Every finding on record at Optalis Health and Rehabilitation at St. Francis

This citation pertains to Intake Number 3027112.Based on interview and record review, the facility failed to ensure physician orders were followed for the timely testing and reporting results of residents' blood tests for three residents (#s 101, 106 and 107) of four residents reviewed for anticoagulant therapy (prevents blood from clotting) resulting in delays in evaluation and treatment for R101, R106 and R107 and the death of R101.Findings Include: A record review revealed Resident #101 who was receiving anticoagulant therapy did not receive the ordered timely testing and reporting of test results since admission into the facility. Additional record review indicated that Resident #101 was subsequently hospitalized and died due to a large brain bleed from decreased blood clotting. The Immediate Jeopardy (IJ) began on [DATE]. The Immediate Jeopardy (IJ) was identified on [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE] at 3:45 pm. A plan to remove the immediacy was requested. The Immediate Jeopardy was removed on [DATE], based on the facility's implementation of the removal plan. Resident #101: Review of the Face Sheet, Laboratory reports dated 2/26, Physician and Nurse Practitioner progress notes dated 2/26, and nurse's note's dated [DATE] through [DATE], revealed Resident #101 was 74 years-old, admitted to the facility on [DATE], was alert, her own person, full Code status, and required extensive assist with all Activities of Daily Living/ADL's. The resident's diagnosis included metabolic encephalopathy, Atrial Fibrillation (Afib), Factor 5 Leiden Deficiency (bleeding disorder, risk for pulmonary embolism and DVT-Deep Vein Thrombosis-blood clot), with a history of pulmonary embolism. The resident had a critical INR lab of 11.9 (normal: 2.0-3.0) reported by lab on [DATE], became unresponsive, was transferred to the hospital on [DATE], and deceased on [DATE] due to a large brain bleed related to a critical INR level (decreased blood clotting). Review of the facility Brief Interview for Mental Status/BIMS dated [DATE], revealed the resident was scored as a 14, intact cognitively. Hospital Discharge to facility Record: Review of the hospital Discharge summary dated [DATE] at 12:40 PM, revealed Resident #101 was admitted to the hospital on [DATE], with Factor 5 Laden Deficiency and on Coumadin 1 MG daily, a history of PE (Pulmonary Embolism), obesity, Acute metabolic encephalopathy, cellulitis of the right leg, UTI (Urinary Tract Infection) with hypokalemia and hypomagnesemia. The resident was given antibiotic vancomycin and ceftriaxone, wound care, hydration and discharged to the facility on [DATE]. Hospital admission Paperwork: Review of the hospital Impression Plan dated [DATE], revealed Factor 5 Leiden Deficiency-Resident was on Coumadin, INR lab ordered, and a history of pulmonary embolism with IVC filter and on Coumadin. The residents ordered Coumadin 1 mg daily (had been on prior to hospitalization due to risk factors). Review of Hospital Lab dated [DATE] through [DATE] (prior to facility admission), revealed on [DATE], the residents' INR was 5.2 (abnormally high, normal range: 2.0-3.0), Coumadin was held and dosed according to INR labs. Upon discharge to the facility the residents INR level dated [DATE], was 2.4. Review of the facility electronic medical record dated [DATE] through [DATE], revealed Resident #101 was admitted from the hospital on [DATE] with a INR lab within the normal range (2.4). At the time of admission to the facility, the resident was receiving 1 mg oral daily of Coumadin. Drugs.com [DATE] Precautions: Blood tests, such as INR, are needed to check for proper dosage and unwanted side effects. Facility admission Orders and Assessment: Review of facility physician admission orders dated [DATE], stated Warfarin (Coumadin) Oral Tablet 1 MG, Give 1 tablet by mouth one time a day for Factor 5 Laden deficiency, Afib. Review of facility physician admission orders dated [DATE], revealed no order for PT/INR labs to be placed. Review of the facility Standing Orders/S.O. found at the nursing station in the nursing information book on [DATE], stated Warfarin (Coumadin, Jantoven) PT/INR on admit-yes (lab to be drawn upon admission to facility), Routine-Q (every) week until stable then q month. Per facility SO, the resident was to receive PT/INR blood draw upon admission due to being on Coumadin when admitted . Review of the facility admission Nursing Assessment and nursing progress notes dated [DATE], revealed no documentation of the resident being on an anticoagulant, nor an INR lab to be drawn. Review of the admission MDS (assessment tool) and residents admission care plans dated [DATE] through [DATE], revealed there was no care plan developed for anticoagulant therapy, Factor 5 Leiden Deficiency, history of pulmonary embolism, nor monitoring for side effects of Coumadin (bleeding, excessive bruising, may cause skin necrosis, assess for purple or dark color of toes, calcium uremic (with or without kidney disease), increased temperature and a color change to any part of body). Facility Progress Notes and Delayed INR lab draw: Review of facility physician orders dated [DATE] stated PT (Prothrombin Time)/INR , one time only related to Paroxysmal atrial fibrillation; an order for a PT/INR lab to be drawn dated [DATE], and per facility Standing Orders (if on Coumadin, admission INR draw), from admission ([DATE]) to the INR lab draw done on [DATE], was a delay of 11 days. From physician order ([DATE]) for a INR lab to be drawn on [DATE], to the lab actually being drawn at the facility on [DATE], was a delay of 8 days. Review of the residents' facility electronic medication administration record (EMAR) dated 2/26, revealed the resident had received Coumadin 1 MG does a total of 8 times (8 doses=8 mg) while at facility with the last dose given on [DATE] (oral Coumadin 1 mg given at facility on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and on [DATE]). Reviewed facility nursing progress notes dated [DATE] through [DATE], no documentation was found regarding assessment for side effects of Coumadin (bleeding, excessive bruising, may cause skin necrosis, assessment for purple or dark color of toes, increased temperature and a color change to any part of body). Review of Physician and Nurse Practitioner/NP, I progress notes dated [DATE] through [DATE], revealed no documentation of INR lab draw needed or follow-up with the [DATE] INR lab order. Review of the resident's facility PT/INR lab result dated [DATE], revealed lab was ordered by physician on [DATE] and was drawn on [DATE], resulting in a PT of 90.1 (normal: 12.5-13.7), and INR of 11.9 (HH/critically high, normal: 2.0-3.0). The residents had a critically high level for PT/INR (increased blood clotting time) which lead to a brain bleed and death. Review of facility nursing progress notes and physician orders dated [DATE], revealed lab had called the facility with a critically high INR (11.9) on [DATE]; the nurse called Physician K and orders were given for a one-time dose of vitamin K to be given. Review of the EMAR (electronic medication administration record) dated 2/26, revealed documentation the one-time dose of vitamin K was given on [DATE]. Review of physician order dated [DATE] stated, Vitamin K Oral Give 5 mg by mouth-phone (phone order) one time only. During a phone interview done on [DATE] at 11:38 a.m., Lab staff F said the PT/INR lab was not in the facility lab book (facility lab binder kept at nursing station) for the lab technician to get to draw the lab on [DATE]. Lab staff F said it was drawn on [DATE], and called as a critical lab to the facility on [DATE] (a 2-day time frame, not put in as a Stat lab-immediately to be drawn by facility). Review of the facility Licensed Nurse LPN H Medication Management Skills Checklist dated [DATE] (after the INR lab draw on [DATE]), revealed on [DATE], nurse Hwas checked off for PT/INR completed as ordered; called to physician; validated prior to administration of medication; recorded on eMAR (EMAR) and/or tracking log (in lab book at nursing station)-Warfarin (Coumadin) administered as ordered; resident monitored for S/S (signs/Symptoms) of bleeding-Dosage change orders documented correctly. Review of the facility Medication Administration policy dated [DATE], stated Medications are administered in accordance with the following rights of medication administration: Right resident, Right medication, Right dose, Right route, Right time and frequency, Right documentation, Right of resident to refuse, Right clinical indication. Transfer to Hospital: Review of facility nurse's progress note's dated [DATE], stated Resident non-responsive to verbal and pain stimuli with shallow breathing, writer alert emergency MMR (Medical Mobil Resecure) patient transferred to hospital at around 7:00 a.m., physician, DON notified of status. No documentation of facility informing Family was found. During a phone interview done on [DATE] at 4:42 pm, Family Member #1 stated The ER call me (on [DATE]) and said to get here asap, because they did not know if (Resident #101) would live. Review of the hospital ED INR lab dated [DATE], had the INR lab result as 10.7 (critical lab). Review of hospital Emergency Department/ED records dated [DATE], revealed the resident was unresponsive upon arrival to ED, and stated her eyes: deviated upward, pupils nonreactive, General: Unresponsive. Review of the hospital CT done on [DATE] at 0759 (7:59 am), stated Large left intraparenchymal hemorrhage (Lg. brain bleed) and significant midline shift towards the right. Altered mental status. There is a large left intraparenchymal hemorrhage measuring at least 7.6 x 7.3 cm with extension into the lateral ventricles bilaterally. There is marked midline shift towards the right of at least 2.6 cm. The resident was admitted to the critical care unit on [DATE]. Review of the hospital ED note addendum dated [DATE], listed main diagnosis as Left intraparenchymal hemorrhage with shift and supratherapeutic INR (critical INR lab value)-Comfort measures only. Cause of Death: Review of Certificate of Death dated [DATE], revealed Resident #101 expired on [DATE] at 4:48 pm, at the hospital. The cause listed for death was Nontraumatic Intracerebral Hemorrhage within 24 hours, (and) Warfarin (Coumadin)-related Coagulopathy (condition where blood's ability to clot is impaired, leading to prolonged or excessive bleeding) within 1 to 2 weeks (time resided in the facility). Review of the facility Abuse policy dated [DATE], stated Neglect: Failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the facility Laboratory Services Agreement dated [DATE], stated Client Facility shall provide Lab with a copy of all physician orders related to requested treatment (in facility lab binder) and each such patient's consent for treatment prior to Lab's provision of any clinical care related Services. Review of the facility Laboratory Results policy dated [DATE], stated The facility will assist the resident in making transportation arrangements to and from the laboratory if necessary. STAT lab results are received according to timeframes established in the contract. The laboratory will notify the facility of critical or panic laboratory results. Statements: Nurse Manager/MDS Coordinator G: During an interview conducted on [DATE] at 11:00 am, Prior Nurse Manager/MDS Coordinator G stated: (Prior MDS Nurse) did the care plans (upon admission for Resident #101). I cannot find a care plan for anticoagulant, Factor 5 blood clotting disorder, PT/INR. You need for her coumadin, INR and Factor 5 blood disorder. I agree that her (resident #101) not having those care plans is a problem. Orders for PT/INR, they typically draw the same day and will get the results in the afternoon. They should have followed up on [DATE] (the INR lab results). Nothing was charted about the lab; I could not find anything. Looks like the lab (PT/INR) was ordered on [DATE], and no result until [DATE]. No one from facility followed up with the lab. I don't remember hearing about this; I believe this was a mess-up a follow-up by the Doctor, Nurse Practitioner and Manager. There is a nursing note on [DATE] for a chest x-ray and labs and hold coumadin to INR 11.9 and PT 90.1 (hold coumadin medication until next lab draw with results) and give vitamin K one time dose. I was the manager, we are to come in and go through morning report, it was not on that, and I went through her chart on [DATE] and saw it wasn't addressed. I then told (Nurse H) she needed to call the doctor. We (Manager G and DON) did go into the hospital records (ED records and hospital discharge records) and saw it (the resident had decreased). The DON and I looked at her labs and looked to see what happened to her. The DON did nothing that I am aware of; no one did and Inservice on PT/INR that I am aware of. During an interview done on [DATE] at 11:16 am, Nurse Manager/MDS Coordinator G stated You get an order from the doctor, place order in PCC, print Face Sheet and order and place in lab binder (for lab tech to get when they come in facility to draw). You put it under the date to be drawn. The lab only comes here twice a week, there are no stat labs, we don't have stat labs. We have been having trouble with our lab; we never know when they are coming. We can't get a phlebotomist and (hospital) won't do labs anymore (lab draws) because of reimbursement issues. We don't have copies of the orders in the book (lab binder). I came in on [DATE] and wanted to know if they drew it then. The lab called us on [DATE] and reported a critical lab, During an interview done on [DATE] at 12:13 pm, Nurse Manager G stated I put the lab slip under [DATE] to be drawn on [DATE]. Unless I have another lab order placed, I don't check the book (lab binder). Labs are done on Tuesdays and Thursdays, we don't have a policy for this. Director of Nursing/DON: During an interview conducted on [DATE] at 12:45 am, the DON stated It usually takes 24 hours to get the results (lab results), it would be on [DATE] (get the residents INR lab results). The lab should call the critical lab to the nurse on the floor, it should be put in the notes or the assessment. When they (lab tech) come to draw, they pull out the orders for the day and draw them (from the facility lab book). It should of been done, I don't know why it wasn't, I don't remember. The nurses are educated upon hire and it's on their yearly competency. I did look up (Hospital) site and found out she (Resident #101) died, the family called and let us know, I did not look back and find the lab concerns (at the facility), I should have. The nurses are to review after visit/discharge summary (from the hospital upon admission), the med's, the order's, the admitting nurse. No education or discipline was done for this. My thought is the lab was not drawn on [DATE] or [DATE], it was not reported until [DATE]. We should follow up on our morning meetings on the board. I didn't follow-up on this because of the annual (DON said the State of Michigan/SOM was in for 3 days during this time doing an annual survey and that's why she did not follow-up). Review of the SOM 2/26 calendar revealed the team was in the facility doing an annual survey a week prior to this event. During an interview done on [DATE] at 11:36 am, the DON stated yes, it should have been followed up on, it was collected on [DATE], and on [DATE] at 3:38 am, the lab called us with the INR of 11.9. During an interview done on [DATE] at 8:45 am, the DON stated We don't have a PT/INR policy. Our driver was busy he could not take residents and that (hospital) and (local lab) would not take their resident's. Transport Driver N: During an interview done on [DATE] at 11:35 am, Transport Driver N stated I do (local lab) and (hospital). I have a part time driver too; I have never refused to take anyone (including for lab draws). If they had asked me, I would have. During an interview done on [DATE] at 8:55 am, the DON stated They (nursing staff) are not going to check it (lab binder) every day because labs are drawn on Tuesdays and Thursdays only. We don't have a procedure for this. When asked if staff nurses are able to draw blood themselves, the DON stated, The nurses have been trained, but some are not comfortable doing it. The DON said the facility does have their own INR machine (small handheld machine that gives PT/INR clotting times), however the strips were recalled some time ago and no one has ordered any more. Review of the facility calendar done on [DATE], with the DON for 2/26, revealed lab was in the facility for blood draws on [DATE] and on [DATE]. Facility Laboratory Services: During a phone interview done on [DATE] at 11:38 am, lab staff F stated The only sample (blood draw from the facility) was on [DATE], this was the first time it was in the lab book. At our SNF's (Skilled Nursing Facilities) there is a binder with the ordered slips in it. The tech (no longer for the lab) takes the orders out and draws (draws blood per each resident's orders). If it was ordered on [DATE], they might not have put it in the binder. On the 10th our tech found it and drew it. We called the facility with the results on [DATE], we must send it out to be processed. The INR was 11.9, the normal is 2.0 to 3.0 and the PT was 90.1, the normal is 12.5 to 14.7. Nurse, LPN M: During a phone interview done on [DATE] at 12:40 pm, nurse, LPN M stated I have never read a policy to check the lab book daily or on Tuesdays and Thursdays. Definitions: INR: International Normalized Ratio lab. PT: Prothrombin Time lab. Factor 5 Laden Deficiency: A change of one of the clotting factors in the blood. A clotting factor is a protein that helps blood to clot. This change in clotting can raise the risk of getting harmful blood clots, mostly in the lungs (Pulmonary Embolism) or legs. This condition can lead to hemorrhage (excessive bleed) and can be fatal. Intraparenchymal Hemorrhage: A serious brain issue; it happens when blood bleeds into the brain tissue. It can lead to severe disability or death. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: -On [DATE], an audit for all active lab services was reviewed to ensure labs testing was scheduled to be completed. Resulted labs were received and reviewed with the physician. -Standing Orders dated 2016, have been removed from Nursing Binders at every nursing station. -When a physician orders Coumadin therapy, nursing staff will immediately clarify INR monitoring frequency and parameters with the physician. -The Director of Nursing (DON) or designee will: *Monitor all lab requisitions daily. *Ensure labs are completed as ordered. *Ensure results are reviewed with the physician upon receipt. -The facility has created a lab tracking log that will assist with identifying when labs are to be drawn. The nursing administration team will audit these logs daily to ensure completion, monitoring for results and ensure MD notification has been completed. -The DON or designee will review all new admission orders and lab orders during the daily morning clinical meeting. -Nursing (RN & LPN) were reeducated on [DATE] * Lab Services policy with emphasis on ensuring labs were being completed by physician orders and resulted in timely and reviewed with the Medical Director/MD. *The emphasis on monitoring lab values while residents receiving coumadin therapy. -Any staff not present on [DATE], will receive this education prior to their next scheduled shift. Resident 106 (R106): A review of Resident 106's medical record revealed an admission into the facility on [DATE] and readmission on [DATE] with diagnoses that included venous insufficiency, anemia, and ulcerative colitis. A review of the Minimum Data Set assessment revealed a Brief Interview of Mental Status score of 15/15 that indicated intact cognition. A review of R106's lab results in the medical record revealed a collection date on [DATE] and reported [DATE] at 00:25 (12:25 AM). The laboratory order was put in on [DATE]. The results included a low Hemoglobin of 7.82 g/dL (with normal levels of 12.00 -16.75) with other abnormal laboratory results. A review of the progress notes revealed no documentation that the physician had been contacted regarding the results of the abnormal labs. On [DATE] at 1:22 PM, an interview was conducted with Nurse P who was assigned to Resident 106. The Nurse was asked if she was aware of the Resident's abnormal laboratory results and the Nurse indicated she was not aware and that no information of labs pending or resulting were passed on in morning report. The Nurse indicated that results or pending labs should be passed on in report. The Nurse was asked where she could find the results but was unsure being that she was still orientating at the facility. At 1:24 PM, the Director of Nursing (DON) was at the nurses' station and reported that she had reviewed the results in the morning and that the Doctor was in and went through the labs with no orders received. The DON reported the Hgb (hemoglobin) was low but everything else was ok for her. When asked if the Doctor will chart, the DON indicated he will put a note in later. On [DATE] at 1:31 PM, an interview was conducted with the DON. The DON was asked how the Nurse was aware of lab results and reported the results show up on the dashboard and the lab tab on the EMR (electronic medical record). When asked when the physician gets notified of abnormal results, the DON reported that the lab would call with any critical and then we notify the doctor. When asked when the Doctor was notified of abnormal lab results, the DON reported they review them in the morning in the clinical meetings. During the interview with the DON at 1:46 PM, Doctor O returned a request for a call back and was interviewed regarding Resident 106's abnormal laboratory results. When asked about the labs, the Physician reported he was not aware of any abnormal results and that the facility had not notified him of the labs and was unaware they were reported to the facility. The DON talked with the Physician on the phone, reported the results and obtained further orders from the Physician for follow-up assessment, further lab testing and consultation to a GI specialist. When asked when he expected to receive abnormal results, the physician reported they should call immediately with critical labs and call with abnormal as well and indicated they should have let him know when he was there in the morning and that he would want to know the abnormal labs as soon as possible, they could have put them in the physicians book or call and leave a message. The physician reported that if the Hgb was under 8 and hypotensive or symptomatic, then it needs to be addressed immediately. It was reviewed with the DON of the concern that the Nurse was unaware that labs were pending/completed and the Physician was not made aware of the abnormal results when at the facility in the morning, the DON indicated earlier that the physician was aware of the results but after the phone interview, he was not aware. The DON reported that she had assumed he reviewed them in the morning, had texted him to review the labs at approximately 12:20 PM and that he had access to the chart. When asked what the facility policy was and the nurses' responsibility for conveying abnormal results to the physician, the DON stated, If they get the lab results, they need to put it in the Dr. book to be reviewed, call the Dr. with high or low abnormals. Resident 107 (R107): A review of Resident 107's medical record revealed an admission into the facility on [DATE] and readmission on [DATE] with diagnoses that included diabetes, resistance to multiple antimicrobial drugs, urinary tract infection, gastro-esophageal reflux disease, intestinal obstruction, and pseudomonas. A review of the Resident's MDS revealed a BIMS score of 13/15 that indicated intact cognition and the Resident was dependent on a helper for toileting hygiene, bathing, dressing and transfer into a chair. A review of R107's laboratory orders revealed an order dated [DATE] for a Basic Metabolic Panel (BMP) and a CBC (complete blood count). A review of the Progress Note dated [DATE] at 5:58 PM, revealed, Call placed to (doctors name), the resident has tea-colored urine. Current vitals: Bp 68/56 HR 89 O2 sats 95% 2L(liters) NC (nasal canula), denies pain or discomfort at this time. (Doctors name) responded with recheck vitals and the 98/63 manual. Check UA (urinalysis), CBC, and BMP. Review of the orders revealed the CBC and BMP were ordered but the UA had not been ordered. A review of the medical record revealed no labs results or urinalysis completed. A review of R107's progress notes revealed an eInteract SBAR Summary for Providers, dated [DATE] at 8:56 AM, Situation: The change in condition/s reported on this CIC Evaluation are/were: Altered mental status tired, Weak, Confused, or Drowsy. BP(blood pressure) 75/40, P (pulse)101. Pulse Oximetry: O2 80% .Positive findings reported on the resident/patient evaluation for this change in condition were: Mental Status Evaluation: Altered level of consciousness, increased confusion; -Functional Status Evaluation: Needs more assistance with ADLs General weakness, Swallowing difficulty. -Respiratory Status Evaluation: Labored or rapid breathing Abnormal lung sounds (rales, rhonchi, wheezing) Other respiratory changes; -Cardiovascular Status Evaluation: Resident pulse greater than 100 or less than 50 .-Neurological Status Evaluation: Altered level of consciousness. Primary Care Provider Feedback:. A. Recommendations: send to ER (emergency room) for eval and treat. Resident 107 readmitted into the facility on [DATE] from the hospital. A review of R107's medical record of the hospital Discharge Summary revealed, .Acute hospital diagnosis: Orthostatic hypotension, Sepsis POA (present on arrival), Complicated catheter associated UTI (MRSA, E faecalis, Pseudomonas), Acute and chronic hypoxic respiratory failure, possible aspiration pneumonia, Acute metabolic encephalopathy, Acute on chronic blood loss anemia, acute GI bleed, AKI (acute kidney injury) resolved, likely metastatic prostate cancer, acute thrombocytopenia, resolved. the discharge summary included, Issues to be addressed at follow-up with PCP/Consultant: Things to be followed up with PCP: CBC and BMP in 3-4 days. Further review of the discharge summary revealed, Hospital course: .brought to ED (emergency department) on 04/23 2026 due to hypotension with blood pressure reading of 60/80 and hypoxia with oxygen saturation in 80s on home 2L O2. Patient reported shortness of breath, cough, abdominal discomfort and multiple episodes of emesis. Recent Labs: HGB 8.5 (low) on [DATE], K+ 3.2 (low). On [DATE] at 1:50 PM, an interview was conducted with the DON regarding Resident 107's lack of labs completed after ordered on [DATE]. A review of the medical record with the DON revealed an order for the BMP and CBC on [DATE], no results in the medical record with the DON stating, I'm not seeing it (lab results). When asked if they were put in to be drawn, the DON reported there was a requisition done for the lab work to be drawn but the DON confirmed there was no lab results and indicated they must not have drawn it. A review of the progress note revealed a UA was also to be completed but the DON was unable to find an order for the UA. The DON was asked about the progression of the Resident's illness and the DON reviewed the medical record and reported that on 4/22 there was a change in condition of hypotension (low blood pressure), medication Midodrine was started and then on 4/23 another change in condition was completed and the Resident was sent to ER with change in mental status. It was reviewed with the DON of the Resident presenting with signs and symptoms to warrant the Physician to order labs on [DATE] for BMP, CBC and UA, the labs were not completed and the Resident transferred to the emergency room and hospitalized with diagnoses that included sepsis, UTI, possible aspiration pneumonia, anemia, GI bleed and acute metabolic encephalopathy and the potential for a different outcome had the labs been completed when ordered. The discharge recommendations from the hospital discharge summary of Things to be followed up with PCP: CBC and BMP in 3-4 days. was reviewed with the DON. The DON reported that the next day the resident would be back for two weeks and indicated the labs had not been done or ordered. When asked why this had not been ordered. The DON replied, that is there jargon they put on everyone that comes back. When queried, the DON reported there was no risk versus benefit documented to not follow the discharge recommendations. On [DATE] at 1:13 PM, an observation was made of Resident 107 lying in bed with the head of the bed elevated and the Resident was watching TV. The Resident was interviewed, answered questions and engaged in conversation. The Resident was asked about his recent hospital stay. The Resident indicated he had been sick and went to the hospital with his blood pressure low, not breathing good and had vomited multiple times, had a fever, was hot, and had pain in his stomach. The Resident reported he was really sick and stayed there a while at the hospital and then came back here.

This citation pertains to Intake Number 2997890.Based on observations, interview and record review, the facility failed to ensure that one resident (Resident #2) had an appropriate call light to meet his safety needs, and that one resident's (Resident #6) call light was within reach of two residents reviewed for accommodations of needs.Findings Include:Resident #2:On 5/6/2026 at approximately 2:15 PM, an audit of call light functionality was completed of resident rooms with Maintenance Staff C. It was found that room [ROOM NUMBER]-2 (Resident #2) did not have a call light and there was a black dowel in the call light panel on the wall (where the call light cord would connect into). Resident #2 was asked where his call light was and he stated he did not have one as the facility thought he was going to hang himself, so they (the facility) took it from him and never gave it back. Resident #2 reported he uses his roommate's call light. There was no other accommodation in place for Resident #2 to alert staff when he needed assistance.On 5/6/2026 at approximately 4:00 PM, a review was conducted of Resident #2's medical records and it revealed he was admitted to the facility on [DATE] with diagnoses that included, Vascular Dementia, Parkinsion's, Major Depressive Disorder, Bipolar II Disorder, Anxiety and Suicidal Ideations. Further review of the record yielded the following:Care Plan: .Anticipate and meet needs. Be sure call light is within reach and respond promptlyto all requests for assistance.Call light within reach. Kardex:There is nothing in Resident #2's Kardex regarding his call light being removed from his room and the alternative for him. On 5/7/2026 at 8:30 AM, CNA (Certified Nursing Assistant) D stated Resident #2 does not have a call light or bell to ring in his room and they (the aides) just check in on him. She was unsure how long he had been without a call light, but it was due to his suicide attempt. CNA D was queried if anything was mentioned in Resident #2's care plan related to him not having a call light due to his prior attempt. She stated she did not think there was. Review was conducted of Resident #2's care plan and there were no alternatives listed in lieu of him not having a call light.On 5/7/2026 at 1:53 PM, Nurse E reported Resident #2 had a bell that he can ring if he needs anything. The resident is not deemed safe to have a call light due to a past suicide attempt and subsequent inpatient psychiatric hospitalization. Nurse E continued Resident #2 does tend to move things around, but his care plan should reflect the reasoning why he does not have the standard call light accessible to him. On 5/8/2026 at 9:24 AM, Unit Manager F reported Resident #2 has not had a standard call light in sometime as he wrapped it around his neck in a suicide attempt. She reported he was 1:1 when he initially readmitted from the psychiatric unit but that was a few years back. Manager F continued Resident #2 utilized his roommates call light if he needed assistance.On 5/7/2026 at 8:20 AM, Resident #2 was observed in bed turned toward the wall. He was asked where the call light was and he said, right here. After the privacy curtain was pulled back the call light card was visualized on the floor where the foot of bed 1 meets the head of bed 2. The call light was on the floor between the two beds and unable to be accessed by either resident. 184-1 explained a long time ago the facility thought Resident #2 was going to kill himself by means of wrapping the call light around his neck. Since then, he has not had a call light and they share his. He added sometimes they have a hard time finding it as when staff come into clean and such it gets moved.On 5/7/2026 at approximately 3:00 PM, in the presence of the DON (Director of Nursing), Resident #2's room was observed. The DON started he does not have a standard call light due to past suicide attempts with the cord but should have a bell in the room. There was no handbell that was in the room. The DON stated Resident #2 should have his own mechanisms to alert staff if he is in need. The DON reported at one point he did have a handbell and she is unsure what happened to it. On 5/7/2026 at approximately 3:30 PM, a review was completed of Resident #2's care plan with the DON and there was no mention of safety concerns for a standard call light due to a prior suicide attempt. The DON reported he was admitted to an inpatient psychiatric unit in August 2023 after wrapping his call light cord around his neck. There was nothing listed in the care plan regarding alternatives in lieu of the safety concerns. The DON stated he will have a handbell that he can ring to alert staff that he needs assistance. Resident #6:On 5/7/2026 at 11:10 AM, Resident #6 touch pad call light was observed on the floor next to his dresser (by the foot of the bed). The resident was resting in bed at the opposite end of the bed, and the call light was not accessible to him. On 5/7/2026 at 11:30 AM, a review was conducted of Resident #6's records and it revealed he was admitted to the facility on [DATE] with diagnoses that included, Anoxic Brain Damage, Anxiety Disorder, Vascular Dementia, Diabetes, Hypertension. Further review of his care plan yielded the following: .have a soft touch call light that needs to be attached to my clothing as I allow. On 5/7/2026 at 1:10 PM, Resident #6 was still observed resting in bed with his eyes closed. His call light was observed still on the floor, next to the dresser toward at the opposite end of the bed. On 5/7/2026 at 3:10 PM, DON was taken to Resident #6's room- he was observed to be resting in bed. His touch pad call light was still at the foot of the bed by his dresser. The DON stated the call light should be within reach of the resident. The DON was informed this was the third observation of the resident with his call light in the same location throughout the day. A review was conducted of the facility policy entitled, Call Light Accessibility and Timely Response, reviewed 2.2.2026. The policy stated, .facility is adequately equipped with a call light at each residents' bedside.Staff will ensure the call light is plugged in, functioning, within reach of residents.The call system will be accessible to residents while in their room at bedside.

Based on observation and interview, the facility failed to have results of the most recent survey readily accessible to facility residents, their families, and their legal representatives.Findings Include:On 5/7/2026 at approximately 11:00 AM, Family Member A shared that for the past two weeks they have been unable to locate the survey results book. They stated It is typically located in the lobby, underneath the bulletin board, on a brown high-top table. The area the family member referenced was observed and there was no book/binder with the survey results located. Receptionist B (located just inside the main office) was queried if she knew where the survey results binder was relocated too? She reported it was on the high-top table in the lobby. She was informed it was not there. She searched for the book in her area and could not locate it. Receptionist B stated that she could not recall the last time she observed the survey results binder. She then contacted the Administrator regarding the location of the book.At approximately 11:20 AM, the survey binder had not been provided, and it was shared that the Administrator was bringing the survey book. The Administrator was observed with the survey book (reviewing the contents), and the DON (Director of Nursing) handed her the most recent 2026 survey results to add into the binder. On 5/7/2026 at approximately 11:40 AM, the survey binder was reviewed, the facility was surveyed in February 2026 for their annual recertification and those results along with their approved plan of correction were not in the book.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents who consume food from the kitchen. Findings include: On 2/10/2026, at 12:56 PM, During lunch dining observation, CNA Lwas observed carrying a resident's plate with their thumbs touching the inside of the plate nearly touching their food. Once CNA L set the plate down, they picked up a lidded cup for a resident and removed the lid. While CNA L removed the lid their hand touched all over the straw. CNA L filled the cup with juice, placed the lid/straw back on the cup and handed it back to the resident. CNA L did not perform hand hygiene and began assisting other residents with meal service. On 2/10/2026, at 1:15 PM, CNA K was observed sitting at a table assisting a resident with their lunch meal. CNA K stood up, pulled their pants up with their hands touching the inside of their waistband and skin. CNA K sat down and began to assist a resident with their meal by picking up their fork and offering bites of food. CNA K did not perform hand hygiene. On 02/11/2026 at 8:25am-8:54am observed meat slicer visibly soiled, located in the dry storage room. During this observation, Dietary Manager B was asked how often the meat slicer was cleaned and he stated the meat slicer isn't really used. On 02/11/2026 at 8:25am-8:54am observed the filter to the dishwasher booster pump leaking with a steady stream of water onto the floor. During this observation, Dietary Manager B was interviewed on the leaking filter, and he stated they are already aware of the leak, and it should be fixed by the end of this week. According to the FDA 2022 Food Code, 5-205.15 System Maintained in Good Repair, Improper repair or maintenance of any portion of the plumbing system may result in potential health hazards such as cross connections, backflow, or leakage. These conditions may result in the contamination of food, equipment, utensils, linens, or single-service or single-use articles. Improper repair or maintenance may result in the creation of obnoxious odors or nuisances and may also adversely affect the operation of warewashing equipment or other equipment which depends on sufficient volume and pressure to perform its intended functions. On 02/11/2026 at 8:25am-8:54am observed ready to use dishes stacked on each other with droplets of water running down the side of dish, located on the dish rack towards the back of the kitchen. According to the FDA 2022 Food Code, 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, Clean equipment and utensils . shall be stored: In a self-draining position that allows air drying. On 02/11/2026 at 8:25am-8:54am observed mixer visibly soiled with residue. When interviewed on how often the mixer is cleaned, Dietary Manager B stated it's cleaned every other day. According to the 2022 Food Code, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, Equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations, nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. On 02/11/2026 at noon-12:45pm during lunch observation, cut onions were observed sitting on a lid that was on top of the steam table. The cut onions were temped at 49 degrees F with Thermapen. During this observation, Dietary Manager B was asked what temperature the cut onions should be during lunch service, and he stated 40 degrees or lower. The Corporate Director of Food and Nutrition P was notified of the cut onion temperature and placed the cut onions on ice. According to the facility's policy on cold holding, Cold foods shall remain under refrigeration or on ice during meal service, to ensure that cold foods are served at no greater than 41 degrees F. According to the 2022 Food Code, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding, Except during preparation, cooking, or cooling, or when time is used as the public health control, time/temperature control for safety food shall be maintained: .at 5 degrees C (41 degrees F) or less. On 2/10/26 at 8:50 AM, the initial kitchen tour was completed with Activities Director A, the following was observed during the tour: 6 tier rack with 100+ ready for use pots/pans stored upon it, was riddled with visible, dried on thick gray dust particles and other unknown substances. Dietary [NAME] C stated the rack needed to be cleaned. Clean Rag Only trashcan had smudges of unknown substances and dirt particles on the lid and circumference of can. The pedal had a black rim around it. The bottom of two blue rolling carts utilized to transport cups and bowls was soiled with old food chucks, dust, and debris. Multitiered rack for insulated food protector lids was visibly soiled on the top two racks. The inside of the microwaves had brown circular stains, with food particles crumbs, unknown dried substances and smudges. Pop station: sliding cover to the ice (that chills the machine) had a brown substance covering the lid. The ice machine had a yellow/brown substance and multiple black speckles on inner white plastic lid. The black ledge had a creamy white substance that continued the length of the ledge. Juice dispenser gun was not enclosed and had white residue surrounding the circumference of it. Top of dishwasher had a white/cream/yellow particles covering it. Kitchen staff reported when the dishwasher is running its shakes and breaks particles from the ceiling loose which land atop the machine. Reach in Refrigerator: Outside it was smudged with prints and other particles. Three brown lunch bags that were undated. Activities Director A stated they were lunches for dialysis residents. Stack of sliced cheese that was undated. Dietary Aide D reported the cheese was for grilled cheese sandwiches and she was unsure why it was not dated as it typically is. Bottom of refrigerator had dried food, food chucks and other unknown food remnants. On the left side of the refrigerator from the top to the bottom was a thick (2-3 centimeter) crusted on, light brown substance. Cooler #1- the fan (that was no longer in use) was covered in brown grime. Directly below the fan was a box of hot dog buns and a box of hot dogs. The two blue fans covers were riddled in brown dust/debris. Dietary Aide D stated the fans should not look like that. One is not in use and never removed when the new fans were installed. She continued the old fan is difficult to clean. Freezer: The plastic entry transparent flaps was spackled with unknown particles. Cleaning logs that were contained in a blue binder were reviewed and they were all dated 2025. Dietary staff stated that is where the logs are kept and they were unsure where the 2026 forms were. On 02/10/2026 at 3:18 PM, an interview was conducted with Dietary Manager B regarding the observations made in the kitchen. He stated there are daily cleaning and deep cleaning logs that are completed by dietary staff. A review was conducted of cleaning schedules provided by the facility. The January 2025 and February 2025 cleaning logs had the 5 tuned into 6 on the logs so it reads January 2026 and February 2026. Manager B explained he utilized the 2025 template and changed the year. He was asked if he was aware of the days of the week did not match the date. Example February 10th is indicated as a Friday in 2026 when it is a Tuesday. He reported when he changed the template year, he did not look at the actual dates. Manager B shared the fans in the cooler should not have been soiled and since have been cleaned. He was not certain what the particles on the transparent flaps entering the freezer were. The multitiered racks for the dome lids and ready to use pots/pans were last cleaned a few months ago. The blue rolling carts he rarely sees the bottom of them but will add it to the tasks list to complete. The microwave is a daily cleaning task and should not have been in that condition. Manager B reported the ice machine was last cleaned in early January 2026 but has since been emptied and cleaned. The juice gun is supposed to be in a tray, and they soak the black plastic piece which makes is ashy. The ceiling in the dishwasher room had a hairline crack that was repaired but when the machine is running some debris breaks loose and falls atop the dishwasher. Review was conducted of Kitchen Cleaning Logs from November 2025- February 2026 and the logs were not consistently completed on a daily and/or weekly basis. Review was conducted of the Ice Machine Cleaning Log 2025/2026, the Ice machine was last cleaning on 1/2/2026.

Based on observation, interview, and record review, the facility failed to have1) An active plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility. 2) Adequate staff hand hygiene during dining service,3) Nursing staff to clean glucose monitors and equipment after use, resulting in the potential for the spread of organisms and infection to all residents and staff. Findings include:Record review of the 'Dining Room Meal Service' dated 1/16/2020 to improve the dining experience, residents in the main dining room will be served their meal restaurant style. (11.) Staff will use utensils provided to help setup/cut up food. Single use gloves may be used for items that cannot be set up with utensils. No bare hand food contact is allowed. Record review of the facility 'Dining Room Meal Service' policy dated 12/31/2024 revealed servers will serve by holding the side of the glass or by the handle of the cup. The hands of the server should never come in contact with the lip of the cup. blade of the knife, tongs of the fork, food contact surface of the spoon. Plates should be handled from the base and edges only. Record review of the facility 'Hand Hygiene' policy dated 4/14/2023 revealed that situations in which using soap and water or alcohol-based hand rub can be used: between direct contact with residents. Observation on 02/10/2026 at 12:10 PM of the main dining room noted 29 residents present, with 3 certified nurse assistants (CNA's) present and activity staff applying clothing protectors around residents' necks without hand washing between residents. Nurses in and out of room passing medications to residents seated at tables with other residents. On the menu pulled pork sandwich, vegetables, potato salad, cookies. Beverages offered and hand hygiene are offered to each resident upon entry with a hand wipe. Staff noted to move from resident to resident with no hand hygiene noted. Observation on 02/11/2026 at 8:40 AM of breakfast meal tray line. The Certified Nursing Assistances (CNAs) go from the kitchen window to the resident at the tables, do plate set-up and back to the window with no hand sanitizing/washing. CNAs put their hands into their pockets and then touch other items in the environment and then grab the next residents a meal/plate. Meal trays are not used so the staff have to touch each plate of prepared food. CNA K, CNA LL, nurse O, CNA M and CNA N. CNAs are serving the plates in the dining room. CNA K in gray scrubs with hoodie sweatshirt over puts her hands into her uniform pants pockets and then gets the next residents meal plate. Blood Glucose Monitors On 2/11/26 at 12:35 PM, an observation was made of the medication cart for the men's cart of the St [NAME] wing with Nurse T. The Nurse was observed to obtain blood glucose monitoring at the Resident's bedside. Upon returning to the medication cart, the Nurse replaced the glucose monitor back into the drawer of the medication cart without cleansing the monitor prior to returning it to the drawer. When asked about cleaning the monitor after use, the Nurse reported that it should have been cleaned. On 2/11/26 at 4:15 PM, an observation was made of Nurse S returning to the med cart after obtaining a Resident's blood glucose with the glucometer. The Nurse returned the glucometer into the drawer of the medication cart. The Nurse was asked what she used to clean the glucometer and indicated bleach wipes. When asked to see the bleach wipes when questioned if they were to use bleach wipes or the purple top Sani wipes, the Nurse returned to the Resident's room and reported she had used the soap in the bathroom. The soap in the bathroom was labeled as shampoo. When queried regarding what facility policy was to cleanse the glucometer after use, the Nurse reported she thought it was the Sani-wipes with the purple top container. On 2/12/26 at 10:40 AM, an interview was conducted with the Director of Nursing (DON), Administrator (NHA) and Corporate Staff. A review of facility policy with the DON and NHA was conducted regarding the cleaning of the glucose monitors after obtaining blood glucose readings. The DON reported that the Nurse was to use the purple top wipes, which was a Sani-Cloth germicidal disposable wipe, let it dry and return the monitor after obtaining glucometer readings. On 02/11/2026 at 9:55am observed a shut off drinking fountain with the bubbler removed, located near room [ROOM NUMBER]. On 02/11/2026 at approximately 10:40am observed a utility sink with one of the faucet levers broken off, located in the soiled utility room in [NAME] hallway. During this observation, Housekeeping Manager Q was asked if the utility sink is used and she stated that housekeeping doesn't use it. On 02/11/2026 at 10:43am observed a tub that appeared to be unused with supplies stored inside of tub, located in the shower room in [NAME] hallway. During this observation, Housekeeping Manager Q was asked if the tub is ever used and she stated that she hasn't seen it used, but she's not really sure. On 02/11/2026 at 10:47am observed a utility sink that appeared to be unused with a chair and an oxygen rack stored in the sink basin, located in the soiled utility room in St. Joe's hallway. During this observation, Housekeeping Manager Q was asked whether the utility sink is used, and she stated that housekeeping does not use it. On 02/11/2026 at approximately 1:00pm Maintenance Director R tested the chlorine with SenSafe Free Chlorine test strips and the result was zero at the hand sink located in the physical therapy room. On 02/11/2026 at approximately 1:00pm when interviewed Maintenance Director R on whether the utility sinks located in the soiled utility rooms are flushed, he stated he isn't sure because he just started working at the facility 4 days ago. Upon record review of the facility's flushing logs given at the time of survey, the only areas flushed once a week are the janitor's closet, bathroom in first room, and priest hall P3 and P4. In addition, the hot water tanks are flushed for 30 seconds on a monthly basis. According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, Eliminate dead legs, which are sections of no- or low-water flow. According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, Ensure disinfectant residual is detectable throughout the potable water system. According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, Flush low-flow piping runs and dead legs at least weekly. Flush infrequently used fixtures (e.g., eye wash stations, emergency showers) regularly as needed to maintain water quality parameters within control limits.

Based on observation and record review, the facility failed to ensure that appropriate backflow prevention was installed at plumbing fixtures, resulting in the potential for contamination to the water supply, affecting all residents. Findings include:On 02/11/2026 at 8:25am-8:54am observed spray nozzle downstream of a hose bib vacuum breaker, located in the dishwasher area. On 02/11/2026 at approximately 10:29am-10:40am during the housekeeping tour with Housekeeping Manager Q, observed a utility sink and an attached hose with a chemical feed downstream of an atmospheric vacuum breaker, located in the wheelchair washing station room.On 02/11/2026 at 1:07pm observed a spray nozzle downstream of an atmospheric vacuum breaker on an outside spigot, located in the courtyard.According to the 2008 Cross Connection Manual on atmospheric vacuum breakers, AVBs shall not be installed where they will be under continuous pressure for more than 12 hours (i.e. no downstream shutoff valve).According to the 2008 Cross Connection Manual on chemical feeder backflow prevention, Another concern with a hose being run from a faucet to the dispenser is that many times a valve is installed on the hose downstream of an AVB, which is not allowed since AVBs cannot be subject to continuous pressure.

Based on interview and record review, the facility failed to provide nursing services for 9 residents (#19, #48, #42, #58, #93, #83, #84, #86, #89) residing on the [NAME] Nursing Unit, resulting in residents to missing medications, blood glucose monitoring, skilled charting assessments and vital signs. Findings include: Resident #48 On 2/11/2026, at 12:27 PM, a record review of Resident #48's electronic medical record revealed an admission on [DATE] with diagnoses that included Diabetes Type 2, Stroke with speaking difficulty, Alzheimer's and Hypertension. A record review of Resident #48's MEDICATION ADMINISTRATION RECORD 2/1/2026 – 2/28/2026 revealed the following missed nursing care and medications on the day of 2/9/2026: AmLODIPine Beaylate Oral Tablet 2.5 MG (Amlodipine Besylate) Give 1 tablet by mouth one time a day for HTN Aspirin 81 MG Tablet chewable Give 1 tablet by mouth one time a day for Health & Wellness Cholecalciferol Oral Tablet 50 MCG (2000 UT) (Cholecalciferol) Give 1 capsule by mouth one time a day for supplement Donepezil HCI Oral Tablet 10 MG (Donepezil Hydrochloride) Give 1 tablet by mouth in the morning for Alzheimer's Insulin Glargine Subcutaneous Solution 100 UNT/ML (Insulin Glargine) Inject 15 unit subcutaneously one time a day for DMII Lipitor Oral Tablet 40 MG (Atorvastatin Calcium) Give 1 tablet by mouth in the evening for High Cholesterol Vitamin B 12 Oral Tablet 500 MCG (Cyanocobalamin) Give 2 tablet by mouth one time a day for supplement Acetaminophen Oral Tablet 500 MG (Acetaminophen) Give 2 tablet by mouth three times a day for pain The pain medication was missed for three consecutive doses 0800 1300 1700 Gabapentin Oral Capsule 300 MG (Gabapentin) Give 1 capsule by mouth three times a day for Pain The medication was missed for three consecutive doses 0800 1200 1600 (4:00PM) Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) Inject 4 unit subcutaneously before meals for DMII. Nurse E did not check Resident #48's glucose level nor give the scheduled insulin for three consecutive doses/glucose checks 0700 1100 1600 (4:00 PM). On 2/11/2026, at 12:40 PM, a phone interview was conducted with Nurse E. Nurse E was asked to explain why they did not pass medications including insulin and did not perform glucose checks for Resident #48 and Nurse E explained that at the start of the shift they were busy with another resident's concerns with needing to call the physician for labs/orders. Nurse E offered, they went back to passing medications and then got a new resident to admit which put them even more behind. Nurse E was questioned if they asked for help with their late medication pass and Nurse E stated, I should have reached out for help and that management did ask if they needed help but then Nurse E stated, that they were just busy. Nurse E was asked when they talked to the physician if they alerted of the missed medications for Resident #48 and Nurse E stated, No they did not tell the physician of the missed medications. On 2/11/2026, at 1:05 PM, a record review along with Unit Manager (UM) F of Resident #48's Medication Administration Record which revealed multiple missed medications including missed glucose levels and insulin on the date of 2/9/2026. UM F offered, they were working that day and asked Nurse F if they needed help with Nurse E refusing the need for help. Resident #93 On 2/12/2026, at 10:56 AM, a record review of Resident #93's electronic medical record revealed an admission 1/30/2026 with diagnoses that included Urinary tract infection, cellulitis of left lower limb and encephalopathy. A review of the Medication Administration Record 2/1/2026 – 2/28/2026 revealed the following missed medications on 2/9/2026: Ferrous Sulfate Oral Tablet 325 (65 Fe) MG (Ferrous Sulfate) Give 1 tablet by mouth one time a day for Supplement Folic Acid 400 MCG Tablet Give 3 tablet by mouth one time a day for Supplement Magnesium Oxide Tablet 400 MG Give 1 tablet by mouth one time a day for supplement Omeprazole 40 MG Capsule delayed release Give 1 tablet by mouth one time a day for GERD (gastroesophageal reflux disease) oxybutynin Chloride ER Oral Tablet Extended Release 24 Hour 5 MG (Oxybutynin Chloride) Give 1 tablet by mouth one time a day for Urinary Retention prednisone Oral Tablet 10 MG (Prednisone) Give 1 tablet by mouth one time a day for allergic reaction for 7 days Vitamin B-12 500 MCG Tablet Give 1 tablet by mouth one time a day for supplement Benadryl Allergy Capsule 25 MG (diphenhydramine HCI) Give 1 tablet by mouth two times a day for allergic reaction for 7 days Bumetanide Oral Tablet 2 MG (Bumetanide) Give 1 tablet by mouth two times a day for Edema Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol Tartrate) Give 0.5 tablet by mouth two times a day for HTN Potassium Chloride ER Oral Tablet (Extended Release 10 MEQ (Potassium Chloride) Give 1 tablet by mouth two times a day for Supplement The medication was not administered by Nurse E for two consecutive doses 0900 1300 (1:00 PM). The record review revealed Nurse E did not complete the pain assessment, vital signs assessment and obtain the physician ordered weight assessment on 2/9/2026. Resident #19 On 2/12/2026, at 10:59 AM, a record review of Resident #19's electronic medical record revealed an admission on [DATE] with diagnoses that included trimalleolar fracture, cellulitis of left lower leg and pneumonia. A review of the MEDICATION ADMINISTRATION RECORD 2/1/2026 – 2/28/2026 revealed the following missed medications for the day of 2/9/2026: bupropion HCI ER (XL) Oral Tablet Extended Release 24 Hour 150 MG (Bupropion HCI) Give 150 mg by mouth in the afternoon for Depression Vitamin-B Complex Oral Tablet (B-Complex Vitamins) Give 1 tablet by mouth in the evening for vitamin On 2/12/2026, at 1:06 PM, Nurse E was further interviewed regarding their workday on 2/9/2026. Nurse E was asked why they documented missed med administration time due Med to late to administer due to admit, resident problems and concerns, etc and Nurse E offered, they got busy and wasn't able to administer the residents' medications. Nurse E was again asked if they alerted the Physician of the multiple residents with missed cares and medications and Nurse E stated, No. Nurse E was not unsure if they had passed on the information for the oncoming nurse. Resident #58 On 2/12/2026, at 11:15 AM, a record review of Resident #58's electronic medical record revealed an admission on [DATE] with diagnoses that included Diabetes Mellitus, Hypertension Major Depressive Disorder. A review of the MEDICATION ADMINISTRATION RECORD 2/1/2026 – 2/28/2026 revealed the following missed care/medications on 2/9/2026: Aspirin 82 MG Tablet chewable Give 1 tablet by mouth one time a day for Prevention Glimepiride Oral Tablet 2 MG (Glimepiride) Give 2 tablets by mouth in the morning for Type two diabetes with breakfast hydrochlorothiazide Oral Tablet 25 MG (Hydrochlorothiazide) Give 1 tablet by mouth with meals for HTB Take with food or milk Losartan Potassium Oral Tablet 100 MG (Losartan Potassium) Give 1 tablet by mouth one time a day for HTN Steglatro 15 MG Tablet Give 1 tablet by mouth one time a day for Type 2 diabetes Metformin HCI Oral Tablet 1000 MG (Metformin HCI) Give 1 tablet by mouth two times a day for Type two diabetes Take twice a day with meals Nurse E failed to provide this medication for two consecutive doses 0800 1700. Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol Tartrate) Give 1 tablet by mouth two times a day for HTN Multivitamin Tablet Give 1 tablet by mouth two times a day for supplement Cabidopa-Levodopa Oral Tablet 25-100 MG (Carbidop-Levodopa) Give 1 tablet by mouth three times a day for parkinsons Nurse E failed to administer two consecutive doses 0800 1200. House Med Pass Supplement three times a day 120 ml Nurse E failed to administer three consecutive doses 0900 1300 1700. Resident #42 On 2/12/2026, at 11:21 AM, a record review of Resident #42's electronic medical record revealed an admission on [DATE] with diagnoses that included stroke, dysphagia and Diabetes Mellitus with foot ulcer. A review of the MEDICATION ADMINISTRATION RECORD 2/1/2026 – 2/28/2026 revealed the following missed care/medications on 2/9/2026: amlodipine Besylate Oral Tablet 10 MG (Amiodipine Besylate) Give 1 tablet by mouth one time a day for HTN (hypertension) Aspirin Oral Tablet Chewable 81 MG (Aspirin) Give 1 tablet by mouth one time day for CVA (stroke) Clopidogrel Bisulfate Oral Tablet 75 MG (Clopidogrel Bisulfate) Give 1 tablet by mouth one time a day for CVA) House Liquid Protein one time a day for wound healing 30 cc per peg Losartan Potassium Oral Tablet 50 MG (Losartan Potassium) Give 1 tablet by mouth in the morning for HTN Omeprazole 40 MG Capsule delayed release Give 1 capsule by mouth one time a day for GERD (Gastroesophageal reflux disease) Zine Oral Tablet 50 MG (Zinc) Give 1 tablet by mouth one time a day for wound healing Carvedilol Oral Tablet 12.5 MG (Carvedilol) Give 1 tablet by mouth two times a day for htn HYDROcodone-Acetaminophen Oral Tablet 5-325 MG (Hydorcodone-Acetaminophen) Give 1 tablet by mouth two times a day for Pain Insulin Lispro Injection Solution (Insulin Lispro) Inject as per sliding scale . subcutaneously two times a day for DM give with lunch and dinner only metformin HCI Oral Tablet 500 MG (metformin HCI) Give 1 tablet by mouth two times a day for DM Type 2 Acetaminophen Oral Tablet 500 MG (Acetaminophen) Give 2 tablet by mouth three times a day for foot pain ok to give with gabapentin This medication was missed for three consecutive doses 0900 1300 (1:00 PM) 1700 (5:00 PM) Gabapentin Oral Tablet 400 MG (Gabapentin) Give 1 tablet by mouth three times a day for nerve pain) This medication was missed for three consecutive doses 0900 1300 1700 Nurse E failed to assess Resident #42's glucose checks for that day and their skin assessment. On 2/12/2026, at 11:28 AM. The Director of Nursing (DON) was alerted of the record review of multiple residents with missed nursing care on 2/9/2026 by Nurse E. The DON offered that they had just completed Nurse E's yearly competency. Record review of the facility 'Abuse' policy dated 5/24/2023 revealed residents have the right to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of resident property . Definition of Neglect: Failure of the facility, it's employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Mistreatment: Inappropriate treatment or exploitation of a resident. Record review of the facility 'Medication Administration' policy dated 2/3/2026 revealed to safely and accurately prepare and administer medication according to physician order, professional standards of practice, and resident needs . Administer medication in accordance with frequency prescribed by physician and standards of practice. Record reviews of the facility 'Resident Rights' policy dated 2/4/2026 revealed that residents had the right to be free from abuse and neglect, have equal access to quality care and be free from discrimination, be informed of and participate in their care planning and treatment, and reasonable accommodation of needs and preferences. Right to be fully informed of their medical condition, of any changes in their condition, and treatment plan . Resident #83: Observation and interview on 02/12/2026 at 10:40 AM of Resident #83 revealed the resident was observed seated up in a wheelchair in the main dining room at table with other residents waiting for the noon meal. Observed a urinary catheter bag at chairside with privacy leaf coverage. In an interview with Resident #83 stated that he was admitted for physical therapy and strengthen. Record review of Resident #83's nursing progress notes dated 1/9/2026 at 5:41 PM documented by Licensed Practical Nurse E noted acetaminophen 500mg give 2 tablets by mouth three times a day for pain, missed med administration time due to medication too late to administer due to admission, resident problems and concerns, etc. Bethanechol chloride 25mg tablet by mouth three times a day for urinary retention, missed med administration time due to medication too late to administer due to admission, resident problems and concerns, etc. House Med Pass Supplement three times a day 120ml missed med administration time due to medication too late to administer due to admission, resident problems and concerns, etc. There were no notes that the physician, resident/resident representative were notified of missed skilled charting assessment or missed medications. Record review of Resident #83's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the month of February 2026 revealed that on 2/9/2026 day shift of Resident #83 noted no weekly weight obtained, missed medication administrations of Ferrous Sulfate (Iron) 325 mg one tablet by mouth two times day for anemia 5:00 PM dose not given. Acetaminophen 500mg, two tablets by mouth three times a day for pain, no dose given at 12:00PM (noon) and no pain evaluation assessment at that time. Bethanechol chloride 25mg tablet by mouth three times a day for urinary retention, missed dose at 12:00PM (noon). House Med Pass Supplement three times a day 120ml missed doses at 1:00PM and 5:00PM. Resident #84: Observation and interview on 2/10/2026 during the initial screening process of the annual healthcare survey of Resident #84 revealed an elderly male with indwelling catheter lying in bed. Resident #84 stated that he had only been at the facility three weeks or so. Record review of Resident #84's nursing progress notes dated 1/9/2026 at 5:38PM documented by Licensed Practical Nurse E noted Skilled charting every shift 'Missed med administration time due to late to administer due to admit (admission), resident problems and concerns, etc. There were no notes that the physician, resident/resident representative were notified of missed skilled charting assessment or missed medications. Record review on 02/12/2026 at 10:20 AM of Resident #84's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the month of February 2026 revealed that on 2/9/2026 day shift of Resident #84 had no blood pressure or vital signs documented or skilled charting every shift. Resident #86: In an observation and interview on 02/10/2026 at 11:53 AM with Resident #86 was noted to by lying in bed partially covered with a brief on. Resident #86 had complainants of short staffing in the afternoons and getting the medication from the nurse should only take 45 minutes and he's having to wait 3-4 hours, or they don't come at all. Observation of a bile duct collection bag lying on the bed next to resident with a brown fluid substants being collected. Resident #86 stated that the staff do empty the bag when it gets half full. Record review of Resident #86's nursing progress notes dated 1/9/2026 at 4:45 PM documented by Licensed Practical Nurse E noted Rifaximin oral 200mg anti-infective/antimicrobial agent med too late to administer due to admit and other resident problems. On 2/9/2026 at 4:47 PM Midodrine 10 mg vasopressor blood pressure medication, med too late to administer due to admit and other resident problems. Noted on 2/9/2026 at 6:07 PM Resident #86 Skilled charting every shift missed med administration time due to med too late to administer due to admit (admission), resident problems and concerns, etc. There were no notes that the physician, resident/resident representative were notified of missed skilled charting assessment or missed medications. Record review on 02/12/2026 at 10:32 AM of Resident #86's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the month of February 2026 revealed that on 2/9/2026 day shift of Resident #86 had no skilled charting for the shift, no supplemental med pass given at 1:00 PM dose, no blood pressure documented and missed Midodrine blood pressure medication. Rifaximin anti-infective/antimicrobial agent medication, no 1:00 PM methocarbamol scheduled pain medication. Resident #89: Observation and interview on 02/10/2026 at 12:06 PM with Resident #89 revealed the resident was receiving oxygen 4 liters nasal canula via concentrator while lying in bed on top of the covers. Resident #89 stated that he had no concerns at that time. Record review of Resident #89's nursing progress notes dated 1/9/2026 at 6:05 PM documented by Licensed Practical Nurse E noted vital signs every shift for 3 days and then daily every shift for monitoring, missed administration time due to med too late to administer due to admission, resident problems and concerns, etc. There were no notes that the physician, resident/resident representative were notified of missed skilled charting assessment or missed medications.

