Every finding on record at Oakridge Manor Nursing and Rehabilitation Center L

Based on observation, interview and record review the facility failed to ensure a resident did not sustain a facility acquired pressure ulcer and ensure continued treatment to the wound for one (R7) out of two reviewed for pressure ulcers resulting in a stage 4 pressure ulcer behind the left ear. Findings include: Upon entrance to the facility a facility matrix was provided to the Surveyors that noted R7 had a facility acquired pressure ulcers.On 7/20/26 at approximately 11:55 AM, R7 was observed lying in bed. The resident had oxygen running at 3L (liters). Oxygen tubing was observed behind both the right and left ear. The resident was alert but not able to answer all questions asked.A review of R7's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: traumatic subdural hemorrhage, dementia without behavioral disturbance, mood disturbance, anxiety and alcohol dependence. A review of R7's Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 4/15 (severely cognitively impaired).Continued review of R7's clinical record revealed, in part, the following:4/27/26-Nurse Note: .Open area noted behind the patient's left ear at the site where nasal cannula tubing rests. Area appears erythematous with superficial skin breakdown, no drainage observed. Nasal cannula repositioned and protective padding applied to reduce pressure.Physician notified and wound-care consult ordered for further assessment and treatment.4/27/26- Order: .Left posterior ear ulcer: cleanse with wound cleanser, pat dry, apply calcium alginate, and cover with hydrocolloid cut-to-size dressing.A review of R7's TAR (Treatment Administration Record) for the above order dated 4/27/26 revealed no treatment was started on 4/27/26.4/28/26: Nurse Note: Resident was transferred out to the hospital due to hypotension.5/5/26: Nurse Note: .Resident returned to facility with oxygen.Full assessment completed upon arrival.Resident noted to have three pre-existing wounds.5/5/26: Skin Check: .No skin issues identified. Skin Issues: .Return from hospital with the same skin issues from when he left.5/5/26; Order: Left posterior ear ulcer; cleanse with wound cleanser, pat dry, apply calcium alginate and cover with hydrocolloid cut to size dressing.5/11/26: Wound Consult: .Wound.Category.Pressure.Left Ear.4/27/26: Developed ulcer at the left posterior ear, a medical device-related from oxygen tubing.Wound Assessment.Size in cm.0.6x.0.6 x0.100% discoloration.5/11/26: Order: .Left posterior ear ulcer cleanse with wound cleanser, pat dry, apply skin prep and border foam.every Mon, Wed, Fri for Medical device related ulcer from 02 tubing and as need for wound care.5/13/26 : Braden Scale (a tool utilized to determine a person's risk for skin breakdown): .Braden Score 11 (high risk).6/2/26: Skin and Wound Note: .wound 3.Location: Left ear.Stage/Severity: Stage 4.Size: 0.5 cm (centimeter)x 0.5 cm x 0.1 cm.Wound base 80% granulation.Exposed tissue: cartilage.Wound Treatment.left ear with medical-device related pressure injury from 02 tubing has improved.6/29/26: Skin and Wound Note: .Wound Treatment.Left ear.Resolved. Continue to cover vulnerable area with band aids behind BL ears to protect areas.Nursing staff reports pt (patient) will not leave ear protectors in place on 02 tubing. (Authored by Wound Nurse I ).*It should be noted that a review of R7's orders, TAR, care plan and notes did not identify when R7 refused their ear protectors. Further, this was the last note located in R7's electronic record indicating a wound care visit.On 7/22/26 at approximately 9:42 AM, R7's left and right ears were observed. Nurse F was present during the observation. There was no ear protectors observed behind either ear. Nurse F reported that the resident should be wearing a gray protector behind each ear and told the resident they would put the protectors on. R7 did not issue any concerns regarding the ear protectors. On 7/22/26 at approximately 9:47 AM, an attempt to contact WN I via phone was made. No return call was made prior to the end of the Survey.On 7/22/26 at approximately 10:29 AM, an interview was conducted with the Director of Nursing (DON) and Nurse Unit Manager A. Both were interviewed regarding R7's facility acquired wound(s), specifically to the left ear. Nurse A reported that they believed the wound behind the left ear had healed.On 7/22/26 at approximately 12:22 PM, a second observation of R7's left and right ears was made. Nurse F and a nurse Surveyor were present during the observation. R7's nasal cannulas were behind both ears. At the time of the observation gray ear protectors covered both ears. R7 did not complain about the protectors. R7's left ear was observed to be deep red and localized behind the ear , with a small scab. On 7/22/26 at approximately 12:53 PM, Nurse A was informed as to the observation of the left ear. Nurse A stated that they believed the wound behind the ear was acquired at the Hospital but could not provide specific documentation.The facility policy titled, Wound Treatment Management (11/1/2022) was reviewed and documented, in part: .Policy: To promote wound healing of various types.Wound treatments will be provided in accordance with physician orders.

Based on observation, interview, and record review the facility failed to maintain general cleanliness and repair of the premises as well as proper storage of clean and sanitary supplies. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living for all residents. Findings Include:On 07/20/2026 at 9:45 AM, observed the 1st floor soiled utility room hopper sink bowl area soiled with buildup and with rust colored water. At this time the housekeeping manager (HK) H indicated it is not used by housekeeping staff and will work with the maintenance director for detail cleaning and flushing. On 07/20/2026 at 9:52 AM, observed the 1st floor central shower with dark staining of the caulk around the shower floor perimeter. HK H indicated that housekeeping staff cleans this area each morning, the Certified Nurse Assistants (CNAs) clean after use during the day, and maintenance will make repairs as needed for staining/damaged caulk and tiles. On 07/20/2026 at 9:55 AM, observed the 1st floor supply closet with (2) unpackaged toothbrushes for resident care stored loose on the shelf, loose plastic gloves stored on the shelf, items on the closet floor (container of cleanser and a glove). The floor in this closet was soiled with buildup. The wood shelves in this closet were observed with peeling painted surfaces. HK H discarded the open toothbrushes and mentioned the concerns to Nurse Unit Manager A who indicated it would be straightened up.On 07/20/2026 at 10:05 AM, observed the 2nd floor soiled utility room hopper sink bowl soiled with green staining. HK H indicated it is not used by housekeeping staff and will work with the maintenance director for detail cleaning and flushing. On 07/20/2026 at 10:10 AM, observed the 2nd floor central shower with dark staining of the caulk around the shower floor perimeter. HK H indicated that housekeeping staff cleans this area each morning, the nursing staff clean after use during the day, and maintenance will make repairs as needed for staining/damaged caulk and tiles. On 07/20/2026 at 11:10 AM, observed the 2nd floor dining room floor to ceiling air conditioning unit with exposed ductwork soiled on the exterior surfaces and slatted vent covers with dust build up. On 07/22/2026 at 9:30 AM, interviewed HK H regarding the facility Cycle Cleaning Policy. HK H described the expectations and tracking for deep cleaning of resident rooms and indicated some additional areas observed will need cleaning attention. HK H indicated they were looking for a product to remove the green staining in the hopper, as regular bleach was not effective and the 1st floor soiled hopper had been cleaned and flushed.

Based on interview and record review, the facility failed to provide justification for the use of pharmacological medication given on an as needed (PRN) basis, identify targeted behaviors, and consistently implement person-centered non-pharmacological interventions prior to administering the medications for one (R7) of five residents reviewed for unnecessary medications. Findings include: A review of R7's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: traumatic subdural hemorrhage, dementia without behavioral disturbance, anxiety and alcohol dependence. A review of R7's Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 4/15 (severely cognitively impaired). Continued review of R7's clinical record revealed the following:2/1/26: Order: Clonazepam .5mg (milligrams).Give one tablet by mouth every 8 hours as needed for (BLANK).Start date 2/1/26. This order did not give a stop date and was administered on 2/10, 2/13, 2/19, 2/21, 2/22 (X2 8:05 AM and 8:52 PM), 2/27, 2/28, 3/1, 3/7, 3/9,3/21, 3/22, 3/27, 4/19, 4/26. 2/11/26: Note to Attending Physician/Prescriber: .Resident (R7).date: 2/11/26.Recommend discontinue PRN use of Clonazepam .5 mg per the following federal guideline: In accordance with State and Federal Guidelines.Psychotropic Drugs, PRN orders for anti-psychotic drugs are limited to 14 day and cannot be renewed unless attending physician.evaluates the resident for the appropriateness of renewal. Response: Agree, disagree other. *It should be noted that there was no response noted to the recommendation. A pharmacy recommendation note dated 3/10/26 was noted in R7's clinical record. No response documentation was found in R7's electronic record. 5/14/26: Order: .Medication Clonazepam.give 1 tablet via PEG (Percutaneous Endoscopic Gastronomy)-Tube every 8 hours as needed for anxiety/agitation for 14 days. A review of R7's MAR (medication administration record) noted R7 received the medication 5/16, 5/17, 5/21,5/22, 5/23, 5/24, 5/25 and 5/27. 6/3/26: Order: .Clonazepam oral tablet .5 mg. Give 1 tablet every 8 hours as needed for agitation. (no stop date was documented) A review of R7's MAR noted R7 received the medication on 6/4, 6/7, 6/8, 6/11 (X2 at 9:38 AM and 8:40 PM), 6/14, 6/16, 6/18, 6/21 (x2 at 1:58 AM and 9:08 PM), 6/23, 6/24, 6/25, 6/28, 6/29, 7/1, 7/2 (x2 at 6:04 AM and 9:52 PM), 7/3, 7/4, 7/5, 7/6 (x2 at 6:38 AM and 10:00 PM), 7/9, 7/10,7/11, 7/12, 7/13, 7/14, 7/18, 7/19, 7/20, 7/21. Care Plan: Focus: I have a diagnosis and TX (treatment) for depression.irritability, loss of interest, sleep disturbances, fatigue.sadness.thoughts of death: Interventions: Administer medications as ordered (2/10/26).Notify MD (Medical Doctor) if having trouble sleeping or sleeping too much.Obtain Psych consult as needed (2/10/26).Provide 1:1 emotional support as needed.Focus: The resident uses antipsychotic medication (2/10/26).Interventions: .Administer psychotropic medications as ordered (2/10/26).Consult with pharmacy, MD.to consider dose reductions.quarterly (2/10/26). *It should be noted that there was no documentation in the care plan that noted any non-pharmacological interventions prior to PRN medication. A look at R7's notes from 2/10/26 through 7/22/26 noted very limited notes as to the need for the PRN medication Clonazepam .5 mg. and/or attempts to utilize non-pharmacological interventions prior to the administration of the medication based on the 61 times the PRN medication was administered to the resident starting 2/10/26. On 7/22/26 at approximately 10:14 AM, an interview and record review were conducted with the DON (Director of Nursing) and Nurse Unit Manager (NUM) A. Both were queried as to the extensive length of the PRN medication, the lack of notes indicating why the medication was administered, the lack of pharmacological interventions and the failure to address the lack of pharmacological response. Nurse (NUM) A did confirm that each administration of the PRN medication did not specify the reason it was given and attempt to try non-pharmacological interventions. They also confirmed that response to the pharmacy report(s) could not be located but noted that R7 had been seen by Psych Services. The facility policy titled, Use of Psychotropic Medication(s) (11/1/22) was reviewed and revealed the following: .Policy: It is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint.The indications for initiating, maintaining, or discontinuing medication(s), as well the use of non-pharmacological approaches will be determined by evaluating the resident's physical, behavioral, mental and psychosocial signs and symptoms.Non-pharmacological approaches must be attempted, unless clinically contraindicated.The residents medical record shall include documentation of rationale for chosen treatment options.Psychotropic medications used on a PRN basis must have diagnostic specific condition and indication for the PRN use documented in the resident's medical record and is subject to the limitations as noted: unless the attending physician or prescribing practitioner believes it is appropriate to extend the order beyond the 14 days.PRN orders for antipsychotic medications only, shall be limited to 14 days with no exception.If the attending physician .believes it is appropriate to write a new order for the PRN antipsychotic, the must first evaluate the resident.

Based on observation, interview, and record review, the facility failed to include person-centered and appropriate fall precaution interventions for one (R43) of two reviewed for accidents. Findings include:On 7/20/26, a medical record review revealed R43 was admitted to the facility 10/13/21 with a past medical history significant for advanced dementia, schizophrenia, depression, and anxiety. R43 was non-verbal and unable to ambulate independently. Record review of the Minimum Data Set (MDS) assessment dated [DATE], documented R43 severely impaired cognition.On 7/20/26 at 10:00 AM, an observation of R43's room revealed the bed was pushed against the wall, and a fall mat was observed next to bedside on the floor.On 7/20/26 at 10:13 AM, R43 was observed in the dining room sitting in their wheelchair at a table facing the wall. An introduction was made, and R43 did not engage in an attempt at an interview, they made eye contact, but was observed without emotional expression, and had a blank stare. R43 was observed leaning to the right and had a pillow propped under their right arm. On 7/20/26, a record review of the nursing progress notes by Licensed Practical Nurse (LPN) F documented on 7/4/26 at 11:55 AM, after being called by the CNA (Certified Nursing Assistant), R43 was found lying on the dining room floor on their face. LPN F further documented .Nurse noted after 30 minutes of following up reassessing resident after fall she had a knot noted on frontal right side of head also noted redness to nose and right cheek area. Nurse will be sending resident out to hospital per provider order.A review of the R43's care plan initiated on 3/31/26, revealed R43 was at risk for falls related to confusion, deconditioning, gait/balance problems, and unaware safety needs. The goal for R43 was to be free of falls through the review date which was targeted for 8/19/26. The following interventions were implemented: .Be sure The [sic] resident's call light is in reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.Anticipate and meet The [sic] resident's needs.Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility such as: .Follow facility fall protocol.Pt [sic] evaluate and treat as ordered of PRN (as needed) .The care plan did not reveal an intervention for a fall mat observed at the resident's bedside, nor were their interventions for increased supervision.On 7/21/26 at 2:06 PM, an interview with Licensed Practical Nurse (LPN) D who was very familiar with R43, confirmed they were nonverbal and unable to make their needs known. They said R43 tends to grab and reach and leans a lot to the right and forward, and that was why they cannot have R43 sit in their wheelchair against a wall. LPN D said they, always have eyes on them in dining room, and when in bed. LPN D acknowledged R43 could not use the call light and if it was activated, it would have been because of their grabbing and reaching habits. LPN D was asked if they were aware of any falls and they remarked they were, but did not recall any details, or whether any interventions other than a fall mat next to their bed had been implemented.On 7/22/26 at 8:34 AM, LPN F was interviewed regarding the fall R43 sustained on 7/4/26, and confirmed it was unwitnessed, and required transfer to the hospital due to facial swelling. LPN F was read the current fall interventions on R43's care plan and acknowledged the fall mat which was at the bedside was an intervention and should had been on the care plan. LPN F also acknowledged R43 was incapable of knowing the purpose of a call light.On 7/22/26 at 9:16 AM, the Director of Nursing (DON) revealed that an interview with LPN Unit Manger A would be the best regarding R43 and their person-centered care plan. LPN A who was present, reviewed the current fall interventions on R43's care plan and acknowledged they were not person centered or appropriate for R43.Review of the facility policy tiled Baseline Care Plan dated 10/2022 documented; .The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident.

Based on interview and record review, the facility failed to provide evidence that irregularities identified by the pharmacist during monthly drug regimen reviews were documented, reviewed by the physician, and acted upon for one (R7) of five residents reviewed for unnecessary medications. Findings include: A review of R7's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: traumatic subdural hemorrhage, dementia without behavioral disturbance, mood disturbance, anxiety and alcohol dependence. A review of R7's Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 4/15 (severely cognitively impaired). Review of monthly Medication Regimen Review (MRR) assessments for R7 revealed the following: 6/8/26: See Report (no report was found in R7's clinical record).5/2026: No MRR assessments were found in R7's clinical record.3/10/26: See Report (no report was found in R7's clinical record. On 7/22/26 at approximately 10:14 AM, Nurse Unit Manager A was asked to locate the reports and physician response noted above. Nurse A could not locate the MRR assessment for 5/2026. Further, Nurse A could not locate the reports and/or physician responses for the dates 6/8/26 and 3/10/26. The facility policy titled, Addressing Medication Regimen Review Irregularities (11/1/22) was reviewed and documented, in part, the following: .Policy: It is the policy this facility to provide a MRR for each resident in order to identify irregularities and respond to those irregularities and respond to those irregularities and respond to those irregularities in a timely manner to prevent the occurrence of an adverse drug event.Policy Explanation and Compliance Guidelines.The medication regimen of each resident must be reviewed by a licensed pharmacist at least once a month.The review must include a review of the resident's medical chart.the pharmacist must report any regularities to the attending physician.the pharmacist during the review must be documented on a separate, written report.the report must be sent to the attending physician, the facility' medical director and director of nursing.The report should be submitted to the DON (Director of Nursing) within 10 working days of review.

Based on observation, interview, and record review, the facility failed to provide at least 80 square feet per resident in multiple resident bedrooms and at least 100 square feet for single resident bedrooms, affecting residents in 18 rooms (rooms 101, 102, 103, 104, 105, 107, 108, 109, 110, 111, 201, 203, 204, 205, 207, 208, 210, 211). Findings include: Observation of the Resident rooms on 07/22/2026 at 11:30 AM, and review of the facility documentation revealed the following: ROOM # SQ. FT # OF BEDS # of Residents 101 216 3 2102 216 3 2103 84 1 1104 221 3 3105 216 3 2107 216 3 3108 216 3 3109 216 3 3110 220 3 2111 80 1 1201 216 3 2203 84 1 1204 221 3 3205 216 3 2207 216 3 1208 216 3 3210 216 3 0211 216 3 0 Observations and interviews with various residents revealed no specific complaints and no specific health/safety concerns.On 07/22/2026 a record review of a facility binder provided by the nursing home administrator (NHA) titled F912 Audit with documentation of monthly interviews about resident satisfaction with their rooms revealed no documented concerns.

Based on observation, interview, and record review, the facility failed to ensure residents were given the opportunity to make decisions about their treatment for one (R32) of two residents reviewed for advance directives, resulting in R32 becoming distressed, tearful, and withdrawn after the facility attempted to petition (send to the hospital involuntarily for a psychiatric evaluation) him to the hospital when he refused dialysis, continuously expressing frustration with having a feeding tube, and not being included in conversations about his care. Findings include: On [DATE] at 9:28 AM, R32 was observed in bed sleeping. A tray containing breakfast was observed on the over bed table. A tube feeding pole with a pump was observed in the room, but was not attached to the resident or infusing. On [DATE] at 10:57 AM, R32 requested to have a conversation. R32 reported feeling frustrated with his legal guardian. R32 explained he had things to take care of outside of the facility, but his legal guardian did not return his phone calls and he had not met her or spoken with her since his admission into the facility. R32 said he was not allowed to leave the facility without the guardian's consent. A review of R32's clinical record revealed R32 was admitted into the facility on [DATE] with diagnoses that included: heart disease, prostate cancer, hypertension, end stage renal disease (ESRD), type 2 diabetes mellitus, history of traumatic brain injury, acquired absence of left leg below knee, and dependence on renal dialysis. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R32 had moderately impaired cognition, no delusions or hallucinations, no behaviors including no rejection of care, required partial/moderate assistance from staff for activities of daily living, had no signs or symptoms of a swallowing disorder, and received nutrition via feeding tube and mechanical soft diet (by mouth). A review of R32's progress notes revealed the following: On [DATE], it was documented in a nursing progress note that R32 refused to go to dialysis because he wanted to wait for his daughter to go with him. The appointment was rescheduled for [DATE]. It was documented R32 attended dialysis on [DATE]. On [DATE], it was documented in a nursing progress note that R32 stated to writer that he doesn't want to go to dialysis. Nurse asked why resident stated because he supposed to go only 3 times a week. Resident stated he went yesterday and he not going to keep going back and forth every day. Nurse contacted daughter to assist with convincing resident to go for schedule dialysis appointment today and resident started using profanity saying allow him to make his own decisions for his life and hung up the phone .Nurse contacted provider made aware and stated its ok for resident to miss if refusing . On [DATE], it was documented in a nursing progress note that R32 told the nurse hes not going to dialysis today. Nurse contacted provider stated he came by facility yesterday and saw resident regarding resident is being non-compliant with care. Provider stated resident code status needs to be changed also for manager to consult hospice r/t (related to) not being compliant w/ (with) care .Nurse contacted guardian. No answer . On [DATE], it was documented in a nursing progress note that R32's guardian called and said that since the resident was not compliant with dialysis and care multiple times she felt it will not (be) safe for resident to leave facility and she would rather for nursing staff to watch resident closely . It should be noted that there was no documentation in R32's clinical record that indicated staff or the legal guardian engaged in a conversation with the resident about why he did not want to go to dialysis at times. It was documented R32 attended dialysis on [DATE]. On [DATE] at 8:40 AM, R32 was observed seated on his bed eating breakfast. R32 was asked about his dialysis schedule. R32 reported he went to dialysis twice a week and that the physician wanted him to go three times a week. R32 said he felt better only going twice a week. R32 further explained he no longer wanted the PEG tube in his stomach. R32 reported he ate all food by mouth and stated, I told them so many times that I don't want this tube. I want it out! R32 reported he was told his legal guardian had to consent for any medical care. R32 stated, I need a patient advocate or something because I have an issue with having a guardian who doesn't return my calls. R32 further explained his guardian or the facility had never had a conversation with him about his goals and treatment preferences. R32 said he wanted to petition the court for a new guardian or to not have one at all. R32 reported the facility social worker had not talked to him about anything. On [DATE] at approximately 10:50 AM, Emergency Medical Services (EMS) was observed outside of R32's room. R32 was observed to be calm, not yelling or screaming. EMS was observed talking with Licensed Practical Nurse (LPN) 'C' and said they could not force R32 to go to the hospital if he did not want to go. At that time, Unit Manager, LPN 'A' handed LPN 'C' a completed Petition for Mental Health Treatment form (a form petitioning the court to order mental health treatment for an individual who is a danger to self or others) for R32 and LPN 'C' contacted the police and told them R32 was a danger to himself because he would not go to dialysis treatment. On [DATE] at approximately 11:00 AM, an interview was conducted with EMS staff. EMS staff said they cannot make R32 go to the hospital if he would not voluntarily go. They were not allowed to restrain the resident. EMS staff reported they believed R32 was of sound mind and made a conscious decision not to go to dialysis. At that time, an interview was conducted with LPN 'C'. LPN 'C' reported she was told by LPN 'A' to petition R32 to the hospital. LPN 'C' reported R32 was combative and agitated and refused to go to dialysis. At that time R32 was observed lying in bed calmly. A review of the petition revealed documentation that R32 .refused several days of dialysis appointments over the past two weeks and has not abided by his hemodialysis orders. Refusing to attend further sessions as well as tube feeding and medications . When queried about whether she thought R32 required psychiatric treatment, LPN 'C' reported she did not think he did. LPN 'C' reported R32's vital signs were currently stable and R32 was not in any physical distress. LPN 'C' stated, (LPN A') did the petition. On [DATE] at 11:06 AM, an interview was conducted with R32. R32 was observed visibly upset and stressed and was teary eyed. R32 reported he knew the doctor's orders were to go to dialysis more often, but he already told the doctor he would only go twice a week. R32 reported he knew what dialysis was for and understood the risks of not going according to the physician's order. R32 reported he went on Monday ([DATE]) and would go again on Friday ( - interview with resident. Visibly upset, teary eyed. Said he talked to the dialysis doctor already. Wants him to go three days but resident only wants to go two. He said he understands the risks of not going all days and knows what dialysis is for. He said he went on Monday and will go on Friday ([DATE]). R32 stated, They don't get to get rid of my rights just because I'm in a nursing home. I have the right. Might as well just discharge me then. On [DATE] at 11:11 AM, an interview was conducted with LPN 'A'. When queried about why the facility had completed a petition for mental health care for R32, LPN 'A' reported R32 had a history of two cardiac arrests (prior to admission into the facility) and missed several dialysis appointments. LPN 'A' stated, I have to ask myself, 'Have I done all I can to help him?' When queried about why they petitioned R32 instead of following his wishes to not go to the hospital, LPN 'A' reported R32 had a legal guardian and they wanted him to get dialysis. When queried about how often the legal guardian interacted with the resident or when they last visited R32, LPN 'A' reported the legal guardian had not visited R32 (admitted on [DATE]). LPN 'A' reported that they had to follow what the legal guardian wanted. LPN 'A' further reported if R32 did not go to the hospital, the physician said the legal guardian had to sign R32 onto hospice services. When queried about R32's choice in signing onto hospice services, LPN 'A' did not offer a response. When queried about what conversation were had with R32 about dialysis and why he did not want to go according to physician's orders, LPN 'A' said R32 just said, You can't make me go. At that time, police entered the facility and attempted to talk with R32. R32 remained calm and did not agree to go to the hospital The police left the building around 11:20 AM. On [DATE] at approximately 11:25 AM, R32 was observed curled into a fetal position. An interview was attempted. R32 was visibly upset and said he could barely talk at the moment because he was very stressed about what just happened. R32 curled back into a fetal position and pulled the bed sheet over his face. On [DATE] at approximately 1:20 PM, R32 was interviewed further. When queried about whether anyone in the facility and/or his legal guardian had talked to him about his treatment wishes related to dialysis or his code status. R32 reported nobody talked to him. R32 reported he would only want CPR (Cardiopulmonary Resuscitation) if he could be brought right back and would not want to be hooked up to machines to breathe. When queried about whether he knew what hospice was, R32 stated, Is that like when you are about to die? R32 reported a nurse asked him if he wanted to be on hospice and he told her No. R32 reported the nurse stated, Are you sure? and left the room. R32 reported nobody had any meaningful discussion about his treatment wishes. A review of a Social Services progress note dated [DATE], written by Social Services Staff (SS 'L') revealed, Writer sent hospice recommendation letter to guardian, guardian approved of consult and gave permission for writer to speak with resident's family regarding hospice consult, writer called resident's sister and left a voicemail, resident daughter phone line was busy unable to leave message. There was no indication hospice was discussed with R32. There were no other Social Services progress notes that indicated R32's refusals of dialysis and other care were addressed by social services. On [DATE] at 1:27 PM, an interview was conducted with SS 'L'. When queried about the facility's process for including residents in decision making when they had a legal guardian, SS 'L' reported both the resident and legal guardians were included in conversations about the resident's care, including discussions about code status and whether the resident wanted CPR or not. When queried about whether R32 was included in a discussed about his code status when he was admitted into the facility, SS 'L' reported R32 was not included, only the legal guardian. When queried about whether R32's legal guardian has been to the facility since R32 was admitted , SS 'L' reported the guardian had not and she did not know if they had talked on the telephone. When queried about any conversations SS 'L' had with R32 about his treatment wishes or why he had refused dialysis at time, SS 'L' reported she talked to R32 on that day because he refused dialysis, but did not talk to him before that. SS 'L' reported she had not talked to R32's legal guardian and R32 together to discuss R32's refusals of dialysis or care and stated, Now he will be having a consult for hospice. When queried about whether R32 was included in a conversation about his feeling about having a hospice consult, SS 'L' reported he was not and stated, It is just a consult. On [DATE] at 2:00 PM, an attempt was made to interview R32's guardian via the telephone using the phone number provided by SS 'L'. There was no option to leave a voice mail message. On [DATE] at 2:19 PM, an interview was conducted with the Administrator. The Administrator reported any care conference or discussion about treatment or care should including the resident and the legal guardian. On [DATE] at 1:40 PM, an interview was attempted with Physician 'K' via the telephone and a voice mail message was left. Physician 'K' was not available for interview prior to the end of the survey. A review of a facility policy titled, Residents' Rights Regarding Treatment and Advance Directives, dated [DATE], revealed, in part, the following: .The facility will provide the resident or resident representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advance directive .Any services that would be otherwise required, but are refused, will be documented in the resident's comprehensive care plan .The facility will not initiate or discontinue any other care based on refusal of care by the resident .

