Every finding on record at Optalis Health and Rehabilitation of Grand Rapids

This citation pertains to intake #3095854, 3063059, a.d 3073875Based on interview and record review, the facility failed to: 1.) protect the residents' right to be free from resident to resident physical abuse for 2 of 5 residents (Resident #6 and 45) reviewed for abuse, resulting in Resident #6 being pushed to the floor, kicked and experiencing pain from a clavicle fracture during an assault by Resident #45, 2.) provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress for 22 of 99 residents ( R6, R8, R30, R45, R9, R60, R36, R110, R38, R91, R57, R17, R45, R68, R72, R90, R34, R3, R80, R95, R28, and R4) reviewed for neglect resulting in R6 having a delay in the assessment and treatment of a wound causing gangrene and toe amputation, R8 experiencing a delay in care and treatment, poor activities of daily living care and undignified treatment for R30, unnecessary involuntary seclusion for R45, lack of behavior health services for R9, R60 and R36, late medications and/or significant medication errors for R110, R38, R91, R57, R17, R45, R68, R72, R90, R34, R3, R80, R95, and R28, and pressure ulcer treatment that does not meet the standards of practice for R4, and 3.) provide adequate staffing and adequate orientation for all agency to ensure resident highest practical physical, mental and psychosocial needs were met.Findings include: Resident #6 (R6) Review of an admission Record for R6 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Alzheimer's disease (brain disorder that slowly destroys memory, thinking skills and the ability to do simple tasks), and psychotic disorder with delusions (mental health disorder in which a person has fixed, false beliefs). Review of a Minimum Data Set(MDS) assessment for R6 with a reference date of 5/8/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 2/15, which indicated the resident was severely cognitively impaired. Section E revealed R6 displayed physical, verbal and other behavioral symptoms directed toward others during 1-3 days of the 14-day assessment period. Review of a Care Plan for R6 with a reference date of 5/8/26 revealed the following focus/goal/interventions: Focus: Psychotic disorder, wandering.will go into other resident's rooms. Goal: will not leave facility. Interventions: calmly redirect as appropriate. In an interview on 8/12/26 at 3:14pm, Certified Nursing Assistant (CNA) BBB reported she heard R6 yelling profanities and responded to find him banging on the medication room door early in the morning on 7/5/26. CNA BBB reported she approached R6 and provided verbal direction, and he began walking toward his room with her when he stated, I'm going to kill you! to her. CNA BBB reported after R6 said that R45 came up and shoved R6 to the ground and kicked him in the back. In an interview on 8/18/26 at 11:16am, Licensed Practical Nurse (LPN) JJ reported on 7/5/26 at approximately 6:00am she was in the medication room on the memory care unit when she heard a Certified Nursing Assistant (CNA) BBB saying loudly No, no, no (R45's name omitted) so LPN JJ responded to the situation. LPN JJ reported when she entered the hallway, she saw R6 lying on the floor on his left side approximately halfway down the hall. CNA BBB was crouched down tending to R6 and reported that R45 had come out of nowhere, pushed R6 down and kicked him in the back. LPN JJ reported she assessed R6 while he was on the floor, saw swelling in his left arm and called 911. LPN JJ reported she attempted to contact NHA A but left a voicemail and then called DON B and told DON B, We have a resident-to-resident incident, R45 threw R6 down on the ground. LPN JJ reported it was not possible to provide R6 with enough supervision to keep him from going into other residents' room and she knew he often swore at other residents and threatened them. LPN JJ reported some residents were very scared of R6 because of the statements he made to them when he wandered into their rooms unsupervised. LPN JJ reported she told DON B and NHA A the memory care unit did not have enough staff to properly supervise the residents, but nothing was done and she opted to end her employment at the facility because she was not comfortable with the lack of care and supervision provided to the residents. Review of an Radiology Order Report for R6 with a reference date of 7/5/26 from a local hospital revealed Findings: suspected fracture fragments from the undersurface of the distal (situated farther away from the center of the body) left clavicle (slender s-shaped bone that connects the breastbone to the shoulder blade). In an interview on 8/11/26 at 2:08pm, CNA WW reported the facility did not have enough staff to keep R6 from wandering into other residents' rooms. CNA WW reported R6 wandered into R45's room and R45 always became very upset afterward. In an observation and interview on 8/12/26 at 9:24am, Human Resources staff (HR) TT sat in the dining room of the memory care unit with a laptop and office supplies on the table in front of her. When queried, HR TT confirmed she was asked to sit in the dining room today to provide more supervision to the residents. HR TT confirmed she did not have dementia care training. In an interview on 8/12/26 at 9:30am, Activity Assistant (AA) SS' reported she worked full time on the memory care unit and had never seen HR TT providing supervision to the residents prior to this date. AA SS reported she was relieved to see HR TT on the unit because the residents did not receive enough supervision. AA SS confirmed R6 wandered into other residents' room regularly and was prone to swearing and threatening others. In an interview on 8/12/26 at 9:31am, CNA GGG reported she worked on the memory care unit regularly and had never seen HR T providing supervision to the residents prior to this date. During an observation on 8/13/26 at 10:52am, R6 was escorted out of another resident's room by Physician (MD) RRR. MD RRR stated he's been laying down in the ladies' room and needed to get out of there. In an interview on 8/13/26 at 10:53am, MD RRR reported he found R6 laying on an empty bed in a room that was occupied by 2 women. MD RRR reported ladies were all worked up now because of the situation. Resident #45 (R45) Review of an admission Record revealed R45 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: personal history of traumatic brain injury (damage to the brain caused by an external physical force) and generalized anxiety disorder (persistent, excessive and uncontrollable worry about everything things like work, health, money). Review of a Minimum Data Set(MDS) assessment for R45 with a reference date of 6/25/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 13/15, which indicated the resident was cognitively intact. Section E revealed R45 demonstrated no behavior symptoms, including wandering, during the 14-day assessment period. Review of a Care Plan for R45 with a reference date of 8/10/26 revealed the following problem/goal/interventions: Focus: At risk for alterations in mood.related to major depressive disorder.low frustration tolerance for loud peer