Based on observation, interview and record review, the facility failed to label medications appropriately, dispose of expired medications, ensure the safe storage of medication and supplies, and ensure unlicensed staff did not have access to medication storage areas, for two of four medication carts and one of two medication rooms reviewed for medication storage and labeling. Findings include:On 2/11/26 at 12:04 PM, an observation was made by the 100 Hall, at the Nurses' Station, staff came into the area with a cart of supplies and asked a Nurse for the keys to the medication storage area. An observation was made with Nurse T of the medication room prior to staff coming up to the Nurses' Station requesting the keys to the medication storage area. The medication room had been accessed to acquire medication during the medication administration task for the survey. The room was empty at the time the staff requested the keys from the Nurse. An observation was made of the keys being given to the staff, who unlocked the med room door, went into the medication room, and the door closed behind the staff. An observation was made of the Nurse not accompanying the staff into the medication room. An observation was made of the staff coming out of the medication room with the cart of items and gave the keys back to the Nurse. On 2/11/26 at 12:35 PM, an observation was made of the medication cart for the men's cart of the St [NAME] wing with Nurse T. An observation was made of a box of Tagamet, opened, with an expiration date of 6/2025. The Nurse removed the medication to dispose of the expired medication. An open Ventolin Inhaler was not labeled with an open date, the expiration date on the sticker of the bag was dated 11/12/25. The Nurse reported that there should be an open date on the inhalers when opened. An observation was made of a Combivent inhaler that was opened without an open date documented on the inhaler. On 2/11/26 at 4:11PM, an observation was made at the Madona hall Nurses Station of a Resident behind the Nurses' Station eating. The Resident was in a wheelchair and propelled herself back and forth. There were other Residents and staff in the area. The staff left the area with the Resident behind the desk with her food. The Resident was near a medication cart that was positioned against a wall at the Nurses' Station. The medication cart was unlocked, not secured and there was not a nurse in the vicinity of the medication cart. Another Resident was in a wheelchair near the wall where the medication cart was positioned. When Nurse S returned to the area, the Nurse was informed of the unsecured medication cart and proceeded to lock the cart. On 2/11/26 at 4:17 PM, an observation was made with Nurse S of the Madona Men's medication cart during the medication storage task of the survey process. An observation was made of TB (tuberculosis) skin test solution for TB screening multidose vial stored in the drawer of the medication cart. There was not an open date on the vial. The Nurse was asked and had reported there should be a date when it was opened. When asked if the vial should be stored in the refrigerator, the Nurse was unsure. The box indicated refrigeration temperatures. An observation was made of an insulin pen stored in the drawer that did not have a Resident's name or when it was opened. The Nurse reported insulin should be dated when opened. The Nurse reported the insulin looked empty and threw it in the sharps container. A nasal spray that was opened had a sticker for a date, but no date was documented on the sticker. The Nurse reported the nasal spray should have an open date recorded on the sticker. An Enulose bottle was opened and did not have an open date documented on the bottle, the Nurse was unsure if the container needed an open date. UTI Heal supplement was dirty with dried supplement in multiple streaks down the bottle. The supplement was stored with other bottles of liquid medications and supplements. On 2/11/26 at 4:25 PM, an interview was conducted with Unit Manager F regarding observation concerns regarding the Madona Men's medication cart. The Unit Manager reported that the TB skin test solution should be stored in the refrigerator and a review of facility policy of labeling multi dose vials of the TB should have an open date and the Enulose should have an open date on the bottle. On 2/11/26 at 4:50 PM, an observation was made with Unit Manager, Nurse F of the medication storage room of the Madona hall area. An observation was made of two culture swabs with an expiration date in 2024. The Unit Manager removed the culture swabs. An observation was made of a bag of medication cards with medications in the cards stored in an open bag on the floor next to the medication storage system. The Unit Manager indicated they should not be stored on the floor and that the bag was for pharmacy to take back and contained multiple cards of medications that were to be returned to pharmacy. The Unit Manager was asked about who was allowed in the medication room. The Unit Manager reported that the two nurses, Unit Manager and the DON (Director of Nursing) have keys to the medication room, and the room is restricted to Nurses and stated, Other staff should have a nurse with them. When asked about the staff with the cart of supplies, the Unit Manager reported that Central Supply Staff should be with a nurse to stock and stated, The nurse should not hand over the keys to get into the med room. A review of the facility policy titled, Medication Administration, reviewed 2/3/26 revealed, .General Instructions: Keep medication cart clean, organized, and stocked with adequate supplies; Cover and date fluids and food; .Lock medication cart when not in direct view of nurse administering medications.

Based on interview and record review, the facility failed to honor one resident's (Resident #25) wishes to discontinue a medication and obtain an informed consent for a dosage change of one resident reviewed for choices.Findings include:Resident #25: On 2/10/26 at 10:15 AM, Resident #25 reported while she has enjoyed her time at the facility, there are some medications she has iterated to the facility that she does not want to be administered but they still give them to her. She reported Sodium Bicarbonate and Escitalopram Oxalate (Lexapro). Resident #25 shared she does not have issues with heart burn, indigestion, or depression. She stated she has never been depressed, denied suicidal ideations, homicidal ideations and other signs/symptoms of depression. Resident #25 stated she has much to live for and look forward to On 2/11/2026 at 1:33 PM, a review was conducted of Resident #25's medical record and it indicated she was admitted to the facility on [DATE] with diagnoses the included, Heart Disease, Major Depression, Diabetes, Kidney Disease and Hypertension. Resident #25 is her own person and able to make her needs known to facility staff. Further review yielded the following:Physician Orders:Lexapro (Antidepressant medication):Initially ordered on 9/15/2024 at 10 MG (milligrams) once daily and gradual dose reduction was completed on 3/6/2025 to 5 MG once daily. Sodium Bicarbonate Oral Tablet 650 MG-give 2 tablets by mouth two times a dayOrdered on 9/15/2024 January 2026 MAR (Medication Administration Record):Resident #25 refused Sodium Bicarbonate 13 times February 2026 MAR:Resident #25 refused Sodium Bicarbonate 14 times Progress Notes:There was nothing located in the progress notes from March 2025 that a discussion was held when Resident #25 regarding her dosage of Lexapro dose being lowered. Resident #25 was not granted the opportunity to express that she no longer wanted to be on the medication. Behavior Charting:There were no behavior charting within the last 30 days that is indicative of any signs/symptoms of depression. Furthermore, the resident is not followed by the contacted psychiatric group. Social Services Assessments:9/16/2025: PHQ--9 score:-4 (none- minimal)12/15/2025: PHQ-9 score: 0Questionnaire conducted for depression screening. Scoring ranges from 0-27 with 0-4 being none -minimal depression severity and 20-27 being severe depression severity. On 02/11/2026 at 1:43 PM, Corporate Social Worker J reported Resident #25 admitted on Lexapro 10 MG and it was decreased in March 2025 to 5 MG. A review was conducted of her chart for a risk verse benefits or informed consent for antidepressant medication monitoring but there was nothing located. On 2/11/2026 at 4:30 PM, Unit Manger G explained the Sodium Bicarbonate was initiated in 9/2024 and she was aware the resident no longer wanted to be on the medication and she has been refusing it. She reported it was on her list to speak to the physician regarding discontinuing the medication. Review was conducted of the facility policy entitled, Psychotropic Medication Use, reviewed 2.3.2025. The policy stated, The Social Service employee, or designee will review the medication prescribed, dosage, side effects, and risk versus benefits of the medications, which are outlined on the psychotropic informed consent evaluation. Review was conducted of the facility policy entitled, Resident Rights, reviewed 2.4.2024. The policy stated, .Right to self-determination to.to request, refuse, and/or discontinue treatment.Right to be fully informed of: their medical condition, of any changes in their condition, and treatment plan.

Based on observation, interview and record review the facility failed to timely refill one resident's (Resident #50) Sevelamer (medication used to control high blood levels of phosphorous) of five residents reviewed for dialysis, resulting in Resident #50 being without the medication since approximately January 17, 2026.Findings IncludeResident #50: On 2/10/2026 at approximately 9:15 AM, Resident #50 was observed in his room. He stated he was waiting to be transported to dialysis. Resident #50 was his own person and able to make his needs know to facility staff. Further review of his records yielded the following: On 2/10/2026 at approximately 3:00 PM, a review was conducted of Resident #50's medical record and it indicated he was admitted to the facility on [DATE] with diagnoses the included, Malignant Neoplasm of Prostate, Congestive Heart Failure, Diabetes, End Stage Renal Disease and Atrial Fibrillation. Further review was conducted of this chart and yielded the following:January and February 2026 MAR (Medication Administration Record):Sevelamer Carbonate Oral Tale- 800 MG (milligrams)- take one table by mouth three times a date for Hypophosphatemia.The code 07 was listed 18 times in January 2026 and 19 times in 2026. The code indicated see progress notes. Progress Notes:1/17/2026 at 10:15: Sevelamer Carbonate Oral Tablet 800 MG for Hyperphosphatemia sent memo to dialysis asking re: process for refilling Sevelemer-no response yet for direction.1/18/2026 at 10:18: Sevelamer Carbonate Oral Tablet 800 MG Give 1 tablet by mouth three times a day for Hyperphosphatemia will re- send memo to dialysis tomorrow for advice re: obtaining refills on Sevelemer.1/21/2026 at 08:46: Sevelamer Carbonate Oral Tablet 800 MG for Hyperphosphatemia re-attempting to get direction from dialysis for procedure to re-order med.1/21/2026 at 17:01: Sevelamer Carbonate Oral Tablet 800 MG for Hyperphosphatemia no response received re: obtaining refills.1/22/2026 at 12:23: Sevelamer Carbonate Oral Tablet 800 MG for Hyperphosphatemia no info received yesterday from dialysis.1/25/2026 at 11:07: Sevelamer Carbonate Oral Tablet 800 MG for Hyperphosphatemia n/a (not available).1/25/2026 at 12:22: Sevelamer Carbonate Oral Tablet 800 MG for Hyperphosphatemia n/a (not available).1/25/2026 at 16:40: Sevelamer Carbonate Oral Tablet 800 MG for Hyperphosphatemia n/a (not available).1/26/2026 at 08:30: Sevelamer Carbonate Oral Tablet 800 MG for Hyperphosphatemia - na- note sent to dialysis- unit manager aware.1/26/2026 at 12:07: Sevelamer Carbonate Oral Tablet 800 MG for Hyperphosphatemia na ( not available).1/26/2026 at 16:27: Sevelamer Carbonate Oral Tablet 800 MG for Hyperphosphatemia Resident did not return from dialysis with refills- manager aware.1/26/2026 at 16:43: Communication received from dialysis center stating their dietary will order sevelamer for resident.2/2/2026 at 08:07: Sevelamer Carbonate Oral Tablet 800 MG.Not available/manager aware/note to dialysis.2/2/3036 at 12:10: Sevelamer Carbonate Oral Tablet 800 MG.not available.2/2/2026 at 17:23 Sevelamer Carbonate Oral Tablet 800 MG.not available.2/4/2026 at 07:58: Sevelamer Carbonate Oral Tablet 800 MG.Once again, requesting info with dialysis paperwork re: refills procedure.2/5/2026 at 12:03: Spoke with R.D (Registered Dietitian) from [NAME] Dialysis re: Renvela refills. He will contact.pharmacy and have product shipped to this facility. [NAME] stated that it often takes about a week or slightly more to place order and receives shipment. Unit manager notified of solution.2/9/2026 at 10:05: Sevelamer Carbonate Oral Tablet 800 MG.not available-manager aware.2/9/2026 at 16:50: Sevelamer Carbonate Oral Tablet 800 MG .na.2/10/2026 at 13:01: Sevelamer Carbonate Oral Tablet 800 MG.Awaiting delivery-placed by dialysis RD. Resident #50 was without medication since mid- January with no intervention from facility management. The MAR was not consistent in the documentation of the resident being without the medication, but it was evident from the progress notes and interviews the resident did not have the medication. Its unknown why the MAR medication was not consistent. Practitioner Notes:There was nothing listed in the progress regarding Resident #50 not receiving his Sevelamer since mid-January 2026. Dialysis Communication Sheets:1/26/2026: .Dietary will call in rx Sevelamer.2/2/2026: .Still has not received Sevelamer in weeks.2/4/2026: Needs refill on Sevelamer, Called # on Rx bottle and they couldn't help.need clinic ID.2/9/2026: .Still has not received Sevelamer. On 2/11/2026 at 10:51 AM, an interview was conducted with Nurse H regarding Resident #50's Sevelamer. The nurse reported he does not have the medication but there are two other residents that have the same medication/dosage within the cart. The medication was observed in the presence of Nurse H and there was no Sevelamer located in the cart for Resident #50.Nurse H shared she contacted the pharmacy number on the bottle to refill the medication but was unsuccessful as they required the dialysis clinic number which she did not have. She then contacted the dialysis unit and was informed she needed to speak to their dietitian, but he was not in. When Nurse H did speak to the dietitian he stated he would reorder the medication, but it would take about a week or a little more to be delivered to the facility. On 02/11/2026 at 12:05 PM, an interview was conducted with Registered Dietitian I regarding Resident #50's Sevelamer. He reported the medication has been ordered through the dialysis pharmacy and then will be mailed to the facility. The medication is a phosphate binder and maintains the phosphorus levels for the resident. He stated he did recently order the medication, but it takes about 5-7 business days for it to be processed and arrive at the facility. He reported the facility would need to contact him prior to the medication being depleted to reorder it. On 02/11/2026 at 4:23 PM, Unit Manager G reported Resident #50's Sevelamer is ordered from his dialysis unit pharmacy and not theirs. She became aware he did not have the medication last week and that is when they were able to get it ordered. Manager G was asked if she has followed up on and she stated she had not as it slipped her mind. Manager G was informed that according to facility charting it appears he has been without the medication since about 1/17/2026. The facility policy entitled, Hemodialysis, reviewed 2/3/2026. The policy stated, .The licensed nurse will collaborate with the physician to ensure medications are given per physician's order which may include medications given at the dialysis facility, medications send with resident to take while at the dialysis facility, adjustment of medication times on dialysis days, medications held on dialysis days, etc.

This citation pertains to Intake Number 2721708 and the recertification survey. Based on observation, interview and record review, the facility failed to provide adequate nursing staff to ensure that the needs of their residents were met for 7 residents (#16, #40, #41, #43, #51, #87, #88) and residents identified through confidential family interviews, resulting in insufficient and unmet resident care needs, feelings of frustration, and complaints about not enough staff. Findings include: Record review of the facility 'Staffing' policy dated 4/18/2025 revealed the facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for the residents in accordance with the residents' plans of care. licensed nurses and nursing assistants are available 24 hours a day, seven days a week to provide competent resident care services including: attaining or maintaining the highest practicable level of physical, mental, and psychosocial well-being of the residents, assessment, evaluating, planning and implementing resident care plans, responding to resident needs. Minimum staffing requirements imposed by the state, if applicable, are adhered to when determining staff ratios but are not necessarily considered a determination of sufficient and competent staffing. Record review on 02/11/2026 at 11:41 AM of Intake 2721708 complaint of short staffing. Pre-survey prep noted facility triggered 4th quarter PBJ, and multiple resident complaints during initial interview screening of long call lights for afternoon shift, staff turning off the light and not providing service, saying I'll be right back, and do not come back'.In an observation and interview on 02/10/2026 at 10:39 AM with Resident #41 had multiple concerns of no stomach pills for gas, and no diarrhea pills, just the liquid form. Observation of the residents' right upper arm Peripheral Inserted Central Catheter (PICC) dressing dated 2/7/2026, also has a dialysis port to right chest area, and goes to hemodialysis every Monday-Wednesday-Friday to the dialysis center. Resident #41 stated that they came to the facility for rehab therapy, but didn't go to the therapy gym today, Resident #41 can also do the exercises in his room. Intravenous Antibiotic Micafungin 150mg IV every morning for 21 days. Resident #41 stated that Some days there are enough helpers and other times there is none, its [NAME] or famine. In an interview on 02/10/2026 at 11:29 AM with Resident #16 revealed that the staffing is low especially on the afternoon shift, they just disappear. Resident #16 stated that she is supposed to get her brief checked or changed every 2 hours and some days it's 4 or 6 hours. Resident #16 stated that she had messed/soiled her pants waiting for staff. Resident #16 stated that she put the call light on at 8:30PM and it was bedtime before anyone came in to change her and get her ready for bed. Resident #16 stated that it was verified by the call lights. I have been here 5 years, it used to be better, that's why I chose this nursing home. The change in staffing came with the new management. The facility says that they are meeting the state requirements, but they are not meeting the residents' needs. In an observation and interview on 02/10/2026 at 11:38 AM with Resident #87 was observed with a left upper arm Peripheral Inserted Central Catheter (PICC) line dressing dated 2/9/2025 and occlusive. Resident #87 stated that she had an infection in her right foot. Resident #87 Complained about call light wait times of 2 hours, she agrees with her roommate on call lights take too long, and the facility was short staffed. In an interview on 02/10/2026 at 11:46 AM with Resident #51 was asked about the facility staffing being timely in response. Resident #51 stated the afternoon shift is scarce, they waited 2 hours with the call light on, they had brought the wrong lunch, the resident can only eat certain foods. The resident #51 stated he understood, having to wait his turn and having no problem with that. But when they come in and shut the light off and don't come back. The afternoon shift is the worst for not responding to the call lights. In an interview on 02/10/2026 at 11:51 AM with Resident #43 revealed that the afternoon shift takes longer to get the call lights answered. In an interview on 02/10/2026 at 1:25 PM with Resident #40 stated that they wait for over an hour, and their room is pretty close to nurse station. The aides will come in, shut the light off and not help me, if I close my eyes because I wait so long that they come in and shut off the light and don't ask what it was on for. They had to tell the aides not to use their phones in the resident care areas, because they would be on their phones and not helping us with our care. It's the first and second shift aides that just don't care, they take a long time to respond to our needs. Record review of the resident council meeting notes for 6 months revealed concerns with:August 2025- Nursing concerns that resident showers are not getting done.September 2025- Nursing concerns that Certified Nurse Assistance (CNA) saying they will be right back, but don't come back, showers are not getting done or made up. October2025- Nursing concerns that CNAs are talking on their phones and earbuds during care, all residents. Residents are not being checked and changed every 2 hours, causing them to pee through their briefs and leave puddles on the floor. After being put to bed residents don't see any CNAs the rest of the night. Residents are being doubled brief.November 2025- Residents not getting showers and hair washed. December 2025- CNAs keep disappearing out of the dining room during mealtimes. Staff sit plates down and do not help set food up. Resident left in dining room after meals. Not getting what's on the meal ticket or getting things crossed offJanuary 2025- Not enough CNAs in the dining room during meals. Record review of the facility 'Resident Council Meetings' policy dated 11/1/2020 revealed the facility supports the right of residents to organize and participate in resident groups in the facility . Definition: Resident group is defined as a group of residents that meet regularly to discuss and offer suggestions about facility policies and procedures affecting resident care, treatment, and quality of life; support each other; plan resident and family activities; participate in educational activities; or for any other purpose . (7.) The facility shall act upon concerns and recommendations of the council, make attempts to accommodate recommendations to an extent practicable, and communicate its decisions to the council .Record review of the 'Facility Assessment' dated 8/14/2025 revealed staffing guidelines: The facility staffing is based on resident population and acuity. The following represents the daily staffing at the facility utilizing the number of employees: licensed nurse 12 hour shift 6:00 AM -6:30PM 3-4 (nurses) late shift 6:00PM -6:30AM 2-3 (nurses), and 6:00PM-10:00PM 1-2 nurses. The facility assessment did not define acuity/complexity of the residents.

Based on interview and record review, the facility failed to implement policies and procedures for antidepressant medication use for one resident (Resident #8) of 4 residents reviewed resulting in a lack of Gradual Dose Reduction (GDR), and the potential for ineffective and inappropriate treatment. Findings include: Record review of the facility 'Psychotropic Medication Use' policy dated 2/3/2026 revealed that it is the policy of the facility to only prescribe psychotropic medications when it is necessary to treat a specific diagnosed condition and the medication is deemed as beneficial to the resident . Residents who use psychotropic medications will receive gradual dose reductions, unless clinically contraindicated . The following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications; Antipsychotics, anti-depressants, anti-anxiety and hypnotics . Gradual Dose Reduction: Psychotropic medications should be reviewed for gradual dose reduction in an effort to find an optimal dose or to determine whether continued use of the medication is benefiting the resident of could have dangerous side effects. A gradual dose reduction should be attempted in two separate quarters (with at least one month between attempts) and then at least annually thereafter unless documented as clinically contraindicated . Resident #8:Record review of Resident #8's 'Psychotropic Medication Consent' dated 10/9/2024 for Fluoxetine oral 40mg capsule by mouth one time a day and Fluoxetine oral 20mg capsule by mouth one time a day (60mg total daily) for depression, anxiety and adjustment disorder. Targeting behaviors of agitation, decreased socialization/withdrawal, and verbal aggression. Record review of Resident #8's January 2026 Medication Administration Record (MAR) noted Fluoxetine oral 20mg capsule by mouth one time a day start date 8/24/2024, and Fluoxetine oral 40mg capsule by mouth one time a day start date 8/15/2024. Record review of Resident #8's psychiatry follow-up note dated 9/24/2025 revealed the provider exchanged information with facility staff to obtain history, develop a diagnostic impression, and provide treatment recommendations with the goal of facilitating resident-centric integration of care activities, having the well-being and needs of the residents as the focus. Specific matters addressed in the visit were the need for follow-up, diagnostics and findings, recommendations and orders. Treatment instructions based on the data obtained included collaboration with facility staff and discussion with patient. Psychiatric medications currently on fluoxetine (Prozac): dose reduction and GDR (Gradual Dose Reduction) are being pursued. Patients are uncertain of current medication regimen. Record review of Resident #8's Nurse Practitioner (NP) progress note dated 9/26/2025 at 10:10PM revealed the diagnosis of depression with Fluoxetine (Prozac) 60mg total daily. Nurse Practitioner (NP) progress note dated 9/30/2025 at 10:40PM revealed the diagnosis of depression with Fluoxetine (Prozac) 60mg total daily. Nurse Practitioner (NP) progress note dated 10/7/2025 at 10:51PM revealed the diagnosis of depression with Fluoxetine (Prozac) 60mg total daily. Record review of Resident #8's psychiatry follow-up note dated 11/26/2025 revealed previously patient was seen on 9/24/2025 had been experiencing tearfulness when family visits and leaves. At that time Prozac decreased from 60mg to 50mg daily as part of a gradual dose reduction plan.In an interview and records review on 02/12/2026 at 9:53 AM with the Director of Nursing (DON) on Residents #8's Fluoxetine (Prozac) oral 20mg capsule by mouth one time a day start date 8/24/2024, and Fluoxetine oral 40mg capsule by mouth one time a day antidepressant medication. The state surveyor pointed out the Documented Gradual Dose Reduction (GDR) recommendation on 9/24/2025 by psychiatry provider notes, but that there had been no change in the Fluoxetine medication orders. The DON did a record review of Resident #8's physician orders and Medication Administration Records from September 2025 through January 2026 with changes in the Fluoxetine dosage found. Record review of the September 2024 documented of last GDR, and then of psychiatry notes dated 9/2025 recommendation of GDR recommended, Physician/Nurse practitioner notes dated September 2025 did not recommendations for GDR. Record review of December 2025 psychiatry notes recommended GDR with no follow up from facility physician/providers. The DON agreed with the state surveyor that there should have been a Gradual Dose Reduction in the Fluoxetine (Prozac) medication in September 2025 but was missed.

This citation pertains to intake Numbers 2708679 & 2708703.Based on observation, interview, and record review, the facility failed to implement appropriate enhanced barrier precautions (EBP) for one resident (Resident #103), identified with an indwelling percutaneous endoscopic gastrostomy (PEG) tube, of three residents reviewed for infection prevention. Findings include:Resident #103 (R103): According to a review of R103's medical record, the resident was admitted to the facility on [DATE] for skilled nursing care related to cerebral edema (fluid collection in the brain), oropharyngeal dysphagia (difficulty swallowing), severe protein-calorie malnutrition, Metastatic malignant neoplasm of right lung (cancer), secondary malignant neoplasm of bone (cancer), antineoplastic chemotherapy, weakness with difficulty walking, on 11/21/2025 PEG tube placement. R103's Minimum Data Set (MDS) record revealed Brief Interview of Mental Status (BIMS) score of 11/15 indicated the resident had moderately impaired cognition.On 01/21/2026 at 11:54 AM, An observation of R103's door was made and there was no EBP signage posted. There was no PPE immediately present at R103's door. R103 was resting in room with eyes closed and was unable to be interviewed.On 01/21/2026 at 12:33PM, Observed R103 was supine in bed watching TV, there was a walker at his bed side, no PPE receptacle was present in the room. R103 agreed to an interview. R103 said that he had been at the facility for a couple of months following a hospital stay, he had hopes of returning home. R103 said that he required some assistance with daily care. R103 said, they help me shower and such, but I can do my own oral care and grooming. R103 said that occasionally he has incontinence, but he can go to the rest room using his walker now. R103 was queried if the staff performing care for him wore protective clothing such as gowns when care was provided or when they handled his tube feeding or dressing, R103 had a furrowed expression and stated Why the hell would they need a gown, No.On 01/21/2026 at 12:41PM, During an interview with Nurse A she was asked, if residents that received nutrition through tube feeding required any special precautions. Nurse A replied Yes, enhanced barrier precautions and further explained It is a direct entrance to their body. When asked what EBP's were, she said, to use gown and gloves with resident care.A record review of R103's orders revealed: Orders dated 11/24/2025: Admit resident to Skilled Level of Care. Physician/Provider has reviewed and agrees with current Care Plans, Diagnosis list, and Physician Orders.Orders dated 11/25/2025: Check resident's tube site every shift for signs of infection, dehydration, N/V distention, diarrhea, constipation, reflux, and breath sounds Q shift.Orders dated 11/25/2025: Monitor patient for clinical signs of misplaced tube: dyspnea, tachypnea, tachycardia, pulmonary congestion, and abdominal distention/tenderness/hardness. every shift for enteral feed.Orders dated 11/25/2025: Change irrigation (flush) kit (peg tube) every 24 hours and PRN as needed for tube feeding.Orders dated 11/25/2025: Enteral Tube Site Care: Cleanse site with soap & water, rinse with water & allow to air dry. If indicated for drainage, apply split gauze date & initial.The orders for R103 revealed: no orders placed for EBP. A record review of R103's Care plan revealed the following:Date Initiated: 11/25/2025 Created by: DON / Infection Control Preventionist (ICP) Focus: The resident is at nutritional risk related to cerebral edema, dysphagia, gastrostomy, malignant neoplasm, COPD, HTN. Intervention related: Diet: NPO. Focus: Need for feeding tube/ potential for complications of feeding tube use related to dysphagia. All Interventions related: Administer tube feeding formula, hydration, and flushes per order. Check tube placement and function per guideline or physician order. Elevate head 30-45 degrees While tube feeding is running. Nothing by Mouth (NPO). Obtain Labs as ordered, and report results to physician. Report signs and symptoms of infection such as redness, tenderness, heat, drainage, fever, acute mental changes, functional decline in ADLs. (and) Speech Therapy evaluation & treatment as ordered. On 01/21/2026 at 1:42PM, During an interview with the DON / ICP She was asked why residents would require EBP and she said, for any type of tube, like ostomies, catheters, dialysis, wounds, IV /PICC. How about I read my check list to you? then stated, it is long I will just send it to you, when asked what the list was called, she said EBP quick reference guide she used for infection control. DON/ICP stated, Basically, it's any man-made tube or opening in your body that could potentially have bacteria.The DON/ICP was asked to demonstrate a walk-through of the hall where R103's room is located and to identify residents on the hall who were on current precautions. The DON/ICP agreed and said the facility only had EBP's in the building and that they had a transmission-based precaution (TBP) that ended on 01/17/2026. During the walk through of the hall the DON/ICP explained that residents with precautions had a sign posted on their door with the type of precaution, and the sign also indicated which resident in the room was on precautions. At the end of the walkthrough the DON/ICP had identified a total of 5 residents with EBP signage posted on the doors and had given the explanation of why each resident was on EBP's. None of the 5 residents the DON/ICP identified included R103.The DON/ICP was asked to review R103's medical chart. DON/ICP was asked what date R103 was admitted to the facility and she said on November 24th, 2025. DON/ICP was asked how long R103 has required tube feeding and she stated, since he came. DON/ICP then exclaimed, There was no (EBP) sign on(R103's) door on the walkthrough. DON/ICP was asked to review R103's care plan for EBP in the plan of care, after looking in the chart she replied no, it is not. The DON/ICP was asked to review resident 103's Kardex bedside care plan for EBP, after looking in the chart she replied no, it is not; It wouldn't be there if it wasn't on the full care plan. The DON/ICP was asked to check R103's orders for enhanced barrier precaution, after looking in the orders she replied no, there is no order. The DON/ICP DON was queried if her staff followed enhanced barrier precautions at any time for R103 since admission in November of 2025 and she stated, Probably not since there's no sign, no orders and no care plan for it.On 01/21/2026 at 2:04 PM, DON stated, I just fixed it in (R103's) chart. And indicated that she was going to place a sign on R103's door as well. DON agreed that it was a problem that R103 need for EBP had not been ordered or identified and followed. She said she was in the process of correcting it and that she could not change what had already happened. A record review of DON referenced facility EBP Quick reference revealed: Residents who have the following are REQUIRED to be placed in Enhanced Barrier Precautions, under Indwelling Medical devices:Central vascular linesHemodialysis cathetersPICC linesTunneled linesImplanted portsIndwelling urinary cathetersFeeding tubesChest tubesSurgical drainsTracheostomy tubesOther indwelling devices/lines that exit the body A record review of facilities policies labeled Enhanced Barrier Precautions revealed: Guidelines: Enhanced barrier precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs). Enhanced barrier precautions involve gown and glove use during high-contact resident activities for residents known to be colonized with a CDC targeted MDRO (where contact precautions do not apply) as well as those residents at increased risk of MDRO acquisition, such as chronic wounds or indwelling medical devices.The policy further defined indwelling lines as:Central vascular lines (including hemodialysis catheters/ PICC lines, tunneled lines, implanted ports)Indwelling urinary cathetersFeeding tubesChest tubesSurgical drainsTracheostomy tubesOther indwelling devices/lines that exit the body.The policy defines High contact resident activities include (for all residents on Enhanced Barrier Precautions) as:Dressing.Bathing/Showering.Transferring.Providing hygiene.Changing linens.Changing briefs or assisting with toileting.Care and use of indwelling medical devices:Any dressing changes.Injecting or infusing medication or tube feeding into the indwelling medical device.Wound care: any skin opening requiring a dressing.Working with the resident in the therapy gym/ specifically when anticipating close physical contact while assisting with transfers and mobility.The policies procedure is defined as: Residents admitted to the facility with or during their stay at the facility acquire a wound and/or an indwelling medical device will be placed in enhanced barrier precautions.A physician order is obtained.Resident's room door does not need to be kept closed.Residents are not restricted to their rooms and do not require placement in a private room.Residents are permitted to participate in group activities, communal dining, and able to move freely around the facility.Enhanced Barrier Precautions signage will be posted on the door or wall outside of the resident's room.Gown(s) and gloves will be available outside the resident room.PPE will be discarded in the trash can in the resident's room prior to leaving the room or before providing care for another resident in the same room. (Staff should attempt to bundle care i.e. complete as many high-contact resident care activities during their visit as needed to decrease the amount of time donning & doffing PPE).Enhanced barrier precautions should be used for the duration of the resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. A review of the CDC Guidance to Nursing homes on EBP revealed: Enhanced Barrier Precautions expand the use of gown and gloves beyond anticipated blood and body fluid exposures. They focus on use of gown and gloves during high-contact resident care activities that have been demonstrated to result in transfer of MDROs to hands and clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated. Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Standard Precautions still apply while using Enhanced Barrier Precautions. For example, if splashes and sprays are anticipated during the high-contact care activity, face protection should be used in addition to the gown and gloves. Enhanced Barrier Precautions are recommended for residents with indwelling medical devices or wounds, who do not otherwise meet the criteria for Contact Precautions, even if they have no history of MDRO colonization or infection and regardless of whether others in the facility are known to have MDRO colonization. This is because devices and wounds are risk factors that place these residents at higher risk for carrying or acquiring a MDRO and many residents colonized with a MDRO are asymptomatic or not presently known to be colonized.

This citation pertains to Complaint Number 2644043.Based on interview and record review, the facility failed to reimburse trust funds for one resident (Resident #1) of three residents reviewed for trust funds, resulting in trust funds not being reimbursed upon death. Findings include. On 11/21/2025, at 11:30 AM, the Interim Director of Nursing was asked to provide all grievances and/or complaints regarding trust funds reimbursement for Resident #1. On 11/21/2025, at 1:00 PM, a record review of Resident #1's electronic medical record reveled a death in the facility on 11/13/2024 at 5:35 AM. A review of the miscellaneous tab revealed no scanned documentation regarding trust fund agreement, balances or reimbursements. On 11/21/2025, at 2:00 PM, the Interim Director of Nursing (DON) was interviewed regarding Resident #1. Per the Interim DON, Resident #1 passed away in November 2024. The Interim DON was asked to provide the ending balance of Resident #1's trust fund account. On 11/25/2025, at 10:00 AM, the Administrator provided a copy of a reimbursement invoice for Resident #1's trust fund balance and offered that the check was mailed to the daughter. On 11/25/2025, at 10:11 AM, a record review of the invoice revealed Invoice Date 11/21/2025 Description (Resident #1) Gross Amount $118.39 . Pay One Hundred and Eighteen Dollars and 39 Cents to the Order of: (daughter) Closed (Resident #1) Trust . On 11/25/2025, at 12:35 PM, a phone interview with the Director of Revenue (DOR) B was conducted. The DOR was asked why Resident #1's trust fund was reimbursed on 11/21/25 and not when they passed away in 2024 and the DOR B offered, there is no reason why and it was an oversight on the part of multiple parties.

This citation pertains to Intake #1230868.Based on observation, interview and record review, the facility failed to 1) Ensure that nursing staff gave appropriate care for failure, 2) Ensure that nursing staff completed a respiratory assessment during a respiratory crisis, and 3) Ensure that nursing staff followed facility nursing care plan for 1 resident (Resident #105) of 3 residents reviewed for nursing care, resulting in pulmonary edema, HH (excessively high) CO2 (Carbon Dioxide-lab) blood level, hypoxia, pneumonia, acute respiratory distress, hospitalization, respiratory failure with the high likelihood of death. Findings Include:Resident #105:Review of the Face Sheet, nurses and physician progress notes dated 7/2/25 through 7/5/25, nursing assessments dated 7/25, physician orders dated 5/25 through 7/25, and care plans dated 5/25, revealed Resident #105 was [AGE] years old, admitted to the facility on [DATE] and re-admitted on [DATE], alert and oriented and able to make healthcare decisions, and dependent on staff for Activities of daily living/ADL. The resident's diagnosis included, chronic respiratory failure with hypercapnia (high much carbon dioxide in blood, respiratory), disorder of the muscle, diabetes, alkalosis (blood pH to alkaline), absence of right leg above knee, and high blood pressure.Review of the facility altered respiratory care plan dated 3/25/25, stated Evaluate lung sounds and vital signs as needed; monitor for s/sx (signs and symptoms) of respiratory distress and report to MD PRN: Increased respirations, decreased pulse oximetry, increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, hemoptysis, cough, pleuritic pain, accessory muscle usage, skin color changes to blue/gray.Review of the Nursing notes dated 7/5/25 at 3 minutes after 12 midnight, stated Resident was transferred to Hospital, oxygen level was dropping. Director of Nursing/DON notified. (Physician Q ) and (Family member) notified. No nurse assessment, vital signs, Spo2 (oxygen levels), mental acuity assessment, skin color, lung sounds, pain, nor breathing pattern was found in the nursing note dated 7/5/25, prior to the resident being transferred to the hospital.During a phone interview done on 7/17/25 at 9:43 a.m., the only Family Member listed (Family Member R) stated, They (the facility) did not call me, no the facility did not call me (Family Member R checked his phone for the call on 7/5/25 and was unable to locate one). The hospital called me and told me I needed to make a decision on her (a code status). The hospital was upset because they did not clean her up before they sent her. Family Member R denied the facility contacted him at the time of transfer to the hospital on 7/5/25.Review of the ambulance run sheet dated 7/5/25 at 11:48 p.m., revealed Resident #105's spo2 (oxygen blood level) was 67% (Spo2 blood oxygen level, normal 90 to 100%). PD (police Department) brought (ambulance staff) to the patient who was found in her room responsive to pain (unresponsive). Facility staff did not enter the patient's (room) upon (ambulance) arrival, and it was reported by PD and rescue that the patient was suffering from unknown breathing problems and unknown for how long. Rescue reported the was at 67% (Spo2) on her nasal cannula upon arrival. The patient was then placed on a non-rebreather (oxygen mask for respiratory distress) at 15 liters. The patient was alert and orientated x0 (unresponsive); the patient's hypotension and hypoxia were addressed. Barries to care: unconscious. The Fire Department and Police were already at the facility when the ambulance arrived. The nurse did not give them any information, vital signs nor Spo2 level or any information about the residents upon arrival. Patient is unresponsive on arrival to the emergency department; patient is being bagged by (ambulance) personnel.Review of the hospital ED Course dated 7/5/25, stated immediately decision was made to intubate the patient (artificial airway for breathing assistance) due to significant respiratory distress, difficulty moving air and concern for impending respiratory failure.Review of the hospital admit date d 7/5/25, stated intubation (artificial airway) due to respiratory distress and impending respiratory failure; We will proceed with a medically necessary hospitalization due to medical complexity for management of sepsis (infection) of unknown origin, respiratory distress, IV diuresis (pulling fluid off lungs). The resident was transferred from the emergency department to the Intensive Care Unit/ICU. Diagnosis: Hyperkalemia, Hypercapnic respiratory failure, Acute on Chronic Congestive Heart Failure, Leukocytosis (infection), Sepsis (acute infection from pneumonia).Review of the hospital Infectious Disease report dated 7/5/25, stated patient started on broad-spectrum antibiotics for healthcare associated pneumonia.Review of the hospital chest x-ray dated 7/5/25, stated Impression: There is a pulmonary edema that could be congestive heart failure and unchanged.Review of the hospital Lab dated 7/5/25, revealed the resident's CO2 was 42 (normal range=22 to 32). Review of the hospital Discharge Diagnosis dated 7/10/25, stated Recurrent acute on hypercapnic and hypoxic respiratory failure (low oxygen level), acute pulmonary edema (fluid on lungs), narcotic induced constipation, contraction alkalosis (abnormal respiratory gases), acute encephalopathy, hypoventilation syndrome.Observation and interview of Resident #105 was done on 7/15/25 at 10:45 a.m. The resident was in her bed, somewhat confused and was unable to recall 7/5/25, I don't remember what went on, I got sick, I don't remember what happened. The resident said she woke up at the hospital, and did not know what had happened.During an interview done on 7/15/25 at 12:36 p.m., Nurse, LPN D said she was working the night shift (7:00 p.m. to 7 a.m.) shift on 7/5/25. When resident #105 was found non-responsive and in a respiratory crisis, she said she did not do a lung or respiratory assessment, did not do a full set of vital signs, and did not do an oxygen saturation blood level (Spo2), did not do any alert or pain assessments, nor a blood glucose level on her. Nurse D had no reason why she did not do any assessment at all on the resident. Nurse D stated I put her oxygen to 8 to 9 (8L to 9L) when she ask's. Review of the physician oxygen order (dated 7/1/25) revealed O2 was to be at 5L. Nurse D said she kept the resident on her Nasel Cannula/NC (for oxygen therapy) and did not put her on a rebreather mask (for respiratory distress, crisis), she had no answer why she did not use a mask for increased oxygen delivery. Oxygen masks were kept on the units crash cart for easy access during an emergency. When this surveyor asked her if she had looked at the resident's respiratory care plan at all, she said no. When asked what she could have done better in this situation, Nurse D said she could of done an assessment. Nurse D stated, It was during COVID, so we did not get to go out (she had no clinical nursing experience due to COVID). Nurse D was assigned to a unit as Charge Nurse starting in January 2025, having been on her own for a total of 7 months; no competency evaluation documentation was found in the HR record. During an interview done on 7/15/25 at 10:59 a.m., Nurse Manager, LPN A stated It was on a weekend, oxygen sat dropped, Nurse on was (Nurse, LPN D), who is a new nurse was the nurse. Nurse Manager A did not recall anything else about the resident's transfer to the hospital on 7/5/25; no flow-up was done by the manager regarding significant respiratory change in condition of Resident #105.During an interview done on 7/16/25 at 1:39 p.m., the DON stated, I think the facility respiratory Therapist/RT is to educate new nurses in the future; we assumed she was safe because she had a license. I did talk to her (Nurse D) on the 5th, I talked to about her (Resident #105) CO2 level was critically high from that day, and her vitals (lack of vital signs), there should of been a change of condition done by her (Nurse D), I did it. Neither ADON or DON followed up with any education for Nurse D until the investigation was initiated by this surveyor on 7/15/25.During an interview done on7/16/25 at approximately 11:25 a.m., Respiratory Therapist/RT L said she had not been informed of the incident regarding Resident #105 until 7/15/25, when an education was requested of her to be done with Nurse D by the DON.Review of the facility documentation of education done with Nurse D on 7/15/25, at 3:30 p.m.; Signs/Symptoms RRT (related to) Respiratory Distress revealed Nurse D was educated by RT.During an interview done on 7/16/25 at 1:40 p.m., the Assistant Director of Nursing/ADON, LPN B stated (Nurse D) is definitely, a brand-new nurse, she needs more education, and she doesn't know assessment education and performance, she may not have known how to put the two together. It's the facilities responsibility to educate prior to assigning to the floor.Review of Nurse D's facility HR file revealed a Licensed Nurse Documentation Skills Checklist, all items were dated 2/20/25. No documentation of emergency care, or respiratory distress education was found on the checklist.During an interview done on 7/15/25 at 11:22 a.m., Human resource/HR M stated I did the first day of orientation with her (Nurse D), I reviewed all of HR file for nurses. No reference check was done because she was a new nurse, so she wouldn't have reference checks (for nursing). She got extra time because she was a new nurse. Yes, we are supposed to get reference checks. Review of the change of condition dated 7/7/25, revealed the DON had done the change of condition documentation 2 days after the transfer to the hospital on 7/5/25. Review of the Documentation in the Medical Record policy dated 1/8/25, stated A record of resident's assessments should be included in resident documentation.Review of the nursing education done by the DON on 7/15/25 revealed the following education was given to nursing staff:- Signs of Hypoxia/Respiratory DistressShortness of [NAME]/accessory muscle usageLow oxygen saturation-less than 92% for most residents (COPD residents less than 88%)Tachypnea (respiratory Rate greater then 20)Tachycardia (Heart Rate greater than 100)Cyanosis (blue/dusky coloring in the face/lips/fingers)AnxietyNon-Responsive/unable to get resident to wake up-What to do in Case of EmergencyIf residents have a low sat (oxygen saturation level), and is already on oxygen, increase the oxygen flow on the concentratorIf the concentrator is at max flow, and the resident's sat is not coming up-place resident on a non-rebreather connected to a tank (oxygen tank-E-tank) set at 15L (15 liters). Note: Non-rebreathers have to be ran at a minimum of 12L and are not to be used with our concentratorsIf the resident is requiring a non-rebreather-contact DON for further steps (i.e. transport to the hospital.-Remember:Hypoxia (low oxygen saturation) will lead to a code if left untreated.We treat all hypoxic residents with the same steps above, including the ones diagnosed with COPD.Review of the facility Nurse (RN/LPN) Position summary (un-dated) stated The charge nurse provides direct care; evaluates resident's medical, physical and mental status and accurately records the resident's care and response to their comprehensive care plan. Performance Requirements: Knowledge, skills, and abilities to perform the essential functions of the job; consistent application of current knowledge, use of good judgement, common sense, ability to establish and carry out priorities.