Based on observation, interview and record review, the facility failed to ensure medications and biologicals were appropriately stored in a safe/sanitary manner in one medication cart reviewed. Findings include: On 5/8/25 at 10:40 AM, observation of the 2nd floor medication cart was made with Licensed Practical Nurse (LPN) D. In the top drawer on the left, money was observed folded in the back right hand corner. LPN D was asked whose money it was. LPN D explained she did not know whose money it was. LPN D was asked how much money was there. LPN D unfolded the money to reveal four one dollar bills. When asked what she was going to do with the money, LPN D explained she would give it to the manager. Continued observation of the medication cart revealed in the third drawer on the left, an open bottle of hand sanitizer with a pump was in the same compartment as a nebulizer treatment for inhalation. LPN D was asked about the hand sanitizer. LPN D immediately removed the bottle of hand sanitizer and said it should not be there. On 5/8/25 at 12:09 PM, the Director of Nursing (DON) was informed of finding money in the medication cart. The DON explained they would keep it in the office until either a resident or staff member asked about it. When asked if money should ever be kept in a medication cart, the DON said no. The DON was informed of a bottle of hand sanitizer in the same compartment as nebulizer medication. The DON explained cleaning supplies should never be in the same space as medications. Review of a facility policy titled, Medication Storage revised 9/27/23 read in part, .External Products: Disinfectants and drugs for external use are stored separately from internal and injectable medications .

Based on interview and record review, the facility failed to ensure accurate assessments were completed for four (R41, R16, R15 and R18) of 13 residents reviewed for Minimum Data Set (MDS) assessments. Findings include: According to the Long-Term Care Facility (LTCF) Resident Assessment Instrument (RAI) 3.0 User's Manual, link to the LTCF RAI User's Manual: https://www.cms.gov/files/document/finalmds-30-rai-manual-v1191october2024.pdf: .an accurate assessment requires collecting information from multiple sources . Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician . R41 Review of the closed record revealed R41 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: hypertension, acute kidney failure and diabetes. According to the MDS assessment dated [DATE], section A2105 which prompted the staff completing the assessment to indicate where the resident discharged to was incorrectly marked as Short-Term General Hospital. Review of R41's progress notes revealed a nursing note dated 2/11/25 at 10:57 AM that read in part, .Resident was transferred to another facility . Discharge transfer paperwork sent with resident . On 5/8/25 at 2:14 PM, the MDS Coordinator, Registered Nurse (RN) H, was interviewed by phone and asked why R41's discharge assessment was marked for the hospital when R41 was discharged to another Long Term Care facility. RN H explained it was a complete accident she had marked hospital. R16 Review of the clinical record revealed R16 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: heart failure, psychotic disorder with delusions and anxiety disorder. According to the MDS assessment dated [DATE], section N0450 which prompted the staff completing the assessment to answer yes or no if there had been a gradual dose reduction (GDR) of an antipsychotic was completed, and the date it was attempted. The assessment was incorrectly marked as Yes and the date entered was 01/05/2025. Review of R16's Psychiatric Evaluation & Consultation report dated 1/27/25 read in part, .Current Assessment/Plan: .GDR is not indicated at this time due to the ongoing need for symptom control . Current medication regimen will remain unchanged . On 5/8/25 at 2:20 PM, RN H was asked, during the phone interview, why R16's assessment on 2/24/25 was marked yes for a GDR. RN H explained she had seen that R16 had a psychiatric evaluation on 1/5/25 and she thought a GDR was done every time a psychiatric evaluation was done. When informed a GDR was not indicated, RN H explained she now saw that it was not done. Additional review of R16's psychiatric evaluations revealed no evaluation was completed on 1/5/25. In Resident Documents the upload date of 1/5/25 was for an evaluation completed 12/30/24. The evaluation dated 12/30/24 also documented a GDR was not indicated. 32568 R15 A review of R15's weights revealed on 1/6/25, R15 weighed 194.6 pounds. On 4/2/25, R15 weighed 173.2 pounds which indicated an 11 percent loss of body weight. A review of R15's progress notes between 1/6/25 and 4/2/25 revealed no documentation that indicated the weight difference was incorrect or what was done to verify that it was accurate. A review of R15's clinical record revealed R15 was admitted into the facility on [DATE] and readmitted on [DATE], 3/8/25, and 3/16/25 with diagnoses that included: normal pressure hydrocephalus, influenza, and acute cystitis. A review of R15's MDS assessment dated [DATE] revealed R15 weighed 185 pounds which indicated a 6.81 percent weight gain since the last documented weight of 173.2 pounds on 4/2/25. It was documented on the MDS assessment that R15 did not have a gain of five percent or more in the last month or a loss of 10 percent or more in the last six months. The weight documented on the MDS assessment was not consistent with the weight documented in the clinical record in the weight summary. On 5/8/25 at approximately 2:16 PM, an interview was conducted with RN 'H'. When queried about how she ensured accuracy of the nutrition assessments conducted by other staff members, RN 'H' reported she went through the assessment and was in communication with RD 'J' and CM 'K' to coordinate with them to ensure their assessments were accurate. When queried about the weight discrepancy and why R15 was coded as not having significant weight loss or gain based on the weight in the MDS and/or the documented weights in the clinical record, RN 'H' stated, I am only signing off that the assessment is done, but I do coordinate with them. RN 'H' reported as a nurse she did not know how to calculate percentage of weight loss to check for accuracy and stated, Dietary is responsible for that. I only sign off that it's complete, not that it's accurate. On 5/8/25 at 3:00 PM, an interview was conducted with the Administrator. When queried about the role of the RN MDS Coordinator in ensuring accuracy of MDS assessments, the Administrator reported RN 'H' was supposed to assess the residents in order to ensure the information entered on the MDS was accurate. If there were any discrepancies, a discussion should be had with the department who conducted the assessment. It should not be assumed that the documented assessment was correct. 47283 R18 R18 was admitted to the facility on [DATE] from another skilled nursing facility. R18's admitting diagnoses included colon cancer, liver cirrhosis, history of falls with fractures and depression. Based on MDS assessment dated [DATE], R18 had a Brief Interview for Mental Status (BIMS) of 12/15 indicative of moderate cognitive impairment. Section M of the MDS assessment revealed that R18 was admitted with a stage 3 pressure ulcer and they had pressure reducing devices for the bed. An initial observation was completed on 5/6/25 at approximately 9:40 AM. R18 was observed lying on their bed that had a regular mattress. When queried how they were doing, R18 stated I feel a lot better. R18 was able to answer questions and reported that they had surgery some time ago related to their cancer. R18 also reported that they came over here from another facility. Later that day the follow-up observations were completed at approximately 11 AM and 12:20 PM. R18 was observed in their room, sitting in a wheelchair. R18 was queried if they had any pain and or sores on their back and they reported no and they have had the same mattress since they were admitted to this facility. Review of R18's Electronic Medical Record (EMR) revealed a physician order dated 3/28/25 that wound on left upper buttock and lower buttocks. Special instructions: clean wound with wound cleaner on left upper and lower buttock and apply Calmoseptine ointment on each shift. Review of nursing admission progress notes dated 3/27/25 read in part, Resident alert oriented x 3 at this moment .skin assessment done, open wound to buttocks,, wound consult done. Further review of EMR did not reveal any wound care consultation or any new orders other than the Calmoseptine order referenced above. Review of nursing progress notes dated 3/28/25 read in part, Midnight nurse assessed resident buttocks for wounds. Resident has one small open wound on upper left buttock and small wound in healing stage on lower left buttocks . Review of admission skin assessment dated [DATE] did not reveal any pressure ulcers marked on the assessment. Review of history and physical note by attending physician dated 3/27/25 revealed R18 had pressure ulcer with no specification on any stage. Review of the facility Matrix revealed that R18 had a stage 3 pressure ulcer. Further review of EMR did not reveal any evidence of stage 3 pressure ulcer after R18's admission to the facility. An interview with Registered Nurse (RN) E was completed on 5/6/25 at approximately 2:55 PM. They reported that they had been at the facility almost 2 years and they regularly worked the floor. They added that they were familiar with the residents. They were questioned about wound treatments on the unit and if they had any stage 3 pressure ulcers. RN E reported that they did not have any resident with open areas on the unit and added that the floor nurses completed the treatments if they had any on their units. An interview with Unit Manager (UM) A was completed on 5/6/25 at approximately 3:10 PM. They reported that they oversaw the facility's wound care program. They were queried about R18 and they had reported that they were familiar with the resident. They were queried if R18 had any stage 3 pressure ulcers, and UM A reported (after reviewing EMR) that that R18 did not have stage 3 pressure ulcer and they had small hypopigmented /open areas on their left buttocks when they were admitted . They added that R18 never had a stage 3 pressure ulcer and they were just using barrier cream since admission. They were queried about the MDS assessment that indicated that R18 was admitted with stage 3 pressure ulcer and they reported that resident was admitted from one of their other facilities and the paperwork from other facility had documentation about stage 3 pressure ulcer during their stay at the other facility. They were notified of the concerns with the accuracy of MDS assessment and they reported that they understood and they would follow up with their Director of Nursing (DON). An interview with DON was completed on 5/6/25 at approximately 3:35 PM. During this interview Administrator and UM A were present in the office. They were notified of the findings and concerns with the accuracy of MDS assessment. DON confirmed that R18 did not have stage 3 wounds after their admission to the facility and UM A completed weekly rounds with their wound care practitioner. The DON reported that the MDS coordinator possibly obtained the information from the transfer records sent from the other facility. They reported that they understood the concern and they would follow up with their MDS coordinator. An interview with RN 'H' was completed via phone on 5/8/25 at approximately 2:15 PM. They were queried how they had completed the section M (skin conditions) under the MDS assessment. They reported that they saw all residents admitted to the facility prior to their comprehensive assessments. When queried further on the process to ensure the accuracy of assessment, they reported they were not trained to do wound staging or assessments and they relied on documentation from the nursing team/wound care team to complete their assessment. When queried about R18 and the stage 3 pressure ulcer coded on R18's MDS assessment, RN 'H' reported that they obtained the information from the documentation that was sent from the previous facility and the admission nursing note had documentation about small open areas and had completed their MDS assessment based on that information. They did not physically verify if R18 had a stage 3 pressure ulcer and did not look any further. They were notified of the concern with the MDS accuracy and they reported that they understood the concern and will submit a modification. Review of the facility provided document tiled Conducting an Accurate Resident Assessment with a revision date of 2/26/25, read in part, The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. Definition: 'Accuracy of assessment' means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate Resident Assessment Instrument (RAI) (i.e. comprehensive, quarterly, significant change in status). Policy Explanation and Compliance Guidelines: 1. The Administrator will ensure that all participants in the assessment process have the requisite knowledge to complete an accurate assessment. 2. Qualified staff who are knowledgeable about the residents will conduct an accurate assessment addressing each resident's status, needs, strengths, and areas of decline. The assessment will be documented in the medical record. 3. The appropriate, qualified health professional will correctly document the resident's medical, functional, and psychosocial problems and identifies resident strengths to maintain or improve medical status, functional abilities, and psychosocial status. 4. A registered nurse will coordinate the RAI completion process with the appropriate participation of health professionals. The registered nurse is responsible for certifying that the assessment has been completed. 5. Information provided by the initial comprehensive assessment establishes baseline data for the ongoing assessment of resident progress. 6. The physical, mental and psychosocial condition of the resident determines the appropriate level of involvement of physicians, nurses, rehabilitation therapists, activities professionals, medical social workers, dietitians, and other professionals, such as developmental disabilities specialists, in assessing the resident, and in correcting resident assessments. Involvement of other disciplines is dependent upon individual resident status and needs. 7. A registered nurse will sign and certify that the assessment/correction request is completed. Each individual who completes a portion of the assessment will sign and certify the accuracy of that portion of the assessment. Whether the MDS assessments are manually completed, or computer generated following data entry, each individual assessor is responsible for certifying the accuracy of responses relative to the resident's condition and discharge or entry status .

Based on observation, interview, and record review facility failed to thoroughly investigate and do a root cause analysis of a fall; and failed to consistently implement fall/accident prevention interventions as recommended for one (R34) of one resident reviewed for falls. This deficient practice has the potential for further falls with/without injury and resulted in hospital transfer of R34 for evaluation after fall. R34 R34 was a long-term care resident of the facility, originally admitted to facility on 9/24/24. R34's admitting diagnoses included dementia, personality disorder, schizoaffective disorder, and drug induced movement disorder, and unsteady gait with history of falls. Based on Minimum Data Set (MDS) assessment dated [DATE], R34 had a Brief Interview for Mental Status (BIMS) score of 3/15 indicative of severe cognitive impairment. An initial observation was completed on 5/6/25 at approximately 9:55 AM. R34 was observed sitting in the dining room in their wheelchair eating a snack. R34 had no shoes and had gripper socks on. Follow-up observations were completed on 5/7/25 at approximately 8:35 AM and 9:30 AM. R34 was sitting up in wheelchair, in their room. They had their bedside table in the front with their breakfast tray. R34 had a non-skid socks. Later that day, at approximately 12:15 PM, R34 was observed sitting in the dining room with their socks. At approximately 1:20 PM, they were observed trying to propel their wheelchair in front of the nursing station with their socks on. Review of R34's Electronic Medical Record (EMR) revealed a nursing progress note dated 03/09/2025 at 08:31 AM, read in part, During shift change, resident fall out of bed, Writer immediately assessed resident, small laceration noted on right-side of head neuro checks in place . Writer contacted MD (Medical Doctor) notified of situation writer also informed MD that resident is currently on Eliquis(blood thinner) writer ordered to send resident to hospital for evaluation. Further review revealed a nursing progress note dated 3/10/25 at 6:50 PM that read in part, Writer received resident from [local hospital] accompanied by two attendees post fall. Resident alert, verbally responsive. No s/s (signs-symptoms) acute distress. Denies sob (shortness of breath). Denies pain. Pupils equal and reactive. Able to move all extremities. Incontinent of bowel and bladder. Abrasion to the right side of forehead. Bed in lowest position . A request was sent via e-mail to the facility administrator on 5/06/25 at 3:05 PM to provide Incident and Accident (IA) reports for R34 between 9/24/24 and 5/6/25. Three sets of event reports (incident and accident) and investigation reports were received. The reports revealed R34 had events on 10/21/24, 11/22/24, and 11/29/24. Review of the IA report dated 10/21/24 revealed that R34 had a fall in the room while they were attempting to self-transfer and they were sent to an emergency room for further evaluation due to an abrasion to their forehead. The IA report for the 11/22/24 fall revealed R34 had a fall from their bed. Review of the investigation reports and R34's care plan did not reveal a thorough investigation of the incident or any immediate interventions that were implemented after the fall. Review of the IA report dated 11/29/24 and progress notes revealed that R34 was sitting in the day room and another resident wheeled over their right foot and their right great toenail was partially detached from the nail bed. Intervention read Certified Nursing Assistant (CNA) educated on importance of proper footwear. The facility did not provide any IA report or investigation report for R34's fall on 3/9/25 when they were transferred out to the hospital with a laceration to their forehead. An interview with License Practical Nurse (LPN) B was completed on 5/7/25 at approximately 2:41 PM. LPN B was assigned to care for R34 during that shift. They were queried about how the resident information/plan of care was shared with the CNAs. LPN B reported they had a Kardex (care card for CNAs) book/binder for the CNA's and nurses shared the information as needed. LPN B provided the Kardex book for the unit. Review of Kardex for R34 revealed an intervention dated 11/29/24 that read proper foot ware and LPN B was queried about what it meant for R34 and they reported that he had tendency to scoot/sit himself on the floor and R34 needed non-skid socks or shoes. When queried if socks were ok they reported yes. An interview with Unit Manager (UM) A was completed on 5/7/29 at approximately 9:30 AM. They were queried about the post fall follow up and investigation process. They reported that the nurse initiated the process and they would call and notify them or Director of Nursing (DON). The nurse would implement immediate interventions and the leadership completed the investigation and further follow up as needed. They were queried about the IA and investigation report for 3/9/25 fall and they reported that they would follow up with the DON. An interview with the DON was completed on 9/7/25 at approximately 9:50 AM. They were queried about the process and they reported that the nurse would notify them or the unit manager of a fall event and they would make recommendations on implementation of immediate interventions. The DON also added that they were involved with handling the fall management program for the facility. DON was queried about the IA and investigation report for the fall event on 3/9/25. The DON reported that they were unaware of the fall event from 3/9/25 and they were not notified that R34 was transferred out to hospital. The DON reviewed the EMR and progress notes from 3/9/25 and 3/10/25. They reported that they would find out more information and would get back. They were queried about staff expectations on R34's intervention dated 11/29/24 proper footwear. The DON reported that R34 should have their shoes on when they were up because of the incident. The DON was notified of the multiple observations when R34 was observed with their socks on in the dining room and hallway. They reported that they would follow up with their staff. On 5/7/25 at approximately 11:10 AM, the DON came back and reported that they did not have any IA reports for this fall and they were trying to reach the nurse and the nurse was taking their exam and they were unable to reach them. They confirmed that they were unaware of the event. They reported that they understood the concern. On 5/7/25 at approximately 4 PM, the facility Administrator was questioned about the fall investigation process. The Administrator notified that the nurse initiated the IA report and notified the DON or the unit manager and the DON followed up after completing the investigation and implemented plans. They were notified of the concern with fall incident on 3/9/25 with IA and investigation, the administrator agreed with the concern. Review of the facility provided document titled Incidents and Accidents with a date of 11/1/22, read in part, Policy: It is the policy of this facility for staff to utilize Incident Reports to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Definitions: Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. An incident is defined as an occurrence or situation that is not consistent with the routine care of a resident or with the routine operation of the organization. This can involve a visitor, vendor, or staff member. Policy Explanation: The purpose of incident reporting can include: Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care. Conducting root cause analysis to ascertain causative/contributing factors as part of the Quality Assurance Performance Improvement (QAPI) to avoid further occurrences. Alert risk management and/or administration of occurrences that could result in claims or further reporting requirements. Meeting regulatory requirements for analysis and reporting of incidents and accidents. Compliance Guidelines: 1. Incident/accident reports are part of the facility's performance improvement process and are confidential quality assurance information. 2. Licensed staff will utilize Incident Reports, falls assessments and Neuro Check Protocol to report incidents/accidents and assist with completion of any investigative information to identify root causes. 3. Incidents or accidents involving employees or visitors will be documented on the following forms/systems: Incident Reports 6. In the event of an incident or accident, immediate assistance will be provided or securement of the area will be initiated unless it places one at risk of harm. 7. Any injuries will be assessed by the licensed nurse or practitioner and the affected individual will not be moved until it is safe to do so. First aid will be given for minor injuries such as cuts or abrasions. 8. The supervisor or other designee will be notified of the incident/accident. If necessary, law enforcement may be contacted for specific events .

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 one (R16) of five residents reviewed for monthly medication regimen reviews. Findings include: Review of the clinical record revealed R16 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: heart failure, dementia and anxiety disorder. According to the Minimum Data Set (MDS) assessment dated [DATE], R16 had severely impaired cognition and required the assistance of staff for activities of daily living (ADL's). Review of a Note To Attending Physician/Prescriber by a Consultant Pharmacist dated 3/11/25 revealed a recommendation that read, .Please consider ordering the following labs: Lipid Panel, TSH (thyroid-stimulating hormone) levels . The Physician/Prescriber Response was marked AGREE and signed 3/13/25. Review of a Note To Attending Physician/Prescriber dated 4/15/25 revealed a recommendation that read, .Please consider ordering the following labs: Lipid panel, TSH levels, Vitamin D levels . The Physician/Prescriber Response was marked AGREE and signed 4/17/25. Review of R16's laboratory results revealed the Lipid panel, TSH level and Vitamin D levels were drawn on 4/17/25. No results were found for the 3/11/25 recommendation. On 5/7/25 at 3:40 PM, Licensed Practical Nurse (LPN) C was asked where it was documented when labs were ordered for a resident. LPN C explained the nurse would fill out a requisition order and place it in the lab book. LPN C was asked if a record was kept of what labs were ordered. LPN C explained since lab would take the requisition form, she would usually write a progress note that labs were ordered, but not everyone did that. On 5/7/25 at 3:43 PM, the Director of Nursing (DON) was interviewed and asked if the Lipid panel and TSH level had been ordered after the pharmacy recommendation on 3/11/25. The DON explained there was no way to see if a lab was ordered or not. Review of a facility policy titled, Medication Regimen Review dated 11/1/22 read in part, .Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities .

Based on observation, interview, and record review, the facility failed to ensure the call light was accessible to the resident for one (R32) of three residents reviewed for accommodation of needs. Findings include: On 5/6/25 at 9:28 AM, R32 was observed in bed sleeping. The call light, which was a long thin string attached to a switch, was observed behind the head of the bed on the floor. On 5/6/25 at 10:56 AM, R32 was observed in bed with the head of the bed at an incline. R32 asked for the head of the bed to be lowered. When queried about how he alerted staff when assistance was needed, R32 reported he used the call light. The call light remained behind the head of the bed on the floor. When queried about whether he could reach the call light string, R32 attempted to reach back and said he could not reach it. On 5/6/25 at 11:00 AM, an interview was conducted with Licensed Practical Nurse (LPN) 'I'. LPN 'I' reported all nursing staff were required to ensure residents had access to their call lights. At that time, an observation of R32's call light was conducted with LPN 'I'. LPN 'I' attached the call light string to R32's blanket. On 5/6/25 at approximately 2:00 PM, R32's call light was observed clipped behind the head of the bed to a bed sheet, not in reach of the resident. At that time, LPN 'I' was informed and said it should be clipped where the resident could reach it. On 5/8/25 at 3:39 PM, an interview was conducted with the Director of Nursing (DON). The DON reported all staff were required to ensure call lights were within reach of the residents. A review of R32's clinical record revealed R32 was admitted into the facility on [DATE] with diagnoses that included: heart disease, end stage renal disease, and history of traumatic brain injury. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R32 had moderately impaired cognition and required partial/moderate assistance with bed mobility, transfers, and activities of daily living. A review of a progress note dated 4/26/25 revealed R32 was not compliant with self-transferring. It was documented the nurse educated R32 on using the call light. A review of R32's care plans revealed a care plan dated 4/24/24 that noted, I am at risk for falling R/T (related to): poor safety awareness, need for assist with mobility and not waiting for help. An intervention dated 4/27/25 noted, Keep call light in reach at all times.

Based on observation, interview and record review the facility failed to assess, monitor and treat a skin tear for one (R16) of one resident reviewed for wounds. Findings include: On 5/6/25 at 8:53 AM, R16 was observed sitting in a wheelchair in the dining room. An undated adhesive foam bandage was observed on R16's right forearm. Shadowing of drainage was visible on the bandage. When asked about the bandage, R16 was not able to explain why it was there. On 5/6/25 at approximately 12:00 PM, R16 was observed sitting in a wheelchair in the dining room. The bandage on R16's right forearm with the same shadowing of drainage had the date 5/6/25 written on it. Review of the clinical record revealed R16 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: altered mental status, dementia and anxiety disorder. According to the Minimum Data Set (MDS) assessment dated [DATE], R16 had severely impaired cognition and required the assistance of staff for activities of daily living (ADL's). Review of R16's physician orders revealed no order for a dressing to the right forearm. Review of R16's progress notes revealed a nursing note dated 5/5/25 at 7:03 PM that read in part, Resident has a skin tear to the right forearm . Writer cleaned area left open to air . On 5/7/25 at 10:41 AM, R16 was observed sitting in a wheelchair in their room. The bandage on R16's forearm, dated 5/6/25, had the same shadowing of drainage that was observed the previous day. On 5/7/25 at 11:10 AM, Licensed Practical Nurse (LPN) C, R16's assigned nurse, was asked if she had received any report of R16 having a skin tear. LPN C explained she had not been told anything about R16 having a skin tear. When asked if there were any orders for a dressing for R16, LPN C explained there were no orders for any dressings for R16. On 5/7/25 at 12:55 PM, Unit Manager (UM) A was interviewed and asked about the dressing of R16 ' s right forearm. UM A explained she had been leaving the facility on 5/5/25 when R16 ' s nurse had told her about R16 ' s skin tear . she thought the nurse had taken care of everything, but now knew there were no physician orders for the skin tear. UM A was asked who had put the dressing on the skin tear as the progress note had said it was left open to air. UM A explained she did not know if it had been the midnight nurse or the day nurse. UM A was asked if a nurse thought a skin tear required a dressing on it, what should be done. UM A explained the nurse should call the physician an obtain orders for the dressing and wound care. When informed the dressing originally had no date, but the same dressing was dated later on in the day, UM A had no answer. Review of a facility policy titled, Wound Treatment Management dated 11/1/22 read in part, .Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change . In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders .

This citation pertains to Intake Number(s): MI00152212. Based on observation, interview, and record review, the facility failed to consistently monitor residents' skin according to physician's orders and appropriately implement preventative interventions for three (R15, R18, R23) of three residents reviewed for pressure ulcers, who had a history of or were at risk of pressure ulcers. Findings include: On 5/6/25 at 9:25 AM, R15 was observed partially inclined in bed, lying on her back. A specialty air mattress was observed on R15's bed which was set to normal pressure and 400 pounds. Protective heel boots were observed in the room, but not on the resident. R15's heels were observed in contact directly with the mattress. On 5/6/25 at 10:56 AM, R15 was observed in the same position in bed and the air mattress was set to 400 pounds. R15 did not appear to weigh 400 pounds. R15's heels were observed in contact directly with the mattress and the heel boots were not applied. On 5/6/25 at 4:15 PM, R15 remained in the same position in bed and the air mattress remained set to 400 pounds. R15 was not wearing the heel boots. R15's heels were observed in contact directly with the mattress. When queried, R15 reported she did not like to wear the boots and that was her choice. R15 further said she liked to stay in bed. A review of R15's clinical record revealed R15 was admitted into the facility on [DATE], and readmitted on [DATE], 3/8/25, and 3/16/25 with diagnoses that included: normal pressure hydrocephalus, acute cystitis, and diabetes mellitus. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R15 had severely impaired cognition, required partial/moderate assistance with bed mobility and transfers, was always incontinent of bowel and bladder, and was at risk of pressure ulcer development. A review of a Braden Scale assessment dated [DATE] revealed R15 was at moderate risk of developing pressure ulcers. The documented interventions included pressure reducing device for bed. A review of R15's Physician's Order revealed an order with a start date of 10/11/24 for Weekly Skin Assessment Special Instructions: Complete under observation/weekly skin assessment once a day on Tue (Tuesday) . A review of R15's weekly skin assessments under observation revealed no skin assessments completed by the nurse between the dates of 4/10/25 and 4/30/25 and 3/16/25 and 4/2/25. A review of R15's care plans revealed no specific interventions regarding the settings for the specialty pressure reducing air mattress. There was an intervention to float R15's heels with pillows or with heel boots. On 5/6/25 at 4:55 PM, an interview was conducted with Unit Manager, Licensed Practical Nurse (LPN) 'A' who was also the wound care coordinator for the facility. When queried about how nursing staff knew what settings to use for residents who had speciality air mattresses used to prevent pressure ulcers, LPN 'A' reported she trained staff to set the mattresses according to the residents' body weight. When queried about whether R15's mattress should be set at 400 pounds, LPN 'A' reported it should not because it would provide too firm of a surface for R15's weight, which was not 400 pounds. When queried about how residents' skin was monitored for any skin alterations, including pressure ulcers, LPN 'A' reported the nurses were required to complete a full head to toe skin assessment using the observation form every week. LPN 'A' reported Certified Nursing Assistants looked at residents' skin during showers and nurses signed off on the shower sheets, but those were not in place of the full head to toe skin assessments ordered by the physician. At that time LPN 'A' reviewed R15's clinical record and confirmed R15 had a physician's order for weekly skin assessments and there as no skin assessments completed between 4/10/25 and 4/30/25; and 3/16/25 and 4/2/25. A review of a facility policy titled, Skin assessment dated [DATE], revealed, in part, the following, .A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter . 47283 R18 A review of R18's clinical record revealed R18 was admitted to the facility on [DATE] from another skilled nursing facility. R18's admitting diagnoses included colon cancer, liver cirrhosis, history of falls with fractures, and depression. Based on the MDS assessment dated [DATE], R18 had a Brief Interview for Mental Status (BIMS) of 12/15 indicative of moderate cognitive impairment. Section M of the MDS assessment revealed that R18 was admitted with a stage 3 pressure ulcer on their buttocks. Based on the definition of staging from Centers for Medicare and Medicaid Services, a stage 3 pressure ulcer is full thickness tissue loss and the subcutaneous (under the skin) fat may be visible, but bone, tendon, or muscle is not exposed. R18 had pressure reducing devices for the bed. An initial observation was completed on 5/6/25 at approximately 9:40 AM. R18 was observed lying on their bed that had a regular mattress. When queried how they were doing, R18 stated I feel a lot better. R18 was able to answer questions and reported that they had surgery some time ago related to their cancer. R18 also reported that they came over here from another facility. Later that day, follow-up observations were completed at approximately 11:00 AM and 12:20 PM. R18 was observed in their room, sitting in a wheelchair. R18 was queried if they had any pain and or sores on their back and they reported no and they have had the same mattress since they were admitted to this facility. Review of R18's Electronic Medical Record (EMR) revealed a physician order dated 3/28/25 that wound on left upper buttock and lower buttocks. Special instructions: clean wound with wound cleaner on left upper and lower buttock and apply Calmoseptine ointment on each shift and weekly skin assessments: under observations. R18 also had an order for weekly skin assessments dated 4/2/25. Review of nursing admission progress notes dated 3/27/25 read in part, Resident alert oriented x 3 at this moment .skin assessment done, open wound to buttocks,, wound consult done. Further review of EMR did not reveal any wound care consultation or any new orders other than the Calmoseptine order referenced above. Review of nursing progress notes dated 3/28/25 read in part, Midnight nurse assessed resident buttocks for wounds. Resident has one small open wound on upper left buttock and small wound in healing stage on lower left buttocks . Review of admission skin assessment dated [DATE] did not reveal any pressure ulcers marked on the assessment. Further review of weekly skin observations revealed that they were not consistently completed as ordered. R18 had an admission skin assessment completed on 3/28/25 revealed no pressure ulcers when the initial record review was completed on 5/6/25 at approximately 1:30 PM. Later that day (after the concern was brought to the attention of facility team) during the follow up review, at approximately 4 PM the admission skin assessment was initially completed on 3/28/25 showed that a modification of assessment was in progress on the EMR. There were no weekly skin assessments for approximately over two weeks after 3/28/24, and the next skin assessment was completed on 4/17/24. Review of R18's care plan revealed a problem area dated 4/9/25 that read, I have a pressure ulcer, due to multiple underlying medical conditions, wound may not heal and formation of more wounds may be unavoidable and interventions included low air loss mattress that initiated on 4/9/25. R23 A review of R23's clinical record revealed R23 was originally admitted to the facility on [DATE] and they were recently hospitalized and readmitted back to the facility on [DATE]. R23's admitting diagnoses included brain cancer (recent finding), urinary tract infection, post COVID, dementia, and compression fracture of the lumbar vertebrae. Based on the MDS assessment dated [DATE], R23 had a BIMS of 11/15, indicative of moderate cognitive deficits. An initial observation was completed on 5/6/25 at approximately 10:15 AM. R23 was observed in their bed. R23 was receiving their nutrition and hydration through Percutaneous Endoscopic Gastrostomy (PEG) tube/feeding tube. R23 also had a Foley catheter (a thin, flexible tube used to drain urine from the bladder) and the bag was connected to their bed frame. R23 was observed laying on their back and they had a specialty low air loss mattress. Review of R23's recent Braden assessment (tool used by healthcare professionals to assess a patient's risk for developing pressure ulcers/bedsores) dated 3/3/25, revealed a score of 14, indicative of moderate risk for pressure ulcer. Review of R23's admission note dated 1/24/25 revealed that R23 was admitted to the facility with two stage 2 pressure ulcers on their sacrum and wounds on their left scapula (shoulder blade). R23's EMR revealed a physician order dated 2/1/25 that read weekly skin assessment. Review of R23's care plan initiated on 2/3/24 read, I have a pressure ulcer. Due to multiple underlying medical conditions wounds may not heal and formation of more wounds may be unavoidable. Review of R23's skin assessments revealed that weekly skin assessments were not completed as ordered. Review of weekly assessments after 2/1/25 revealed assessments dated: 2/5/25. No assessment on 2/12. R23 was admitted to hospital between 2/14/25 and 3/2/25. They were readmitted to the facility on [DATE]. After the initial assessment that was done on readmission there were no weekly skin assessments until 4/3/25 (approximately one month). There was no assessment for the week of 4/11- 4/17. The shower sheets that were provided later by the facility revealed R23 had multiple weeks with areas of redness or open areas marked by the CNAs and signed by the nurse, with no further follow-up nursing assessment. The shower sheets dated 3/19/25, 3/22/25, 3/26/25, 3/29/25, 4/9/25 and 4/12/25 that had red area or open area checked on shower sheet with no further skin assessment/follow-up by the nurse. An initial interview with the DON was completed on 5/7/25 at approximately 9:45 AM. They were questioned about the weekly skin assessment process and they reported that they added the skin assessments orders to Medication Administration Record (MAR) section for the nurses to give weekly alerts and the nurses completed the assessments under the observation sections of the EMR. The DON also added that the CNAs completed their skin checks during the shower and they were verified and signed off by the nurses. They were questioned why the weekly skin assessments as ordered by the physician were not consistently completed by the for R18 and R23. They reviewed the EMR and agreed that they were completed weekly and understood the concerns and reported that they would check and report back. An initial interview with Unit Manager, LPN A was completed on 5/7/25 at approximately 9:35 AM. They reported that they oversaw the facility's wound care program. They were queried about the weekly skin assessment process. They reported that they were completed weekly by the floor nurses under observation section of their EMR. Certified Nursing Assistants completed weekly skin checks during showers/bed baths and they were completed on paper by the CNAs and signed off by the nurses. They were questioned about the low air loss mattress that was on R18's care plan and they reported that they were not sure why it was recommended and did not believe that R18 needed one. LPN A was reported that they would check and provide the shower sheet for the R18 and R23. An interview with LPN B was completed on 5/7/25 at approximately 12:10 PM. They were questioned about the facility's weekly skin assessment process. They reported that the nurses completed the skin assessment on shower days. They signed off on the shower sheets and documented their assessment under weekly skin assessment observations in the EMR. They were questioned what their process was if they identified any skin concerns during skin checks on shower days. LPN B reported that they would notify the physician after they complete further assessment on the identified area of concern and document under the weekly skin assessment. During a follow up interview completed with the DON on 5/7/25 at approximately 11:10 AM, they reported that paper shower sheets that were used by CNAs were signed off by the nurses and they were also considered as the weekly skin assessments. They were queried further about the discrepancies between shower sheets and skin observations. They were asked to explain how R18's admission nursing note completed on 3/28/25 had a reflected small open area with treatment orders and wound consult and skin was marked clear on shower sheet dated 3/29/25. Also, they were queried further about multiple shower sheets for R23 dated 3/19/25, 3/22/25, 3/26/25, 3/29/25, 4/9/25 and 4/12/25 that had red area or open area checked on the shower sheet with no further skin assessment/follow-up by the nurse on where the redness or open areas were. When queried further, the DON did not have any further explanation and they reported that they understood the concerns. On 5/07/25 at approximately 04:00 PM, the Administrator was notified of the concerns with the skin assessments. Review of the facility provided document titled Skin assessment dated [DATE], read in part, Policy: It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment. Policy Explanation and Compliance Guidelines: 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury . 2. Documentation of skin assessment: a. Include date and time of the assessment, your name, and position title. b. Document observations (e.g. skin conditions, how the resident tolerated the procedure, etc.). c. Document type of wound. d. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain). e. Document if resident refused assessment and why. f. Document other information as indicated or appropriate .

Based on observation, interview and record review facility failed to ensure a resident admitted with an indwelling catheter was assessed for removal; failed follow-up with urologist as ordered and failed to have orders for catheter care for one (R23) of two residents reviewed for urinary catheter. This deficient practice has the potential to cause Urinary Tract Infections (UTI) and loss of normal bladder function. Findings include: Review of R23's clinical record revealed R23 was originally admitted to the facility on [DATE] and they were recently hospitalized and readmitted back to the facility on [DATE]. R23's admitting diagnoses included brain cancer (recent finding), urinary tract infection, post COVID, dementia, and compression fracture of the lumbar vertebrae (stable). Based on a Minimum Data Set (MDS) assessment dated [DATE], R23 had a Brief Interview of Mental Status (BIMS) of 11/15, indicative of moderate cognitive deficits. An initial observation was completed on 5/6/25 at approximately 10:15 AM. R23 was observed in their bed. R23 was receiving their nutrition and hydration through Percutaneous Endoscopic Gastrostomy (PEG) tube/feeding tube. R23 also had a foley catheter (a thin, flexible tube used to drain urine from the bladder) and the bag was connected to their bed frame. R23 was observed laying on their back and they had a specialty low air loss mattress. Multiple follow up observations were completed on 5/7/25 (at approximately 8:30 AM and 12:35 PM) and 5/8/25 (at approximately 8:35 AM), R23 had their foley catheter during all the follow-up observations. Review of R23's Electronic Medical Record (EMR) revealed a diagnosis list, with the diagnosis of urinary retention dated 1/24/25 (upon admission to the facility). Further review of discharge summary from the hospital dated 1/23/25 revealed the following diagnoses: acute back pain, dementia, essential hypertension (high blood pressure), history of seizure, cranial neoplasm (brain cancer), sinus bradycardia (slower heartbeat/rhythm), leukocytosis (high white blood cell count), COVID infection, multiple vertebral compression fractures, and severe protein calorie malnutrition. The hospital records did not reveal a diagnosis of urinary retention or any urologist consultation. Review of physician orders did not reveal any orders for the foley catheter use and care, since admission to the facility. Review of Care Area Assessment under the MDS assessment dated [DATE] revealed the following indicators for catheter use: Restricted mobility, urinary urgency and need assistance for toileting and did not have any other clinical rationale/diagnoses for the use of the indwelling catheter. The supporting documentation section for use of foley catheter was blank. Review of physician progress notes revealed a note dated 4/3/25, with recommendation to follow up with urology regarding urinary retention. There was no evidence in the EMR that R23 had any urology follow-up and it was later confirmed by Director of Nursing (DON) on 5/7/25. Review of R23's care plan revealed an intervention that read change catheter per MD (Medical Doctor) order and use a Fr. (size), type per MD order but there were no physician orders for foley catheter use and care. An interview with Licensed Practical Nurse (LPN) B was completed on 5/7/25 at approximately 2:35 PM. They were assigned to care for R23 during that shift. They were queried about the facility process to care for foley catheter. LPN B reported that they followed the physician order for catheter use and the standards for nursing care. They were unaware that R23 did not have any physician orders for the foley catheter use and care. An interview with the DON was completed on 5/7/25 at approximately 3:45 PM. They were queried about the rationale for foley catheter use for R23 and the facility process. The DON shared the facility process and reviewed the EMR for R23. After reviewing the records, the DON agreed that R23 did not have any orders for foley catheter use/care and they were unable to locate the diagnosis of urinary retention based off hospital records. They also confirmed that R23 did not have any urology appointment. They reported that they understood the concern. A facility provided document titled Appropriate Use of Indwelling Catheters' with a date of 11/1/22, read in part, Policy: It is the policy of this facility to ensure that a resident who is continent of bladder on admission receives services and assistance to maintain continence unless his/her clinical condition is or becomes such that continence is not possible to maintain. An indwelling urinary catheter will be utilized only when a resident's clinical condition demonstrates that catheterization is necessary . 1. It is the policy of this facility to ensure each resident with urinary incontinence: a. Who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary. b. Who is admitted with an indwelling urinary catheter, or each resident who subsequently receives an indwelling catheter, will be assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary. c. Who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible . 3. Any decision regarding the use of an indwelling urinary catheter will be based on the resident's condition and goals for treatment. The resident and/or representative will be included in discussions about the indications, use, potential benefits and risks of urinary catheters, and alternatives to help support the resident's right to make an informed decision. 4. The use of an indwelling urinary catheter will be in accordance with physician orders, which will include the diagnosis or clinical condition making the use of the catheter necessary, size of the catheter, and frequency of change (if applicable). 5. Examples of appropriate indications for indwelling urethral catheter use: a. Resident has acute urinary retention or bladder outlet obstruction. b. Need for accurate measurements of urinary output. c. To assist in healing of open sacral or perineal wounds in incontinent residents. d. Resident requires prolonged immobilization (e.g., potentially unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fractures). e. To improve comfort for end-of-life care, if needed. 6. Documentation to support decision making will be included in the medical record, including but not limited to: a. Clinical or medical conditions demonstrating the need for an indwelling urinary catheter. b. Assessment of incontinence, including the type, frequency, duration, and complicating factors associated with the incontinence. c. Assessment of psychosocial and functional factors affecting urinary continence status. d. Services provided to restore normal bladder function to the extent possible. e. Response to interventions prior to the decision to use an indwelling catheter. f. Resident's wishes and prognosis. 7. Indwelling urinary catheters will be used on a short-term basis, unless the resident's clinical condition warrants otherwise. The interdisciplinary team, with the support and guidance from the physician, will assure the ongoing review, evaluation, and decision making regarding the insertion, continuation, or removal of an indwelling urinary catheter. 8. Indwelling urinary catheters (urethral or suprapubic) will be utilized in accordance with current standards of practice, with interventions to prevent complications to the extent possible .