behavior, uninvited peers entering his personal space.interventions: resident relocated to room on different unit (7/6/26). In an interview on 8/11/26 at 11:38am, R45 reported he was often fearful of the other residents on the locked unit because they frequently wandered into his room unsupervised and he didn't know what they were going to do. R45 reported on the evening of 7/4/26, R6 entered his room and when told to leave, R6 threatened R45. R45 stated he said he was going to kill me. R45 reported no staff were present at the time and he was scared and frustrated by what was said to him. R45 reported early the next morning he was sitting in the dining room drinking coffee when R6 began yelling, calling staff names, and slamming his fists against the medication room door. Certified Nursing Assistant (CNA) BBB approached R6 and began walking down the hall with him when R45 heard R6 say to CNA BBB I'm going to kill you!. R45 stated Something inside me snapped when I heard him (R6) say that statement again and I acted. I pushed him down and then kicked him in the back. In an interview on 8/14/26 at 1:47pm, Nursing Home Administrator (NHA) A reported the facility substantiated R45 physically assaulted R6 on 7/5/26. NHA A reported she was initially told by DON B on 7/5/26 that R45 had pushed R6 and she did not consider pushing to be physical abuse but the following day (7/6/26) when she learned R6 was injured during the altercation, she initiated an investigation. Review of an Investigation Report completed by NHA A revealed On June 5, 2026, (LPN JJ) informed (DON B) regarding an incident involving R45 and R6. Per (LPN JJ) (R45) was observed pushing (R6) onto the floor. Review of an Abuse policy with a reference date of 2/2/26 revealed Policy overview: Residents have the right to be free from abuse.Definitions: Physical abuse includes, but is not limited to hitting, slapping, punching, biting and kicking. Resident #6 (R6) toe amputation Review of an Face Sheet for R6 revealed he was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Alzheimer's disease (brain disorder that slowly destroys memory, thinking skills and the ability to do simple tasks) and diabetes (diseased in which the body cannot properly regulate blood sugar levels). Review of a Minimum Data Set(MDS) assessment for R6 with a reference date of 5/8/26, Section M revealed R6 had no wounds at the time of the assessment. In an interview on 8/12/26 at 2:19pm, Certified Nursing Assistant (CNA) DDD reported she told several nurses R6 had developed a wound on his left 2nd toe in the weeks prior to him being sent to the hospital, but she never saw any treatments begin. CNA DDD reported R6 would say This sh** hurts! referring to his toe when she was assisting him with bathing/cares. CNA DDD reported she continued to tell nurses about the wound and several days later, Licensed Practical Nurse (LPN) XXX came and took pictures of the wound and said she would alert Assistant Director of Nursing (ADON) F, who was responsible for wound care. Review of a History and Physical for R6 from a local emergency department, with a reference date of 8/5/26 at 6:46pm, revealed Toe is malodorous (having a bad, offensive smell) and very obviously gangrenous (affected by a serious medical condition involving death of body tissues due to loss of blood supply or severe bacterial infection). Assessment: Osteomyelitis (bone infection) of second toe on left foot. Pt. (patient) resides at (name of facility omitted) .it appears (cephalexin, brand name omitted) antibiotic was started today. Review of a hospital Inpatient Podiatry Consultation for R6 with a reference date of 8/6/26 revealed History of Present Illness: Patient's wife reported they first noticed a small bloody area to the tip of the toe a couple weeks prior.states that this past Saturday (8/1/26) the toe became increasingly edematous (swollen), discolored and malodorous. Review of an Internal Medicine Hospitalist Progress Note for R6 with a reference date of 8/10/26 revealed s/p (status post, meaning after) toe amputation on 8/7/26, well tolerated. In an interview on 8/12/26 at 7:06am, LPN XXX reported she was notified of the wound on R6's second left toe approximately 1 month ago, shortly before she ended her employment at the facility. LPN XXX confirmed she took pictures of the wound at that time, initiated a wound assessment and notified ADON F. LPN XXX defined the wound as a stage 2 (loss of the outer layer of skin with damage to the second layer). LPN XXX reported treatment for the wound should have begun as soon as the wound was identified but she was unsure when treatment was initiated. In an interview on 8/12/26 at 2:19pm, ADON F reported she was responsible for providing and coordinating wound care services for residents. ADON F confirmed LPN XXX had provided her with pictures of R6's toe wound. ADON F reported she regularly worked as a floor nurse due to staffing issues, and this made it difficult to complete her other responsibilities. ADON F reported she was unsure when she first saw the wound on R6's toe but was certain the wound care provider had not seen it prior to R6 being sent to the hospital on 8/5/26. ADON F reported the wound care nurse practitioner did not assess R6 when she was present in the building to address wound care needs on 8/4/26. ADON F reported she assessed the wound on 8/5/26, noted it smelled bad, was blackened and she was concerned it was gangrenous, so she alerted Nurse Practitioner (NP) C. In an interview on 8/12/26 at 12:18pm, NP C reported she was aware R6 had a wound on his second left toe for approximately a week but did not know the wound was open. NP C reported ADON F came to her with concern about the toe on 8/5/26 so she went and assessed it for the first time that day. NP C reported upon seeing the wound, she instructed staff to send R6 to the hospital immediately due to a suspicion of osteomyelitis and gangrene. NP C reported she called R6's family members to let them know his toe wound had worsened and the family member confirmed the wound had been present for approximately a month. NP C reported per facility protocol, floor nurses were expected to complete weekly skin assessments on each resident, at which time they would identify any new wounds and seek guidance from a provider. When further queried, NP C reported the facility was staffed primarily by agency employed nurses and she was aware the protocol for weekly skin assessments was not being followed. NP C reported she was not always informed when residents developed a wound and as a result, there was a risk for wounds to go untreated and worsen. NP C then stated We (the facility) lost 2 toes (2 residents had toe amputations) that week and confirmed she felt that may have been avoidable if the wounds been identified and treated sooner. Resident #8 (R8) In an interview on 08/11/2026 at 10:46 AM, R8 reported she had a cold since 8/7/26, with a runny nose and cough, and was waiting to have a chest x-ray. R8 reported that she saw a provider on 8/10/26 and was told she would be having a chest x-ray right away. NP C entered the room at 10:55 AM and explained to R8 