This citation pertains to Intake Number MI00150995. Based on observation, interview and record review, the facility failed to ensure supervision for 1 resident (Resident #101) with a known history of falls prior to admission and after admission (who fell on [DATE], with a facial injury) of 3 resident's reviewed for falls, resulting in a contusion above the left eye, skin tear on bridge of nose, pain and hospitalization . Findings Include: Resident #101: Review of the Face Sheet, Minimum Data Set, dated dated dated ,d+[DATE], nursing and physician notes dated 2/24/25 through 3/4/25, and facility fall assessments dated 2/26/25 and 3/4/25 (total of 8 day's), revealed Resident #101 was [AGE] years old, admitted to the facility on [DATE] and discharged after a fall on 3/4/25, confused with a BIMS (cognitive assessment, 1 to 15) of 0, had memory loss, was unsteady, repeatedly attempted to self-transfer, had poor safety awareness, required total Activities of Daily Living assistance and had a history of falls prior to admission and at the facility. The resident's diagnosis included, diabetes, anxiety, severe depression, Alzheimer's Disease, Dementia, disorder of muscle, muscle weakness, reduced mobility, and lack of coordination. Review of the facility nurse's notes dated 2/26/25, revealed the resident was found lying by her bed on the floor. This was the first fall in the facility. No injury was documented at this time. Review of the facility fall assessment dated [DATE], revealed the resident was at risk for falls due to a history of falls, unsteadiness, decreased cognition, repeated self-transfer attempts and failure to use the call light. Review of the resident's Fall Care Plan dated 2/24/25, revealed she had a low bed, was orientated to the use of her call light, and had a soft touch call light; she did not have bedside mats due to trip hazard. The resident had a BIMS of 0, was forgetful, self-transferred repeatedly, had a history of falls and had documented behaviors. No intervention of increased supervision was found after this fall at the facility on her care plan. Observation of facility video of resident #101's fall on 3/4/25 was done on 3/18/25 at approximately 1:00 p.m., with the Director of Nursing. The resident was in her wheelchair next to the fire double doors on her unit sitting. She abruptly stood up, tripped over the foot peddles and fell to her left side, hitting her head on the metal door frame. Nurse A was charting at the nursing station, and the resident was not in her view. She looked up, caught her standing; when she began to fall, the nurse immediately ran over to the resident. Review of the facility nurse's notes dated 3/4/25 at 8:44 p.m., stated The resident was sitting in the hallway in her wheelchair and the resident started to walk and fell and hit her head on the floor. The resident had a laceration above her left eye and another small skin tear on her nose. The resident was transferred to the hospital for further evaluation. During a phone interview done on 3/19/25 at 9:00 a.m., Nurse, LPN A stated It was at shift change; I asked (family member of Resident #101) to let me know when he left so we could watch her, he didn't because he said there were people at the desk, so he left her there (near the fire doors). I did not see her there. I saw her start to fall, and I yelled for someone to get her, it was too late she fell . I did not see her hit the door frame, I saw her on the floor and ran to get her. I did neuros and vitals on her and we sent her out for a head injury. Nurse A denied the resident had lost consciousness. Review of hospital ED (Emergency Department) note dated 3/4/25 at 8:23 p.m., stated 4 cm with large hematoma seen by critical care service and trauma. Per resident's left eye laceration dated 3/4/25, looked to be approximately 3.5 cm in length (a ruler was held up above the laceration). It was red, swollen and open, requiring sutures. Review of the hospital ED note dated 3/4/25 at 10:24 p.m., stated The patient's (patient) stood up from her wheelchair and then fell forward hitting her head against a metal door frame. They report that the patient did have a loss of consciousness. Review of the hospital ED note dated 3/4/25, stated We discussed the need for admission, the resident was admitted to the hospital critical care unit. Review of the hospital critical care note dated 3/4/25 at 11:02 p.m., stated she stood up from her wheelchair and fell forward, striking her left forehead against a metal door frame. She sustained a 4 cm scalp laceration that has been sutured. Review of the nurse's notes dated 3/4/25, revealed the resident fell when she got up and tried to walk in the hallway, hit her head and was transferred to the hospital and was admitted to the ICU (intensive care unit). Review of the Fall Care Plan dated 3/4/25, revealed an intervention of increased supervision, the resident was to be taken to activities when out of her room. This was done after her second fall with injury at the facility (within 8 days). During an interview done on 3/19/25 at 10:10 a.m., Administrator, Director of Nursing and Assistant Director of Nursing reviewed resident's facility and hospital documentation and no new information was given.

This Citation pertains to Intake Number MI00150622. Based on observation, interview and record review, the facility failed to ensure that medications were administered to 4 residents (#702, #703, #704, #705) of 5 sampled residents, and 10 unsampled residents, resulting in multiple residents not receiving their 5:00 PM medications on 02/25/2025. Findings include: Observation on 2/27/2025 at 8:10 AM of the [NAME] nursing unit revealed Licensed Practical Nurse (LPN) H was observed to be passing medications to residents on the 101-113 hallway. Record review of Resident #702's Medication Administration Record (MAR) for the month of February 2025 revealed that on 2/25/2025 at 5:00 PM that Xarelto (anticoagulant) 20 mg tablet by mouth for DVT/PE (Deep [NAME] Thrombosis/Pulmonary embolism) was not signed out as being completed. The medication Questran 4-gram packet was not signed out as being completed. Record review of Resident #703's Medication Administration Record (MAR) for the month of February 2025 revealed that on 2/25/2025 at 5:00 PM, Calcium Acetate 667 mg capsule was not signed out as being completed. Record review of Resident #704's Medication Administration Record (MAR) for the month of February 2025 revealed that on 2/25/2025 at 5:00 PM, that the chem for diabetes (blood sugar check) was not signed out as being completed. Record review of Resident #705's Medication Administration Record (MAR) for the month of February 2025 revealed that on 2/25/2025 at 5:00 PM, that the chem for diabetes (blood sugar check) was not signed out as being completed. Lispro insulin injection to scale was not signed out as being completed. Free water flush of 350 cc via peg tube was not signed out as being completed. Record review of the facility 'Medication Administration' policy, dated 08/07/2023 revealed that the policy was to safely and accurately prepare and administer medication according to physician's order, professional standards of practice, and resident needs . Sign the MAR (Medication Administration Record) after administered. For those medications requiring vital signs, record vital signs on the MAR. Report and document any adverse side effects or refusals. In an interview on 2/27/2025 at 1:55 PM, Registered Nurse (RN) B (Unit manager on medication administration) stated that the process was to follow the resident 6 rights of medication administration, wash hands, compare the medication cards with resident name and dose, take the medications to the resident and ensure resident takes the medications, come back to document in the Medication Administration Record (MAR). Medications are clicked/checked off on the electronic MAR. A record review was conducted of Resident #702's February 2025 Medication Administration Record (MAR). An open/blank square in regard to Xarelto (anticoagulant) meant that the medication was not documented as being administered. If an open/blank square if not clicked/checked off, then the medication was not administered. The nurse should document medication refusal. Record review of Resident #702 Progress notes, dated 2/25/2025, revealed only documentation of refusal of shower/bath as authored by RN B Unit manager. The state surveyor asked for an audit of resident names for missed medications on 2/25/2025. RN B was asked if the facility audits or reviews medication administration records to monitor if medications are administered, and she stated No. In an interview on 2/27/2025 at 2:30 PM, Registered Nurse (RN) B Unit manager revealed she did an investigation, and that on 2/25/2025 Licensed Practical Nurse (LPN) H left and counted off medications with the oncoming nurse at 4:00 PM which was Registered Nurse P. Registered Nurse P, did not give the 5:00 PM medications. LPN H left at 4:00 PM that day. An interview on 2/27/2025 at 2:35 PM with Licensed Practical Nurse (LPN) H revealed that it was her day off on the 2/25/2025 and she came in at 9:00 AM and left at 4:00 PM. LPN H stated that she gave all the resident medications up to 4:00 PM that day. Record review of the facility 'Missed Medication Administration on 2/25/25' form/audit revealed that there were 14 residents affected by the missed medication administration for that date on the [NAME] nursing unit.

This Citation pertains to Intake Number MI00149640. Based on interview and record review the facility failed to address the disparities in one resident's (Resident #701) significant weight fluctuations over a short time period of one resident reviewed for weight loss. Findings include: Resident #701: On 2/27/2025 at approximately 9:00 AM, a review was conducted of Resident #701's clinical record and it revealed that he initially admitted to the facility on [DATE] with diagnoses that included, Lymphedema, Cellulitis, Congestive Heart Failure, Anxiety and Ulcer of left lower leg. Resident #701 was his own responsible party and able to make his needs known to staff. Further review of Resident #701's records yielded the following: Care Plan: The resident is at potential for nutrition risk rt (related to) venous insufficiency, chronic le (lower extremity) wounds, lymphedema morbid obesity. anticipated significant weight changes r/t edema/diuretic .weight per facility protocol as resident allows . Weights: Resident #701 was being monitored closely due to his disease process and being weighed almost daily. Many times, his weights from day to day differed by 20-80 pounds without meaningful intervention or investigation of possible inaccuracies from the facility. The weight history was as follows: 09/08/2024: 374.4 Lbs (pounds) 09/20/2024: 374.0 Lbs 10/02/2024: 355.4 Lbs 10/04/2024: 356.0 Lbs 10/05/2024: 371.0 Lbs 10/08/2024: 370.0 Lbs 10/10/2024: 360.0 Lbs 10/11/2024: 341.0 Lbs 10/12/2024: 353.0 Lbs 10/18/2024: 346.0 Lbs 10/19/2024: 374.9 Lbs 10/23/2024: 374.1 Lbs 10/25/2024: 316.2 Lbs 10/28/2024: 305.8 Lbs 11/08/2024: 295.0 Lbs 11/18/2024: 292.6 Lbs 11/28/2024: 288.4 Lbs 12/03/2024: 276.8 Lbs 12/04/2024: 280.0 Lbs 12/11/2024: 274.7 Lbs 12/14/2024: 282.0 Lbs 12/24/2024: 282.4 Lbs 12/30/2024: 283.0 Lbs 01/02/2025: 201.2 Lbs On 2/27/2025 at 9: 45 AM, an interview was conducted with ADON (Assistant Director of Nursing) regarding Resident #701's weight that was entered into his record on 1/2/2024. The ADON explained they recalled the CNA (Certified Nursing Assistant) providing the weight and upon looking at it she thought it was inaccurate. They went back together and reweighed the resident to verify the weight, and it was correct. The ADON stated a progress note was inputted and follow up to be completed once the reweighs were completed over the course of the next few days as he was on daily weight. On 2/27/2025 at 10:40 AM, CNA E was asked about his involvement with weighing Resident #701 in early January 2025. He stated after weighing the resident he provided the value to the ADON, and she believed it was not accurate. They went back and reweighed the resident and received the same number. CNA E weighed the resident using the mechanical lift as the resident was unsure if he had the strength to transfer or not. On 2/27/2025 at 11:30 AM, Registered Dietitian O was queried regarding Resident #701's fluctuations in his weights throughout his stay at the facility. Dietitian O stated the resident had lymphedema in his bilateral lower extremities, heart failure and was on a diuretic. While they noticed the weight fluctuations (as he was on daily weights) they looked at the big picture, to include food acceptance, wounds healing, laboratory work up, and medications and he was doing stable. Dietitian O was asked if there are consistent large weight disparities, why was it not addressed, and she stated the discrepancies were not expressed as a concern with his visits and she had multiple progress notes regarding his weight loss. When asked if the weight loss was intended, she reported this was not a discussion held with the resident as she was more concerned about his acute illness. Multiples weights were pointed out in Resident #701's clinical record and Dietitian O did not have a substantial answer as to what the facility did to investigate the accuracy of the weights provided. It can be noted Dietitian Os progress notes and interview were contradictory, as she stated the she did not speak to Resident #701 regarding intended weight loss but her progress notes state otherwise. It is unknown what is accurate, as Dietitian O verified she had access to her full documentation during the interview. Review was conducted of Registered Dietitian O progress notes for Resident #701. The notes detailed the substantial weight fluctuations, but stated it was due to his disease process. There were no other meaningful interventions put forth to determine why there were such extreme variations. The larger variations were as follows: 12/30/2024: 283.0 Lbs; 1/2/2025: 201.1 Lbs - Difference of 82 pounds in three days 10/27/2024: 316.0 Lbs: 10/28/2024: 305.6 Lbs - Difference of 10.4 pounds in one day 10/23/2024: 374.1; 10/25/2025: 316.0 Lbs - Difference of 58.1 pounds in two days 10/11/2024: 341.0 Lbs; 10/12/2024: 353.0 Lbs -Difference of 12 pounds in one day 10/4/2024: 356.0 Lbs; 10/5/2024: 371.8 Lbs -Difference of 15.8 pounds in one day 9/8/2024: 374.0 Lbs: 9/20/2024: 347.4 Lbs - Difference of 26.6 pounds in twelve days Dietitian Progress Notes: 10/4/2024 at 19:46: . weight fluctuations r/t lymphedema, chf, diuretic therapy. currently 355# . 10/26/2024 at 08:11: .currently 316# bmi 42.9, on daily weight monitoring as resident allows weight loss desired/planned estimated needs with chronic le venous non pressure ulcers . 11/22/2024 at 10:39: .weight loss planned/desired fluid coupled with likely gradual body mass loss-desired . 12/6/2024 at 11:34: 274.6 12/5 .weight history .280 12/4, 276.8 12/3, 288.4 11/28; 11/6 305.7#; 356-371 10/4-10/5 . 12/6/2024 at 11:51: root cause analysis of weight loss and weight fluctuations due to planned fluid losses; diuretic therapy schedule . 12/13/2024 at 12:12: #274 .-5.0% change [ 19.7% , 60.6 ] -7.5% change [ 28.9% , 100.4 ] -10.0% change [ 34.0% , 127.0 ]. 12/20/2024 at 10:19: .weight stabilizing . There was no documentation from Registered Dietitian O on or around 1/2/2025 when Resident #701's weight decreased by 83 pounds in three days. From the discussion it was evident Dietitian O did not address the fluctuations in Resident #701's documented weights. On 2/27/2025 at 12:40 PM, Resident #701's documented weights were reviewed with Unit Manager B, to include the documented weight of 283 on 12/30/2024 to 201 on 1/2/2025. The manager reported the discrepancies are not just from fluid the resident retained due to his disease processes. On 2/27/2025 at 1:45 PM, phone contact was attempted with past Unit Manager Q. A voicemail was left requesting a return phone call. There was no return phone call received by the time of exit. The facility was asked to provide any additional documentation related to his weight variations and none was received prior to or at exit. Review was completed of the facility policy entitled, Weights, revised 2.1.2024. The policy stated, .Daily weights maybe ordered by the medical practitioner for a specific resident and my contain parameters .Reweights will be completed when: the resident gains or loses 5 pounds if they weight 100 pounds or greater .The Registered Dietitian or designee is responsible for the weight management program to include compliance with weights obtained, tracking and trending .

Based on observation, interview and record review, the facility failed to prevent a Stage III coccyx pressure ulcer from developing for 1 resident (Resident #76), and failed to implement meaningful and planned interventions for 1 resident (Resident #332), of 2 residents reviewed for pressure ulcers, resulting in a Stage III infected pressure ulcer, IV antibiotic usage, and hospitalization with the potential for delayed healing of pressure ulcers. Findings Include: Review of hospital records dated 1/22/25, stated The patient had Covid and pneumonia in December (2024) and was admitted from 12/7/24 to 12/26/24 and has been in rehabilitation (living at the facility) until today. The patient was getting settled his noon nursing facility (the resident was transferred from the facility to a Assisted Living facility/ALF on 1/22/25), they (ALF) noticed of the wound and thought it looked significant and recommended that he come to the emergency department. Do (the ER physician) have concerns that patient may be developing cellulitis (inflammation/infection of skin) around his sacral (coccyx area) wound. Do believe he needs to be admitted for IV antibiotics and to see wound care. Spoke with (hospital physician) hospitalist and discussed the medical management of the patient's case. They agreed to admit the patient for infected decubitus (coccyx area) ulcer stage III. Patient is still symptomatic with decubitus sacral ulcer with surrounding cellulitis and has not achieved medical stability for safe discharge from the hospital. I am concerned that, if discharged today (on 1/22/25, day of discharge from the facility), the current condition would worsen and an adverse event like cysts and deaf (death) may occur. Large stage 2-3 sacral ulcer with severe tenderness to palpation. 600 mg Zyvox IVPB (antibiotic given per IV) and 1 g Maxipime IVPB (antibiotic given per IV) were ordered for the patient's infected sacral ulcer. Diagnosis: Infected decubitus ulcer, stage III, dehydration. Review of hospital records dated 1/28/25, stated I (Infectious Disease physician) was consulted from Infectious Disease perspective regarding the patient having a infected sacrococcygeal decubitus ulcer. Patient has redness, tenderness, induration around the margins of the ulcer. Patient also has leukocytosis (high white blood cells in blood, indicating saver infection). Resident #76: Review of the Face Sheet, Nursing Admission assessment dated [DATE], nursing notes dated 12/26/24 through 1/22/25, physician orders dated 12/27/24 through 1/22/25, revealed Resident #76 was [AGE] years-old, alert and able to make his needs known, admitted to the facility on [DATE], and required staff assistance with all Activities of Daily Living/ADL's. The resident's diagnosis included, cervical disc disorder, acute respiratory failure, muscle weakness, dysphagia (swallowing deficit), cancer of the prostate, cognitive communication deficit, atrial fibrillation, and history of falls. Review of the facility admission skin total body eval dated 12/27/24, revealed numerous bruises and scratches, however no documentation of any pressure ulcers was found. No coccyx stage III pressure ulcer was documented by staff. Observation of the resident's coccyx pressure ulcer dressing change was done on 1/21/25 at 11:00 a.m., Nurse, LPN N did the dressing. When Nurse N went to take the dressing off his coccyx area, there was no dressing. Nursing Assistant/CNA O stated I took it off earlier, it had BM on it. The CNA did not inform the nurse when she removed the coccyx dressing. The resident had a large stage III pressure ulcer on his coccyx area; he complained of pain and discomfort during the application of a dressing. Review of the resident's shower sheets done on 1/22/25, revealed only 1 shower sheet available that was filled out for the resident from his admission to discharge. Nurse Manager, RN H and the Director of Nursing looked for additional shower sheets, however no other sheets were available. Review of the resident's only shower sheet dated 1/14/25, revealed no documentation of any pressure ulcers and stated, No skin concerns. Review of the physician order dated 1/6/25, stated House zinc paste every 12 hours for reddened coccyx. Review of the facility at risk for alteration in skin integrity care plan dated 12/30/24, revealed staff were to observe skin condition with ADL care daily; report abnormalities. Review of the facility actual skin impairment care plan dated 1/14/24, and nursing notes dated 1/14/24, revealed the resident had developed macerated skin on the coccyx area, and staff were to do weekly treatment documentation (including measuring). Review of the physician order dated 1/20/25, stated Cleanse area on coccyx with normal saline, apply calcium alginate to wound bed, cover with abd (dressing) secure with tape, z guard to surrounding areas of maceration. Review of the physician order dated 1/20/25, stated Order to discharge to ALF on 1/21/25, with skilled home care services including PT/OT, nurse and home health aide. During an interview done on 1/21/25 at approximately 11:40 a.m., Family Member #2 stated every time I come here, he is soiled and wet, he has gone down since he has been here. Family Member #2 revealed the resident did not have any pressure ulcers when he was admitted to the facility. A second observation of the resident was done on 1/21/25 at 11:00 a.m. when he was at the nursing desk waiting to be discharged ; he was complaining about pain in his feet, so Nurse, RN P took him in a private room and evaluated his feet. Nurse P found 2 more pressure ulcers (on both feet) that were not documented prior to 1/21/25 (the day the resident was discharged ). Review of the nursing note dated 1/21/25 at 11:00 a.m., stated At approximately 11 am this nurse (Nurse, RN P) was called into room to assess a resident (Resident #76). Upon assessment a area was found on the back of his left heel. This area was approximately 4 x 4 x 0.0, there was no open areas and had approximately .02 area of redness surrounding area (this was a unstageable pressure ulcer per Nurse P verbalization to surveyor, it was a harden black cap (eschar) on top of a pressure ulcer), no odor, no drainage. This nurse also assessed an area on the right foot between the first and second toe and the second and third toe that had a small open area approximately 1 x 1 x .01 small open area in the middle (a small pressure ulcer). Review of the facility Communication with physician form dated 1/21/25 at 13:46 (1:46 p.m.), stated Area of unstageable eschar (harden black cap over pressure ulcer) was found on the left heel. A small open area between the first and second toe and between the second and third toe. During an interview done on 1/21/25 at 11:15 a.m., Nurse P stated I would of checked (the resident for pressure ulcers and wound abnormalities) more frequently then weekly. 37668 Resident #332: On 1/22/25 at 9:19 AM, an observation occurred of Resident # 332 in their room. The Resident was sitting in bed with a meal tray on the overbed table in front of them. The Resident's heels were positioned directly against the bed. When spoke to, Resident #332 made eye contact but did not engage when asked questions. On 1/22/25 at 10:32 AM, Resident #332 was observed sitting in a Broda chair (reclining, high back wheeled chair with solid, padded leg and footrests). Resident #332 was visibly upset and crying and their lower extremities and heels were positioned directly against the solid leg/footrest of the chair. A Hoyer (mechanical lift) sling was under the Resident in their Broda chair. Record review revealed Resident #332 was a [AGE] year-old individual who was admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke) with right sided hemiplegia and hemiparesis (one sided paralysis), Multiple Sclerosis (MS), aphasia (impaired ability to understand language and express speech), and Deep Tissue Injury (DTI) pressure ulcers (wound caused by pressure with unknown depth) on their left ankle and both heels. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required maximum to total assistance with transferring, mobility, toileting, bathing, and dressing. The MDS further detailed the Resident had three unstageable DTI pressure ulcers. Review of Resident #332's Electronic Medical Record revealed a Care Plan entitled, At risk for alteration in skin integrity related to: currently has 3 DTI's admitted with, incontinence, and immobility (Initiated: 12/31/24). The care plan included the interventions: - Elevate heels as able (Initiated: 12/31/24) - Encourage and assist as needed to turn and reposition; use assistive devices as needed (Initiated: 12/31/24) - Use pillows/positioning devices as needed (Initiated: 12/31/24) A second care plan entitled, Resident has Deep Tissue Injuries to right heel, right ankle, left heel (Initiated: 12/31/24) was also present in Resident #332's EMR. This care plan included the interventions: - Administer treatment per physician orders (Initiated: 1/3/25) - Heel Protectors (FYI) (Initiated: 12/31/24) On 1/23/25 at 7:30 AM, Resident #332 was observed sitting near the nurses' station with a blanket over their head. The Resident did not respond when spoke to. Their lower extremities and heels were positioned directly against the leg/footrest of the Broda Chair. A Hoyer (mechanical lift) sling was under the Resident in their Broda chair. At 9:41 AM on 1/23/25, Resident #332 was observed sitting in the same place near the nurses' station and in the same position in their Broda chair. Certified Nursing Assistant (CNA) CC took Resident #332 to their room to complete incontinence care with CNA BB and an observation of care was completed. When queried how long Resident #332 had been sitting up in their Broda chair, both CNA BB and CNA CC stated, Been up since before we got here. When asked what time they started work, the staff revealed they start at 6:00 AM. When queried if they had repositioned the Resident in their Broda chair since they started work at 6:00 AM, both staff verbalized this was the first time they had provided care to the Resident today. Resident #332 was noted to have dressings in place to both their heels/ankles. During care an open wound was observed on the Resident 's left coccyx. The center of the wound was red, and the surrounding tissue was white in color. The removed brief had bright red blood where it had been positioned against the wound. When queried, CNA CC and CNA BB stated the area had healed and had reopened. A second open wound was observed towards the back of the Resident's left mid upper thigh. This wound bed was red in color with the first layers of skin gone, elongated, irregularly shaped, and larger than a quarter in size. When queried regarding the wound on the Resident's thigh, both CNA's verbalized the area was new. The location of the open wound on the Resident's left thigh correlated with the location of the Hoyer sling was positioned for transfer. When queried if the wound was located where the sling had been positioned, both CNA CC and CNA BB confirmed it was. CNA CC stated the Resident may need a bigger sling because it's digging in. At 10:00 AM, the Resident's assigned Nurse was unable to be located, and Unit Manager Registered Nurse (RN) B was asked to come to the room. RN B entered the room to observe the wounds. RN B verbalized the open area on the Resident's coccyx was caused by moisture and indicated they would obtain cream to apply to the area. When queried regarding the area on the Resident's left upper/mid-thigh, RN B confirmed the area was new. When asked if the wound was caused by the Hoyer sling, RN B did not provide a direct response but indicated it was possible. RN B exited the room at this time and returned with the Director of Nursing (DON). The DON revealed they were going to apply a dressing to the new wound on the Resident's left upper/mid-thigh. Review of documentation in Resident #332's EMR revealed the following: - 12/31/24 at 4:00 PM: Admission Evaluation . Clinical Evaluation Integumentary (Skin) . abnormality . Right buttock: 3.5 x 2.5 cm (centimeter) pink/white area . Left Heel: 5 x 4 cm eschar to inner heel, 4 x 4 (cm) dark area lateral outer heel . Right heel: 5 x 6 cm blister filled area to inner heel . Other: Dark skin on left outer ankle . - 1/1/25 at 9:03 AM: Physician Team - Progress Note . Sacral decub (Pressure Ulcer) at level 3 (full thickness tissue loss). Right heel blister . Sacral decub is stable. Right heel is stable. Both medial and lateral malleolus, eschar of the right heel . Skin and Wound: Intact . - 1/10/25 at 11:46 AM: Physician Team - Progress Note . Left heel skin damage . Skin and Wound: Intact . Upon request for all Resident #332's pressure ulcer wound documentation, the facility provided documentation related to the Rear Left Malleolus (ankle), Lateral (side) DTI and Rear Right Malleolus DTI. No documentation was provided for the sacrum pressure ulcer identified in the Physician note on 1/1/25 and/or any other pressure injuries. On 1/23/24 at 11:44 AM, Resident #332 was observed sitting alone by the wall in the [NAME] Hall, near the nurses' station, in their Broda Chair. The Resident's lower extremities and heels were positioned directly against the leg/footrest of the Broda chair. An interview was completed with the DON on 1/23/25 at 12:24 PM. When queried regarding the new wound identified on Resident #332's left upper/mid-thigh, the DON stated, I put a border gauze on it. A review of the Resident's EMR at this time revealed the open area had been documented as MASD (Moisture Associated Skin Damage). When queried how the area was MASD when it was not an area covered by a brief and not in an area prone to moisture, the DON replied, I have to chose something to put it (wound) in (the EMR) and we will change it after the wound nurse evaluates it. When queried if the wound was caused by rubbing from the Hoyer sling, the DON stated, I am doing an investigation. The DON was asked if the open wound was in the area where the Hoyer sling would rub/apply pressure and did not provide a response. When queried how often Resident #332 should be turned and repositioned in their Broda chair, the DON did not provide a direct response. When queried regarding observations and staff interviews revealing the Resident had not been repositioned for approximately four hours, no explanation was provided. Review of Resident #332's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for January 2025 revealed the following: - Skin prep to blister on right heel every 12 hours for Blister (Start Date: 1/1/25 at 9:00 AM). The TAR was blank, indicating the treatment was not completed on 1/9/25 at 9:00 AM and 1/12/25 on 9:00 AM. - Skin prep to Dark spot Lateral heel and Dark spot on lateral heel every 12 hours for Wound care (Start Date: 1/1/25 at 9:00 AM) The TAR was blank, indicating the treatment was not completed on 1/9/25 at 9:00 AM and 1/12/25 on 9:00 AM. - Betadine to Eschar to left inner heel, wrap with ABD pad every day shift for Wound care (Start Date: 1/1/25 at 6:00 AM). The TAR was blank, indicating the treatment was not completed on 1/9/25, 1/12/25, 1/13/25, and 1/15/25. - Boarder dressing to right buttock, ever 2 days and as needed every day shift every 2 day(s) for Wound care (Start Date: 1/1/25). The TAR was blank, indicating the treatment was not completed on 1/3/25, 1/9/25, 1/13/25, 1/13/25, and 1/15/25. - Left heel DTI apply skin prep daily every day shift for DTI (Start Date: 1/3/25). The TAR was blank, indicating the treatment was not completed on 1/9/25 and 1/12/25. -Left outer ankle-DTI-apply skin prep daily every day shift for DTI (Start Date: 1/3/25). The TAR was blank, indicating the treatment was not completed on 1/9/25 and 1/12/25. - NO: Zinc hose paste to sacral area daily and prn (as needed) for MASD every day shift for MASD (Start Date: 1/3/25). The TAR was blank, indicating the treatment was not completed on 1/9/25 and 1/12/25. - Right Hell (sic) -apply skin prep daily DTI every day shift for DTI (Start Date: 1/3/25). The TAR was blank, indicating the treatment was not completed on 1/9/25 and 1/12/25. On 1/23/25 at 1:34 PM, an interview was completed with RN B. When queried if staff should document resident refused in the EMR if a Resident refuses care and/or treatment, RN B indicated they should. When queried regarding observations of Resident #332's heels/lower extremities being positioned directly against the leg/footrests of their Broda chair, RN B did not provide a response. When asked why the Resident did not have heel boots in place as per their care plan, RN B stated, I will discuss with (the DON). Review of the facility Skin and Wound procedure dated 3/20/24, revealed staff were to do weekly skin checks. Review of the facility Skin and Wound Guidelines Policy dated 3/20/24, stated Body audits are completed: BY licensed nurse routinely and documented in the resident's electronic medical record. By the nursing assistant during scheduled baths/showers (twice weekly showers), and if indicated during routine daily care. The nursing assistant will inform the licensed nurse of any new areas of skin breakdown for evaluation and documentation. Pressure Ulcer: Localized damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical or other device. Can be present as intact skin or an open ulcer and may be painful.

Based on interview, and record review, the facility failed to complete a performance review every 12 months for five Certified Nurse Aides (CNA's S, T, U, V, & X) of 5 reviewed for an annual performance review. This deficient practice resulted in the potential for inadequate and unmet resident care needs. Findings include: On 1/23/2025 at 9:40 AM, review of human resource files in the presence of Human Resources Director R was completed. It was found five of the five CNA's reviewed for annual competencies were not completed in 2024. The following staff members did have annual skills checks completed. CNA S - last completed 10/2023 CNA T - last completed 10/2023 CNA U last completed 10/2023 CNA V - last completed 10/2023 CNA X - last completed 10/2023 Director R explained they hold annual competencies classes yearly for staff instead of basing it on their hire date and she shared Educator B is actively holding classes this week. It can be noted when reviewing the files the 2023 competencies were filed but the date completed for each specific competency were checked off at different month increments (some being five + months apart). On 1/23/2025 at 1:00 PM, an interview was conducted with Educator R regarding annual competencies. He accepted the role as Unit Manager/Educator in October 2024 and his training was initially more focused on Unit Manager tasks. Manager B was queried when he was aware facility staff did not have skills checks completed in 2024. He stated it was discovered about a month ago and that is when they enacted their plan. Review was completed of the facility policy entitled, Skill Evaluation, dated 2/9/24. The policy stated, .The skills evaluation checklist(s) is completed during job-specific orientation, re-validated annually, and completed as needed .The employee's immediate supervisor or designee is responsible for completion of the annual review at the time of the employee's annual performance evaluation .

Based on observation, interview and record review, the facility failed to prevent and document the occurrence of a skin abrasion and Deep Tissue Injury (DTI) for one resident (Resident #1) and the development of pressure ulcers for one resident (Resident #2), resulting in Resident #1 to be found with an abrasion to the left lateral hip and right heel deep tissue injury and Resident #2 developing a pressure ulcer to the left heel as a deep tissue injury and increased to a Stage III pressure ulcer and, also, the left foot 5th toe pressure ulcer to develop and increase in size to a Stage II pressure ulcer, resulting in skin breakdown, pain, the likelihood for infection and diminished overall health and wellbeing. Findings include: Record review of the facility 'Skin and Wound Guidelines' dated 3/20/2024 revealed to describe the process steps required for identification of residents at risk for development of pressure injuries, identify prevention techniques and interventions to assist with the management of pressure injuries and skin alterations. Stages of pressure injury: Stage II Partial thickness skin loss with exposed dermis .Stage III Full thickness skin loss . Deep Tissue Injury (DTI) persistent non-blanchable deep red, maroon, or purple discoloration .Skin alterations and pressure injuries are evaluated and documented by the licensed nurse. Body audits are completed routinely and documented in the resident's electronic medical record. The nursing assistant will inform the licensed nurse of any new areas of skin breakdown for evaluation and documentation. definition: Pressure Injury- Localized damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical or other device. Can present as intact skin or as open ulcer and may be painful. Injury occurs because of intense and or prolonged pressure or pressure in combination with shear and is classified by stage. Resident #1: Observation on 9/17/202 at 11:10 AM of Resident #1 who resided in room [ROOM NUMBER]-2, revealed no there was no roommate residing in room. Resident #1 was asleep with the head of bed elevated, and the resident slumped to the bottom of the bed. There was a breakfast tray set in front of resident still, thick fall mat noted at bedside, other side of bed against the wall. Upper half side rails noted to be in use bilateral. the TV was on. The Oxygen concentrator was set at 2 liters with nasal cannula looped over the concentrator and running. The oxygen concentrator was located across the room behind room divider curtain, not on resident, out of reach of resident. Resident #1's left leg was amputee, right leg/heel noted to be resting on the gray plastic mattress extender pieces at foot of the bed, there was no prafo boot noted to be visible in the room, Right post heel noted to have discoloration spot and dry flaky skin noted. Resident #1 did not arouse to her name. Record review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed a female resident with cognitive impairment. Brief Interview of Mental status (BIMS) score of 5 out 15, severe cognitive impairment. Medical diagnosis included: Debility, hypertension, peripheral vascular disease, diabetes, dementia, depression, respiratory failure. Review of the bowel/bladder assessment revealed always incontinent. Record review of section M: skin- revealed no pressure ulcers or skin issues. Record review of Resident #1's care plans pages 1- 30 revealed impaired skin related to history of right heel diabetic ulcer. Interventions: right heel allevyn foam dressing at all times for protection started on 8/26/2024. Bridge heels with pillows. Right Profa boot at all times. There was no mention of a left hip/abdomen abrasion, no treatment. Record review of Resident #1's cardiovascular care plan and other diagnosis care plans revealed that there were no interventions for the use of oxygen. Record review of Resident #1's physician orders revealed that on 8/15/2024 oxygen at 2 liters via nasal cannula while napping/sleeping to maintain oxygen saturation above 90% as needed. Observation on 9/17/2024 at 1:10 PM of Resident #1 revealed the resident was asleep with her lunch tray sitting on the bedside over table with lid off. Observed pork roast, carrots, potato cubes, chocolate ice cream. peaches or mandarin oranges in cup. Resident is sleeping with head of bed slightly elevated, noted right foot to be resting on the same spot of the gray plastic bed extensions, same as the last observation of resident. Observed a dark discolored area at back end of right heel, there were no Profa boot in place. The Profa boot was found in the closet. Resident care plan stated that Profa boot to be on. Observed Housekeeper C into room to clean, she swept and mopped the floor, wiped the tabletop and windowsill, Resident #1 did not wake up at all, loud snoring noted, oxygen noted to be left on the concentrator and running, not on or near the resident. Record review of Resident #1's 'Total body skin evaluation' dated 9/12/2024 revealed no skin abnormalities noted on assessment. Observation and interview on 9/17/2024 at 1:30 PM the state surveyor requested Licensed Practical Nurse (LPN)/Unit manager A was brought into Resident #1's room by surveyor. Both the surveyor and LPN A Observed Resident #1 to be slumped over and to be in the same position as surveyor earlier observation, asleep with no oxygen on resident, but concentrator running with nasal cannula looped over the concentrator. Observed Resident #1 to be sleeping with head slumped to side with a whole baby carrot noted in her mouth. The state surveyor revealed that the resident had not been repositioned since the 11:10 AM observation. LPN A made several attempts to move the resident or to wake her up. LPN A left the room to get nurse registered Nurse (RN) B into the room to assist with positioning. Then Registered Nurse (RN)/Infection Control Nurse I came into the room and assisted with resident repositioning. Once repositioned, the state surveyor noted the resident to have a wet brief. The three nurses rolled the resident side to side to change the brief, when there was a noted abrasion to the left hip/abdomen area that was open and had scabbed edges and was not bleeding. The Registered Nurse/Infection control I nurse stated that it was new and that she would get wound care photo of open skin area. Record review of Resident #1's 'Wound & Skin Assessment' dated 9/17/2024 at 1:50 PM revealed an abrasion to left front trochanter (hip) that was in-house acquired, new on 9/17/2024 measuring 3.78 cm length X 0.73 cm width X 0.1 cm depth with granulation noted. Doctor notified. Resident #2: Record review of Resident #2's re-admission assessment dated [DATE] identified the resident to be a mechanical lift for transfers, skin assessment noted no left foot/heel skin issues or injury and to turn/reposition every 2 hours. Record review of Resident #2's physician progress note dated 1/23/2024 at 11:54 AM identified resident required total assistance with bed mobility, transfers, and Activities of Daily Living (ADL). Identified Resident #2 was high risk for developing contractures, pressure ulcers if not receiving adequate therapy . Record review of Resident #2's nursing progress note dated 1/24/2024 at 1:45 PM revealed resident had a medium purple/maroon discoloration to left heel. Heel injury measuring 0.9 cm X 0.5 cm in-house acquired. Record review of Resident #2's wound progress note dated 2/28/2024 revealed deep tissue injury measuring 5.2 cm X 4.0 cm to left heel . Record review of Resident's #2's wound progress note dated 7/9/2024 revealed left dorsum 5th digit (toe) lateral in-house acquired blister measuring 2.4 cm X 2.3 cm (new wound). Record review of Resident's #2's 'wound & skin evaluation' dated 9/10/2024 revealed left heel stage III pressure ulcer measuring 3.5 cm length X 1.9 cm width X 0.4 cm depth. In an Interview and record review on 9/17/2024 at 3:12 PM with Registered Nurse (RN) Infection Control nurse I Wound care- On 8/15/2024 the facility started a new PCC electronic records system for the new owner company. Resident #2's wounds left foot wounds/ulcers- The top of the foot lateral foot started on 7/9/2024 as a blister with dark discoloration area. Not sure how it started. The profa boots are to be worn daily at all times. Back in December Resident #2 went to the hospital for 3 weeks and came back, then on 1/24/2024 the left heel started as a discolored area from pressure.

This Citation Pertains to Intake Number MI00136368. Based on observation, interview and record review, the facility failed to establish and operationalize policies and procedures to ensure adequate supervision and monitoring during dining and implementation of emergency medical management procedures and care for choking and respiratory distress, per professional standards of practice, for one resident (Resident #701) of two residents reviewed. This deficient practice resulted in a lack of timely identification and delivery of care, per Basic Life Support (BLS) protocols, for Resident #701 who was experiencing respiratory distress due to a presumed airway obstruction (choking), and death. Findings include: Resident #701: Review of Facility Reported Incident (FRI) intake documentation revealed Resident #701 was eating in the cafeteria on [DATE] and found to be not breathing at approximately 12:52 PM by Certified Nursing Assistant (CNA) A. CNA A notified other staff members and two nurses immediately responded to the dining room who initiated suctioning and Heimlich compressions. EMS (Emergency Medical Services) personnel arrived at the facility, did not attempt additional resuscitation efforts due to Resident #701 having a Do Not Resuscitate (DNR) order, and the Resident was pronounced dead at the scene. Record review revealed Resident #701 was most recently admitted to the facility on [DATE] with diagnoses which included heart disease, Transient Ischemic Attacks (TIA- mini strokes), dysphagia (difficulty swallowing)- oral phase (difficultly controlling food/fluids and moving to the back of the mouth to swallow), and dysphagia- oropharyngeal phase (difficulty moving food/fluid from the oral cavity to the upper part of the esophagus causing symptoms such as pulmonary aspiration and food/fluids remaining in the throat and/or mouth). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required supervision and setup assistance with eating. The MDS also detailed Resident #701 experienced, Coughing or choking during meals or when swallowing medications and was receiving a mechanically altered diet. The Resident passed away in the facility on [DATE]. A review of Resident #701's health care provider orders and order summary in the Electronic Medical Record (EMR) was completed. A code status (resuscitation) order was not noted. A review of scanned documents in the EMR revealed a form entitled, Advance Directive, originally signed by the Resident on [DATE] and reviewed on [DATE]. The form detailed Resident #701 wished to be transferred to the hospital if their medical condition deteriorated but did not want to be given CPR (Cardiopulmonary Resuscitation), which consists of mouth-to-mouth resuscitation and chest compressions . and did not wish to have a gastric feeding tube inserted for nutrition . The form did not address interventions related to respiratory obstruction/choking. The following orders related to swallowing and diet were present in the EMR: - Regular diet Dysphagia Mech Soft texture, Nectar consistency, Supervision and upright in chairs for meals. small portions (Ordered: [DATE]; Discontinued: [DATE]) - Diet Recommendation: Please advance liquids to nectar thick consistency (Ordered: [DATE]; Discontinued: [DATE]) - Late Entry: ST (Speech Therapy) Clarification: Skilled SLP (Speech Language Pathologist) services recommended 3 x/week for 6 weeks to assess and determine the least restrictive diet consistencies to maximize safest PO (oral) intake. Patient presents with high risk for aspiration due to recently reported congestion and coughing noted at meals. Recent chest x-ray ordered from nursing staff (Ordered: [DATE]; Discontinued: [DATE]) - Late Entry: ST Recertification: Continue ST services 3 x/week for 4 weeks as of [DATE] for dysphagia intervention due to need for continuation of training/education and diet trials . (Ordered: [DATE]; Discontinued: [DATE]) Review of Resident #701's care plans revealed a care plan entitled, Nutrition . I receive a mech altered, therapeutic diet, Nectar thickened liquids. I have hot beverage safety and swallow precautions. I would want gastric feeding tube placed if indicated per AD (Advance Directive) . (Initiated: [DATE]; Revised: [DATE]). This care plan was revised after the Resident died in the facility on [DATE]. Further review revealed the care plan in place, prior to the revision on [DATE], was entitled, Nutrition . I receive a mech altered, therapeutic diet, thin liquid precautions. I have hot beverage safety and swallow precautions. I would want gastric feeding tube placed if indicated per AD (Advance Directive) . (Initiated: [DATE]; Revised: [DATE]). This care plan included the interventions: - I dine in the (dining room) provide set up assist. supervision, upright for meals (Initiated: [DATE]; Revised: [DATE]). - Please provide me with a lid on my hot beverages. Provide and encourage fluids with and between meals Nectar thick (Initiated: [DATE]; Revised: [DATE]) Further review of Resident #701's care plans did not include a care plan specifically identifying the Resident's code status wishes. A care plan entitled, I reviewed my Advanced Directives on: [DATE]. I have Capacity. Date of most recent Mental Capacity statement review: [DATE]. I am capable of making my own healthcare decisions/giving informed consent, I have a Durable Power of Attorney for Finances, I have a Durable Power of Attorney for Health Care (Initiated: [DATE]; Revised: [DATE]) was present in the Electronic Medical Record (EMR). The care plan included the interventions: - Ensure that a copy of my advanced directive is on my medical record and accessible (Initiated: [DATE]) - For Code Status: Verify presence of paperwork in my chart. Verify presence of status on Point Click Care (Initiated: [DATE]) - Notify my physician of my wishes regarding life-prolonging procedures (Initiated: [DATE]) - Request for my Physician to assess my mental capacity and certify capacity or incapacity (Initiated: [DATE]) Review of facility provided investigation documentation for Resident #701 included the following: - Registered Nurse (RN) H Statement, dated [DATE]: I was in my office when CNA I informed me that a page to the dining room was needed. I observed (RN G) and (RN C) attending to (Resident #701). Resident was on their side. (RN G) was suctioning. (RN G) stated to me that Resident was Agonal in the beginning of the incident. I observed vomit on Resident. I obtained Resident's chart and code status and confirmed that (Licensed Practical Nurse [LPN] J) had called 911. When I arrived back . I observed (RN C) giving compressions while (RN G) was still suctioning. We discussed if we should take (Resident #701) out of the chair. We were not able to get (Resident #701) from their chair. Resident did not have a pulse at that time. (RN G) continued to suction foam; phlegm that was blood tinged. Resident then became absent of pulse. (EMS) then arrived . - Activity Staff K Statement, dated [DATE]: At 12:42 (PM), I was finishing up helping residents in the dining room and I did not normal talking to . (Resident #701) and I didn't notice anything out of the normal. (Resident #701) was eating . Approximately 10:30 (AM) ish, (Resident #701) was in the Activity Room . had a gurgling cough. I asked (Resident #701) if they were okay and said yes so I asked if they needed anything and (Resident #701) asked for a glass of water. I went to the kitchen and asked (Staff L) to get me a glass of water for (Resident #701) . (Resident #701 finished the water and didn't cough anymore . DON (Director of Nursing) Clarification Questions: 12:10 PM I was in dining room helping pass drinks and trays. I always read tickets to assure liquid consistency and diet. 12:42 PM: I left dining room- I went to time clock to punch out for lunch. I heard someone call for nurse. (RN C) responded to dining . I did not go back right away . - RN M Statement, dated [DATE]: I walked into the dining room at approx. 12:40 PM . I stopped and talked to (Unsampled Resident #1 sitting at table with Resident #701) . (Resident #701) was in their chair at the table with their food and drinks in front of them . didn't appear in any distress. I left the dining room . Note: Nurse Manager in Dining Room was written on the statement in different handwriting. - CNA N Statement, dated [DATE]: Today I was in the dining room as dining staff. I was feeding (Unsampled Resident #2) with my back towards (Resident #701's) table . I heard someone shout for the nurse, so I went over to see if I could help without being in the way. It was (RN G) and (RN C) laying (Resident #701's) chair back because (the Resident) was blue in the face. There was nothing I could do so I came back to the table I was at to try to wrap up and get the other residents out of the dining room . DON Interview [DATE]: 12:09 (PM) - I was in dining room. I assisted residents with drinks at various tables. Then I helped assist with outer residents with passing of trays . - CNA O Statement, dated [DATE]: I came to dining room around 12:15 PM, I was assisting two other residents with their meal. I heard (CNA A) say (my name). I got up right away and went to (Resident #701's) table. (Resident #701's) head was tilted to the left side- (the Resident) was breathing but color was blue, Nurse was summoned within seconds- suction machine was brought in. Nurses were suctioning and Heimlich maneuver. (Resident #701) did have a lot of phlegm. I then helped the nurses and stood by in case they needed my help . - LPN P Typed Statement, dated [DATE]: I was walking down the hallway and (CNA Q) called to (LPN P), 'We need a nurse'. I walk into the (dining room) and see (RN C), (RN G), and (LPN D) over (Resident #701). (Resident #701) was blue. I assisted (LPN D) with hold (Resident) upon the side of the w/c (wheelchair) in flat position. Moments later, (RN C) returns and provides chest compressions. Suction machine then becomes plugged during compressions. I open up a new yankauer and hand to (RN G). (RN G) continues suctioning. Blood noted in Yaunker. Resident noted with phlegm with particles on sided of the face. Observed (RN G) intermittently checking for pulse. Pulse was present at the time. (RN G) continues suctioning with no more matter being extracted. Resident was then observed absent of vital signs. (EMS) arrived . hooked up to monitor . pronounced deceased . - LPN D Statement, dated [DATE]: I observed nurses running into (dining room), I followed . Resident (#701) was gasping, and color was changing. (RN G) and (RN C) were attending to the Resident. (RN G) was suctioning and resident began to vomit. (RN C) and I assisted (Resident #701) to their right side while (RN G) continues suctioning. Yaunker then get clogged, and it was changed. (RN C) and I put Resident on their back and (RN C) attempts the Heimlich. RN G continued suctioning with minimal results. (EMS) arrives . take over and pronounce death . - RN G Statement, dated [DATE]: I was walking from a resident's room to the nurses' station, and I saw a female staff member walk out of the dining room and gesture in my direction and said, 'They need a nurse in there (pointed at dining room), like right now.' IO ran into the closest dining room door and yelled, 'Where?' I was directed by pointing to (Resident #701). (Resident #701) had head handing down, mucous like secretions coming out of mouth and skin on face had a bluish hue. I ran to Resident and attempted to roll them on their side while they were sitting in a cardiac chair. I was unable to on my own. I simultaneously yelled for help and the suction machine. (RN C) and (LPN D) arrive with crash cart and suction machine. I noted Resident to have agonal breathing or gasping, so Resident was lowered to a laying position and rolled on to her side. During this, she continued to have small particles of food and grey to tan mucus= like secretions pouring out of mouth. (Resident #701) was turned on right side and I was facing them. Suction machine turned on and I began suctioning their mouth. Just prior, blood was noted in the mucus like secretions. I began suctioning mouth, and it was very thick mixture of food particles, blood, and grey/tan mucus. Resident was maintained on side, pulse still palpable radially. After approximately 5 minutes, Resident's color became more blue, but thready pulse palpable and resident gasped for air and the suction tubing was clogged. A staff attempted 3 or 4 abdominal thrusts (Heimlich maneuver- to dislodge airway obstruction) - to while resident laying to attempt to dislodge and it was unsuccessful. Suctioning continued and mucus like secretions continued to pour from mouth. Pulse checked via carotid and unable to feel pulse. Resident's RN at chairside and stated Resident was a DNR. Apical pulse listened to all interventions ceased. No heartbeat noted by (LPN E). (EMS) arrived at that time., notified resident is DNR . EMS crew hooked resident up to monitor. I left at that point to wash my hands. I did not return to the scene. I am unsure of times, but it was during lunch time which is served after 12:00 PM daily. - RN C Statement, dated [DATE]: I was in the hallway and hear someone yell, 'we need a nurse.' I enter the dining room and (RN G) was approaching (Resident #701). I approached (Resident #701) and see that they were blue in color. I grab the suction machine that was located in the (dining room). Resident is placed in flat position. (RN G) suctions Resident. Resident starts vomiting and (RN G) removes Yaunker and myself and (LPN D) assist Resident to side as resident vomits. (RN G) continues suctioning. I indicate that suctioning is not producing any additional matter. I complete ,d+[DATE] thrusts with no results. Mouth was observed with no matter noted. After thrusts were completed, Resident was noted to be absent of pulse and breath. (EMS) arrives . pronounced deceased . - CNA A Typed and Signed Statement, dated [DATE]: Met with (CNA A) in dining room to review incident with (Resident #701) on [DATE]. (CNA A) indicated they were assisting (other) resident in the dining room at another table next to (Resident #701's). (CNA A) finished assisting with first resident then moved to another resident then moved to the side of the table where they assisted another resident which was in direct eyesight of (Resident #701). Approximately 10 minutes prior to the incident (CNA A) heard (Resident #701) coughing in which they asked (Resident #701) if they were ok. (Resident #701) stated . 'ok.' At approximately 12:52 PM, (Resident #701's) tablemate (Unsampled Resident #1) said, 'Hey.' (CNA A) got up to check on resident and observed . (Resident #701) to be unresponsive. (CNA A) stated there was a foam like substance coming from their mouth and their head was slumped over . stated (Resident #701's) O2 (oxygen) was on . called for help and (RN G) arrived first then (RN C) arrived to begin working on (Resident #701). - Speech Therapist (ST) R Statement, dated [DATE]: I was in dining room with (other Resident) who was located in the back of the dining room. Patient's wheelchair was visible to this therapist. I went up to the counter to get a chocolate milk . While standing at the counter, I heard (CNA O) and (CNA A) stated that (Resident #701) was not breathing, to get a nurse so I immediately ran out to hallway and yelled . that we needed a nurse. Immediately . (RN G) and (LPN D) as well as (RN C) came. From there, nurses were requesting that everyone leave the dining room . Events happened so quickly. I was unable to recall specific time. (Resident #701's) tray was barely touched- four ounce of nectar thick liquid of water was gone . looked like only had a couple of bites of meat - 90% was still on tray . - Resident #701 Paper Code Blue Record, dated [DATE]: Time Event Recognized: 12:52 (PM) . Location . Dining Room . Code Blue Called: Yes . Interventions Already In Place . Supplemental O2 (delivery rate not identified) . Time Code Blue was called: 12:53 PM . Time EMS Called: 12:53 PM . Time Family Called: 13:12 (1:12 PM) . Time Physician Notified: 1:30 PM . Status: Expired . The form did not include any vital sign measurement documentation including pulse oximetry (SPO2- percentage of oxygen in blood) nor any detail related to suction. - Written Timeline signed by RN C. The timeline was not dated and did not include a Resident Name. The document detailed the following: 12:52 (PM): Resident discovered 12:53 (PM): Nurse arrives with suction 12:53 (PM): Crash cart arrives 12:53 (PM): Resident begins vomiting, shifted resident to side 12:54 (PM): suction began again 12:56 (PM): Resident turned color, lifted in chair. Resident turning purple again. Chair reclined again. 12:56 (PM): Heimlich initiated and suction continues 12:57 (PM): First suction machine clogged with matter 12:58 (PM): Second suction machine started with minimal additional matter present 1:00 (PM): Resident non-responsive, no pulse, no breaths 1:04 (PM): (EMS) arrives- DNR provided. Resident Assessed and pronounced deceased - Typed Investigation Summary, dated [DATE]: On [DATE], (Resident #701) was in the (dining room) for lunch . At approximately 12:51 PM, (Resident #701) was observed to be unresponsive by (CNA A). (CNA A) had previously interacted with Resident approximately ,d+[DATE] min prior to noting the resident became unresponsive. (CNA A) asked (Resident #701) if they were ok because Resident coughed. The resident responded 'yes.' Several other staff passed by (Resident #701) prior to being observed nonresponsive and noted no concerns. (CNA A) was in visual line of sight assisting another resident next to (Resident #701's) table. Residents' (table mate) who is not able to recall the incident alerted to (CNA A) to the table by saying 'hey.' When (CNA A) observed the Resident to be unresponsive, (CNA A) states that resident had a foam like substance coming out their mouth with their head slumped to the side. (CNA A) observed resident to have O2 on. (CNA A) alerted other staff in dining room, (3 other CNA's and Speech Therapist). Staff alerted nurses who arrived immediately. Nurses ([RN G)] and [RN C] assessed and immediately began emergency intervention. Nurses also observed phlegm foam coming from (Resident #701's) mouth and bluish color in face. Suction machine was present in the dining room and brought to Resident's table immediately. 911 called at 12:53 PM by (LPN J). (RN G) began suctioning Resident. Resident was in a Broda chair and was placed in a flat position. (RN C) and (LPN D) were present and assisting in resident interventions. Crash cart arrives moments after (RN G begins suctioning of resident. Resident was noted to be vomiting after suctioning. Resident assisted to their side by (RN C) and (LPN D). (LPN P) also entered dining room to assist. (RN G) continues to suction. Resident sat up in Broda chair and some color returns to resident. Resident pulse is noted throughout suctioning. Nurses note color begins to fade from Resident again. Resident is still absent of any response. Resident is laid back in chair and (RN C) starts compressions consistent with protocol for unconscious choking patient to evaluate if food particle remains in airway. Several compressions were completed by (RN C) while (RN C) continues to suction and assessment oral cavity for any food particle. Second Suction machine was started as first suction machines Yankauer was noted with blood-tinged mucus and small food particle. (RN C) takes over suctioning with suction machine from crash cart. Nurses continue to assess resident, suction and assist in positioning resident to evaluate if food particle is observed in airway. Nothing visibly observed. Minimal blood-tinged mucus was removed from oral cavity with second suction machine. Resident meal plate notes mechanical ground meat with approximately ,d+[DATE] bites taken from meat (approximately 10%) with no other food touched on plate and one 4 oz nectar thick water was consumed by resident prior to resident being observed unresponsive. Speech therapist evaluated food plate and confirmed appropriate food provided based on resident diet order. Plan of care was being following ensuring that Resident eats in dining room and was in supervised setting during meals. Resident #701 had a history of dysphagia (difficulty swallowing) and an order for supervision while eating. Review of documentation in Resident #701's EMR revealed the following progress note documentation: - [DATE] at 11:46 AM: Physician Progress Note . DOS (Date of Service): [DATE] . Patient is being evaluated today for follow up in management of chronic disease . seen in room and is in no apparent distress . Neck supple, trachea midline . Cardiovascular: RRR (Regular Rate Rhythm); S1S2 (normal heart sounds). No murmurs. Pulses 1+ and symmetrical . LCTAB (Lungs Clear To Auscultation Bilaterally -normal) . exertional dyspnea (shortness of breath with exertion), no wheezes (normal), no rhonchi (normal), wears oxygen . Current Level of Function as of [DATE]: Skilled speech therapy intervention targeted completion of diet analysis and advancement trial of nectar thick liquids. Pt (patient) demonstrates good tolerance and no overt s/s (signs/symptoms) of aspiration or difficulty. Pt recommended being advanced to nectar thick liquids as tolerated. Continue POC. 2. Diet Recommendation [DATE]: Please advance liquids to nectar thick consistency. 3. Pt tolerating regular diet- Regular diet Dysphagia Mech Soft texture, Nectar consistency, Supervision and upright in chairs for meals. Small portions . - [DATE] at 2:06 PM: Nurse Note . Late Entry . Writing RN (Registered Nurse) was walking . towards the nursing station. A female staff member walked out of the far dining room door and gestured in my direction and said, 'They need a nurse in there (pointed at dining room), like right now.' I ran into the closest dining room door and yelled, 'Where?' I was directed by pointing to an obese resident sitting up in a cardiac chair. (Resident #701's) head was hanging down, greyish mucus-like secretions pouring out of mouth, and skin on face and neck had a bluish hue. I ran to resident and attempted to roll on side while sitting in the cardiac chair due to the secretions. I was unable to due to body habitus. I simultaneously yelled for help and the suction machine. (RN C) and (Licensed Practical Nurse [LPN] D) arrived with crash cart and suction machine. I noted resident to have agonal breathing or gasping for air with a pulse, so resident was lowered to laying position in preparation for Heimlich compressions as well as the code status was unknown to writing RN as I haven't cared for this resident in months, I was staffed on a different unit, there are no indicators on resident stating status, and the resident's nurse was not at chairside yet to provide the information. Resident was then turned on side because they had grey to tan mucus-like secretions pouring out of mouth. I then noted her to have blood in secretions while awaiting the suction machine to be set up. I began suctioning out thick, tan and red mucus-like secretions and very small particles of food. Resident was maintained on side, pulse still palpable radially. After approximately 5 minutes. resident's coloring became more clue (sic), but thready pulse palpable on carotid artery, and resident gasped for air. ,d+[DATE] Heimlich compressions attempted but unsuccessful due to resident being in the cardiac chair, body habitus, and safety of staff. The suction tubing became clogged with thick secretions and a blood clot. A second suction machine was available and continued to suction red mucus-like secretions. Resident had not been noted to have any additional agonal breathing or responsiveness, so pulse was checked. It was not palpable radially or via the carotid artery. Resident's nurse at chairside and stated resident was a DNR. Apical pulse auscultated and not heard, and all interventions ceased. No heartbeat noted per (LPN E). (EMS) arrived at approximately the same time, notified them that the resident is a DNR immediately, and the EMS staff connected to a telemetry monitor. Writing RN left the scene due to having resident bodily fluids on skin to wash. I am unsure of exact times, but it was during lunch time, which is served after 12 pm daily. - [DATE] at 6:06 PM: Nurse Note . At 1302 (1:02 PM), CNA called nurses station and stated nurse was needed immediately in the main dining room. Staff stated resident was in the dining room unresponsive. MMR called at 13:04 (1:04 PM). Medical examiner arrived and completed his examination and gave consent for funeral home to be called. Family called 1312 (1:12 PM) and awaited for their arrival before calling funeral home. Physician notified of resident passing at 1:30 PM. Resident transferred from dining room to bedroom where post-mortem was completed. Family remained at resident's bedside until 4:40 PM, family called funeral home before their departure from the building. Funeral home arrived at 5 pm to transfer body to funeral home . - [DATE] at 6:13 PM: Discharge Summary . Patient has been discharged from the facility. Patient found unresponsive at 1304 (1:04 PM) . (EMS) was called. Medical Examiner arrived and examined the patient and pronounced death. Family called at 1312 . Funeral Home was called and arrived at 5:00 PM to transfer patient . Patient is DNR Code Status. Further review revealed Resident #701 was a high risk for aspiration and was treated for aspiration pneumonia in February/[DATE] and documentation of improvement in aspiration pneumonia in April and [DATE]. Review of the EMS report for Resident #701 detailed, Prehospital Care Report . [DATE] . PSAP (Public Service Answering Point- 911) Call Date/Time: [DATE] 12:53:35 (PM) . Arrived at Patient Date/Time: [DATE] 13:00:00 (PM) . Cardiac Arrest: Yes, Prior to EMS Arrival . Cardiac Arrest Etiology: Other. Resuscitation Attempted By EMS: Initiated Chest Compressions. Arrest Witnessed By: Witnessed by Healthcare Provider. CPR Care Provided Prior to EMS Arrival: Yes. Who Provided CPR Prior to EMS Arrival: Healthcare Professional (Non-EMS) . Type of CPR Provided: Compressions-Continuous . First Monitored Arrest Rhythm of the Patient: PEA (Pulseless Electrical Activity- electrical activity in the heart with no heartbeat) Date/Time of Cardiac Arrest: [DATE] 12:54:00. Date/Time Resuscitation Discontinued: [DATE] 13:00:00. Reason CPR/Resuscitation Discontinued: DNR. Cardiac Rhythm on Arrival at Destination: PEA. End of EMS Cardiac Arrest Event: Expired in the Field . Patient Care Report Narrative: Dispatched . for choking. Changed to cardiac arrest. ATF (Arrived to Find) pt (patient) unresponsive and not breathing sitting in a recliner. Staff states that pt was just started eating and began to choke. Staff worked to help with the choking. Staff states that pt turned blue and stopped breathing. CPR was started but staff stopped because pt was a DNR . ME (Medical Examiner) is requested. Monitor is placed and pt is PEA. ME arrived and pt was turned over to them . Incident/Patient Disposition: Patient Dead at Scene-No Resuscitation Attempted (Without Transport) . An interview was conducted with Dietary Manager B on [DATE] at 2:25 PM. When queried if they observed the events on [DATE] involving Resident #701, Manager B replied, No, I was in the kitchen, not the dining room. Manager B was then asked how they were made aware and replied, My staff let me know they were evacuating (other) residents from the dining room, so they didn't have to see that. When asked if Resident #701 usually ate in the dining room, Manager B replied, Yes. Manager B was queried regarding the level of assistance Resident #701 required when eating and stated, Supervision. A list of all dining staff working on [DATE] was requested from Manager B at this time. On [DATE] at 2:50 PM, an interview was completed with Dietary Staff F. When queried if they recalled what occurred during lunch in the dining room on [DATE] with Resident #701, Staff F revealed they did. Staff F was asked to relay their observations of what occurred and revealed they were working at the serving line that day. Staff F stated, I was getting a thickened milk for someone in therapy. I looked over and happened to see RN C coming in (the dining room) with something and somebody went to go get some help. When queried, Staff F stated, (Resident #701) was in their chair, like laying down, on their side. Staff F revealed they asked a nursing staff member what they could do to help and were asked to assist in getting other residents out of the dining room. Staff F was asked if they saw Resident #701 in the dining room before the emergency situation and replied, (Resident #701's) back was to me when they would be eating. At 3:10 PM on [DATE], the facility Administrator approached this Surveyor and asked the reason dining staff were being interviewed. When queried the reason dining room staff were not interviewed as part of the facility investigation, the Administrator indicated they had interviewed clinical staff. No further explanation was provided. Video footage of the Front Camera from the dining room on [DATE] was received on [DATE] at 2:30 PM. Due to where Resident #701 was sitting in the dining room, they were unable to be visualized until after staff responded to their respiratory distress. However, the corner of the table they were sitting at was identified. A tour of the dining room was completed, and a second camera was observed at the other side of the dining room, facing the table Resident #701 had been seated at. Video footage from the second camera was requested from the Administrator. An interview was conducted with RN C on [DATE] at 3:21 PM. When queried what had occurred on [DATE], RN C stated, I was called into the dining room. I saw (RN G) was getting to (Resident #701) as I was getting there so I turned around to get the suction machine. RN C indicated they returned to the dining room and stated, I started hooking up the suction machine. RN C was asked what needed to be hooked up and revealed they had to locate a power outlet and connect the suction tubing and Yankauer (hard plastic suction device commonly used to suction oral secretions from oral cavity). When queried regarding the Resident's clinical condition at that time, RN C replied, I was more concerned to get the suction hooked up and (RN G) was working with (Resident #701). When queried where and what position Resident #701 was in at that time, RN C revealed RN G had leaned Resident #701 back in their Broda chair (high backed, wheeled chair for positioning with padded, solid leg and footrest, folding footrest, cushioned arm rest support, and bilateral lateral raised wings on each side of the upper portion of the chair, near the head). When asked what the nursing staff had assessed/identified as the concern, RN C revealed, They were choking. RN C was then asked why the Resident was leaned back in their Broda chair and replied, To help (Resident #701) breath. When queried how far the chair was reclined, RN C indicated the chair was flat. RN C then stated, (Resident #701's) color returned and we (staff) could hear (Resident #701) breathing and trying to clear it. When asked if the Resident was conscious, RN C and how they were attempting to clear the respiratory obstruction, RN C revealed the Resident was conscious and coughing but not talking. RN C then stated, You could hear (Resident #701) breathing but not good. RN C was asked to clarify and indicated the Resident's respirations were labored. RN C [TRUNCATED]