Based on observation, interview, and record review, the facility failed to identify and address a significant weight loss in a timely manner for one (R15) of one resident reviewed for nutrition. Findings include: On 5/6/25 at 9:25 AM, R15 was observed in bed eating her breakfast meal. A plate cover was observed over the plate and a bowl of cereal appeared eaten. When queried about the food in the facility, R15 opened the cover that was placed over the plate and said Yuck! The plate was observed to contain scrambled eggs and toast that were not eaten. R15 reported she did not like the food in the facility and did not ask for anything different when served something she did not like. R15 stated, I don't believe in that. When queried about whether she lost any weight, R15 reported she did not know. On 5/6/25 at approximately 12:00 PM, R15 was observed in bed eating her lunch meal. R15 was observed attempting to eat peaches from a bowl which fell into her lap when she tried to eat it. When queried about how the food was, R15 stated, Yuck! Yuck! Yuck! A review of R15's clinical record revealed R15 was admitted into the facility on [DATE], and readmitted on [DATE], 3/8/25, and 3/16/25 with diagnoses that included: normal pressure hydrocephalus, acute cystitis without hematuria, influenza A, bradycardia, hypertension, type 2 diabetes mellitus, and frontotemporal neurocognitive disorder. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R15 had severely impaired cognition, required setup or clean-up assistance for eating, and weighed 173 pounds with no weight loss or gain (five percent over 30 days or 10 percent over 120 days). A review of R15's progress notes revealed multiple hospitalization s, a history of poor appetite, and gastrointestinal (GI) issues that included vomiting over the past several months. A review of a summary of R15's weights since her admission into the facility on [DATE] revealed the first weight taken was on 1/6/25 and was 194.6 pounds. The next recorded weight was on 2/27/25 and was noted to be 172.6 pounds which was an 11.31 percent loss of body weight within 30 days. Subsequent weights were recorded as follows: 3/3/25 - 171.5 pounds 4/2/25 - 173.2 pounds 5/1/25 - 174.7 pounds According to the weights recorded in R15's clinical record, as noted above, R15 had an 11 percent loss of body weight between 1/6/25 and 4/2/25. A review of an Admission Observation for R15 dated 10/12/24 revealed no documented weight for R15. A review of two Nursing progress notes written on 10/10/24 (R15's day of admission into the facility) revealed no documented weight for R15. A review of a Nursing progress note dated 12/27/24 revealed, Resident refused breakfast and lunch, staff encouraged resident to eat and drink resident refused . It was documented in a Nursing progress note that R15 was sent to the hospital on 2/18/25 due to coffee ground emesis (vomiting) to rule out a GI bleed. R15 returned to the facility on [DATE]. A review of a Admission Nursing Comprehensive Evaluation dated 2/24/25 revealed a (re)admission weight of 199.9 pounds. It should be noted that three days later, R15's weight was recorded as 172.6 pounds. A review of a Admission Nursing Comprehensive Evaluation dated 3/8/25 revealed a readmission weight of 199 pounds. A review of a Admission Nursing Comprehensive Evaluation dated 3/26/25 revealed a readmission weight of 172 (pounds) per d/c (discharge) paper work. Further review of R15's progress notes revealed no documentation from the dietary department or physician regarding the significant weight loss documented. There was no evidence that it was reported to anyone or addressed. There was no evidence that a re-weigh was conducted to confirm the accuracy of the 11.31 percent loss of body weight. A review of a Nutritional Assessment note dated 4/18/25 (the first note after the documented weight loss), written by Certified Dietary Technician (DT) 'M', revealed, .Resident's CBW (current body weight) is 173 lbs (pounds), no significant wt (weight) changes noted . There was nothing documented that addressed the weight loss that was noted between 1/6/25 and 2/27/25. A review of a progress note written by Registered Dietitian (RD) 'J' on 4/19/25 revealed, .there have been no significant weight changes observed . A review of a progress note written by RD 'J' on 5/4/25 revealed, CBW 174.7 lbs. last month's weight at 173.2 on 4/2. Weight in the past 4 months ranges between 171 lbs-175 lbs. Weight loss triggers related to erroneous weighing in January at 194.6 lbs . There was no evidence in the clinical record that the documented weight loss that occurred between 1/6/25 and 2/27/25 was evaluated by the RD or physician to determine if it was erroneous. Further review of R15's full clinical record revealed no documentation of R15's initial weight when admitted into the facility on [DATE]. A review of R15's Nutritional Assessments revealed the first assessment was completed on 1/16/25 (three months after R15 was admitted into the facility) and noted R15 weighed 195 pounds with no weight changes in 30 days. The next Nutritional Assessment was completed on 4/18/25 and noted R15 weighed 173 pounds with no weight change in 30 days, but did not acknowledge the weight loss that occurred within that assessment period. On 5/8/25 at 10:25 AM, an interview was conducted with DT 'M'. DT 'M' explained she was a Certified Dietary Manager, but had certification as a dietary technician which allowed her to conduct dietary assessments. DT 'M' explained RD 'J' was the Registered Dietician for the building and she handled all high risk residents such as residents who required tube feeding or dialysis and she (DT 'M') handled the basic residents and conducted assessments on them. When queried about how residents were monitored for significant changes in weight, DT 'M' reported if she found a significant weight change, it was reported to RD 'J'. Staff who took residents weights also reported any changes to RD 'J' or herself. When queried about the documented significant weight loss for R15 between 1/6/25 and 2/27/25 and how that was addressed, DT 'M' reported the Director of Nursing (DON) was working on looking into weight discrepancies at that time so it might have had to do with that. DT 'M' did not have any additional information on how R15's weight loss was addressed. On 5/8/25 at 10:36 AM, an interview was conducted with RD 'J'. RD 'J' reported she was hired as a Corporate Dietitian and covered six facilities for the past year. RD 'J' reported she was currently the RD for the facility and covered high risk residents and DT 'M' was able to assess and monitor the non-high risk residents with her oversight. When queried about how resident's weights were monitored for any significant changes, RD 'J' reported the documented weights in the Electronic Medical Record (EMR) were reviewed and if there were any significant weight losses or gains she requested a re-weight to confirm the accuracy of the weight changes. When queried about whether she was informed or if she identified R15's significant weight loss between 1/6/25 and 2/27/25, RD 'J' reported the facility had erroneous weights taken before I came in and I noticed a lot that did not seem right or consistent with how the resident looked. RD 'J' reported they hired a new person to take weights because they were not being done correctly. When queried about how an actual weight loss was ruled out for R15 given the documented appetite changes and medical issues during that time, RD 'J' reported she should be contacted regarding significant weight loss. On 5/8/25 at 11:07 AM, an interview was conducted with the DON. The DON reported monthly weights were taken on residents, as well as on admission and for the first couple weeks after admission, they were done weekly. Any significant changes in weights were reported to RD 'J'. When queried about what RD 'J' should do if a significant weight loss was identified, the DON reported she would let the staff know if a reweigh was needed and then make recommendations for additional interventions. When queried about R15's weight loss and the lack of documentation to address it, the DON reported they identified a lot of discrepancies with weights and discovered the person who used to weigh residents was not doing it correctly or consistently so they hired someone new. When queried about how it was known that R15 did not actually lose weight given her medical conditions, no weight taken on admission, and inconsistent documentation of weights in the clinical record, the DON reported she understood the concern. When queried about whether the significant weight loss should have been addressed at the time it was identified, even if it was erroneous, the DON reported it should have been addressed right away and any discrepancy should have been documented at that time. A review of R15's care plans revealed a care plan initiated on 10/16/24 that read, Resident is at risk for nutrition-related declines . Interventions initiated on 1/16/25 revealed, .Obtain weight per policy. Observe and report to physician/responsible party significant weight changes . There were no additional interventions implemented after the documented weight loss on 2/27/25. A review of a facility policy titled, Weight Monitoring, revised 3/27/24, revealed, in part, the following: .The facility will utilize a systemic approach to optimize a resident's nutritional status .Identifying and assessing each resident's nutrition status and risk factors .Evaluating/analyzing the assessment information .Developing and consistently implementing pertinent approaches .Monitoring the effectiveness of interventions .A weight monitoring schedule will be developed upon admission for all residents .Resident with weight loss - monitor weekly .A significant change in weight is defines as .5% change in weight in 1 month (30 days) .7.5% change in weight in 3 months (90 days) .10% change in weight in 6 months (180 days) .

Based on interview and record review, the facility failed to ensure accurate tracking and administration of the pneumococcal vaccinations for three (R143, R16 and R10) of five residents reviewed for vaccinations. Findings include: Review of a facility policy titled, Pneumococcal Vaccine (Series) revised 1/8/25 read in part, .Each resident will be offered a pneumococcal immunization upon admission . The type of pneumococcal vaccine (PCV15, PCV20, PCV21 or PPSV23) offered will depend upon the recipient's age, having certain risk conditions, and previously received pneumococcal vaccines, in accordance with current CDC (Centers for Disease Control and Prevention) guidelines and recommendations . R143 Review of the clinical record revealed R143 was admitted into the facility on [DATE] with diagnoses that included: fracture of right femur, chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia. Review of a facility provided Michigan Care Improvement Registry (MCIR) report dated 4/23/25 revealed there was no record of R143 receiving any pneumococcal vaccination. The MCIR report indicated R143 was Overdue for PCV15/PCV20/PCV21 vaccinations. According to (CDC) guidelines, R143 was due for a dose of PCV15, PCV20, or PCV21. R16 Review of the clinical record revealed R16 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: heart failure, dementia and anxiety disorder. Review of a facility provide MCIR report dated 6/16/23 revealed R16 had received a Pneumococcal Adult vaccination 3/28/19 and was Overdue for PCV20/PPSV23 vaccinations. Review of R16's Preventive Health Care record revealed no Pneumococcal vaccinations had been given by the facility. According to CDC guidelines, R16 was due for a dose of PCV15, PCV20 or PCV21. R10 Review of the clinical record revealed R10 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: diabetes, acute respiratory failure with hypoxia and liver transplant status. Review of a facility provided MCIR report dated 6/16/23 revealed R10 had received Pneumococcal Adult vaccinations 12/22/09 and 3/26/15, and was Overdue for PCV15/PCV20 vaccinations. Review of R10's Preventive Health Care record revealed a Pneumococcal Vaccine was given to R10 on 8/18/18 outside of this building. It should be noted this dose was not listed on R10's MCIR dated 6/16/23. According to CDC guidelines, R10 was due for PCV20 or PCV21. On 5/8/25 at 11:21, Licensed Practical Nurse (LPN) A, who served as the Infection Control Nurse, was interviewed and asked about Pneumococcal vaccinations. LPN A explained she followed CDC guidelines for vaccinations. LPN A was asked about why R143 had not received any vaccinations even though they had been admitted for two weeks. LPN A explained the consent for vaccinations was included in the admission paperwork, and she did not have that paperwork yet. When asked if she ever went to the resident herself and asked if they wanted to get the vaccination, LPN A explained she did not, she would wait for the paperwork. LPN A was asked why R16 had not received a Pneumococcal vaccination. LPN A explained R16 was due this year as it was five years since their last vaccination. When informed that was not the CDC guideline for vaccination, and the MCIR listed the vaccination as overdue on 6/16/23, LPN A explained she must be using outdated guidelines. LPN A was asked why R10 had not received a vaccination as it had been well over five years since their last dose. LPN A explained they thought if the vaccine was given after the age of 65, no more doses were required.

Based on observation and interview, the facility failed to provide 80 square feet per resident for 7 of 20 multiple resident rooms and failed to provide 100 square feet per resident for 3 of 4 single bed resident rooms, resulting in the potential for inadequate space and resident dissatisfaction with their living conditions. Findings Include: On 5/07/25 at 11:00 AM, the following Medicare/Medicaid resident rooms were observed: Room # Square Ft. Beds 102 227 3 103 93 1 107 222 3 109 222 3 110 231 3 111 83 1 203 93 1 204 230 3 205 224 3 207 225 3 The health and safety of the residents were not affected by the room size. Interviews revealed residents had no problems with their rooms.

This citation pertains to Intake MI00145936. Based on interview and record review, the facility failed to protect the one resident (R902)'s right to be free from physical abuse a resident (R903). Findings include: A review of a Facility Reported Incident (FRI) intake MI00145936 revealed an allegation of resident-to-resident physical abuse involving R903 (perpetrator) and R902 (victim) that occurred on 7/23/24 at 5:45 AM. A record review revealed R902 was admitted to the facility on [DATE] with medical diagnoses including, diabetes, chronic kidney disease, hypertension, and psychomotor deficit following a stroke. A Brief Interview for Mental status (BIMS) score assessed on 8/8/24 scored 15/15 indicating R902 was cognitively intact. A clinical record review revealed R903 was admitted to the facility on [DATE] with right sided hemiparesis (weakness on right side of body) following a stroke, asthma, and heart disease. The BIMS assessed on 8/25/24 scored 13/15 indicating R903 was cognitively intact. On 10/8/24 at 10:00 AM, A record review of the FRI documented on 7/23/24 at 5:45 AM, while providing morning care, Certified Nurse assistant (CNA) A documented they noticed R902's lip was injured. When inquired what happened, R902 said R903 punched them because they refused to turn down the TV. On 10/8/24 at 10:37 AM, an attempt was made for a telephone interview with Licensed Practical Nurse B. for confirmation of their involvement with the incident. No return call was made by the end of this survey. On 10/8/24 at 10:40 AM, a telephone interview with CNA A was conducted and confirmed when they went to provide morning care, an obvious injury to the lip was identified on R902. CNA A stated R902's lip was split open, bleeding, and swollen, and denied pain. CNA A asked R902 what happened, and R902 replied they did not turn down their TV volume and R903 got upset, walked over and punched them in the face. When CNA A questioned R903 what had happened, they replied the volume was too high, R902 would not turn it down, and proceeded to punch R902 in the face. R903 was immediately removed from the room, they said they knew it was wrong and apologized to CNA A. CNA A confirmed R902 and R903 have never had a history of incidents, and commented the two televisions in that room always have very high volumes and this was the first time this was a problem. On 10/8/24 at 10:55 AM, R903 was observed lying in their room, quiet and alone. When questioned the recollection of the event with R902, R903 acknowledged the volume on the TV was too loud, asked R902 to turn it down, at which time they refused. R903 stated, I went over to turn off the TV and [R902] started swinging at me, and I punched them in the face. On 10/8/24 at 11:15 AM, R902 was interviewed and confirmed R903 was telling them to turn down their TV volume, R902 stated, 'I can't' and [R903] came over and punched me in the face, and my lip got hurt. On 10/8/24 at 12:05, an interview was conducted with Social Services (SS) C who also observed R902 had trauma to their lip. R903 was removed from the room and placed in another residence downstairs. SS C commented R903 recognized what they did was not right and apologized. SS C commented neither R902 or R903 ever had a conflict with each other, or other residents, and the entire incident was a shocker. Further record review revealed the local authorities were contacted on 7/23/24 at 9:00 AM and a police report was filed. Review of the facility policy title; Abuse, Neglect and Exploitation dated 11/2022 documented: .The facility will make efforts to ensure all residents are protected from physical and psychosocial harm .

This citation pertains to Intake Number MI00145339 Based on interview, and record review, the facility failed to complete a comprehensive admission assessment for one resident (R701) of three residents reviewed for assessments. Findings include: A review of a complaint submitted to the State Agency revealed an allegation that noted R701 doesn't know when he needs to use the bathroom and can't control it because he's incontinent. Staff want to accompany him to the bathroom every few hours to see if he needs to go but he doesn't want to do that. He would rather use the brief and then alert staff when it needs to be changed . A review of R701's clinical record revealed R701 was admitted into the facility on [DATE] with diagnoses that included: type 2 diabetes mellitus. A review of R701's Minimum Data Set (MDS) assessments revealed he was not yet fully assessed. The MDS was noted to be in progress with a due date of 7/4/24 (14 days after admission). Some sections were complete, but others were not, including the assessment for bowel and bladder continence. On 7/16/24 at approximately 9:35 AM, an interview was conducted with the DON (Director of Nursing). The DON reported they were not aware R701's comprehensive MDS assessment not being completed. The DON reported the MDS coordinator was not at the facility and reported they would follow up with any additional information. No additional information was provided prior to the end of the survey. A review of a facility policy titled, Assessment Frequency/Timeliness, revised on 2/23/24, revealed, in part, the following, .The comprehensive admission assessment will be completed within 14 days after admission .

Based on observation, interview and record review, the facility failed to identify and implement interventions to address changes in range of motion (ROM) for one (R14) of two residents reviewed for limited ROM, resulting in R14 developing contractures in three fingers. Findings include: On 4/22/24 at 9:26 AM, R14 was observed lying in their bed. R14 was asked if they had any concerns about care at the facility. R14 explained when they were admitted , they could use their left hand, now it was useless and they had to keep a napkin in their palm to keep their fingernails from digging into their palm. Observation of R14's left hand revealed the middle, ring and little fingers bent down with the fingernail tips of the ring and little fingers making contact with R14's palm. When asked if they could straighten out their three fingers, R14 explained that was as far as they could straighten them. R14 was asked if staff could get their fingers straight. R14 explained they did not know, as no one ever tried to straighten them out. Review of the clinical record revealed R14 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: atrial fibrillation, diabetes and depression. According to the Minimum Data Set (MDS) assessment dated [DATE], R14 was cognitively intact, was independent for eating and oral hygiene, and required the assistance of staff for all other activities of daily living (ADL's). The MDS assessment also indicated R14 had no impairment in ROM to the upper extremities (arms). Review of R14's comprehensive care plan revealed no ROM goals or interventions. On 4/23/24 at 9:15 AM, Occupational Therapist (OT) F was interviewed and asked when was R14's last OT evaluation. OT F explained it was on 11/28/23. OT F was asked if R14 had any limitations or contractures to their left hand. OT F explained there was no limitation or contractures at the evaluation or when the last screening was done in February 2024. OT F was informed R14 was unable to straighten out their fingers and kept a napkin in their hand to keep their nails from digging into their palm. On 4/23/24 at 9:25 AM, observation of OT F checking R14's left hand was completed. OT F attempted to straighten R14's middle, ring and little fingers, but was unable to straighten them. OT F explained she had generic palm splints, but would have an Orthotist (makes and fits braces and splints) come and make R14 a splint to protect the hand and try to prevent further contractures. Review of the OT evaluation dated 11/28/23 read in part, .LUE (left upper extremity) ROM = WFL (within functional limitation) . LUE Strength = WFL . Functional Limitations Present d/t (due to) Contracture = No . On 4/23/24 at 11:25 AM, Certified Nursing Assistant (CNA) G, who provided restorative therapy at the facility, was interviewed and asked about R14. CNA G explained she and the Activity Supervisor did the ROM, therapy would give them the orders for what to do and how often to do the exercises. CNA G was asked if they had noticed any decrease in ROM in R14's left hand. CNA G explained she had noticed a decrease in ROM approximately 2-3 weeks ago. When asked who she had told about the limitation, CNA G explained she had told the nurse, but could not remember which nurse. CNA G was asked to provide restorative documentation. Review of restorative documentation for R14 revealed a Restorative Flow Sheet for January 2024 that read in part, .PRESCRIPTION: Pt to complete AROM (active range of motion) ex (exercises) all planes 20 reps (repetitions) 2 sets for BUE (bilateral upper extremities)/BLE (bilateral lower extremities) to maintain strength . FREQUENCY: 3x/wk (week) x 8 wks . No other flow sheets were provided however, a ONE TO ONE ACTIVITY PROGRAM PARTICIPATION AND RESPONSE sheet for R14 read in part, .3/14 (R14) participated upper body exercises. 10 mins; 3/18 (R14) refused . No other documentation was provided before the end of the survey. On 4/24/24 at approximately 9:00 AM, OT F was asked if she had done an evaluation on R14. OT F explained she had, and confirmed R14 had hand and finger contractions. OT F was asked if these contractures could have developed in 2-3 weeks. OT F explained contractures take 2-3 months to develop. Review of the OT evaluation dated 4/23/24 read in part, .LUE ROM = impaired . Hand = impaired; Middle Finger = impaired; Ring Finger = impaired; Little Finger = impaired . AROM - (L) Middle Finger: PIP (proximal interphalangeal joint - middle joint) Extension = -16* (degrees); DIP (distal interphalangeal joint - end joint) Extension -28* . AROM - (L) Ring Finger: PIP Extension = -44*; DIP Extension = -31* . AROM - (L) Little Finger: PIP Extension = -33*; DIP Extension = -39* . Functional Limitations Present d/t Contracture = Yes . Location of Contracture: left hand . Review of a facility policy titled, Prevention of Decline in Range of Motion dated 11/1/22 read in part, .Residents who enter the facility without limited range of motion will not experience a reduction in range of motion . Based on the comprehensive assessment, the facility will provide interventions, exercises and/or therapy to maintain or improve range of motion . Staff will be educated on basic, restorative nursing care that does not require the use of a qualified therapist or licensed nurse to oversight .

Based on observation, interview, and record review, the facility failed to ensure interventions to prevent pressure ulcers were implemented and identify and treat two new pressure ulcers for one (R24) of two residents reviewed for pressure ulcers, resulting in the development of pressure ulcers to the outside of both knees, one which had green purulent drainage and caused the resident pain. Findings include: On 5/16/23 at 8:30 AM, 9:30 AM, and 10:45 AM, R24 was observed lying on their back in bed. They had heel protector boots on both feet and their legs turned out to the sides which placed the outer aspect of their knees in direct contact with the mattress. A low air loss mattress was observed. However, the console was not turned on. R24 was sleeping during all observations except for at 10:45 AM when they requested the head of their bed to be adjusted. Review of R24's clinical record revealed R24 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: hypertension, cerebral infarction, atrial fibrillation, schizoaffective disorder, bipolar disorder, dementia, and glaucoma. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R24 had intact cognition, required limited physical assistance with bed mobility, did not transfer during during the assessment period, and was totally dependent on staff assistance for toilet use. Review of R24's Physician's Orders revealed R24 was to have a specialty mattress to bed to aid in wound healing and Weekly skin assessments. Review of R24's care plans revealed a care plan initiated on 1/25/23 that read, RESIDENT HAS history of A PRESSURE ULCER; DUE TO MULTIPLE UNDERLYING MEDICAL CONDITIONS, WOUND MAY NOT HEAL AND FORMATION OF MORE WOUNDS MAY BE UNAVOIDABLE: RETURN FROM HOSPITAL WITH STAGE 3 TO COCCYX .ulcer .is resolved but continues to be at risk for breakdown . It should be noted that although the care plan indicated the previous wound may not heal and formation of more wounds may be unavoidable, the previous pressure ulcer did heal. The care plan documented the following interventions initiated on 1/25/23: .AVOID PRESSURE TO BONEY PROMINENCES UTILIZING CUSHIONING DEVICES .DOCUMENT ANY REFUSALS OF CARE, TREATMENTS OR POSITIONING/OFFLOADING DEVICES AS NEEDED; (R24) prefers to lay on his back and will refuse to be positioned on his side .LOW AIR LOSS MATTRESS; MONITOR FOR INFLATION AND FUNCTION EVERY SHIFT .TURN AND REPOSITION EVERY 1-2 HOURS PER SCHEDULE .UTILIZE PRESSURE REDUCTION DEVICES: LAL (low air loss - mattress) . On 5/17/23 at 11:27 AM, R24 was observed sleeping on their back with their legs turned out to the side and outer aspect of their knees in direct contact with the mattress. On 5/18/23 at 9:42 PM, R24 was observed sleeping on their back with their legs turned out to the side and the outer aspect of their knees in direct contact with the mattress. The low air loss mattress was not turned on. R24 was asked if they had any wounds on their body and responded they did not know. When queried about whether staff checked their skin, R24 reported they did not. R24 had difficulty talking, was grimacing, and appeared to be in pain. On 5/18/23 at 11:38 AM, R24 was observed lying on their back in bed. CNA 'D' and CNA 'C' were observed providing incontinence care to R24. R24 asked CNA 'D' and CNA 'C' to stop when they attempted to turn them over and verbalized they had pain to their left knee. An observation of R24's left knee was made and there was a nickel sized open area to the outer part of R24's left knee. The wound bed was obscured and could not be visualized and the surrounding skin was raised and red in color. Drainage that was tan and greenish in color was observed on the bed sheet directly under R24's knee where the wound was located. R24 continued to express pain to the left knee. It was verified with Nurse 'B' that R24 had been medicated for pain relief an hour and a half prior to the care being provided. R24 verbalized pain to the left knee and screamed for CNA 'D' and CNA 'C' to stop providing care. On 5/18/23 at approximately 12:30 PM, Nurse 'B' was queried about the wound observed to the outer part of R24's left knee. Nurse 'B' reported they were not notified of the wound. On 5/18/23 at 1:47 PM, an interview was conducted with Unit Manager, Nurse 'A'. Nurse 'A' explained that the Director of Nursing (DON) was the facility's wound care coordinator (The DON was not available at the time of that interview and Nurse 'A' reported they would be the person to interview in the DON's absence). When queried about how residents were assessed for any skin impairments and what the process was if a new skin impairment was identified, Nurse 'A' explained the DON would be notified of all new skin impairments and nurses conducted weekly skin assessments on all residents. When queried about where skin assessments were documented, Nurse 'A' reported the skin assessments were conducted by the nurses and documented in the electronic medical record (EMR) on a Weekly Skin Assessment. Nurse 'A' reported if a resident developed a new pressure ulcer, the contracted wound provider would be contacted and they would evaluate the wounds and diagnose and stage the wounds. Nurse 'A' reported that nurses signed off on shower sheets when CNAs gave showers and they could indicate any skin changed on that form as well. When queried about whether they were aware of the wound observed on R24's left knee, Nurse 'A' reported they were not aware. On 5/18/23 at 2:45 PM, CNA 'C' and CNA 'D' were observed turning R24 onto their left side to position a sling for a mechanical lift. An open area was observed to the outer aspect of R24's right knee. R24 verbalized pain to their leg and was observed with facial grimacing. The CNAs had to stop moving R24. CNA 'D' was interviewed and queried about whether they were aware of the open areas to R24's right and left knees. CNA 'D' reported they were not aware but that they did provide care that day. CNA 'D' stated, I don't usually work over here so I just assumed they (the wounds) had been there). Review of R24's Weekly Skin Assessments revealed the following: A skin assessment dated [DATE] that was not completed and left blank. A skin assessment dated [DATE] that indicated R24 did not have any changed to their skin. The next documented skin assessment in the EMR was dated 2/2/23 (three months prior to the one done on 5/9/23). Review of R24's Shower Sheet for May 2023 did not have a CNA signature or anything documented on the form for the dates of 5/3/23, 5/6/23, 5/10/23, 5/13/23, and 5/17/23. Each date had a signature from Nurse 'K' even though there was no indication that R24 received a shower. Review of R24's progress notes revealed no documentation of any open area to R24's right or left knee prior to the observation made on 5/18/23 at 11:38 AM and 2:45 PM. Review of a progress note written by Nurse 'B' on 5/18/23 at 12:49 PM revealed, Resident observed with an open area on the left side of the left knee. Noted with greenish purulent (pus) drainage and painful upon movement . Review of a progress note written by Nurse 'B' on 5/18/23 at 3:36 PM revealed, Resident medicated for pain as ordered. Complete skin assessment .event/new pressure sore completed x 2 . Review of a progress note written by Nurse 'B' on 5/18/23 at 3:47 PM revealed, Skin assessment completed .Side of left knee open area with purulent drainage noted .side of right knee open area no drainage noted . On 5/18/23 at 2:52 PM, an interview was conducted with Nurse 'G' who was the designated person to interview in the absence of the DON. Nurse 'G' explained weekly skin assessments were to be completed, they were unaware of R24's wounds until that day, and the low air loss mattress was to be on at all times and if observed to be not functioning, maintenance should have been notified. Review of a facility policy titled, Skin assessment dated [DATE], revealed, in part, the following: A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter .Documentation of skin assessment: .Document observations .Document type of wound .Describe wound .Document if resident refused assessment and why .