that she would be prescribing medication for R8's cough as soon as the chest x-ray results came back. Review of R8's Physician Orders revealed, a STAT (immediately) chest x-ray was ordered on 8/10/26 at 1:59 PM. In an interview on 08/12/2026 at 9:22 AM, R8 reported she had not received her chest x-ray yet. R8 reported having a productive (spitting up phlegm) cough, sore throat, tiredness, and her chest felt heavy. R8 reported that she had not had her vital signs checked. Review of R8's Progress Notes related to signs, symptoms, and/or complaints of an upper respiratory issue. There was not any documentation from 8/7/26-8/12/26. Review of R8's Vital Signs Record revealed the only temperature taken was on 8/1/26. The most recent BP (blood pressure), pulse, and oxygen level were from 8/8/26. Review of R8's Progress Note dated 08/12/2026 at 12:12 PM revealed, this nurse contacted (provider) regarding ordered x-ray. states the technician will be out this afternoon to complete. In an interview on 08/12/2026 at 4:22 PM, Unit Manager (UM) D reported that she had looked into R8's chest x-ray the day before because NP C had asked about why it had not been done yet. UM D reported that there had been no vitals signs checked or ordered to monitor R8's signs and symptoms. UM D reported that the nurse should have entered orders for monitoring when R8's signs and symptoms started. In an interview on 08/13/2026 at 11:04 AM, UM D reported she was not sure if R8's chest x-ray results were back yet. After reviewing R8's record UM D reported that the results were available the night before and NP C had ordered a cough medication for R8. In an interview on 8/12/26 at 2:42 PM, ADON/IP F reported that R8 should have had her vital signs monitored from the time of her first reported signs and symptoms of an upper respiratory infection. ADON/IP F reported that her expectation would have been to check vital signs every shift until the symptoms resolved. ADL care Resident #30 Review of a Face Sheet revealed Resident #30 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: a stroke (blood clot in brain that blocks blood flow and oxygen and causes brain damage), dysphagia (difficulty speaking) from the stroke, paralysis (inability to move) on the left side of his body from the stroke and dementia. Review of a Minimum Data Set (MDS) assessment for Resident #30, with a reference date of 8/11/26 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated Resident #30 was severely impaired and never/rarely made decisions. Review of the Functional Status revealed that Resident #30 required assistance of 2 or more helpers for all mobility and hygiene. Review of R30's ADL Care Plan dated 7/19/26 revealed the following interventions: assist with daily hygiene, grooming, dressing, oral care and eating as needed, 2 assist for bed mobility (ability to move from side to side in bed), break ADL tasks into sub-task for easier patient performance, staff to assist with feeding, encourage and/or assist to reposition frequently, prefers bed bath but offer shower as well to promote good hygiene, resident is incontinent (2 assist for toileting). The care plan also indicates R30 is resistive to care, refused ADL care including nails to be trimmed, incontinence care, and shower/bath. The interventions include allowing the resident to make decisions about treatment regimen, negotiate a time for ADLS so that the resident participates in the decision-making process, and if the resident is resistant, reassure resident and try again later. Review of R30's Skin Care Plan dated 8/28/25 revealed, R30 was at risk for alteration in skin integrity and should have an offloading pillow boot applied to his left foot. Review of R30's At Risk for Aspiration Care Plan dated 8/28/25 revealed, R30 should have close supervision due to risk of choking and 1:1 feed assist due to impulsivity. Review of R30's Enabler bar (supportive devices to help move and reposition) Care Plan dated 7/19/26 revealed that the resident used enabler bars on the bed to assist with bed mobility and repositioning. The interventions include the enabler bars are fixed to both sides of the bed at all times. During an observation on 08/11/2026 at 11:47 AM R30 was lying in his bed, with his eyes open and appeared alert, but would not speak to this surveyor. Observed R30's fingernails long (about 1/4 inch past the fingertip) and caked with brown substance on both hands, his hair was overgrown (about 6 inches long) and sticking up all over, and his facial hair was long and unkempt. R30 was observed still in a facility gown that had food residual down the front. In an interview on 08/11/2026 at 3:18 PM, Family Member (FM) BBBB reported that R30 seemed depressed that last time the family saw him; his hair was very long, and it didn't look like they were taking care of him. FM BBBB reported that R30 had always worn his hair very short, and his beard was clean and trimmed. During an observation on 08/12/2026 at 9:28 AM R30 was lying in bed, with the HOB (head of bed) raised to sitting position, and he was leaning far towards the left side of the bed. R30's fingernails were still long and dirty, and he had food/fluids on his face and gown. There was a partially eaten tray of food in front of R30. This surveyor requested assistance for R30 and Certified Nursing Assistant (CNA) N boosted R30 up in bed and took the food tray out of the room. CNA N did not speak to R30 or offer to provide any care to the resident. CNA N reported that she did not know what R30's preferences were for his hair and nails and stated, (R30) refuses care and doesn't like to be touched. In an interview on 08/12/2026 at 9:44 AM, R30 reported that he wanted his fingernails short, and his hair cut close to his head (short) and all the same length. R30 reported that he would like his facial hair trimmed to a goatee (hair only on chin and around mouth). R30 reported that no one ever helped him brush his teeth or wash his face. R30 reported that he would like someone to come in and help him get cleaned up, cut his hair and brush his teeth. R30 reported that he would like to attend church but could not remember the last time he had been up in his chair. In an interview on 08/12/2026 at 12:26 PM, CNA O reported that she was assigned to R30 but had not made it into the room to provide cares yet. CNA O reported that she had arrived at 7:00 AM and was working her way down the hall, room to room doing morning cares. CNA O reported R30 was independent for eating and was not sure who dropped off R30's breakfast. In an observation on 8/12/26 at 12:28 AM in R30's room, CNA O entered the room with clean linens and towels for a bed bath. CNA O said to R30, Are you gonna fight today?, but R30 did not answer. CNA O did not offer R30 a shower. Observed R30's incontinence brief soaked, and the bed linens to be wet and discolored brown underneath R30. CNA O asked R30 when the last time he had gotten changed and R30 replied that he did not know. CNA O struggled to reposition R30 multiple times and turned the resident back and forth using her own strength and the linens underneath the resident. R30 winced in pain. R30 