This Citation pertains to Intake Number MI 365. Based on observation, interview and record review, the facility is placed in Immediate Jeopardy for its failure to (1.) use an Automated External Defibrillator (AED) and provide Cardiopulmonary Resuscitation (CPR) during a [CONDITION(S)] event for one resident (Resident #116) in violation of facility CPR Policy and the Basic Life Support (BLS) Standards of Care. (2.) Accurately document Cardiopulmonary Resuscitation efforts for two residents (Resident #116 and Resident #268) who expired at the facility. This deficient practice places all residents, who are designated as a Full Code and who suffer [CONDITION(S)] or are found unresponsive, at risk for serious harm and/or death. Immediate Jeopardy: Immediate Jeopardy began on [DATE]. Immediate Jeopardy was identified on [DATE]. NHA was notified of the Immediate Jeopardy on [DATE] at 4:00 PM. Immediate Jeopardy was abated or removed on [DATE]. Immediate Jeopardy began on [DATE] at 4:00 AM, when, per interview done on [DATE] at 2:00 PM, Registered Nurse (RN) A stated that on [DATE] at 4:00 AM Resident #116 had heavy breathing and shortness of breath and there were no vital signs or oxygen saturation levels noted. Per facility provided typed statement of RN A revealed that Resident #116 was breathing hard, nostrils were flaring, had intercostal contractions. RN A was noted to level Resident #116 to go help with a catheterization and bladder scan on another resident. Around 4:30 AM it was noted Nurse A went back to Resident #116's room and found the resident not breathing. RN A assessed for a pulse with a stethoscope for a full 2 minutes and no heart sounds. RN A did not check a code status on Resident #116 or initiate immediate cardiopulmonary resuscitation (CPR). Record review of facility 'Code Status' policy dated [DATE] revealed on admission, the licensed nurse will document the resident's choice of code status on the Advanced Directive form. The Licensed nurse is also responsible for entering the Code Status in the electronic medical record. The resident will be treated as Full Code until the advanced directives are in place. Code status will be documented in the care plan in the electronic medical record . Cardiopulmonary Resuscitation (CPR) will be initiated on all full code residents no matter their condition at the time they are found. Record review of Basic Life Support/Emergency Medical technicians (EMT) 'Prehospital Care Report' dated [DATE] arrived at patient at 5:24 AM. Crew arrived on scene to police and staff stating that they believe this is going to be a code 12. Staff did not initiate compression or ventilation and did not place an AED (Automated External Defibrillator) on patient. Crew went into patient's room to find [AGE] year-old female on her bed in [CONDITION(S)]. Crew examined patient . Crew initiated compressions at 5:26 AM. Fire arrived to room and assisted crew to move patient from bed to floor . In an interview on [DATE] at 2:40 PM with the Nursing Home Administrator (NHA) and Director of Nursing (DON). The NHA stated that it was an Immediate Jeopardy situation and had a Past non-compliance packet for surveyor. The past Non-compliance Packet reviewed, and PNC form filled out and rejected. Survey Manager made aware of Past Non-compliance packet for review. Record review of the 59-page Past Non-Compliance packet received from the facility revealed that there were mock code assessment forms filled out with time frames and comments. There was no step noted for checking code status of unresponsive resident. There was no documentation of Code Blue Record' for times and sequence of initiated CPR or AED use per facility policy noted missing from the Past Non-Compliance packet. There were no audits of monitoring of resident code statuses or of new admissions in the packet. The Immediate Jeopardy was identified on [DATE]. The Administrator and Director of Nursing were notified on [DATE] at 4:00 PM of the Immediate jeopardy that began on [DATE] at 4:00 AM, due to the facility's failure to implement the use of the facility's Automatic External Defibrillator (AED), initiate compressions or ventilation, or documentation of the facility 'Code Blue Record' during a [CONDITION(S)] event for Resident #116 on [DATE] at 4:30 AM. Findings include: Resident #116: Resident #116 was admitted to the facility from the hospital setting on [DATE] at 11 AM. Record review of Resident #116's Admission assessment dated [DATE] at 11:00 AM revealed respirations of 16 breaths/minute with 92% oxygen saturation on room air. Resident #116 was noted to be oriented to person, place, time and able to understand Record review of Resident #116's electronic medical record revealed late entry physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Another late entry physician note dated [DATE] at 12:08 PM revealed Record review of Resident #116's progress notes revealed on [DATE] at 12:24 PM IDT (Inter-Departmental Team) meeting noted resident admission from hospital and medications reviewed with physician, and baseline care plan initiated. The next progress note was not until [DATE] at 4:00 AM when resident is noted to have heavy breathing and shortness of breath. The resident was repositioned and pulled up in bed with elevated head of bed slightly by Registered Nurse (RN) A. There were no oxygen saturation levels or vital signs taken at that time, no documented lung sounds, or physical assessment noted by RN A with a change of condition. Record review of Resident #116's vital signs: last blood pressure taken on [DATE] at 4:23 PM was ,d+[DATE]. Last pulse taken on [DATE] at 4:23 PM was 91 beats per minute (bpm). Last respirations taken on [DATE] at 4:23 PM was 18 breaths/minute. Oxygen saturation summary taken on [DATE] at 4:22 PM was 100%, [DATE] at 11:22 PM oxygen saturation level 96%, and [DATE] at 1:29 AM oxygen saturation level 95%. Progress note dated [DATE] at 6:42 AM written by Registered Nurse A revealed: family/son notified of resident expired. Progress note dated [DATE] at 06:45 Note Text: At 04.30 went in to check on the patient and repositioned her still having shortness of breathing her SPO2 was 95% and requested to be repositioned to the left side. At 04.30 I checked on the patient no respiration was observed and was pulseless a code was initiated, and CPR was started immediately. DON was informed and 911 call was placed at 04.32 and Township were on site 04.35 followed by MMR was on site at 04.36 Family was called and informed of the condition of her parent. Physician was called and informed of the patient. Record review of Basic Life Support/Emergency Medical technicians (EMT) 'Prehospital Care Report' dated [DATE] arrived at patient at 5:24 AM. Crew arrived on scene to police and staff stating that they believe this is going to be a code 12. Staff did not initiate compression or ventilation and did not place an AED (Automated External Defibrillator) on patient. Crew went into patient's room to find [AGE] year-old female on her bed in [CONDITION(S)]. Crew examined patient . Crew initiated compressions at 5:26 AM. Fire arrived to room and assisted crew to move patient from bed to floor . Interviews: In an interview on [DATE] at 1:19 PM with Licensed Practical Nurse (LPN) B agency staff revealed: That she worked with Registered Nurse (RN) A that night [DATE]-[DATE] night shift). LPN B stated that nurses get report, from the previous shift, lots of residents around 40 on that unit. That day RN A's computer was not working or something on the [NAME] Hallway. There are two medication carts. In the morning LPN B was doing medication pass and there was a hospice patient (Resident #118) and then Resident #116 was in the next room. In the morning RN A came down the hall to the nursing station and said that his lady had just passed away. Around ,d+[DATE]:30 AM, I asked Resident #118? he said yes. LPN B finished her medication pass. LPN B said she would come down and help RN A. LPN B looked in Resident #118's room and she was still alive. LPN B went to find RN A and we went down the hall to Resident #116's room, she was in the room before the hospice Resident #118's Room. It was a different room, LPN B went to Resident #116's bedside, LPN B asked is she a full code, RN A said no a Do Not Resuscitate (DNR). LPN B stated that We didn't do anything at that time. Then we went to the nursing station, and I called the Director of Nursing (DON) to report the resident death. The DON was trying to figure out which resident we were talking about. Then RN A went to the DON's office and then the DON came to the nursing station and stated that she was a full code. It was the end of the shift; we took the crash cart down the hall, and I went home. In an interview on [DATE] at 2:00 PM with Registered Nurse (RN) A via phone: Revealed Resident #116 came to the facility from the hospital. (Shift) Report was given to RN A about Resident #116 with difficulty in breathing, she had cancer. they were told her condition would get better. That night we had computer problems. RN A was told about Resident #116 and that she was short of Breath (SOB) on 2 lt. nasal cannula, pale and sickly looking. Why did the facility try to bring her here if we didn't have treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] ? the treatment was oxygen. Vital signs were OK, oxygen saturations were in the 90%, I had 30 residents that night. I had the next room where Resident #118 (hospice resident) was and this lady (Resident #116). I kept my eyes on them, checking on them. I went back to check on her and she would remove her oxygen cannula. RN A stated he had Certified Nurse Assistant (CNA) C working with him. I had a few things to do, (straight catheterize a resident) I had to take a long time to get to it. RN A stated that he worked at (the facility) as needed (PRN), contingent. RN A revealed that he did not know the population very well as he should have. RN A stated that he did not have access to the computer system. It was after midnight when he did get access. RN A stated that he kept checking on residents. RN A stated that around 4:00 AM Resident #116 was still restless. RN A stated that he went back (at 4:30 AM) and Resident #116 wasn't breathing. Around 5 AM or later RN A had to let the Director of Nursing (DON) know that the Resident #116 expired. RN A went to the Director of Nursing office, (off the unit) and she looked up the resident, due to the confusion with the hospice Resident #118, and she stated that the Resident #116 was a Full Code. RN A stated he went back to the nursing unit and grabbed the crash cart and went to the room. She was deceased after that. RN A stated that at 4:00 AM I saw her I was passing meds (medications). Record review of Registered Nurse (RN) As typed In an interview on [DATE] at 2:30 PM with Information Technologist J revealed he reviewed all the (facility) computers and they were working the night ([DATE]-[DATE]) that Registered Nurse (RN) A was working. IT J was asked to write a note for the file. Record review of IT note was done. IT J stated that RN A never called with computer problems, and that he is available ,d+[DATE] and keeps a log of the calls. Call log reviewed, with no calls from nurse A noted. In an interview on [DATE] at 2:40 PM with the Nursing Home Administrator (NHA) and Director of Nursing (DON). The NHA stated that it was an Immediate Jeopardy situation and had a Past non-compliance packet for surveyor. The past Non-compliance Packet reviewed, and PNC form filled out and rejected. Survey Manager made aware of Past Non-compliance packet for review. The NHA and DON both denied referring Registered Nurse As nursing license to the Bureau of Professional Licensing for review. . On [DATE] at 3:30 PM the State Surveyor requested facility 'Code Blue Record' form found in the crash cart binder for all code blues in facility. The NHA notified surveyor that there was no documentation of code blue performed. The NHA stated that it wasn't done we don't have a form filled out. Resident #116: In an interview on [DATE] at 3:50 PM with the Director of Nursing (DON) revealed: We reviewed the video but didn't save it, that's how we got a timeline. Surveyors were given a timeline that was not part of the Past Non-Compliance (PNC) packet. The surveyor noted inconsistent interviews with PNC packet. The DON stated that she was here that day, she came in at 4:30 AM usually. The DON stated that she had a routine, she gets ready for the morning meeting, review orders and stuff. A Half hour after she got here (to facility), she got a call that the resident had passed away. The DON got a different resident name Resident #118 then the one that died (Resident #116). The DON stated that she was told that Resident #118 (hospice resident) had died , she was a Do Not Resuscitate (DNR) and hospice. The DON was not a surprise. The DON stated that some time went by, maybe ,d+[DATE] minutes that she was notified, then the DON was notified that it was not Resident #118 (hospice resident). The DON stated that she didn't get a name yet. It was Licensed Practical Nurse (LPN) B that called me. She said that Registered Nurse (RN) A came down the hallway to tell me. The DON stated that she was dealing with the lab tech getting him his blood draw information. Registered Nurse A came to her office. RN A was showing her his report sheet, showed her that it was a room number and a DNR. So, I went to the electronic record to check the code status in electronic medical record and told him that she was a Full Code and to get back there and start CPR, and she called 911. We did a timeline from the hallway video. We reviewed it for the investigative file (but did not save for the investigation). The surveyor had the DON review the investigative file and there was no timeline provided in the investigation provided to the state agency. In an interview on [DATE] at 11:25 AM with licensed Practical Nurse (LPN) O stated that she gave report to Registered Nurse (RN) A. LPN O stated that she did not really recall Resident #116 as a resident. Resident #116 was Short of Breath (SOB), stating Resident #116 came in SOB always was Short of breath no matter what she did. LPN O stated that Resident #116 had Lung cancer and just always SOB. I think she was terminal. I don't know if she (Resident #116) was a full code or not. Resident #116 had mets (metastasis-spread) to the body. LPN O stated that she really didn't remember anything else. In an interview on [DATE] at 8:22 PM with Certified Nurse Assistant (CNA) D revealed that she was working that night with Registered Nurse (RN) A and Licensed Practical Nurse (LPN) B as the nurses. CNA D stated that she already gave a statement to the consultant lady. CNA D stated that the lady (Resident #116) that passed away was in room ,d+[DATE]. There was a hospice lady (Resident #118) in room ,d+[DATE]. RN A the nurse got them mixed up. He thought the hospice lady (Resident #118) passed away. It was me and CNA.C working RN A wanted us to help him straight catheter a lady in room ,d+[DATE]. On the way into room ,d+[DATE] before the straight catheter RN A stated to us that the lady in ,d+[DATE] had passed away. It was before we started the straight catheter procedure. It took us ,d+[DATE] minutes to position and straight catheter the lady. Then CNA C went to room ,d+[DATE] and she (Resident #118) was still alive. CNA C went out and told RN A that Room ,d+[DATE] was still alive. RN A said no it was the other lady, room ,d+[DATE], he mixed up the rooms. He looked down the hallway to see what room he was in. He was not very familiar with our residents. CNA D said that she stated didn't that lady just get here to the facility? was she supposed too passed away? I don't know if they tried to do CPR, it was at shift change 5:30 AM close to 6:00 AM. RN A and CNA C went to the room, we were at the desk when we found out she was a full code. When we found out she wasn't supposed to pass, I believe the Director of Nursing (DON) told them she was a full code, and the DON went to the front door to let the EMS in. In an interview on [DATE] at 11:33 AM with Certified Nurse Assistant (CNA) C revealed That was her first time working with Resident #116. CNA C stated that she received report from second shift stated (Resident #116) would call if she needed anything. She did not call, so halfway through the shift (10:00 PM to 6:00 AM) around 1:00 AM, CNA C checked on Resident #116, she was sleeping, had oxygen on, I left her alone. CNA C stated that then Registered Nurse (RN) A was giving pills and he came out into the hall and said that the lady in room [ROOM NUMBER] had passed away. I went to room [ROOM NUMBER] to check the resident. I went into the room [ROOM NUMBER], I said Hello, the resident #118 (hospice resident) woke up and I said that someone had told me you had passed away. Resident #118 said, I'm not dead yet. I went out to RN A the nurse and I said that she's still alive. He said I meant room ,d+[DATE]. I went to room ,d+[DATE], she was definitely dead. She was cold to me. I started postmortem care, cleansed her face, and cleaned her up the shower aide Certified Nurse Assistant R helped me. CNA C stated that she washed Resident #116's face, did a bed bath, put on a clean gown, and put the sheets back over her. CNA C stated that she was presenting Resident #116 for family viewing. CNA C had just covered her back up when RN A came into the room with the Automated External Defibrillator (AED but didn't put it on the resident, and then the EMS came. I left the room when the EMS put her on the floor and started working. I had to go back in later, put her back into the bed and dress her again. None of the four staff members (2- Licensed nurses and 2- Certified Nurse Assistance) working at the time of the event/incident checked Resident #116's code status in the electronic medical record or the hard binder chart located at the nursing station within reach. Policy review: Record review of facility 'Code Blue Procedure' policy dated [DATE] revealed if the resident is unresponsive: attempt to arouse, if no response, yell for help and give location and note the time. Verify the code status. Page code blue and location, three times, call 911 and responsible party. Obtain crash cart. Direct any staff member to record on the 'Code Blue Record' which is located on the clipboard on the crash cart. Record review of facility 'Acute Change of Condition' policy dated [DATE], revealed the facility strived to provide care that enables each resident to achieve and maintain the highest practicable level of living possible for him/her given his/her physical and mental conditions. In order to do so, prompt identification, assessment, and intervention should occur when a resident experiences an acute change in condition that may be reversible or that may have the effects mitigated by prompt medical attention. Assessment and Problem Recognition: Upon admission the licensed nurse performs a baseline history and assessment on the resident. The nursing staff establishes the resident's baseline vital signs by monitoring and recording these each shift for 72 hours following admission noting these in the medical record. (a.) The Certified Nursing Assistant takes the vital signs of the resident once per shift for the first 72 hours after admission and records in the medical record. (2.) When interacting with residents, staff is to note any changes in the resident . (3.) The licensed nurse promptly assesses the resident. If the assessment determines that the resident may be experiencing an acute change in condition, the licensed nurse will contact the physician for further directives . (4.) The licensed nurse describes the symptoms in detail and accurately in the medical record. Record review of Registered Nurse (RN) A typed interview dated [DATE] (should have been dated [DATE]) provided in the Past Non-Compliance packet revealed: Resident #116 was use 2 liter (oxygen) and RN A put it (oxygen) up to 4 liters because he assumed she was breathing harder with her shortness of breath. RN A had another resident with a bladder scan and went to look for someone to assist him with the scan. RN A found the nursing assistance. RN A checked on Resident #116 describing shortness of breath, nostrils flaring, with intercostal contractions, breathing hard not the way she was supposed to be breathing. On [DATE] at 9:00 AM received Abatement plan from facility and was reviewed and sent to survey manager via email. On [DATE] at 3:00 PM surveyor received phone acceptance of the abatement plan from the survey manager. The Immediate Jeopardy was abated on [DATE], based on confirmation during interviews conducted on [DATE] at 3:00 PM, that the facility had implemented the following to remove the immediate jeopardy. 1.) On [DATE] the facility Identify those residents who have suffered, or are likely to suffer, serious adverse outcome as a result of noncompliance; and All residents residing in the community have the potential to be affected. On [DATE] All resident's charts were audited by the unit managers to verify that code status is in paper chart and EMR. o as of [DATE] at 5:00 PM, all resident charts have been audited and confirmed code status is in place for all residents. On [DATE] at 10:00 am - second Ad Hoc QAPI committee meeting was held to review the progress of the PIP implemented on Friday [DATE]. o Additional discussion included verification that door name tags were accurate on rooms, chart photos were all up to date in the EMR and Hard Charts on the units had the correct room numbers to be added to the PIP action plan. o All door tags audited by Unit Manager and found 2 residents without name tags on door, this was corrected. o All charts audited by Unit Manager for resident photo and found 5 residents without a photo. Photos were obtained and uploaded to chart o All hard charts audited for proper room number and 12 found with incorrect room numbers. These were updated. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. 2.) The facility QAPI committee met on [DATE] at PM and again on [DATE] to complete a root cause analysis of the delay in initiating CPR per code status. Based on findings from the interviews and the QAPI committee discussion, the following actions were implemented and will be completed by [DATE], to reduce likelihood of recurrence: [DATE] at 6:30 am, the facility implemented immediate education to direct care licensed nurses on change of condition, notification of provider, and how to respond when finding a resident unresponsive. This was implemented by the Director of Nursing or Education Director. o as of [DATE] at 5:00 PM, ,d+[DATE] direct care licensed nurses completed this education. On [DATE] at 8:00 am - All nurses files were reviewed by the nurse educator for verification of BLS Certification. It was noted that all nurses are in compliance with current BLS Certification. On [DATE] at PM - Ad Hoc QAPI held to review investigation findings and implemented PIP action plan. On [DATE] All resident's charts were audited by the unit managers to verify that code status is in paper chart and EMR. o as of [DATE] at 5:00 PM, all resident charts have been audited and confirmed code status is in place for all residents. [DATE] at 4:00 PM - Administrator evaluated available computers/laptops for nurse use and identified that there are sufficient numbers on each unit in addition to a desktop computer. On [DATE] at 5:00 PM - The policy code status/advance directives were reviewed by the Director of Nursing and Administrator and deemed appropriate. On [DATE] at 10:30 PM - Mock code was conducted by the nurse educator with third shift staff with 8 staff present and participating. 3.) On [DATE] at 10:00 am - second Ad Hoc QAPI committee meeting was held to review the progress of the PIP implemented on Friday [DATE]. o Additional discussion included verification that door name tags were accurate on rooms, chart photos were all up to date in the EMR and Hard Charts on the units had the correct room numbers to be added to the PIP action plan. o All door tags audited by Unit Manager and found 2 residents without name tags on door, this was corrected. o All charts audited by Unit Manager for resident photo and found 5 residents without a photo. Photos were obtained and uploaded to chart o All hard charts audited for proper room number and 12 found with incorrect room numbers. These were updated. o A weekly audit of 3 resident rooms per week will be added to QAPI monitoring for compliance. 4.) On [DATE] at 11:30 am - IT evaluation for proper functioning of laptops for nurse utilization was completed and all found to be functioning properly. [DATE] at 3:00 PM - Implemented QAPI audits to determine ongoing compliance of 3 nurses per week with reporting to the QAPI committee to determine ongoing need for review. [DATE] at 3:00 PM - Implemented QAPI audits to ensure door tags, resident photo, and hard chart room numbers are all up to date On [DATE]- The facility will be re-educating direct care nurses on taking immediate action to implement policies and procedures to immediately ascertain the Code status of a resident who is found unresponsive and act in accordance with the parameters of the code status. The following policies were presented as education to direct care nurses by the Inservice Director. CPR Change of condition-The policy includes notification of provider and accurate documentation of events in the medical record Code Blue Procedure with the emphasis with utilizing the Code Blue Record As of [DATE] 8:00 AM 14 Nurses are educated. Resident #268: On [DATE], at 9:49 AM, a record review of Resident #268's electronic medical record revealed the following progress notes: [DATE] 14:30 Nurse Note Late Entry: Note Text: Resident was observed maybe an hour prior to incident. And family was fighting with each other, resident seemed to be fine sitting in her chair, and the daughter stated so, nurse was in room for 5 min (minutes) or more talking with daughter. AED was used and no shock advised. [DATE] 14:30 Nurse Note Late Entry: Note Text: Resident was pronounced at 14:06, 911 was call and CPR was performed. Family states she was yelling as normal to go to bed, but had to wait up for therapy. She was mad and refused to eat for her daughter. She closed her eyes and put her head down as usual when upset with the family. Family, therapy and CENA believed resident was tired also from sitting up since breakfast. Family asked nurse to check her to see if she was asleep or something else was wrong, patient did not respond, SPO2 (oxygen blood saturation) was checked, it was low, 911 was called, CPR continued until responders for EMS arrived and took over. On [DATE], at 11:00 AM, The Director of Nursing (DON) was asked to provide any additional documentation or the code blue sheet for the CPR for Resident #268 and the DON stated, there wasn't one. The DON was asked to provide the EMS call record for Resident #268. On [DATE], at 11:25 AM, Nurse O was interview regarding Resident #268's CPR efforts. Nurse O stated, that the resident would often put her head down when family was there because they tried to get her to eat. The family came and got me to go check on her so I entered and she was unresponsive. Nurse O further offered that It took about five staff to get her into the bed. Her oxygen sat was low around 40%. Nurse O stated they initiated the code blue protocol and 911 was called. Nurse O stated the resident already had oxygen applied, CPR was started once she was in bed and until EMS arrived. Nurse O stated the AED was applied but no shock was advised. Nurse O was asked if they documented the CPR timeline on a code blue sheet, piece of paper or possible a napkin from the room and Nurse O stated, no that they were performing the CPR and was unsure if another staff member was keeping the timeline but offered generally, someone tries to take notes. Nurse O was asked if they were able to recall what time chest compressions were stated, when the AED was placed, when 911 was called, how and when the oxygen was provided, when EMS arrived or when the crash cart was brought to the room and Nurse O stated, no they couldn't recall. Nurse O was asked if that was an important medical procedure and why wasn't it documented and Nurse O stated, we should have done a better job at documenting it. On [DATE], at 11:30 AM, a record review along with Nurse O of Resident 268's medical record revealed the last documented vitals on [DATE] was at 8:15 AM. A review of the progress notes documented by Nurse O was conducted with Nurse O. Nurse O read the progress notes that were timed at 2:30 PM and stated, I think the CPR was started around lunch time because the family was trying to get her to eat and lunch is at 11:30 am. Nurse O stated, I see what mean on the documentation. On [DATE], at 8:30 AM, a record review of the Ambulance Call sheet revealed [CONDITION(S)]: Yes Prior to EMS Arrival . AED Use Prior to EMS Arrival: Yes, applied without defibrillation . Upon arrival pt (patient) was in [CONDITION(S)]. Compressions already initiated, bag valve mask being used. Placed on monitor showing asystole . Family stated that they thought she fell asleep in her chair but that they weren't sure if she had been breathing for the prior 30 mins (minutes) .

Based on interview and record review, the facility failed to do a complete assessment, monitor and provide care, per professional standards of practice for one resident (Resident #116) who had a change of condition with heavy breathing and shortness of breath and who was then found unresponsive, resulting in delayed emergency medical care/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: Record review of facility 'Acute Change of Condition' policy dated ,d+[DATE], revealed the facility strived to provide care that enables each resident to achieve and maintain the highest practicable level of living possible for him/her given his/her physical and mental conditions. In order to do so, prompt identification, assessment, and intervention should occur when a resident experiences an acute change in condition that may be reversible or that may have the effects mitigated by prompt medical attention. Assessment and Problem Recognition: Upon admission the licensed nurse performs a baseline history and assessment on the resident. The nursing staff establishes the resident's baseline vital signs by monitoring and recording these each shift for 72 hours following admission noting these in the medical record. (a.) The Certified Nursing Assistant takes the vital signs of the resident once per shift for the first 72 hours after admission and records in the medical record. (2.) When interacting with residents, staff is to note any changes in the resident . (3.) The licensed nurse promptly assesses the resident. If the assessment determines that the resident may be experiencing an acute change in condition, the licensed nurse will contact the physician for further directives . (4.) The licensed nurse describes the symptoms in detail and accurately in the medical record. Record review of the facility 'Acute Change of Condition' policy and 'Guidelines for Reporting to Physician' policy revealed the condition for shortness of breath was not addressed or/nor guidance to report assessment to physician. Resident #116: Resident #116 was admitted to the facility from the hospital setting on [DATE] at 11 AM. Record review of Resident #116's Admission assessment dated [DATE] at 11:00 AM revealed respirations of 16 breaths/minute with 92% oxygen saturation on room air. Resident #116 was noted to be oriented to person, place, time and able to understand Record review of Resident #116's electronic medical record revealed late entry physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Another late entry physician note dated [DATE] at 12:08 PM revealed Record review of Resident #116's progress notes revealed on [DATE] at 12:24 PM IDT (Inter-Departmental Team) meeting noted resident admission from hospital and medications reviewed with physician, and baseline care plan initiated. The next progress note was not until [DATE] at 4:00 AM when resident is noted to have heavy breathing and shortness of breath. The resident was repositioned and pulled up in bed with elevated head of bed slightly by Registered Nurse (RN) A. There were no oxygen saturation levels or vital signs taken at that time, no documented lung sounds, or physical assessment noted by RN A with a change of condition. Record review of Resident #116's vital signs: last blood pressure taken on [DATE] at 4:23 PM was ,d+[DATE]. Last pulse taken on [DATE] at 4:23 PM was 91 beats per minute (bpm). Last respirations taken on [DATE] at 4:23 PM was 18 breaths/minute. Oxygen saturation summary taken on [DATE] at 4:22 PM was 100%, [DATE] at 11:22 PM oxygen saturation level 96%, and [DATE] at 1:29 AM oxygen saturation level 95%. Record review of Registered Nurse (RN) A typed interview dated [DATE] (should have been dated [DATE]) provided by the facility revealed: Resident #116 was use 2 liter (oxygen) and RN A put it (oxygen) up to 4 liters because he assumed she was breathing harder with her shortness of breath. RN A had another resident with a bladder scan and went to look for someone to assist him with the scan. RN A found the nursing assistance. RN A checked on Resident #116 describing shortness of breath, nostrils flaring, with intercostal contractions, breathing hard not the way she was supposed to be breathing. Record review of facility 'Code Status' policy dated [DATE] revealed on admission, the licensed nurse will document the resident's choice of code status on the Advanced Directive form. The Licensed nurse is also responsible for entering the Code Status in the electronic medical record. The resident will be treated as Full Code until the advanced directives are in place. Code status will be documented in the care plan in the electronic medical record . Cardiopulmonary Resuscitation (CPR) will be initiated on all full code residents no matter their condition at the time they are found. In an interview on [DATE] at 8:22 PM with Certified Nurse Assistant (CNA) D revealed that she was working that night with Registered Nurse (RN) A and Licensed Practical Nurse (LPN) B as the nurses. CNA D stated that she already gave a statement to the consultant lady. CNA D stated that the lady (Resident #116) that passed away was in room ,d+[DATE]. There was a hospice lady (Resident #118) in room ,d+[DATE]. RN A the nurse got them mixed up. He thought the hospice lady (Resident #118) passed away. It was me and CNA.C working RN A wanted us to help him straight catheter a lady in room ,d+[DATE]. On the way into room ,d+[DATE] before the straight catheter RN A stated to us that the lady in ,d+[DATE] had passed away. It was before we started the straight catheter procedure. It took us ,d+[DATE] minutes to position and straight catheter the lady. Then CNA C went to room ,d+[DATE] and she (Resident #118) was still alive. CNA C went out and told RN A that Room ,d+[DATE] was still alive. RN A said no it was the other lady, room ,d+[DATE], he mixed up the rooms. He looked down the hallway to see what room he was in. He was not very familiar with our residents. CNA D said that she stated didn't that lady just get here to the facility? was she supposed too passed away? I don't know if they tried to do CPR, it was at shift change 5:30 AM close to 6:00 AM. RN A and CNA C went to the room, we were at the desk when we found out she was a full code. When we found out she wasn't supposed to pass, I believe the Director of Nursing (DON) told them she was a full code, and the DON went to the front door to let the EMS in. In an interview on [DATE] at 11:33 AM with Certified Nurse Assistant (CNA) C revealed That was her first time working with Resident #116. CNA C stated that she received report from second shift stated (Resident #116) would call if she needed anything. She did not call, so halfway through the shift (10:00 PM to 6:00 AM) around 1:00 AM, CNA C checked on Resident #116, she was sleeping, had oxygen on, I left her alone. CNA C stated that then Registered Nurse (RN) A was giving pills and he came out into the hall and said that the lady in room [ROOM NUMBER] had passed away. I went to room [ROOM NUMBER] to check the resident. I went into the room [ROOM NUMBER], I said Hello, the resident #118 (hospice resident) woke up and I said that someone had told me you had passed away. Resident #118 said, I'm not dead yet. I went out to RN A the nurse and I said that she's still alive. He said I meant room ,d+[DATE]. I went to room ,d+[DATE], she was definitely dead. She was cold to me. I started postmortem care, cleansed her face, and cleaned her up the shower aide Certified Nurse Assistant R helped me. CNA C stated that she washed Resident #116's face, did a bed bath, put on a clean gown, and put the sheets back over her. CNA C stated that she was presenting Resident #116 for family viewing. CNA C had just covered her back up when RN A came into the room with the Automated External Defibrillator (AED but didn't put it on the resident, and then the EMS came. I left the room when the EMS put her on the floor and started working. I had to go back in later, put her back into the bed and dress her again. None of the four staff members (2- Licensed nurses and 2- Certified Nurse Assistance) working at the time of the event/incident checked Resident #116's code status in the electronic medical record or the hard binder chart located at the nursing station within reach.

Based on observation, interview and record review, the facility failed to meet professional standards of care for one resident (Resident #116) during a cardiac arrest event when Registered Nurse (RN) A failed to provide Cardiopulmonary Resuscitation (CPR) and the use of an Automated External Defibrillator (AED) in violation of facility CPR Policy and the Basic Life Support (BLS) Standards of Care, resulting in Resident #116 expiring at the facility. The facility also failed to refer Registered Nurse (RN) A nursing licensure to the Bureau of Professional Licensing for review for failing to provide emergent lifesaving services. Findings include: Record review of facility 'Code Status' policy dated [DATE] revealed on admission, the licensed nurse will document the resident's choice of code status on the Advanced Directive form. The Licensed nurse is also responsible for entering the Code Status in the electronic medical record. The resident will be treated as Full Code until the advanced directives are in place. Code status will be documented in the care plan in the electronic medical record . Cardiopulmonary Resuscitation (CPR) will be initiated on all full code residents no matter their condition at the time they are found. Resident #116: Resident #116 was admitted to the facility from the hospital setting on [DATE] at 11 AM. Record review of Resident #116's Admission assessment dated [DATE] at 11:00 AM revealed respirations of 16 breaths/minute with 92% oxygen saturation on room air. Resident #116 was noted to be oriented to person, place, time and able to understand Record review of Resident #116's electronic medical record revealed late entry physician progress note dated [DATE] at 12:07 PM noted resident was on 2 liters oxygen, medications were reviewed and noted full code status. Another late entry physician note dated [DATE] at 12:08 PM revealed Record review of Resident #116's progress notes revealed on [DATE] at 12:24 PM IDT (Inter-Departmental Team) meeting noted resident admission from hospital and medications reviewed with physician, and baseline care plan initiated. The next progress note was not until [DATE] at 4:00 AM when resident is noted to have heavy breathing and shortness of breath. The resident was repositioned and pulled up in bed with elevated head of bed slightly by Registered Nurse (RN) A. There were no oxygen saturation levels or vital signs taken at that time, no documented lung sounds, or physical assessment noted by RN A with a change of condition. Record review of Resident #116's vital signs: last blood pressure taken on [DATE] at 4:23 PM was ,d+[DATE]. Last pulse taken on [DATE] at 4:23 PM was 91 beats per minute (bmp). Last respirations taken on [DATE] at 4:23 PM was 18 breaths/minute. Oxygen saturation summary taken on [DATE] at 4:22 PM was 100%, [DATE] at 11:22 PM oxygen saturation level 96%, and [DATE] at 1:29 AM oxygen saturation level 95%. Progress note dated [DATE] at 6:42 AM written by Registered Nurse A revealed: family/son notified of resident expired. Progress note dated [DATE] at 06:45 Note Text: At 04.30 went in to check on the patient and repositioned her still having shortness of breathing her SPO2 was 95% and requested to be repositioned to the left side. At 04.30 I checked on the patient no respiration was observed and was pulseless a code was initiated, and CPR was started immediately. DON was informed and 911 call was placed at 04.32 and Township were on site 04.35 followed by MMR was on site at 04.36 Family was called and informed of the condition of her parent. Physician was called and informed of the patient. Record review of Basic Life Support/Emergency Medical technicians (EMT) 'Prehospital Care Report' dated [DATE] arrived at patient at 5:24 AM. Crew arrived on scene to police and staff stating that they believe this is going to be a code 12. Staff did not initiate compression or ventilation and did not place an AED (Automated External Defibrillator) on patient. Crew went into patient's room to find [AGE] year-old female on her bed in cardiac arrest. Crew examined patient . Crew initiated compressions at 5:26 AM. Fire arrived to room and assisted crew to move patient from bed to floor . Record review of Resident #116's care plans pages ,d+[DATE] revealed there to be no advance directive care plan noted. Record review of Registered Nurse (RN) A's employee file revealed that the nurse was trained in Basic Life Support (BLS) and worked in the acute care hospital setting and was trained in Advanced Cardiac Life Support (ACLS). Record review of RN As nursing license revealed the State of Michigan issued license was current. In an interview during the state survey [DATE] through [DATE] revealed that the Nursing Home Administrator or/nor the Director of Nursing referred Nurse As professional nursing license to the Bureau of Professional licensure for review.

Based on interview and record review, the facility failed to do a complete assessment, monitor and provide care, per professional standards of practice for one resident (Resident #116) who had a change of condition with heavy breathing and shortness of breath and who was then found unresponsive, resulting in delayed emergency medical care/treatment of changes in condition and death. Findings include: Record review of facility 'Acute Change of Condition' policy dated 9/2017, revealed the facility strived to provide care that enables each resident to achieve and maintain the highest practicable level of living possible for him/her given his/her physical and mental conditions. In order to do so, prompt identification, assessment, and intervention should occur when a resident experiences an acute change in condition that may be reversible or that may have the effects mitigated by prompt medical attention. Assessment and Problem Recognition: Upon admission the licensed nurse performs a baseline history and assessment on the resident. The nursing staff establishes the resident's baseline vital signs by monitoring and recording these each shift for 72 hours following admission noting these in the medical record. (a.) The Certified Nursing Assistant takes the vital signs of the resident once per shift for the first 72 hours after admission and records in the medical record. (2.) When interacting with residents, staff is to note any changes in the resident . (3.) The licensed nurse promptly assesses the resident. If the assessment determines that the resident may be experiencing an acute change in condition, the licensed nurse will contact the physician for further directives . (4.) The licensed nurse describes the symptoms in detail and accurately in the medical record. Record review of the facility 'Acute Change of Condition' policy and 'Guidelines for Reporting to Physician' policy revealed the condition for shortness of breath was not addressed or/nor guidance to report assessment to physician. Resident #116: Resident #116 was admitted to the facility from the hospital setting on [DATE] at 11 AM. Record review of Resident #116's admission assessment dated [DATE] at 11:00 AM revealed respirations of 16 breaths/minute with 92% oxygen saturation on room air. Resident #116 was noted to be oriented to person, place, time and able to understand Record review of Resident #116's electronic medical record revealed late entry physician progress note dated [DATE] at 12:07 PM noted resident was on 2 liters oxygen, medications were reviewed and noted full code status. Another late entry physician note dated [DATE] at 12:08 PM revealed Record review of Resident #116's progress notes revealed on [DATE] at 12:24 PM IDT (Inter-Departmental Team) meeting noted resident admission from hospital and medications reviewed with physician, and baseline care plan initiated. The next progress note was not until [DATE] at 4:00 AM when resident is noted to have heavy breathing and shortness of breath. The resident was repositioned and pulled up in bed with elevated head of bed slightly by Registered Nurse (RN) A. There were no oxygen saturation levels or vital signs taken at that time, no documented lung sounds, or physical assessment noted by RN A with a change of condition. Record review of Resident #116's vital signs: last blood pressure taken on [DATE] at 4:23 PM was 105/51. Last pulse taken on [DATE] at 4:23 PM was 91 beats per minute (bpm). Last respirations taken on [DATE] at 4:23 PM was 18 breaths/minute. Oxygen saturation summary taken on [DATE] at 4:22 PM was 100%, [DATE] at 11:22 PM oxygen saturation level 96%, and [DATE] at 1:29 AM oxygen saturation level 95%. Record review of Registered Nurse (RN) A typed interview dated [DATE] (should have been dated [DATE]) provided by the facility revealed: Resident #116 was use 2 liter (oxygen) and RN A put it (oxygen) up to 4 liters because he assumed she was breathing harder with her shortness of breath. RN A had another resident with a bladder scan and went to look for someone to assist him with the scan. RN A found the nursing assistance. RN A checked on Resident #116 describing shortness of breath, nostrils flaring, with intercostal contractions, breathing hard not the way she was supposed to be breathing. Record review of facility 'Code Status' policy dated [DATE] revealed on admission, the licensed nurse will document the resident's choice of code status on the Advanced Directive form. The Licensed nurse is also responsible for entering the Code Status in the electronic medical record. The resident will be treated as Full Code until the advanced directives are in place. Code status will be documented in the care plan in the electronic medical record . Cardiopulmonary Resuscitation (CPR) will be initiated on all full code residents no matter their condition at the time they are found. In an interview on [DATE] at 8:22 PM with Certified Nurse Assistant (CNA) D revealed that she was working that night with Registered Nurse (RN) A and Licensed Practical Nurse (LPN) B as the nurses. CNA D stated that she already gave a statement to the consultant lady. CNA D stated that the lady (Resident #116) that passed away was in room [ROOM NUMBER]-1. There was a hospice lady (Resident #118) in room [ROOM NUMBER]-1. RN A the nurse got them mixed up. He thought the hospice lady (Resident #118) passed away. It was me and CNA.C working RN A wanted us to help him straight catheter a lady in room [ROOM NUMBER]-1. On the way into room [ROOM NUMBER]-1 before the straight catheter RN A stated to us that the lady in 123-1 had passed away. It was before we started the straight catheter procedure. It took us 5-10 minutes to position and straight catheter the lady. Then CNA C went to room [ROOM NUMBER]-1 and she (Resident #118) was still alive. CNA C went out and told RN A that room [ROOM NUMBER]-1 was still alive. RN A said no it was the other lady, room [ROOM NUMBER]-1, he mixed up the rooms. He looked down the hallway to see what room he was in. He was not very familiar with our residents. CNA D said that she stated didn't that lady just get here to the facility? was she supposed too passed away? I don't know if they tried to do CPR, it was at shift change 5:30 AM close to 6:00 AM. RN A and CNA C went to the room, we were at the desk when we found out she was a full code. When we found out she wasn't supposed to pass, I believe the Director of Nursing (DON) told them she was a full code, and the DON went to the front door to let the EMS in. In an interview on [DATE] at 11:33 AM with Certified Nurse Assistant (CNA) C revealed That was her first time working with Resident #116. CNA C stated that she received report from second shift stated (Resident #116) would call if she needed anything. She did not call, so halfway through the shift (10:00 PM to 6:00 AM) around 1:00 AM, CNA C checked on Resident #116, she was sleeping, had oxygen on, I left her alone. CNA C stated that then Registered Nurse (RN) A was giving pills and he came out into the hall and said that the lady in room [ROOM NUMBER] had passed away. I went to room [ROOM NUMBER] to check the resident. I went into the room [ROOM NUMBER], I said Hello, the resident #118 (hospice resident) woke up and I said that someone had told me you had passed away. Resident #118 said, I'm not dead yet. I went out to RN A the nurse and I said that she's still alive. He said I meant room [ROOM NUMBER]-1. I went to room [ROOM NUMBER]-1, she was definitely dead. She was cold to me. I started postmortem care, cleansed her face, and cleaned her up the shower aide Certified Nurse Assistant R helped me. CNA C stated that she washed Resident #116's face, did a bed bath, put on a clean gown, and put the sheets back over her. CNA C stated that she was presenting Resident #116 for family viewing. CNA C had just covered her back up when RN A came into the room with the Automated External Defibrillator (AED but didn't put it on the resident, and then the EMS came. I left the room when the EMS put her on the floor and started working. I had to go back in later, put her back into the bed and dress her again. None of the four staff members (2- Licensed nurses and 2- Certified Nurse Assistance) working at the time of the event/incident checked Resident #116's code status in the electronic medical record or the hard binder chart located at the nursing station within reach.

