reported that standard interventions would be implemented for residents' who have or are at risk of developing pressure ulcers and stated they would include (brand name redacted) (mattress and wheelchair seat overlay to prevent skin breakdown), turning interventions, a request for wound care consult, they come every Tuesday. Wound Care Nurse X further reported a Braden scale would be completed and weekly skin assessments would be documented in the facility's electronic medical record. When queried about the process if a skin alteration was identified by a certified nursing assistant (CNA), Wound Care Nurse X reported they would report to her and interventions would be started. It was reported that the CNA's electronic documentation system would send out an alert if skin changes were noted. At that time, Wound Care Nurse X (in the presence of the Director of Nursing - DON) was queried about R#72. Wound Care Nurse X reported R#72 had one unstageable pressure ulcer to the sacral area when he was originally admitted into the facility on [DATE]. Wound Care Nurse X reported that the following interventions were started upon admission: treatment to the wound, mattress overlay, heel protectors, and an extra pillow while in bed. Wound care Nurse X stated, He wasn't here the whole time. He was in and out of the hospital. When queried about R#72's skin upon discharge to the hospital on [DATE], Wound Care Nurse X reviewed R#72's clinical record and reported that R#72 was evaluated by the consulting wound care Nurse Practitioner (NP) on 5/14/19 and at that time it was documented R#72 had an unstageable pressure ulcer to the sacrum and blanchable redness to the left hip. At that time, foam dressing to the left hip was ordered. When queried about how residents were monitored to ensure staff were implementing the interventions to prevent pressure ulcers, the DON stated, They turn him every two hours. He has poor nutritional status. The DON was asked how it was known that staff were turning R#72 every two hours. The DON stated, They don't log it. The nurses know who is at risk and they give that information to the CNAs. They are expected to check and change, and turn. I think he (R#72) just wasn't absorbing his nutrition which is why we tried to get him a PEG (Percutaneous Endoscopic Gastrostomy) tube. All weekly skin assessments were requested for R#72 at that time as the electronic medical record (EMR) organized the skin assessments by each wound and not by date. The DON stated, There is different stuff in every tab. I don't map the (name of EMR software). R#72's clinical record and hospital records were reviewed and revealed the following: A Nursing Comprehensive Evaluation dated 5/8/19 (admitted ) documented R#72 was a two person assist for transfers and bed mobility. The Skin section documented R#72 had a wound with slough and eschar, mod (moderate) serous (thin, watery) drainage to the sacrum. No other wounds were documented at admission. A Skin/Wound Progress Note dated 5/8/19 written by Wound Care Nurse Y documented, Resident admitted with Sacral UTD (unable to determine) .Notified MD and orders to continue (name brand for an ointment that removes dead tissue from a wound, also called [MEDICATION NAME] - generic name [MEDICATION NAME]) QD (every day) initiated and skin interventions: (brand name mattress overlay), (brand name wheelchair cushion overlay), heel protectors, extra pillows and wedge given to aide in positioning while in bed. A Physician order for [REDACTED]. A Physician Note dated 5/9/19 and 5/13/19 did not acknowledge the Stage 4 pressure ulcer to R#72's sacrum. A Skin/Wound Progress Note dated 5/14/19 written by Wound Care Nurse Y documented, Resident was seen by wound care NP today. Sacrum UTD is stable at this time. (R#72) does have some blanchable redness to left hip and foam dressing ordered 3x/week for protection. No changes in sacral wound treatment .Care plan reviewed and skin interventions in place . A Wound Care Consult completed by the consulting wound care NP dated 5/14/19 was reviewed and documented, .At the time of admission he was noted to have a significant sacral wound .Skin: sacral wound 8.3 (centimeters - cm) x 8.4 (cm) by UTD minimal amount of serosanguineous (watery drainage mixed with blood) drainage no clinical evidence of infection surrounding tissue is intact the base is covered with dark and nonviable tissue .Ulcer of sacral region, unstageable .Plan: Recommend: Treat sacral wound with ([MEDICATION NAME] ointment) covered with moist gauze and ABD pad change daily and as needed. (Mattress overlay) to his bed for more aggressive pressure downloading. Continue the nutrition monitoring and interventions . The wound care consult did not document or address the blanchable redness to R#72's left hip as documented in the progress notes. A Total Body Skin assessment dated [DATE] documented, No new issues to report at this time. A SBAR Summary dated 5/18/19 documented R#72 was sent out to the hospital for further evaluation due to a change in mental status. Hospital records for R#72's hospital admission from 5/18/19 through 5/30/19 were reviewed and revealed upon admission on 5/18/19 R#72's left hip was assessed as being a Stage 2 pressure ulcer. (There was no documentation of R#72's left hip in the facility's clinical record besides the note on 5/14/19 that documented blanchable redness.) A Discharge Summary documented, .Discharge Diagnoses: [REDACTED]. Unstageable coccygeal ulcer 2). Right hip deep tissue pressure injury 3). Left hip stage 2 Coccyx: Cleanse with Dermal Wound Cleanser, pat dry, apply Triad (a wound dressing that absorbs excess drainage while maintaining a moist wound environment) and cover with Large Allevyn Foam (a border foam dressing). Apply Triad BID (twice a day) and change Foam Q 3 days and PRN (as needed) . On 5/29/19, R#72 received a Sharp debridement of sacrum. The post debridement measurements of the sacral pressure ulcer were documented as 12.0 (cm) x 11.0 cm x 0.3 cm .Findings: Eschar tangentially removed from the wound bed with the use of a #15 scalpel to the depth of muscle. Physician's orders upon readmission to the facility on [DATE] were reviewed and revealed the following order for treatment of [REDACTED]. (The hospital discharge documented recommended Triad BID with Allevyn foam dressing). A Skin/Wound Progress Note dated 5/30/19 and written by Wound Care Nurse Y documented, Resident wound assessment completed and MD notified. New orders for treatments. Skin interventions in place including (mattress and wheelchair cushion overlays), heel protectors, extra pillows and wedges to aid in positioning . The progress note did not document any specific information about the wounds or treatments. A Nursing Comprehensive Evaluation dated 5/30/19 (readmission) was reviewed and documented the following in the Skin section: .Right trochanter (hip) desiccated blister .Left trochanter (hip) open area .Sacrum open area with necrosis .Other (specify) bilt (bilateral) heels blanchable redness and mushy . The Nurse's Note section documented, .He has multiple open areas to sacrum and bilt hips . A Skin & Wound Evaluation dated 5/31/19 for the right hip present upon readmission to the facility on [DATE] documented the type of wound as Pressure and Deep Tissue Injury . It was documented the wound was present since 5/30/19 upon admission into the facility and measured 3.3 cm in length, 1.3 cm in width. The rest of the evaluation was left blank, including treatment and interventions. A Skin and Wound Evaluation dated 5/31/19 for R#72's right heel documented that the wound was a pressure sore, deep tissue injury present on admission into the facility on [DATE] and it measured 1.9 cm in length by 2.4 cm in width. The rest of the evaluation was left blank. A Physician Note dated 6/3/19 documented R#72's prognosis as fair and did not document anything regarding R#72's additional pressure ulcers and/or the sacral pressure ulcer. A Wound Care Consult note dated 6/4/19 at 10:00 [NAME]M. documented, .At the time of admission he was noted to have a significant sacral wound, and heel and hip breakdown. Treatments were implemented. Pressure downloading interventions implemented .sacral wound 9.0 (cm) x 8.2 (cm) by UTD minimal amount of serosanguineous drainage no clinical evidence of infection .the base is covered with dark and nonviable tissue (the hospital records documented the sacral wound was debrided and the eschar was surgically removed) .Right hip is a desiccated (dried out) blister 2.8 x 1.3 cm no drainage .Left hip wound 1.0 x 0.9 x 0.1 cm scant amount of serosanguineous drainage .Right heel desiccating blister 1.3 x 2.0 cm no trauma .[DIAGNOSES REDACTED].Decubitus ulcer of left hip, stage 2 .Deep tissue injury right hip, right heel .Plan: Recommend: Treat sacral wound with (Collegenase) covered with moist gauze and ABD pad change daily and as needed Treat right hip, left hip with foam dressing change 3 times a week and as needed Treat right heel wipe with skin prep cover with foam dressing change 3 times a week and as needed. Continue current pressure downloading interventions . A Nurses Note dated 6/4/19 at 5:46 P.M. documented R#72 was transferred to the hospital with a concern [MEDICAL CONDITION]. A Nurses Note dated 6/17/19 documented R#72 was readmitted into the facility on that date. A Skin/Wound Progress Note dated 6/18/19 documented, Resident was assessed by wound NP today . A Physician Note dated 6/24/19 documented, .Infected sacral decub stage 4. Wound care team claims the wound has increase slough since 48 hours. Wounds are looking worse . (There was not documentation in the progress notes and no skin assessments provided by the facility that documented any increased slough or worsening of the sacral wound). A Skin & Wound Evaluation dated 6/24/19 documented a facility acquired pressure ulcer/DTI to R#72's left ischial tuberosity (sit bone) that measured 3.6 cm in length by 3.0 cm in width. A Nurses Note dated 6/25/19 documented, Patient returned from (hospital name) at (3:30 P.M.) 6/25/19. Sent out earlier this morning for [MEDICAL CONDITION] .hospital gave no new orders at this time, discharge papers noted the clinical impression was Leukocytosis, unspecified (elevated white blood cell count). On 6/25/19, Nurses Note revealed documentation of when R#72 was turned and to what side. A Physician Note dated 6/26/19 documented, .Infected sacral decub stage 4. Wound care team claims the wound has increase slough since 48 hours. Wounds are looking worse. Patient was transferred to (hospital name) for leukocytosis and infected wounds . A SBAR Summary indicated R#72 was transferred to the hospital on [DATE]. Hospital records revealed a Discharge Summary that documented a [DIAGNOSES REDACTED]. Recommendations documented, Patient should continue to be on (brand name redacted) bed (an air fluidized therapy bed for patients with serious wounds), patient does not have any turning surfaces .Stage 4 sacrococcygeal cleanse with dermal wound cleanser, pat dry, apply Triad Nickel Thick, lightly moisten 2- 4x4 gauze with saline and fill dead space cover with large size Allevyn Foam .Left trochanter, Left ischium, Right trochanter pressure injuries cleanse daily with dermal wound cleanser, pat dry, apply Triad Nickel Thick, cover with Allevyn Foam. Re-apply a second application of Triad, Triad does not have to be removed between applications .CT pelvis showed interval erosion of the bone near the sacrococcygeal junction . R#72 was readmitted into the facility on [DATE]. Physician's orders did not include a therapy bed as recommended by the hospital or the recommended treatment of [REDACTED]. Treatments for the sacrum pressure ulcer, right hip, left ischium, and left hip were to cleanse with normal saline, pat dry and apply [MEDICATION NAME], moistened normal saline gauze and foam dressing every day shift. At the time of this readmission into the facility, R#72 had a total of approximately 16 pressure ulcers. On 7/29/19 at 9:50 [NAME]M., Wound Care Nurse Y was interviewed. Wound Care Nurse Y reported that residents skin was assessed by the floor nurses assess residents' skin weekly and if there were impairments, they would notify Wound Care Nurse Y. When queried about who checked residents' skin on the other days of the week, Wound Care Nurse Y stated, CNAs see residents' skin on a daily basis during care and showers twice a week. If there is something new they tell the nurse and the nurse will tell me or the doctor. Then treatment is implemented. Wound Care Nurse Y did not offer an explanation of why R#72 was assessed to have a Stage 2 pressure ulcer upon admission to the hospital, but it was not identified at the facility. Wound Care Nurse Y reported that no changes to