tried to turn onto his side but could not move his body and there were no enabler bars observed on either side of the bed for him to grab per the care plan. After CNA O finished washing R30's body and face, this surveyor asked CNA O if R30's fingernails would be cleaned and trimmed, teeth brushed, and his hair washed. CNA O turned to R30 and stated, .oh are you gonna let me now? CNA O asked R30 if he would like to brush his teeth and R30 replied Yes. CNA O stated, oh I am going to go get stuff to do that right away, so you don't change your mind! CNA O could not find oral care supplies in the room, so she went to the supply closet. CNA O reported that R30 would allow her to trim his beard, but she did not have time that day. CNA O reported that R30 really needed 2 staff to complete cares and make things comfortable for him. CNA O did not offer to put the foam boot on R30's left foot. At 1:20 PM an unknown staff member dropped off R30's lunch tray and CNA O exited the room at that time. CNA O did not attempt to wash R30's hands or assist with eating. CNA O was in the room providing care for approximately 50 minutes. During a subsequent observation on 08/12/2026 at 1:30 PM R30 was sitting up in bed eating and drinking from his lunch tray. The privacy curtain was pulled so that R30 was not visible from the doorway. R30 had red juice on his face and chest. During an observation on 08/13/2026 at 11:39 AM R30 was lying in his bed. R30's fingernails appeared trimmed on his right hand but were still long and dirty. R30's hair and beard were still long and unkempt. R30 did not have the foam boot in place on his left foot, it was sitting in his chair. In an interview on 08/13/2026 at 12:40 PM, Director of Nursing (DON) B reported that staff should encourage residents to have good personal hygiene including cleaning and trimming fingernails and toenails, washing and combing hair, and trimming facial hair. DON B reported that all residents should be offered a haircut when the hair stylist comes in but he was not familiar with R30. DON B reported that staff should know what the resident's preferences are for hair length and it should be listed on the care plan. DON B reported that if a resident refused ADL care, the staff would be expected to encourage and offer the care at another time. DON B agreed that reminding R30 of his past refusals or asking him if he was going to fight were not acceptable interactions. When asked about the enabler bars and foam foot boot, DON B reported that R30's care plan should be an accurate reflection of his needs and if the tasks are not being done, then staff are not following the care plan. During an observation on 08/19/2026 at 2:07 PM R30 was lying in his bed, his hair was still long and unkempt and his beard had not been trimmed. R30 was not wearing the foam boot on his left foot and there were no enabler bars observed on the bed. In an interview on 08/13/2026 at 3:38 PM, Registered Dietician (RD) H reported that R30 required 1:1 assistance for eating beginning on 7/20/26 and had always needed some assistance prior to that. Review of R30's Eating task documented by CNA's for July and August 2026 revealed a mix of independent and assisted eating, several instances not applicable was documented, and 8 refusals documented. Seven of the eight refusals were documented during sleeping hours between 10:00 PM and 3:00 AM. Review of R30's Behavior Monitoring & Interventions task documented by CNA's revealed for the past 30 days R30 had 14 instances documented of no behaviors, and zero instances of physical, verbal or social behaviors. Review of R30's Shower/bath task documented by direct care givers for the past 30 days revealed R30 had received 0 showers, 6 bed baths, and refused twice. Using the reasonable person concept, R30 would not like to be treated inhumanely or without dignity and respect and likely any previous refusals were related to his undignified care and treatment which likely led to continued feelings of low self-esteem and low self-worth and of being unwanted. Seclusion Resident #45 (R45) Review of an admission Record revealed R45 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: personal history of traumatic brain injury (damage to the brain caused by an external physical force) and generalized anxiety disorder (persistent, excessive and uncontrollable worry about everything things like work, health, money). Review of a Minimum Data Set(MDS) assessment for R45 with a reference date of 6/25/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 13/15, which indicated the resident was cognitively intact. Section E revealed R45 demonstrated no behavior symptoms, including wandering, during the 14-day assessment period. Review of a Care Plan for R45 with a reference date of 8/10/26 revealed the following problem/goal/interventions: Focus: At risk for alterations in mood.related to major depressive disorder.low frustration tolerance for loud peer behavior, uninvited peers entering his personal space.interventions: resident relocated to room on different unit (7/6/26). In an interview on 8/11/26 at 10:45am, Activity Staff (AS) SS reported R45 was easily frustrated and upset when residents with severe dementia wandered into his room on the locked unit. AS SS confirmed this happened regularly. AS SS reported R45 spent most of his time in his room. In an interview on 8/11/26 at 2:08pm, CNA WW reported R6 wandered into R45's room regularly on the memory care unit and R45 became very upset when this happened. CNA WW confirmed R45 spent most of his time alone in his room while on the memory care unit. Review of a Incident Report submitted to the state agency on 7/6/26 at 12:23pm, revealed Date/Time Incident Occurred: 7/5/26 6:30am. Summary: Administrator received call from DON (Director of Nursing) on 7/5/26 at 8:30am informing of an incident that occurred at 6:30am. (R45) was observed pushing (Resident #6{R6}) onto the floor. In an interview on 8/11/26 at 11:38am, R45 reported he was kept in the locked memory care units, against his will, for many months until the facility recently moved him to main resident area of the building. R45 reported he was originally admitted to the open unit when he came to the facility in December but was moved after he was near the door and expressed that he wanted to leave. R45 reported that for several months both his legal guardian and his daughter expressed to the facility that they felt it was detrimental to his psychological wellbeing to be on the locked memory care unit, but nothing happened. R45 reported he felt out of place there and quickly realized he was not at all like the other residents. When further queried, R45 reported the first night he was on the unit, a female resident who was severely cognitively impaired, wandered into his room and laid down on top of him while he was in his bed. R45 reported no staff were present and he did not know what to do. R45 reported he was thankful the woman got up on her own and left the room. R45 reported he was often fearful of the other residents on the locked unit because they got right up in my face and he didn't know what they were going to do. R45 reported on the evening of 7/4/26, R6 entered his room and when told to leave, R6 threatened R45. R45 stated he said he was going to kill me. R45 reported no staff were present at the time and he was scared and frustrated by what was said to him. R45 reported early the next morning he was sitting in