This citation pertains to intakes #MI 626 and MI 549 Based on observation, interview and record review the facility failed to ensure an unsupervised exit did not occur a for resident (R#901) with previously identified elopement behaviors and known cognitive deficits resulting in R#901 exiting the building without staff knowledge increasing the likelihood of serious injury, serious harm, serious impairment or death. Findings include: The immediate jeopardy (IJ) began on [DATE]. The immediate jeopardy was identified on [DATE]. The Administrator was notified of the immediate jeopardy on [DATE] at approximately 2:15 PM and a plan to remove the immediacy was requested. The immediacy was removed on [DATE] based on the facility's implementation of an acceptable plan of removal verified on-site by the survey team. Although the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance that has not been verified by the State Agency. On [DATE] a compliant that was received by the State Agency was reviewed that indicated R#901 had eloped from the facility. On [DATE] the medical record for R#901 was reviewed and revealed the following: R#901 was last admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of R#901's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of [DATE] revealed R#901 needed extensive assistance from facility staff with most of their activities of daily living. R#901's BIMS score (Brief Interview of Mental Status) was 3 indicating severely impaired cognition. An elopement risk assessment (ERA) that was undated and unsigned for R#901 was reviewed and revealed the following: Instructions-Complete upon admission or per facility policy. For each question under resident evaluation factors, check yes or no as appropriate. On reverse check all interventions used and enter date initiated for each one checked. Summarize findings, conclusions and recommendations in the space provided Further review of the ERA revealed 5 Yes checks. and the Interventions Section and the Summary/Conclusions/Recommendations Sections were blank as well as the interventions section that would have indicated what interventions would be used. The ERA also did not indicate any measured level or score of elopment risk which may have assisted staff in indentifying the appropriate level of interventions needed to ensure R#901's safety. A nursing progress note dated [DATE] revealed the following: Alert with confusion. Monitor closely-pt (patient) is a elopement risk .Safety maintained. A nursing progress note dated [DATE] at 6:00PM revealed the following: Approx (approximately) 6PM writer was notified by staff staff member that resident (R#901) was observed outside on an unauthorized leave. Writer immediately assisted resident back into building .Upper management notified. Guardian notified, MD (Medical Doctor) notified. Resident re-educated on elopement and asking for assistance when needed. Q (every) 15 minute VS (visual checks) initiated. Will continue to monitor resident closely and report any changes . A social service note dated [DATE] revealed the following: This writer observed resident in (R#901's room number) outside when she was leaving work for the day. Writer called into the facility to let staff know she was outside. This writer stayed with resident until staff came to get her from outside .Resident (R#901) remains alert to her name otherwise confused and disoriented. She has a [DIAGNOSES REDACTED]. IDT (interdisciplinary team) will continue to monitor and update plan of care as needed. An incident and Accident investigation pertaining to R#901's elopement on [DATE] revealed the following: Alleged incident:-Date/Time/Location-[DATE]. 6PM .Resident(s) involved in incident: (R#901) .Employee(s) involved in incident, if applicable: (Social Worker C) .Brief Description of the incident: Pt demonstrating exit seeking behavior. New onset. Observed by staff exiting patio door. Staff identified and returned resident to nuilding <sic> .Provide a brief description of conclusion of investigation: Resident has a new onset of exit seeking behavior secondary to family visiting her frequently in the patio since COVID-19 visitor limitations. Resident exited doors. Staff identified resident exited door and returned resident to building. Resident returned to building and placed on elopement precautions . On [DATE] at approximately 3:46 p.m., during an interview with AIT A (Administrator-in-training), AIT A was queried regarding R#901's elopement on [DATE]. AIT A indicated that R#901 exited the building though an alarmed door located in the facility dining room rolled through the facility back patio and out through a gate and into one of the facilities parking lots. R#901 was found in the parking lot by the facility social worker (SW C) after they had clocked out and were leaving for the day. SW C called the Nurse (LPN D) and they came out and brought R#901 back into the facility. AIT A was queried if R#901 had permission to be alone in the parking lot and they indicated they did not. On [DATE] at approximately 4:47 p.m., during an interview with LPN D, LPN D was queried regarding R#901's elopement on [DATE]. LPN D indicated they were unaware of R#901 leaving the building until SW C called them and told them that R#901 was in the parking lot. LPND was queried if R#901 was able to be in the parking lot without staff supervision and they indicated they couldn't. LPND was queried if they were aware how R#901 got out of the facility without the staff being aware and they reported that herself and both of the Certified Nursing Assistants were providing care to other residents and that they believed the dining room door which leads to the patio was left propped open from the smoking residents and that R#901 went thorough the patio and through the gate which is unlocked. LPN D was queried if they had heard the door alarming and they indicated that they didn't. On [DATE] at approximately 8:42 a.m., during an interview with SW C, SW C was queried regarding R#901's elopement. SW C indicated they had clocked out for the day and were walking to the parking lot towards their car when they identified R#901 in their wheelchair, unsupervised in the parking lot. SW C reported when they observed R#901 in the parking lot they called the facility and R#901's nurse came out to take R#901 back in the building. SW C was queried if R#901 was permitted to be in the parking lot by themselves and they indicated they weren't and that a new BIMS assessment was completed with a score of 5 indicating R#901 had severe cognitive impairment. SW C indicated that when they found R#901 they were in their wheelchair propelling themselves towards the street/sidewalk. SW C was queried if they knew how R#901 excited the building and they reported that they thought that R#901 excited the back door from the dining room and that the door was ajar. SW C was queried if they had heard any door alarms sounding when they excited the building and they reported they didn't. SW C was queried if R#901 had displayed any exit seeking behavior before and they indicated that R#901 had made verbal expressions of wanting to go home and that on a few occasions R#901 has sitting by the front door. SW C indicated that after R#901's elopement, R#901 was placed on the elopement awareness program and a care plan was put into place. On [DATE] at approximately 11:00 a.m., during another conversation with SW C, SW C was queried regarding R#901 being previously documented as an elopement risk on [DATE] by RN E and the incomplete elopement risk assessment in R#901's chart. SW C indicated they were unaware of the documentation on [DATE] and if they had been aware of it R#901 would have been enrolled in the elopement awareness program at that time which would consist of putting R#901's demographic information in the elopement awareness binders at each nursing station and a care plan pertaining to elopement behaviors would have been developed. SW C was queried how the nursing staff make them aware of behaviors for residents in the building and they indicated that it was through a behavior log. At that time R#901's behavior log for [DATE] was reviewed which revealed no elopement behaviors. SW C was queried if RN E should have documented in the behavior log on [DATE] and they reported they should have and they would have found it when they revived the log in the morning the next day. SW C was queried regarding the incomplete and undated elopement risk assessment and indicated the assessment should have been fully completed and any Yes checks should have had interventions documented for them. On [DATE] at approximately 11:11 a.m., during a phone conversation with RN E, RN E was queried regarding their documentation on [DATE] that R#901 was an elopement risk and needed to be monitored closely. RN E indicated that they thought everyone knew that R#901 was an elopement risk. RN E reported that R#901 has a history of wandering and telling staff members that they are going home and that R#901 has pushed on the front door before trying to get out. RN E was queried if they had informed SW C of R#901's behaviors and they indicated that they had thought that SW C already knew about them. RN E was queried if they document in the behavior log and they reported that they do but didn't remember if they had documented on R#901's elopement behaviors. RN E indicated that they should have been more forthcoming. On [DATE] at approximately 4:30 p.m., during a conversation with the Vice President of Operations B (VPO B), VPO B was queried how R#901 got through the alarmed dining room door without staff being aware and they indicated the alarm for the door was not loud enough for the staff to hear. On [DATE] a facility document titled Elopement/Missing Resident/Code Pink (last revised ,[DATE]) was reviewed and revealed the following: Policy: Resident safety is to be ensured when an individual is confused and may tend to wander or has a history of confusion and or a potential for elopement .Procedure: 1. Assessment-An assessment will be made by Nursing at the time of admission and as appropriate during the resident's stay for elopement potential. Elopement risk is established based on diagnosis, mobility, cognition and behavior. A history of wandering behavior, verbalization of wanting to leave the facility and the physical ability to ambulate without assistance of another person is needed. Elopement assessment is located under Evaluations in the residents chart. Should a resident be identified as an elopement risk, resident information, including a current photo will be immediately added to the elopement book. The photo is obtained from the resident's record .Care plan-Collaboratively once the assessment confirms an elopement risk, nursing will initiate an initial elopement care plan; social services will follow up with a comprehensive care plan in accordance with the RAI (resident assessment instrument) process .

This citation pertains to Intake # MI 804: Based on observation, interview and record review the facility failed to institute and operationalize appropriate infection control principles and practices per the Centers for Disease Control Prevention (CDC) safety measures to prevent the exposure/transmission of residents to 2019 Novel Coronavirus (COVID-19) for 18 (R#'s 702, 703, 705, 706, 708, 709, 710, 711, 712, 713, 714, 716, 717, 718, 720, 721, 723 and 724) out of 27 residents reviewed for cohorting (sharing a room) with COVID-19 positive or presumed positive residents and follow the correct procedure to clean and disinfect the glucometer devices, resulting in the increased likelihood of transmission of COVID-19 and putting all residents who receive glucose monitoring at risk for the likelihood of serious harm or death by contracting a bloodborne illness. The failure to follow current CDC recommendations for COVID-19 resulted in an Immediate Jeopardy (IJ) to the health and safety of all residents, many of whom were at high risk due to age and co-morbidities, to be exposed and/or develop COVID-19, given the high risk of spread once COVID-19 enters a nursing home, facilities must take immediate action to protect residents, families, and healthcare personnel (HCP) from resulting in serious health complications from COVID-19 hospitalization s, and death. Findings include: The IJ began on [DATE]. The IJ was identified on [DATE]. The Administrator was notified of the IJ on [DATE] at 1:43 PM and a plan to remove the immediacy was requested. Although the immediacy was removed on [DATE], the facility remained out of compliance at a scope of widespread and a severity of potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance that has not been verified by the State Agency. Review of a complaint filed with the State Agency on [DATE] included an allegation that the facility failed to follow current guidance related to infection prevention and control, related to cohorting residents. An onsite investigation into the above complaint and a COVID-19 Focus survey was conducted on [DATE] to [DATE]. On [DATE] at 9:10 AM, the Administrator was queried about the facility's residents and whether testing for COVID-19 had been conducted and reported all residents were tested and most were positive. When asked if the local health department and State Agency had been contacted for those residents with positive results, the Administrator reported, When tested all residents, reported to county health. On [DATE] at 10:05 AM, Licensed Practical Nurse (LPN) E was observed working on the first floor (where the residents that are negative for COVID-19 resided), preparing paperwork to send a resident out to the hospital. Continued observations were conducted as follows: At 10:09 AM, a resident (later identified as R#712) was observed walking into the hallway and near the nursing station (on the non COVID-19 unit) without the nose or mouth covered. When asked about simple questions, R#712 did not respond and proceeded to walk throughout the hallway. At that time, Certified Nursing Assistant (CNA H) was observed exiting another room and redirected R#712 back to her bed. CNA H proceeded to pick up the resident's oxygen tubing (which had been observed directly on the floor) and attempted to secure the tubing to the resident's face/nose without replacing or cleaning the tubing. When asked about the resident's use of oxygen and whether a pulse ox could be completed, CNA H reported she did not do vitals and would need to follow up with Nurse (name of Licensed Practical Nurse/LPN E). At that time, R#712 began to cry and stated Please Please repeatedly to CNA H. At approximately 10:12 AM, LPN E was observed at the nursing station and when queried about R#712's status reported, I'm sending her out right now. She won't keep oxygen on. At 10:25 AM, observation of the first floor elevator doors and stairwell door which lead to the facility's designated COVID-19 unit (all residents on second floor were on droplet precautions) included a document which read, ATTN: (Attention) You must be in full PPE (Personal Protective Equipment) at all times when entering this unit no exceptions!!! At 10:30 AM, further observations on the designated COVID-19 unit included all the doors to the resident's rooms were opened, not closed and there were several residents observed walking in the hallway, and/or accessing the shared bathroom without their nose or mouth covered. At 10:35 AM, Maintenance Staff A was observed walking throughout the designated COVID-19 floor with only a face mask. There was no other PPE worn. Also at 10:35 AM, LPN E was then observed caring for the residents on the second floor (which is the facility's designated COVID-19 unit), following observations of LPN E working on the first floor approximately 30 minutes earlier. Per review of the CDC long term care (COVID-19) guidance, which documented in part .Dedicate space in the facility to care for residents with confirmed COVID-19 . Assign dedicated HCP (health care professionals) to work only in this area of the facility . At 10:39 AM, the Social Service Tech (Staff B) was observed to exit the second floor elevator (located in the center of the COVID-19 designated floor), wearing a winter jacket, and face mask while carrying an insulated cup in one hand and two face masks in the other hand. Staff B proceeded to walk throughout the unit, towards the office located on the second floor and was stopped by a resident seated just inside a doorway of one of the rooms. Staff B then proceeded to head towards the office. There was no other PPE donned. At 10:43 AM, MDS Nurse L (who was not assigned to work the second floor) was observed to exit an office wearing full PPE. When queried about the facility's nurse staffing for the day, MDS Nurse L reported CNA (Certified Nursing Assistant) G) is the only CNA here today (on the COVID-19 floor) and the Nurse is (name of LPN E). At 10:44 AM, a resident was observed standing in the hallway with the door opened and the resident did not have the nose or face covered. Nurse L identified this resident as R#714 and further reported this resident and another on first floor (R#712) had wandering behaviors and required constant redirection to stay in their rooms. At 10:45 AM, Certified Nursing Assistant (CNA) G was queried on working on the COVID designated unit alone when the nurse is downstairs on the first floor (non-COVID unit) caring for those residents and how they would immediately contact the nurse if there was a crisis on the COVID unit, CNA G stated in part, .I don't really feel good about it. I would pick up the phone and call for her . At 10:47 AM, LPN E was queried on how they felt having to work both the first and second (COVID unit) floors LPN E stated That is a problem . LPN E was then asked how the facility was doing on providing staff with the necessary supplies and stated in part .We have ran out of hand sanitizers and disinfectant wipes . When asked what the nurses were using to clean the glucometers between each use, LPN E opened the glucometer kit and said Alcohol, this alcohol prep patch . (While pointing to an alcohol prep pad). The glucometer devices are required to be cleaned and disinfected per facility policy and manufacturer instructions to prevent the spread of infections. The facility policy titled Cleaning and Maintenance of Resident Equipment with a revision date of February 13, 2020 documented in part, .Glucometer, before/after each use, Disinfect- Bleach-based cleaner .Do not use alcohol. Allow 5 minutes to dry . At 10:49 AM, LPN E was observed at the medication cart on the second floor. LPN E had a face shield and face mask, there was no other PPE in use. At 10:53 AM, CNA G confirmed she was the only assigned CNA for the COVID-19 floor (facility census of 26 with seven residents on first floor and 19 on second floor) and was queried about the opened resident rooms and reported Usually doors stay open. When asked what was done for residents that required the use of a mechanical lift with sling, CNA G reported If I need help, I'll ask the nurse. When asked if there was a resident that required two people (such as use of mechanical lift) or a resident was in distress and the nurse was not available on the floor (due to working on another unit at same time) what would be done, CNA G reported, If I couldn't do it myself, I'd call on phone overhead. At 11:00 AM, R#718 was observed self propelling in a wheelchair from the shared bathroom (accessed in the hallway on the COVID-19 designated floor) to the room without the nose or face covered. The door to the room remained open. At 11:55 AM, R#717 was observed self propelling a wheelchair in the hallway toward the nursing desk, asking for water. The resident did not have the nose or face covered and staff did not offer the resident the use of a face mask. At 5:25 PM, the Administrator and Director of Nursing were queried on what disinfectant the nurses are supposed to utilize on the glucometers between each use and the Administrator stated in part, .It's a bleach mixture that we made. They should be using that . Resident #703, #720 & #721 Review of the census record revealed R#703 and R#721 became roommates on [DATE] and continued as such until [DATE]. Resident #703 Review of the clinical record revealed R#703 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Nurses Note dated [DATE] at 4 pm, documented in part, Lethargic all morning. CNAs said she ate a little lunch . A Nurses Note dated [DATE] at 3 pm, documented in part, Slept through breakfast. Ate very little lunch . A Nurses Noted dated [DATE] at ,[DATE] (exact documented time), documented in part, Nonproductive cough noted . A Nurses Note dated [DATE] at 11 pm, documented in part, . dry cough, T- (temperature) 99.3) . A Nurses Noted dated [DATE] at 4 pm, documented in part, .(doctor name redacted) notified of cough. New orders received for Stat (immediate) CXR (chest x-ray) today and for CBC (complete blood count) CMP (comprehensive metabolic panel) next lab draw on [DATE] . A Nurse Practitioner (NP) note dated [DATE] documented in part, . Following up on this patient after a report from staff 2 days ago the patient started coughing .assist in care, good bp (blood pressure) control, pt (patient) will need ,[DATE] (24 hours and 7 days a week) care, assistance and supervision . A review of R#703's [DATE] vital signs revealed the following: ,[DATE] morning (temperature)- 99.4 ,[DATE] AM (temp)- 99.1 ,[DATE] PM temp- 100.4 ,[DATE] AM temp- 99.6 and cough noted ,[DATE] PM temp- 99.1 ,[DATE] AM temp- 101.6 A facility discharge list provided by the Administrator documented R#703 was transferred to the hospital on [DATE]. On [DATE] the Director of Nursing informed the surveyor that R#703 was positive for COVID-19. During the above dates resident #703 remained roommates with R#721 (until [DATE]) and roommates with R#720 (from [DATE] until [DATE]), despite having displayed signs and symptoms related to COVID-19. CDC's guidance for (COVID-19) in long term care documented in part, .Actively monitor all residents upon admission and at least daily for fever (T-100.0 F) and symptoms of COVID-19 (shortness of breath, new or change in cough, sore throat, muscle aches). If positive for fever or symptoms, implement Transmission-Based Precautions .Older adults with COVID-19 may not show typical symptoms such as fever or respiratory symptoms. Atypical symptoms may include new or worsening malaise .Identification of these symptoms should prompt isolation and further evaluation for COVID-19 . Resident #721 Review of the clinical record revealed R#721 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Nurses Note dated [DATE] (no time noted) documented in part, .Resident observed with temp of 100.4 this shift .SPO2 (oxygen saturation) 89% . A Nurses Note dated [DATE] at 5 am, documented in part, .B/P (blood pressure) ,[DATE], P (pulse) 128, Resp (respirations) 28, SPO2 70, Temp 102 .send to (hospital name redacted) . During the above dates resident #721 remained roommates with R#703 (who was showing signs and symptoms of COVID- 19) until [DATE]. On [DATE] the Administrator and DON confirmed that R#721 was diagnosed with [REDACTED]. Resident #720 Review of the clinical record revealed R#720 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the census record revealed R#720 and R#703 (exposed resident) became roommates on [DATE]. Review of the CDC long term care (COVID-19) guidance, which documented in part .Residents with known or suspected COVID-19 do not need to be placed into an airborne infection isolation room (AIIR) but should ideally be placed in a private room with their own bathroom. Residents with COVID-19 should, ideally, be cared for in a dedicated unit or section of the facility .As roommates of residents with COVID-19 might already be exposed, it is generally not recommended to place them with another roommate until 14 days after their exposure, assuming they have not developed symptoms or had a positive test . A lab report dated [DATE] at 9:12 pm, revealed R#720 was positive for the Coronavirus. Resident #705, #723 & #724 Review of the census record revealed R#'s 705, 723 and 724 all became roommates on [DATE] and continued until [DATE]. Review of the clinical record revealed R#705 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the documentation of monitored vitals documented by the nurses revealed the following for R#705 in [DATE]: ,[DATE] AM & Midnights- Cough ,[DATE] PM- T (temperature)- 99.9 ,[DATE] PM- T- 99.5 ,[DATE] PM- T- 99.2 ,[DATE] AM- T- 99.6, PM- 99.4 ,[DATE] AM- T-100.8 A Nurse Practitioner (NP) note dated [DATE] documented in part, .patient was noted to have poor p.o. (by mouth) intake the past 3 days. Patient also have not been drinking fluids and appeared to be weak . A review of a COVID test result document with a reported date of [DATE] at 8:11 pm, revealed R#705 was positive for the COVID 19. Despite having displayed signs and symptoms related to COVID as indicated above R#705 remained room mates with R#'s 723 & 724 until [DATE]. Resident #723 Review of the clinical record revealed R#723 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the document of monitored vitals (documented by the nurses) revealed the following for R#723 in [DATE]: ,[DATE] PM- BP (blood pressure) ,[DATE], T- 99.2 ,[DATE] PM- T- 99.2 Review of the census revealed R#723 was transferred to unit one (a non-covid unit) and placed with another room mate (R#717). On [DATE] R#723's previous room mate (R#705) test result confirmed that they were positive for COVID-19. Further review of R#723's clinical record revealed the following: ,[DATE] PM- P (pulse)- 120, T- 103, midnight T- 99.8 A Nurses Note dated [DATE] at 9 pm, documented in part, .SPO2 (oxygen saturation) 76% . oxygen was administered via nasal cannula. A Nurses Note dated [DATE] at 9:05 pm, documented in part, .New order given to transfer to (hospital name redacted) . On [DATE] at 9:32 AM, the administrator confirmed that R#723 was currently admitted into the hospital for respiratory difficulty. Resident #724 Review of the clinical record revealed R#724 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the paper document of monitored vitals (documented by the nurses) revealed the following for R#724 in [DATE]: ,[DATE] AM- T- 100.6 ,[DATE] PM- T- 99.3 ,[DATE] PM- T- 99.1 ,[DATE] Midnight- 99.3 A review of the clinical record revealed R#724 was diagnosed with [REDACTED]. Resident #706, #709 & #710 Review of the census record revealed R#706, R#709 and R#710 became roommates on [DATE]. Review of the clinical record revealed R#706 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the documentation of monitored vitals (documented by the nurses) revealed the following for R#706 in April of 2020: ,[DATE] MN (midnight)- 99.3 ,[DATE] PM- T- 99.3 ,[DATE] MN- T- 99.1 A Nurses note dated [DATE] at 10 pm, documented in part In bed the entire shift. Took fluids only for dinner . A hospital consult dated [DATE] at 1301 (1:01 pm) documented in part, .patient was found to be hypoxic at 60%, tachypenic (fast breathing), HR (heart rate) 108, Temp 108 .Was found to be staring into space and appearing lethargic which promoted this admission . On [DATE] at 11:39 AM, test results of the COVID-19 test completed at the hospital revealed .COVID- 19 Result- Detected . Despite being symptomatic, R#706 remained roommates with R#'s 709 and 710. Resident #709 Review of the clinical record revealed R#709 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the documentation of monitored vitals (documented by the nurses) revealed the following for R#709 in March and April of 2020: ,[DATE] MN- T- 99.0 ,[DATE] AM- blood pressure ,[DATE], pulse 102 and T- 99.0 ,[DATE] PM- T- 99.0 ,[DATE] AM- T- 99 ,[DATE] MN- T- 99.5 R#709 remained roommates with R#'s 706 and 710, until [DATE] when R#709 was discharged to another facility (Despite being symptomatic and being roommates with another symptomatic resident R#706 who four days later tested positive for COVID-19). Resident #710 Review of the clinical record revealed R#710 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the census record revealed R#710 shared a room with R#'s 706 and 709 until [DATE] and then again on [DATE] until discharged to the hospital on [DATE]. Resident #714, #717 & #718: A review of the clinical record revealed R#714 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the clinical record revealed R#718 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the clinical record revealed R#717 was admitted into the facility on [DATE] and recently moved from the second floor (COVID unit) to the first floor (non COVID unit) on [DATE] with [DIAGNOSES REDACTED]. A review of the documentation provided by the facility included a form which read, COVID Resident Tracking and included a list of names for six residents that had been hospitalized between [DATE] and [DATE] (which included R#713 and R#716). On [DATE] when queried about the multiple room changes identified during the survey for many of the residents, the Administrator reported all residents were moved to the second floor to attempt to maintain adequate staffing. However, once facility COVID-19 testing was conducted on [DATE] and most of the residents tested positive, those residents that were negative were moved back down to the first floor. When asked about what process was implemented for those residents that had been exposed to positive COVID-19 residents and/or staff, despite negative testing, and relocated to the non-COVID-19 floor, the Administrator reported they were monitoring vitals every shift and offered no further explanation. Resident #712, #713 & #716 Review of census records revealed R#712, R#713, and R#716 all shared a room on the first floor between [DATE] to [DATE]. Since then, all three residents had been confirmed COVID-19 positive either by the facility testing, or upon hospitalization . According to the documented census information, R#716 had been hospitalized on [DATE]; R#712 had been hospitalized on [DATE]; and R#713 had been hospitalized on [DATE]. Facility Administration reported that both R#713 and R#716 were now deceased . Resident #711, #702 & #708 Review of the census records revealed R#711, R#702 and R#708 shared a room as of [DATE]. Since then, all three residents had been confirmed COVID-19 positive either by the facility testing, or upon hospitalization . Resident #711 & #712 Review of the census records revealed R#711 and R#712 first began sharing a room on [DATE] on the non COVID-19 unit. Both residents had been confirmed COVID-19 positive either by the facility testing, or upon hospitalization and exhibited ongoing respiratory signs and symptoms within 14 days of readmission on [DATE]. Resident #711: A review of the clinical record revealed R#711 was admitted into the facility on [DATE], was transferred to another room on [DATE], hospitalized on [DATE], and readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the hospital documentation dated [DATE], R#711 .COVID-19 positive per state testing at ECF (extended care facility) . Review of R#711's progress notes on [DATE] revealed R#711 had loss of appetite and a temperature of 102.7. On [DATE] at 2:45 PM, R#711 was noted to have a temperature of 100.2. On [DATE], R#711 was noted to be extremely tired, had no appetite, had temperature of 100.2 and was sent to the hospital at approximately 12:15 PM. There was no documented evidence that the facility had placed R#711 on isolation precautions when symptoms first appeared, and R#711 continued to share a room with other residents (R#702 and R#708) despite testing positive for COVID-19. Review of the physician/physician extender progress notes since February included three consults dated [DATE], [DATE] and [DATE]. The entry on [DATE] read, .Here to follow-up patient after report from staff that patient has confirmed COVID positive infection .patient is febrile with T-max of 101.8 .Assessment/Plan Lethargy, acute mental status change secondary to confirmed COVID positive infection. Attempted to start IV (intravenous) fluids however secondary to decreased po (oral) intake, will send patient to ER (emergency room ) for further eval (evaluation) . Review of the vital sign documentation provided by the facility on [DATE] at 3:45 PM revealed blank documentation for vital signs on [DATE] for all shifts, [DATE] AM shift, PM shift only had temperature - no respiratory monitoring, [DATE] MN (midnight) shift was blank for all residents, [DATE] AM, PM and MN (Midnight) shifts were blank, [DATE] AM, PM, and MN shifts were blank, and ,[DATE] AM shift was blank and had documentation for PM shift only. Resident #712: A review of R#712's census information included: clinical record revealed R#712 was admitted into the facility on [DATE] , was hospitalized on [DATE], readmitted on [DATE], hospitalized on [DATE], readmitted on [DATE], hospitalized on [DATE], readmitted on [DATE] (to a room with R#711), and hospitalized on [DATE] for increased signs and symptoms of respiratory distress. Further review of the clinical record revealed R#712 had [DIAGNOSES REDACTED]. Review of R#712's discharge hospital paperwork indicated that a test for COVID-19 had been completed on [DATE] but also documented, Can the Post-Acute Care Setting Provide care for patient with Transmission-Based Precautions?. An X was marked by Yes, (which indicated) May Transfer Patient. Review of the clinical record revealed there was no documented evidence that any isolation precautions or transmission-based precautions had been implemented. The resident was not isolated from other residents as well despite exhibiting symptoms consistent with COVID-19. Review of R#712's hospital documentation included a COVID-19 test completed on [DATE] which documented, Detected!!. Review of the documentation provided by the Director of Nursing (DON) who also acted as the Infection Control Preventionist included an Infection Surveillance Report Line Listing [DATE] which identified R#712 as having change in oxygen saturations, shortness of breath or respirations greater than 25, fever and was treated with [MEDICATION NAME] 200 mg (milligrams) 2 tabs) 400 mg x 1 day, [MEDICATION NAME] 500 mg x 1 day on [DATE]. Review of the clinical record further documented on [DATE] at approximately 6:15 AM, R#712 was found unresponsive, Cardiopulmonary Resuscitation (CPR) had been initiated successfully and the resident was transferred to the hospital. Review of the progress notes included an entry on [DATE] at 2:30 PM which indicated R#712's readmission. The portion of the note which read, .VS (vital signs) at time of admission were blank. There were no documented vital signs. The next entry was on [DATE] at 10:15 AM that the nurse was called to the room and R#712 did not have oxygen on at the time, was non-compliant with putting on, had pulse ox of 91% and complained of shortness of breath and abdominal pain and was sent to the hospital. Review of the additional vital sign documentation provided by the facility which included monthly and every shift revealed the Monthly Vital Sign and Weight Form had vital signs without a date or time of when obtained, and the Active Screening of Residents form did not include R#712. Resident #713 A review of the clinical record revealed R#713 was admitted into the facility on [DATE], discharged to hospital on [DATE], readmitted on [DATE], discharged to hospital on [DATE], readmitted on [DATE], discharged to hospital on [DATE], readmitted on [DATE] (to a room shared with R#712 and R#716) and discharged to hospital on [DATE] with [DIAGNOSES REDACTED]. Per Administration, R#713 was now deceased . According to the census information, R#713 remained on the first floor throughout these dates mentioned above. A review of additional documentation provided by the facility included a log titled, COVID Resident Tracking that identified six residents as positive COVID-19 and included dates the state agency was contacted. This list of residents included R#713 which was reported to the state on [DATE]. Additionally, review of a facility's Infection Surveillance Report Line Listing for [DATE] documented R#713 with respiratory symptoms on [DATE] with notations by change in oxygen saturation, fever, and mental status changes. Review of the progress notes included: An entry on [DATE] at which read, Resident started feeling sick unable to give writer symptoms .2A (2:00 AM) B/P (blood pressure) ,[DATE], P (Pulse) 110, R (Respirations) 18, T (Temperature) 96.7 .4A Resident restless request to go to the hospital .Send resident to ER, T 96.7, P - 148, R-20, B/P ,[DATE] . The next documented entry in the progress notes provided was an entry on [DATE] at 1:00 AM which read, .B/P (Blood Pressure) ,[DATE], P (Pulse) 69 .Resp (Respirations) 26, SpO2 83%. She appeared pale, slunched <sic> over and her breaths were short with poor depth. Her lungs were crackling in all 4 quadrants .she stated she felt like something was sitting on her chest. 911 called . Resident #716 A review of R#716's clinical record revealed R#716 was admitted into the facility on [DATE] (to a room shared with R#712) and discharged to the hospital on [DATE]. Per Administration, R#716 was now deceased . According to the face sheet, [DIAGNOSES REDACTED]. R#716's census information included an admission date of [DATE] to a room on the first floor shared with R#712. On [DATE], R#716 was transferred to the hospital. A review of documentation of a COVID Resident Tracking log provided by the facility identified R#716 had been hospitalized on [DATE] and had tested positive for COVID-19 (date of testing was not documented). Per discussion with the Administrator, R#716's positive COVID-19 results were reported to the facility by phone from the hospital. Review of the additional documentation provided by the facility regarding R#716's vital signs for March and [DATE] revealed incomplete, missing (blank) vital signs for: ,[DATE] 11p-7a; ,[DATE] 7a-3p; ,[DATE] 7a-3p; ,[DATE] 11p-7a; ,[DATE] 11p-7a; ,[DATE] 11p-7a; ,[DATE] 11p-7a; ,[DATE] 11p-7a; ,[DATE] 3p-11p. The entries for all three shifts on ,[DATE] read hospital. On [DATE] at 8:57 AM, all COVID 19 related polices and infection controls polices was requested from the Administrator. At 11:07 am, a second request was made to the Administrator and Director of Nursing to provide the policies on contact, droplet and airborne precautions. A policy titled Isolation- Notices of Transmission-Based Precautions with a revision date of [DATE] was provided. At 4:01 pm, the DON was queried on the policy Isolation- Notices of Transmission-Based Precautions and asked if that was the facility's policy on contact, droplet and airborne precautions and stated yes. The policy was reviewed and revealed no guidance for staff to follow regarding the appropriate steps to implement if the facility staff had to initiate contact, droplet or airborne precautions. On [DATE] at approximately 9:30 AM, the Administrator was asked to clarify the facility's decision to cohort residents that were exposed to positive residents and/or readmission from hospitalization following positive COVID-19 diagnosis, the Administrator acknowledged the concern and reason for policy changes since notification of the IJ and offered no further response. A facility policy titled Covid-19 Investigation Guidance dated [DATE] documented in part, . The purpose of this policy is to assure procedures to investigate suspected cases of Covid-19 so that implementation of appropriate protocol will occur . Validation of daily vitals signs, including temperatures and 02 sats . Onset date of symptoms/suspected illness . Isolate resident and implement contact and droplet precautions . Abatement Plan: (Facility name redacted) submits the following Credible Allegation of Compliance outlining the measures it has completed to abate the findings of immediate jeopardy to resident health and safety identified by the survey team regarding the facility's alleged failure to adhere to CDC guidelines and facility policy for Covid-19 residents in nursing homes (Facility name redacted) believes that as of [DATE], the measures it has implemented are sufficient to demonstrate measure to control infection control practices according to CDC guidelines and Facility policy(s). Resident identified to b (TRUNCATED)