R#72's left hip were reported to her and on 5/14/19 an order for [REDACTED]. A review of the Treatment Administration Record (TAR) revealed the treatment to R#72's left hip was administered on 5/16/19. Wound Care Nurse Y reported R#72 was readmitted into the facility on [DATE] with the following pressure ulcers: 1. Stage 2 to left hip 2. DTI to right hip 3. DTI to right heel 4. Stage 1 to right calf 5. Unstageable to sacrum When queried about any new interventions that were implemented after R#72 returned to the facility with multiple pressure ulcers, Wound Care Nurse Y stated, Turning and repositioning. The family would only let us use their wedges and draw sheet that was used at that hospital. (Mattress and wheelchair cushion overlay), and heel protectors. When queried about any new interventions, Wound Care Nurse Y reported dietary added Liquacel (a nutritional supplement) to R#72's diet. (Physician's orders documented Liquacel had been in place since 5/9/19 when R#72 was originally admitted ). At that time, Wound Care Nurse provided a document called Unavoidable Pressure Ulcer Assessment (which was not present in the clinical record or provided during previous interviews on 7/25/19). Wound Care Nurse Y stated, I ask the physician to do one of these when residents come back with more pressure sores. Wound Care Nurse Y further reported that she would be notified if an existing pressure ulcer worsened and stated, If I am alerted about a new wound or a worsening wound, I would assess it. I would not document anything unless something changed. Wound Care Nurse Y reported that any alerts regarding wounds drop off of the EMR after a certain amount of time and therefore, there was no way to review when and who notified her of wound and skin changes. Wound Care Nurse Y reported that R#72 only developed one facility acquired pressure ulcer which was assessed by her on 6/24/19 as a DTI to the left ischial tuberosity. Wound Care Nurse Y did not know who first observed the change in skin and when they notified her. The only documentation of the new wound was from her. When queried about any change in interventions for R#72 who was admitted into the facility with one unstageable pressure ulcer that worsened with osteo[DIAGNOSES REDACTED], developed one DTI in the facility, and developed approximately 14 other pressure ulcers at some point during his stay in the facility and the hospital stays, Wound Care Nurse Y stated, He had an extensive sacral wound and then developed wounds on his hips. When we laid him on his side he had muscle spasms. We had a hard time repositioning him. He was very hard to turn. It was reported that no additional interventions besides dietary changes were implemented. When queried about any discussion about a change in type of mattress per the hospital's recommendation due to having no turning surface (wounds on backside and both hips) or whether or not the facility was able to care for R#72's extensive wounds, Wound Care Nurse Y reported he was discussed all the time in morning meeting. On 7/29/19 at 11:50 [NAME]M., the DON was further interviewed. When queried about how R#72's skin developed 16 pressure ulcers, the DON stated, I believe he had a nutrition absorption problem. When asked if he was diagnosed by a physician with that problem, the DON reported he was not and stated, That's why we wanted him to get a PEG tube. A facility policy titled, Skin Management (revised 8/2016) documented, .If a new area of skin impairment is identified, notify the resident, responsible part, attending physician, DON and treatment team, if applicable .The licensed nurse will notify the attending physician with any changes as needed .A Resident at Risk meeting will be conducted weekly by the Interdisciplinary Team (IDT. During the meeting, the IDT will evaluate resident skin changes, review treatment modalities, interventions and will make recommendations as needed .Residents reviewed for skin alterations are as follows: newly developed .pressure injuries .Any pressure .area that has shown no signs of healing within a two-three-week time frame .New admissions & readmission with skin conditions .

This citation pertains to Intake # (s): MI 307 and MI 500. Based on observation, interview and record review, the facility failed to consistently assess, monitor and implement ordered pressure ulcer treatments and interventions for three (R#702, R#704 and R#706) of three residents reviewed for pressure ulcers, resulting in the development of a stage 4 pressure ulcer for (R# 702) and the increased likelihood for the worsening of a pressure ulcer for (R#704 and R#706). Findings include: Resident #702 On 5/7/19, review of a complaint submitted to the State Agency included concerns of the facility failing to prevent pressure sores. On 5/7/19 at 9:47 A.M., a phone interview was conducted with R#702's legal guardian who alleged, During a care conference call around the end of (MONTH) they (the facility staff) said that she (R#702) wasn't doing any better and wanted to take her off of physical therapy and start restorative services. I told them if that's the case she can be discharged back home with us, if they weren't going to provide her with the services that she needed. Thats when they (facility staff) said, We need to keep her here for wound care. I asked her if she meant a wound like a bed sore and she stated, 'a pressure ulcer.' I asked her to clarify that for me because I don't know what a pressure ulcer is. She then told me that she had a wound on her buttocks. I wasn't informed about this wound. I was aware of some scrapes on her elbows that they referred to as wounds but not about her bottom area. When I asked how long it would take to heal they told me, 'Seven to 10 days.' So I thought it was something little, like a size of a nickel or something. I had my sister go there to visit my mother and take a picture to send to me and the picture looked like my mother was shot in the butt. That's when I pulled her out of that facility and had her sent to the hospital. On 5/7/19, an onsite investigation into the complainant's allegation was conducted. R#702's clinical record was reviewed and revealed the following: R#702 was admitted into the facility on [DATE], with a readmission date of [DATE]. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented R#702 had moderately impaired cognition and required extensive assistance with a two persons physical assist for bed mobility, transfer, eating, bowel/bladder, one unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar and one stage 3 pressure ulcers. A nursing summary note dated 1/5/19 at 17:00 documented, Note text: Resident readmit from (hospital name redacted) per ambulance. Received awake and verbal. denies comfort. total care with adls (activity of daily living). inc (incontinent) of bowel and bladder. Has left elbow skin tear. Sacral and coccyx area excoriated. Review of the Nursing comprehensive admission evaluation form dated 1/5/19 documented, excoriation to coccyx and sacrum, however there was only a skin breakdown care plan implemented for the open wound to left elbow. Review of the wound documentation revealed there was no documentation of a physician being informed of R#702's sacral and coccyx excoriation upon readmission into the facility until 1/6/19 at 12:38 P.M A skin/wound progress note dated 1/6/19 documented, Note text: Upon skin assessment, resident has left elbow wound. Resident has left elbow wound. Resident has history of admission to facility and was seen by wound care practitioner for the same wound. The wound etiology is pressure injury stage 3. No clinical s/s (signs/symptoms) of infection noted. Also, there are pressure injury wounds noted on coccyx/ upper left buttock and right upper buttock. No s/s of infection noted. Sacrum area and heels are bilaterally intact. Resident denies any pain or discomfort at affected areas. MD (medical doctor) is notified. Treatment is initiated. Wound care consult is requested. Care plan is updated. A physician's orders [REDACTED]. Spread Santyl ointment on the moistened with NS gauze and apply on the wound bed. Cover with Sacral Foam Dressing daily and PRN every day shift for Wound care. and Clean RIGHT buttock wound with NS. Apply Hydrogel to the wound. Cover with Foam Dressing daily and PRN (as needed), every shift for wound care. On 1/7/19 a physician's note documented, .SKIN, ABRASIONS, BILAT (bilateral) ELBOWS, HEELS INTACT .WOUND CARE CONSULTED. A wound care consult dated 1/8/19 documented, Chief complaint: Left elbow and coccyx wounds .I was referred by (doctor name redacted) consult regarding this patient's left elbow and coccyx wounds .At the time of admission she was noted to have a wound on her left elbow and coccygeal region. Topical treatments were recommended. Pressure downloading interventions .She has an open area running from her coccyx down bilateral buttocks. The entire region measures 4.5 x 10.4 x utd (unable to determine) centrally. Minimal amount of serosanguineous drainage no clinical evidence of infection surrounding tissue is intact base has central documents necrotic tissue with granular tissue off to the sides on the buttocks regions .Decubitus ulcer of coccygeal region, unstageable .Recommend .Treat coccyx wound Santyl to central necrotic region cover with hydrogel gauze to the entire area then cover with ABD (abdominal) pad change daily and as needed. Continue all other current interventions. A physician order [REDACTED]. Apply Santyl to base then cover with hydrogel gauze and cover with foam dressing. A Treatment Administration Record dated 1/1/19-1/31/19 documented treatment provided to the coccyx wound with ordered [MEDICATION NAME] ointment. On 1/14/19 there was a blank entry on the record with no initials or code documented (which indicated that no treatment was provided on that day). A wound care consult dated 1/15/19 documented, .She has an open area running from her coccyx down bilateral buttocks. The entire region measure 4.6 x 8.9 x utd centrally. Minimal amount of serosanguineous drainage no clinical evidence of infection surrounding tissue is intact base has central necrotic tissue with granular tissue off to the sides on the buttocks regions .Decubitus ulcer of coccygeal region, unstageable .Recommend .Treat coccyx wound Santyl to central necrotic region cover with calcium algonate to the entire area then cover with ABD pad change daily and as needed. Continue all other current interventions. A physician's orders [REDACTED]. Apply Santyl ointment on Calcium Alginate gauze and apply to the wound base. Apply skin prep to periwound area. Cover with FOAM dressing daily. A Treatment Administration Record dated 1/1/19-1/31/19 documented treatment provided to the coccyx wound with ordered [MEDICATION NAME] ointment. On 1/20/19 there is a blank entry on the record with no initials or code documented, which indicates that no treatment was provided that day as ordered. Further review of R#702's clinical record revealed there was no documentation regarding the worsening of the wound or notification that the wound nurse practitioner had been notified from the period of 1/15/19 to 1/22/19. A wound care consult dated 1/22/19 revealed, .She has an open area running from her coccyx down bilateral buttocks. The entire region measures 7.8 x 10.9 x 2.6 .