This citation pertains to intake #3073875Based on observation, interview and record review, the facility failed to provide sufficient nursing staff for 5 (Resident #6, #45, #57, #30, and #110) of 99 residents who reside in the facility, resulting in a delay in wound assessment and treatment for Resident #6 who developed osteomyelitis and required a toe amputation, unmet care needs (#30), lack of supervision for a resident who wanders (Resident #6), missed or late medication administration (Resident #45 & #57), long call light wait times and unmanaged pain (Resident #110) and a potential for decreased overall well-being of all 99 residents within the facility. Resident #6 Review of an Face Sheet for R6 revealed he was originally admitted to the facility on [DATE] with pertinent diagnosis which included: diabetes (diseased in which the body cannot properly regulate blood sugar levels). Review of a Minimum Data Set(MDS) assessment for R6 with a reference date of 5/8/26, Section M revealed R6 had no wounds at the time of the assessment. Review of a Care Plan for R6 with a reference date of 5/11/26 revealed 1.) Focus: At risk for alteration in skin integrity.Goal: minimize skin breakdown. Interventions: administer treatment per physician orders (initiated 8/11/26), skin evaluation per facility protocol (initiated 8/11/26) 2.) Review of a History and Physical assessment for R6 from a local emergency department, with a reference date of 8/5/26 at 6:46pm, revealed Toe is malodorous (having a bad, offensive smell) and very obviously gangrenous (affected by a serious medical condition involving death of body tissues due to loss of blood supply or severe bacterial infection). Assessment: Osteomyelitis of second toe on left foot. Pt. (patient) resides at (name of facility omitted) .it appears (cephalexin, brand name omitted) antibiotic was started today. Review of a Inpatient Podiatry Consultation (podiatry service provided while in the hospital) for R6 with a reference date of 8/6/26 revealed History of Present Illness: Patient's wife reported they first noticed a small bloody area to the tip of the toe a couple weeks prior.states that this past Saturday (8/1/26) the toe became increasingly edematous (swollen), discolored and malodorous. Review of an Internal Medicine Hospitalist Progress Note for R6 with a reference date of 8/10/26 revealed s/p (status post, meaning after) toe amputation on 8/7/26, well tolerated. In an interview on 8/12/26 at 2:19pm, Certified Nursing Assistant (CNA) DDD reported she told several nurses R6 had developed a wound on his left 2nd toe in the weeks prior to him being sent to the hospital, but she never saw any treatments begin. CNA DDD reported she continued to tell nurses about the wound and several days later, Licensed Practical Nurse (LPN) XXX came and took pictures of the wound and said she would alert Assistant Director of Nursing (ADON) F, who was responsible for wound care. In an interview on 8/12/26 at 7:06am, Licensed Practical Nurse (LPN) XXX reported she was notified of the wound on R6's second left toe approximately 1 month ago. LPN XXX confirmed she took pictures of the wound at that time, initiated a wound assessment and notified ADON F. LPN XXX reported treatment for the wound should have begun as soon as the wound was identified but she was unsure when treatment was initiated. In an interview on 8/12/26 at 2:19pm, Assistant Director of Nursing (ADON) F reported she was responsible for providing and coordinating wound care services for residents. ADON F confirmed LPN XXX had provided her with pictures of R6's toe wound. ADON F reported she regularly worked as a floor nurse due to staffing issues, and this made it difficult to complete her other responsibilities. ADON F reported she was unsure when she first saw the wound on R6's toe. In an interview on 8/12/26 at 12:18pm, Nurse Practitioner (NP) C reported she was aware R6 had a wound on his second left toe for approximately a week but did not know the wound was open. NP C reported ADON F came to her with concern about the toe on 8/5/26 so she went and assessed it for the first time that day. NP C reported upon seeing the wound, she instructed staff to send R6 to the hospital immediately due to a suspension of osteomyelitis and gangrene. NP C reported she called R6's family members to let them know his toe wound had worsened and the family member confirmed the wound had been present for approximately a month. NP C reported per facility protocol, floor nurses were expected to complete weekly skin assessments on each resident, at which time they would identify any new wounds and seek guidance from a provider. When further queried, NP C reported the facility was staffed primarily by agency nurses who often did not communicate new care needs. NP C stated We (the facility) lost 2 toes (2 residents had toe amputations) that week and confirmed she felt that may have been avoidable if the wounds been identified sooner. In an interview on 8/12/26 at 2:57pm, LPN HH reported when she last cared for R6, prior to him going to the hospital, she noticed the wound on his 2nd left toe appeared to be worsening and she thought she had left a note for the provider. LPN HH reported she was covering the 100 and 200 halls that day and it was difficult to ensure she had successfully completed all her responsibilities. In an interview on 8/11/26 at 2:08pm, CNA WW reported the facility did not have enough staff to keep R6 from wandering into other residents' rooms. CNA WW reported R6 wandered into other residents' rooms, and they became very upset with him. In an observation and interview on 8/12/26 at 9:24am, Human Resources staff (HR) TT sat in the dining room of the memory care unit with a laptop and office supplies on the table in front of her. When queried, HR TT confirmed she was asked to sit in the dining room today to provide more supervision to the residents. HR TT confirmed she did not have dementia care training. In an interview on 8/12/26 at 9:30am, Activity Assistant (AA) SS' reported she worked full time on the memory care unit and had never seen HR TT providing supervision to the residents prior to this date. AA SS reported she was relieved to see HR TT on the unit because the residents did not receive enough supervision. AA SS confirmed R6 wandered into other residents' room regularly and was prone to swearing and threatening others. In an interview on 8/18/26 at 11:16am, LPN JJ reported LPN JJ reported it was not possible to provide R6 with enough supervision to keep him from going into other residents' room and she knew he often swore at other residents and threatened them. LPN JJ reported some residents were very scared of R6 because of the statements he made to them when he wandered into their rooms unsupervised. LPN JJ reported she told DON B and NHA A the memory care unit