Based on observation, interview and record review, the facility failed to ensure assessment and follow wound clinic recommendations for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] #36, and Resident #8 developing a facility-acquired Stage II new pressure area discovered during a dressing change observation while residing in the facility. Findings include: Record review of facility 'Pressure Ulcer/Injury Risk Assessment' policy dated 5/2/2018 revealed the purpose of the procedure was to provide guidelines for the structured assessment and identification of residents at risk of developing pressure ulcers/injuries. Steps in procedure: (4.) (c.) If a new skin alteration is noted, initiate (pressure or non-pressure) documentation in the facility medical record program related to the type of alteration in skin. Record review of the 'Clinical Nursing Skills & Techniques' book, Perry, Potter and Ostendorf, 9th edition, copyright 2014, Chapter 39- Pressure injury prevention and care, pages 990-997, revealed the following: Pressure injuries occur from unrelieved prolonged soft tissue compression, which interferes with blood flow to the tissues. If this compression continues for prolonged period of time, the tissue dies from lack of blood flow, or tissue ischemia. Ischemia develops when pressure inside the vessels, causing the vessels to collapse and decreasing tissue perfusion. Staging of Pressure Injuries: Stage 1- Pressure injury: non-blanchable [CONDITION(S)] or intact skin. Stage 2- Pressure Injury: Partial-thickness skin loss with exposed dermis. Stage 3- Pressure Injury: Full thickness skin loss. Stage 4- Pressure Injury: Full-thickness skin and tissue loss. Resident #8: In an interview on 10/17/22 at 12:19 PM with Resident #8 about her sacral wound pressure ulcer revealed that she was not sure where it came from, she had been in and out of the hospital, not sure where came from. Observation on 10/18/2022 at 8:45 AM Resident #8 is laying on her back with no supporting device in place, record review of care plan, she refuses repositioning or devices. Record review of all care plans pages 1-26 revealed that there was no mention of the wound vac to the sacral pressure ulcer wound. In an interview on 10/18/2022 at 1:30 PM with Registered Nurse (RN) F Wound Care Certified (WCC) revealed that Resident #8 has a wound to the sacral area. Record review of wound care assessments revealed that on 7/28/2021 the sacral pressure ulcer started as a stage II facility acquired, and the size decreased. Then on 11/3/2021 the sacral pressure ulcer increased in size when Resident #8 went to an appointment and in the facility van, she felt like it ripped. On 3/8/22 Resident #8 sacral pressure ulcer increased in size to 3.6 X 1.5 X .01 Centimeters (cm), then on 3/15/22 the wound increased again. On 6/1/22 the sacral pressure ulcer size grew 5.51 X 2.38 CM, we started wound clinic at hospital. On 6/30/22 Resident #8 became COVID positive and stayed here in the facility. The facility placed Resident #8 into the COVID unit, and it became larger in size again. RN/WCC F stated that the facility started a wound vac at the facility. RN/WCC F stated that the rectal tube was for constant loose stools and the Foley catheter was urine. RN/WCC F stated that there is a left upper arm PICC line that we did use for IV antibiotics. The rectal tube is re-evaluated every 30 days by the Nurse Practitioner who also does the wound clinic. RN/WCC F stated that the rectal tube and urinary catheter is emptied per shift. The wound vac dressing is changed Mondays, Wednesday, Fridays around 9:30 AM. Observation and interview on 10/19/22 9:35 AM with Registered Nurse (RN/WCC) F and Certified Nurse Assistant (CNA)H of Resident #8's sacral pressure ulcer dressing wound vac change. Observation of Resident #8's back side revealed a rectal tube observed in place with a Foley catheter also in place. Observed Resident #8 with left leg above the knee [CONDITION(S)], stump well healed. catheter strap in place. RN/WCC F performed hand hygiene, prepped the dressing field on over bed table, barrier put down. and wound vac kit prepped. Resident #8 rolled to right side with assistance of CAN H. RN/WCC F removed the old dressing and wound vac canister removed and vac machine turned off. The State surveyor noted sacral wound to be odorous and foul smelling through face mask. Observation of sacral wound is large in size and stage IV with tunneling at 6 o'clock area toward rectum, with green/gray slough noted in the upper 1/3 of the wound bed, bleeding noted. RN/WCC F removed gloves and performed hand hygiene, RN/WCC F gloved again, Sacral wound cleansed with saline wipes used to clean the inner wound area by nurse. [MEDICATION(S)] AG 2 x 2 dressing placed into the wound bed and black sponge cut to area size and placed within the wound. CNA H then placed her hand onto the black sponge to hold in place. The State surveyor pointed the cross contamination to the nurse and the dressing change was started over. Clear adhesive dressing applied over sponge and a hole was cut and suction hose apparatus was applied. [CONDITION(S)] paste was applied to the open buttocks crack area of the dressing to get a seal for the vac to work per RN/WCC F. Suction hose and canister applied. The State surveyor noted a smaller open area to the right buttocks area. RN/WCC F. did take a wound photo of the area. RN/WCC F. stated that it was a new open area and was not aware of the wound. RN/WCC F. stated that he would get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #8's 'Wound Evaluation' dated 10/19/2022 new area measurements of 1.66 cm X 0.9 cm in size facility acquired. 10/19/22 11:05 AM Record review of pressure ulcer care plan revealed that there was no wound vac noted on the care plans. In an interview and record review on 10/20/2022 at 10:05 AM of Resident #8's electronic record with RN/WCC F revealed that Resident #8's new buttocks wound area was staged as an abrasion, that is facility acquired. The treatment put in place was magic butt paste, a Zinc base product. Review of the care plans revealed there was no intervention of Wound vac noted to pressure ulcer or skin care plans. Record review of the National Pressure Ulcer Advisory Panel September 2016 'Pressure Injury and Stages' definitions revealed Stage II pressure injury is partial-thickness skin loss with exposed dermis. Adipose is not visible, and deeper tissues are not visible . This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [CONDITION(S)] (IAD), intertriginous [CONDITION(S)] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, [CONDITION(S)], abrasions). Resident #36: A review of Resident #36's medical record revealed an admission into the facility on [DATE] with a readmission on 10/8/22 and was transferred to the hospital on 10/19/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #36's Minimum Data Set assessment, dated 9/3/22, revealed Brief Interview of Mental Status (MDS) score of 11/15 that indicated moderate cognitive impairment and the Resident needed extensive assistance of two person assist with bed mobility, dressing, toilet use and personal hygiene and was total dependence on staff for transfers and eating. Further review of the MDS indicated the Resident had a Stage 4 full thickness tissue loss with exposed bone, tendon or muscle of one pressure ulcer that was present upon admission/reentry. The MDS dated [DATE], OBRA Admission assessment revealed the Resident had one Stage 2 pressure ulcer that were present upon admission/reentry. The MDS dated [DATE], Discharge assessment-return anticipated revealed the Resident had one Stage 2 pressure ulcer that was present upon admission/reentry. The MDS dated [DATE], Discharge assessment-return anticipated, revealed the Resident had one Stage 3 pressure ulcer that was present upon admission/reentry. A review of Resident #36's medical record revealed the following: Admission Assessment, dated 6/1/22, skin assessment that revealed, . coccyx 11 cm (centimeters) length top 10 cm width, lower 5.75 cm width, area dark red in color. Progress Note, dated 6/8/22, revealed, Resident admitted with a stage 2 pressure area to sacrum. Area measures 10.4 x 7.05 x 0.1 cm. Area is absent of odor and exudate after cleansing. Area is 90% granulation tissue and 10% slough. Resident mobility is limited and has a difficult time turning and reposition self. Interventions for turning and repositioning in place, and resident is on an air mattress for pressure relief. Treatment: cleanse area with normal saline, pat dry, apply calcium ag and cover with alyven foam dressing. Resident and family educated on the importance of compliance with cares and interventions. Resident, doctor, dietary and family aware and agree with treatment. Admission Assessment, dated 7/2/22, skin assessment that revealed, .Pressure ulcer on coccyx . The documentation lacked measurements and wound description. Progress Note, dated 7/2/22 at 10:15 AM, revealed, (Resident name) arrived via (transport ambulance) from (hospital name) and is alert and oriented x 3-4 and able to make needs known . Skin assessment done upon arrival. Progress Note, dated 7/6/22 at 12:43 PM, revealed, Resident admitted with a stage 2 pressure area to sacrum. After returning from a recent hospitalization resident's wound has progressed to a stage 3. Area measures 10.38 x 5.82 x 0.1 cm. Area is absent of odor and exudate after cleansing. Area is 50% granulation tissue and 50% slough. Resident mobility is limited and has a difficult time turning and reposition self. Interventions for turning and repositioning in place, and resident is on an air mattress for pressure relief. Treatment: Clean with NS. Apply santyl. Cover with wet to dry dressing and ABD, Resident and family educated on the importance of compliance with cares and interventions. Resident, doctor, dietary and family aware and agree with treatment. Progress Note, dated 7/13/22 at 11:04 AM, . Area measures 10.1 x 6.16 x 0.1 cm. Area is absent of odor and exudate after cleansing. Area is 50% granulation tissue and 50% slough. Area surrounding wound is firm. Doctor ordered ultra sound. Ultra sound completed and did find there to be an abscess in the area. Doctor ordered warm compresses and if the area does not decrease in size doctor will order incision and drainage. Progress Note dated 7/20/22 at 12:42 PM, Skin/Wound Note, .Area measures 10.2 x 6.12 x 0.1 cm . Area is 60% granulation tissue and 40% slough . Treatment: Clean with NS, apply santyl. Cover with wet to dry dressing and ABD. Progress Note dated 7/27/22 at 11:27 AM, Skin/Wound Note, .Area measures 6.51 x 5 x 0.1 cm .Area is 70% granulation tissue and 30% slough . Treatment: Clean with NS, apply santyl. Cover with wet to dry dressing and ABD. Progress Note, dated 8/3/22 at 5:13 PM, Skin/Wound Note, .Area measures 6.25 x 4.85 x 0.1 cm .Area is 70% granulation tissue and 30% slough . Treatment: Clean with NS, apply santyl, pack open area with [MEDICATION(S)] Ag and cover with alyven foam dressing. Progress Note dated 8/7/22 at 11:51 AM, Resident was sent to the hospital at 12 PM for slow response, not eating . Resident returned on 8/18/22. Progress Note dated 8/24/22 at 1:14 PM, Skin/Wound Note, .Area is currently unstageable. Area measures 15.18 x 9.27 x utd (unable to determine) cm. Area is 80% granulation and 20% slough . Treatment: Cleanse area with normal saline, pat dry, apply xeroform gauze [to prevent foam from adhering to the wound bed], apply NPWT (negative pressure wound treatment-wound vac). Progress Note, dated 8/31/22 at 5:54 PM, Skin/Wound Note, .Area measures 12.84 x 10.2 x utd cm. Area is 80% granulation and 20% slough . Treatment: Cleanse area with normal saline, pat dry, apply xeroform gauze [to prevent foam from adhering to the wound bed], apply NPWT (negative pressure wound treatment-wound vac) . Progress Note, dated 9/7/22 at 2:35 PM, Skin/Wound Note, .Area measures 12.94 x 13.49 x 7.2 cm. Area is 80% granulation and 20% slough . Treatment: Cleanse area with normal saline, pat dry, apply xeroform gauze [to prevent foam from adhering to the wound bed], apply NPWT. Progress Note, dated 9/14/22 at 4:14 PM, Skin/Wound Note, .Area measures 11.98 x 11.92 x 7 cm. Area is 90% granulation and 10% slough . Treatment: Cleanse area with normal saline, pat dry, apply NPWT. Progress Note, dated 9/21/22, Skin/Wound Note, .Area measures 10.64 x 6.74 x 1 cm. Area is 90% granulation and 10% slough . Treatment: Cleanse area with normal saline, pat dry, apply NPWT. Progress Note, dated 9/28/22, Skin/Wound Note, .Area measures 10.93 x 7.15 x 1 cm. Area is 80% granulation and 20% slough . Treatment: Cleanse area with normal saline, pat dry, apply NPWT. Progress Note, dated 10/5/22, Skin/Wound Note, .Area measures 13.56 x 11.98 x 1 cm. Area is 90% granulation and 10% slough . Treatment: Cleanse area with normal saline, pat dry, apply NPWT. Progress Note, dated 10/12/22, Skin/Wound Note, .Area measures 9.82 x 8.8 x 1 cm. Area is 90% granulation and 10% slough . Treatment: Cleanse area with normal saline, pat dry, apply NPWT. A review of Resident #36's wound clinic notes revealed the following: 7/22/22, The patient referred to wound clinic for R buttock abscess. He actually has a known sacral decubitus ulcer for the past few weeks. He suffered a stroke back in [DATE] and has been in and out of the hospital ever since, and he still has a fair amount of debility from this . He had a PEG placed in May. He was hospitalized in June with mental status change and was found to have bacteremia related to heart valve vegetations. I was consulted during this hospitalization for his sacral ulcer, and at that time, he had an unstageable sacral ulcer that did not require any acute intervention. We started managing this with Santyl dressings once daily. He was discharged to ECF (extended care facility), but unfortunately, he did not have appropriate wound clinic follow-up scheduled as planned/intended. We then received a referral earlier this week for right buttock abscess. Wound Assessment: Wound #1 Sacral is an acute Stage 4 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 6.42 cm length x 5.26 cm width x 4 cm depth, with an area of 33.769 sq cm (square centimeters) and a volume of 135.077 cubic cm. Adipose is exposed . Integumentary: Has stage 4 sacral ulcer with deep tunneling under right buttock with some foul-smelling necrotic tissue and seropurulent drainage tender to deep palpation; superficial portion of wound is clean with beefy red granulation . A debridement was performed.Dressings: Santyl-Apply a thin film of Santyl to wound bed only, then cover with clean dressing. Santyl to wound bed, cover with [MEDICATION(S)] ag, and allevyn. Change daily and as needed. Keep dressing dry and intact. Cover and secure with: allevyn. [MEDICATION(S)] Ag- Apply skin protectant or barrier ointment to protect surrounding skin. Apply [MEDICATION(S)] Ag to wound bed, may use Normal Saline to activate if needed. Cover with dry gauze and wrap with Kerlix/Conform roll gauze. Secure with tape. [NAME] dressing as directed: -santyl to wound bed, [MEDICATION(S)] ag, cover with allevyn, change daily and as needed . Brief debridement performed . I believe he will benefit from operative debridement, but given his overall medical status, will need to obtain cardiac risk assessment. For now, will continue Santyl dressings and add [MEDICATION(S)] Ag packing to deep portion, change once daily and as needed. Continue offloading. Maximize nutrition. Need to check nutrition labs and A1C. Follow-up in one week. 7/29/22, .He is a diabetic. The last A1C in the system was from [DATE] and was 11.4 . His last [MEDICATION(S)] was 2.4 on 6/28. I do not see any more recent labs in the system. 7/29/2022 update: Doing the same. Labs were not done last week. Still with pain and copious drainage . (Labs were completed at the facility on 7/27/22 per reviewed lab results but not communicated to the wound clinic.) .Wound Assessment: Initial wound encounter measurements are 6.69 cm length x 5.15 cm width x 3.5 cm depth with an area of 24.29 sq cm, Adipose is exposed. Tunneling has been noted at 1:00 with a maximum distance of 7.5 cm . Topical Treatments: Enzymatic [MEDICATION(S)] Agent: Santyl- Continue Santyl to wound bed, special attention to necrotic tissue to upper right quadrant. Apply Nickel Thick. Dressings Santyl- apply a thin film of Santyl to wound bed only, then cover with clean dressing. - Apply Nickel Thick to wound bed. Keep dressing dry and intact. Cover and secure with: -allevyn. [MEDICATION(S)] Ag-Apply skin protectant or barrier ointment to protect surrounding skin. Apply [MEDICATION(S)] Ag to wound bed, may use Normal Saline to activate if needed. Cover with dry gauze and wrap with Kerlix/Conform roll gauze. Secure with tape. Change dressing as directed: [MEDICATION(S)] Ag rope to tunnel at 1 o'clock to depth of 7.5 . Bedside debridement performed, as much as he could tolerate. Will continue Santyl/[MEDICATION(S)] Ag to deep area of wound, change daily and as needed for soilage. Will schedule for operative debridement of sacral wound. Need to obtain pre-op cardiac risk to make sure it is safe to give him anesthesia. Will schedule for surgery ASAP. Follow-up in one week. The facility orders for wound treatments did not include the [MEDICATION(S)] Ag rope to tunnel at 1 O'clock to the depth of 7.5 nor the nickel thick Santyl to the wound bed. 8/5/22, .8/5/2022 update: Continues to have copious foul-smelling drainage . Wound Assessment: Wound #1 sacral is an acute Stage 4 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 6.16 cm length x 3.6 cm width x 3.5 cm depth, with an area of 22.4224 sq cm. Adipose is exposed. Tunneling has been noted at :00 with a maximum distance of 5.5 cm . There is a copious amount of purulent drainage noted which has no odor . Integumentary [Hair, Skin]: Sacral wound with foul-smelling purulent drainage and moderate amount of necrotic fibrinous material within wound, very tender . Topical Treatments: Enzymatic [MEDICATION(S)] Agent: Santyl- Continue Santyl to wound bed, special attention to necrotic tissue to upper right quadrant. Apply Nickel Thick. Dressings Santyl- apply a thin film of Santyl to wound bed only, then cover with clean dressing. - Apply Nickel Thick to wound bed. Keep dressing dry and intact. Cover and secure with: -allevyn. [MEDICATION(S)] Ag-Apply skin protectant or barrier ointment to protect surrounding skin. Apply [MEDICATION(S)] Ag to wound bed, may use Normal Saline to activate if needed. Cover with dry gauze and wrap with Kerlix/Conform roll gauze. Secure with tape. Change dressing as directed: [MEDICATION(S)] Ag rope to tunnel at 1 o'clock to depth of 7.5 . Physician Review: Discussed the Plan of Care @ bedside with- 8/5/22: lido and debridement. A lot of drainage purulent drainage noted . Culture taken and sent to lab. More discussion regarding surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident was sent to the hospital on 8/7/22 and returned to the facility on [DATE]. Resident had incision and drainage of the abscess on 8/11/22. 8/26/22 appointment was canceled due to physician illness. 8/30/22, .Pt (patient) is here for follow up . Wound Assessment: Wound #1 sacral is an acute Stage 4 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 17 cm length x 13 cm width x 7.2 cm depth, with an area of 221 sq cm and a volume of 1591.2 cubic cm. Adipose is exposed . General Notes: 8/30/22 drainage volume in canister 250 cc. canister not changed. Battery dead on wound vac .Dressings: Keep dressing dry and intact. Cover and secure with: Negative Pressure Wound Therapy: -125 continuous suction, Vac changes to occur every three days. Recommend white foam to be placed to greatest depth of 7.1 cm followed by black foam on top . [MEDICATION(S)] Ag rope packed gently to greatest depth of 7.1 cm with tail exposed for removal. [MEDICATION(S)] ag applied to remaining wound bed . Physician Review: . 8/30/22 4% Lido and debridement. Wound bed looks good. Crush [MEDICATION(S)] and [MEDICATION(S)] ointment to wound bed. [MEDICATION(S)] ag rope to deepest point 7.1 cm and [MEDICATION(S)] ag to wound bed. Wound vac applied but battery dead. Only sent black foam with patient. Recommend white foam to deepest depth of 7.1 cm followed by black foam. Dressing changes every 3 days . 9/7/22, .Patient here for wound care office large decubitus sacral ulcer. Recently he had debridement in the OR with (Physician name) . Wound Assessment: Wound #1 sacral is an acute Stage 4 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 12.94 cm length x 13.49 cm width x 7.2 cm depth, with an area of 174.5606 sq cm and a volume of 1256.836 cubic cm. Adipose is exposed . Topical Treatments: Antibiotic/Antimicrobial Ointment/Cream-Crushed [MEDICATION(S)] to wound bed with each vac change. [MEDICATION(S)] ointment to wound bed with each vac change. Enzymatic [MEDICATION(S)] Agent: Santyl - Santyl to dark necrotic tissue in wound bed. [left side of wound bed]. Dressings: Santyl- Apply a thin film of Santyl to wound bed only, then cover with clean dressing.- santyl to black/brown necrotic tissue to left side of wound bed. Keep dressing dry and intact. Cover and secure with:-[MEDICATION(S)] ag and wound vac. Negative Pressure Wound Therapy:- -125 continuous suction. Vac changes to occur every three days. Recommend white foam to be placed to greatest depth of 4.0 cm followed by black foam on top. [MEDICATION(S)] Ag-Apply skin protectant or barrier ointment to protect surrounding skin. Apply [MEDICATION(S)] Ag to wound bed, may use Normal Saline to activate if needed . [MEDICATION(S)] Ag rope packed gently to greatest depth of 4.0 cm with tail exposed for removal. [MEDICATION(S)] ag applied to remaining wound bed. Change with each vac change . Physician Review: .9/7/22: Lido and debridement. Pt has a large area of blackish brown necrotic/fibrotic tissue that doctor (name) was unable to do with a curette and he stated that the tissue would need to be surgically debrided. He did not feel comfortable [MEDICATION(S)] any of that here in the clinic because it is very attached and he felt it goes rather deep and this would cause possibly a lot of bleeding and pain. He did debride all of the nice beefy red tissue for biofilm and slough that was present. He added santyl to the tx to the area that has that necrotic tissue along with what was ordered prior. Wound vac dressing was put back on but the box they sent us did not match the dressing they sent with us. Called over to (facility name) to let them know and they understood . There were no wound clinic notes provided by the facility and no progress notes that indicated the Resident was sent back to the wound clinic until 9/30/22. 9/30/22, . 9/30/2022 update; Still has rectal tube in place. Currently at (facility name) . Had operative debridement on 8/11/22. Bone biopsy positive for [CONDITION(S)]. Wound, bone, and tissue cultures positive for Proteus, but ID (Infections Disease) only wanted to treat with IV (intravenous) abx (antibiotic) for 7 days .Wound Assessment: Wound #1 sacral is an acute Stage 4 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 9.68 cm length x 15.02 cm width x 7.2 cm depth, with an area of 113.26 sq cm and a volume of 1256.836 cubic cm. Adipose is exposed . Integumentary [Hair, Skin]: Sacral wound with mostly pink granulation tissue but moderate fibrinous exudate some exposed bone with friable bone tissue . Physician Review: . 9/30/22: Lido and debridement. Doctor took a lot of loose slough out of wound with pick up and scissors. Wound is clean and healthy. Pt still has a rectal tube. (Doctor's name) does not feel that a long term rectal tube is good for the pt and discussed with the wife about taking pt to surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . Pt and wife agree . 10/14/22, . Wound Assessment: Wound #1 sacral is an acute Stage 4 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 10.8 cm length x 12.99 cm width x 7.2 cm depth, with an area of 140.292 sq cm and a volume of 1010.102 cubic cm. Adipose is exposed . Integumentary [Hair, Skin]: Sacral wound with pink granulation tissue, moderate fibrinous exudate and debris in wound two small areas of exposed bone, moderately tender, mostly healthy pink granulation tissue . Physician Review: .10/14/22: lido and very aggressive debridement done. Pt's wound is getting cleaner. There is an area on the right side of the wound at about 3 o'clock that has a depth of 7.5. Wound vac applied as ordered. Pt has a new [CONDITION(S)] . A review of Resident #36's orders for the dressing to the coccyx wound include the following: Dated 6/1/22, Cleanse coccyx with NS (normal saline), pat dry, apply Calcium alginate to wound bed, cover with allevyn, daily and PRN. Dated 7/2/22, start date on 7/3/22, Coccyx: Clean with NS. Apply santyl. Cover with wet to dry dressing and ABD. Dated 7/23/22 to start, Coccyx wound treatment: apply 2% [MEDICATION(S)] topical to coccyx wound bed prior to dressing then cleanse wound with NS and apply Santyl then cover with [MEDICATION(S)] Silver and Allevyn, daily and as needed. Dated 8/18/22, start date 8/19/22, Wound treatment negative pressure wound therapy. Apply wound vac. Change every Monday, Wednesday and Friday and PRN. The wound clinic recommendations were for the wound vac to be changed every three days. Dated 8/31/22, start date 9/2/22, Wound Treatment negative pressure wound therapy. White foam to be placed at greatest depths. Apply [MEDICATION(S)] ag to wound bed and pack [MEDICATION(S)] ag gently at greatest depth, leaving a tail. Apply wound vac, Change every Monday, Wednesday and Friday and PRN. Dated 9/1/22, start date on 9/2/22, Wound Treatment negative pressure wound therapy. White foam to be placed at greatest depths. Apply [MEDICATION(S)] and [MEDICATION(S)] to wound bed with each vac change. Apply [MEDICATION(S)] ag to wound bed and pack [MEDICATION(S)] ag gently to greatest depth, leaving a tail. Apply wound vac. Change every Monday, Wednesday and Friday and PRN. Review of Resident #36 medical record revealed the Resident was readmitted on [DATE], transferred to the hospital on 6/22/22, returned on 7/2/22, transferred to the hospital on 8/7/22, returned to the facility on [DATE], transferred to the hospital on 10/5/22 and returned on 10/8/22 and transferred to the hospital on 10/19/22. Review of Resident #36's hospital records with admission on 6/22/22 revealed, .came to the ED from nursing facility where the patient was feeling more drowsy and patient was not at his baseline. When the patient brought to the ED (emergency department) he looks severely dehydrated and his labs showed severe dehydration with elevated [MEDICATION(S)] was elevated so based on his assessment of dehydration patient was immediately started on fluids. On assessment patient was responsive with only yes or no and mostly nods his head on initial presentation but after rehydration patient mentation slightly improved his drowsiness got better . Review of Resident #36's wound culture, with results reported on 9/5/22 revealed heavy growth Escherichia coli carbapenem-resistant (Carbapenem resistant enterobacteriacea-CRE), light growth Citrobacter koseri and light Growth Enterococcus faecalis. According to the Centers for Disease Control and Prevention (CDC), https://www.cdc.gov>organisms, CRE are a major concern for patients in healthcare settings because they are resistant to carbapenem antibiotics, which are considered the last line of defense to treat multidrug-resistant bacterial infections. Often, high levels of antibiotic resistance in CRE leave only treatment options that are more toxic and less effective. Further review from the CDC include, CRE are usually spread person to person through contact with infected or colonized people, particularly contact with wounds or stool. This contact can occur via the hands of healthcare workers, or through medical equipment and devices that have not been correctly cleaned, last reviewed 11/13/2019. On 10/17/22 at 10:12 AM, an observation was made on the initial tour of the facility of Resident #36 lying in bed on his back. The Resident was on transmission-based precautions for a wound infection. The Resident was alert and tracked this surveyor with his eyes. When asked questions, the Resident was able to answer simple questions when given extra time to answer, one- or two-word answers, with a barely audible voice. The Resident did not converse in conversation. The Resident indicated he had a wound on his buttock area and wound odor was noted when near the bedside where a wound vac was positioned. An observation was made in the Resident's bathroom of the vent in the ceiling with built up dust and debris. On 10/17/22 at 1:43 PM, an observation was made of Resident #36, lying in bed on his back, sleeping. The Resident appeared to be in the same position as earlier, but it was noted that the wound vac canister had been replaced and the there were no longer an odor in the room. On 10/18/22 at 10:05 AM, an observation was made of Resident #36 lying in bed on his back, sleeping. On 10/20/22 at 10:14 AM, an interview was conducted with Nurse Manager (NM), Nurse S and Wound Care Nurse F regarding Resident #36's wound history of a Stage II documented on 7/6/22, deterioration to a Stage IV with infections in the wound. The NM indicated Resident #36 had been transferred to the hospital on 6/22/22 and returned on 7/2/22, and the Resident presented with the pressure ulcer to his coccyx/sacral area on his readmission into the facility. A review of the admission assessment revealed a documented pressure ulcer to the coccyx area but did not give a description or measurements of the pressure ulcer and documentation of the wound description was not documented until 7/6/22 when the Wound Care Nurse had assessed the wound. The NM indicated that the measurements might be on the paper copy of the skin assessment. After looking for the paper copy, the NM was unable to find the documentation. When asked if wound assessment with measurements were to be done on admission, the NM stated, Yes, if should be in the admission assessment. When asked about the Resident not having an appointment consistently on a weekly basis, the NM and the Wound Care Nurse F indicated the Doctor had been sick and the appointment was canceled and another time, the ambulance transport service was late on picking the Resident up for the appointment due to priority calls and the Resident was not seen when he had arrived at the wound clinic, so the appointment calls got pushed back. When asked about the wound clinic notes that indicated the Resident did not have appropriate wound clinic follow-up scheduled as planned/intended after the Residents hospitalization , the NM indicated that the hospital discharge instructions did not indicate follow-up with the wound clinic. The Resident observed lying on his back in bed in the same position on 10/17 and 10/18 was reviewed with the Nurse Manager and Wound Care Nurse. The Wound Care Nurse indicated that the Resident had interventions in place for turning every two hours and stated, we can turn him, but

Based on observation, interview and record review, the facility failed to prevent the development of pressure ulcers for 2 residents (Resident #1 and Resident #2) of 4 sampled residents, resulting in Resident #1 developing a pressure ulcer of the sacrum/buttocks that required surgical debridement, and Resident #2 developing an unstageable pressure ulcer of the right lower buttocks that required wound clinic treatment. Findings include: Record review of facility 'Pressure Ulcers/Injury Risk Assessment' policy, dated 5/2018, revealed the purpose of the procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing pressure ulcers/injuries. Risk factors that increase a resident's susceptibility to develop pressure ulcers include: impaired/decreased mobility and decreased functional ability, exposure of skin to urinary and fecal incontinence, co-morbid conditions, such as end stage [MEDICAL CONDITIONS] disease or diabetes mellitus, cognitive impairment are some of the factors listed in the policy. Once the assessment is conducted and risk factors are identified and characterized, a resident-centered care plan can be created to address the modifiable risk assessment data. The risk assessment should be conducted as soon as possible after admission, but no later than eight hours after admission is completed. Record review of facility 'Pressure Ulcers/Skin Breakdown-Clinical Protocol' policy, dated 4/2018, revealed (1.) the nursing staff and attending physician will assess and document an individual's significant risk factors for developing pressure ulcers. (3.) The staff will examine the skin of a new admission for ulcerations or alterations in skin. Resident #1: Record review of Resident #1's admission assessment, dated 9/9/19 revealed that the resident was assessed by staff and under the skin assessment was noted left hip surgical (incision site), left arm antecubital bruising/scab, and a scar to the left abdomen. There were no marks, redness or open areas noted for the back/buttock's region. Record review of Resident #1's hospital discharge record dated 9/9/19, revealed there were no sacrum/buttocks skin issues identified at time of discharge. Record review of facility physician's visit note, dated 9/13/19, revealed That Resident #1 was admitted to St. Francis on 9/9 after a Fracture of Part of Neck of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing. Patient has a medical history of [REDACTED]. Gastro-[MEDICAL CONDITION] Reflux Disease Without Esophagitis, [DIAGNOSES REDACTED], Muscle Wasting And Atrophy, Not Elsewhere Classified, Unspecified Site , Need For Assistance At Home And No Other Household Member Able To Render Care, Muscle Weakness (Generalized) , Unsteadiness On Feet. The patient denies SOB or dyspnea. The patient denies chest pain and palpitations. Pain is well controlled. There was no mention of sacrum/buttocks skin issues. Record review of Resident #1's admission Minimum Data Set (MDS), dated [DATE], Section M: Skin- noted one unstageable pressure ulcer. MDS section M- question F2; Number of unstageable pressure ulcers present upon admission? Zero. Record review of Resident #1's skin assessment form, dated 9/17/19, revealed residents' testicles with excoriation and sacrum with redness. The skin sheet form identified the stages of pressure ulcers as: Stage II- Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured serum-filled blister. Stage III - Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. Record review of Resident #1's 'Order Summary Report', dated 9/1/19 through 10/9/19, revealed that on 9/13/19 physician ordered Z Guard (barrier cream) to excoriation to coccyx area every day and evening shift for excoriation. On 9/16/19 there was a physician's orders [REDACTED]. On 9/20/19 the pressure ulcer treatment changed to Dakin's (1/4 strength) Solution: apply to sacrum wounds topically every day for wound care cleanse with Dakin's solution, rinse with normal saline, pat dry, apply skin prep to peri wound (around wound), apply saline activated opticell fiber to wounds, cover with dry gauze and [MEDICATION NAME] daily and as needed. According to website: woundsource.com/product/opticell, opticell is indicated for the use on partial and full thickness wounds .pressure ulcers. Record review of Resident #1's care plans, pages 1- 66, revealed that on 9/19/19 a pressure ulcer care plan was implemented which included: Give medications as ordered, notify physician id sign/symptoms of infection noted, such as odor, fever, increased drainage. Notify physician with any changes in wound, such as increased in odor, drainage, or worsening of wound appearance, and treatments as ordered. There was no addition of interventions to prevent further pressure to the sacrum/buttocks area of: specialty mattress to reduce pressure areas, no turn or repositioning added to care plan, no resident education on importance of changing positions. On 9/22/19 Record review of Resident #1's hospital record, dated 9/22/19, revealed that on 9/23/19 physical assessment identified stage III pressure ulcer on the buttocks and skin overlying the coccyx with a roughly 4 cm X 4 cm area of eschar. Record review of hospital infectious disease consult on 9/24/19 revealed a large stage III decubitus ulcer with irregular boarders, some areas of healthy granulation tissue present, but some areas with fluctuant and were productive of very foul-smelling discharge. Ulcer developed in the past two weeks. Resident #2: Record review of Resident #2's Electronic Medical Record (EMR) revealed a [AGE] year-old with [MEDICAL CONDITION], diabetes, dementia, need for assistance with personal care, dysphagia, anxiety, depression Alzheimer's and muscle weakness. Resident #2 had lower limb ulcers and injuries to the skin not listed on the [DIAGNOSES REDACTED]. Record review of Resident #2's skin/wound note, dated 9/6/19, revealed moisture associated skin damage to right upper posterior thigh. Wound presents with dark crusted center with blanching [DIAGNOSES REDACTED] surrounding crusted area. Wound measures 4.51 X 2.38 X UTD (undetermined depth). Wound has excoriation to surrounding area. Absent of drainage. No sign/symptoms of pain upon palpitation. Resident is incontinent of bowels and bladder. History of arterial insufficiency. Current treatment: Z Guard paste twice daily for 14 days. Family/physician agrees with treatment recommendation. Record review of Resident #2's skin/wound note, dated 9/16/19, revealed that the wound was originally classified as moisture associated skin damage to right upper posterior thigh. Today's assessment shows 100% slough which classifies the wound as unstageable pressure injury. Wound presents with 100% slough tissue, attached edges, blanching to surrounding skin. Wound measurements 1.88 X 1.49 X UTD (undetermined depth). Moderate serosanguineous exudate. No sign/symptoms of pain upon palpation, absent of odor after cleansing. Resident is incontinent of bowels and bladder. Current treatment: cleanse with normal saline, pat dry, apply skin prep to peri wound (around wound) followed by alginate (debridement ointment), cover with foam dressing every other day. Record review of Resident #2's skin/wound note, dated 9/25/19, revealed unstageable pressure injury to right upper thigh, wound presents with 100% slough attached edges, blanching [DIAGNOSES REDACTED] to surrounding skin. wound measures 3.27 X 1.76 X UTD (undetermined depth). Moderate serosanguineous exudate. No sign/symptoms of pain upon palpation, absent of odor after cleansing. Resident is incontinent of bowels and bladder. Current treatment: cleanse with normal saline, pat dry, apply skin prep to peri wound (around wound) followed by alginate (debridement ointment), cover with foam dressing every other day. Record review of Resident #2's skin/wound note, dated 10/3/19, revealed unstageable pressure injury to right upper thigh, wound presents with 100% slough attached edges, blanching [DIAGNOSES REDACTED] to surrounding skin. wound measures 3.27 X 1.76 X UTD (undetermined depth). Moderate serosanguineous exudate. No sign/symptoms of pain upon palpation, absent of odor after cleansing. Absent of induration, no [MEDICAL CONDITION]. Resident is incontinent of bowels and bladder. Current treatment: cleanse with normal saline, pat dry, apply skin prep to peri wound (around wound) followed by Santyl (topical [MEDICATION NAME] agent) to saline moistened gauze applied to wound, covered with ABD and secured with [MEDICATION NAME] tape daily and as needed. Resident visits hospital wound clinic every two weeks. Turn and repositions with staff assistance every hour while in chair and every two hours while in bed. Record review of Resident #2's 'Risk for Skin Breakdown' care plan, dated 7/2/19, revealed interventions of air mattress (for bed), skin assessment every 90 days (MDS assessment), bridge heels off of bed with pillows, encourage to reposition in bed and assist as needed (Not listed as Turn and repositions with staff assistance every hour while in chair and every two hours while in bed). An observation was made of Resident #2 on 10/8/19@ 12:06 PM in the presence of Licensed Practical Nurse (LPN) C, who was wound certified. An observation was made of the right buttocks wound of Resident #2. Resident #2 stated it hurts when turned to left side in bed. Bruising noted to left forehead from fall on 9/23/19. Observed right posterior upper thigh unstageable pressure ulcer. LPN C applied normal saline to cleanse, packed wound with 4 x 4 gauze with Dakin's solution, covered with ABD dressing, and applied tape. LPN C stated that Resident #2 goes to the wound clinic once every 2 weeks. The pressure ulcer developed on 9/6/19- started as an abrasion to right lower buttocks area and now is open with slough in bed of wound. Surveyor observation estimated wound estimated to be 1.5 inches long by 1 inch wide and 1/2-inch-deep with slough in bed of wound (Stage III). Red/bright pink was noted around the wound opening and the resident acknowledged pain with dressing change and touching of the area. Record review of facility electronic skin sheets defined pressure ulcers: Stage II- Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured serum-filled blister. Stage III - Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. In an interview on 10/9/19@10:08 am, Registered Nurse RN/MDS F stated that Resident #2's MDS, dated [DATE] section M, noted no pressure ulcers. On 9/22/19 significant change MDS section M pressure ulcer unstageable. RN/MDS F stated that a new pressure ulcer located on the right thigh rear/buttocks, measuring 1.98 cm length X 1.96 cm width no depth due to slough was a facility acquired pressure ulcer. The pressure ulcer triggered the significant change MDS. RN/MDS F stated Resident #1's admission MDS, dated [DATE] section M F1, skin- triggered PU unstageable with slough not on admission. It is an in-house acquired pressure ulcer. RN/MDS F stated that she does add to the care plans for triggered problems.

This citation pertains to Intake Number MI 987. Based on observation, interview and record review, the facility failed to provide adequate supervision and apply functioning safety devices to ensure the safety and prevent the elopement of one resident (Resident #1) of six residents reviewed for elopement, resulting in Resident #1 being outside the facility alone unbeknown to facility staff, and Resident #1 having a fall outside, with the likelihood of being struck by a vehicle resulting in serious injury, serious injury and/or death. The Immediate Jeopardy began on (MONTH) 24, 2019. The Immediate Jeopardy (IJ) was identified on 9/20/19. The Director of Nursing was notified of the Immediate Jeopardy on 9/24/19, at approximately 11:00 AM. The Director of Nursing was instructed to provide a plan of correction. The IJ was removed on 8/26/19 based on facility's implementation of the removal plan as verified by the onsite survey on 9/25/19. Findings include: On 9/20/19, at 12:11 PM, an observation of exit doors near administration and priest hallways was conducted with Nurse D. The administration door had a key-pad alarm that Nurse D enabled. At the end of the administration hallway there was an exit door with a push bar to open. Nurse D was asked if the administration door was always locked with the key-pad alarm and Nurse D stated, No. That's new. There was a key-pad alarm on the priest door leading to their living space. On 9/20/19, at 12:30 PM, a record review of Resident #1's electronic medical record revealed an admission on 8/24/19 at approximately 12:23 PM with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) was not completed. A review of nursing admission assessment dated [DATE] revealed; Resident is forgetful . resident is unsteady on her feet . Comprehension Oriented to: Person . Mood Anxious . Elopement Risk Assessment . Ambulatory . Disorientated but does not wander . Accepting of Placement . A review of Resident #1's progress notes revealed the following: 8/24/2019 19:35 Patient redirected and assisted to bedroom . Author (Agency Nurse E) 8/24/2019 20:10 Patient's poor safety awareness was brought to this writer's attention by assigned CN[NAME] Patient was not receptive to redirection form self ambulation with poor gait and balance. When staff attempted redirection patient became more agitated. This nurse suggested to assigned aid to give a bit of grace to allow patient to acclimate to new environment Author (Agency Nurse E) 8/24/2019 20:34 This nurse responded to an emergency egress alarm 13D. This nurse observed several staff members assisting patient away from emergency egress. As this nurse approached the assigned CNA was asked to shut off the egress alarm and patient was asked what was going on. Patient stated she was just walking around until all the noise started. This nurse stated to the patient that the door placard reads. STOP, emergency exit only. Wherein patient stated that she did not read it and ambulated to her room. Assigned CNA assisted patient into bed after making sure patient's under garments were unsoiled. Patient appeared to be receptive to lying down and watching TV Author (Agency Nurse E) 8/24/2019 21:30 This nurse was informed by (Sister I) at 2100 that her family had just left and are sitting with a woman in nightgown in the driveway. This nurse activated a head count of all residents and patient in room [ROOM NUMBER]-1 was not accounted for. This nurse proceeded with a wheel chair to the 12D emergency egress and (Sister I) stated that her family member stated patient had fell . This nurse made contact with patient at 2115 and observed resident patient standing with arms crossed . Patient continued to be agitated with this writer . as we guided patient back inside building . Author (Agency Nurse E) 8/24/19 22:24 Patient was provided with a location device upon her right ankle, as well as 1:1 . Author (Agency Nurse E) A review of Resident #1's Focus I am at risk for elopement care plan revealed the following interventions: Signaling device to extremity. Check every shift for placement and function Date Initiated: 8/25/2019 Re-direct if seeking an exit Date Initiated: 8/25/2019 I have been placed on 1:1 care until further notice. Date Initiated: 08/25/2019 A review of facility investigation for Resident #1's elopement revealed the following: BIMS undetermined-Resident was only in facility for 24 hours. (Resident #1) [AGE] year old female admitted to (facility). Alert to self. Resident is able to ambulate . Resident resided with daughter til about a couple weeks prior, was admitted to assisted living due to changes in her mental status. Camera reviewed and Resident was observed exiting the building through Administrative/Priest Hallway. The facility does not have cameras on either hallway. Resident was observed on camera by the Administration/Priest living quarters at approximately 2039. It is inconclusive as to when Resident exited the building due to no camera capturing event. We can conclude an approximate time frame per witness statements and nursing notes that Resident was observed outside of building by (Family Witness C) . at approximately 9pm. Conclusion: Facility did substantiate that this incident occurred . A review of staff statements for Resident #1's elopement revealed the following: Name of Person Making Statement (Staff J) The last time I seen (Resident #1) she was trying to get out the door Name of Person Making Statement (Staff K) The last time I was in the room with (Resident #1) . was getting in and out of bed . We got a knock at the back door that they found (Resident #1) outside . Name of Person Making Statement (Staff L) Last time I seen (Resident #1) was about 7:30 pm she was confused . Name of Person Making Statement (Staff M) The last time I saw (Resident #1) was when she was walking around the hallway and I took her to her room . Name of Person Making Statement (Staff N) The last time I seen (Resident #1) she was trying to get out of one of the side doors around 8pm. I helped away from the door . Name of Person Making Statement (Agency Nurse F) Approximately between 2030-2100, (Resident #1) made several attempts to open the exit door down St Joe's Women Hall. I observed (staff) redirecting the resident. I redirected her a couple of times in between passing meds . After this time frame sister came to me and told me one of the residents is outside. Name of Person Making Statement (Staff O) At 9:00 pm staff made it clear that (Resident #1) was not in the building . On 9/20/19, at 1:30 PM, a phone call to Agency Nurse [NAME] was made and a message left of the need to speak. On 9/20/19, at 2:30 PM, the Administrator was asked to clarify if Agency Nurse [NAME] was educated on how and when to apply a signaling device and the Administrator stated, I don't believe so. The staffing agency does a check off list with them regarding general nursing assessment. The Administrator was asked to provide all education documentation for Agency Nurse E. A record review of Agency Nurse E's education documents revealed Policy and Guideline Review Date 10/21/15 signed by Agency Nurse E. There were no other facility offered documents that detailed education on wandering or placing a signaling device for Agency Nurse E. On 9/20/19, at 4:27 PM, Agency Nurse F was interviewed regarding the night Resident #1 eloped. Agency Nurse F was working that shift and was passing medications on the women's hall. Agency Nurse F was asked if she had seen Resident #1 wandering and attempting to exit the building and Agency Nurse F stated, (Resident #1) had multiple attempts to exit. I was trying to divert her, all of us were. Agency Nurse F was asked if they knew what time the signaling device was placed onto Resident #1 and Agency Nurse F stated, I can't even guess what time it was placed and it was a CNA from the[NAME]hall because she knew where it was. I didn't know where to get the signaling device. Agency Nurse F offered that she had been educated as to where the signaling devices are and clarified, I didn't know prior but I do know where they are now. Agency Nurse F was asked if she knew how many times Resident #1 attempted to exit the building and Agency Nurse F stated, I seen her more than once approach that same door. On 9/24/19, at 900 AM, a review of facility video surveillance along with Social Services Designee G revealed Resident #1 was seen walking passed the courtyard windows at 20:39. Resident #1 then turned right and stood at the end of the hallway which was dark and near the administration/priest doorways. A staff member was seen coming down the hall away from the Resident at 20:42:50 and then out of view of camera at 20:42:55. Resident #1 backed up out of view while the staff member was walking in the hallway. Resident #1 then walked across the hallway towards the administration doorway and was out of view at 20:44:07. Social Services Designee G was asked if the video times were accurate and Social Services Designee G stated, it could be 10 minutes off up or down. We had maintenance done and at that time I noticed the times were not accurate. An observation of a present time camera revealed that the time was accurate during survey. On 9/24/19, at 9:55 AM, an observation along with Maintenance Director H of the priest doorways was conducted. The priest doorway that faced the facility had a key-pad alarm. Maintenance Director H enabled the alarm. There was a second door that opened into the priest quarters that did not have a lock. There was a 4 foot by 4 foot area separating these doors. There was a door immediately inside leading to the kitchen with a door on the opposite side of the kitchen that opened up into the administration hallway. Maintenance Director H stated, they could cut through the priest door and cut through the kitchen into the administration hallway. The Maintenance Director H was asked to clarify if the priest doors were ever locked and Maintenance Director H stated, these doors were never locked. The exit door at the end of the priest hallway had a push bar to exit and Maintenance Director H offered we alarmed both of them. Maintenance Director H was asked why the administration door was unlocked on 8/24/19, the day Resident #1 eloped and Maintenance Director H stated, they all have master keys and are supposed to lock the door. There are three nuns that come eat supper at 6:00 PM and I think (staff member) was here. Maintenance Director H could not verify who was responsible for locking the administration/priest doors after the elopement until the alarms were placed on 9/10/19. On 9/24/19, at 11:30 AM, the Director of Nursing (DON) was questioned regarding the safety and security of the administration/priest doors. The DON denied any policy or delegated responsibility to ensure the administration/priest doors were locked after the elopement until the alarms were placed. On 9/24/19, at 11:45 AM, a review of facility provided email from alarm company revealed; Also is attached is the sales order to install additional forced door alarms Administration and Priest Hallways. Technician was on site on (MONTH) 10,2019 to complete work on sales order . On 9/25/19, at 9:00 AM, a phone interview was conducted with family witness C that revealed; As we pulled out of the nun entrance, we seen a lady in her pajamas who appeared scared. We stopped right away. Family Witness C was asked where they first seen Resident #1 and Family Witness C stated, we seen her standing near the corner of the exit drive as we were pulling onto the service road that goes between the facility and the church. Family Witness C further offered she said there were murderers out here but then asked us our names. I called my sister and about 3 minutes later three staff members came out and helped her. At that time, we left. Family Witness C was asked if they witnessed Resident #1 fall and Family Witness C stated, Yes, she was talking with us through the car window and started backing up slowing then fell backwards onto the grass. Family Witness C denies seeing Resident #1 hit their head. The service drive divides the facility with a church and leads to the main road. On 9/25/19, at 9:30 AM, a review of facility policy Safety and Supervision of Residents . Reviewed 2/5/19 revealed the following; Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . 2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes . 4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents . 1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents . 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. Communication specific interventions to all relevant staff; b. Assigning responsibility for carrying out interventions; c. Provide training as necessary; d. Ensuring that interventions are implemented; and e. Documenting interventions . Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include: e. Unsafe Wandering . A review of facility policy Wandering Resident, Signaling Device Purpose: Signaling device will be used to alert staff of any resident with device that is attempting to leave the facility . Resident may be recommended for the signaling device system when they exhibit one or more of the following and are mobile: a. Seems confused or disorientated e. Attempt to leave the facility . The Immediate Jeopardy was abated on 8/26/19, based on confirmation during interviews conducted on 9/25/19 at 10:00 AM that the facility had implemented the following to remove the Immediate Jeopardy: 1. Signaling Devices validated for placement and function on all residents on 8/26/19 and 8/27/19. 2. The Agency LPN (nurse) will no longer work at facility. 3. The residents identified as exit seekers received complete review of plan of care on 8/27/19 for a total of 11. 4. All residents not currently identified as a risk for exit seeking in the facility were reassessed for current risk on 8/26/19. 5. Education initiated to staff on 8/24/19 on Safety and supervision including when to initiate a signaling device and or 1:1. 6. Newly admitted residents continue to be evaluated for elopement risk during admission evaluation, quarterly and as needed with care plans being reviewed and revised as appropriate. 7. Agency Packet that includes: Elopement Protocol, Wandering Resident, signal device, how to activate the signaling device, where signaling device located. Agency staff will sign that they have read and understand Policy and Procedures. 8. Door alarm installed on 9/10/19 to Administration and Priest hallway. The installation of the door alarms on the doors to the Administration Hallway and the Priest's Hallway was an extra measure taken by the facility and not relevant to the elopement of Resident #1 on 8/24/19. If the Agency Nurses on duty had placed a signaling device on Resident #1 at the time, an alarm would have sounded before the resident got to either of the two hallway doors. This information was received by the Survey Team Manager in a telephone conversation with the Nursing Home Administrator on Wednesday, (MONTH) 9, 2019 at 0932 hours. Without the application of a signaling device, the resident could have walked out of any of the facility's doors and no alarm would have sounded. With this clarification the Removal Date for the Immediate Jeopardy is 8/26/19. Although the Immediate Jeopardy was removed on 8/26/19, the the facility remains out of compliance at a scope of Isolated and a severity of No actual harm with potential for more than minimal harm that is not immediate jeopardy pending the facility's ability to sustain compliance as verified by the State Agency. As of the date of exit, only one Agency nurse had a signed acknowledgment of the new education material including where to locate the signaling device. The facility remained out of compliance due to incomplete in-service training for all staff including agency staff.