@1000 3.2 Moderate amount of serosanguineous drainage no clinical evidence of infection surrounding tissue is intact base has central necrotic tissue with granular tissue off to the sides on the buttocks regions .Decubitus ulcer of coccygeal region, unstageable .Recommend .Treat coccyx wound Santyl to central necrotic region cover with calcium algonate to the entire area then cover with ABD pad change daily and as needed. Continue all other current interventions. A skin/wound progress note dated 1/22/19 documented, Resident has been seen by wound care practitioner for left elbow and sacrum PI (pressure injury) wounds evaluation. Left elbow wound is improving. Sacral/coccyx wound has depth now, and still unstageable due to slough at the wound base. No s/s of infection noted. Treatment is not changed. Care plan is up to date. A physician's orders [REDACTED]. Apply Santyl ointment on Calcium Alginate gauze and apply to the wound base. Apply skin prep to periwound area. Cover with ABD pad. Secure with tape DAILY. A wound care consult dated 1/29/19 documented, .She has an open area running from her coccyx down bilateral buttocks. The entire region measures 6.7 x 8.8 x 3.2 .7-1, 3.2 Moderate amount of serosanguineous drainage no clinical evidence of infection surrounding tissue is intact base has central necrotic tissue with granular tissue off to the sides on the buttocks regions. The proximal one third of the wound was found to be covered anesthetized with 20% bezocaine I was able to surgically excisionally debride this with a scalpel down into viable subcutaneous tissue estimated blood loss less than 5 cc (cubic centimeter) patient tolerated the procedure well .Decubitus ulcer of coccygeal region, stage 4 .Recommend: Treat coccyx wound Santyl to central necrotic region cover with calcium algonate to the entire area then cover with ABD pad change daily and as needed. Continue all other current interventions. Review of the physicians orders and treatment administration record revealed there was no implementation of the newly recommended coccyx treatment order as indicated in the 1/29/19 wound care consultation. A skin/wound progress note dated 1/29/19 documented, Resident has been seen by wound care practitioner for the left elbow and sacrum PI wounds evaluation. Left elbow wound is improving. Sacral/coccyx wound was debrided with sharp by wound care NP (Nurse Practitioner). Wound stage is changed to stage 4 with undermining 3.2 cm No s/s of infection noted. Treatment is not changed. Care plan is up to date. continue with current interventions. A nursing progress note dated 2/3/19 documented, POA- power of attorney (daughter) request mom to be sent to the hospital; regarding mental status change and concern regarding ulcer of the coccyx. A care plan initiated 1/6/19 and revised 1/30/19 titled impaired skin integrity related to Left elbow stage 3, Coccyx PI STAGE 4 documented, Observe for signs of infection related area(s) (i.e. temperature increases, increased drainage or odor) and report abnormal findings to the physician. A care plan initiated 1/6/19 titled risk for skin breakdown/pressure ulcers or further breakdown r/t (related to) Actual pressure ulcer, Decreased mobility, Incontinence documented, Administer treatments as ordered and observe effectiveness. On 5/7/19 at 2:40 P.M., Wound Nurse Practitioner (WNP) C was interviewed by phone. When asked if staff observed a change in residents' wounds, such as the worsening of, or any changes in between her weekly wound consulation visits, what is the process for notificaiton, WNP C reported, The staff know to call my cell phone. I am available 24/7. On 5/7/19 at 2:50 P.M., the Director Of Nursing (DON) was interviewed regarding R#702's wound care, however the DON was unable to offer any input and reported she was not employed at the facility at that time. The DON did report, The expectations that when a resident is readmitted into the facility, the primary nurse for that resident should inform the physician of any abnormal findings when they call to reconcile the medication orders. The DON also stated, It is the resident's primary nurse responsibility to inform the WNP of worsening of the wound and to also inform family of any medical changes. Resident#706 On 5/7/19 at 10:12 A.M., an observation of R#706's wound care treatment provided by a Certified Wound Nurse (CWN) A was conducted. It was observed that the wound patch on R#706's right buttock documented 5/2/19 with the initials (initials redacted). As CWN A prepared to remove the previous wound patch on R#706 right buttock, CWN A was asked to confirm the date documented on the patch. CWN A replied, It says 5/2/19. A review of the clinical record of R#706 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. MDS assessment dated [DATE] documented R#706 had moderately impaired cognition and there were no unhealed pressure ulcers. There was no care plan developed specifically for R#706's right buttock pressure ulcer. A physician's orders [REDACTED]. Apply Hydrogel to the wound. Cover with foam dressing. every day shift every Tue, Thu, Sat for wound care. The Treatment Administration Record dated 5/1/19-5/31/19 revealed the above treatment to the right buttock wound documented as administered with initials documented on the date of 5/4/19. On 5/7/19 at 11:40 A.M., CWN A was interviewed and was asked about the initials observed documented for R#706's right buttock wound care on 5/4/19. CWN A confirmed that it was their initials documented for that day. When asked how wound care was provided on 5/4/19 as documented, if the patch that was removed on 5/7/19 was dated 5/2/19. CWN A stated, I actually worked this Saturday and a lot of treatments was on that set. The nurse for the floor usually rounds with me and we do the wound treatment together. I don't remember how that happened or why it wasn't done. The DON was interviewed on 5/7/19 at 1:04 P.M., when informed of the wound care treatment that wasn't performed but signed off by CWN A, the DON was queried regarding the expectation of the nursing staff or CWN when documenting on wound care. The DON stated, It should be changed as ordered by the physician, unless the resident refused then that should be documented. Resident #704 On 5/7/19 at 8:30 AM, review of the facility's documentation of residents with pressure ulcers identified R#704 as having a facility acquired pressure ulcer to the left heel, which was unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Eschar is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like; Slough is non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture). On 5/7/19 at 10:20 AM, R#704 was observed lying in bed with both feet covered by a sheet. R#704 gave permission to observed the feet under the covers which revealed heel protectors (padded boot like covering) were applied to both feet. When asked about whether he had any open wounds, R#704 stated, It's my left foot (heel). They showed my a picture of it. When asked about the use of the heel protectors, R#704 stated, They've put these booties on to keep air flowing. I don't get out of bed much. I can't walk. When asked if he had been admitted with the wound on the left heel, R#704 stated, No. On 5/7/19 at 10:30 AM, an observation of R#704's wound was completed with Wound Care Nurse A. At that time, upon removal of the gauze bandages, the resident's left heel was observed to have a nickel sized black scab. The treatment was provided and the resident did not have any voiced pain during this observation. R#704's clinical record was reviewed and revealed the following: R#704 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment dated [DATE], R#704 had intact cognition (scored 14/15 on mental status exam), required extensive assistance of two people for bed mobility, was totally dependent upon two people for transfer, was at risk for developing pressure ulcers, and or more unhealed pressure ulcers, and had an unstageable deep tissue injury (Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface.) Review of the care plans included, (R#704) is at risk for impaired skin integrity/pressure injury R/T (related to): Decreased mobility, hx (history) [MEDICAL CONDITION] lesion to right lower leg; Incontinence. This had been initiated on 1/30/19 and revised on 5/1/19. Interventions included: Braden scale per protocol (initiated 3/19/19) Conduct weekly head to toe skin assessments, document and report abnormal findings to the physician. (initiated 3/19/19) Cue to reposition self as needed (initiated 2/1/19; At that time, R#704 required extensive assistance of two people for bed mobility.) Encourage to wear heel protectors on while in bed and assist as needed (revised on 5/1/19) (The original intervention initiated 2/1/19 read, Encourage to float heels while in bed and assist as needed.) roho mattress to bed (initiated 5/1/19) Review of the current physician ordered treatment included: Santyl Ointment 250 Unit/GM (gram) apply to left heel topically every day shift for wound care. Cleanse left heel with NS (normal saline), apply Santyl then moistened NS gauze and cover with dry bulky dressing. Review of R#704's Treatment Administration Records identified the blank and/or unavailable supporting documentation which did not indicate if the treatment had been provided as ordered. On 2/12/19, the TAR entry was coded 5 (which indicated Hold/See Nurse Notes however review of the interdisciplinary notes revealed no available documentation. On 2/16/19, the TAR entry was left blank. On 5/7/19 at 11:40 AM, an interview and record review was conducted with Wound Care Nurse A. When asked to identify when the pressure ulcer was first identified, Wound Care Nurse A reviewed the clinical record and reported, It was started on 2/5/19. When asked what interventions had been implemented and when, Wound Care Nurse A accessed the care plan section. Upon review of the documentation that identified when care plan interventions were initiated and/or revised, Wound Care Nurse A revealed there was an initial intervention and two revisions, all implemented by Wound Care Nurse A which read, on 2/1/19 Encourage to float heels while in bed and assist as needed, on 2/8/19 Heel protectors on while in bed and assist when needed, and on 5/1/19 Encourage to wear heel protectors on while in bed and assist as needed. When asked about the delay in identification of the heel protectors (three days after the wound was identified), Wound Care Nurse A reported, Usually I put everything in place, then sit down and document later. When asked how it could be verified that the intervention for the heel protectors had been implemented on 2/5/19 upon discovery of the wound, despite documentation that reflected it had not been entered into the clinical record (so that direct care staff were aware of the added intervention) until 2/8/19, Wound Care Nurse A confirmed the discrepancy with the dates and offered no further explanation. Additional record review with Wound Care Nurse A included the resident's Nursing Comprehensive Evaluation assessment dated [DATE] which identified no skin concerns upon admission for the left heel. There were two areas of identified skin conditions which read, Site .Coccyx .Description .dent in area not open and Site .Right lower leg (front) .Description .right and left lower leg discoloration. Review of the initial wound consult with Wound Care Consultant, Nurse Practitioner (NP C) dated 2/5/19 documented, in part: .I was referred by .to consult regarding this patient's left heel wound .Today on routine skin check he was found to have a darkened area on his left heel. I was asked to evaluate the region. He is complaining of some tenderness to the area but no pain .Arterial: Normal carotids. Normal pedal pulses. Normal femoral artery .No [MEDICAL CONDITION] or varicosities .Left heel has a blood blister measuring 1.5 x 1.4 cm (centimeters) no drainage no clinical evidence of infection surrounding tissue is intact .Cooperative with exam .A&O (alert and oriented) x 3 (to person, place and time) .Recommend: Treat left heel blood blister .He now has heel lift pressure offloading boots to be worn while in bed . (There was no documentation to reflect the heel boots had been implemented until 2/8/19; nor was there any available documentation that this pressure ulcer was clinically unavoidable.) On 5/7/19 at approximately 2:00 PM, the Director of Nursing (DON) was informed of the concerns regarding R#704's facility acquired pressure ulcer and reported she had only been at the facility for about two weeks and would be following up. When asked about the facility's expectation regarding complete documentation to ensure the treatments were provided as ordered and informed of the concern identified on 2/12 and 2/16, the DON reported there should be a note from the nurse as to what did or did not occur, and was unable to offer any further explanation as to the blank entry. At that time, the DON was requested to provide any additional documentation regarding R#704's pressure ulcer, including progress notes and wound care consultations, however only the initial wound consultation was provided and there no progress notes provided by the end of the survey. Review of the facility's Skin Management policy dated Revised: 8/2016 documented, in part: It is the policy of the facility that a resident does not develop pressure injury unless clinically unavoidable .Appropriate preventative measures will be implemented on residents identified at risk (a score of 18 or less on the Braden Scale) and the interventions are documented on the care plan .The licensed nurse will initiate documentation <sic> the electronic health record, which includes a description of the pressure and non-pressure injury .The licensed nurse will document preventative measures on the care plan/kardex .If a new area of skin impairment is identified, notify the resident, responsible party, attending physician, DON and treatment team, if applicable .Resident's with pressure injury will be assessed, measured and staged weekly in accordance with the practice guidelines until healed .The licensed nurse will notify the attending physician with any changes as needed .