did not have enough staff to properly supervise the residents, but nothing was done and she opted to end her employment at the facility because she was not comfortable with the lack of care and supervision provided to the residents. Resident #30 (R30) Review of a Face Sheet revealed R30 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: a stroke (blood clot in brain that blocks blood flow and oxygen and causes brain damage), dysphagia (difficulty speaking) from the stroke, paralysis (inability to move) on the left side of his body from the stroke and dementia. Review of a Minimum Data Set (MDS) assessment for Resident #30, with a reference date of 8/11/26 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated Resident #30 was severely impaired and never/rarely made decisions. Review of the Functional Status revealed that Resident #30 required assistance of 2 or more helpers for all mobility and hygiene. Review of R30's ADL Care Plan dated 7/19/26 revealed the following interventions: assist with daily hygiene, grooming, dressing, oral care and eating as needed, 2 assist for bed mobility (ability to move from side to side in bed), break ADL tasks into sub-task for easier patient performance, staff to assist with feeding, encourage and/or assist to reposition frequently, prefers bed bath but offer shower as well to promote good hygiene, resident is incontinent (2 assist for toileting). Review of R30's Kardex (care guide for direct care givers) revealed the following interventions related to ADL's: staff to assist with feeding, uses enabler bar on both side of the bed, required 2 staff assistance for bed mobility, ensure placement of off-loading pillow boot to left foot, staff to assist with feeding, check for pocketing and residual food, alternate liquids and solids often, small sips, close supervision: monitor for choking, coughing, and any food or fluid being pocketed in mouth. During an observation on 08/11/2026 at 11:47 AM R30 was lying in his bed, with his eyes open and appeared alert, but would not speak to this surveyor. Observed R30's fingernails long (about 1/4 inch past the fingertip) and caked with brown substance on both hands, his hair was overgrown (about 6 inches long) and sticking up all over, and his facial hair was long and unkempt. R30 was observed still in a facility gown that had food residual down the front. In an interview on 08/12/2026 at 9:44 AM, R30 reported that he wanted his fingernails short, and his hair cut close to his head (short) and all the same length. R30 reported that he would like his facial hair trimmed to a go-tee (hair only on chin and around mouth). R30 reported that no one ever helped him brush his teeth or wash his face. R30 reported that he would like someone to come in and help him get cleaned up, cut his hair and brush his teeth. R30 reported that he would like to attend church but could not remember the last time he had been up in his chair. In an interview on 08/12/2026 at 12:26 PM, CNA O reported that she was assigned to R30 but had not made it into the room to provide cares yet. CNA O reported that she had arrived at 7:00 AM and was working her way down the hall, room to room doing morning cares. In an observation on 8/12/26 at 12:28 AM in R30's room, CNA O entered the room with clean linens and towels for a bed bath. CNA O did not offer R30 a shower. Observed R30's incontinence brief soaked, and the bed linens to be wet and discolored brown underneath R30. CNA O asked R30 when the last time he had gotten changed and R30 replied that he did not know. CNA O struggled to reposition R30 multiple times and turned the resident back and forth using her own strength and the linens underneath the resident. R30 tried to turn onto his side but could not move his body and there were no enabler bars observed on either side of the bed for him to grab. CNA O reported that R30 would allow her to trim his beard, but she did not have time that day. CNA O reported that R30 really needed 2 staff to complete cares and make things for comfortable for him. At 1:20 PM an unknown staff member dropped off R30's lunch tray and CNA O exited the room at that time. CNA O did not attempt to wash R30's hands or assist with eating. CNA O was in the room providing care for approximately 50 minutes. Resident #57 (R57) Review of a Face Sheet revealed R57 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: polyneuropathy (nerve damage that typically causes pain in the hands and feet). During an observation on 08/12/2026 at 12:16 PM in the common area near the nurse's station, R57 was moaning and asking for help. This surveyor observed several ancillary staff consoling R57 for approximately 30 minutes. Review of R57's MAR for August revealed, Tramadol (narcotic pain medication) 50 mg give 1 tablet by mouth two times a day for pain at 7:00 AM and 5:00 PM. Start date 7/27/26. The corresponding medication administration time audit indicated that the 7:00 AM dose was administered late (9:36 AM) on 8/8/26 and (12:46 PM) on 8/12/26. Review of R57's Controlled Substance Log for Tramadol revealed that there were no doses signed out from R57's Tramadol pill card on 8/12/26. In an interview on 8/18/26 at 11:12 AM, LPN J reported that R57 does not refuse pain medication but that it was not uncommon for medications to be administered late due to the amount of time it takes to complete the medication pass on the hall. In an interview on 8/19/26 at 10:45 AM, Unit Manager (UM) D reported that on 8/12/26 a nurse had called in for first shift, therefore UM D worked on the hall but got started late on the morning medication pass. UM D reported that R57 was having pain in his hands that morning. This surveyor asked if UM D had noticed that R57 had not received his pain medication that morning, to which UM D stated, no, but that would explain why he was having so much pain. Resident #45 (R45) Review of a Face Sheet revealed Resident #45 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: Epilepsy (seizure disorder). Review of a Minimum Data Set (MDS) assessment for Resident #45, with a reference date of 3/27/26 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #45 was cognitively intact. Review of R45's Care Plan revealed, the resident had a seizure disorder related to head injury and interventions included: to give seizure medication as ordered by the doctor. In an interview on 8/12/26 at 2:31 PM, Family Member (FM) PPP reported R45 called her the previous weekend (8/8/26) and reported he did not get any of his morning medications until noon, including his seizure medications. FM PPP reported it was very important R45 received his seizure medications as ordered, and she was concerned he was at risk for having a seizure if the physician orders were not followed for those medications. Review of R45's MAR for August 2026 revealed, Clobazam (anti-seizure medication) 20 mg give 1 pill twice daily at 8:00 AM and 5:00 PM. For 8/8/26 the record indicated R45 received 1 dose at 12:13 PM by Agency-RN MM. On 8/12/26 the record indicated R45 received the first dose at 11:09 AM by UM D. Review of R45's MAR for August 2026 revealed, Lacosamide (anti-seizure