Based on observation, interview and record review, the facility failed to prevent the development of pressure ulcers and failed to implement timely interventions for two Residents (#60,66) of three residents reviewed for pressure ulcers resulting in one Stage II pressure ulcer, (partial-thickness skin loss), 2 unstageable pressure ulcers (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar - dead tissue), and infection. Findings include. Resident #60: On 5/02/19, at 10:30 AM, a record review of Resident #60's electronic medical record revealed an admission on 1/10/17 with [DIAGNOSES REDACTED]. Resident required extensive assistance with their Activities of Daily Living and had intact cognition. A review of Resident #60's physician orders [REDACTED]. Suprapubic open area cleanse with ns (normal saline), pat dry, apply skin prep, apply [MEDICATION NAME] cut to size to open area, change. Assure tube is not taunt. Change every 5 days and prn (as needed) . 5/02/2019 . A review of Resident #60's care plans revealed I am at risk for skin breakdown D/T (do to) incontinence and decreased mobility and a Foley catheter Date initiated 08/12/2016 Goal I will not have any skin breakdown QD (every day) x (times) 90 days . I have a suprapubic catheter and require catheter care Q shift . date initiated 08/12/2016 . A review of nurse progress notes revealed 5/2/2019 Upon observing suprapubic cath site this afternoon, a small pea size red area was noted under where the cath tubing lay pulled taunt . be sure the cath tubing is not being pulled by leg strap or brief during care and repositioning . On 5/02/19, at 3:23 PM, an observation of Resident #60's Supra pubic catheter site along with Nurse B revealed an indwelling catheter pulled taut to the left side. Nurse B' exposed the insertion site by lifting Resident #60's abdominal fold which revealed brownish drainage surrounding the site. Nurse B cleansed the area revealing a pea size Stage II pressure ulcer from the catheter tubing resting on their skin. The edges were bright red with the center noted to be yellowish tan with a slight depth. Nurse B was asked if the pressure area was from the catheter tubing and Nurse B' stated, it does look that way. Resident #60's catheter tubing was pulled to the left side and hooked to a leg bag on the left leg. On 5/02/19, at 3:50 PM, Unit Manager A was asked if they felt Resident #60 had pressure from the catheter and Unit manager A' stated, Yes. It looks like it when asked if they felt it was from the catheter tube resting on their skin. On 5/02/19, at 5:17 PM, the Director of Nursing (DON) was interviewed regarding Resident #60's catheter and their pressure ulcer and the DON stated, the edge is pink yes I agree. I did look at it this morning and we put a dressing on there so her skin is not laying on it. We also removed the strap so it's not pulling. We repositioned the gauze to protect her skin. Resident #66: On 5/02/19, at 1:04 PM, Resident # 66 was observed lying on their back in bed with their feet resting on the bed. Resident #66 had enabler bars to both sides of their bed. Wound Nurse CC had to assist the resident in rolling to their left side in order for Resident #66 to grab the enabler bar for wound observation. Resident #66's sacrum wound dressing was removed which had a moderate amount of yellow reddish drainage. Their wound measured approximately 10 centimeters (cm) long and 10 cm wide with reddened skin surrounding the wound with yellow slough noted. Resident #66's heel wound measured approximated 1 inch by 1 inch rounded area with eschar noted to more than half of the wound bed. On 5/2/19, at 4:00 PM, a record review of Resident #66's electronic medical record revealed an admission on 4/4/19 with [DIAGNOSES REDACTED]. Resident #66 required extensive assistance with Activities of Daily Living (ADL) and had intact cognition. A review of Resident #66's care plans revealed Focus I have a self care deficit R/T (related to): Muscle weakness and wasting . date initiated: 04/04/2019 . Goal I will have my needs met and participate with ADL's as I am able . I am assist of 2 with bed mobility . Interventions . Help me reposition Q (every) 2 hours and PRN (as needed) Keep off bottom while in bed Date initiated: 04/04/2019 . Resident #66's Focus I am at risk for skin breakdown . Date initiated: 04/04/2019 Goal I will not have any skin breakdown . care plan revealed the following interventions I have a recirculating air mattress to my bed. Date Initiated: 04/16/2019 . I have a roho cushion to my wheel chair. Date initiated: 04/16/2019 . Resident #66 did not have an intervention placed on their care plan to keep heels off the bed. A review of physician orders [REDACTED]. Every shift for skin protection 4/16/2019 . Bactrim DS Tablet 800-160 MG (milligrams) Give 1 tablet by mouth twice a day Start date 5/1/2019 End date 5/15/2019. A review of nursing admission assessment effective date 04/04/2019 revealed . Skin assessment Summary . boney prominences intact . Activity 1. Bedfast . was checked and mobility . Very Limited . was checked. A facility provided document Pressure . Resident #66's name appears on two separate lines that revealed Date first observed 4/12/19 In house Heel L: (length) 3.52 W: (width) 3.67 D: (depth) UTD (unable to determine) . Date first observed 4/16/19 In house Sacrum L: 8.31 W: 6.2 D: UTD . On 5/03/19, at 10:04 AM, Wound Nurse CC was interviewed regarding the development of Resident #66's pressure ulcers and Wound Nurse CC stated, well she did not have it and it suddenly appeared so I would say yes it started here. Wound Nurse CC was further questioned why Resident #66 was receiving Bactrim DS (antibiotic) and Wound Nurse CC stated, she [MEDICAL CONDITION] (a staph bacteria resistant to some antibiotics) in her heel wound. Wound Nurse CC further offered that Resident #66 goes to the wound clinic and was asked to provide the latest documentation for Resident #66's wound care visit. On 5/03/19, at 2:30 PM, a record review of report of consultation for Resident #66 from 5/3/19 wound care appointment revealed cultures Pseudomonas/[MEDICATION NAME] on sacrum . Pseudomonas/MRSA on heel . cont (continue) Bactrim . On 5/03/19, at 2:45 PM, a record review of facility policy Prevention of Pressure Ulcers/Injuries Policy Review/Revised Date: 05/02/2018 revealed the purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors . Review the resident's care plan and identify risk factors as well as the interventions designed to reduce or eliminate those considered modifiable . Teach residents who can change positions independently the importance of repositioning. Provide support devices and assistance as needed. Remind and encourage residents to change positions.

Based on observation, interview and record review, the facility failed to ensure appropriate care, management, and documentation of an indwelling catheter change (catheter inserted into the bladder to aide in urinary drainage), for two of three residents (#34, #60) reviewed for catheter care, resulting in a lack of catheter assessment, undocumented proof of catheters being changed, and urinary tract infections. Findings include: Resident #60: On 05/01/19, at 11:26 AM, Resident #60 was lying in their bed with catheter tubing draining yellow urine. Resident #60 stated, It's been awhile and I think I'm do to be changed. On 5/02/19, at 10:30 AM, a record review of Resident #60's electronic medical record revealed an admission on 1/10/17 with [DIAGNOSES REDACTED]. Resident required extensive assistance with their Activities of Daily Living and had intact cognition. A review of Resident #60's physician orders [REDACTED]. Suprapubic open area cleanse with ns (normal saline), pat dry, apply skin prep, apply [MEDICATION NAME] cut to size to open area, change. Assure tube is not taunt. Change every 5 days and prn (as needed.) On 5/02/19, at 1:46 PM, Unit Manger A was asked to provide the last time Resident #60 had their indwelling/Supra pubic catheter changed and Unit manager A stated, the physician here manages her catheter and it's changed as needed. On 5/02/19, at 3:23 PM, an observation of Resident #60's Supra pubic catheter site along with Nurse B revealed an indwelling catheter. Nurse B was asked when the last time Resident #60's catheter was changed and Nurse B stated, we don't change them here unless there is an issue with it but she just came back from the hospital and I want to say they did change it there, yeah. Resident #60's catheter tubing was pulled tight to the left side and hooked to a leg strap to their left leg. On 5/02/19, at 3:50 PM, Unit manager A was asked to provide the last documented proof that Resident #60 had their catheter changed at the facility and Unit Manager A stated, I don't have any documentation to prove that it has been changed by our staff. Unit manager A further offered, I have not found any progress notes referring that the doctor was called regarding the Supra Pubic catheter and any change dates. Unit Manager A was asked if they felt Resident #60 had pressure from the catheter and Unit manager A' stated, Yes. It looks like it when asked if they felt it was from the catheter tube resting on their skin. Unit manager A further offered that Resident #60 went to the hospital on [DATE] for leg pain and they found a UTI (urinary tract infection) and she returned [MEDICATION NAME](antibiotic.) On 5/02/19, at 5:17 PM, the Director of Nursing (DON) was interviewed regarding Resident #60's catheter and their pressure ulcer and the DON stated, the edge is pink yes I agree. I did look at it this morning and we put a dressing on there so her skin is not laying on it. We also removed the strap so it's not pulling. We repositioned the gauze to protect her skin. The DON was asked to provide the facility policy for catheter care and the DON provided 2 pages of a 6 page document that noted appropriate urinary catheter use and did not state how often a catheter should be changed. On 5/03/19, at 12:15 PM, a phone interview was conducted with the Medical Director Y asking how often Supra pubic catheters be assessed for change and the medical director Y stated, monthly or every 6 week but may be determined on individual needs. Resident #34: Record review of Resident #34's Minimum Data Set ((MDS) dated [DATE], revealed a resident with Brief Interview of Mental Status (BIMS) score of 8 out of 15, indicating cognitive impairment. [DIAGNOSES REDACTED]. Record review of Resident #34's paper and electronic medical record revealed that on 4/6/19 Resident #34 was sent to the hospital for change of condition. Record review of hospital discharge summary, dated 4/11/19, revealed discharge Diagnoses: [REDACTED]. Suprapubic catheter was changed on 4/9/19 and patient did not have any further fever spikes. In an interview on 05/02/19 at 01:47 PM, Licensed Practical Nurse (LPN) A, revealed that Resident #34 did have a urinary tract infection on 4/6/19 and was sent out to the hospital. LPN A was asked when the last time the supra pubic catheter was changed. Also, a policy was requested. LPN A stated that she did not know the last time the suprapubic catheter was changed and would have to review the record. In an interview on 05/03/19 at 01:14 PM, Licensed Practical Nurse (LPN) MDS Nurse J, revealed the catheter care plan, whether its Foley or Suprapubic, and the reason why, with a diagnosis. Nurse J stated that a nurse should add to the care plans. When a resident comes in, the admitting nurse can start the care plan. There is a template the nurse can follow. Record review of Resident #34's care plans, pages 1- 20, revealed on page 17, bladder incontinence related to [MEDICAL CONDITION] bladder with history of frequent UTI's. Interventions included: to clean suprapubic site daily and apply dry dressing, note amount, frequency, color or odor of urine, change catheter bag monthly, and change suprapubic catheter as per CDC guidelines. The care plan did not note the size of the catheter, either silicone or latex material, leg strap usage or when the last date it was changed. The state surveyor requested the CDC catheter guidelines that the facility used and was presented with 2 pages of 6 pages of a document that noted appropriate urinary catheter use, but had no mention of when to change a suprapubic catheter Observation on 05/02/19 at 02:34 PM of suprapubic catheter care for Resident #34 revealed the catheter site with a split drain sponge in place. There was fecal material on split sponge. Area was cleansed with normal saline and the sponge reapplied. In an interview on 05/02/19 at 03:12 PM, Licensed Practical Nurse (LPN) A, stated Supra pubic catheter procedure was in discharge summary in 2014 that Resident #34 had a suprapubic catheter. The response as to when the catheter was last changed was, I have no documentation of when it was changed by facility. I looked in medical record as far back as January. Usually if no output/low output, we attempt to flush catheter sterile water. If it doesn't flush, we change the catheter all together. I Reviewed records back to (MONTH) 28th, (YEAR), catheter was changed that day (6 months prior). When I first started here, we changed them every 30 days, then a consultant stated we should change them as needed, when an issue arises. An interview was conducted on 05/03/19 at 09:53 AM with the Director of Nursing (DON) regarding when Suprapubic (SP) catheters are to be changed. The DON stated that changes of SP or Foley catheters used to be every 30 days. Now changes occur when it is clogged or there are issues. Nurses should have documentation of color of urine, and intake/output. State surveyor requested documentation of I/O's for Resident #34. None were received. The DON was further queried if catheter size, leg strap, latex versus silicone and change-as-needed be on care plans? The DON replied, Yes, care plan should have size of catheter, note clarity color and sediment.

This citation pertains to intake number MI 378 Based on observation, interview and record review the facility to prevent a fall from shower chair for 1 resident (#701) out of 3 residents reviewed for falls, resulting in Resident #701 experiencing severe pain, hospitalization and usage of leg brace for a right femur fracture. Findings include: On 3/1/19 at 10:30 AM, a review was completed of Resident #701's medical records and it revealed the resident was readmitted to the facility on [DATE] with primary [DIAGNOSES REDACTED]. According to the MDS (Minimum Data Set) Assessment the resident is cognitively intact and requires extensive assistance for dressing, personal hygiene and toileting. She is total dependence for transfers and bathing and has impairment on both of her upper and lower extremities. A review was completed of Resident #701's progress notes from 12/31/18 and the following was noted: - Progress note at 2:19 PM created by Nurse A: At 1205p, CNA (Certified Nursing Assistant) notified nurse that resident (#701) slid onto shower room floor. Nurse went into shower room and assessed resident, she was sitting upright on her bottom with no c/o (complaints of) pain or discomfort . CNA stated that she asked resident to sit up in shower chair, resident held on to the arm rests on the shower chair, her weight shifted, and resident fell on to the floor . - Progress Note at 5:58 PM created by Nurse A: Resident started having c/o pain to right leg once she was in bed. Nurse heard resident moaning and when assessed resident was seen grimacing and saying she is having a lot of pain . Notified physician resident husband is requesting for her to go to hospital. Physician agreed for her to go hospital . On 3/1/19 at 10:50 AM, Family Member B was interviewed regarding the fall with Resident #701. She reported the CNA's had Resident #701 secured in the shower chair but had to remove it (the seatbelt) as they could not get the sling from under her. When the resident leaned forward for the aide to get the sling from underneath her, she fell out of the chair. There was one aide on the left side of the resident that was able to protect the resident from hitting her head, but as she was falling her leg went out to the right. Resident #701's husband returned to the facility for dinner and the resident was in extreme pain was sent the emergency room to be assessed further. Resident #701 remained in the hospital for a few days as it found she had a fracture to her leg. Family Member B reported the Physician's at the Acute Care Hospital recommended a leg brace and will evaluate Resident #701 to see if it heals. If the fracture does not heal, they will then recommend surgery. Family Member B expressed their concern about the placement of the CNA's while they were removing the sling from Resident #701. In addition to the CNA's unstrapping the resident as they felt this was a safety concern. On 3/1/19 at 11:50 AM, Resident #701 was observed enjoying coffee, watching television and visiting with her husband. The resident was observed to have on a leg brace and appeared to be comfortable in her wheelchair. Resident #701 was asked if she remembered the fall in December, she stated the fall was some time ago and she does not remember much. Resident #701's husband stated the resident was in the shower room with two CNA's and they had her lean forward to get the sling from underneath his wife and she fell forward. He expressed his concern with the positioning of the CNA's, as he did not understand why a CNA was not standing in front of her. Resident #701 was queried if she could remember where the CNA's were positioned in relation to her and she reported she could not. On 3/1/19 at 11:56 AM, an interview was conducted with Unit Manager C regarding her knowledge of the fall that occurred with Resident #701 on 12/31/18: The Unit Manager explained the two CNA's were preparing to shower the resident and attempted to remove the sling from underneath the resident and she (Resident #701) slid down onto the floor. The CNA's had just released the seatbelt on the shower chair to get the sling from beneath her. The Unit Manager was asked if the documentation states where the CNA's were positioned in relation to the resident. She reported it did not state in the incident report but from her recollection CNA D was located on the side of Resident #701 and CNA E was toward the back of the resident. CNA D asked the resident to lean forward while they were pulling the sling from underneath her and she slid down. The two back brakes (on shower chair) were locked, and the shower chair tipped forward engaging the anti-tips of the chair; which caused the resident to slip forward, slipping her leg to the right. On 3/1/19 at approximately 12:20 PM, Staff Educator F was queried about the education provided to facility nursing staff regarding lifts and slings. The Educator explained part of the nursing staff's orientation includes lift training and they have to complete a competency check off at orientation and yearly thereafter. The Staff Educator explained during the training she instructs aides on ensuring they have the current sling, rolling and placing the resident and having two people at all times. The Educator was further queried on the instructions provided on how many aides it takes to remove a sling from a resident. She reported she instructs them to utilize two aides in order to remove a sling from underneath a resident. On 3/1/19 at 1:28 PM, an interview was conducted with CNA E regarding Resident #701's fall in the shower room on 12/31/18. CNA E reported she customarily only provides showers during her shift but on this day, she was working the floor. CNA E reported it was almost noon and they were instructed to provide a shower to Resident #701. The resident was placed in the shower chair via Hoyer lift and secured with the seatbelt that is attached to the chair. CNA E reported she was in the shower room moving the resident's wheelchair and gathering towels in preparation for the shower. As CNA E was doing this, CNA D unbuckled the seatbelt and asked Resident #701's to lean forward. The resident leaned so fast that the anti-tip breaks on the shower chair enabled and the resident fell forward. CNA D was able to guide the resident enough so that she did not hit her head on the hard surface in the shower room. CNA E was asked to clarify where she was located in relation to Resident #701. CNA E explained she was not behind Resident #701 but behind the wheelchair, that was behind Resident #701. She continued that normally they utilize two CNA's to remove a sling from underneath a resident. She explained it is normally one CNA on the side of the resident and one in front of the resident. CNA E reported she observed the incident and was not involved in guiding the resident to the floor. On 3/1/19 at approximately 1:45 PM, phone contact was attempted with Nurse A but there was no answer and voicemail was left requesting return phone call. On 3/1/19 at approximately 1:50 PM, a review was completed of Resident #701's care plan and it revealed the following: Focus: Self-care deficit R/T (related to): Dementia & muscle weakness - Initiated on 8/12/16 and revised on 10/27/17 Interventions: I am an assist of 1 with dressing - Initiated on 8/12/16 and revised on 4/20/18 I am assist of 1 with bathing . - Initiated on 8/12/16, revised on 7/17/18 I need 2 staff members to help me with my showers - Initiated on 1/5/19 It can be noted Resident #701's MDS assessment dated [DATE] list the resident as the following: -Dressing: Extensive assistance with two plus person physical assist. - Bathing: Total dependence with two plus person physical assist. On 3/1/19 at approximately 2:00 PM, an interview was conducted with MDS Nurse G regarding the inconsistencies in Resident #701's MDS and care plan. This writer and MDS nurse reviewed the residents MDS and care plan and she agreed they were not consistent with one another. It was asked if the care planned item of the Resident being 1 person assist for showers would carry over to the CNA Kardex. The MDS Nurse reported yes it would carry over. On 3/1/19 at approximately 2:15 PM, Staff Educator F was queried if there is documentation showing she instructs facility staff to utilize two aides while removing a sling from a resident. The Educator reported she does not believe she has any instruction material that states this, nor does she believe there is a facility policy that would be this detailed. But reported again she teaches aides to utilize two people when removing a sling. On 3/1/19 at 2:30 PM, Unit Manager C was queried if it was listed in any of Resident #701's medical records how many aides it requires to remove the sling from underneath her. The Unit Manager reported it is not listed anywhere. The Unit Manager was asked to clarify her understanding of where CNA D & E were located in the shower room. She reported it was her understanding that both aides were right next to the shower chair. At 2:50 PM on 3/1/19, this writer and Unit Manager C observed the shower room and bariatric shower chair (one like the one Resident #701 was in). The shower chair does have an adjustable securement device attached to the chair. At 3:00 PM, an interview was conducted with CNA E regarding Resident #701's fall on 12/31/18. CNA E explained she and CNA D were in the shower room and she asked Resident #701 to lean forward so she could remove the sling from underneath her leg. When the resident leaned forward, she slid out of the chair and one leg was pointed straight out and the other was at an angle. CNA D compared the angle of one leg as going into the splits. She stated her main objective was to protect the resident's head as she was not able to prevent her from falling. CNA D was queried if there is a securement device located on the shower chair and if so was why was it unfastened versus being loosened. CNA D reported there is a securement device attached to the shower chair and added she took off the device prior to asking Resident #701 to lean forward. CNA D explained the resident never sits all the way back in chair no matter how much staff try and scoot her back in it which causes the device to have to be fully extended (already loosened). CNA D reported she was positioned on one side of Resident #701 closer to the front of the chair. CNA E was behind the wheelchair that was behind the shower chair. CNA D explained they were educated during facility training and during her CNA certification that two staff are needed to remove a sling from a resident. On 3/1/18 at approximately 3:30 PM, a review was completed of the facility's investigation on Resident #701's fall on 12/31/18: Interview from CNA E completed on 1-1-19: - .We took her (Resident #701) in the shower room. I (CNA E) was bringing her chair in the room and getting the towels and wash cloths. As I (CNA E) was getting the stuff CNA D asked her (Resident #701) could she lean forward to get the sling out from underneath her. (Resident #701) said sure. All of a sudden she was on the floor, CNA D said she didn't hit her head . Interview with CNA D (included within the facility's investigative summary): - .She (CNA D) was assisting this resident (#701) with removing her sling from beneath her while she was sitting on the bariatric shower chair she unhooked the seat belt as she was trying to remove the sling and asked the resident to lean forward and noted resident to lean quickly causing the chair engage the anti-tippers. Which caused the resident to slide to the floor .resident (#701) slid to the floor onto her buttocks with her left leg straight out and right leg extended laterally to the right . Facility's investigative summary stated the following: - . Residents (#701) prior functioning is physically dependent for dressing, showering and all lower body transferring and toileting .Resident is noted to have a fracture per (Acute Hospital) Radiology .The resident suddenly slipping to the floor was unavoidable and the fracture was unavoidable . On 3/1/19 at 4:02 PM, an interview was conducted with PTA H and OT I regarding Resident #701's trunk support. OT I reported when the Resident returned to the facility, she was started on therapy services again. During therapy the resident would sit in chair and they had her lean forward and she required extensive assistance. PTA H explained the resident has a posterior lean and cannot sit unsupported. Since admission the resident has been a full lift and she has no active leg movement. A review was completed of Resident #701's Physical Therapy notes, the following was indicated: Physical Therapy Plan of Care Start of Care: 1/10/18 and End of Care: 2/6/18 - Current Level of Function: .Required 100% physical assistance by one or more persons to position. Even with constant cueing, patient is unable to sustain and perform each gross motor action of the positioning. In all positioning including bed and wheelchair. PT- Therapist Progress from 2/1/18 - Current level of functioning: .Pt. and caregivers require further training due to poor compliance with proper positioning .Due to safety reasons, the patient requires total assist for all mobility and positioning . Functional Limitation Assessment-Discharge Value (2/6/18) - .(100% impaired) Changing and maintaining body position functional limitation . Physical Therapy Plan of Care: 1/4/19-1/16/19 - .Patient was admitted from the hospital post fall here with a fracture right lower femur and proximal end of tibia with knee immobilizer and NWB (non-weight bearing) on B (bilateral) LE (extremities) . - Balance, GG: Picking Up Object Prior Level: Dependent- Helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity . Current Level: Dependent- Helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity . PT- Therapist Progress & Discharge Summary 1/16/19 - Sitting Balance: General: The patient will increase sitting balance to F-static (able to maintain static balance with UE support) and tolerate 0 minutes to participate in activities improving to minimal assistance with 5% verbal instructions/cues .Prior Level as of 1/4/19 the patient demonstrates sitting balance of P dynamic (unable to maintain balance without mod/max support, mod/max to reach) . tolerates for 0 minutes requiring dependent assist with 25% verbal instruction .End of Goal Status as of 1/16/19: Goal not met- DC'd (discharged ) on 01/16/19 .The patient demonstrates sitting balance of P static (unable to maintain balance without mod/max support) . On 3/1/19 at 4:50 PM, an interview was conducted the Administrator and DON (Director of Nursing) regarding Resident #701's fall. The concerns from the investigation were discussed and the information reported in the facility's investigation differed from the information gathered from this writer. The DON reported they completed reenactments to gain clarity on the fall and from their investigation concluded the aides were not at fault. The DON and NHA were queried if they asked the CNA's why the securement device on the resident was not loosened versus unbuckled. They reported this question was not asked of the aides. The DON and Administrator contacted CNA D for an additional interview. The Administrator asked the CNA if she had her hand on the sling and was actively pulling when she asked Resident #701 to lean forward. CNA D explained she was positioned on the side of the resident toward the front of the chair and pulling the sling from underneath her leg as she was leaning forward. The Administrator asked if when CNA D pulled the sling did it propel her forward and she stated the resident slid out of the chair. CNA D reported when asking a resident to lean forward to remove or adjust a sling they utilize two people. When asked why she did not utilize two staff in this situation, the CNA stated she was only removing one side of the sling. It can be noted during the interview some of the questions for CNA D were leading and the information provided was not listed in their investigation that was completed by the facility and provided to this writer. The additional questions for this CNA were asked due to the investigation findings of this writer. On 3/8/18 at 4:00 PM, a review was completed of Resident #701's medical records from her admission at the hospital from 12/31/19-1/4/19, the following was revealed: emergency room Physician Discharge Diagnosis: [REDACTED].[MEDICAL CONDITION] for last 3 years . pt (patient) has hx (history) of spine injury in the past .known paraplegic, bed bound . Imaging Results of CT (computed tomography) w/o (without) contrast results: - Indication: fell . Pain right knee .Impression: . significantly comminuted oblique fracture involving medical aspect of distal metaphyseal region with fractures lines extending to the articular surface of the intercondylar region of distal right femur .separation of fracture fragments is noted. Nondisplaced [MEDICAL CONDITION] aspect of proximal shaft of tibia is suspected . On 3/8/19 at 4:15 PM, a review was completed of CNA D and E Competencies Checklist: CNA D hired on 3/15/18 - On 3/26/18 CNA D was marked as competent regarding bathing and usage of lifts with residents. CNA E hired on 9/11/1996 - On 11/7/18 CNA E was marked as competent regarding bathing/bedbath of residents and usage of lifts with residents. On 3/8/19 at 4:30 PM, a review was completed of the facility policy entitled, Lifting Machine, Using a Mechanical revised (MONTH) (YEAR), the policy revealed the following: .Carefully remove the sling from under the resident. Be mindful of the residents' position and balance, and skin .

This citation pertains to MI 490. Based on interview and record review, the facility neglected/failed to adequately supervise and delayed treatment for 2 Residents (#101 and #104) of 4 sampled Residents, resulting Resident #101, who was on anticoagulant (blood thinner), sustaining a fall with hit to the back of head in the morning. Resident #101 was placed in front of the nursing station for increased supervision, and sustained a second fall on the same day with head/facial fractures and bleeding, which resulted in Resident #101's hospitalization . Resident #104 sustained a fall with complaints of headache and was hospitalized hours later with a subdural hematoma. Findings include: Record review of facility 'Safety and Supervision of residents' policy dated (MONTH) (YEAR), revealed the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Individualized, Resident-Centered approach to safety: (3.) the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Record review of facility 'Acute Change of Condition' policy dated 9/2017, revealed the purpose was to assure prompt recognition of clinically important deviation in a resident baseline in physical, cognitive, behavioral, of functional domains. Our focus seeks to evaluate and manage a resident her at the nursing home and avoid a transfer to a hospital or emergency room . (2.) When interacting with residents, staff is to note any changes in the resident. These include, but are not limited to, changes in: Emesis, Falls, Level of Consciousness, sudden onset or increase in severity of pain, sudden onset or persistent decline in function, weakness . Monitoring: (1.) The licensed nurse continues to assess and monitor the resident's symptoms and physical functioning at least once per shift until the resident is stable and documents in detail the relevant findings, interventions, and response in the medical record Record review of facility 'Charting Documentation' policy date 9/7/2017, revealed all services provided to the resident, or any changes in the resident's medical condition, shall be documented in the resident's medical record. Documentation is a requirement. Failure to document as per policy will result in progressive discipline. Resident #104: Record review of Resident #104's medical record revealed some medical [DIAGNOSES REDACTED]. Resident #104 was noted to receive [MEDICATION NAME] (antiplatelet-decreases clotting factor) 75 mg orally every day. Record review of Resident #104's accident/incident report dated 8/24/18 at 11:55 PM revealed the resident was found by staff kneeling on the floor in front of her bed with her ted hose on. Injury of small abrasion noted to left anterior knee of 3 mm with some bruising noted was assisted back to bed. The fall was not witnessed. Resident was noted to state she got out of bed because she heard the boy crying (confusion). There was no Neurological assessment presented or attached to the incident report given to the state surveyor. Record review of Resident #104's accident/incident report dated 8/25/18 at 7:20 AM revealed that the resident was observed on floor in front of her closet door sitting up holding her head. The resident stated that she bumped her head when she fell on the floor. Assessment noted resident stated the left side of her head hurt. Staff noted no contusion, bruising or swelling to the area. Assessment noted confusion. Record review of the Neurological checks documented on the Neurological Assessment Flow sheet on 8/28/18 as late entries by Licensed Practical Nurse (LPN) D, for the fall incident on 8/25/18, revealed that on 8/25/18 at 10:20 AM there was a change in the level of consciousness and the resident complained of headache. There was no corresponding nurse note documented. On 8/25/18 at 11:20 AM there was a change in the level of consciousness and the resident complained of headache. There was no corresponding nurse note documented. On 8/25/18 at 12:20 PM there was a change in the level of consciousness and the resident was unable to perform hand grasps and complained of headache. There was no corresponding nurse note documented. On 8/25/18 at 1:30 PM there was a change in the level of consciousness and the resident was unable to perform hand grasps and complained of headache and had a small emesis, at this point the resident was sent out to the hospital. Record review of Resident #104's nurse notes dated 8/25/18 through 8/28/18 revealed that on 8/25/18 at Licensed practical Nurse (LPN) D noted at 9:37 AM resident was found on floor next to her closet this morning at 7:15 AM. An assessment was done and continues neuro checks and monitoring. The next nurse notes on 8/25/18 at 1:33 PM by LPN D revealed resident was found on the floor at 7:20 AM, at 1:30 PM the resident was sent out to the hospital. The resident complained of having a headache and had a small emesis, the resident was very confused An interview on 8/28/18/at 3:49 PM with Licensed Practical Nurse (LPN) D revealed that on 8/25/18 at 7:20 AM she found Resident #104 on the floor in front of her closet and did an assessment. LPN D stated that Resident #104 complained of a headache and thought that she had hit her head. LPN D stated that she did an assessment and proceeded to get the resident up off the floor and into a wheelchair and brought the resident out to the nursing station to sit. LPN D stated that the day progressed and between 10:00 AM and 11:00 AM the Resident #104 started to go downhill with sluggish eye response and she was tired. LPN D stated that there was an emesis of yellow and that she though the resident had a concussion. LPN D stated that she did get an order to send the resident to the hospital. LPN D stated that the resident did come back to the facility on hospice services. LPN D stated that she did fill out the neurological assessment sheet today (8/28/18) and not on 8/25/18 the day of the fall, but that she had written the assessments in a personal note book she kept in her pocket and takes home with her. Record review of Resident #104's Hospital CT scan 8/25/18 demonstrated large subdural hematoma on the right with midline shift. Hospital transfer summary dated 8/27/28 revealed discharge [DIAGNOSES REDACTED]. Resident #101: Record review of resident #101's medical record revealed a he/she was a recent new admission to the facility on [DATE]. Some of the Medical [DIAGNOSES REDACTED]. Resident #101 was receiving Xarelto (anticoagulant-blood thinner) 10 mg orally every day. Record review of Resident #101's Accident/incident report dated 3/3/18 at 10:11 AM revealed the resident was sitting in hallway in front of nursing station. Staff heard a thud and looked over and saw resident sitting on the floor on his bottom with his back against the wall. No witnesses found. Resident (#101) stated that he was getting up to go for a walk and slipped and fell . Resident stated that he hit his head pretty hard, resident stated that his head hurts, but nothing else. Facility staff intervention was to re-educate the resident to ask for help. (Resident had dementia diagnosis). The incident report noted resident had small bump to top left posterior head, reports mild pain when pressure is applied. No redness, bruising or open areas observed. Resident was assisted back into wheelchair. Record review of Resident #101's nursing notes dated 3/3/18 at 10:22 AM through 3/3/18 at 2:45 PM revealed that at 10:22 AM there was a note describing the fall at the nursing station and staff would continue to monitor. The next note on 3/3/18 at 11:27 AM noted the resident was on [MEDICATION NAME] antibiotic for [MEDICAL CONDITION], temperature was 98 and there were no stools this shift. Will continue to monitor. Record review of Resident #101's 'First 24-hour Neurological Assessment' sheet noted at 10:15 AM right pupil size of 1 sluggish, left pupil size of 1 brisk (they were not equal). Neurological documentation for pupils is sluggish right side and brisk left side through 12:00 PM (noon). There were no pupil checks done at 1:00 PM. At 2:00 PM both pupils are documented as sluggish with weak lower extremities. Record review of Resident #101's Accident/incident report dated 3/3/18 at 2:55 PM revealed 'Staff heard loud noise and saw resident on floor next to wheelchair, face down. Bleeding noted coming from nares. Alert with confusion noted. No witnesses found. Record review of occurrence statement attached to the incident report noted fall location at the nursing station, staff heard loud noise and observed resident on floor. Resident was unable to give a statement. Resident had a hematoma to left forehead, gross left orbital swelling. resident had fall earlier today at 10 AM. Fall not witnessed. Record review of Resident #101's nurse note dated 3/3/18 at 4:00 PM: resident found on floor, face down next to wheelchair. Brakes locked. Bleeding noted from nares. Alert with confusion noted. Gentle swabbing of nares and face done to assess for injuries An interview on 8/28/18 at 2:47 PM with Registered Nurse (RN) C, revealed that on 3/3/18 RN C came on shift at 2:00 PM got report from first shift in the alcove in a secluded area for a face-to-face shift report. RN C stated that she/he did not see Resident #101 because she was behind the nurse station and the counter was in the way. One of the nurse aides who doesn't work here anymore alerted the nurse Resident #101 was on the floor. RN C stated that the first fall was on day shift and was notified in report to keep resident at the nurse station for observation. RN C stated that the fall was not witnessed, that no one saw the fall and the aides found the resident already on the floor. Record review of resident #101's care plan for falls dated 3/1/18 noted no added interventions post fall on 3/3/18 at 10:11 AM, such as keeping the resident at the nursing station for observation or increase supervision post fall.

This citation pertains to MI 490. Based on observation, interview and record review, the facility failed to prevent falls and ensure fall interventions were in place to prevent re-occurrence of fall for 2 (101, 104) of 4 residents, resulting in Resident #104 sustaining a fall with head injury of subdural hematoma, and Resident #101 sustaining a second fall after interventions to increase supervision resulting in head trauma, subdural hematoma and hospitalization . Findings include: Record review of facility 'Abuse, Neglect, Exploitation & Misappropriation of Resident Property' policy dated (YEAR) defined Neglect: the failure of the facility, it's employees, or facility service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. Record review of facility 'Safety and Supervision of residents' policy dated (MONTH) (YEAR), revealed the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Individualized, Resident-Centered approach to safety: (3.) the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Record review of facility plan of correction (P[NAME]) in-service for falls dated (MONTH) (YEAR) included the following policies for staff education: 'Incident/Fall Prevention Policy' hand dated by the Nursing Home Administrator 5/29/18, revealed the home will ensure the residents' safety by having adequate supervision and assistive devices to prevent accidents or incidents. 'Fall' is defined as an unplanned descent to the floor with or without injury. Post incident protocol: (e.) The resident's condition, vital signs and pertinent information concerning the injury are to be documented in the nurse notes Monitor closely for any condition changes. 'Falls-Clinical Protocol' policy hand dated by the Nursing Home Administrator 5/29/18, revealed treatment and management: Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. Examples of interventions may include addressing medical issues of [MEDICAL CONDITION] and dizziness Monitoring and Follow-up: (1.) The staff, with the physician's guidance, will follow-up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. (a.) Delay complications such a late fractures and major bruising may occur hours or several days after a fall, while signs of subdural hematoma or other intracranial bleeding could occur up to several weeks after a fall. 2. Staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. (a.) Frail elderly individuals are often at greater risk for serious adverse consequences of falls. (b.) Risk of serious adverse consequences can sometimes be minimized even is falls cannot be prevented. Neurological Assessment policy hand dated by the Nursing Home Administrator 5/29/18, revealed the purpose of this procedure is to provide guidelines for a neurological assessment (3.) subsequent to a fall with a suspected head injury. Observation on 8/28/18 and 8/29/18 revealed sampled Residents #102 and #103 to be observed with facial and occipital area bruising noted visible to the head in the dining room during tours. Observation on 8/29/18 of the St.(NAME)nursing station noted four elderly females seated in wheelchairs at the nursing station and appeared to be sleeping in the chairs. Facility staff were noted to come and go from the area. An interview on 8/29/18 at 10:59 AM with the Director of Nursing (DON) services revealed that the facility was an alarm free facility. The facility had no policy or no alarm free program interventions for re-peat falls. Resident #104: Record review of Resident #104's medical record revealed some medical [DIAGNOSES REDACTED]. Resident #104 was noted to receive [MEDICATION NAME] (antiplatelet-decreases clotting factor) 75 mg orally every day. Record review of resident #104's accident/incident report dated 8/24/18 at 11:55 PM revealed the resident was found by staff kneeling on the floor in front of her bed with her ted hose on. Injury of small abrasion noted to left anterior knee of 3 mm with some bruising noted was assisted back to bed. Fall was not witnessed. Resident was noted to state she got out of bed because she heard the boy crying (confusion). There was no Neurological assessment presented or attached to the incident report given to the state surveyor. Record review of Resident #104's accident/incident report dated 8/25/18 at 7:20 AM revealed observed on floor in front of her closet door sitting up holding her head. The resident stated that she bumped her head when she fell on the floor. assessment noted resident stated the left side of her head hurt staff noted no contusion, bruising or swelling to the area. assessment noted confusion. Record review of the Neurological checks documented on the Neurological Assessment Flow sheet on 8/28/18 as late entries by Licensed Practical Nurse (LPN) D, for the fall incident on 8/25/18, revealed that on 8/25/18 at 10:20 AM there was a change in the level of consciousness and the resident complained of headache. there was no corresponding nurse note documented. On 8/25/18 at 11:20 AM there was a change in the level of consciousness and the resident complained of headache. there was no corresponding nurse note documented. On 8/25/18 at 12:20 PM there was a change in the level of consciousness and the resident was unable to perform hand grasps and complained of headache. There was no corresponding nurse note documented. On 8/25/18 at 1:30 PM there was a change in the level of consciousness and the resident was unable to perform hand grasps and complained of headache and had a small emesis, at this point the resident was sent out to the hospital. There was no documentation of the level of pain assessed for the complaints of headache to signify if the pain was increasing. Record review of Resident #104's nurse notes dated 8/25/18 through 8/28/18 revealed that on 8/25/18 at Licensed practical Nurse (LPN) D noted at 9:37 AM resident was found on floor next to her closet this morning at 7:15 AM. An assessment was done and continues neuro checks and monitoring. The next nurse notes on 8/25/18 at 1:33 PM by LPN D revealed resident was found on the floor at 7:20 AM, at 1:30 PM the resident was sent out to the hospital. The resident complained of having a headache and had a small emesis, the resident was very confused In an interview on 8/28/18/at 3:49 PM with Licensed Practical Nurse (LPN) D revealed that on 8/25/18 at 7:20 AM she found Resident #104 on the floor in front of her closet and did an assessment. LPN D stated that Resident #104 complained of a headache and thought that she had hit her head. LPN D stated that she did an assessment and proceeded to get the resident up off the floor and into a wheelchair and brought the resident out to the nursing station to sit. LPN D stated that the day progressed and between 10:00 AM and 11:00 AM Resident #104 started to go downhill with sluggish eye response and she was tired. LPN D stated that there was an emesis of yellow and that she though the resident had a concussion. LPN D stated that she did get an order to send the resident to the hospital. LPN D stated that the resident did come back to the facility on hospice services. LPN D stated that she did fill out the neurological assessment sheet today (8/28/18) and not on 8/25/18 the day of the fall, but that she had written the assessments in a personal note book she kept in her pocket and takes home with her. Record review of Resident #104's Hospital CT scan 8/25/18 demonstrated large subdural hematoma on the right with midline shift. Hospital transfer summary dated 8/27/28 revealed discharge [DIAGNOSES REDACTED]. Observation and interview on 8/29/18 at 8:54 AM with a visitor of Resident #104 revealed observation of Resident #104 laying in bed, unresponsive to name or verbal stimuli. The visitor stated that the Resident #104 had fallen and hit the head, was sent to the hospital where a CT scan showed a large brain bleed. The visitor stated that the hospital put the resident on hospice. Resident #101: Record review of resident #101's medical record revealed a he/she was a recent new admission to the facility on [DATE]. Some of the Medical [DIAGNOSES REDACTED]. Resident #101 was receiving Xarelto (anticoagulant-blood thinner) 10 mg orally every day. Record review of Resident #101's Accident/incident report dated 3/3/18 at 10:11 AM revealed the resident was sitting in hallway in front of nursing station. Staff heard a thud and looked over and saw resident sitting on the floor on his bottom with his back against the wall. No witnesses found. Resident (#101) stated that he was getting up to go for a walk and slipped and fell . Resident stated that he hit his head pretty hard, resident stated that his head hurts, but nothing else. Facility staff intervention was to re-educate the resident to ask for help. (Resident had dementia diagnosis). The incident report noted resident had small bump to top left posterior head, reports mild pain when pressure is applied. No redness, bruising or open areas observed. Resident was assisted back into wheelchair. Record review of resident #101's nursing notes dated 3/3/18 at 10:22 AM through 3/3/18 at 2:45 PM revealed that at 10:22 AM was a note describing the fall at the nursing station and staff would continue to monitor. The next note on 3/3/18 at 11:27 AM noted the resident was on [MEDICATION NAME] antibiotic for [MEDICAL CONDITION], temperature was 98 and there were no stools this shift. Will continue to monitor. Record review of Resident #101's 'First 24-hour Neurological Assessment' sheet noted at 10:15 AM right pupil size of 1 sluggish, left pupil size of 1 brisk (they were not equal). Neurological documentation for pupils are sluggish right side and brisk left side through 12:00 PM (noon). There were no pupil checks done at 1:00 PM. At 2:00 PM both pupils are documented as sluggish with weak lower extremities. Record review of Resident #101's Accident/incident report dated 3/3/18 at 2:55 PM revealed 'Staff heard loud noise and saw resident on floor next to wheelchair, face down. Bleeding noted coming from nares. Alert with confusion noted. No witnesses found. Record review of occurrence statement attached to the incident report noted fall location at the nursing station, staff heard loud noise and observed resident on floor. Resident was unable to give a statement. Resident had a hematoma to left forehead, gross left orbital swelling. resident had fall earlier today at 10 AM. Fall not witnessed. Record review of Resident #101's nurse note dated 3/3/18 at 4:00 PM: resident found on floor, face down next to wheelchair. Brakes locked. Bleeding noted from nares. Alert with confusion noted. Gentle swabbing of nares and face done to assess for injuries An interview on 8/28/18 at 2:47 PM with Registered Nurse (RN) C, revealed that on 3/3/18 RN C came on shift at 2:00 PM got report from first shift in the alcove in a secluded area face-to-face shift report. RN C stated that she/he did not see Resident #101 because she was behind the nurse station and the counter was in the way. One of the nurse aides who doesn't work here anymore alerted the nurse Resident #101 was on the floor. RN C stated that the first fall was on day shift and was notified in report to keep resident at the nurse station for observation. RN C stated that the fall was not witnessed, that no one saw the fall and the aides found the resident already on the floor. Record review of resident #101's care plan for falls dated 3/1/18 noted no added interventions post fall on 3/3/18 at 10:11 AM, such as keep at nursing station for observation or increase supervision post fall. An interview on 8/29/18 at 10:59 AM with the Director of Nursing (DON) services reviewed Resident #101's fall on 3/3/18 at 10:00 AM where the staff heard a thud and looked over to the resident sitting on the floor and the facility implemented intervention of re-educating resident (with dementia) to ask for assistance and resident to stay at the nursing station. Review of the second fall on 3/3/18 at 2:55 PM revealed that the wheelchair brakes were locked in place. The DON could not say that the staff did not lock the brakes or if the resident locked the brakes, but that they were locked. The DON was asked if this would be considered a restraint and had no comment. Record review of Resident #101's emergency room visit revealed that Resident #101 presented from the nursing home via ambulance for fall approximately one-hour prior. The staff at the nursing home reported that the did not see the fall but that they heard the fall. Nursing home staff reported that the resident had already fallen earlier in the day at 10:00 AM, 7 hours prior. Record review of CT scan of head (1.) Hemorrhagic contusion and small subarachnoid hemorrhage in the left frontal lobe. Subarachnoid hemorrhage in the right posterior lobe. (2.) Large subcutaneous soft tissue hematoma at the left forehead region. Fracture of underlying left frontal bone extending to superior orbital margin.

This citation pertains to Intakes and . Based on observation, interview and record review the facility failed to provide services for wound care to meet the professional standards of care for 2 (#177 and #234) of 4 sampled residents reviewed for wound care, resulting in Resident #177 right heel wound infestation of maggots and Resident #234 found with old (out dated dressings) and not the dressing physician ordered in place. Findings include: Record review of the facility 'Infection Control Guidelines for all Nursing Procedures' dated 8/2012, revealed the purpose was to provide a guideline for general infection control while caring for residents. (1.) Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on general infection and exposure control issues (2.) Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on managing infection in residents: (a.) Types of Healthcare-Associated infections. (b.) Methods of preventing spread. Record review of the facility 'Standard Precautions' policy dated 12/2007, revealed standard precautions will be used in the care of all residents regardless of their diagnosis, or suspected or confirmed infection status. Standard Precautions presume that all blood, body fluids, secretions, and excretions. non-intact skin and mucous membranes may contain transmissible . (1.) Standard precautions shall apply to the care of all residents in all situations regardless of suspected or confirmed presence of infectious disease. (2.) Staff shall be adequately trained in the various aspects of standards of precautions to ensure appropriate decision-making in various clinical situations. Resident #177: Record review of Resident #177's minimum data Set ((MDS) dated [DATE] revealed a [AGE] year old female with modified cognitive skills. Medical [DIAGNOSES REDACTED]. Section G of the MDS- noted total assist with transfers, nonambulatory, assist with dressing and hygiene. Record review of facility 'Shower' sheet schedule (undated) revealed that Resident #177 had showers on Mondays and Thursdays on the first shift. In an interview on 6/26/18 at 1:21 PM with Certified Nursing assistant/Shower aide P revealed that on 6/18/18 a Monday, Shower CNA P went to Resident #177's room to get her for a shower around 9:30 AM. CNA P stated that when she went to the room to get the Resident #177 there was no dressing or sock on her foot and that the Resident stated that it was hurting. CNA P stated that she did not know how long the dressing was off. CNA P stated that the dressing was already off when she took her by wheelchair to the shower room and needed assistants from CNA Q to mechanical lift Resident #177 to the shower chair. CNA P stated that she gave the shower, dried off the resident, put lotion on the resident's arms, dressed her, did not put anything on the foot. CNA Q came back and assisted with mechanical lift back to the wheelchair and wheeled the resident back to her room and put the call light on for the nurse to come. Usually the nurse does the dressing right away. We (CNA P and CNA Q) told the agency Registered Nurse (RN) D that the Resident #177 was ready. CNA P stated that she did not see RN D go in the room and do the foot, CNA P stated that she did not see the RN D go into the room at all. CNA P stated that she did not know how long the foot was left out uncovered. In an interview on 6/26/18 at 3:33 PM with Certified Nurse Assistant Q stated that yes, she did push the Resident #177 back to her room after the shower, waited for the nurse, then put the call light on and left the resident sitting up in the wheelchair in her room. CNA Q stated that no, she did not cover the foot, the nurse was supposed to do a dressing. Record review of Resident #177's 'Skin Report' dated 6/18/18 at 9:30 AM revealed there were no skin concerns but noted old sores to back of right heel. In an interview on 6/26/18 at 2:17 PM with agency Registered Nurse (RN) D, stated that she has 20 patients, and did not know what time she did the dressing. Agency RN D could not describe the wound, even though she did the dressing change for three days in a row. Agency RN D stated that it had been days ago (8 days) and that she did not want to say. Record review of Resident #177's treatment Administration Record for the month of (MONTH) (YEAR), revealed: Cleanse right heel with Normal saline pat dry, apply [MEDICATION NAME] solution, dry gauze and kerlix daily. Scheduled at 8:00 AM. Record review of the dates 6/16/18, 6/17/18 and 6/18/18 revealed that the dressings were done by agency Registered Nurse (RN) D. Record review of the Resident #177's dressing change administration history revealed that agency Registered Nurse (RN) D did not initial the dressing changes on 6/16/18 until 12:22 PM. 6/17/18 at 12:56 PM, and on 6/18/18 at 1:16 PM. Record review of Resident #177's progress notes dated 6/19/18 at 12:22 PM revealed Assessment of right heel wound reveals rapidly declining tissue that is opened with purulent drainage, strong odor and what would appear to be slough. After further investigation the slough was very small larvae hatching In an interview on 6/26/18 at 9:24 AM with Licensed Practical Nurse (LPN) U revealed that she does Resident #177's dressing in the mornings but had taken a 5-day vacation and was off work from 6/14/18 through 6/18/18 and came back to work on 6/19/18. On 6/19/18 LPN U went to Resident #177's room to do her dressing change and there was no dressing in place. LPN U stated that there was a red sock, not a gripper sock but a red fuzzy sock on the foot. LPN U stated that the sock was stuck to the foot and that she had to moisten the sock with wound cleanser to loosen the sock and had to pull the off the sock with some skin. It (wound) looked bad since the last time she had seen the wound. LPN U stated that the wound was bigger and green around the edges with an odor of rotting was very strong. The LPN U went to get the unit manager and the unit manager took over the cleaning of the wound. In an interview on 625/18 at 2:33 PM with Licensed Practical Nurse (LPN) Unit Manager V revealed that on 6/19/18 around 10:00 AM LPN U came to her to look at a wound on Resident #177's heel. LPN Unit manager V stated that she went to Resident 3177's room eye balled the wound and thought she saw something moving in the wound. LPN V stated that she got closer to verify and yes there were things crawling in the wound. LPN V stated that she stepped out of the room to notify the Director of nursing B. Then both LPN V and Director of Nursing B went back to the verify that there was something crawling around in the wound. Both LPN V and Director of Nursing B stepped back out of the room and consulted LPN E who went on the Internet and found some instructions for cleaning the larvae out. LPN V stated that she went ahead and got the supplies, explained to Resident #177 that she was going to clean the wound. LPN V stated that she cleaned the wound following the Internet instructions, twice. LPN V stated that she did a skin assessment with photo. LPN V stated that then she called the doctor to notify him and that the physician would be coming in later that evening to see the wound. The state surveyor asked if she LPN V had gotten an order from the physician before cleaning the wound procedure? LPN V stated no, right afterwards. Resident #234: Record review of Resident #234's 'Wound Assessment' dated 6/22/18 revealed medial right foot arterial ulcer 22 days old acquired in-house (facility). Measurements: Length 1.8 cm X width 3.2 cm. Observation on 6/26/18 at 12:45 PM of Resident #234 with Certified Nurse Assistants (CNA) X and Y during catheter care, revealed that the medial (inner) right foot had a pink boarder dressing dated 6/24/18 with initials CAS and right hip had white ABD dressing dated 6/25/18 with no initials. Record review of resident #234's Medication Administration Record [REDACTED]. There were no initials of staff on 6/25/18 or 6/26/18 as having performed dressing change. Treatment: Right foot apply Santyl (debridement ointment), cover it with dry gauze and wrap with kerlix every evening shift to right foot wound. There were no initials of staff on 6/25/18 or 6/26/18 as having performed dressing change. Observation and interview on 6/27/18 at 10:10 AM with Licensed practical Nurse (LPN) U and Registered Nurse W while in Resident #234's room at bedside, revealed observations on Resident #234's right medial (inner) foot revealed a pink boarder foam dressing dated 6/24/18 (not the dry gauze wrapped with kerlix) with initials CAS. LPN U stated that the initials where her's and that was the last time/day she worked at the facility. Observation of the right hip had white ABD dressing dated 6/25/18 with no initials.