This citation pertains to intake #MI 22 Based on interview and record review, the facility failed to use a two person assist during repositioning in bed based on the resident's assessed needs for one resident, (R#707) of two residents reviewed for accidents and falls, resulting in the resident rolling out of the bed and sustaining a femur fracture and a decline in mobility. Findings include: A review of R#707's clinical record was conducted and revealed an admission date of [DATE] and a re-admission date of [DATE] with [DIAGNOSES REDACTED]. A review of R#707's quarterly Minimum Data Set (MDS) assessment dated [DATE] was conducted and revealed severely impaired cognition and extensive assistance from two staff members for transferring and bed mobility. It was noted on the MDS assessment in Section G Functional Status, Bed mobility, the coding instructions read, Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture . A review of R#707's care plan and care guides was conducted, however; neither indicated R#707's bed mobility or transfer status. A review of the nursing progress notes was conducted, and a note dated 11/18/18 by LPN 'B' read, Informed by can <sic> that during adl care (activity of daily living) at 1830 (6:30 PM) resident rolled out of bed on to the floor landing on her left side .c/o (complaints of) left shoulder, left side of chest, left hip and left temporal pain .facial grimacing and moaning observed .mild swelling noted to left upper thigh area .radiographs were obtained with results noted of an intertrochanteric femoral fracture . On 2/5/18 a review of a facility provided investigation file for a fall sustained by R#707 on 11/18/18 was conducted. A review of the staff interviews included the following: Certified Nursing Assistant (CNA) 'A'- I went into the room to assist (with) feeding (R#707). I observed her on the edge of the bed. I assisted her in the center of the bed then turned around to call for assistance when she rolled onto the floor . Licensed Practical Nurse (LPN) 'B'- I heard a scream and went around the corner. I entered the resident's room and observed (R#707) on the floor next to the bed on her left side. I asked what happened and the CNA stated, 'She rolled out of the bed.' A review of an x-ray dated 11/18/18 for R#707's left hip was conducted and read, .Results: Intertrochanteric LEFT femoral fracture .Mild soft tissue swelling .Conclusion: Acute intertrochanteric LEFT femoral fracture as noted . A document titled, Post Fall Evaluation in the investigation file was reviewed and and read, .4. Fall Summary: Observed on the floor (unwitnessed) .Re-Creation of Last 3 Hours Before Fall: Resident rolled out of bed during ADL care .Re-enactment of fall .Resident rolled out of bed during ADL care . A review of CNA 'A's personnel file was conducted and a document titled, DISCIPLINARY ACTION RECORD WORK RULES was reviewed and read, Specific Plan for Improvement, including timeline (to be completed by supervisor): CNA re-educated on the importance of not taking her eyes off a resident that may be at risk for falling. Rather utilizing the call light for assistance . On 2/5/19 at 3:05 PM, and 4:05 PM, phone calls were placed for an attempted interview with CNA 'A'; however no-one answered and there was no option to leave a voicemail. On 2/5/19 at 5:05 PM, an interview with the facility's Director of Nursing (DON) was conducted regarding R#707's fall resulting in a femur fracture. The DON was queried about the incident and explained that CNA 'A' was not R#707's assigned CNA and she entered the room to assist with feeding R#707. When CNA 'A' saw R#707 positioned on the edge of the bed she repositioned her in the bed and exited the room to get assistance from another CNA to provide incontinence care for R#707. When queried if CNA 'A' repositioned R#707 by herself the DON indicated she did. When the DON was queried which side of the bed R#707 was positioned on and which side she rolled out of, the DON indicated she didn't know. When queried if CNA 'A' should have called for assistance to re-position R#707 considering her bed mobility status was extensive two person assistance, the DON indicated she didn't think repositioning someone in bed was considered bed mobility. A review of a facility provided policy titled, Fall Management with a revision date of 8/2016 was conducted and read, Policy The facility will identify hazards and resident risk factors and implement intervention to minimize falls .A plan of care is developed and implemented . The facility was asked if they had any additional information regarding the concern and none was received the end of the survey.

This citation refers to Intake(s): MI 317 Based on observation, interview, and record review, the facility failed to transfer one (R#804) of two residents reviewed for accidents, in a safe manner, resulting in the resident falling and sustaining two lower femur fractures above both knees that required surgical repair, loss of mobility, continuous unresolved pain, and a cancelled discharge home. Findings include: A complaint was received by the State Agency. A phone interview with the complainant was conducted on 12/10/18 at 8:33 A.M. The complainant stated, I am trying to get some records. There was an accident at (facility name) in August. The wheelchair wasn't locked and when I turned and went to sit down, the wheelchair went flying. I got two broken legs. I've been in severe pain for 3 months. They keep changing the story. When asked how many people were assisting the resident, the complainant stated, There was one girl, but when they lifted me off the floor after I fell there were about three. On 12/10/19 R#804's clinical record was reviewed and revealed the following: R#804 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set (MDS) assessments dated 9/13/18 and 6/15/18 documented R#804 had intact cognition and was totally dependent upon assistance of at least two staff members for transfers. The MDS dated [DATE] documented R#804 required extensive assistance from at least two staff members for toilet use and did not have any range of motion impairment to the upper or lower extremities. The MDS dated [DATE] documented R#804 was totally dependent on at least two staff members for toilet use and had range of motion impairment to both lower extremities. A progress note written by Nurse F dated 8/3/18 at 12:23 P.M. documented, Resident was being assisted from bed to chair with the assist from staff when resident lost her balance and fall down to the floor on right side .Resident c/o (complained of) bilateral pain to knees .new order for x-ray to bilateral knees .At this time discharge to home is on hold. A progress note dated 8/3/18 at 10:29 P.M. documented, X ray completed and results received. Resident has fracture. Sent out to hospital. On 12/10/18 at 4:37 P.M., an Incident and Accident Report (I&A) for R#804 was reviewed and revealed the following: On 8/3/18 at 11:40 A.M., the I&A documented, Resident was being assisted from bed to chair with the assist from staff when resident lost her balance and fall down to the floor on the right side. The assigned CNA (Certified Nursing Assistant) was CNA E. CNA E and CNA D were noted as witnesses. It was documented the physician ordered x-rays to both knees. Interventions documented R#804 was transferred to the hospital. A Post Fall Evaluation dated 8/3/18 completed by Nurse F documented, .What did the resident say they were trying to do just before they fell ? Resident was transferring from bed to w/c (wheelchair) .Factors observed at time of fall .Resident lost their balance .Describe the position the resident was observed .on right side .What was the resident doing during or just prior to fall? .Transfer assisted by staff .Resident alert and oriented times 3 .no change in mental status .Gait Assist devices at time of fall: (this was left blank) . The section for re-enactment of fall (to be done if root cause is not determined) was left blank. The initial intervention was documented as xray STAT. An Incident and Accident Investigation Form signed 8/6/18 by the former Director of Nursing (DON) was reviewed and revealed the following: The date of the alleged incident was 8/3/18 at 11:40 A.M. in R#804's room. A Brief Description of the Incident documented, (R#804) fell forward onto the floor while she was being transferred by two CNA's into wheelchair for discharge. Under the investigation section it was documented that the resident involved in the alleged incident was not questioned (it was documented still at hospital). It was documented that CNA D, CNA E, and Nurse F were interviewed as part of the investigation on 8/6/18 (three days after the incident occurred). The Conclusion documented, (R#804) was being assisted by two CNAs preparing for discharge when she went to sit down on the wheelchair she fell forward onto the walker. A Quality Assurance Interview Summary signed by the former DON documented the following: The Summary of Resident Interview was left blank. A Summary of Staff Interviews documented the following: A Summary of Statement/Interview with CNA D on 8/6/18 documented, Assisting (CNA E) getting (R#804) out of the bathroom. (R#804) was using the walker about to sit down into the wheelchair and she fell forward half onto the bed and half onto the floor she was face down. Went to go get Nurse and assisted her into the chair transportation was there to get her she only c/o knee discomfort. A Summary of Statement/Interview with CNA E on 8/6/18 documented, (CNA D) and I assisted (R#804) onto the toilet. She was using walker and quit (CNA D) and I assisting the wheelchair was right outside the bathroom door She went to sit down onto the wheelchair and then just feel forward onto her knees and then onto her side. Immediately went to get the nurse (Nurse F), took vitals and placed her back into the chair. She stated her leg hurt. A Summary of Statement/Interview with Nurse F on 8/6/18 documented, (CNA E) came to get me stating the (R#804) had fallen. Immediately went into room assessed (R#804). She only c/o leg pain, no usual abnormalities able to move all extremities put her in the wheelchair gave her pain medication and notified physician and ordered x-rays held discharge pending x-ray results. A Radiology Results Report dated 8/3/18 documented R#804 had an X-ray completed on both knees. The results for the Left knee documented, The key [MEDICATION NAME] fracture distal femoral shaft with superior and posterior displacement Osteopenia (loss of bone density). Soft tissue swelling .Conclusion: Acute displaced fracture follow-up recommended. The Right knee results documented, Incompletely evaluated comminuted fracture distal femoral shaft. Posterior displacement . On 12/11/18 at 8:11 A.M., R#804 was observed lying in bed. R#804 was interviewed at that time about the fall that occurred on 8/3/18. R#804 stated, I was going home that day. There was a nurse getting my paperwork ready. I was lying on the bed and the aide said I needed to get up to be discharged . She had me sit on the side of the bed. Brought my walker so I could hold it when I stood up. She instructed me to stand up, turn, then sit down in the wheelchair. When I went to sit down, the wheelchair went flying and I fell forward onto my legs. I heard her saying 'I'm going to get fired.' then they all came in and wanted to lift me up. I told them to leave me and call 911. They tried to lift me and couldn't do it and had to put me back down. R#804 reported she felt pain in her legs immediately after falling. R#804 reported she required two staff members to assist her with transfers. R#804 stated, The wheelchair must not have been locked the way it flew back. Otherwise it wouldn't move. R#804 stated, This happened in August. I was about to go home and now I'm still here. My walking declined. The pain was so bad. It is still really bad, but relieved with medication. When the pain starts it is at a 10 (out of 10 with 10 being the worst pain). I had to have surgery. R#804 reported that after the fall, nobody talked to her about the incident before or after the hospital transfer. On 12/11/18 at 8:48 A.M., CNA D was interviewed. CNA D reported she was not assigned to R#804 on 8/3/18. When asked if she provided any care to R#804 on 8/3/18, CNA D stated, (CNA E) was assigned to her (R#804) but I helped transfer her from the bed to the chair. When we were transferring her, she lost balance and she fell over. Her walker was in front of her, once you get her up she uses it to hold on to. We put it there before the transfer. When we picked her up we tried to hold her but we couldn't and she fell forward. I know she couldn't go home after. The lady was here to transport her. CNA D was queried about what was done after R#804 fell . CNA D stated, I got the nurse and about 4 people from the unit came to help get her up. We rolled her