Based on interview and record review, the facility failed consistently and timely assess, monitor, and treat pressure ulcers for one (R#801) of one resident reviewed for pressure ulcers, resulting in an open area worsening to an infected unstageable pressure ulcer requiring hospitalization , surgical debridment of the wound, and placement of a [MEDICAL CONDITION]. Findings include: A complaint submitted to the State Agency alleged the following: .(R#801) has a 10 x 18 inch bed sore on her bottom that needed to have the dead tissue removed from it in order to heal . On 4/24/19 and 4/25/19, an onsite investigation was conducted. On 4/24/19, R#801's clinical record was reviewed and revealed R#801 was originally admitted into the facility on [DATE] and readmitted on [DATE], 12/19/18, and 3/4/19 with [DIAGNOSES REDACTED]. An Minimum Data Set (MDS) assessment dated [DATE] documented R#801 had severely impaired cognition, was totally dependent on one to two staff members for transfers, bed mobility, and all activities of daily living, and had three stage two pressure ulcers (Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister) present upon readmission into the facility on [DATE]. On 4/24/19 at 11:00 AM, 2:00 PM, and 3:45 PM, a request was made for R#801's clinical record. R#801's clinical record was unable to be located according to Nurse Manager A the facility could not locate the clinical record. At 3:45 P.M., Nurse A was interviewed about R#801. When queried about whether or not R#801 had any pressure ulcers, Nurse A stated, I think she did on one of her readmissions. Nurse A reported that all documentation for skin assessments, treatment administration, progress notes, and wound consultation notes would be in the clinical record. On 4/24/19 at approximately 4:45 P.M., the Administrator and Director of Nursing (DON) reported they were unable to locate R#801's clinical record. At approximately 5:00 P.M., the Administrator and DON provided the clinical record and said they found it under a bunch of stuff. On 4/25/19 at approximately 8:30 A.M., it was discovered that the Administrator and DON from the previous day resigned. The Interim Administrator and Interim DON began in their positions at approximately 7:30 A.M. on 4/25/19. On 4/25/19 at 10:10 A.M., Nurse A was interviewed and R#801's clinical record was reviewed. When queried about the facility's protocol for skin alterations such as pressure ulcers, Nurse A reported that if a wound was identified after admission, the nurse would start a treatment order, the physician would be notified, and a wound care consultation would be conducted. When asked who assessed wounds for stage, measurement, appearance, Nurse A reported the consulting wound care team would. Nurse A reported that the consulting wound team came to the facility weekly, the nurses were responsible for administering treatments, and Nurse A oversaw residents with wounds. Upon review of R#801's clinical record with Nurse A the following was revealed: An Admission Nursing Notes form dated 12/3/18 did not document R#801 had any wounds or pressure ulcers. A Nursing Care Note dated 12/4/18 documented, .Cream applied to macerated (softening of tissue due to prolonged contact with moisture) area on buttocks . R#801 was discharged to the hospital on [DATE] and was readmitted to the facility on [DATE]. An admission Nursing Evaluation dated 12/19/18 documented, R#801 had .L (left) & R (right) buttocks and gluteal (illegible word) open area . A Physician's Admission Order Sheet dated 12/19/18 documented the following order: L buttocks, R buttocks, Gluteal cleft skin tear. Apply [MEDICATION NAME] (an antimicrobial agent) cover (with) dry dressing QD (every day) & PRN (as needed) . At that time, Nurse A was asked for the Treatment Administration Records (TAR) for R#801 and reported that she did not know where they were. An Admission Nursing Notes form dated 12/19/18 documented, .L & R buttocks and Gluteal (illegible writing) pressure ulcer & skin tear .bilateral buttocks pressure ulcer noted . An Initial Care Plan dated 12/19/18 documented, .Actual Pressure Ulcer, Alteration Skin Integrity .admitted to the facility with alteration in skin integrity . Interventions documented, Apply treatment as ordered, Inform if s/sx of inft (infection) develop (warm, [MEDICAL CONDITION], drainage) .Wound consultation as ordered . physician progress notes [REDACTED]. A physician's orders [REDACTED]. According to Nurse A there was no TAR available to review at that time. Nurse A was queried about the interventions in place for R#801 upon readmission on 12/19/18. Nurse A reviewed the physician's orders [REDACTED]. 1. Wound care to eval & treat. Dietary to eval. 2. Low air loss mattress. Recliner chair when out of bed. Reposition Q2 hours. Pressure relieving cushion to chair. 3. Cleanse open area at sacrum with NS apply [MEDICATION NAME] gel & cover with dry drsg (dressing) QD & PRN . When queried about whether or not interventions were in place prior to 1/7/19, Nurse A stated, I don't see where it's written. Nurse A was asked when R#801 was first evaluated by the consulting wound care team. Upon review of the clinical record, Nurse A reported it was on 1/10/19 (23 days after R#801 was readmitted with the new skin alterations). When queried about who assessed the wounds (documented and treated as open areas and skin tears) on R#801's buttocks prior to 1/10/19, Nurse A did not offer a response. A progress note completed by the consulting wound care team dated 1/10/19 documented the following: .Wound #1 coccyx is a Stage 3 Pressure Injury Pressure Ulcer (Full-thickness loss of skin, in which fat is visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough - dead tissue that may have a yellow or white appearance and/or eschar - dead tissue that is tan, brown, or black in appearance may be visible.) .Initial wound encounter measurements are 0.8cm (centimeter) length x (by) 0.7cm width x 0.01cm depth .There is a small amount of serous (thin, watery) drainage noted. Wound bed has pale yellow base [MEDICATION NAME] . A progress note completed by the consulting wound care team dated 1/17/19 documented the following: .Coccyx Stage 3 Pressure Injury Pressure Ulcer .0.9cm length x 0.3cm width .There is a small amount of serous drainage noted. Wound bed has pale pink base [MEDICATION NAME] . Upon review of the progress notes for R#801 with Nurse A, a note dated 1/24/19 documented, Writer noted 2 new open areas to resident buttocks this shift. [MEDICATION NAME] Q shift ordered & wound consult . R#801 was transferred to the hospital on [DATE] (one month after the documented identification of 2 new open areas to R#801's buttocks). There was no evidence of a wound consultation between 1/24/19 and 2/24/19. Prior to 1/24/19, the last documented progress note was 1/2/19. There was no documentation of R#801's existing pressure ulcer (mentioned above) or the new open areas in the clinical record. physician progress notes [REDACTED].#801's buttocks. A physician's orders [REDACTED]. Wound consult . R#801 was readmitted from the hospital on [DATE]. A physician's orders [REDACTED].cleanse with NS, apply [MEDICATION NAME]. Cover with dry dressing QD . A progress note from the consulting wound care team dated 3/7/19 documented the following: .Coccyx/Bilateral Buttocks is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 4.2cm length x 4.2 cm width x 0.2cm depth .There is a small amount of serous drainage noted. Wound bed has Necrotic Base . At that time, Nurse A was queried about where treatments, skin assessments, and any wound documentation would be documented. Nurse A reported the TARs could not be found at that time. Nurse A did not provide an explanation for the delay in consultation from the wound team and missing documentation. (MONTH) and (MONTH) 2019 physician's orders [REDACTED]. On 4/25/19 at approximately 12:00 P.M., the interim DON was interviewed. When queried about the facility's protocol for residents who were identified as having pressure ulcers, the interim DON stated, It depends on the resident. When asked when the consulting wound care team would be expected to see a resident after a pressure ulcer was identified, the interim DON stated, It is resident centered. When queried about R#801 and the lack of documentation of treatments and assessments of the wounds and the delay in consultation from the wound care team, the DON stated, I cant' answer without looking at the chart. The chart was provided to the interim DON. No further explanation was provided regarding R#801. On 4/25/19 at approximately 2:30 P.M., the facility provided the following documentation: Charge Nurse Weekly Hydration and Skin Assessment forms for (MONTH) 2019 and (MONTH) 2019. Skin Assessments on 2/5/19, 2/13/19, and 2/20/19 documented that R#801 had a pressure sore. There were no skin assessments provided for (MONTH) (YEAR) and (MONTH) 2019. No TARs were provided for (MONTH) (YEAR) and (MONTH) 2019. There was no documented evidence that treatments were provided for R#801's pressure ulcers during those months. An undated TAR documented L buttocks, R buttocks, Gluteal L, Gluteal cleft skin tear. Cleanse with NS Apply [MEDICATION NAME]. Cover with Abdominal pad QD documented 4 treatments were completed and then discontinued. A TAR for (MONTH) 2019 documented the following orders: Cleanse bilateral Buttocks & Gluteal (cleft) skin tear (was identified as a pressure ulcer by the wound physician on 1/10/19) with N/S then apply [MEDICATION NAME] once a day. The TAR revealed the treatment was not administered on 2/1/19, 2/4/19, 2/6/19, 2/7/19, 2/9/19, 2/10/19, 2/11/19, 2/12/19, 2/14/19, 2/15/19, 2/16/19, 2/17/19, 2/18/19, 2/20/19, 2/21/19, 2/22/19, and 2/23/19. L buttocks R buttocks Gluteal L & Gluteal cleft cleanse with soap & H2O (water) Apply barrier cream. The TAR revealed the treatment was not administered on 2/1/19, 2/4/19, 2/6/19, 2/7/19, 2/8/19, 2/10/19, 2/11/19, 2/12/19, 2/14/19, 2/15/19, 2/18/19, 2/19/19, 2/21/19, 2/22/19, and 2/23/19. A TAR for (MONTH) 2019 documented R#801 did not receive treatment to her sacrum pressure ulcer on 3/2/19, 3/3/19, 3/4/19, 3/13/19, 3/15/19, and 3/16/19. Further review of R#801's clinical record revealed R#801 was transferred to the hospital on [DATE] due to having a high fever. A progress note dated 3/18/19 at 11:50 A.M. documented, .Very warm, diaphoretic (sweating). HR (heart rate) 104 BPM (beats per minute). O2 Sat (oxygen saturation) varies from 86-90% on RA (room air). Resps (respiration) 25 breaths/min (minute) . A progress note dated 3/19/19 at 3:42 A.M. documented, Resident is being transferred to (hospital name redacted) via ambulance per request of MD (physician). VS (vital signs) Temp: 103.3 (degrees Fahrenheit) . A line was drawn under the above progress note to indicate it was the end of the page. However, another progress note was written in that space that noted, .Pressure Ulcer on sacral area .Dressing dry and intact upon transfer to ER . On 4/25/19, hospital records for R#801's 3/19/19 admission were reviewed and revealed the following: An Emergency Department Note dated 3/19/19 documented, .Chief Complaint: Fever .EMS state that the patient has been experiencing a fever for the past 3 days. The patient had a temperature of 104 (F) today and therefore was called for ambulance to be transported to emergency department for further care .Physical Exam General Impression: In acute distress, cachetic .Alert and oriented x 0 .Skin exam revealed decubitus ulcers (pressure ulcers) stage III-4 (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) at the mid sacrum .The patient was started on aggressive IV (intravenous) fluid hydration [MEDICAL CONDITION] (a serious infection that causes the immune system to attack the body) protocol .Exam is concerning for a decub ulcer and UTI (urinary tract infection) patient's likely source of infection .Final Impression: .Acute infected decubitus ulcer [MEDICAL CONDITION] . A History and Physical dated 3/19/19 documented, .Unstageable ( sacral decub ulcer present on admission .suspected infection .Upon arrival to the emergency department patient was in significant respiratory distress and was subsequently intubated . A CT Abd/Pelvis w/o Contrast radiology examination on 3/19/19 documented, .There is soft tissue air at the low back at the level of the sacrum extending inferiorly to the perianal soft tissues presumably related to the patient skin ulceration and concerning for [DIAGNOSES REDACTED] (flesh-eating bacteria). This air very nearly borders the sacrum placing the sacrum at risk for osteo[DIAGNOSES REDACTED] (bone infection) . A Infectious Disease Consultation dated 3/20/19 documented, .Reason for consultation: Infected Sacral Wound with concern about [DIAGNOSES REDACTED] .sepsis . A Infectious Disease Progress Note dated 3/21/19 documented, .Infected sacral wound status [REDACTED].Resident on IV antibiotic .Blood cultures positive for multi-microbial organism most likely associated with [DIAGNOSES REDACTED] involving the patient's sacral wound . A Consultation Note from the Wound Care RN (Registered Nurse) Specialist on 3/20/19 documented, Patient with malodorous (foul smelling) unstageable pressure injury to the sacral area. Surgery completed debridment (a medical procedure to remove dead tissue from a wound bed to promote healing) this a.m. and plan for OR (operating room) today or tomorrow for further sharp debridment . Follow up notes from the Wound Care RN specialist documented the following: On 3/22/19, .Wound care follow up after surgical debridment. Pt noted with Stage 4 injury site s/p (status [REDACTED].Wound measures 10x13x5 (cm) .Wound bed is dark moist brown tissue .bone is palpable (able to be felt) .undermining (erosion of tissue under the wound edges that cause a pocket to form under the edge of the wound) .strong foul malodor . Further review of hospital wound notes documented the need for R#801 to have a diverting loop [MEDICAL CONDITION] (a medical procedure in which one end of the large intestine is diverted through an incision made in the abdominal wall for elimination). The facility's policy titled, Pressure Ulcers/Skin Breakdown dated 6/1/16 documented, .the nurse shall assess and document/report the following: .Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue .The physician will help the staff define the type (for example, arterial or stasis ulcer) and characteristics (necrotic tissue, status of wound bed, etc.) of an ulceration .The physician will help identify medical interventions related to wound management .The physician will authorize pertinent orders related to wound treatments .