This citation pertains to Intakes and . Based on observation, interview and record review, the facility failed to provide quality of care for wounds for 1 (#177) of 2 sampled Residents reviewed for wounds, resulting in the Resident #177 being found with larvae/maggots in the wound of her right heel and being sent to the hospital. Findings include: Record review of facility 'Wound Care Policy' dated 5/2018, revealed the purpose of this procedure is to provide guidelines for the care of wounds to promote healing. (1.) Verify that there is a physician order [REDACTED]. Mark tape or dressing with initials, time, and date and apply to dressing. Documentation: The following information should be recorded in the resident's electronic medical records. (1.) type of wound care given. (2.) the date and time the wound care was given. (3.) The position in which the resident was placed. (4.) The name and title of the individual performing the wound care. (5.) Any change in the resident's condition. (6.) All assessment data (i.e., wound bed color, size, drainage, etc ) obtain when inspecting the wound. (7.) How the resident tolerated the procedure. (8.) Any problems of complaints made by the resident related to the procedure. (9.) If the resident refused the treatment and the reason why. (10.) The signature and title of the person recording the data. Record review of the Hospital emergency room Triage note dated 6/19/18 at 10:39 PM, revealed: Patient (Resident #177) arrived from (facility) for diabetic wound check on right foot. Patient has an amputation on the left leg above the knee. Upon arrival patient wound smelled foul. After undressing the wound, which was marked with 6/18/19 date, small maggots were noted. Patient was made aware of the maggots Record review of Resident #177's hospital consult dated 6/25/18 revealed patient admitted 5 days ago through the ED for wound check, [DIAGNOSES REDACTED]. Review of the medical record, failed to reveal that Resident #177 had a physician order [REDACTED].>During observation and interview on 6/25/18 at 12:13 PM of the all-purpose dining room with Marketing Director Z and Certified Nurse Assistant (CNA) AA noted to have 2-3 flies flying about the room and landing on residents, tables, and food plates. CNA AA picked up a fly swatter and began to patrol the dining room once the state surveyor pointed out the flies. CNA AA stated, I'm chasing the fly's away. Observations at the time of the meal revealed that visitors exited and re-entered through the exit door at the back of the all-purpose dining room into a courtyard back parking lot. Record review of Resident #177's minimum data Set ((MDS) dated [DATE] revealed a [AGE] year-old female with modified cognitive skills. Medical [DIAGNOSES REDACTED]. Section G of the MDS- noted total assist with transfers, non-ambulatory, assist with dressing and hygiene. Record review of facility 'Shower' sheet schedule (undated) revealed that Resident #177 had showers on Mondays and Thursdays on the first shift. In an interview on 6/26/18 at 1:21 PM with Certified Nursing assistant (CNA)/Shower aide P revealed that on 6/18/18 a Monday, Shower CNA P went to Resident #177's room to get her for a shower around 9:30 AM. CNA P stated that when she went to the room to get the Resident #177 there was no dressing or sock on her foot and that the Resident stated that it was hurting. CNA P stated that she did not know how long the dressing was off. CNA P stated that the dressing was already off when she took her by wheelchair to the shower room and needed assistance from CNA Q to mechanically lift Resident #177 to the shower chair. CNA P stated that she gave the shower, dried off the resident, put lotion on the resident's arms, dressed her, did not put anything on the foot. CNA Q came back and assisted with mechanical lift back to the wheelchair and wheeled the resident back to her room and put the call light on for the nurse to come. Usually the nurse does the dressing right away. We (CNA P and CNA Q) told the agency Registered Nurse (RN) D that the Resident #177 was ready. CNA P stated that she did not see RN D go in the room and do the foot, CNA P stated that she did not see the RN D go into the room at all. CNA P stated that she did not know how long the foot was left out uncovered. In an interview on 6/26/18 at 3:33 PM Certified Nurse Assistant Q stated that yes, she did push the Resident #177 back to her room after the shower, waited for the nurse, then put the call light on and left the resident sitting up in the wheelchair in her room. CNA Q stated that no, she did not cover the foot, the nurse was supposed to do a dressing. Record review of Resident #177's 'Skin Report' dated 6/18/18 at 9:30 AM revealed there were no skin concerns but noted old sores to back of right heel. In an interview on 6/26/18 at 2:17 PM with agency Registered Nurse (RN) D, stated that she has 20 patients, and did not know what time she did the dressing. Agency RN D could not describe the wound, even though she did the dressing change for three days in a row. Agency RN D stated that it had been days ago (8 days) and that she did not want to say. Record review of Resident #177's Treatment Administration Record (TAR) for the month of (MONTH) (YEAR), revealed: Cleanse right heel with Normal saline pat dry, apply [MEDICATION NAME] solution, dry gauze and kerlix daily. Scheduled at 8:00 AM. Record review of the TAR for the dates 6/16/18, 6/17/18 and 6/18/18 revealed that the dressings were done by agency Registered Nurse (RN) D. Record review of the Resident #177's dressing change administration history revealed that agency Registered Nurse (RN) D did not initial the dressing changes on 6/16/18 until 12:22 PM. 6/17/18 at 12:56 PM, and on 6/18/18 at 1:16 PM. Record review of Resident #177's progress notes written by agency Registered Nurse (RN) D dated 6/16/18, noted cream to inner thigh, but nothing describing the right heel wound or treatment given. Progress notes written by agency Registered Nurse (RN) D dated 6/17/18, noted a behavioral note, but nothing describing the right heel wound or treatment given. Progress notes written by agency Registered Nurse (RN) D dated 6/18/18 noted medications given, but nothing describing the right heel wound or treatment given. Record review of Resident #177's progress notes dated 6/19/18 at 12:22 PM revealed Assessment of right heel wound reveals rapidly declining tissue that is opened with purulent drainage, strong odor and what would appear to be slough. After further investigation the slough was very small larvae hatching In an interview on 6/26/18 at 9:24 AM Licensed Practical Nurse (LPN) U revealed that she does Resident #177's dressing in the mornings but had taken a 5-day vacation and was off work from 6/14/18 through 6/18/18 and came back to work on 6/19/18. On 6/19/18 LPN U went to Resident #177's room to do her dressing change and there was no dressing in place. LPN U stated that there was a red sock, not a gripper sock but a red fuzzy sock on the foot. LPN U stated that the sock was stuck to the foot wound and that she had to moisten the sock with wound cleanser to loosen the sock and had to pull the off the sock with some skin. It (wound) looked bad since the last time she had seen the wound. LPN U stated that the wound was bigger and green around the edges with an odor of rotting was very strong. The LPN U went to get the unit manager and the unit manager took over the cleaning of the wound. In an interview on 6/26/18 at 2:33 PM with Licensed Practical Nurse (LPN) Unit Manager V revealed that on 6/19/18 around 10:00 AM LPN U came to her to look at a wound on Resident #177's heel. LPN Unit manager V stated that she went to Resident #177's room eye balled the wound and thought she saw something moving in the wound. LPN V stated that she got closer to verify and yes there were things crawling in the wound. LPN V stated that she stepped out of the room to notify the Director of Nursing B. Then both LPN V and Director of Nursing B went back to the verify that there was something crawling around in the wound. Both LPN V and Director of Nursing B stepped back out of the room and consulted LPN E who went on the Internet and found some instructions for cleaning the larvae out. LPN V stated that she went ahead and got the supplies, explained to Resident #177 that she was going to clean the wound. LPN V stated that she cleaned the wound following the Internet instructions, twice. LPN V stated that she did a skin assessment with photo. LPN V stated that then she called the doctor to notify him and that the physician would be coming in later that evening to see the wound. The state surveyor asked if she LPN V had gotten an order from the physician before cleaning the wound procedure, LPN V stated no, right afterwards. In an interview on 6/26/18 at 10:29 AM with Certified Nurse Assistant (CNA) G who worked the night shift 6/18/18 10:30 PM through 6/19/18 6:30 AM, revealed that Resident #177 was already in bed and that she did not put any red socks on the resident or get her out of bed. In an interview on 6/26/18 at 12:18 PM with Certified Nurse Assistant (CNA) J who worked 6/18/18 afternoons (2:30 PM to 10:30 PM) stated, 'I did put her to bed that night. I haven't seen her foot unbandaged, I don't know what it looks like. I don't know about a red sock, I don't know. In an interview on 6/26/18 at 2:41 PM with the physician C, revealed that he was notified of the maggots and that he came into the facility in the evening to see the wound. The physician C stated that the wound was odorous and that he had no defense about the maggots. Record review of facility provided 'Nosocomial myiasis in a patient with diabetes' M. Dutto, M. Pellegrino, S. Vainin, page 74-75, journal of Hospital Infections 83 (2013) The Healthcare Infection Society. Myiasis are caused by parasitic fly larvae identified by the code B87 in the international classification of Diseases-10th Revision. Human myiasis can be classified into two groups: specific myiasis caused by flies that need a live host to develop their immature stages, and semi specific myiasis caused by flies that usually develop in decomposing organic matter but occasionally develop on/in living organisms, mainly in the presence of wounds. Myiasis can be very upsetting and, as evidence of a degree of neglect they can lead to litigation, particularly when they occur in hospitals or other medical facilities (Nosocomial Myiasis). The most important contributing factors for nosocomial myiasis have been identified as: (i) depressed levels of consciousness or decreased mobility; (ii) presence of exposed wounds or necrotic tissue; (iii) poor standards of hygiene; (iv) lack of screened windows and (iv) hot weather. Myiasis can be a risk to patients with trauma and decreased mobility To avoid myiasis, recommend that wounds should not never be left undressed.

Based on observation, interview and record review the facility failed to implement appropriate fall interventions for one Resident (#14) and failed to complete neurological (neuro) checks post fall for two Residents ( #40 and 44) of 7 reviewed for falls from a total sample of 22, resulting in the potential for decreased neurological function and the fracture of Resident #14's hip. Findings include: Review of the facility policy entitled, Incident/Fall Prevention Policy, revised 12/4/17 revealed the following: (The facility) will ensure the Residents' safety by having adequate supervision and assistive devices to prevent accidents or incidents . Resident #14 Review of the Progress notes associated with Resident #14's fall with fracture revealed, the hip X-rays were ordered on [DATE] at 11:32 PM (fall occurred at 4:15 PM). The X-rays were obtained, and the facility was awaiting results at 6:43 PM. The Doctor was notified Resident #14 had a right [MEDICAL CONDITION]. Review of Resident #14's medical records revealed that Resident #14 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment indicated that Resident #14 is severely cognitively impaired and requires two person assist for a majority of their Activities of Daily Living (ADL's). Review of Resident #14's falls with Unit Manager Z Resident #14 sustained a [MEDICAL CONDITION] from a fall on 1/15/18 and required surgical intervention. There were multiple falls before and after the resident sustained [REDACTED]. The majority of the Resident's falls occurred in his bedroom; it can be noted the Resident's room is located a little more than half down the hallway. Review of the medical record revealed the following related to Resident #14's multiple falls: 9/8/17 at 1:39 PM: Resident found half on the floor and half in the bed. Intervention: No immediate intervention added Interdisciplinary Team Note: Dated 9/8/18- initiate concave mattress. 9/10/17 at 6:15 AM: Resident slid out of bed trying to get up. Intervention: Have (Resident #14) be one of the first people they get up when 1st shift starts. Interdisciplinary Team Note: Dated: 9/11/17- . Speech to evaluate for communication. 10/1/17 @ 11:14 AM: Resident slid out the bed. Intervention: No immediate intervention added Interdisciplinary Team Note: Dated 10/2/17, discontinued bed alarm and requested lab work. 10/7/17 at 10:20 AM: Resident was found lying on the floor in their room. Intervention: Encourage resident to attend morning activities after breakfast. Interdisciplinary Team Note: Dated 10/9/17- prompt resident to go to bathroom every two hours if awake. 10/13/17 at 5:39 AM: Resident was observed on the floor, next to recliner. Resident had small bump on the back of his head, small purple bruise on top of right forearm. Interventions: No immediate interventions were added Interdisciplinary Team Note: No new interventions added. 11/13/17 at 1:45 AM: Resident observed sitting on floor next to bed. Intervention: No new interventions were added Interdisciplinary Team Note: Dated 11/13/17- No new intervention added. 12/15/17 at 1:45 AM: Resident sitting on bottom with legs extended in front of him, with his blanket wrapped around him. Interventions: No new interventions added Interdisciplinary Team Note: Dated 12/15/2017-Check and change every two hours while awake and every four hours during the night. 12/18/17 at 6:30 AM: Resident found sitting on floor next to his bed. Intervention: Gripper sock placed on feet Interdisciplinary Team Note: No new interventions added 1/5/18 at 9:00 PM: Resident found lying on floor between recliner and closets. Left arm tucked under torso, right arm extended above head. Interventions: No new interventions added Interdisciplinary Team Note: No new interventions added. 1/15/18 at 4:15 PM: Resident observed laying supine on floor. Resident wheelchair with brakes locked was 5-10 inches from where he was found lying in dining/activity room. Had a 2 cm (Centimeter) diameter purple bruise to tight torso below waistline. 2.5 cm diameter raised lump to right occipital area. resident sustained [REDACTED]. Interventions: No new interventions Interdisciplinary Team Note: Dated 1/16/18-Resident later complained of pain to right thigh and hip areas, aspect of right shoulder. X-rays pending. Will assess resident for a different wheelchair. 2/10/18 at 3:15 PM: Resident was observed on side of bed with head up against mattress. Resident's hand was inside dresser drawer, with dresser half tipped. Interventions: No new interventions added Interdisciplinary Team Note: Dated 2/12/18-Offer resident a nap after lunch and when it is noted he's awake to get resident up into wheelchair. 2/15/18 at 3:00 AM: Certified Nursing Assistant (CNA) observed Resident on floor mat, head underneath bed with his feet sticking out. Resident had a small scrap between eyebrows. Interventions: No new interventions added. Interdisciplinary Team Note: Dated 2/15/18- Will switch current floor mat out for 4 inch floor mat and educate staff to make sure resident bed is in the lowest position when resident is in bed. 3/12/18 at 11:30 PM: CNA observed Resident on floor mat, next to his bed. Interventions: No new interventions Interdisciplinary Team Note: Dated 3/16/18- . Will care plan Resident to be 1 hour checks while in bed. After review of the falls were completed, Unit Manager Z was queried as to when the Interdisciplinary Team (IDT) meets. It was reported they meet daily and speak about the falls and implement interventions. The Unit Manager was further queried as to if they felt the facility attempted all interventions possible to prevent falls for this Resident. Unit Manager Z reported the facility has implemented many interventions and proceeded to name interventions that were not listed on the Incident and Accident report or care plan. Unit Manager Z was asked if with just the interventions listed in the Incident and Accident Reports did they seem inclusive based on the numerous falls Resident #14 had. The Unit Manager agreed they were not inclusive. On 4/23/18 at 3:30 PM, a review was completed of Resident #14's care plan for falls. It revealed the following: 9/8/17: Concave mattress, I frequently self- transfer. 9/10/17: I prefer to be one of the first residents to get up in the morning. 10/4/17: Grip strips on floor by bed, recliner and toilet. 10/7/17: Offer and encourage resident to attend morning activities after he is done eating breakfast. 12/20/17: If I'm awake during the night please get me up and offer me a snack as I allow. 2/12/18: Offer nap after lunch, when it is noted that he is awake, get resident up. 2/15/18: 4 inch floor mat to left side of bed. 2/16/18: Gripper socks as resident allows. 3/16/18: 1 hour checks while in bed. Resident #40 According to admission face sheet, Resident #40 was a [AGE] year old female admitted to the facility on [DATE], readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident #40 required assistance with Activities of Daily Living (ADL) care, and was admitted for Hospice Services on 2/26/18, and discharged off Hospice Services on 4/17/18. Review of Incident/accident reports revealed that Resident #40 had a fall on 1/14/18, resulting in Resident #40 hitting her head on the floor and receiving a bump, elevated 2 centimeter by 2 centimeter purplish reddish area, and a one half inch skin tear to the back of her head. Review of the accident report documented that neuro checks (neurological assessment, checking level of vital signs ,consciousness) were initiated, and ice applied to the back of Resident #40's head. Review of Neurological assessment, that was provided to this Surveyor with this Incident report, revealed Neuro Checks were being done, but there was no date as to when, and there were multiple areas all over the form, on different shifts, that were uncompleted to include level of consciousness and vital signs. Review of Neuro assessment forms dated 1/16/18, 1/17/18, and 1/18/18, again revealed multiple incomplete, or non-existent entries for vital signs, pupil size and level of consciousness. An interview was conducted on 4/26/18, at 10:00 AM, with Registered Nurse F about the incomplete Neuro Checks. RN F was shown the incomplete documents and indicated she was aware recently by audits the nurses are not doing the Neuro checks, on the forms, and that the forms are supposed to be filled out completely for 72 hours post fall to assess for injuries related to falls, and possible changes with level of consciousness. Resident #44 According to admission face sheet, Resident #44 was a [AGE] year old female admitted to the facility on [DATE], readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident #44 required assistance with Activities of Daily Living (ADL) care. Review of Accident /Incident report, dated 3/20/18, revealed Neurological checks were initiated on 3/20/18, at 7:30 PM, on 3/21/18, 3/22/18, and 3/23/18. The form had multiple areas that were blank with no documentation. On 3/20/18 at 13:15 (military time, 1:15 PM) the section for vital signs was left blank, also for pupil reaction, consciousness, speech, pain all areas down the column on the form were not filled out. On 3/20/18, at 17:15 (5:15 PM), documentation was blank again for vitals, pupil reaction, level of consciousness. On 3/21/18, columns on the form were left blank for third shift to document in all areas, and again blank on 3/22/18, 1st shift. During an interview, RN F stated she was aware of the incomplete Neuro check documentation, I know we have a problem. Review of facility 'Incident/Fall Prevention Policy' dated as revised 12/17, documented under 'Post Incident Protocol' letter E: The resident's condition, vital signs and pertinent information concerning injury are to be documented in the Nurses Notes, 24 hour report and passed on in Shift to Shift report for a minimum of 72 hours. Monitor closely for condition changes. Letter F: Any immediate interventions that are initiated by the Nurse may be communicated to other departments by a communication form. The Licensed Nurse will implement the applicable flow sheets to monitor residents Neuro checks, Maintenance work orders, Treatment Assessment Record, etc.

Based on observation, interview and record review the facility failed to immediately provide cardiopulmonary resuscitation (CPR) and to develop and follow emergency procedures for 1 of 1 residents (Resident #105) reviewed for CPR in a total sample of 16 residents, resulting in Resident #105 being found unresponsive, was not provided timely CPR, and passed away in the facility. The facility was placed in Immediate Jeopardy (IJ) as a result of the facility's failure to immediately provide cardiopulmonary resuscitation (CPR) and to develop and follow emergency procedures. This deficient practice places all residents, identified as full code status, at risk for serious harm, injury and/or death. On [DATE] at 11:51 AM the Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy that began on [DATE] at approximately 7:21 AM, due to the facility's failure to respond appropriately to an unresponsive resident. On [DATE], the surveyors verified the following corrective action plan had been implemented: 1. On [DATE] at 11 AM the Director of Nursing reviewed and revised the policy for Code Status to specify how to identify the resident's code status in the electronic medical records accessible on the computers throughout the building, on the laptops accessible to nurses, and on the kiosks in each hall accessible to any member of the nursing staff. These are on each resident's care profile (dashboard). 2. On [DATE] at 11 AM the Director of Nursing reviewed and revised the policy for Code Blue. This clarifies that the nurse does not leave the resident but starts emergency actions. It also include a process to record what occurs during a code including a timeline. This states CPR is to be done on ALL FULL CODE residents. To visually identify Full Code residents, There is a blue dot on the spine of the resident's chart. It is on the electronic medical record under the Care Profile as special instructions. This is accessible through Point-Click-Care at any computer and through the Point Of Care Kiosks in the hallways. If a resident is unresponsive: Shake the resident and call out the resident's name. If no response, Yell HELP! and give location - note the time. Have any member of the nursing staff verify the code status if you are unsure. If a full code, Begin CPR (see below) a. Direct staff members to: Page CODE BLUE by picking up the phone handset, pressing the PAGE button and say CODE BLUE and location three times; Call 911 and family; b. Direct any staff member to obtain crash cart from treatment room. c. Direct any staff member to record on the St. Francis Home Code Blue Record which is located on the clipboard on the crash cart. 3. On [DATE] at 11:15 AM the Director of Nursing instructed the Educator to schedule training of the licensed nurses on the changes to these policies and the procedures expected when a resident requires CPR. The Educator will begin these trainings before 2 PM today. She / designee will continue at change of each shift until the licensed nursing staff is trained. Those licensed nurses excused due to approved leave will be trained on their first day returning to work. There are a total 27 licensed nurses to be trained. 16 licensed nurses are scheduled today and will be trained by 4 PM today. 2 more will be trained at by midnight. ,[DATE] = 67%. 3 additional nurses will be trained at the start of their shift on [DATE] bringing the total to ,[DATE] = 78%. These are the minimum to be trained. At the time of this writing Human Resources is calling the 6 nurses not scheduled today or tomorrow asking them to come in for the training. 4. On [DATE] at 12 noon the Social Workers verified the code status of each resident and compiled a list of the residents who are a full code. Staff then assured that each resident's paper medical record had a blue dot on the spine. The Social Workers confirmed that the code status was properly entered into the electronic records. 5. Beginning on [DATE] the Director of Nursing will review every Code Blue to identify potential improvements in the process. She will monitor documentation in the medical record and the Code Blue Record. She will conduct a full investigation if the process was not followed. The Immediate Jeopardy was removed on [DATE]. The corrective action plan was verified as being implemented, however the facility remained out of compliance with a scope of isolated and severity of Actual harm that is not immediate jeopardy as sustained compliance could not be verified by the state agency. Findings include: Resident #105 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] reflected Resident #105 was a [AGE] year-old female, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), reflected a score of 12 out of 15 which represents Resident #105 had moderate cognitive impairment. Resident #105 required staff assistance with all activities of daily living. Record review of the Advanced Directive reflected Resident #105 indicated that she wished to be transferred to the hospital and wished to be given CPR, in the event of cardiopulmonary arrest. This document was signed by Resident #105 on [DATE]. Record review of the admission orders [REDACTED]. Record review of the Code Status policy dated [DATE] with a revised date of [DATE] reflected, On admission, Admitting Nurse will document the resident's, or in the case of mental incapacity, the legal representative's choice of code status on the Advanced Directive form .Code status will be documented in the care plan in the chart, and in the resident's room .Full Code (Blue dot): Nurses are to maintain CPR certification including use of an AED machine. To visually identify Full Code residents, a blue dot is placed on the resident's chart spine. Full Code is written on the blue care plan in the resident's closet and has a blue dot placed on it. The doctor must sign a Full Code order. CPR will be done on Full Code residents no matter what their condition is at the time they are found. Record Review of the Code Status (located in the facility's Emergency Preparedness Book) dated [DATE] last revised on ,[DATE], reflected, Nurse Assessment Procedure: The following steps are to be initiated if a resident is not breathing. Shake the resident and call out the resident's name. YELL for HELP!!! And give location. Stay with the resident and continue CPR steps. Position resident for CPR - flat in bed with backboard, or place resident face up, on the floor. Direct staff to: Page CODE BLUE and location of resident (3) times. Call 911. Bring ER cart to location, (it is assigned to two aide groups to be sure it is brought but it can be taken by anyone.) During an interview on [DATE] at approximately 6:30 AM, CNA EE stated that she was not assigned to Resident #105 on [DATE]. CNA EE stated that approximately 5:00 AM while assisting with another resident next to Resident #105's room, she could hear Resident #105 moaning. CNA EE stated, I remember I told (name of LPN CC) that she (Resident #105) was real pale, paler than normal and she was moaning. During an interview on [DATE] at approximately 7:00 AM, CNA DD stated that she was assigned to Resident #105 on [DATE]. CNA DD recalled that around 5:00 AM Resident #105 was noted to have her oxygen tubing slid to the side so that only one piece was in one side of her nose. CNA DD stated that Resident #105 was pale, clammy, moaning and had a grimaced expression on her face. CNA CC also noticed that the head of the bed was down (flat) so she elevated the head of the bed, repositioned the oxygen tubing and reported the findings to LPN CC. An interview was conducted with LPN CC on [DATE] at approximately 3:50 PM. LPN CC stated that she was assigned to Resident #105 on the midnight shift of [DATE] and stayed past her shift to the day shift that morning. LPN CC stated that she did not recall anything out of the ordinary for Resident #105 during the night shift. LPN CC stated that when she entered Resident #105's room to pass medications at approximately 7:20 AM she found Resident #105 laying in her bed. LPN CC stated, I could tell she was expired. I turned the light on and noticed that her color was white and her mouth was open. I walked out of the room and went to the nurses' desk to check her code status. I saw (name of RN S). I told her that (name of Resident #105) was expired and she was a full code. We grabbed the crash cart and I told the staff to call 911. We started CPR and applied the AED. When asked if she assessed for signs of life (such as air way, breathing or circulation) before CPR started, LPN CC stated, No, I didn't because I knew she was expired. When asked if Resident #105 was moved to the floor or a back board used and LPN CC stated, We used a back board. When asked if anyone recorded (took notes) during this event, LPN CC stated, No. An interview was conducted with RN S on [DATE] at approximately 9:00 AM. RN S stated that on [DATE] at approximately 7:20 AM she saw LPN CC at the nursing desk. LPN CC stated that Resident #105 was expired and they went together to her room. RN S stated, (Name of Resident #10) was (in bed) still warm, but her color was pale and you could tell she was gone. I listened to her heart and lungs, and we placed the back board and started CPR. The video of the hall (dated [DATE]) was reviewed with the NHA A, and two surveyors on [DATE] at 10:15 AM. The following was a timeline from the video: 7:21:59 LPN CC enters Resident 105's room and exits at 7:22:36 and walks to the nurses desk. 7:23:20 LPN CC and RN S enter Resident #105 together. No crash cart, back board, stethoscope or AED is was noted. 7:23:46 RN S runs from the room back towards the nurses' desk. 7:24:17 RN S enters the room with the crash cart, and back board. An interview with the DON B was conducted on [DATE] at 10:00 AM. The DON B stated that the facility converted to an electronic medical record on [DATE] and no longer used the Kardex in the resident closet (per the facility current policy). The DON B stated that the facility did not use the policy Code Status dated ,[DATE] and revised ,[DATE] that was found in the emergency book. The surveyor reviewed the video timeline with the DON and the DON B agreed that LPN CC should not have left the room once she found that Resident #105 was unresponsive. The DON B stated that she should have called out for help (do not leave the resident) and started CPR immediately. During an interview on [DATE] at approximately 10:00 AM, LPN XX stated that she was also in the room during the code but she did not record or document the events of the code. Record review of the nursing notes dated [DATE] at 7:51 with actual created time of 8:15 AM reflected, Resident was sleeping comfortably on morning rounds at 6:00 AM. Nurse found resident expired at med pass rounds at 7:15 AM. Resident is a full code, all nursing staff started CPR, and called 911. EMS arrived and continued CPR. Family was notified to come to facility immediately. Nurse notified DON and administrator. (Name of doctor) was notified and ok to release body. TOD (time of death) was called at 7:55 AM. This note was the only entry for [DATE] - [DATE]. It did not reflect an assessment for pain, or signs of life such as vital signs, air way, breathing, and circulation nor did it reflect the assessment and need for the CPR that took place.

Based on observation, interview and record review the facility failed to immediately provide cardiopulmonary resuscitation (CPR) and to develop and follow emergency procedures for 1 of 1 residents (Resident #105) reviewed for CPR in a total sample of 16 residents, resulting in Resident #105 being found unresponsive, was not provided timely CPR, and passed away in the facility. The facility was placed in Immediate Jeopardy (IJ) as a result of the facility's failure to immediately provide cardiopulmonary resuscitation (CPR) and to develop and follow emergency procedures. This deficient practice places all residents, identified as full code status, at risk for serious harm, injury and/or death. On [DATE] at 11:51 AM the Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy that began on [DATE] at approximately 7:21 AM, due to the facility's failure to respond appropriately to an unresponsive resident. On [DATE], the surveyors verified the following corrective action plan had been implemented: 1. On [DATE] at 11 AM the Director of Nursing reviewed and revised the policy for Code Status to specify how to identify the resident's code status in the electronic medical records accessible on the computers throughout the building, on the laptops accessible to nurses, and on the kiosks in each hall accessible to any member of the nursing staff. These are on each resident's care profile (dashboard). 2. On [DATE] at 11 AM the Director of Nursing reviewed and revised the policy for Code Blue. This clarifies that the nurse does not leave the resident but starts emergency actions. It also include a process to record what occurs during a code including a timeline. This states CPR is to be done on ALL FULL CODE residents. To visually identify Full Code residents, There is a blue dot on the spine of the resident's chart. It is on the electronic medical record under the Care Profile as special instructions. This is accessible through Point-Click-Care at any computer and through the Point Of Care Kiosks in the hallways. If a resident is unresponsive: Shake the resident and call out the resident's name. If no response, Yell HELP! and give location - note the time. Have any member of the nursing staff verify the code status if you are unsure. If a full code, Begin CPR (see below) a. Direct staff members to: Page CODE BLUE by picking up the phone handset, pressing the PAGE button and say CODE BLUE and location three times; Call 911 and family; b. Direct any staff member to obtain crash cart from treatment room. c. Direct any staff member to record on the St. Francis Home Code Blue Record which is located on the clipboard on the crash cart. 3. On [DATE] at 11:15 AM the Director of Nursing instructed the Educator to schedule training of the licensed nurses on the changes to these policies and the procedures expected when a resident requires CPR. The Educator will begin these trainings before 2 PM today. She / designee will continue at change of each shift until the licensed nursing staff is trained. Those licensed nurses excused due to approved leave will be trained on their first day returning to work. There are a total 27 licensed nurses to be trained. 16 licensed nurses are scheduled today and will be trained by 4 PM today. 2 more will be trained at by midnight. ,[DATE] = 67%. 3 additional nurses will be trained at the start of their shift on [DATE] bringing the total to ,[DATE] = 78%. These are the minimum to be trained. At the time of this writing Human Resources is calling the 6 nurses not scheduled today or tomorrow asking them to come in for the training. 4. On [DATE] at 12 noon the Social Workers verified the code status of each resident and compiled a list of the residents who are a full code. Staff then assured that each resident's paper medical record had a blue dot on the spine. The Social Workers confirmed that the code status was properly entered into the electronic records. 5. Beginning on [DATE] the Director of Nursing will review every Code Blue to identify potential improvements in the process. She will monitor documentation in the medical record and the Code Blue Record. She will conduct a full investigation if the process was not followed. The Immediate Jeopardy was removed on [DATE]. The corrective action plan was verified as being implemented, however the facility remained out of compliance with a scope of isolated and severity of Actual harm that is not immediate jeopardy as sustained compliance could not be verified by the state agency. Findings include: Resident #105 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] reflected Resident #105 was a [AGE] year-old female, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), reflected a score of 12 out of 15 which represents Resident #105 had moderate cognitive impairment. Resident #105 required staff assistance with all activities of daily living. Record review of the Advanced Directive reflected Resident #105 indicated that she wished to be transferred to the hospital and wished to be given CPR, in the event of cardiopulmonary arrest. This document was signed by Resident #105 on [DATE]. Record review of the admission orders [REDACTED]. Record review of the Code Status policy dated [DATE] with a revised date of [DATE] reflected, On admission, Admitting Nurse will document the resident's, or in the case of mental incapacity, the legal representative's choice of code status on the Advanced Directive form .Code status will be documented in the care plan in the chart, and in the resident's room .Full Code (Blue dot): Nurses are to maintain CPR certification including use of an AED machine. To visually identify Full Code residents, a blue dot is placed on the resident's chart spine. Full Code is written on the blue care plan in the resident's closet and has a blue dot placed on it. The doctor must sign a Full Code order. CPR will be done on Full Code residents no matter what their condition is at the time they are found. Record Review of the Code Status (located in the facility's Emergency Preparedness Book) dated [DATE] last revised on ,[DATE], reflected, Nurse Assessment Procedure: The following steps are to be initiated if a resident is not breathing. Shake the resident and call out the resident's name. YELL for HELP!!! And give location. Stay with the resident and continue CPR steps. Position resident for CPR - flat in bed with backboard, or place resident face up, on the floor. Direct staff to: Page CODE BLUE and location of resident (3) times. Call 911. Bring ER cart to location, (it is assigned to two aide groups to be sure it is brought but it can be taken by anyone.) During an interview on [DATE] at approximately 6:30 AM, CNA EE stated that she was not assigned to Resident #105 on [DATE]. CNA EE stated that approximately 5:00 AM while assisting with another resident next to Resident #105's room, she could hear Resident #105 moaning. CNA EE stated, I remember I told (name of LPN CC) that she (Resident #105) was real pale, paler than normal and she was moaning. During an interview on [DATE] at approximately 7:00 AM, CNA DD stated that she was assigned to Resident #105 on [DATE]. CNA DD recalled that around 5:00 AM Resident #105 was noted to have her oxygen tubing slid to the side so that only one piece was in one side of her nose. CNA DD stated that Resident #105 was pale, clammy, moaning and had a grimaced expression on her face. CNA CC also noticed that the head of the bed was down (flat) so she elevated the head of the bed, repositioned the oxygen tubing and reported the findings to LPN CC. An interview was conducted with LPN CC on [DATE] at approximately 3:50 PM. LPN CC stated that she was assigned to Resident #105 on the midnight shift of [DATE] and stayed past her shift to the day shift that morning. LPN CC stated that she did not recall anything out of the ordinary for Resident #105 during the night shift. LPN CC stated that when she entered Resident #105's room to pass medications at approximately 7:20 AM she found Resident #105 laying in her bed. LPN CC stated, I could tell she was expired. I turned the light on and noticed that her color was white and her mouth was open. I walked out of the room and went to the nurses' desk to check her code status. I saw (name of RN S). I told her that (name of Resident #105) was expired and she was a full code. We grabbed the crash cart and I told the staff to call 911. We started CPR and applied the AED. When asked if she assessed for signs of life (such as air way, breathing or circulation) before CPR started, LPN CC stated, No, I didn't because I knew she was expired. When asked if Resident #105 was moved to the floor or a back board used and LPN CC stated, We used a back board. When asked if anyone recorded (took notes) during this event, LPN CC stated, No. An interview was conducted with RN S on [DATE] at approximately 9:00 AM. RN S stated that on [DATE] at approximately 7:20 AM she saw LPN CC at the nursing desk. LPN CC stated that Resident #105 was expired and they went together to her room. RN S stated, (Name of Resident #10) was (in bed) still warm, but her color was pale and you could tell she was gone. I listened to her heart and lungs, and we placed the back board and started CPR. The video of the hall (dated [DATE]) was reviewed with the NHA A, and two surveyors on [DATE] at 10:15 AM. The following was a timeline from the video: 7:21:59 LPN CC enters Resident 105's room and exits at 7:22:36 and walks to the nurses desk. 7:23:20 LPN CC and RN S enter Resident #105 together. No crash cart, back board, stethoscope or AED is was noted. 7:23:46 RN S runs from the room back towards the nurses' desk. 7:24:17 RN S enters the room with the crash cart, and back board. An interview with the DON B was conducted on [DATE] at 10:00 AM. The DON B stated that the facility converted to an electronic medical record on [DATE] and no longer used the Kardex in the resident closet (per the facility current policy). The DON B stated that the facility did not use the policy Code Status dated ,[DATE] and revised ,[DATE] that was found in the emergency book. The surveyor reviewed the video timeline with the DON and the DON B agreed that LPN CC should not have left the room once she found that Resident #105 was unresponsive. The DON B stated that she should have called out for help (do not leave the resident) and started CPR immediately. During an interview on [DATE] at approximately 10:00 AM, LPN XX stated that she was also in the room during the code but she did not record or document the events of the code. Record review of the nursing notes dated [DATE] at 7:51 with actual created time of 8:15 AM reflected, Resident was sleeping comfortably on morning rounds at 6:00 AM. Nurse found resident expired at med pass rounds at 7:15 AM. Resident is a full code, all nursing staff started CPR, and called 911. EMS arrived and continued CPR. Family was notified to come to facility immediately. Nurse notified DON and administrator. (Name of doctor) was notified and ok to release body. TOD (time of death) was called at 7:55 AM. This note was the only entry for [DATE] - [DATE]. It did not reflect an assessment for pain, or signs of life such as vital signs, air way, breathing, and circulation nor did it reflect the assessment and need for the CPR that took place.

This citation pertains to facility reported incident MI 418 and MI 413. Based on interview, and record review, the facility failed to prevent a choking incident that resulted in death, failed to ensure that emergency procedures were performed correctly, failed to perform proper assessments after a prior choking incidence that occurred on [DATE], failed to prevent a fall (sliding from a shower chair), and failed to follow facility procedures for standards of care post- fall assessments, resulting in Immediate Jeopardy for sampled Resident #7, and harm from an undiscovered fracture for sampled Resident #8, in a sample of 8 residents and 13 supplemental residents from an extended survey reviewed for safety practices resulting in death and harm. St. Francis Home is placed in Immediate Jeopardy as a result of the facility's failure to prevent a choking death for one resident (Resident #7) on [DATE], by not ensuring that 1. Necessary assessments were performed after a prior choking episode by Resident #7 that occurred on [DATE], and 2. All correct emergency procedures were followed. This deficient practice places all residents, identified as being at risk for choking or any resident, who experiences a choking episode, at risk for serious harm, injury and/or death. Immediate Jeopardy was identified at F-323 on [DATE], at 4:30 PM. The Nursing Home Administrator, Staff A, was notified of the Immediate Jeopardy on [DATE] at 5:30 PM Findings include: The Immediate Jeopardy began on [DATE], according to an Occurrence Statement report. It was documented that Resident #7 had died on [DATE] at 12:55 PM, from a choking incident in the facility after emergency procedures had been performed. According to the facility 5-day report, Certified Nursing Assistant I delivered a lunch tray for Resident #7 to her room at approximately 1:00 PM. Resident #7 was in her bed. CNA I cut Resident #7's food up, which consisted of baked potatoes, baked chicken, and a vegetable of the day, with plastic utensils, and documented it was difficult to cut up the chicken. CNA I put the tray in front of Resident #7 and went to get her roommate's tray. She then heard Resident #7 cough. CNA I hit Resident #7 on the back a couple of times to see if something would come out. CNA I then called for help from LPN H. LPN H came and took over. LPN H noted Resident #7 in bed, trying to cough, with a red face and having trouble catching her breath. LPN H encouraged Resident #7 to cough, and reported she coughed a couple of times. Back blows were given 4 or 5 times, and on the last back blow Resident #7 coughed. LPN G entered the room to assist, and encouraged Resident #7 to keep coughing and the resident appeared to be unable to breathe. LPN G then began to get behind her and gave abdominal thrusts times 4, then checked her mouth and was unable to see anything. LPN H and G repositioned Resident #7 on the bed and attempted to give additional abdominal thrusts, as Resident #7's color was ash/gray. LPN F entered the room to assist Resident #7 with a ventilation device (Ambu bag), with no air forcibly able to enter Resident #7's airway. According to the report, there were no pulse or respirations noted at that time, and the skin was blue. According to the report, Resident #7 received a regular diet, and the diet had not been changed. The report also documented that Resident #7 had a choking incident on [DATE] at 6:00 PM, with the Heimlich maneuver performed three times, and Resident #7 was able to cough particles out. At that time diet/food consistency was not changed. The report also documented that Resident #7 was admitted with a full set of dentures, and was seen by the Dentist on [DATE], as Resident #7 was edentulous, with no idea when dentures became missing. When the Dentist tried to bill for the dentures, it was discovered her Medicaid coverage was not in force, and Resident #7 never received her new dentures. All rescue interventions were attempted unsuccessfully. Findings include: According to admission face sheet, Resident #7 was an [AGE] year-old female, who was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to Minimum Data Set (MDS), dated [DATE], Resident #7's Brief Interview for Mental Status (cognitive assessment) was 11, revealing moderate cognitive impairment and she required assistance with all activities of daily living. Section K Swallowing/Nutritional Status on the same MDS had coded none of the above for coughing or choking during meals or swallowing medications. Section L of the MDS Oral/Dental Status was left blank. Resident #7 was not assessed or evaluated for dentures or broken teeth. According to Resident #7's Advance Directive, dated [DATE], Resident wished to be hospitalized and did not wish to have Cardiopulmonary resuscitation (CPR). Evidence of a prior choking incident was obtained by a review of Resident #7's Nurse Progress notes, dated, [DATE], which revealed Res was starting to turn purple around her mouth, resident was stood up and Heimlich maneuver performed. Food cleared airway . The Nursing Home Administrator A indicated he did not have an Occurrence report for that date, when asked on [DATE]. Review of Resident #7's care plans indicated a Nutrition/Hydration care plan with an initiation date of [DATE], indicated I have a full set of dentures, but do not require a mechanically altered diet at this time signed by Certified Dietary Manager U, and signed again on [DATE], by CDM U. There were no added interventions or modifications to the care plan since [DATE], and no changes to the care plan related to the choking incident that occurred on [DATE]. During an interview on [DATE] at 10:25 AM, LPN H reported that CNA I called the charge nurse LPN G into Resident #7's room. LPN H reported that she had instructed CNA I to get LPN G, who was Resident #7's nurse providing care that day. CNA I went to find the nurse when LPN H entered Resident #7's room and observed the resident coughing and choking, while sitting up in bed. Resident #7's lunch tray, which was at her bedside which included baked chicken, baked potatoes and green beans, all cut up in pieces. LPN H reported that CNA I had not thought anything was removed off of the tray except that the plastic utensils were soiled. Resident #7 appeared to be choking and was ashen in color with her eyes open. LPN G was reported to have entered Resident #7's room, instructed the resident to lean forward slightly, got behind her and to have given ,[DATE] back blows. LPN G was reported to have told Resident #7 to cough. LPN H reported that LPN G gave ,[DATE] more back blows. Resident's lips were becoming dark. LPN G got behind the resident and attempted to performed the Heimlich maneuver, while the resident was sitting up in bed. LPN G did a finger sweep of mouth and did not see anything. Another cycle of the Heimlich maneuver was performed unsuccessfully. Both nurses decided to reposition Resident #7 diagonally in the bed. LPN H reported at that time LPN F entered Resident #7's room to assist and was attempting to assess, by use of a ventilation bag, if any air was able to pass through the airway. LPN H reported no breaths went through. LPN H reported that the apical pulse was assessed and there was none and there were no observable breaths at that time. LPN H was asked if 911 was called and who responded, She was a DNR (Do Not Resuscitate). LPN H was asked about Resident #7's code status, which stated that she wanted to be hospitalized . LPN H responded, I focused on DNR and no one called 911. LPN H stated, If I could do it again I would move her to the floor on a hard surface to have some support for the abdominal thrusts. A review of the facility policy entitled Heimlich Maneuver, indicated Pressure forces the diaphragm upward, compressing the air in the lungs, and expelling the object blocking the breathing passage. During an interview on [DATE] at 1:30 PM, pertaining to the choking incident on [DATE], LPN G, who was the nurse caring for Resident #7 on that day, LPN G was asked what happened on [DATE], and verbalized that she was called to Resident #7 room by CNA I who indicated that Resident #7 appeared to be choking and LPN H needed assistance. She entered Resident #7's room and observed LPN H giving Resident #7 back blows. I walked up to Resident #7 and told her to cough and she coughed one or two more times. I looked at her mouth and it was open. I then got behind her while she was sitting in bed, and positioned myself at an angle to her the best I could and tried to perform the Heimlich maneuver on her. I didn't have a good alignment behind her, so the other nurse and I tried to reposition her in the bed. We moved her diagonal in bed, so I could get better positioning. She turned colors and went limp. I looked in her mouth and didn't see anything. Then the nurse from another unit came to help and brought an Ambu bag. He tried to give her some air to see if her chest would rise. It didn't. It was over in 10 minutes. She was a DNR. We listened for a pulse and looked for respirations and there were none. We called the Doctor, The Administrator and the Director of Nursing, and called her son. LPN G was asked if Resident #7 was placed on a back board while in bed. She said No. LPN G was asked if anyone called 911 and she said No, she was a DNR. LPN G was asked if anyone tried to suction Resident #7 and she said No. LPN G was asked why no one activated EMS as Resident #7 code status was documented as Yes to hospitalization , but No to CPR. LPN G said, It happened so fast, then it was over. An interview that was conducted on [DATE] at 3:45 PM, with LPN F who was the third nurse to assist with Resident #7 on [DATE]. LPN F was asked about the incident and verbalized he was called to Resident #7's room and upon entering the room, he witnessed two nurses LPN H and LPN G attempting to perform the Heimlich maneuver to Resident #7 while she was in bed. LPN F said he came with an Ambu bag. LPN F verbalized the first few attempts with the Heimlich maneuver were unsuccessful so the two nurses repositioned Resident #7 in bed diagonally. He verbalized he had asked the two nurses how long this has been going on because the resident was blue. I got the Ambu bag and tried to deliver a breath to see if her chest would rise, and it did not, nothing was effective. I asked if someone called 911 and they said No, she is a DNR. I listened for a pulse, and observed for breaths. There were none. The two nurses took over, so I then went back to my unit. An interview that was conducted on [DATE] at 4:15 PM, with Certified Nursing Assistant, I who was the CNA that delivered the lunch tray on [DATE]. CNA I verbalized that she was helping on the unit passing trays that day and that residents were eating in their rooms due to a flu outbreak at that time. CNA I verbalized that she was not very familiar with Resident #7 and she had a ticket on her tray for regular diet, and to cut up the food. CNA I said It was difficult for me to cut up the food, because I had to use a plastic fork and knife. I cut the food up, set the tray in front of the resident and turned to get her roommate's tray. I took 3 steps and heard her cough. I turned to look at her. She was coughing 3 times. I went over to her and asked if she was choking. She did not nod her head or anything. I went and got the nurse who was out in the hall at the medication cart. She came in to help. I then went to get her nurse that was caring for Resident #7. I don't really know if she took a bite, but her silverware was soiled because I cut her food up with them. I didn't know her dentures were not in her mouth at that time, or that they were missing until later, and she was on a regular diet. I looked at her care guide, because I was not very familiar with this resident. I was put on the unit to help pass trays. A review of Resident #7's Nurse Progress note by LPN G, dated [DATE], revealed Late entry, I was called to the resident's room by CNA (name) upon entering the resident's room, (nurse) was giving back blows, the resident begin to cough. I started encouraging the resident to keep coughing, I looked into the resident face it appeared as if she couldn't breathe, I started giving the resident abdominal thrusts x 4 then I looked in the resident's mouth, unable to see anything in her mouth. We repositioned the resident and continued giving abdominal thrusts, resident color changed (ash/gray) limbs flaccid, the resident had a blank stair (sic). (LPN F) entered the room, attempted to give air with an ambu bag. No rise & fall of chest. Resident mouth checked again, unable to see anything present. Checked resident's pulse, no pulse present, no heartbeat present. (LPN H) checked pulse and heart sounds, (LPN H) stated no pulse or heartbeat. Nurse manager notified, (physician) notified at 1 PM, DON notified at 1:10 PM, Administrator notified at 1:15 PM, Son notified at 1:20 PM. Per (Physician) OK to release the body. An interview that was conducted on [DATE] at 1:30 PM, with Director of Nursing B related to missing dentures for Resident #7. The DON B verbalized that nursing was responsible to list the residents who are missing their dentures on the 24 hour report, and that a search is initiated with nursing, house keeping and maintenance. If that is unsuccessful, then nursing puts them on a list that goes to an Administrative Assistant who sets up a dental visit for the residents. The DON B verbalized that Resident #7 was seen by the dentist in [DATE], and a set of dental impressions was done at that time to get Resident #7 a full set of dentures. The DON, B verbalized that Resident #7 never received her dentures due to lack of Medicaid coverage. DON B did not verbalize that there were any other financial options pursued. The DON B also verbalized that there was not an Occurrence report filled out for the choking incident that occurred on [DATE], with the Heimlich maneuver used to clear Resident #7's airway. The DON B verbalized that there was not a designated Unit manager in place over that unit during that time, and that she and two other nurses were sharing the responsibility of covering the unit. The DON B was asked if Resident #7 was evaluated by the Speech Therapist after the first choking episode. She said No, it was not communicated to me. I found out after she had the second choking episode and died . She was asked if Resident #7 had any diet modifications due to missing dentures and a choking episode in November. No, Resident #7 was receiving a regular diet and didn't have her dentures. There were no new interventions put in place or added to her care plan. The nurses did not call 911 with the second choking because she was a DNR and they should have. An interview was conducted with the Nursing Home Administrator A on [DATE] at 3:00 PM, related to missing dentures for Resident #7. I don't know what happened to the dentures and when they were missing. They never told me about it. The Administrator was asked why 911 wasn't called with the choking incident and he verbalized his investigation showed the nurses were focused on DNR and didn't activate EMS, and didn't follow the code Status in place for Resident #7. A review of the facility policy entitled Heimlich Maneuver, indicated 5. Repeat several times if necessary until food or foreign body has been removed. Instructions indicated that the body was to be moved to the floor or a hard surface. A review of facility-provided information indicated that, A DNR Order Doesn't Mean Do Not Treat, dated [DATE], A DNR order does not mean do not treat. Acute episodes such as choking should be treated by appropriate means. A DNR order usually applies to cardiac or respiratory arrest, not mechanical airway obstruction from a foreign object. Immediate Jeopardy is due to the facility's failure to assess Resident #7, following a choking episode in [DATE], and the facility's failure to use correct emergency procedures, including calling EMS, while Resident #7 was choking and died on [DATE]. These deficient practices place all facility residents, identified as being at risk for choking, or any resident who experiences a choking incident, at risk for serious harm, injury, and/or death. The Immediate Jeopardy was removed on [DATE] at 6:00 PM, when this Surveyor confirmed by observation, interview, and record review, that the following had been initiated: Abatement Plan Element 1: Corrective Action 1. Missing Items policy revised 2. A Missing Dentures, Glasses, Hearing Aid Log will be created and maintained by Social Services. 3. Resident with Chewing/Swallowing Difficulty policy created 4. Adult Choking Victim policy created 5. CPR class was provided February 2, 2017 with 9 nurses attending by a certified Red Cross instructor, another CPR class is scheduled for [DATE] by the same instructor. 6. A Mandatory ALL Staff Meeting will be scheduled on [DATE] to include education on all above policies as well as review the Occurrence/Fall Prevention policy and expectation related to completing the Occurrence forms. Choking intervention return demonstration will be mandatory for all nursing staff at that meeting. 7. During morning clinical report, all 'Missing Item Complaint Forms' will be reviewed along with any investigation and follow-up assigned by the administrator. 8. Social Service department will be the designated contact for ancillary services (dental, vision and podiatry) and will be responsible for the follow-up of completion of the needed service. 9. An Ancillary Service Log will be created and maintained by Social Services Department. 10. All resident care plans were reviewed and updated to reflect the audit completed on [DATE]. 11. MDSs were reviewed for any errors. Modifications will be completed as necessary. Element 2: Identify Residents at Risk Every resident residing in the facility was assessed for dentition issues/dentures, diet, and swallowing/chewing difficulties. All those identified with an issue regarding dentures/dentition problems, chewing/swallowing or diet issues will be referred to the appropriate service for evaluation and treatment. Eighteen residents were identified and refered to Speech Therapist on [DATE] for screening. Those identified with a need after screening will be evaluated and treated. Four residents are scheduled to see the dentist. Element 3: Preventing Recurrence 1. Missing Items policy revised 2. A Missing Dentures, Glasses, Hearing Aid Log will be created and maintained by Social Services. 3. Resident with Chewing/Swallowing Difficulty policy created 4. Adult Choking Victim policy created 5. CPR class was provided February 2, 2017 with 9 nurses attending by a certified Red Cross instructor, another CPR class is scheduled for [DATE] by the same instructor. 6. A Mandatory ALL Staff Meeting will be scheduled on [DATE] to include education on all above policies as well as review the Occurrence/Fall Prevention policy and expectation related to completing the Occurrence forms. Choking intervention return demonstration will be mandatory for all nursing staff at that meeting. 7. During morning clinical report, all 'Missing Item Complaint Forms' will be reviewed along with any investigation and follow-up assigned by the administrator. 8. Social Service department will be the designated contact for ancillary services (dental, vision and podiatry) and will be responsible for the follow-up of completion of the needed service. 9. An Ancillary Service Log will be created and maintained by Social Services Department. 10. All resident care plans were reviewed and updated to reflect the audit completed on [DATE]. 11. MDSs were reviewed for any errors. Modifications will be completed as necessary. Element 4: Monitoring: Corrective actions will be monitored by/with: A monthly audit of dentition/dentures, diet, chewing/swallowing difficulties will be completed on the identified residents with potential problems as well as any new admissions, residents with change of condition and 5 randomly chosen residents. The audit will be completed by the DON or designee. Any identified issues will be immediately addressed. The IDT will complete a monthly audit of every resident/resident's representative to inquire if they have any missing assistive devices (dentures, glasses or hearing aids) for the previous month. If missing items are identified, the Missing Dentures, Glasses, Hearing Aid Log will be reviewed to see if the item had previously been identified and what has been done related to the missing item. If the item had not been previously identified on the log, an investigation for that item will be initiated at that time. A monthly audit of the Ancillary Service Log will be completed by Social Services. Findings will be brought to QAPI Committee bimonthly. The DON and administrator will be responsible for sustained compliance. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at the scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, due to the facts that all staff had not been in-serviced and sustained compliance had not yet been verified by the State Agency. Resident #8 The facility provided a policy/procedure for Occurrence/Fall Prevention Policy with an effective date of [DATE] reflected, Procedure: For the purpose of this policy, an 'Occurrence' is any event that did cause or could have caused injury to a resident, including falls .Use gait belts for all resident transfers and ambulation unless resident is interdependent. CNA RN competency will be checked annually related to safe transfers and mobility of residents .3. Following an Occurrence a. The Charge/Nurse Manager/Director of Nursing (DON) will assess the Resident for an injury and give medical treatment as needed. The resident is not to be moved after a fall until a nurse has evaluated them for an injury. The Charge Nurse/Nurse Manager/DON will complete the sections of the Unusual Occurrence Statement form in full. Including if all interventions were in place at the time so that a root cause analysis can be completed. c. Immediate investigation and staff interviews are to be completed with any occurrence. Statements detailing what happened are required. Statements from all staff in the area are needed .d. The Resident's condition, vital signs, and pertinent information concerning the injury are to be documented in the Nurse's Notes, 24 Hour Report Book and passed on in Report shift to shift for a minimum of 3 days. If no injury, documentation will be done for 24 hours on the 24 hour Report Sheet, Nurse's Notes and passe on shift to shift in Report. Monitor closely for any condition changes. e. If there are any immediate interventions that are taken by the Charge Nurse/Nurse Manager, a Communication Form for the involved Departments will be filled out and distributed. The Charge Nurse/Nurse Manager will implement the proper flow sheet to monitor Resident i.e., Neuro-Checks, 30-Minute Check Logs, 1;1 supervision, Maintenance Work Order, Treatment Assessment Record (TAR) etc. f. Resident Falls will be investigated and reviewed on the next weekday by the Falls Review Committee . According to the State Operations Manual F-323 483.25(h) Accidents reflected, Definitions .Fall- refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force .An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall . Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], reflected that Resident #8 was a [AGE] year-old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #8's MDS, dated [DATE], for Brief Interview for Mental Status (BIMS), reflected a score of 7 out of 15 which represents severe cognitive impairment. Resident #8 required ,[DATE] staff assistance and a mechanical lift for all activities of daily living. Resident #8 was observed in her room and was not able to answer questions regarding this incident. During an interview on [DATE] at 1:00 PM, CNA N stated that she assisted CNA M to provide Resident #8 with a shower on [DATE] at approximately 5:00 PM. CNA N stated that while drying Resident #8 off Resident #8 slid from the shower chair and was lowered to the floor by CNA N and CNA M. CNA N stated that Resident #8 did not say she was in any pain. CNA N stated that together with CNA M they lifted Resident #8 back to the shower chair. When asked how Resident #8 slid out of the chair, CNA N stated that the brakes were not applied to the chair and when Resident #8 leaned forward the chair slipped away from the back side. When asked if the nurse assessed Resident #8 before she was moved, CNA N stated, No. When asked if a gait belt was used to assist resident up off the floor, CNA N stated, No, we picked her up one on each side under her arms. When asked if the she notified the nurse of the fall, CNA N stated, No, we dressed her and I took her to the family room where her family were. When asked if she completed a witness statement for an occurrence report, CNA N stated, Not that day but I think I was asked to the next day. During an interview on [DATE] at approximately 1:30 PM, CNA M stated that she assisted CNA N with providing Resident #8 with a shower and while drying Resident #8, she leaned forward and the shower chair went out behind her because the brakes were not on. CNA M said she was able to hold Resident #8 until CNA N came around to front of the chair and them both CNA's lowered Resident #8 the floor. CNA M stated that together with CNA N the two CNA's lifted Resident #8 (under her arms) back to the shower chair, dried her, dressed her and while CNA N took her to the family room, CNA M cleaned the shower room, and then went to assist another resident. When asked if she notified the nurse about the fall, CNA M stated, No, but RN L came to me and asked me if she had fallen in the shower and said that (name of Resident #8's husband) just told her that Resident #8 had fallen in the shower. When asked if RN L assessed Resident #8, CNA M stated, Yes, I saw her looking her over in the family room. During a phone interview [DATE] at 2:55 PM, RN CC stated on [DATE] she was orientating with RN L doing the medication pass when Resident #8's family reported that Resident #8 said that she had fallen in the bathroom. RN CC stated that Resident #8 was seated in her wheelchair in the family room and she was wearing slacks. RN CC stated that Resident #8 complained of knee pain so RN L raised her pant leg and checked her knee. When asked if Resident #8 received pain medication for her complaint of knee pain, RN CC stated, No, not at that point, she went back to her medication pass and I left about a half hour after that. RN CC stated that later in the month the family came to me and told me that her (Resident #8) knee was still hurting from when she fell in the shower so RN CC assessed the knee and found that the left knee was swollen greater than the right, notified the doctor and an x-ray was ordered that found she had a fracture of the distal femur (bone just above the knee). During an interview on [DATE] at approximately 1:00 PM, RN L stated that on [DATE] just after 5:00 PM, Resident #8's husband came to her and said that his wife (Resident #8) told him that she fell in the shower. RN L stated that she went to find the CNA's and ask them if Resident #8 had a fallen in the shower. CNA M told RN L that Resident #8 had slid from the shower chair and had to be lowered to the floor. RN L stated that she went to the family room and Resident #8 complained of lower back and leg pain so I looked at her leg (pulled up her pant leg) and did not see any trauma, bruising or swelling. When asked if she assessed the upper leg or back where Resident complained of pain, RN L stated, No. When asked if Resident #8 received pain medication for her complaint of pain, RN L stated, Yes, I gave her some Tramadol. RN L stated that she called and notified the doctor. When asked if the doctor provided any new orders, RN L stated, No new orders, her just said to continue to monitor her. When asked about the monitoring process, RN L stated, We put it on the TAR and monitor her for 72 hours after a fall. When asked about other documentation that is done by the facility after a fall occurs, RN L stated, We chart it in the nurse's notes, do a fall occurrence report, get statements from other staff involved, put it on the 24 hour report (nurse to nurse report sheet), and on the TAR. When asked if the facility assessed and documented for pain, RN L stated, Yes, we do it on the pain assessment sheet before and after pain medication and in the nurses notes. RN L was asked if she had any further interaction with Resident #8 that evening and RN L stated, Yes, about 8:30 (PM) or so I checked her over a little bit more and I looked at her skin while she was in bed. When asked if she put Resident #8 through range of motion to check her joints, RN L stated Yes, I raised each leg up and down and in and out and bent her knee. When asked to demonstrate how far each joint was tested for range of motion, RN L demonstrated that she raised Resident #8's foot off the bed about ,[DATE] inches and then bent the knee slightly. RN L did not move each joint to the fullest extent therefore did not assess whether Resident #8 had full range of motion and if Resident #8 had complaints of pain under full range of motion. RN L agreed that she had not assessed for full range of motion for each joint and that Resident #8 was not assessed before she was picked up off the shower room floor. When asked if RN L could locate the documentation in the chart after the fall, RN L reviewed the nurses notes and said, I guess I may not have done it. Review of the nurses notes reflected that there were no entries made between [DATE] at 2:50 PM through [DATE] at 11:20 AM and that entry reflected, Resident left facility this AM via MMR @9:10 AM for transport to appt at (name of hospital) for surgery . There was no notes found after the fall on [DATE] at approximately 5:00 PM, nor any subsequent assessments documented within the nurse's notes. According to the nursing assignment sheet for [DATE] (the day after the fall), RN L was assigned to Resident #8 for the second shift from 2:00 PM - 10:00 PM. There were no nursing notes found for this shift related to the fall follow up monitoring or pain assessment that she stated in her interview that she had completed. According to the physicians order dated [DATE] reflected an order for [REDACTED]. According to the [DATE] Medication Administration Record (MAR) and corresponding Pain Management Flow Record for [DATE] there were no pain assessments or pain medications provided on [DATE] as RN L stated in her interview. Additionally, there were no pain assessments or doses provided on [DATE] - [DATE] (during the 72 hour post fall monitoring period). Review of the hospital records under Brief Hospital Course including treatment rendered and response to treatment: .They were not a