over and got her up into the chair. CNA D reported she could not remember how they lifted R#804 from the floor to the chair and that R#804 expressed she had pain in her legs. On 12/11/18 at 1:19 P.M., CNA E (who was no longer an employee at the facility) was interviewed via the telephone. CNA E was queried about R#804's fall on 8/3/18. CNA E reported she was assigned to the resident on that day and was present when the fall occurred. CNA E stated, I took her to the bathroom. There were two of us in the room. (CNA D) was primarily helping me. We had her in the bathroom and she was on the toilet. The wheelchair was just outside or halfway in the door. We assisted her up from the toilet. She is only supposed to be turned around. When she turned around she fell forward. My hand was on her but she is really heavy. When asked if the wheelchair was locked, CNA D stated, She never even had a chance to sit back into the wheelchair. She fell forward toward the bed and hit her knees on the floor. She hit so hard I just knew her legs broke. Me and (CNA D) rolled her over and got the nurse and then five of us assisted her into the chair. CNA D could not recall how R#804 was lifted from the floor to the chair. On 12/11/18 at approximately 11:30 A.M., the facility's Administrator and DON (who was not an employee at the time of R#804's fall on 8/3/18) were interviewed. When queried about how falls with serious injuries were investigated by the facility, the DON stated, We find out the circumstances, look at the medical record to see what kind of transfer, diagnoses, get information from the computer. When queried about who would be interviewed after a fall with serious injury, the DON stated, The nurse, CNAs, the resident, any witnesses or family. The Administrator stated, We would start an immediate investigation. I would be made aware on the day of the fall. We would speak with the resident, review the medical record, and interview and staff involved. When queried about whether or not the wheelchair was locked or if R#804 was interviewed about the fall, the Administrator and DON could not provide an answer based on the documented investigation. R#804's clinical record was further reviewed and revealed the following: A Nursing Home to Hospital Transfer Form dated 8/3/18 documented a report was called into the hospital on [DATE] at 8:08 P.M. The most recent pain level was documented as 9 (out of 10). Hospital records were reviewed and ED (Emergency Department) Notes documented, Pt presents to ER via EMS from ECF (Extended Care Facility). States she is here for 'tremendous left leg pain.' .There is tenderness to light palpitation along entire left thigh .Pt reports she cannot perform any ROM (range of motion) or muscle testing due to pain .She is alert and oriented to person, place, and time .Closed displaced supracondylar fracture of distal end of left femur without intracondylar extension .Closed displaced supracondylar fracture of distal end of right femur without intracondylar extension .Pt reports a mechanical fall and left thigh pain. She reports femur fracture noted at rehab today . A Medical Intensive Care Unit History and Physical (from the hospital) dated 8/29/18 documented, .She was admitted to (hospital name) on 8/4/18 after having a fall from standing at subacute rehab facility resulting in bilateral femur fractures. She underwent ORIF of the right femur and intramedullary nailing of the left femur with orthopedic surgery on 8/5/18 . Facility progress notes revealed the following: On 9/6/18 at 6:00 P.M. a nursing summary documented R#804 was readmitted into the facility and Resident complained of pain 8/10 in BLE (bilateral lower extremities) .Dx (diagnosis) is bilateral knee fx (fracture) . On 9/9/18 at 7:25 A.M. a Nurses Note documented, Nurse writer entered residents room and resident lying in bed flat on her back crying. nurse writer asked resident what was going on and why was she crying. resident stated, 'im hurting so bad.' nurse writer then asked where was the pain and on scale from 0-10 how bad was it hurting resident verbalized in both her knees and was a 11 to 12 out of 10 .new orders to give additional 1 x dose of [MEDICATION NAME] 5/325 (a narcotic medication to treat pain) and [MEDICATION NAME] 500mg (a muscle relaxant) x 1 now . On 9/12/18 at 9:13 A.M. a Nurse Practitioner Note documented, .chief complaint: BL leg pain .ROM limited BLE due to pain .Walking difficulty 2/2 (secondary to) Bl femur fx sp (status [REDACTED]. On 9/12/18 at 11:50 P.M., a Physician Note documented, .Patient c/o pain in her b/l LE. She states that [MEDICATION NAME] helps with the pain but effects do not last for 6 hours . On 9/16/18 at 7:02 A.M., a Nurses Note documented, RN (Registered Nurse) was called by Pt at the BS (bed side) reporting a 10/10 pain in the bi-lower extremities. PRN meds are not due till 0930 (were both given at 0330). Pt said she can't wait that long anymore. RN left voice msg to on-call MD .logged on (physician name) binder requesting for pain regimen review . On 9/16/18 at 4:07 P.M., a Nurses Note documented, Resident complains of increased pain at 11/12 .one time order for ONE TAB [MEDICATION NAME] 5325 rESIDENT REQUESTS INCREASE IN DOSAE <sic> AND OR DECREASE IN FREQUENCY . On 9/17/18 at 3:06 A.M., a Nurses Note documented, RN was called by Pt at the BS 30 minutes after she was given the PRN [MEDICATION NAME] followed by the PRN Tylenol per Pt request. Pt was crying and stated, 'the pain pills are not working.' . On 9/17/18 at 6:39 A.M., a Nurses Note documented, RN was called to the BS with Pt's report of a 10/10 pain. STAT [MEDICATION NAME] 1 Tab was given. On 9/17/18 at 7:41 A.M., a Nurses Note documented, Pt's pain remains uncontrolled despite new interventions . On 9/17/18 at 11:49 A.M., a Physicians Note documented, Requested by nursing to evaluate for uncontrolled pain. (R#804) states pain in legs not controlled over last 3 days, waking up at night with pain in legs, attributing to possible elevated activity on Friday .will add MScontin 15 mg q 12 x 7 days total . A Physical Therapy Discharge Summary for dates of service 6/9/2018-8/2/2018 (before the fall) documented at the time of discharge R#804 was assessed as Partial/Moderate Assistance for Chair or Bed to Chair Transfer and Toilet Transfer. A Physical Therapy PT Evaluation & Plan of treatment for [REDACTED].Reason for referral: Patient exhibits new onset of decrease in strength, decrease in functional mobility, decrease in transfers, reduced ability to safely ambulate, reduced balance, reduced functional activity tolerance, reduced static and dynamic balance, increased need for assistance from others and pain indicating the need for PT to evaluate .Pleasant and cooperative. Anxiety with standing .Pain limits the following functional activities: bed mobility, transfers and gait; What relieves pain? = Prescribed Medications .Functional Assessment . Transfers = Total/1 .Clinical Impressions: .max X 2PA (person assist) for transfers . It was documented in the Tests/Measures and Outcomes section that R#804 was Dependent for Sit to Stand, Chair or Bed to Chair Transfer, Toilet Transfer, and Walking. A facility policy titled, Fall Management (revised 8/2016) documented, .When a fall occurs, the licensed nurse will assess the resident for injury. Do not move the individual until he/she has been examined by a nurse. The first responder (the first person to identify that the resident has falled) will summon a nurse after ensuring the resident is safe, and then ask the resident what they were attempting to do .

This citation pertains to Intake #MI 038 Based on interview and record review the Facility failed to ensure a safe transfer when using a hydrolic lift for one Resident (#703) out of two Resident's reviewed for accidents/injuries, resulting in Resident #703's head striking a metal trapeze bar on two occassions causing headaches, dizziness, a [DIAGNOSES REDACTED]. Findings include: On 8/8/18 a complaint was filed with the State Agency alleging that during a transfer using a Hoyer lift the resident's head struck a metal bar. On 10/1/18 at approximately 9:00 AM a phone interview was conducted with the Complainant. The Complainant reported that on at least two occasions, the Facility staff, during a Hoyer lift (a hydrolic lift used to transfer patients) transfer, bumped Resident #703's head on a metal trapeze bar causing headaches, dizziness, speech and memory loss. The Complainant detailed that Resident #703 was taken to the Hospital emergency roiagnom on [DATE] and was diagnosed with [REDACTED]. On 10/1/18 an initial review of Resident #703's clinical record revealed that the Resident was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Resident's Minimum Data Set ((MDS) dated [DATE] documented the Resident had a Brief Interview for Mental Status (BIMS) score of 15/15 (cognitively intact) and required extensive two person assist for bed mobility and transfers. A review of the Resident progress notes documented, in part, the following: 8/1/18 (nurses note): Resident alert and oriented x2-3 .residents states as CNAs (certified nursing assistant) were getting her in bed she hit her head on the trapeze bar hanging from her bed. Nurse completed a skin assessment, PRN (as needed) pain medication given, pain assessment complete 8/2/18 (therapy note) : Writer spoke with resident this date regarding use of trapeze. Resident states she continues to use trapeze bar to reposition when uncomfortable in bed or needs to roll side to side Recommended continued use of trapeze bar as a device to assist in mobility. 8/2/18 (physician note): .while being transferred with a Hoyer lift the handle attached to her bed hit the top part of her head. Patient c/o (complains of) pain yesterday. However pain has subsided there is a soft swelling on top of her head . 8/7/18 (nurses note): .Resident is incontinent and is a Hoyer transfer. As CNAs were transferring resident from wheelchair to bed resident hit head on the trapeze bar . 8/7/18 (nurses note): MD ordered x-ray resident was given ice pack and PRN pain medication. 8/8/18 (nurses note): .Resident complaining of headaches during this day shift. No skin redness, hemotoma or bruising to head .[MEDICATION NAME] given and icepacks applied without relief Resident being sent to hospital for CT scan. A review of the Resident's ADL (activities of daily living) Care Plan (initiated 1/09/18) documented, (name redacted) has an ADL Self Care Performance Deficit and requires assistance with ADLS and mobility .Interventions/Tasks .Bed Mobility . Resident requires total assistance to reposition and turn in bed .Transfer .Resident requires hoyer lift for transfers .(8/3/18) .ensure trapeze is moved prior to transfer On 10/1/18 at 12:30 PM a review of (name redacted) Hospital records dated 8/8/18 -8/10/18 was conducted and documented, in part, the following: History of Present Illness .(name redacted) Resident #703 presents with recent concussions and head injury with complaints of headaches and dizziness. This patient was staying at (name redacted) Facility and recently was being lifted by a Hoyer lift and hit her head in the frontal region which caused some pain in the head, then again more recently the patient's head was hit again in the same way but harder this time and since then she has had frontal throbbing headache in the region it was hit, with associated blurry vision, dizziness, fogginess of thinking and an increase in her baseline [MEDICAL CONDITION] from prior stroke and this has persisted since the last head injury a few days ago Neurology Consulted .Assessment recommendations . Concussion and Post Traumatic Headache and Post Concussive Syndrome .Discussed HA will improve with time, average about 2 weeks .advised cognitive and physical rest for a couple of days .follow up with Neurology as needed if no improvement .Discharge [DIAGNOSES REDACTED].intractable acute post traumatic headache .headache . On 10/1/18 at approximately 1:30 PM, the Facility Accident and Investigation (I &A) documents for Resident #703 was reviewed. An I & A dated 8/1/18 was a one page paper that documented, in part, the following: Date: 8/1/18 .Time 6:00 PM. Location of Injury: Top of Head Describe the nature of the Accident .Resident was being transferred via Hoyer lift and bumped top of head on trapeze bar hanging from bed .physician statement no new orders .Assess to ensure need for trapeze. The I & A dated 8/1/18 did not report the name(s) of the staff members providing the transfer with the Hoyer lift. There were no documents that detailed the incident, including statements from staff. A request was made to the Facility to provide additional documentation. Nothing was provided by the end of the survey. The DON (Director of Nursing) reported, I thought we had some additional documentation, but I am not able to find it. When queried as to the statements made by the CNA's who transferred the Resident's on 8/1/18 and what interventions were taken after the first incident to prevent the second incident, the DON stated, I know we did talk with the CNA's, but again I can't find the documentation. A review of the Facility I & A dated 8/7/18 was conducted and documented, in part, the following, Date 8/7/18 .Time 8:15 PM .Describe nature of the accident .Resident was being transferred with Hoyer lift from wheelchair to bed. Resident hit head on trapeze bar .CNA (certified nursing assistants assigned) .