This citation refers to intake MI 1176: Based on observation, interview, and record review the facility failed to protect a resident from serious injury when a resident with a documented history of poor judgement, poor insight, and delusional behavior exited the front doors of the facility and fell for one (R#801) of two residents reviewed for accidents, resulting in the resident sustaining a trimalleolar right ankle fracture requiring emergency transport and surgical intervention. Findings include: On 2/8/19 a complaint was received by the State Agency which alleged, in part that R#801 fell outside the facility in (MONTH) and broke his ankle. Review of an incident and accident (I/A) report dated 12/16/18 authored by Registered Nurse (RN) 'I' dated 12/16/18 at 1:10PM revealed the following incident description: Resident was seen going out the front door-staff followed to try to stop him and he was observed on the ground in front of the building. Nurse was called and came out to assist in getting him up. Ankle seemed out of allignment so nurse went in and called 911. As paperwork was being complete 911 drivers left with resident. Drivers were told to take him to (Hospital Name). When asked Why did you leave resident stated- I pay all this money and I wanted to get some fresh air. Also per the form it was documented the location of the incident was in front of the building. Per the question on the form Was person authorized to be at location of incident/accident a response indicating no had been marked. Per a question indicating the resident's condition prior to the incident, a box had been checked to indicate the resident was confused. On 2/12/19 at 1:10PM R#801 was observed seated in a padded wheelchair in the dining room. The resident was queried about his right foot and the resident explained, I broke it both sides. The resident said that he had had three surgeries, and reported,I walked across the street and then I thought I could run . R#801 then explained that when he got across the street to the tree it twisted and it broke. R#801 reported persons came running and asked him if he was alright. R#801 was queried as to where he was headed on that occasion and responded, I was going across the street to see if my leg worked alright I was running from the traffic I didn't want to get hit. Per R#801 he headed out the front door, and explained he had been in a wheelchair, left the wheelchair at the facility, and began walking. When queried as to whether he had asked permission to go outside the resident responded, No I did not. R#801 explained, I got tired of people calling me names and saying I'm this and that so I got out of my wheelchair and said to heck with it .I found out my right leg wasn't as good as I thought it was. The resident reported that he had got to a tree, had leaned up against the tree so everybody came running out asking if he was alright. R#801 explained that he needed an ambulance. A review witness statements pertaining to the incident revealed, in part, the following: Per a statement by RN 'I' dated 12/16/18 the following was documented: I was with the med cart down the hall when CNAs (Certified Nursing Assistants) called for help. I ran up front and was told (R#801) went outside. I went out to see him on the ground in front of the building. He said his foot hurt and his ankle look like it may have been dislocated. I told staff to watch him and I went in to call 911 Per a statement provided by CNA 'E' dated 12/16/18 it was documented, At the time of the incident Pt was going to the door staff tried to stop him but he went out and fell on the ground. I noticed his ankle looked popped out at that time I yelled for help the nurse was notified come saw him & went in to call 911. Per a statement by Activity Staff 'F' it was documented, As I was coming out of the bathroom I heard somebody say a Resident was outside staff went out side and I observed resident sitting on the ground in front of the building someone called the nurse and she came and talk to him and she called 911 and we waited with him until the ambulance came. Review of the clinical record for R#801 revealed the resident had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per review of the resident's minimum data set (MDS) assessment dated [DATE] it was revealed the resident scored 14 out of 15 on a brief interview for mental status exam, which indicated the resident was cognitively intact. Also per this assessment it was documented the resident had delusions. Per review of guardianship paperwork issued for R#801 dated 8/20/14 active through 10/15/19 it was documented that In the matter of (R#801) Legally Incapacitated Individual the resident had been appointed a full guardian by the court. Review of a psychiatric provider note signed on 11/28/18 documented, in part, the following: Complaint: Psych following up for ongoing delusion, new set of auditory hallucination HPI (history of present illness): (Age Redacted) year old male is followed for [MEDICAL CONDITION], escalating delusion, mood DO (disorder). Last seen on 11/14. (Brand Name Quetipine) was started for escalating delusion and mood disturbances. Since last visit, he was seen by psychologist on 11/23 due to distressful auditory hallucination Pt cont being delusional and paranoid towards staffs. Pt is taking psych medications without issues or drowsiness. At eval, he reports people were trying to kill me. States he heard something from the kitchen. However, he still want to be in this facility. as long as I can be here, I am fine Pt believes staffs are trying to transfer him to another place I am worried Admits low mood from his delusion Per this note it was documented that R#801's mood was depressed, affect was constricted, thought process had periods of confusion, thought content included suspicious thinking and delusions, the resident was oriented to time, place, and person, and had poor judgement and poor insight. Review of a psychiatric provider note signed on 12/15/18 (the day before the resident's injury) documented the following: .Complaint: Follow up delusions HPI: (Age redacted) year old male was seen for above complaint. Patient seen at facility seated in wheelchair in day area. Patient continues to present with [MEDICATION NAME] affect and depressed mood. Patient also continues with his delusional thought suggesting that someone in the kitchen wants to harm him by cutting off his legs. Patient also admitted to writer that he has seen these people from the kitchen that want to harm him. Patient did not exhibit any distress regarding said issue Review of a social work note dated 12/16/18 at 3:48PM documented, in part, the following: This writer was notified that (R#801) was found outside on the ground in front of the facility with his wheel chair sitting by the door. (R#801) was asked by staff why he was outside. He stated that he was getting some air and that he pays $6000 a month to this facility. Staff nurse told this writer he was transferred to the hospital because they were unable to get him off the ground . Review of hospital paperwork for an emergency department arrival date of 12/16/18 documented, in part, that R#801 was, brought to the ED (emergency department) via EMS (emergency medical services) s/p (status [REDACTED]. Pt was attempting to get up and ambulate when he lost his footing and twisted his right ankle. He was unable to ambulate after the injury . The following was also documented: Obvious deformity of the right ankle w/ [MEDICAL CONDITION]. Per the Radiology Impression section of the document it revealed, in part, the following: XR (X-ray) ankle complete right IMPRESSION: Displaced medial [MEDICATION NAME] malleolar and and oblique distal fibular fractures. Possible [MEDICAL CONDITION] malleolus and osteochondral injury lateral talar dome. Per the Internal Medicine Consult dated 12/17/18 it was documented the resident had an active [DIAGNOSES REDACTED]. Review of a care plan for R#801 dated 12/16/18 revealed the following: (R#801) experiences wandering (moves with no rational purpose, seemingly oblivious to needs or safety). Review of R#801's Elopement Risk Assessment revealed it had been been dated 12/19/18. Per this assessment the following question had been marked with a response of yes: Does the resident have a history of leaving the facility without needed supervision? If yes, number of times and circumstances. The documented explanation next to this question stated, Left out front door to get air x1 On 2/13/19 at approximately 2:48PM the facility's Director of Nursing (DON) and Unit Manager (UM) 'A' were queried in regard to R#801's I and A for 12/16/18. The DON explained that she had not been the DON at the time of the incident. UM 'A' explained that she had been contacted that the resident had walked out (of the facility). Review of a facility policy titled Elopements (undated) revealed, in part, the following: Staff shall investigate and report all cases of missing residents .1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. 2. If an employee observes a resident leaving the premises, he/she should a. Attempt to prevent the departure in a courteous manner; b. Get help from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises .

This citation pertains to Intake(s) #MI 095, MI 431, MI 260 Based on interview and record review the Facility failed to ensure a safe transfer when using a hydraulic lift for one Resident (#704) out of three Resident's reviewed for accidents/injuries, resulting in Resident #704 sustaining a hematoma to the forehead, pain and an extended hospital stay. Findings include: On 10/22/18 two Complaints and a Facility Reported Incident (FRI) were reviewed pertaining to an incident involving R#704. On 10/23/18 at approximately 4:00 PM a phone call was conducted with Complainant #1 who reported that R#704 was no longer a resident at the Facility due to an incident that was reported on or about (MONTH) 16, (YEAR) and further stated, We were never informed as to what happened to R#704 that caused the injury to her head. She spent almost almost a week at the Hospital. The Facility never had enough staff to help. She would sit wet all day and I was never sure if anyone was feeding her. This was the second time something happened where she had a head injury and nobody at the Facility could ever let us know what happened. The first one happened sometime in (MONTH) (YEAR) A second complaint reported that on or about 4/17/18 the following, R#704 resides at the Facility (name redacted) .Last (MONTH) .(name redacted) noticed bruising on R#704's face. The staff could not explain where the bruising came from. Today R#704 was transported to Hospital (name redacted) for a possible broken hip. R#704 had a bruise on her forehead above .right eye. Staff could not explain any explanation for the injuries . A FRI reported to the State Agency on 4/18/18 documented, in part, Name #704 .Was the primary resident injured in the incident? Yes Date Discovered 4/17/18 .Incident Summary resident has a bruise to R (right) forehead from Hoyer lift during a transfer in her room .the CNA (certified nursing assistant) X was caring for the resident, thinks the handle on the Hoyer lift could have possibly hit the resident during transfer .Facility investigation summary . the bruise size was approximation to the handle bar of the Hoyer lift .CNA X was in-serviced on the proper use of the Hoyer lift Action taken .the CNA was disciplined, she also was in-serviced on proper use of the Hoyer lift and a return demonstration of the proper use of the hoyer lift .resident sent out to Hospital secondary to hematoma. On 10/22/18 at approximately 1:00 PM the Facility was asked to provide all I & A (incident and accident reports) and investigation documentation pertaining to R#704, including, but not limited to the incident reported to the State Agency on 4/17/18. At approximately 4:00 PM the Facility reported that they were not able to produce any I & A's pertaining to the R#704. On 10/23/18 a second request was made to provide documentation pertaining to the incident that resulted in R#704 being sent to the Hospital. No documents were provided by the end of the Survey. On 10/23/18 at 8:00 AM a review of R#704's clinical record documented that the Resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the R#704's Minimum Data Set ((MDS) dated [DATE] documented that the resident was severely cognitively impaired and was totally dependent and required two person assistance for bed mobility and transfers. A review of R#704's care plan dated 4/5/17 documented, Resident has a self care deficit .has impaired mobility .TRANSFER .two person assist with hoyer lift . On 10/23/18 at 11:30 AM a review of the (name redacted) Hospital Records was conducted and revealed, in part, the following: Admit Note (4/17/18) Reason for Admit: Head Trauma/fall . ED (emergency department) RN (registered nurse) NOTES .Female presents via EMS (emergency medical services) from (name redacted) Facility with c/o (complaints of) Hematoma on the right side of pt's (patients) forehead .Bruise is black and yellow in color. Per LPN (licensed practical nurse) from Facility, time of fall or how it happened is unknown . Pt is disoriented to person, time, and place Discharge notes (4//23/18) .This is a female with advanced dementia who presented from (Facility) with bruise on her forehead. Patient is AxoX1 (cognitively impaired) and cannot provide any history. Family was concerned about abuse and neglect and they wanted her placed somewhere else. During her stay in the hospital, patient was found to have [MEDICAL CONDITION], Patient was found to have a UTI (urinary tract infection) .Patient has bruising on the head with unknown circumstances . On 10/24/18 at 8:39 AM an interview was conducted with CNA X. CNA X was queried as to the injury sustained by R#704 on or about 4/16/18. CNA X reported that she did not remember anything about the incident and stated, I know that after R#704 went to the Hospital. I was re-orientated on how to use a Hoyer Lift and made aware that there should always ` two people involved. Everybody in the building was in-serviced. As far as I know, they could never come up with a reason as to what happened to the Resident. On 10/24/18 at approximately 11:30 AM an interview was conducted with the Administrator/Abuse Coordinator. When queried as to the incident involving R#704, the Administrator reported that he was new to the Facility and was not aware of the incident.

Based on observation, interview and record review, the facility failed to immediately report an allegation of neglect and two bruises of unknown origin to the abuse coordinators, report an allegation of verbal abuse to the State Agency, conduct investigations for all allegations, and protect residents following an allegation of neglect for four (#506, #507, #509, and #510) of six residents reviewed for abuse and neglect, from a total sample of 13 and nine supplemental sampled residents (#9, #11, #23, #25, #29, #31, #39, #45, and #48) resulting in a witnessed incident of neglect and the potential for undetected and continued abuse when Certified Nurse Assistant (CNA) J continued to work in the facility. Findings include: Allegation #1 On 4/19/16 at 8:00 A.M., an Abuse Prohibition Interview was conducted with Housekeeper H. When asked if she had ever witnessed abuse, Housekeeper H replied, Yes. Housekeeper H was queried about what she witnessed and stated, A CNA (certified nursing assistant) took a resident out of bed without changing her brief, put a 'pad' in her chair and put the resident into the chair and let the resident 'poop' right through the chair. She had the 'runs' . Housekeeper H was asked what she did and stated, I told (Nurse D). The nurse didn't do anything so I reported it to my supervisor (Housekeeping and Laundry Director, Staff K). Housekeeper H reported that the incident occurred not this past weekend, but the one before. Housekeepe H reported that the Resident involved was Resident #506 and the CNA was CNA J and stated, She's here today (CNA J ) .I hope I don't get in trouble for this. On 4/19/16 at 11:00 A.M., the DON was asked if CNA J was working and stated, Yeah. She's here today. On 4/19/16 at 4:00 P.M., an Abuse Prohibition Interview was conducted with Nurse D. Nurse D was asked if she ever witnessed abuse and stated, No one has reported abuse to me personally. An example of staff placing a resident in a chair with a pad and allowing the resident to have bowel movements in the chair instead of taking them to the bathroom was given to Nurse D. Nurse D was asked if that would be considered abuse. Nurse D stated, It could be considered neglect. That actually did happen recently over the weekend and I found out on a Monday. So did (the Director of Nursing - DON). Nurse D was queried about how she found out about the above incident and stated, I think another resident told me. I don't really remember. I know (the DON) was aware of it though and I think she talked to the employee about it. Nurse D was asked what was reported to her and stated, That a resident had a bowel movement and a CNA left a towel under her in the hallway. On 4/19/16 at 4:15 P.M., the Administrator and DON were asked if there were any investigations regarding Resident #506. The Administrator reported there were no investigations and the DON stated, No. There's nothing that I know about. Let me make sure. On 4/19/16 at 4:30 P.M., Staff K was interviewed and asked if any allegations were reported to her regarding Resident #506. Staff K stated, (Housekeeper H) told me that a CNA put a pad on the floor or something and let her (Resident #506) have a bowel movement in the chair. Staff K was asked when this was reported to her by Housekeeper H. Staff K stated, It happened on a weekend. I think last weekend. (Housekeeper H) said it happened, I think on a Saturday (4/9/16). She told me on a Monday or Tuesday. I wasn't called about it or anything. By the time I knew about it, they were already doing something about it (the DON and Nurse D). The Administrator and DON were interviewed on 4/19/16 at 4:45 P.M. and confirmed that there were no investigations regarding Resident #506. The Administrator and DON were asked what staff should do if they witnessed a resident placed in a chair to have a bowel movement with a pad underneath instead of taking the resident to the bathroom. The DON stated, That would be hard to believe. We would start an instant investigation. The Administrator stated, If someone witnessed that, it should be reported to me. The DON was asked if anyone reported an incident involving Resident #506 being placed in a chair with a pad underneath and allowed the resident to have a bowel movement in the chair. The DON reported that she was not aware of it. When queried about Nurse D and Staff K reporting that the DON was informed and aware, the DON stated, That's not true. The Administrator was asked what should have been done and stated, Someone should have brought it to my attention immediately. If someone would have brought it to me, I would have investigated it. I didn't know anything about it. The Daily Staff Assignment sheets were reviewed on 4/20/16 at 7:30 A.M. from 4/9/16 through 4/19/16 and revealed that CNA J was assigned to Resident #506 on 4/9/16, 4/10/16, 4/12/16, 4/14/16, 4/15/16, and 4/19/16 on the day shift. In addition to Resident #506, CNA J was assigned to Residents #507, #509, #510, #9, #11, #23, #25, #29, #39, #45, and #48 on the above days. The Housekeeping Schedule revealed that Housekeeper H worked on 4/9/16, 4/10/16, and 4/11/16. The DON and Administrator were interviewed on 4/20/16 at 8:30 A.M. about the facility's process for protection of residents when there was an allegation of abuse or neglect by an employee of the facility. The DON stated, We always remove the resident from danger. We would suspend the employee immediately. We would protect the employee as well as the resident. Social work would get involved to talk with the resident. When queried about if the residents assigned to CNA J were protected after the allegation of witnessed neglect on 4/9/16, the DON stated, I can't comment on that. On 4/18/16 at 12:30 P.M., Resident #506's clinical record was reviewed and revealed that Resident #506 was admitted into the facility on [DATE] and a readmitted on [DATE] with [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) assessment, dated 2/26/2016 documented that Resident #506 had a BIM (Brief Interview of Mental Status) score of 5 (which indicated severe cognitive impairment), was totally dependent on staff for all activities of daily living including toileting, bathing, dressing, transfers and was always incontinent of bowel and bladder. Allegation #2 On 4/20/16 at 1:30 P.M., Resident #510's clinical record was reviewed and revealed the following: Resident #510 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #510 was receiving hospice services since 11/2015. A Minimum Data Set (MDS) assessment, dated 12/23/15, documented that Resident #510 had moderately impaired cognition and required extensive to total physical assistance from one to two staff members for bed mobility, transfers, and all activities of daily living (ADLs). A Nurse's Notes were reviewed and revealed the following documentation: 3/31/16 at 10:00 P.M., documented, Resident's daughter was visiting with resident in dining room and observed small bruised area on right side of cheekbone close to right eye . 4/1/16 at 3:30 P.M., Day 2 I&A (incident and accident) for right cheek bruise, very faint . 4/2/16 at 12:00 P.M., Alert, yelling and screaming all shift thus far, noted purple/blue discoloration right cheek . 4/15/16 at 8:30 A.M., Hospice RN (registered nurse) visit .Right foot bruised inner and outer, tender, c/o pain with touch. Reports 'body aches'. Pain med given by staff nurse . 4/19/16 at 8:25 A.M., a note by the Hospice RN documented, .Right foot healing bruise. Pt has tenderness to site and shoes too tight so left shoes off today .collaborated with staff nurse (Nurse C). Incident and Accident (I&A) Reports from March and April 2016 for Resident #510 were requested from the Director of Nursing (DON) on 4/20/16 at 1:45 P.M. I&A reports were received and reviewed with the DON and did not include any I&As regarding a right cheek bruise or right foot bruise. The DON stated, I remember something with her eye, but it was nothing if I remember correctly. An observation of Resident #510's right foot was made with Nurse D (the wound care nurse) on 4/20/16 at 2:00 P.M. Resident #510's right foot was observed to have a light purple bruise covering the bottom of her right foot that extended up to her ankle. Nurse D reported that she was unaware of any bruising to her feet. Resident #510 was asked what happened to her foot and was unable to recall. Nurse D was asked at this time about the process for skin assessments in the facility. Nurse D reported that skin assessments were completed on a weekly basis by the nurses and documented on the treatment record and documented by the Certified Nursing Assistants (CNA) on the shower sheets. The Treatment Record for April 2016 for Resident #510 was reviewed with Nurse D and revealed that the last weekly skin assessment for Resident #510 was completed on 4/6/16. Skin & Body Alert Form (Bath/Shower Day & Admission Day) Forms were reviewed with Nurse D and revealed only one form for the month of April 2016, dated 4/18/16, that documented no new skin concerns/problems observed. In the section for CNA signature, hospice aides was written in, but no signature. In the Nursing section, it was signed by Nurse P. Nurse D stated that the skin assessments were not completed for Resident #510 based on the documentation. Nurse P was interviewed on 4/20/16 at 2:15 P.M. regarding any bruising to Resident #510's right foot and stated, I don't know of any. Nurse P did not offer any other explanation. Nurse P was queried about the documentation of a purple/blue discoloration on Resident #510's right cheek on 4/2/16 and stated, I remember looking at it and it wasn't much of anything. I wasn't the one who found it. The DON and Administrator were interviewed on 4/20/16 at 2:25 P.M. regarding the facility's process for reporting and investigating bruises of unknown origin. The Administrator stated, An I&A should be completed and brought to me so that I can begin an investigation. Until you know the origin, it must be investigated. The DON reported that she remembered something about Resident #510's eye or cheek, but stated, I don't have an I&A. The DON reviewed the nurse's notes and indicated that Nurse F was the nurse who documented there was an I&A completed. An interview was conducted with Nurse F at this time via the telephone. Nurse F reported that Resident #510 had a faint bruise next to her right eye on her cheekbone. Nurse F stated, I knew she didn't fall or anything so I did an incident report anyway. Nurse F was asked if she reported the bruise to anyone and stated, I made an incident report and we are supposed to do 72 hour monitoring. It looked like it was old. It was really faint. The daughter is the one who pointed it out. You had to really look closely. I don't remember if I reported it. I did an incident report which would have been reviewed in the morning meetings. Contracted Hospice Nurse E was interviewed via the telephone on 4/20/16 at 3:15 P.M. Hospice Nurse E indicated that she had been to the facility to see Resident #510 within the past couple days, I think on Tuesday (4/19/16). Hospice Nurse E was asked if she observed any bruising to Resident #510's foot or if any facility staff had reported it to her. Hospice Nurse E stated, Yeah. Last week she had some bruising on her right foot, on the top and side of her ankle. We didn't put her shoes on. She gets agitated and the aides have difficulty transferring her. I talked to the staff nurse (Nurse C). They were aware of it. Hospice Nurse E was asked if she was aware of any bruising to Resident #510's cheekbone next to her right eye and stated, I think she scratched her eye or something. Maybe she rubbed it. Our patients bruise easily and get scratches easily. Her skin is dry and tears easily. Allegation #3 On 4/18/16 at 8:15 A.M., the facility was asked to provide any abuse investigations they conducted but did not report to the State Agency. On 4/18/16 at 2:00 P.M., an investigation provided by the facility regarding Resident #510 was reviewed and revealed the following: A summary of the investigation, dated 4/2/16, signed by the Director of Nursing (DON) documented the following: Interview for (Resident #510): Upon completion of the investigation it is determined that there is no evidence of verbal abuse. (Housekeeper G) is the housekeeper that made the report. Upon interview it was found that (Housekeeper G) is very verbally negative towards life in general. She was asked what verbal abuse is and was unable to tell the interviewee the definition. She was also making assumptions during the interview. Staff and residents were also interviewed and there was no evidence of abuse. The nursing assistant was immediately removed from the schedule until it was determined (that) there was no abuse. She has no history of abuse in her record. She has a good record and most of the residents spoke highly of her and still want her to be their assistant. She was moved to the second floor away from the resident just as extra precaution. SW (social worker) and DON arrived to the building on 4/3/16 to begin investigation. The DON kept the Administrator informed as to what was going on regarding the allegation. The following notes and interviews were included in the investigation: A statement from Social Worker (SW) A that documented that Resident #510 was pleasant and appeared to not be in any distress, that she denied that any caregivers were abusive, exhibited periods of confusion and forgetfulness, and that she would be observed for 3 days. A written and signed statement from Housekeeper G that documented, On 4/2/16, (Certified Nursing Assistant - CNA I) worked the afternoon shift and around 8:00 P.M. (Resident #510) had her legs over the bed. I let (the Dietary Manager) and (CNA I) know so (Resident #510) won't hurt herself. (CNA I) walked in her room (and said) I'm not going to make (illegible writing) because I'm not going to be dealing with this and yelled at her that she wanted in bed so she is going to stay in bed that she was not going to get up. I never seen (CNA I) acting mean to none of the residents. She is always nice to them. I was shock(ed) and asked (Housekeeping and Laundry Director - Staff K) and I was told to call (the DON). Handwritten notes documented the following: Voice mail. 4/2/16 at 10:14 P.M. (Housekeeper G) .(CNA I) being a little rough with (Resident #510). Getting hostile, yelling .Not getting her up .Obtained message at 7:15 A.M. 4/3/16 .took (CNA I) off schedule until further investigation . Interview with (Housekeeper G): 4/3 8:50 A.M. When 8 P.M. collecting linen from 1st floor, (Resident #510) with feet hanging off bed, mentioning that she was trying to get out of bed .(CNA I ) was at nursing station, she got irritated and stated if she can handle being here to 11:00 P.M. Bad attitude. It was disturbing to (Housekeeper G). She was (observed) to be rough when putting her feet back into bed. Has never seen any staff treat residents like this. She have never seen staff like that including (CNA I), toward residents .Abuse - What do you classify. To me verbal abuse you didn't think it was verbal towards (Resident #510) but the way she told her she wasn't getting her up. The way she told her (her tone, rough, irritated). Did you inform the nurse? No. It wasn't physical abuse. Report to (Staff K) at 10:00 P.M (Staff K) 9:10 A.M., (CNA I) verbally abused (Resident #510) You told her to call me . .4/3/16 5 P.M. (signed by DON) .Interview with (Housekeeper G)/conclusion of investigation. Based on investigation it is concluded that there was no abuse to the resident. (Housekeeper G) was very assumptive as she referred to those involved in the situation. She is also ignorant to the definition of abuse. Very negative attitude . It was documented that a statement from CNA Q was obtained via the telephone on 4/3/16 that noted, She wasn't abused physically. She was talking in disrespectful manner out of frustration. A telephone statement from Nurse F documented, I know nothing. Nobody reported anything. Resident was anxious, calling out. Staff try to redirect. Given PRN (as needed medication). A written and signed statement from Staff K, dated 4/4/16, documented, On 4/2/16, (Housekeeper G) texted me at 10:05 P.M. stating, '(CNA I) verbally abused (Resident #510) and I know (Nurse F) is not going to do nothing.' I told (CNA I) she needs to call (the DON). There was no written statement or documented statement from CNA I (the alleged perpetrator). It was handwritten, by the DON on a sheet of paper, No answer, 10:50 text call, 11:30 text call, 11:17 (staff name) educate (CNA I), remove her from having (Resident #31 and Resident #510) .Customer Service, Abuse & Neglect, Impeding the Investigation . Other residents in the facility were asked by SW A and DON, Did you see anyone being physically or verbally abusive towards (used Resident #510's name)? Did (CNA I) provide care to you Saturday? Is she abusive towards you? Is she rough with you while providing care? Signed interviews with residents were reviewed and revealed the following: Resident #31 - .Don't want (CNA I) to be your CNA. She can be nasty at times . On 4/19/16 at 4:25 P.M., Staff K was interviewed regarding Resident #510 and what was reported to her. Staff K stated, I got a call from (Housekeeper G) who told me that one of the CNAs was yelling at (Resident #510). I told her to let the nurse know and to call (the DON). On 4/19/16 at 5:00 P.M., an interview was conducted with Housekeeper G via the telephone regarding the above incident with Resident #510. Housekeeper G stated, One of the girls pulled a double. (Resident #510) hangs her feet out of bed. I let her know. She went into the room and was loud and told her that she wasn't going to keep getting her up and out of bed. She was really loud and her tone felt like it could be neglect or verbal abuse. She had an angry tone of voice. I told the DON about the incident and she told me I should have removed the aide out of the room and told the nurse and that I did it all backwards. They were going to investigate it. Housekeeper G was asked if she had observed the CNA behaving in an angry manner in the past and stated, No, I haven't. She was always pleasant and joking around and encouraging to residents. It was out of character that day and made me uncomfortable. On 4/20/16 at 8:30 A.M., the DON and Administrator (abuse coordinators) were interviewed regarding the facility's policies and procedures for preventing and reporting abuse. They were asked how the facility was ensuring that staff, residents and families could communicate concerns without fear of reprisal. The DON stated, They can call me anytime, but with staff it's a problem. The word abuse gets thrown around too much when it's not really abuse. The DON was asked who should determine whether or not an incident or allegation is abusive. The Administrator stated, It's brought up to us and we investigate. The DON and Administrator were further interviewed at this time about the investigation of alleged verbal abuse by CNA I toward Resident #510. The DON stated, I got a text from (Housekeeper G), I removed (CNA I) from the schedule. When I talked to CNA I, she said she didn't abuse her (Resident #510) and that nothing happened. The DON was asked if CNA I's interview was documented and did not offer a response. The DON was queried about the handwritten notes in the investigation provided by the facility that documented CNA I's name, multiple attempts to contact and impeding investigation. The DON did not offer a response. The DON was asked about the conclusion of the investigation and how the investigation was conducted. The DON reported that she contacted SW A and the Administrator, looked at the resident and she didn't have any marks or injuries, SW A talked to Resident #510, she obtained all the names of staff who worked that day and interviewed them, as well as residents who were assigned to CNA I. When asked about the conclusion of the investigation, the DON stated, We couldn't substantiate abuse. When queried about the statement from Resident #31 not wanting CNA I to care for him and reporting that she was nasty at times, CNA Q's statement that CNA I was disrespectful out of frustration, the DON reported that she moved CNA I to the second floor unit away from Resident #510 and #31. The DON was asked if CNA I and Housekeeper G received any education following the incident to prevent additional incidents in the future and reported that they did. The DON stated, I told (CNA I) that she has to be careful how she speaks with the residents. The DON reported that there was no documentation of the above mentioned education for CNA I or any education for Housekeeper G. The DON and Administrator were asked why the allegation of verbal abuse was not reported to the State Agency. The Administrator stated, I didn't think it was abuse. The residents, including the roommate didn't have a problem with the CNA and the staff said they didn ' t see anything. When queried about what Housekeeper G reported that she witnessed, the DON stated, She's disgruntled and negative. She should have told the nurse and removed the aide to protect the resident and instead she called me (the abuse coordinator). When queried about whether or not Housekeeper G followed the process by going directly to the abuse coordinator with an allegation of abuse, the DON stated, Not good enough. On 4/20/16 at 11:30 A.M., interviews were conducted with the following residents: Resident #510 was interviewed about the staff and stated, They are all pretty good, I guess. When asked if anyone has every yelled at her, Resident #510 became quiet and turned her head away and did not talk any more. Resident #31 was interviewed about staff and was asked if he ever had a problem with any staff members who cared for him. Resident #31 stated, Oh boy. Yeah. She's up on 2 (2nd floor unit) now. I don't like her. I got rid of her. Resident #31 was unable to recall the staff member's name, but said she was moved off his care about two weeks ago or so. When asked to describe what he did not like about the staff member, Resident #31 stated, Don't even ask me that. Do you have all day? I don't want to talk about it. They took care of it and everyone is fine now. The facility's policy titled, Abuse Policy and Procedure, revised 5/2015, was reviewed on 4/18/16 at 10:00 A.M. and documented the following: .Suspected or substantiated cases of resident abuse, neglect .or mistreatment shall be thoroughly investigated and documented by the Administrator, and reported to the appropriate state agencies . .All allegations by anyone who becomes aware of verbal, physical, mental, sexual or emotional abuse and mistreatment, neglect .must immediately report it to his/her charge nurse, supervisor, DON and Administrator. The Administrator will conduct the investigation . .A preliminary, on-site investigation will be initiated within twenty-four (24) hours of any report . .If the accused is an employee of the facility, he/she will be suspended until the investigation has been completed . .The staff will report any allegations or suspicions of mistreatment, abuse, neglect, misappropriation of property, and injuries of unknown source to the Administrator and DON immediately. If the Administrator or DON is out of the building, the staff will notify the Administrator or DON by phone . .The Administrator or designee will notify .any State or Federal agencies of allegations per state guidelines . .Identification through the safety program begins with the Incident Report . .The Director of Nursing and Administrator will review all incident reports to identify and further investigate any suspicious incidents . ( , )