Based on observation, interview, and record review, the facility failed to ensure safety measures were followed per care plan and prevent a second degree burn for one resident (Resident #8) out of 13 residents reviewed for accidents/hazards in a total of 15 sampled residents resulting in a burn from a coffee spill, increased pain from the burn, and the potential for infection. Findings include: Review of sampled Resident #8 ' s clinical record, revealed that he was a [AGE] year old male admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set ((MDS) dated [DATE], revealed that Resident #8 ' s Brief Interview for Mental Status (cognitive assessment) was 10, revealing moderate cognitive impairment, but able to make his needs known. The MDS also revealed that Resident #8 was dependent on staff for Activities of Daily Living (ADL) care, required set up with meals, but able to feed himself. Review of Therapy Screen for Use of Hot Liquids, dated 2/17/14, documented that Resident #8 has been observed to be unsafe drinking hot liquids without a covered cup, and kitchen notified of resident being unsafe. Review of Resident #8 ' s clinical record, revealed that Resident #8 had spilled coffee on himself on 5/27/14, 8/16/14, 1/18/16. Review of Injury Occurrence Tracking Tool, provided to Surveyor by Registered Nurse, Unit Manager Staff D , documented that Resident #8, on 5/27/14 spilled coffee after removing lid, Rt. (right) groin blister, will use sippy cup with lid. Review of Injury Investigation form documented Resident was given coffee in his room with a lid covering. Resident removed lid and spilled coffee on Right groin area, area is red with small blister fluid filled forming. An interview was conducted with Staff D on 4/19/16 at 1:00 PM, related to several coffee spills for Resident #8. Staff D was asked what interventions had been in place prior to the coffee spill on 5/27/14. Staff D said Resident #8 had been receiving his coffee in a regular cup covered with a lid, and they changed it to a sippy cup, water pitcher with a snap on lid. Further review of the Occurrence Tracking Tool documented on 8/16/14, coffee spill after removing lid, in bed, (L) (left) inner thigh reddened from coffee spill . 1/18/16, Coffee spill with redness, blister, in bed, make coffee ½ coffee, ½ cool water. Review of Nutrition/Hydration Care Plan, dated 1/18/16 under goal documented Residents coffee must be ½ cold water and ½ coffee. Ensure coffee temp is less than 120 degrees . Review of Nutrition/Hydration Care Plan dated 1/31/16 only documented under interventions to provide me with a water pitcher for all my hot liquids . The intervention to cool Resident #8 ' s coffee was not on the updated on the dietary care plan. Review of Nutrition /Hydration care plan dated, 2/18/14, documented 5/26/14 Tall sippy cups for all hot liquids, water pitcher. Entry for 8/9/14, documented under Focus , Please make sure my coffee is not too hot since I sometimes take the lid off the top of my cup. Review of Safety Care Plan, dated 1/18/16, documented Coffee spill with redness and blisters, coffee to be served ½ coffee, and ½ cool water. Review of Occurrence Prevention/Rehab communication form, dated 2/10/16, documented For Meals, make sure Resident is positioned well in his bed, head of the bed upright, and that he is sitting upright, prepare tray if any hot foods cereal/soup etc. make sure they are safe temp hot liquids/coffee is care planned to mix at cooler temp. Interview continued with Staff D related to Resident #8 spilling his coffee. Staff D was asked if Resident #8 sustained injuries from spilling his coffee. Staff D said that on 1/18/16, Resident #8 sustained injuries from the coffee spill that resulted in redness and 2 large blisters, and Resident #8 was being sent and treated at a wound clinic for partial thickness, second degree burns. Staff D was asked that if interventions in place were being followed, how Resident #8 received a burn. Staff D said that for the burn on 1/18/16, dietary staff did not cool his coffee and sent it to the unit, and then Resident #8 took the lid off and placed the sippy cup of coffee on his left side, by his hip area while he was in bed, and it spilled. Staff D was asked why Resident #8 was not up out of bed for his breakfast. Staff D said that he often refused to get up for breakfast and request his meal while in bed. Staff D also said that during their investigation, it was found out that somehow the intervention listed on the dietary care plan had gotten dropped off, and staff did not cool Resident #8 ' s coffee. Review was done of Skin Condition Log, dated 1/18/16 documented Burn-coffee spill. 1/18/16, (L) (left) hip tiny blisters/redness, unmeasurable at this time, 1/28/16, (L) hip 1.9 centimeters by 16 centimeters, slough/eschar (dead tissue), 2/4/16,(L) hip 17.5 centimeters by 12.5 centimeters, slough/eschar, 2/11/16, (L) hip 9.6 centimeters by 10.2 centimeters, slough/eschar, 2/ 22/16, (L) hip 5 centimeters by 8.5 centimeters, slough, no eschar, 3/4/16, (L) hip 2.4 centimeters by 5.6 centimeters, no slough, no eschar, 3/18/16, (L) hip 2.3 centimeters by 1.2 centimeters, no slough, no eschar, 4/8/16 (L) hip 0.4 centimeters by 0.4 centimeters, no slough, no eschar. An Observation was made on 4/20/16, at 9:45 AM, of area to left hip and treatment provided to area by Staff I . The Left hip area had pink/red tissue in the form of an L shape that had no slough or eschar noted, with no drainage present, Staff I did not measure the area at that time, and said the wound clinic did the measurements. Review was done on 4/20/16 of Investigation Summary completed by Nursing Home Administrator, Staff A dated 1/18/16, documented that Resident #8 had his breakfast tray set by staff, and because of two past hot spills, Resident #8 was assessed by Occupational Therapy to receive his hot liquid (coffee) in a special mug with a snapping lid that was in place when delivered, Resident #8 removed the lid and set the mug next to his left outer hip in the bed and it dumped over on his hip. The investigation went on to reveal the root -cause analysis was due to Resident #8 removing the lid to cool his coffee. An interview was conducted with Licensed Practical Nurse, Staff I on 4/20/16, at 1:30 PM, who was the nurse that observed Resident #8 on 1/18/16, after the coffee spill. Staff I revealed that upon entering Resident #8 ' s room to give him his medication, he told her he spilled his coffee. Staff I said he did not call out, put the call light on, or inform her that he was having any pain at that time. Staff I said that she went and felt his leg and it was cool, and asked Resident #8 what happened, and he informed her that he was trying to cool off his coffee. Staff I said that the lid was off the sippy cup and in the bed with him. Staff I said that she then went to get Staff D . She said that Staff D and herself rolled Resident #8 over, removed his pants and observed the red area to left hip. Staff I said there were no blisters observed at that time. Staff I said they cleaned him up, got clean clothes for him and then went and called the Doctor and said the Doctor ordered a treatment to the area for a burn. Staff I said that the Doctor came to the facility a few hours later around 1:30 PM, and there were blisters at that time. On 1/18/16 to see Resident #8 and that the spill occurred around 8:30 AM. Staff I was asked if the staff was following the interventions listed on his care plan for cooling his coffee. Staff I said that I assumed they were, but we found out later that it got dropped off of a care plan and they did not that day, We assumed That they were. Review was done of Nurse/Physician Communication Form, dated 1/18/16, for Resident #8, revealed that Resident #8 was receiving Norco 7.5 milligrams/325 milligrams, orally every 6 hours around the clock for pain control, and can have one tab orally every 4 hours as needed, requested additional increase in dosage for pain control as Resident #8 said his pain was constant. The Physician/Prescriber order, dated 1/18/16 ordered Duragesic Patch 25 milligrams every 72 hours (topical morphine patch), Silver Sulfadiazine 1% cream bid (two times a day) to affected area on Left thigh. Review of Physician documented Progress Note dates 1/18/16, documented under reason for visit Patient dropped coffee on his left thigh, blisters positive, generalized pain, educated patient on safety precautions to keep lid on coffee, coffee not to be served too hot, always keep lids on coffee cups, educated patient. Review of Physician documented Progress Notes, dated 2/1/16, under reason for visit, documented F/u (follow up) partial thickness burn Lt (left) thigh, and F/u pain, Partial Thickness burn, seen and followed up at wound clinic, labs as ordered, pain adequate controlled, continue current regimen. An interview was conducted with Nursing Home Administrator, Staff A on 4/20/16, at 2:30 PM related to the investigation for Resident #8 coffee spill that resulted in a burn. Staff A said that It was determined that dietary staff had sent the coffee out from the kitchen that way, and was not aware it was to be cooled, due to current changes in staff, new staff in different positions, the intervention for Resident #8 to have his coffee cooled prior to serving somehow got dropped off the care plan. Staff A also said they did a root- cause analysis as to why Resident #8 was removing his lid and it was determined that he wanted to cool his coffee. Staff A said they did not have an old Policy for handling of hot liquids, but they have implemented a Policy titled Coffee Standards , dated 1/25/16. Under heading Normal Coffee Service documents Optimal temperature for normal service of coffee that is palatable is 160-175 degrees. Commercial machines brew coffee in the range of 180 to 205 degrees in order to properly extract coffee from grounds. Warmers used to hold brewed coffee can hold the temperature at reduced levels and/or coffee can be air cooled before services according to policy incorporating resident preference and safety. Resident #8 suffered a second degree burn and increase in pain from a coffee burn as a result of interventions being dropped off a care plan and staff not aware of the interventions that had been put in place.

This citation pertains to MI 619. Based on interview, and record review, the facility failed to provide adequate and appropriate care for 1 of 4 sampled residents (Resident #3), from a total of 4 sampled residents, resulting in the lack of medical intervention for [MEDICAL CONDITION] that caused/contributed to 2 falls, one of which resulting in an avoidable fall that resulted in a [MEDICAL CONDITION]. Findings include: According to Resident #3's MDS/Minimum Data Set, dated dated [DATE], revealed she was admitted to the facility on [DATE], scored 11 out of 15 on the Brief Interview for Mental Status, indicating she had moderate cognitive impairment, and had [DIAGNOSES REDACTED]. According to Physician's Admission Order Sheet, dated 2/05/16, Resident #3 readmission [DIAGNOSES REDACTED]. According to an Occurrence Statement Form, dated 12/24/16 at 10:49 PM, (Resident #3) was found sitting on floor next to bathroom . According to the Post-Fall Investigation Form, dated 12/24/15 at 10:49 PM, .Has medical conditions that may contribute to falls? Yes. Review status of medical condition. Assess conditions causing dizziness/[MEDICAL CONDITION]. According to an Occurrence Statement Form, dated 1/31/16 at 5:18 PM, (Resident #3) attempted to climb out of bed and fell on floor next to bed . Vitals documented on the Occurrence Statement revealed Resident #3's pulse rate was 56 beats per minute after the fall. According to the Post-Fall Investigation Form, dated 1/31/16 at 5:18 PM, .Has medical conditions that may contribute to falls? .arthritis, dementia, depression, IBS (irritable bowel syndrome). Yes. Review status of medical condition. Assess conditions causing dizziness/[MEDICAL CONDITION]. According to the American Heart Association, 2016, A heart rate of less than 60 beats per minute (BPM) in adults is called [MEDICAL CONDITION] .Elderly people are more prone to problems with a slow heart rate. Causes of [MEDICAL CONDITION] .Problems with the [MEDICAL CONDITION] (SA) node, sometimes called the heart's natural pacemaker, Problems in the conduction pathways of the heart (electrical impulses are not conducted from the atria to the ventricles), Metabolic problems such as [MEDICAL CONDITION], Damage to the heart from [MEDICAL CONDITION] or [MEDICAL CONDITION] .Symptoms of [MEDICAL CONDITION] .A heart rhythm that's too slow can cause insufficient blood flow to the brain with symptoms such as .Dizziness, Lightheadedness, [MEDICAL CONDITION] or near-[MEDICAL CONDITION] spells, In extreme cases, [MEDICAL CONDITION] may occur. http://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/[MEDICAL CONDITION]-Slow-Heart-Rate_UCM_ 6_Article.jsp#.Vr4Bz6x0zX4 Review of Resident #3's Vital Signs Record, Resident #3's pulse rate was below 60 the following dates (none of the entries contained staff signature/initials): 12/18/15 at 2:00 AM - pulse 45, 3:00 PM - pulse - 50, 5:00 PM - 51 12/19/15 at 3:00 AM - 47 2/20/15 at 2:00 AM - 52, 8:00 AM- 48, and 6:00 PM - 48 12/21/15 at 2:00 AM - 45, and 8:00 PM - 54 12/22/16 at 12:40 PM - 51 12/23/15 at 3:00 PM - 53 12/25/15 at 4:00 PM - 53 12/26/16 at 2:00 AM - 59, and 11:00 PM - 50 12/27/15 at 6:00 PM - 50, 11:00 PM - 53 12/28/15 at 9:00 AM - 51 12/30/15 at 12:00 AM - 53, 9:00 AM - 49, and 6:00 PM - 53 1/06/16 at 4:00 PM - 54 1/13/16 at 1:50 PM - 53 1/20/16 at 3:00 PM - 53 1/27/16 at 2:45 PM - 55 2/07/16 at 10:00 PM - 57 2/09/16 at 9:30 PM - 59 (No heart rate was recorded on 12/24/15, 12/29/15, 1/01/16-1/04/16, 1/07/16-1/12/16, 1/14/16-1/19/16, 1/21/16-1/26/16, or 1/28/16-2/03/16). According to Nurse's Notes, dated 1/31/16 at 6:05 PM, LPN/Licensed Practical Nurse G documented, (Resident #3) fell in room next to bed at 5:18 PM. Found by this nurse and RN on shift .pain in left his and left upper leg .(Physician H) on site .sent to (emergency room ) .(Resident #3) last seen at 4:45 PM by this nurse during med pass. Resident resting in bed and not ready to get up. Call light in reach. Bed in lowest position. (Resident #3) was reminded by this nurse to call for assistance if she needed anything; when I left the room at 4:45 PM. (Resident #3) did repeat what I said to her . According to call light reports, Resident #3 put her call light on on 1/31/16 at 5:05 PM, and it stayed on for 11 minutes (until 10:59 PM); then, 7 minutes elapsed until she was found on the floor. In an interview, on 2/11/16 at 3:00 PM, LPN/Licensed Practical Nurse F reported she regularly made entries on Resident #3's Vital Signs Record but was not aware that Resident #3's heart rate had been low. LPN F stated she would not alert the doctor for heart rates in the 50's, but would have if she had noticed the ones in the 40's, and said, If I would have seen a trend, I would have reported it to the doctor. When asked what the effects of [MEDICAL CONDITION] were, LPN F replied, weakness, dizziness. LPN F reviewed Resident #3's medical record and found no indication the physician had been alerted to Resident #3's low heart rates. Review of Resident #3's medical record, including physician progress notes [REDACTED].#3's was assessed for conditions causing dizziness/[MEDICAL CONDITION], or the physician was made aware of Resident #3's low heart rates. On 2/11/16 at 4:15 PM, Unit Manager/Registered Nurse E also reviewed Resident #3's medical record and found no indication that Resident #3 was assessed for conditions causing dizziness/[MEDICAL CONDITION], or staff had alerted the physician of Resident #3's low heart rates. Unit Manager E reported Resident #3 did not have a roommate on 1/31/16 and no one was present on the unit, to her knowledge, except staff. Unit Manager E reported Resident #3 would not have been able to shut the call light off by herself; indicating a staff member turned Resident #3's call light off without assisting her to the bathroom. When asked who shut Resident #3's call light off, Unit Manager E reported all staff that were interviewed denied turning off the call light and said, I have no answer as to who shut it off. In an interview, on 2/11/16 at 4:25 PM, DON/Director of Nursing reported she was unaware Resident #3 was having low pulse rates, and said, I didn't know until I looked at it (vital signs record) when you asked for it to be copied. In an interview, on 2/11/16 at 5:40 PM, Resident #3 stated she could not recall sustaining any falls while at the facility, and said, I had some falls at home a couple of years ago. Review of Resident #3's Care Plans revealed no intervention, before or after her 5 day hospitalization , to monitor/report [MEDICAL CONDITION] or to increase supervision due to [MEDICAL CONDITION]. Review of Resident #3's Hospital Discharge Summary, dated 2/05/16, revealed, Discharge Diagnoses: [REDACTED]. [MEDICAL CONDITION] .7. status [REDACTED]. [MEDICAL CONDITION] .Altered mental status (due to) [MEDICAL CONDITION] . The Hospital Discharge Summary also revealed Resident #3 acquired a urinary tract infection, facility acquired pneumonia, and acute [MEDICAL CONDITION]/confusion, during her admission to the hospital. Review of Resident #3's Care Plans revealed no intervention to monitor/report [MEDICAL CONDITION] before or after her 5 day hospitalization . The facility did not have a policy and procedure for regarding notifying physician(s) of clinical problems in residents. ( )

This citation pertains to facility reported incident intake number MI 938. Based on interview and record review, the facility failed to provide timely assistance and ensure that a call-bell was placed with in reach for 1 of 8 residents (#2) reviewed for falls out of a total sample of 16 residents, resulting in a the resident sustaining a fall and painful hip fracture. Findings include: According to Resident #2's care plan dated 2/19/15 and updated 4/6/15, Resident #2 was at risk for falls related to cerebrovascular disease, flaccid [DIAGNOSES REDACTED] (paralysis on one side of the body) affecting the non-dominant side, anemia and dementia. The Transfer Face Sheet (undated but with an admission date of [DATE]) had an added [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #2 had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15, indicating that Resident #2 was cognitively intact. On 4/15/15 PM, at about 2:30 PM, Social Worker P stated she had just completed a BIMS (Brief Interview for Mental Status Score) for Resident #2 on 4/11/15 and his score was still 14 out of a possible 15. According to a facility Occurrence Statement Form dated 3/29/15 (4:45 PM), Resident #2 was .lying in bed, attempting to transfer self, fell on bottom on floor, leg (left) flex back (and) yelling out in (increased) pain to leg. ROM (functional assessment of range of motion) could not be completed. According to the same document, the resident's immediate statement upon interview was, I was trying to get help. On 4/14/15 at about 4:00 PM, Resident #2 was interviewed in the second dining room, where he was waiting to participate in an activity. Resident #2 was asked if his call light was on the afternoon of the fall, and Resident #2 replied, she clipped it too far out of reach. During continued interview on 4/15/15 at about 8:15 AM, Resident #2 stated he didn't remember any of the staff's names, but he did remember it was the nurse aide who cared for him who had placed the call light out of reach. Resident #2 said it was way over there, while pointing to the box on the wall where the red call light button comes on. Resident #2 stated he remembered yelling for help, but did not know how long it was because he did not have a watch. He also stated he did not remember who had closed the door to his room, but he did remember it being closed. According to the facility's Report Summary for the incident that occurred on 3/29/15, the following was documented: At 4:15 (PM) CNA (Nurse Aide L) checked in with the resident (Resident #2) before going to break and he was okay and waiting for his dressing to be reapplied since it came off when being cleaned up after an incontinent BM (bowel movement). Resident was in bed waiting for a dressing to be applied to his perineum when nurse (LPN K) heard him yelling for her to do his dressing. She checked in with him saying it would be a few more minutes. (LPN K) was helping a family member with another resident concern. (Nurse Aide Q) heard a loud noise right after the nurse left his room. (Nurse Aide Q) went to check on him (Resident #2) and found she had a hard time opening the door because the floor pad and over bed table was against the door of the bedroom. (Nurse Aide Q) went and found him on the floor next to his bed. (Resident #2) has been known to throw things in his room and push things around. He is easily agitated and impatient at times especially since returning from the hospital from 3/23 to 3/26 for the perineal abscess Because of pain when trying to assess his legs he was left on the floor and sent to ER (emergency room ) where the fracture to his left leg was identified. The second page of the report stated that Resident #2 was not ambulatory or able to bear weight on his good leg and required the use of a full mechanical lift. The report documented that: (LPN K) will receive a discipline when she is able to come to the facility for not providing the treatment he needed in a timely manner. The aide (Nurse Aide L) was given an education related to the call light not being within reach of the resident when she went to break . (LPN K) had been in the room a couple of times and didn't notice (Resident #2) didn't have a call light. The xray of his leg showed diffuse osteopenia (bone density loss). He had a comminuted displaced fracture involving the femoral metadiaphysis . The hospital discharge summary report dated 4/3/15 reflected Resident #2 required surgery for definitive management of the left femur (hip) fracture . A Past Non-Compliance Checklist submitted by the facility (and dated 3/30/15) described the Deficient Practice for Resident #2's fractured left leg, that occurred on 3/29/15, as follows: Delay in providing treatment when Resident (#2) wanted to get up in w/c (wheelchair). Call light was not in reach. Floor mat slid away from bed when overbed table was moved by the resident. ( )

This citation pertains to intake number MI 921. Based on interviews and record review, the facility failed to provide adequate care and services to prevent falls for 1 of 4 sampled residents (Resident #101), from a total of 4 residents reviewed for fall risk, resulting in Resident #101 experiencing a fall with nondisplaced fracture at the left greater trochanter of the left humerus (a broken bone in the area of the left shoulder) and transfer to a local hospital for evaluation. Findings include: The facesheet revealed Resident #101 was an [AGE] year old woman who was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Sets ((MDS) dated [DATE], revealed Resident #101 was severely cognitively impaired, experienced both long- and short- term memory loss, and required extensive assistance with activities of daily living (ADL's). According to the Fall Risk assessment dated [DATE], Resident #101 was at high risk for falls. The Falls Care Plan initiated 10/12/2011, and reviewed 12/1/2014, specified Resident #101 was "to be out in the hallway, when not in bed, for supervision." According to the CNA Care Plan Information form (undated), Resident #101 was "to be out in hallway when not in bed for supervision." Review of the Occurrence Statement Form dated 2/13/2015 (untimed), revealed Resident #101 was "found lying on her side with wheelchair in front of her, in another resident's room (identified as room number 182, bed 2)" by dietary aide "A." Resident #101 was documented to have sustained a hematoma (lump with a bruise) to her forehead, and was observed with bleeding from the site. The report documented that the Resident continued care at the facility, yet complained of left upper extremity pain on 2/13/2015; she was ordered to have an x-ray, and was found to have sustained a fracture of the left humerus. According to the Primary Care Provider's order dated 2/13/2015 at 7:04 PM, Resident #101 was to be sent to a local hospital for evaluation. Review of the Nurse's Notes dated 2/13/2015 (untimed), revealed Resident #101 was transferred to a local hospital for evaluation of the left upper extremity fracture. According to the x-ray performed at the local hospital on [DATE] at 8:27 PM, Resident #101 sustained a "nondisplaced fracture of the greater trochanter of the left humerus." She was documented in the Emergency Care Center progress note to have returned to the facility on [DATE] for continued care. During an interview on 2/19/2015 at 11:55 AM, Dietary Aide "A" said, " I found her (identified as Resident #101). I was passing water to residents' rooms on 2/12/2015. I could hear her (Resident #101) mumbling; I turned and saw her in the room I was going to next, room 182. I saw her face down on the floor. She was on her stomach. Her legs were under the wheelchair. Her wheelchair wasn't tipped. There was a lift next to her wheelchair. The wheels of her wheelchair were caught on the leg of the lift. Looked like she might have slid out of her wheelchair when the wheel got stuck on the legs of the lift. I didn't witness the fall. I didn't see any other staff in the area where she (Resident #101) was; they (identified as "other staff") were all up at the nurse's station. No one was really watching her. I wasn't assigned to any residents on that hallway; I just passed water to all the residents in the facility. I told a nurse (identified as Nurse "B") the Resident fell . The nurse (Nurse "B") was at the med cart which was near the nurse's station. I don't know how long she (Resident #101) was on the floor. She could've been there awhile. I hadn't seen her in the hall in her wheelchair before I found her. I'd been passing water on that hallway for about 15 minutes when I found her on the floor in room 182." During a phone interview on 2/19/2015 at 3:00 PM, Nurse "B" said, "I wasn't assigned to her (identified as Resident #101) on 2/12/2015. I'd cared for this Resident a lot. She was at high risk for falls; had a few in the past, most of them she tipped forward out of her wheelchair. She leans forward when her wheelchair is moving; quite a bit forward. When her wheelchair isn't moving she still leans, but not as much. When she propels herself in her wheelchair, both her forearms rest on her knees, like to support her trunk. I didn't observe the fall. A Dietary Aide (Dietary Aide "A") told us the Resident fell and was on the floor in room number 182; I went to the room. She (Resident #101) wandered. I could visualize her in the hallway. She wasn't clearly visible to me at all times. I have no idea how long she would've been on the floor in room 182. All of us were aware she was a fall risk and that she needed to be watched. She'd been known to go into other residents' rooms. Not too much a surprise she tipped out of her wheelchair and onto the floor." During an interview on 2/20/2015 at 4:20 PM, the Director of Nursing said, "On 2/12/2015 at about 7:10 PM, she (identified as Resident #101) was wandering in the hall, in her wheelchair, and was found by a dietary aide (identified as Dietary Aide "A") on the floor in a men's room. This Resident goes all over the building, even goes to the other side of the building. It can place her at risk; some residents don't want other residents in their rooms."

THIS CITATION PERTAINS TO MI 717. BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE SUPERVISION TO PREVENT ACCIDENTS FOR 1 (RESIDENT #205) OF 8 SAMPLED RESIDENTS, WHOSE WHEELCHAIR LANDED ON TOP OF HER WHEN IT TIPPED OVER DURING A FACILITY OUTING, RESULTING IN A FRACTURE OF THE LEFT WRIST WITH A SKIN TEAR, AN ABRASION TO THE FOREHEAD, INJURIES TO THE LEFT SHOULDER AND HIP, AND hospitalization FOR PAIN CONTROL. FINDINGS INCLUDE: RESIDENT #205 WAS LIVING AT THE FACILITY AT THE TIME OF THE INVESTIGATION (7/20/11 THROUGH 7/28/11). REVIEW OF THE FACE SHEET, MINIMUM DATA SET (MDS, RESIDENT ASSESSMENT TOOL) DATED 6/13/11, physician progress notes [REDACTED].#205 WAS admitted to the facility on [DATE], WAS ALERT, REQUIRED STAFF ASSISTANCE WITH ACTIVITIES OF DAILY LIVING (ADL'S), TRANSFERS AND AMBULATION DUE TO UNSTEADY GAIT AND DECREASED BALANCE. RESIDENT #205'S [DIAGNOSES REDACTED]. RESIDENT #205 ATTENDED A FACILITY OUTING ON 6/25/11, fell FROM HER WHEELCHAIR ACQUIRING ABRASIONS, A FRACTURE OF HER LEFT WRIST, AND WAS hospitalized for [REDACTED]. REVIEW OF THE FACILITY UNUSUAL OCCURRENCE REPORT DATED 6/25/11, REVEALED ON 6/25/11 AT 12:00 P.M., DURING A PARADE, RESIDENT #205'S WHEELCHAIR HIT A POT HOLE AND TIPPED OVER. RESIDENT #205'S INJURIES INCLUDED LEFT HIP AND LEFT SHOULDER PAIN, A SKIN TEAR TO LEFT HAND, AND ABRASION TO HER LEFT FOREHEAD ABOVE THE EYE. REVIEW OF THE HOSPITAL RECORD DATED 6/25/11, INDICATED "[AGE] year OLD LADY WHO HAS A HISTORY OF DEGENERATIVE JOINT DISEASE OF THE SPINE AND KNEES AS WELL AS SOME LUMBAR SPINAL STENOSIS, WAS APPARENTLY AT THE HOMECOMING PARADE WHEN HER WHEELCHAIR TIPPED WHEN IT HIT A POTHOLE, AND THE PATIENT fell , HITTING HER LEFT FOREHEAD ON THE GROUND WITH A SKIN TEAR TO HER LEFT WRIST, AND AN ABRASION TO HER FOREHEAD. THE PATIENT WAS NOTED TO HAVE LOW BACK PAIN TO THE POINT WHERE SHE WAS UNABLE TO SIT UP. SHE TELLS ME THE PAIN IS WORSE WHEN SHE SITS UP, SHE ALSO HAS SOME LEFT SHOULDER AND WRIST PAIN. THE PATIENT NEEDS TO BE admitted for PAIN CONTROL. ASSESSMENT AND PLAN: LEFT RADIUS FRACTURE (A FRACTURE OF THE WRIST), ORTHOPEDIC WILL BE CONSULTED". REVIEW OF THE HOSPITAL ORTHOPEDIC CONSULT DATED 6/25/11, INDICATED "PATIENT REPORTS A FALL OUT OF HER WHEELCHAIR ONTO HER LEFT SIDE, WHILE BEING PUSHED IN THE PARADE. LEFT WRIST PAINFUL, IMPROVED WITH SPLINT AND ELEVATION, LEFT SHOULDER IS SORE, LEFT LATERAL HIP IS SORE, LEFT WRIST PAIN IS INCREASED WITH MOVEMENT OF HER THUMB. SHE HAS BACK PAIN, AND SHE DID HIT HER HEAD". REVIEW OF THE HOSPITAL X-RAY OF RESIDENT #205'S LEFT HAND DATED 6/25/11, INDICATED, "ACUTE FRACTURE NOTED OF THE DISTAL RADIUS". OBSERVATION AND INTERVIEW OF RESIDENT #205 WAS DONE ON 7/20/11 AT 10:35 A.M. RESIDENT #205 WAS ALERT, SITTING IN HER WHEELCHAIR IN HER ROOM WITH TV ON. RESIDENT #205 HAD A LIGHT BLUISH/PURPLE BRUISE UNDER HER LEFT EYE AND A BLACK VELCRO SPLINT ON HER LEFT LOWER ARM/WRIST. WHEN THE SURVEYOR ASKED RESIDENT #205 WHAT HAPPENED WHEN SHE WAS AT THE FACILITY OUTING ON 6/25/11, SHE STATED, "HIS NAME IS (VOLUNTEER #1), IT'S ONE OF THE GIRLS (STAFF MEMBERS) SON, HE WAS PUSHING ME BY HIMSELF WHEN I fell OVER". RESIDENT #205 STATED, "I WENT SLIDING ON THE PAVEMENT; I fell TO THE LEFT AND HIT MY HEAD. ALL I WAS TOLD IS MY WHEELCHAIR HIT A POT HOLE AND MY WHEELCHAIR LANDED ON ME, THE WHEELCHAIR FLIPPED OVER, IT HURTS. (VOLUNTEER #2) WAS PUSHING ME ALL THE WAY (APPROXIMATELY 3 MILES DURING THE PARADE) AND THEN SHE (VOLUNTEER #2) SAID SHE WAS GOING TO GET MORE CANDY AND ASKED HIM (VOLUNTEER #1) TO FINISH PUSHING ME. THAT'S WHEN I HIT SOMETHING AND fell ; I WAS IN THE HOSPITAL FOR A FEW DAYS " . AN INTERVIEW WAS DONE ON 7/21/11 AT 10:40 A.M., WITH VOLUNTEER #2. VOLUNTEER #2 STATED, "I ASKED (VOLUNTEER #1) TO PUSH (RESIDENT #205), I WAS ASSIGNED TO PUSH (RESIDENT #205). WHEN WE TURNED ONTO (THE ROAD) MY HANDS STARTED CRAMPING UP, THE RESIDENT WAS HEAVY. HE (VOLUNTEER #1) WAS NEAR BY WALKING AND I ASKED HIM TO PUSH HER. HE PUSHED FOR ABOUT 5 MINUTES. I WAS NOT PUSHING HER CLOSE TO THE SIDE (OF THE ROAD) BECAUSE OF THE GRAVEL. HE WAS THE ONLY ONE PUSHING A RESIDENT THAT CLOSE TO THE GRAVEL AND STONES, HE WASN'T EVEN ON THE ROAD WITH HER. VOLUNTEER #2 REVEALED SHE HAD NOT GIVEN VOLUNTEER #1 ANY INSTRUCTIONS, NOR HEARD ANYONE ELSE GIVE HIM INSTRUCTIONS ON HOW TO SAFELY PUSH A RESIDENT IN A WHEELCHAIR. VOLUNTEER #2 SAID THERE WERE SEVERAL ADULT STAFF MEMBERS AND VOLUNTEERS WALKING IN THE PARADE AND NO ONE TOOK OVER FOR VOLUNTEER #1 TO PUSH RESIDENT #205. AN INTERVIEW WAS DONE ON 7/20/11 AT 11:30 A.M., WITH THE INFECTION CONTROL/RESTORATIVE NURSE (THE I/C NURSE). THE I/C NURSE REVEALED SHE WAS ASSISTING WITH FACILITY RESIDENTS AT A PARADE ON 6/25/11 AND (VOLUNTEER #1) WAS HANDING OUT CANDY AND PUSHING RESIDENT'S DURING THE PARADE. THE I/C NURSE STATED, "HE (VOLUNTEER #1) WAS PUSHING HER (RESIDENT #205) AND I TOLD HIM TO GET TO THE SIDE OF THE ROAD TO THROW CANDY TO THE KIDS. SHE (RESIDENT #205) fell OVER TO THE LEFT SIDE, WE PICKED UP THE WHEELCHAIR, IT WAS ON TOP OF HER AND I PUT THE SKIN BACK IN PLACE ON HER LEFT WRIST AREA". THE I/C NURSE REVEALED VOLUNTEER #1 WAS [AGE] years OLD AND HAD NOT BEEN INSTRUCTED ON HOW TO SAFELY PUSH A WHEELCHAIR OR GIVEN ANY GUIDELINES REGARDING RESIDENT SAFETY. THE I/C NURSE ALSO REVEALED VOLUNTEER #1 WAS NEVER ORIENTATED BY THE FACILITY REGARDING VOLUNTEERING, RESIDENT SAFETY, EMERGENCIES OR ON ANY FACILITY POLICIES/PROCEDURES AND HE HAD BEEN VOLUNTEERING AT THE FACILITY FOR OVER 3 MONTHS. THE I/C NURSE STATED, "BUT HE HAS VOLUNTEERED AT (ANOTHER FACILITY) BEFORE". A PHONE INTERVIEW WAS DONE ON 7/20/11 AT 2:00 P.M., WITH THE SURVEYOR, THE I/C NURSE AND VOLUNTEER #1, WITH PARENTAL CONSENT GIVEN FOR THE INTERVIEW. VOLUNTEER #1 SAID HE WAS PUSHING RESIDENT #205 WHEN HER WHEELCHAIR HIT A POT HOLE AND THE RESIDENT fell WITH HER WHEELCHAIR LANDING ON TOP OF HER. AN INTERVIEW WAS DONE ON 7/21/11 AT 9:30 A.M., WITH THE DIRECTOR OF MAINTENANCE. THE DIRECTOR OF MAINTENANCE REVEALED HE WAS AT THE PARADE ON 6/25/11 AND REVEALED TOWARDS THE END VOLUNTEER #1 WAS PUSHING RESIDENT #205 IN HER WHEELCHAIR AT THE EDGE OF THE ROAD. THE DIRECTOR OF MAINTENANCE STATED, "THERE WERE ABOUT 12 RESIDENT'S IN THE PARADE (INCLUDING RESIDENT #205). I WENT RIGHT OVER AND HELPED HER (RESIDENT #205) RIGHT AWAY, SHE WAS BLEEDING, THE CHAIR (WHEELCHAIR) WAS ON TOP OF HER". REVIEW OF A WRITTEN WITNESS STATEMENT FROM A NON-EMPLOYEE OF THE FACILITY DATED 6/25/11, STATED, "AS LADY WAS BEING PUSHED ALONG EDGE OF (ROAD), WHEELCHAIR WHEEL fell INTO POT HOLE ON EDGE OF ROAD. WHEELCHAIR STARTED TO LEAN TO THE LEFT SIDE, PERSON PUSHING (VOLUNTEER #1) GOT BALANCE AT FIRST BUT THEN WHEELCHAIR WEIGHT CAUSED IT TO FALL DEEPER INTO HOLE, THEN EVERYTHING fell TO THE LEFT SIDE INTO STONES. SHE (RESIDENT #205) TRIED TO CATCH HERSELF WITH LEFT HAND BUT THEN THE WHEELCHAIR ROLLED OVER HER HAND AND ARM CAUSING THE BLUNT OF THE FALL ON HER SHOULDER AND ARM". REVIEW OF THE FACILITY PARADE LIST DATED 2011, REVEALED THE FACILITY HAD A TOTAL OF 12 STAFF MEMBERS (5 CNA'S, 1 NURSE, 1 SOCIAL WORKER, 4 MAINTENANCE STAFF AND 1 OFFICE STAFF) AND 5 VOLUNTEERS AT THE PARADE. THERE WERE A TOTAL OF 14 RESIDENT'S, 3 WHO STAYED ON THE BUS AND 11 WHO WERE IN THE PARADE. THERE WERE 16 STAFF AND VOLUNTEERS TO 11 RESIDENT'S PARTICIPATING IN THE PARADE. REVIEW OF THE FACILITY OCCURRENCE REPORT DATED 6/25/11, STATED, "WILL REDO GUIDELINES FOR VOLUNTEERS AND SAFETY GUIDELINES FOR OUTINGS UP-DATED". THIS REPORT WAS SIGNED BY THE ADMINISTRATOR, DON, THE INFECTION CONTROL/ RESTORATIVE NURSE AND THE RESIDENTS PRIMARY PHYSICIAN. ON 7/20/11, THE SURVEYOR REQUESTED OF THE DON AND ASSISTANT ADMINISTRATOR SEVERAL TIMES FACILITY DOCUMENTATION OF VOLUNTEER GUIDELINES FOR SUPERVISING AND ASSISTING RESIDENTS ON AN OUTING OR IN ACTIVITIES, AND ANY VOLUNTEER ORIENTATION OR TRAINING DONE. DURING AN INTERVIEW DONE ON 7/21/11 AT 11:35 A.M., THE DON REVEALED THE FACILITY HAS NO VOLUNTEER GUIDELINES FOR RESIDENT SAFETY AND STATED THE "VOLUNTEERS ARE TRAINED ONCE A YEAR AT THE VOLUNTEER LUNCH". NO DOCUMENTATION OF VOLUNTEER TRAINING FOR VOLUNTEER #1, OR FOR GUIDELINES FOR ASSISTING RESIDENTS IN ACTIVITIES OR ON OUTINGS FOR VOLUNTEERS WAS GIVEN TO THE SURVEYOR. REVIEW OF THE ACTIVITY AND NURSING POLICY BOOKS REVEALED NO DOCUMENTATION OF GUIDELINES FOR VOLUNTEERS OR RESIDENT SAFETY DURING ACTIVITIES OR OUTINGS. REVIEW OF RESIDENT #205'S FALL assessment dated [DATE] REVEALED SHE WAS AT HIGH RISK FOR FALLS. REVIEW OF THE THERAPY CARE PLANS DATED 5/24/11 AND 6/7/11, REVEALED THE RESIDENT HAD "DECREASED MOBILITY" AND "DECREASED STRENGTH". REVIEW OF THE FALL CARE PLAN DATED 7/29/08 AND UP-DATED ON 6/20/11, REVEALED THE RESIDENT WAS A HIGH RISK FOR FALLS AND NEEDED ASSISTANCE AT TIMES WITH HER WHEELCHAIR FOR LOCOMOTION. RESIDENT #205 PARTICIPATED IN A FACILITY OUTING (A PARADE) ON 6/25/11, THAT WAS SUPERVISED BY 12 STAFF MEMBERS AND 5 VOLUNTEERS. THE RESIDENT WAS IN THE PARADE AND BEING PUSHED IN HER WHEELCHAIR BY VOLUNTEER #2. VOLUNTEER #2'S HAND STARTING CRAMPING, SO SHE ASKED VOLUNTEER #1 ([AGE] years OF AGE) TO PUSH TAKE OVER PUSHING THE RESIDENT. WHILE VOLUNTEER #1 WAS PUSHING THE RESIDENT, THE I/C NURSE ASKED HIM TO PUSH HER CLOSER TO THE EDGE OF THE ROAD, SO SHE COULD GIVE THE CHILDREN CANDY. THE ROAD WAS CROWNED WITH POT HOLES, STONES AND GRAVEL ON BOTH SIDES. WHILE VOLUNTEER #1 WAS PUSHING THE RESIDENT AT THE EDGE OF THE ROAD, HER WHEELCHAIR TIRE WENT INTO A POT HOLE, SHE fell on TO THE GRAVEL AND STONES AND HER WHEELCHAIR fell on TOP OF HER. THE RESIDENT RECEIVED A FRACTURE OF HER LEFT WRIST, A SKIN TEAR, AN ABRASION TO HER FOREHEAD AND INJURIES TO HER LEFT SHOULDER AND HIP AND SHE WAS hospitalized for [REDACTED]. THE FACILITY FAILED TO PROPERLY SUPERVISE RESIDENT #205 AND THE [AGE] year OLD VOLUNTEER (VOLUNTEER #1) AND FAILED TO INSTRUCT VOLUNTEER #1 REGARDING RESIDENT SAFETY AND HIS RESPONSIBILITIES DURING AN OUTING. ( )