medication) 100 mg give 1 tablet two times a day for Epilepsy at 8:00 AM and 5:00 PM. For 8/8/26 the record indicated R45 received 1 dose late at 12:09 PM by Agency-RN MM and a second dose at 6:47 PM by RN M. For 8/12/26 the record indicated R45 received 1 dose late at 11:09 AM and a second dose at 4:35 PM both given by UM D. Review of R45's MAR for August 2026 revealed, Lacosamide 50 mg give 1 in the evening in addition to the 100 mg dose to total 150mg at 5:00 PM. For 8/8/26 Agency-RN NN marked medication not given, absent from home with meds. R45 was present in the facility on 8/8/26. Review of R45's MAR for August 2026 revealed, Divalproex Sodium (anti-seizure medication) ER extended-release 500 mg give 3 tablets by mouth twice daily at 8:00 AM and 5:00 PM for seizures. For 8/8/26 the record indicated R45 received 1 dose at 12:09 PM by Agency-RN MM and 5:00 PM dose was marked absent from home with meds by Agency-RN NN. In an interview on 8/18/26 at 10:56 AM, LPN J reported that R45 does not ever refuse his medications and furthermore R45 knew exactly what medications he should be given and when he was supposed to get them. LPN J reported that morning medications were frequently administered late simply due to workload and when that happened, they would adjust the timing of R45 second dose, to avoid giving the medications too close together. Resident #110 (R#110):Review of R#110's face sheet, dated 8/14/26, indicated the resident had been at the facility for approximately one week and had pertinent diagnoses of chronic pain, peripheral vascular disease (PVD; blood circulation disorder that slows/blocks blood flow in blood vessels), and osteoarthritis (joint disease in which the cartilage (cushions joints and prevents bones from rubbing together) at the end of bones wears down over time and can lead to pain).Review of R#110's care plan, dated 8/13/26, indicated that R#110 was at risk for pain and had pain related to osteoarthritis, PVD, chronic pain, and chronic knee pain and included an intervention to monitor/record pain severity on a (1 to 10 scale) (0 meaning no pain and 10 meaning severe pain). During observations and interviews on 08/14/2026 at 8:26 AM, the call light monitor (A screen that showed where call lights were turned on/activated at and the time of when the call light was activated) at the nurses' station between the 300s and 400s units showed the call light for R#110's room had been on since 4:43 AM. The surveyor proceeded down to R#110's room, and the call light outside the room in the hallway on the ceiling was lit up and activated. Upon entering R#110's room at 8:28 AM, R#110 reported she wanted her as needed (not scheduled) pain medication and reported no one ever answered her 4:43:59 AM call light to fulfill this request. R#110 reported her pain level was an 11 (on a scale of 0-10; 0 being no pain and 10 being severe pain) and it was isolated to both of her knees. R#110 appeared frustrated and wanted to know how she was supposed to get her as needed medication if staff didn't answer her call light. At 8:29 AM, CNA (Certified Nurse Aide) TTT entered the room to answer the call light and reported she didn't know how long R#110's call light had been on. CNA TTT informed R#110 she would let the nurse know about her pain medication request. CNA TTT reported she just had got to work at 7:00 AM and was the only CNA working the 400s unit (which R#110 resided on) and the 300s unit only had 2 CNAs. CNA TTT reported short staffing happened all the time. CNA TTT reported she was the only CNA on the 400s unit to provide resident care, answer call lights, and pass breakfast trays. CNA TTT stated, No.It is way too much, when asked if there was enough staff to meet resident care needs timely. CNA TTT reported as she understood it the nurses on the units count towards available staff to provide resident cares, but the nurses are often busy passing medications and not able to assist with resident care as much. After CNA TTT left the room, R#110 reported she was recently admitted about a week ago, she appeared upset, and reported she felt hopeless when staff don't answer her call light timely. R#110 stated, I cried through the night last night. At 8:43 AM, Agency Registered Nurse (ARN) W arrived in R#110's room with her as needed pain medication and when she asked R#110 about her pain level, R#110 reported 12. ARN W reported it was herself and 1 CNA working on the 400 unit and she didn't know how long R#110's call light had been on. Review of R#110s' medication administration record (MAR), dated 8/8-8/14/26, indicated she had been reporting pain levels ranging 0-9 (on a scale of 0-10) prior to the morning of 8/14/26. On 8/13/26 her pain levels were taken and was administered her as needed pain medication (hydrocodone (5 milligrams (mg))-acetaminophen (325 mg) oral tablet (opioid pain medication used to treat moderate to severe pain) 5-325 mg, give 1 tablet by mouth every 4 hours as needed for pain, maximum of 6 tablets daily). R#110's pain levels were noted to be at a 4 or 5 on 8/13/26 with the last pain level of 4 assessed at 9:03 PM. During an interview on 08/14/2026 at 9:02 AM, UM D confirmed there was only 1 CNA working the 400s hall and reported they were working on getting someone to come in and work. UM D reported The Coast unit's (300s and 400s units combined) day shift was supposed to be staffed with 5-6 CNAs and confirmed there were only 3 CNAs and 1 CNA on light duty (modified or reduced work duties). UM D reported they had 1 nurse on 300s and 1 on 400s. When asked about R#110's call light being on since 4:43 AM, UM D reported she went in to try and answer R#110's call light request somewhere between 7:30 and 8 AM. UM D reported she did not have keys to the medication cart so she left the call light on and left the call light on and then told ARN W that R#110 was requesting pain medication. UM D confirmed they were short staffed. In an interview on 8/18/26 at 1:57 PM, Agency-RN MM reported that 8/8/26 was the first time he had worked for the facility, the first time he had worked in long-term care, and the first time he had used the electronic health record system that the facility had in place. Agency-RN MM reported his assignment include 35 residents, 2 medication carts and he was given report by another agency nurse who told him to do the best he could. Agency-RN MM reported that he was completely lost. Agency-RN MM reported that he had to go to another unit to find the vitals machine, was trying to prioritize medications, and keep track of the medications that he could not find in the cart, but that residents kept coming up to the cart screaming, demanding medications and saying they were in pain. Agency-RN MM reported that multiple medications were not in the cart, and he did not know where to look for them but had planned to ask another nurse when he was finished passing the medications that he had available in the cart. In an interview on 08/13/2026 at 11:25 AM, Unit Manager (UM) D reported that she started working about 3 months ago but had not been able to complete all her job duties due to having to cover on the floor. UM D