(names redacted) CNA A andB .Conclusion .Two CNAs were assisting (name redacted) from wheelchair back to bed via Hoyer lift. They put trapeze handle over the .Hoyer lift bar knocking handle off and hitting Resident #703 in the head . A Summary of Resident Interview dated 8/9/18 for CNA A documented, in part, (name redacted) was in wheelchair. CNA B and I were transferring from chair into bed with the hoyer lift the trapeze handle was wrapped around the bar the hoyer lift hit the handle and the handle came down and hit (name redacted) Resident #703 on the head . On 10/1/18 at 2:40 PM an attempt to contact CNA A via phone was made. A voice message was left with the CNA. No return call was made. A Summary of Resident interview dated 8/9/18 for CNA B documented, in part, (name redacted) CNA A and I were transferring (name redacted) Resident #703 from wheelchair to the bed with the hoyer lift. We put the handle of the trapeze over the pole when we were raising the hoyer lift up it hit the trapeze pole and knocked the handle off hitting (name redacted) in the head. I did grab it so it didn't hit her very hard .placed her in bed and immediately go the nurse. On 10/1/18 at 2:49 AM a phone interview was conducted with CNA B. When queried as to the incident on 8/7/18, CNA B stated, We were using the Hoyer lift to transfer the resident from the wheelchair to her bed. We moved the Hoyer over her bed. As we did it the lift hit the trapeze and it swung down and hit her head. We placed her on the bed and got a nurse because she said her head really hurt. When queried as to whether CNA B was aware that the Resident had been hit by the trapeze prior to this date, CNA B stated, I think it happened a few days before. When further questioned as to whether she was ever made aware of how to prevent the trapeze from hitting the Resident, CNA B stated, I tried to wrap it (the trapeze) around a pole, but the Hoyer lift hit it. On 10/1/18 at approximately 4:50 PM an interview was conducted with the DON and the Administrator. When asked about the incidents that occurred on 8/1/18 and 8/7/18 , the DON stated, It was an accident. I don't think there was any intent. The first time it happened, the Resident did not have any pain. We did do an x-ray and didn't see anything. The second time, the Resident did have some pain, we did not see bruising or redness. We did an x-ray that showed no hematoma. The Resident seemed okay that day and then after a visit by (name redacted) family member, the Resident asked to go to the Hospital. The Resident did not return to the Facility. When further questioned about the investigation conducted after the 8/1/18 event and the CNA's involved, the DON reported that she was not aware of the CNAs involved and could not locate any further documentation. On 10/1/18 at 5:00 PM a review of the Facility Policy titled Transfer with a hydraulic lift (revised (MONTH) 18, (YEAR)) was conducted and documented, in part, the following: Using a hydraulic lift to raise an immobile patient from supine to the siting position allows safe, comfortable transfer from a bed to a chair or other surface .

Deficient Practice #1 Based on interview and record review, the facility failed to provide treatment for one (#9) of two residents reviewed for quality of care from a total of 25 sampled residents, resulting in the resident sustaining metatarsal fractures in the right foot, and a delay in treatment. Findings Include: On 4/2/18 at 3:46 p.m., Resident #9 said she had a fall in the shower room a few months ago. Resident #9 further stated, I was in a shower wheelchair. I was done with my shower and dressed. The CNA (Certified Nursing Assistant) asked another CNA to bring in my wheelchair. I got out of the shower wheelchair, to transfer to my wheelchair. I fell at the threshold between the shower room and hallway. I went down . The facility's x-rays showed that I had two fractured toes . I had an orthopedic appointment a few days later, and my doctor's x-rays showed that I had three broken toes. I really reinjured my rotator cuff on the left shoulder. My range has decreased. Now I'm back in therapy . On 4/2/18 at approximately 4:50 p.m., a review of the clinical record revealed Resident #9 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the resident's quarterly MDS (Minimum Data Set) assessment dated [DATE], revealed Resident #9's BIMS (Brief Interview for Mental Status) exam score was 15 out of 15, which indicated the resident was cognitively intact for decision making. The MDS assessment also documented Resident #9 required extensive assistance of two persons for bed mobility and transfers. Resident #9's care plan initiated 06/14/2017 and revised on 9/15/17 revealed (resident's name) is at risk for falls r/t (related to) history of falls . On 4/3/18 at 1:15 p.m., a review of a Incident and Accident Report (I/A) provided by the facility revealed, in part, the following: Date: 11/27/17, Date of Occurrence: 11/20/17, Location: Resident room [ROOM NUMBER] / Shower/Tub Room; Type of I/A: Fall; Type of Injury: No Injury; Location of Injury: None; Activity before: Shower; Resident reported that Monday night around 8p or 9p she was in her shower with CNA (Certified Nurse Assistant) assisting her when she stood up to turn around and lost her balance and fell on buttock. She then states she fell on left side and hurt her shoulder, and then she states she fell on both knees and bumped her (R) right toes. CNA Assigned: CNA 'Witness: Yes. Patient states CNA 'N' and LPN (Licensed Practical Nurse) 'O' and CNA 'P'. Physician: (Dr. 'Q') Date Notified: 11/27/17. Time Notified: 11:00 am. Responsible Party: 11/27/17 (no time). No new orders. At that same time, a review of the facility's Incident and Accident Investigation Form completed on 11/28/17 revealed the following: Alleged Incident Date: 11/20/17, .Employee(s) involved in incident . CNA 'N' and LPN 'O' and CNA 'P', Brief Description of the Incident: Resident self-reports that Monday evening during her shower, she stood up to turn around and slipped and fell on to her buttock. With further questioning she then stated she fell on her left side and her shoulder hurt for a day or so. After re-questioning resident about what happened, she stated she fell on both knees, more so the right knee and bumped her (R) right toes on floor. She also stated she discussed the incident with Dr. 'Q' and he was ordering an x-ray . 3. Was there an examination by a physician? Date Examined: 11/28/17. Time Examined: (blank). Name of Physician: Dr. 'Q'. Physician Findings: No fractures or signs of injury. 4. Was the resident file reviewed? Date Reviewed 11/27/18. Time Reviewed: 11 am. Name of Physician: Dr. 'Q'. 5. Was any other documentation reviewed? Hospital Record. 6. Were additional interviews performed? Yes. Additional Interviews: Name Interviewee #1: LPN 'O' - Date: 11/27/17, Interviewee #2: CNA 'P' - Date: 11/27/17, Interviewee #3: CNA 'N' - Date: 11/28/17, Interviewee #4 - Dr. 'Q' - Date: 11/28/17. Conclusion: Resident assessed by nurse and MD. No s/s (signs/symptoms) of fall, nor injury. Staff interviewed, and no fall occurred. Provided a brief description of the plan to avoid this situation in the future if applicable . Refer to Behavior Care Solutions for depression and false accusations . Further review of the clinical record revealed a Radiology Results Report, Examination date 12/04/2017 - 09:35 . PR[NAME]EDURE . FOOT AP and LAT 2V, RIGHT. INTERPRETATION: Results: There is a fracture involving second and fourth metatarsal necks. There is associated soft tissue swelling. No foreign body is seen. Conclusion: Acute right foot fractures as described above. On 4/3/18 at approximately 1:45 p.m., during an interview and record review of the facility's investigation, when queried about the staff on the I/A report, the Administrator stated, All three were let go immediately for false statements during the investigation. On 4/4/18 at 1:59 p.m., Resident #9 was interviewed and stated, It was before Thanksgiving. I don't remember the day. I took a late shower in the evening. I had a fall, and the next day I was sore. People around me were talking about the fall. I guess it was a State Law that when you fall, you have to report it right away, and that wasn't done. When they took the x-rays here, they said that I had two broken toes, but when I went to my orthopedic appointment, that I already had made before the fall, he told me that I had three broken toes, and traumatized my already injured shoulder . I did not have a fall after that . On 4/4/18 at 2:20 p.m., an interview was conducted with the Director of Nursing (DON). When queried about Resident #9's delayed treatment for her fractured metatarsals, the DON stated, I knew nothing about this until 11/27/17. The employees gave false information during an investigation. They stated that she didn't fall. Resident complained of pain, that's when we did the x-rays. We re-opened the investigation, and that's when the staff came forward. Deficient Practice #2 Based on observation, interview, and record review, the facility failed to ensure physician's orders and treatments for one resident (R#13) of one resident reviewed for treatment orders, from a total sample of 25 residents, resulting in the potential for worsening and infection of wounds. Findings include: On 4/2/18 at 9:30 AM, R#13 was observed in bed. R#13 had a large bandage on the top of his head. It was noted the bandage was undated. When queried about the dressing, R#13 was not able to cognitively provide an explanation. On 4/3/18 at 9:35 AM, R#13 was observed in the hallway in his wheelchair. R#13 was observed to have a large bandage on the top of his head. The dressing was dated 4/3/18. On 4/3/18 at 1:41 PM, a review of R#13's clinical record was conducted and revealed a readmission date of [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment dated [DATE] indicated severely impaired cognition and extensive assistance of one to two staff members for all activities of daily living. On 4/3/18 at 2:26 PM, a review of a Nursing Comprehensive Evaluation dated 3/19/18 read, Skin area: top of head growth A weekly nursing head to toe skin assessment dated [DATE] read, .Top of Scalp Description: Top of the head with growth . A Nurse Practitioner noted dated 3/28/18 read, .dressing over front scalp cdi (clean/dry/intact) . A review of R#13's Medication Administration Records (MARs) included an order started on 3/20/18 and discontinued 3/21/18 for a wound care treatment to the top of R#13's head. A second order for a treatment started on 3/22/18 and discontinued on 3/25/18 was also reviewed. It was discovered at that time that no treatment orders were placed, or treatments performed since the treatment discontinued on 3/25/18. On 4/3/18 at 3:27 PM, an interview with R#13's private caregiver was conducted. The private caregiver explained that R#13 had recently had a biopsy for [MEDICAL CONDITION] lesion on the top of his head. On 4/4/18 at 8:14 AM, R#13 was observed in bed. R#13 had a dressing to the top of his head dated 4/3/18. The dressing was observed to be soiled through with a brownish, red exudate. On 4/4/18 at 10:05 AM, an interview with Registered Nurse (RN) 'K' was conducted regarding the dressing on R#13's head. RN 'K' said, He does have orders for treatments. RN 'K' was then asked to pull up the orders for the treatment to R#13's head and in doing so, stated, I don't see it now, that's weird. It's not on the MAR, I can't find it, I don't know. Maybe it's not there anymore. On 4/4/18 at 10:10 AM, an interview with the facility's Director of Nursing (DON) was conducted regarding the absence of treatment orders for the treatment to R#13's head. The DON stated, I'll have to look into that. On 4/4/18 at 10:19 AM, a follow-up interview with the DON was conducted. The DON explained that R#13 went out to the hospital and the order for the treatment never got renewed when he readmitted . The DON stated, I'll call the doctor and put an order in. On 4/4/18 at 1:35 PM, a review of the facility provided policy titled, Skin Management revised 8/2016, read, .Residents with wounds and/or pressure injury and those at risk for skin compromise are identified, assessed and provided appropriate treatment to promote healing. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes .

This citation pertains to MI 689: Based on interview and record review the facility failed to transfer a resident per the resident's assessed needs for one (#903) of two residents reviewed for accidents from a total sample of six, resulting in the resident sustaining a 9.4 centimeter laceration to the left leg requiring hospitalization , 19 sutures to the laceration site, and requiring antibiotic treatment. Findings include: On 3/28/18 at approximately 9:00am the clinical record for Resident #903 was reviewed and revealed the resident had been admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Per review of the resident's quarterly minimum data set (MDS) assessment dated [DATE] the resident scored 13 out of 15 on a brief interview for mental status (BIMs) exam, which indicated the resident was cognitively intact. Also per this assessment it was documented that the resident required the extensive assistance of two persons for bed mobility and transfers. On 3/28/18 at 11:28am review of a 5 Day Report provided by the facility was reviewed and revealed, in part, the following: On (MONTH) 18, (YEAR), at approximately 1:00PM, nurse aide, (CNA 'O') was in the process of transferring (Resident #903) from his bed to his wheelchair and the resident bumped his left leg on the peg that holds the footrest on the wheelchair The resident was immediately assessed and a skin flap was identified was on the resident left lower leg. The nursing staff immediately initiated treatment. The resident is on anti-coagulants and the physician ordered the resident to be sent out to the hospital for evaluation and treatment of [REDACTED].(Resident #903), resident stated that he was sitting up on the edge of the bed with the CNA, who is a very strong manlifted him over to the chair and after he sat down he felt something on his leg. (Resident #903) said I think I must've bumped it on the wheelchair The 5 Day Report also documented, in part, that CNA 'O' had immediately notified the nurse (identified as Nurse 'H')and the resident's wound had been assessed by Nurse 'H' and the unit manager. On 3/28/18 at 2:34pm Nurse 'H' was queried in regards to her observation of Resident #903's injury. Per Nurse 'H', she and the unit manager had assessed the resident after the resident's transfer. On assessment, Nurse 'H' stated the resident's left lower extremity had a large laceration, and the bleeding was not able to be controlled. Nurse 'H' explained the area was cleaned to see the laceration, the site was assessed, and they attempted to steri-strip the area, however it was still uncontrollable. Per Nurse 'H' the resident returned (to the facility) with stitches. Nurse 'H' was queried as to whether the resident had been a one or two person transfer, and confirmed the resident had been a two person transfer. On 3/28/18 at 11:49am review of hospital discharge instructions for a date of visit of 10/18/17 revealed the following Diagnosis: [REDACTED]. Also per the hospital paperwork it was documented the resident was to follow up with internal medicine in a week for suture removal. Continued review of Resident #903's clinical record revealed a consult sheet dated 10/19/17 that revealed, in part, the following: Reason for Appointment 1. Left lateral leg abrasion History of Present Illness Details: I previously saw the patient about a month ago for a little breakdown on his buttock which we resolved. He now has developed an abrasion on his left lateral leg and hematoma. He had the area sutured close and I have been asked to evaluate the region. On 3/28/18 at 11:53am progress notes for Resident #903 were reviewed and revealed, in part, the following: Per a Nurses Note dated 10/18/17 at 11:30PM, the following was documented: RETURNED FROM (HOSPITAL NAME) ER VIA 2-PARTY (AMBULANCE COMPANY NAME) TRANSPORT TO FACILITY AT 1700 (5:00PM) WITH [DIAGNOSES REDACTED]. Per a Skin/Wound Progress Note dated 10/19/17 at 4:27pm, it was noted that the resident's laceration to the left lower extremity measured 9.4cm (centimeters). Review of physician orders [REDACTED]. Continued review of the resident's care plans on 3/28/18 revealed the following canceled care plan for Resident #903, dated 10/20/16 and revised on 12/28/17: (Resident #903) has an ADL (activities of daily living) Self Care Performance Deficit and requires assistance with ADL's and mobility r/t Pain, Impaired balance. Per an intervention dated 3/30/17 and canceled on 12/28/17, the following was documented: TRANSFER: Two person assistance for transfers. On 3/28/18 at 3:35pm one to one inservice education related to Resident #903's transfer was requested from the facility Administrator. On 3/28/18 at 3:55PM the facility Administrator was queried in regards to how Resident #903 should have been transferred, and responded the resident had been a two person transfer at the time of the incident. Review of a One to One In-Service sheet for CNA 'O' dated 10/18/17 was reviewed and revealed the CNA had received education related to resident transfers. Per the Expectations section of the form, the following was documented: Ensure to follow individual resident care plans when transferring residents. Check kardex (care guide) prior to transferring if you are unsure of transfer status. On 3/29/18 at approximately 10:00am review of a document provided by the facility titled Standards of C.N.A. Practice dated (YEAR) was reviewed and revealed, in part, the following: The CNA provides care to the resident per the plan of care. The CNA assists the resident in activities of daily living .

This citation pertains to MI 567: Based on interview and record review the facility failed to administer insulin per physician order [REDACTED]. On [DATE] a complaint was received by the State Agency which alleged that a facility nurse administered regular insulin instead of long-acting insulin to a resident. During a conversation with the resident on [DATE] at 3:35pm, the resident stated that a nurse had run out of the room, had ran back into the room, and said, Oh my God I gave you the wrong medication. The resident also stated, To find out that you could have died and finding out you have to go back there (to the facility) it was hard On [DATE] at approximately 9:20am the clinical record for Resident #801 was reviewed and revealed the resident had been admitted into the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's admission minimum data set (MDS) assessment dated [DATE] revealed that Resident #801 scored 15 out of 15 on a brief interview for mental status exam which indicated that the resident was cognitively intact. On [DATE] at 9:29am a review of Resident #801's physician orders [REDACTED]. The following was order observed for long-acting insulin: Insulin [MEDICATION NAME] solution pen-injector 100 unit/ml (milliliter) inject 40 unit subcutaneously at bedtime for DM (diabetes mellitus). The following order was observed for a rapid-acting insulin: Insulin [MEDICATION NAME] solution pen-injector 100 unit/ml Inject as per sliding scale (dependent on resident's blood sugar): if ,[DATE]=2 units; ,[DATE]=4 units; ,[DATE]=6 units; >300 call MD (medical doctor), subcutaneously before meals and at bedtime for DM. Continued review of physician orders [REDACTED]. Resident #801 had been ordered 50% [MEDICATION NAME] 25 grams (g) 0.5g/ml (milliliter) via IV push on [DATE] at 12:19am and at 1:57am for the purpose of a blood sugar less than 50 (mg/dl,Milligrams per Deciliter). Another dose of [MEDICATION NAME] 50% 25g via IV push had been ordered for Resident #801 on [DATE] at 4:17 am related to [DIAGNOSES REDACTED]. An order dated [DATE] at 4:32am documented, Transfer to (hospital name) for [DIAGNOSES REDACTED]. On [DATE] at 9:40am a review of Resident #801's blood sugars revealed, in part, the following: [DATE] at 4:07pm: 113 mg/dl [DATE] at 10:09pm: 141 mg/dl [DATE] at 10:45pm: 93 mg/dl [DATE] at 12:05am: 46 mg/dl [DATE] at 12:37am: 86 mg/dl [DATE] at 1:50am: 46 mg/dl [DATE] at 3:09am: 102 mg/dl [DATE] at 4:00am: 59 mg/dl [DATE] at 4:14am: 46 mg/dl [DATE] at 4:15am: 59 mg/dl On [DATE] at 1:47pm a review of a physician note dated [DATE] at 9:09am written by Physician 'M' revealed, in part, the following: .patient was given (brand name rapid-acting insulin, insulin [MEDICATION NAME]) 40 units instead of (brand name long-acting insulin, insulin [MEDICATION NAME]) 40 units on Friday night .patient was transferred to (hospital name) early Saturday morning for [DIAGNOSES REDACTED] and monitoring BL sugar On [DATE] at 2:26pm an interview was conducted with Physician 'M' in regards to the events documented in the physician progress notes [REDACTED]. Physician 'M' stated, The nurse called me after he/she gave the insulin I got a call they had made a mistake. Physician 'M' stated that she had been notified right away. Physician 'M' responded that the resident's blood sugars were checked throughout the night, intravenous fluids and other interventions were started, and that the resident was sent to the hospital. Physician 'M' stated, I felt like we should monitor her more. On [DATE] at 2:49pm the facility's Director of Nursing (DON) was queried in regards to an insulin administration error for Resident #801. The DON responded that a medication error form had been completed, and identified the nurse who had administered the insulin to Resident #801 on the evening of [DATE] as Nurse 'N', who was no longer employed by the facility. The DON stated that she had interviewed Nurse 'N' the day after the incident, and said that, She (Nurse 'N') had the wrong pen (insulin pen). The DON said that Nurse 'N' had known right away of the error, and the DON confirmed at this time that the medication error did occur. On [DATE] at 3:24pm a Medication and Treatment Incident Report form dated [DATE] for Resident #801 was reviewed and revealed the following: Description of event: (Brand name rapid-acting insulin) 40 units was given at 10:15pm. The order was for (Brand name long-acting insulin) 40 units. On [DATE] at 4:15pm a review of an ambulance Patient Care Report with a date of service of [DATE] revealed, in part, that ambulance services were called to the facility for, a (age) yo (year old) (sex of Resident #801) [DIAGNOSES REDACTED]. BGL (blood glucose level) 59 mg/dl. Arrive to find pt (patient) in bed asleep. Pt is alert to us and is A&Ox4 (alert to person, place, time, and situation) according to staff. Pt was given the wrong type of insulin and the wrong dose at approx (approximately) 0000 and has been dealing with rebound [DIAGNOSES REDACTED] for the past 5 hours Review of hospital emergency department documentation with a date of visit listed as [DATE] listed [DIAGNOSES REDACTED]. On [DATE] at 4:27pm a facility policy titled Medication Administration with a copyright date of 2017 was reviewed and revealed, in part, the following: Physician Orders-Medications are administered in accordance with written orders of the attending physician. Per electronic review of manufacturer information for insulin [MEDICATION NAME], it was noted that [DIAGNOSES REDACTED] could result in [MEDICAL CONDITION], loss of consciousness, or death.