This citation pertains to MI 272 Based on interview and record review, the facility failed to revise and implement individualized safety interventions to limit the potential for falls and/or injuries for one (#801) of three sampled residents reviewed for falls, out of a total sample of three residents, resulting in the resident experiencing falls with and without injuries, injuries of unknown origin (hematoma and bruises) and a fractured clavicle (collar) bone due to lack of supervision, and fall intervention precautions that were not in place. Findings include: On 6/19/15 at 9:19 a.m., at 12:23 p.m., and at 3:35 p.m., efforts to contact the complainant via telephone were unsuccessful. Voice mail messages were left for the complainant to contact the surveyor in regards to the complaint allegations. On 6/19/15 at 4:55 p.m., a return call was received from the complainant who acknowledged receipt of the aforementioned voice mail messages. Concerns were identified that the resident had endured multiple falls and injuries that included goose egg head injuries and unexplained facial bruising and most recently a fractured collar bone. They call me all the time to tell me she's (#801) fallen. The complainant further stated, I'm fearful for her safety. She's been there over 5 years. There have been so many changes with the Administration and the (DON). It's no longer safe there. I don't know what to do. On 6/19/15 at 10:00 a.m., resident #801 was observed asleep in bed lying on her left side facing the wall. A tab alarm was observed attached to the resident's shirt. A fall mat was observed next to the resident's bed. On 6/19/15 at 12:15 p.m., resident #801 was observed in the dining room seated in a gerichair. The resident's eye remained closed. (LPN) (B) explained the resident had good days and some days where she slept a lot and today was one of those days. (LPN) (B) was asked if the resident was wearing an arm sling. She stated, No. I've ever seen one but she does have a fracture. At that time without prompting, (LPN) (B) proceeded to lower the resident's top off of the resident's right shoulder and a dark pink circular half dollar sized bruise was observed. On 6/19/15 at 11:00 a.m., a Facility Reported Incident (FRI) involving Resident #801 was reviewed with the Director of Nursing (DON) and the Administrator (ADMIN). During the discussion a review of an incident and accident (I/A) report dated 6/2/15 at 2:30 p.m., and a post (I/A) investigation review, documented Resident #801 was observed sitting up in a chair with discoloration of skin to her upper right shoulder. According to the (DON) as a result of the facility's investigation it had been determined that a Certified Nurse Assistant (CNA) (A) had used improper body mechanics to transfer the resident as evidenced by the (CNA) (A) statement and lack of knowledge of proper body mechanics that resulted in the resident's right clavicle fracture. On 6/19/15 at 11:30 a.m., a review of the clinical record documented the following: A review of the admission facesheet documented the resident was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent Quarterly Minimum Data (MDS) assessment dated [DATE] documented the resident was severely cognitively impaired for decision making skills and required total assistance for bed mobility and transfers with 1-2 person physical assistance. A review of the resident's Safety care plan dated 11/6/14 documented: Problem: Potential for alteration in Safety related to medications, impaired mobility, cognition deficits. Goal: Will lessen the risk of falls and/or injuries. Review in 90 days. Approach: .12/27/14, body pillow ordered. 1/8/15, wheelchair and bed alarm, 1/11/15 monitor closely, 1/18/15, continue with current plan of care (POC), 2/13/15, continue with (POC), 3/26/15, continue with (POC), 6/3/15, reviewed. There were no further safety interventions or revisions documented on the resident's care plan after 1/18/15 to decrease the further potential for falls or injuries. A review of the resident's (I/A) reports documented the following: 1. On 12/27/14 at 10:45 p.m., .alerted by another resident that (#801) was on the floor in her room. No injury. Additional comments and/or steps taken to prevent recurrence: Urinalysis, culture and sensitivity, rule out urinary tract infection. Body pillow with bolster mattress. 2. On 1/18/15 at 10:15 p.m., Resident observed lying on her right on the floormat next to bed. Bed in lowest position. Body pillow and bed bolster down on the floor mat. No injury. There were no additional comments and/or steps taken to prevent recurrence documented on the (I/A) report. There was no evidence documented that indicated the resident's wheel chair or bed alarms were in place and functioning properly on the (I/A) report. 3. On 3/26/15 at 9:00 p.m., Resident was observed in her room on the floor mat next to her bed. No injury noted. There were no additional comments and/or steps taken to prevent recurrence documented on the (I/A) report. Further review of the report documented the resident did not have a personal alarm applied or in use. Additionally, the (I/A) was marked that it was not applicable for the alarms to sound. 4. On 5/30/15 at 7:00 a.m., Resident observed at 7:00 a.m., during get up time with hematoma left facial side and left upper eye lid. Additional comments and/or steps taken to prevent recurrence: Monitor resident for restlessness and maintain safety and continue to check devices. Further review of the report documented the resident did not have personal alarm applied nor did the alarm sound. 5. On 6/2/15 at 2:30 p.m., Resident was observed sitting up in chair with discoloration of skin to upper right shoulder. Additional comments and/or steps taken to prevent recurrence: Determine ways to ensure safety/educate staff on proper transfer. Monitor resident for restlessness and maintain safety and continue check devices. Further review of the report documented the resident did not have person alarm applied nor did the alarm sound. During a telephone interview on 6/19/15 at 1:30 p.m., (CNA) (A) stated, I think I was off work Sunday or Monday. I told the nurse (LPN) (B) I saw the bruise on her shoulder. I don't know how it happened. The midnight shift gets her (#801) up. When as asked if had noticed any other injuries on the resident (CNA) (A) explained she did recall. On 6/19/15 at 3:00 p.m., during an interview with the (ADMIN) and (DON) when queried regarding the multiple falls and injuries for Resident #801, and the identified safety interventions that were not consistently put in place. The (DON) stated, I'm currently inservicing staff regularly on monitoring the resident's at risk for falls. I agree it doesn't look like the alarms were in place as indicated on the resident's 'Safety' care plan. I know that we are monitoring resident's more closely now. I can't account for what happened previously. I've only been here since last month. On 6/19/15 at 3:10 p.m., during an interview Social Worker (C) stated, On the afternon of 6/2/15 around shift change (3pm) I saw the resident (#801) sitting up near the nursing station in her gerichair. She was restless. Her shirt was off her shoulder. I immediately noticed her right shoulder was discolored black and purple. When I touched her shoulder she grimaced. I told the nurse. On 6/19/15 at 3:30 p.m., a review of the facility's Falls-Clinical Protocol, policy dated 10/2010 documented: Treatment/Management: .2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation. ( )

Based on observation, interview and record review, the facility failed to ensure alarms and/or supervision were in place for two sampled residents (#s402 and 403) of seven sampled residents reviewed for falls, from a total sample of 14, resulting in a large bruise and laceration to Resident #402's forehead and a transfer to the emergency department for acute care, and the potential for more falls. Findings include: During a tour of the facility on 5/17/15 at 9:30 A.M., Resident #402 was observed lying in bed. Resident #402 had a large yellow bruise that extended from the middle of his forehead above his right eye around the side of his right eye. There was a quarter sized raised dark scabbed area on his forehead above his right eye. Resident #402 was asked what happened and was unable to say what happened. Resident #402's clinical record was reviewed on 5/18/15 at 8:50 A.M. and revealed the following: A face sheet documented that Resident #402 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #402 had severely impaired cognition and required extensive physical assistance from one staff member for transfers, ambulation, dressing, and eating. A Patient Transfer Form dated 5/11/15 documented that Resident #402 was transferred to the hospital with [DIAGNOSES REDACTED]. Small swelling noted with cut above right eye. Small bleeding noted. Incident/Accident Reports (I&A) were reviewed on 5/18/15 at 2:50 P.M. and revealed the following falls: On 1/3/15, Resident #402 had a fall out of a wheelchair in the second floor dining room. A statement of witness form from the MDS nurse documented, Resident (#402) was found down on the floor on 1/3/15 by his wheelchair, in the second floor dining room, by (another resident's) family member. The MDS nurse was at the second floor front desk.the family member came and got her to examine and observe the situation. The MDS nurse, then sent the family member to come down the hallway to (another resident's room number) where the nurse.and the CNA were assisting (another resident). The steps to prevent recurrence were documented as bed and chair alarm. On 2/22/15, Resident #402 was observed on the floor of his bedroom after he rolled out of bed. The bed alarm sounded. On 5/11/15 at 8:30 A.M., Resident #402 attempted to stand and fell on to the floor from the wheelchair in the dining room. It was documented that Resident #402 endured a laceration and swelling on his forehead above his right eye and was transferred to the emergency department (ED) by ambulance. The steps to prevent recurrence documented, to provide staff in dining room at all times with resident while present with high risk residents. An Investigative Review form documented that a personal alarm had not been applied and had not sounded. A statement of witness form was completed for LPN E which documented, Resident noted on the floor in dining room. Other resident stated that resident attempted to get up and fell to the floor. Resident suffered a blow to the right side of forehead. Laceration above right eye on forehead. Small swelling noted.Plan of action to have staff in dining room with patients at all times. On 5/19/15 at 8:40 A.M., Resident #402 was observed in the second floor dining room with seven other residents, seated in a wheelchair with no tab alarm. There were no staff members observed in the dining room. At 8:50 A.M., two Certified Nursing Assistants (CNAs), including CNA F' who was assigned to Resident #402 came into the dining room and began assisting residents out of the dining room. CNA F was interviewed at 8:53 A.M. about the absence of the alarm on Resident #402's wheelchair. CNA F stated, He should have an alarm. When queried about whether or not residents should be left alone in the dining room, CNA F stated, Someone should be in here at all times. Licensed Practical Nurse (LPN) C was interviewed at 8:55 A.M. and confirmed that Resident #402 was supposed to have an alarm on his wheelchair. At 10:30 A.M. on 5/19/15, Resident #402 was observed lying in bed. There was an alarm unit attached to the bed frame, however, the switch was in the 'off' position and it was not attached to the resident. CNA F was asked to come into Resident #402's room and was queried about whether or not he should have a bed alarm. CNA F stated, He has an alarm. It's right here and pointed to the alarm unit that was turned 'off'. CNA F then proceeded to take the alarm from the wheelchair, attached it to the bed frame, and clipped it to Resident #402's shirt collar. A Daily Staff Assignment Sheet dated 5/11/15 was reviewed on 5/19/15 at 11:00 A.M. and documented that CNA Y was the CNA assigned to Resident #402 on 5/11/15 at 8:30 A.M. when the fall occurred in the dining room. An attempt was made to interview LPN E via telephone on 5/19/15 at 11:05 A.M., however, she was not available for interview prior to the end of the survey. A interview was conducted with CNA Y via the telephone on 5/19/15 at 11:10 A.M. regarding the fall incident on 5/11/15. CNA Y stated, I brought (Resident #402) into the hallway at breakfast time. He is a fall risk and stands up unassisted sometimes, so I put him in the hallway at the nurse's station. A new young lady (CNA) must not have been aware that he needed to be supervised and put him at a table in the dining room. He stood up in there and fell and hit his head. I didn't see him fall. I don't think there was anyone (staff) in the dining room when it happened. I was not in there. I just know he fell . The Director of Nursing (DON) was interviewed on 5/19/15 at 1:30 P.M. regarding fall interventions for Resident #402. When queried about whether or not Resident #402 should have been unsupervised in the dining room on 5/11/15, the DON stated, I never heard that he was in there alone when he fell . The I&A reports mentioned above were reviewed with the DON at this time. The DON was asked about the witness statement that documented another resident informed the staff of the fall and the intervention documented on the 5/11/15 I&A that documented staff were to be in the dining room with high risk residents at all times. The DON stated, I'm going to change that because that is impossible. When queried about the documentation in the Investigative report from the 5/11/15 fall that documented personal alarms were not applied or sounding, the DON did not offer an explanation. When queried about the absence of alarms on the bed and wheelchair during the observation on 5/19/15, the DON reported that he should have a wheelchair alarm, but she was not sure about the bed alarm. When queried about how bed and wheelchair alarms were monitored to ensure they are placed and functioning, the DON reported that the CNAs are to ensure they are placed and working, but that it was not documented anywhere. Further review of Resident #402's clinical record was conducted on 5/19/15 at 11:30 A.M. and revealed the following: A physician's orders [REDACTED]. Apply self releasing alarm belt when up in w/c. A physician's orders [REDACTED]. Add tab alarm to w/c and bed. Fall Risk Evaluations were reviewed and indicated that Resident #402 was at high risk for falls, as evidenced by a score of 17 on 1/15/15, 19 on 2/22/15, 19 on 4/17/15, and 16 on 5/11/15 (A total score of 10 or above represents high risk). ( ) On 5/19/15 at 8:05 a.m., Resident #403 was not observed in her bedroom nor in any common areas of the facility. Her nurse (Nurse L) was queried as to where Resident #403 was. Nurse L went to Resident #403's room, then up and down the halls, then finally to a shower room (door closed) where she found her sitting in a shower chair alone and naked. Resident #403 was in the shower with the water running and sitting in a shower chair with the wheels unlocked. Resident #403 was observed with a towel in her hand washing herself. Nurse L was queried as to who and where was Resident #403's Certified Nursing Assistant (CNA). Nurse L reported it was CNA R. Nurse L went up and down the hall looking for CNA R before she finally found her. During this time (of approximately three minutes), Resident #403 was still left in the shower alone. On 5/19/15 at 8:20 a.m., CNA R was interviewed regarding leaving Resident #403 in the shower alone with the door closed and wheels of the shower chair unlocked. CNA R stated, I always leave her in the shower alone. That is how she wants to shower. On 5/19/15 at 11:10 a.m., review of Resident #403's face sheet indicated an admission into the facility on [DATE] and a re-admission on 5/12/15 with [DIAGNOSES REDACTED]. On 5/7/15 per the nurse's notes, Resident #403 was transferred out to the hospital due to syncope with collapse and mental status changes. Resident #403's annual Minimum Data Set (MDS) assessment, dated 4/3/15, indicated a severely impaired cognition. Also, the MDS indicated that Resident #403 required extensive assistance with hygiene, bathing and other activities of daily living (ADL's). On 5/19/15 at 11:20 a.m., Resident #403's care plans were reviewed and none of them included the intervention of allowing Resident #403 to shower alone and unsupervised. The care plan titled Resident is at risk for falls related to history of falls, impaired balance and gait, poor safety awareness, [DIAGNOSES REDACTED]. The care plan did not include the intervention to allow Resident #403 to shower alone. On 5/19/15 at 11:35 a.m., the Director of Nursing (DON) was informed of how Resident #403 was found in the shower. The DON stated, I will be educating the CNA. There was no explanation provided. The facility's policy titled, Safety and Supervision of Residents, revised December 2013, was reviewed on 5/19/15 at 3:30 p.m. and documented the following: .Implementing interventions to reduce accident risks and hazards shall include the following: a. communicating specific interventions to all relevant staff; b. assigning responsibility for carrying out interventions;.d. ensuring that interventions are implemented; and e. documenting interventions. .5. Monitoring the effectiveness of interventions shall include the following: a. ensuring that interventions are implemented correctly and consistently. ( )

This citation pertains to MI 423. Based on interview and record review, the facility failed to ensure one (#301) of 3 sampled residents reviewed for significant medication errors, from a total of three sampled residents, was not administered medication prescribed to another resident (Resident #303--[MEDICATION NAME] and Soma), resulting in a significant medication error because Resident #301 experienced a decrease in blood pressure and was administered [MEDICATION NAME] secondary to opioid overdose enroute to the hospital. Findings include: It was reported that a staff member dispensed the wrong medication to a resident. According to the "Resident Incident and Accident Report", dated 5/28/14 at 6:45 AM, the following incident (significant medication error) occurred: "Patient (Resident #301) was given another patients (Resident #302's) medication ([MEDICATION NAME] 30 milligrams--opioid narcotic pain medication) [MEDICATION NAME]([MEDICATION NAME] 350 mg--a muscle relaxer used to block pain). The other patient (Resident #301) was in the next room in the same bed...Room numbers were mixed up on bottom of MAR's (Medication Administration Records)...Patient (Resident #301) will be monitored carefully for somnolence, weakness, neuro changes, changes in vital signs..." A review of the nursing notes for Resident #301, dated 5/28/14 at 8:15 AM, was as follows: "At 8:00 AM, resident (#301's) BP (blood pressure) was 76/50 down from 7:00 AM 100/72...called 911--they arrived in 5 minutes...BP 76/43, Resident (#301) alert and oriented to person-sluggish-transferred to...ER (emergency room )." The nursing notes, dated 5/28/14 at 10:40 AM, documented: "Resident #301 was returned to facility via ambulance...in good spirits-report from nurse at local hospital ER-[MEDICATION NAME] administered in route by EMS (emergency medical service)-IV (intravenous) fluids given-vital signs stable...BP 152/72...". This progress note was signed by Nurse "D". ([MEDICATION NAME]--used for reversal of acute opioid overdose) ( ) On 6/16/14 at 2:00 PM, a review of the clinical record revealed that resident #301 was readmitted into the facility on [DATE] and had [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS), dated [DATE], indicated that Resident #301 had moderately impaired cognition and required physical assistance with some activities of daily living. A review of the May 2014 and June 2014 physician orders [REDACTED].#301 was not [MEDICATION NAME]. On 6/16/14 at 2:30 PM, the Director of nursing (DON) was asked if Resident #301 had received the wrong medication and reported that Resident #301 received the wrong medications, and stated, "She didn't follow standards of practice..." The DON provided no other information. On 6/16/14 at 2:40 PM, the administrator stated, "That Nurse (Nurse "C") went into the wrong room and administered meds to Resident #301 that belonged to Resident #302. Resident #301 was in bed. Resident #302 was at the medication cart. She took the meds she had poured (for Resident #302) into resident #301's room...the picture is in the MAR (medication administration record), they (residents) have armbands, the name is outside the door, and they are supposed to ask them (residents) their names." The administrator revealed that Nurse "C" had pre-poured medication for all residents who resided in three rooms "at the end of the hallway on the first floor". Further investigation revealed Nurse "C" pre-poured medications for nine residents. On 6/16/14 at 2:54 PM, during a telephone interview, Nurse "C" was asked about the medication error. Nurse "C" stated, "It was the end of shift. I've never done it before, fixed (pre-poured) meds for the end of the hall...I fixed medications ahead of time. Someone mentioned it helped you get through quicker. I had already fixed up the medication for resident (#302). I poured medication for all the residents at the end of the hallway (There were nine residents, three to a room). He liked his meds at 6:00 AM. I gave them to resident #301. I walked into the wrong room and the minute he (resident #301) took them, I knew they were the wrong meds...They [MEDICATION NAME](acute musculoskeletal pain) and [MEDICATION NAME] (moderate-severe pain). Resident #301 does not have orders for those meds...I should not fix medicines before hand. He did not have a name band on. I probably glanced at it (the photo), but not let it sink in. Lots of patients were new to me." On 6/16/14 at 3:12 PM, during a telephone interview, Nurse "D" stated, "I came in about 6 AM. In talking to Nurse "C" she told me she had given Resident #301 Resident #302's meds. I thought it was just the pain med, then it came out it was [MEDICATION NAME], which is strong muscle relaxant. The blood pressure started going down. It was 100 over something but went down to 76 over something. I got scared and called 911. He was a little sluggish, but alert and oriented, was able to answer questions and did not loose consciousness. They gave him [MEDICATION NAME] when they got him out to the truck (ambulance) and hydrated him with IV fluids per the ER nurse." On 6/16/14 at 3:40 PM, a review of the clinical record revealed that resident #302 was readmitted into the facility on [DATE] and had [DIAGNOSES REDACTED]. The admission MDS, dated [DATE], indicated that resident #302 was cognitively intact and was able to perform most activities of daily living independently. A review of the MAR for May 2014 revealed that resident #302 had physician orders [REDACTED]. On 6/16/14 at 3:15 PM, a review of the facility's policy titled "Drug Information - Med Pass Guidelines", dated December 2007, stated, " (H) The med pass should not be interrupted unless there is an emergency...(J) Do not pre-pour unit dose packages until administration of the medication...(M) Identify your resident before administering medications." ( )