Based on observation, interview, and record review, the facility failed to ensure proper wound care for two residents (Resident #301 and #303) out of three residents reviewed for wound care, out of a total sample of three, resulting in the potential for the development of infection and an actual development of a wound infested with maggots requiring a visit to the emergency room . Findings include: Resident #301 On 9/29/16 at 10:35 am, wound care for Resident #301 was observed. Licensed Practical Nurse (LPN) 'K' was observed to remove a soiled dressing from Resident #301's coccyx area. It was observed that Resident #301 had stool in her gluteal folds. LPN 'K' prepared her supplies including a thin strip of anti-microbial packing pulled from a jar and cut to size with scissors. LPN 'K' was not observed to sanitize her scissors prior to cutting the anti-microbial packing. LPN 'K' cleansed the coccyx wound, packed the wound with the packing, applied gauze and covered the wound with a large absorbant pad. LPN 'K' taped the pad to the Resident #301's skin, but only secured the top part, of the dressing. LPN 'K' then re-secured the resident's incontinence brief. LPN 'K' was not observed to provide incontinence care for the stool in the resident's gluteal folds prior to cleansing and applying a new dressing. LPN 'K' was also not observed to sanitize her scissors after the completion of the wound care. On 9/29/16 at 10:50 am, wound care for a second wound on Resident #301's left heel was observed. LPN 'K' cut the old dressing from the resident's foot with the same scissors used for the wound on Resident #301's coccyx. After the dressing was removed LPN 'K' used the scissors to cut the cap from the sterile tube of normal saline. LPN 'K' then removed residual gauze stuck to the resident's heel by peeling it. LPN 'K' did not moisten the residual gauze to loosen it from the wound bed. The peeling of the gauze made an audible ripping sound as it was removed, and the resident stated, Your are rough. LPN 'K' was next observed to moisten a small piece of gauze with approximately 2 milliliters of normal saline, place it over the heel wound and wrap kerlix fluff dressing to secure it in place. LPN 'K' was not observed to cleanse the wound with normal saline prior to placing the saline moistened gauze over the wound and securing it. During the course of the the two wound care observations, a black house fly was noted to be buzzing around the room. On 9/29/16 at 11:10 am, an interview with LPN 'K' was conducted regarding the observations during wound care. LPN 'K' was asked first why she did not sanitize her scissors before and appropriately during wound care, to which she responded that she had already done it in the hallway. Next LPN 'K' was asked why she did render incontinence care for the resident before applying a clean dressing and she stated, I didn't think she was done having her bowel movement yet. On 9/29/16 at 11:50 am, an interview with the Director of Nursing (DON), was conducted. The DON was asked about whether LPN 'K' should have provided incontinence care prior to applying a clean dressing, and the DON responded that she should have. On 9/29/16 at 11:20 am, a review of Resident #301's wound care orders for her left heel indicated the area should be cleansed with normal saline prior to covering and wrapping with kerlix. Resident #303 On 9/29/16 at 12:45 pm, a review of Resident #303's closed medical record was conducted. Resident #303's record indicated a re-admission date of [DATE] with [DIAGNOSES REDACTED]. A review of an admission skin assessment dated [DATE] noted multiple skin impairments, however; nothing was noted to be impaired with the resident's left heel until a weekly skin assessment on 8/24/16 where it was documented, .Left heel wonf <sic>(wound) noted. The next weekly skin assessment conducted on 9/7/16 did not indicate a wound on the left heel. Multiple orders were reviewed that indicated the resident had treatments ordered to his left heel. A progress note documented by LPN 'D' on 9/6/16 read, .Patient was sent to (name of hospital) .last evening due to maggots in his wound to his left heel . The discharge instructions from the hospital were also reviewed and read, .presents to the emergency department .with complaint of parasites to left heel wound . On 9/29/16 at 2:45 pm, an interview with the facility's DON was conducted. During the interview, the DON was asked about how the resident went from no wound upon admission, to having a wound with maggots in it in approximately a month she stated, I don't know. She was next asked if she believed that staff were performing appropriate wound care techniques, should the wound have developed a maggot infestation, to that she had no response. On 4/29/16 at 4:25 pm, a telephone interview with the facility's wound care physician was conducted. When asked if he had knowledge Resident #301's left heel wound he indicated that he was consulted for multiple wounds but the left heel was not one of them, he explained that he looked at the left heel only during his first visit on 8/9/16. He indicated that he removed a dry, odorous callous from the left heel, but the removal of the callous did not result in a wound or open area. When asked about his knowledge of maggot infestations in wounds he stated, It's rare. When asked if staff were performing proper wound care treatment, should a maggot infestation occur to which he replied, Probably not. He also stated, Possibly no one was doing their assessments. On 4/29/16 a review of the facility's policy titled, Procedure for Clean Dressing Technique revised 6/2016 read, .9. Cleanse wound with solution ordered .wash from the center of the wound to the periphery . The facility was asked if they had any other documentation to provide regarding the concern and none was provided by the end of the survey. ( )

This citation pertain to intake number MI 980 Based on interview and record review, the facility failed to ensure that staff followed the care plan of a resident who was assessed as requiring a two person physical assist and gait belt use during transfers, causing transfer trauma for one (#202) of three sampled residents reviewed for accidents from a total sample of three, resulting in a deep left knee laceration and bone protrusion. Findings include: On [DATE] at 9:30 A.M., the complainant was interview by phone. The complainant identified that the resident (#202) had been admitted to the facility for rehabilitation following a knee replacement surgery and was currently not available for interview (expired). The complainant stated, "The staff was getting her (#202) out the bed when she (staff) slipped and the resident fell . They (the facility) called me saying she (resident #202) was critical, bone of right knee cap was exposed (through skin). My mother is a two person assist, heavy (200 pounds), she told me she had been pulled, transferred from the bed under arm pits without the use of a gait belt (as required) when the staff (aide) hands slipped and she fell ." On [DATE] at 10:00 A.M. Resident #202's closed clinical record was reviewed. The resident's admission was dated [DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) resident assessment and care screening dated [DATE], described the resident with independent cognitive and decision-making skills. A plan of care for fall risk was initiated [DATE]. Resident #202 was at risk for falls due to gait/balance problems and recent right knee surgery. Interventions in place noted that the resident required extensive two person physical assistance from staff for transfers, mobility and other activity of daily living needs. Revisions dated [DATE], noted to ensure the resident is wearing appropriate footwear and follow fall protocol. On [DATE] at 11:00 A.M., the Incident Report and progress notes dated [DATE] at 5:30 A.M. were reviewed. It identified that the "CNA (certified nurse aide) called nurse into room, states the resident's knees buckled and resident began to go down, CNA lowered the resident to the floor with left leg extended out and right leg bent. The nurse noticed blood and the CNA noticed an exposed bone. The midnight nurse came to assist and 911 was called." On [DATE] at 11:00 A.M., the Director of Nursing (DON), was interviewed. The DON was queried about the facility's fall protocol and the use of gait belts. The DON stated, "The resident was transferred from bed to wheelchair and when her knee gave out and she was lowered to the floor ...The nurse applied pressure to stop the bleeding. The knee had opened (under knee cap, straight across)." The DON went on to state that "a review of the plan of care noted that the resident had two documented transfer statuses that conflicted, but the therapy is responsible for indicating appropriate transfer status for residents." The resident was transferred to the hospital and did not return. The facility was made aware by family that the resident had emergency knee replacement surgery. On [DATE] at 11:45 A.M., certified nurse aide (CNA), employee 'A' was interviewed by phone. "I transferred her (#202) from bed to wheelchair. She was a one person assist. I had her daily, she was a two person transfer on initial admit ([DATE]) only. I am supposed to use a gait belt, but that day I did not use it. I was rushing to get the resident to the bathroom (she had to go bad) her knee gave out so I slid her down on my leg onto the floor. She was on her knee sitting sideways on left cheek. Her right leg was bent. I called the nurse to assist her (#202) right knee bone was exposed and bleeding." The aide, employee 'A' stated, "I got a write up for not using the gait belt ...Gait belts are used to help with the transfer. She (#202) had complained of knee not getting better, hurting every morning. " On [DATE] at 12:20 P.M., the nurse, employee 'B' was interviewed. Employee 'B' stated, "I entered the room and the resident was going down, but was not on the floor. Her left leg was extended and right knee was bent and began to bleed, bone was exposed. I assisted with lowering her onto the floor/bottom. I called for assistance from the midnight nurse. I was planning to address the right leg that was bent under but upon noticing that the right knee bone was protruding, I did not touch the leg. 911 (emergency) was called, pressure was applied to the open area and the resident was kept calm. 911 arrived and took the resident to the hospital." On [DATE] at 1:00 P.M. the Therapy Manager, employee 'C' was interviewed. Employee 'C' stated, "Review of the physical therapy evaluation and plan of treatment dated [DATE] noted that the resident required max assist for bed mobility and transfers. We determine the need which one person max assist and wobbly knees would concern me for recommendations and ensuring aides could appropriately transfer." When further queried about the care plan for nursing staff the therapy manager stated, "The resident required two person assist with bed mobility and transfers. The resident was weight bearing as tolerated to right lower extremities and was on knee replacement precautions." When queried about gait belt use the Therapy Manager stated, "It's a standard of practice for all staff to use a gait belt with transfers." The facility was asked to provide a policy for falls and transfers. The policy titled "Fall Management Program" (released ,[DATE], revised ,[DATE]) was reviewed. Policy: The facility will identify hazards and resident risk factors and implement interventions to minimize falls. Overview: Each resident is assisted in attaining/maintaining his highest practical level of function by providing the resident adequate supervision, assistive devices and functional programs as appropriate to minimize the risk for falls ...A plan of care is developed and implemented based on this evaluation with ongoing review ...etc." ( )