reported that she was supposed to review the 24-hour report in the morning and still had not gotten to that. UM D reported that agency nurses are expected to be experienced and only needing to be acclimated with the facility when they arrive. In an interview on 08/13/2026 at 11:03 AM, Registered Nurse (RN)/Regional Clinical Consultant (RCC) E reported that when residents have blood work and x-rays ordered, the results would appear either on the dashboard and/or in the 24-hour report. RN/RCC E reported that the dashboard and 24-hour report was not completed 8/12/26 because UM D and DON B were both working the floor. During an interview on 08/12/2026 at 9:07 AM, on the 400s unit, Registered Nurse (RN) L reported normally the 300 and 400 units would have 3 nurses working, but today only 2 nurses were working the units. RN L reported she spent most of her days passing medications and had less time to spend with the residents/resident care. RN L reported there was not adequate staff to meet resident needs timely. During an observation and interview on 08/12/2026 at 12:32 PM, DON (Director of Nursing) B removed a medication from the medication cart on memory care unit and administered it to an unknown female resident as she sat in the dining area of the unit. DON B reported he was working as the nurse for the unit at the time. DON B reported the nurse from the night shift stayed over to cover part of the shift that morning and he (DON B) was now responsible to provide nursing care for the residents on the unit. DON B reported he worked as a floor nurse several times since being hired a few months ago.During an observation and interview on 08/12/2026 at 9:15 AM, on the 300s unit, Unit Manager (UM) (A Licensed Practical Nurse (LPN)) D reported an agency nurse (contracted nurses) showed up to work but informed the facility that the workload was not doable with the day's staffing and left. UM D was working the medication cart/passing medications and reported she was filling in until she could be replaced. UM D reported the agency nurse was supposed to have started working at 6:30 AM, but left a little after 7:00 AM. UM D confirmed there were a lot of call ins (call off from work) from nursing staff. UM D reported the facility needed nurses so they had to use agency nurses. During an observation and interview on 08/12/2026 at 12:50 PM, UM D was still on the 300s unit passing medications to residents. UM D confirmed no nurse had come in to fill the open nurse assignment for that unit. UM D confirmed she had not been scheduled to work the floor as a nurse, but was the Unit Manager for that shift. UM D confirmed the 300 and 400 unit combined had 2 nurses working. During an interview on 08/12/2026 at 1:05 PM, Director of Nursing (DON) B reported he had temporarily taken over the scheduling role for nursing staff beginning on 8/6/26 until they could find a new scheduler to fill the position. DON B was asked how many nurses were to work the 300/400 unit (The Coast) that day and he reported technically 3 with one nurse in each unit (1 on 300s unit and 1 on 400s unit) and 1 nurse split between the two. When asked to clarify technically, DON B reported 3 nurses is ideal. DON B reported UM D was a charge nurse this day and was working the 300s unit medication cart today after a call in and continued to work the cart at that time as no facility or agency nurses had picked up the assignment. DON B then proceeded to report the expected staffing for The Coast (300/400 combined unit) was 6 CNAs (Certified Nurse Aide) and 2 nurses for day shift and 4 CNAs and 2 nurses for night shift. The Bay (100s unit) was expected to have 1 CNA and 1 nurse for days and nights. The Harbor (200s unit) was expected to have 3 CNAs and 1 nurse for both day and night shifts. DON B reported unit managers were not on the working nurse schedule as the role didn't provide direct patient care and had other duties. DON B reported unless there was a call in, like today (8/12/26), the unit manager would not have been working the floor. Nurse working schedules were reviewed with DON B and DON B confirmed short staffing on the following dates:- 8/7/26, DON B confirmed The Coast unit's day shift had 5 CNAs who worked but were scheduled to have 6. DON B confirmed they were short staffed.- 8/8/26, DON B confirmed The Coast unit's day shift showed 4.5 CNAs who worked but were scheduled to have 6. DON B confirmed they were short staffed.- 8/9/26, DON B confirmed The Coast unit's day shift had 4 CNAs who worked but were scheduled to have 6. DON B confirmed they were short staffed.- 8/12/26, DON B confirmed The Coast unit's day shift had 5 CNAs working but were scheduled to have 6. DON B confirmed they were short staffed. The staffing sheet reviewed for this date indicated 1 CNA called in who was to work 7:00 AM-7:00 PM and that empty CNA slot was not filled. The fifth CNA working was noted to not work a whole shift and worked 7:00AM-3:00 PM. LPN J had been scheduled to work the 300s unit and was the slot UM D filled in for. The schedule noted DON B was scheduled to work The Harbor unit 11:00 AM-3:00 PM and a nurse scheduled to work the unit came and left (did not work). DON B was serving as DON, scheduler, and as a charge nurse on this shift. DON B confirmed staffing had been short and they were working on hiring. In an interview on 8/13/26 at 7:04am, Licensed Practical Nurse (LPN) XXX reported the facility did not have enough staff to adequately supervise residents on the 200 hall who wandered into other residents' rooms. LPN XXX reported she often worked as the floor nurse for both 100 and 200 halls simultaneously. LPN XXX reported the 200 hall was regularly staffed with only 2 nursing assistants after 4:00pm, so when she was off the hall to provide care to a resident on the 100 hall, and 1 nursing assistant provided toileting assistance while the other nursing assistant walked with a resident, there was no other staff to prevent a resident who wandered from going into other residents' rooms. Licensed Practical Nurse (LPN) XXX reported staffing levels were not meeting resident needs, ADON F and DON B frequently worked as floor nurses, providing nursing care for as many as 3 halls at one time. LPN XXX reported resident clinical evaluations were not being done and medications were provided late. LPN XXX reported she and ADON F cared for 90 residents at one time during the previous week. Review of the Daily Schedule revealed multiple days in which the 200 hall was staffed by a nurse who covered 100 and 200 halls and 2 CNAs. During an observation and interview on 08/12/2026 at 12:32 pm, DON B removed a medication from the medication cart on the memory care unit and administered it to an unknown female resident as she sat in the dining area of the unit. When queried, DON B he was working as the floor nurse for this unit. DON B reported the nurse from the night shift stayed over to cover part of the shift this morning and he (DON B) was now responsible to provide nursing care for the residents on this unit. DON B reported he worked as a floor nurse several times since being hired a few months ago. In an interview on 8/12/26 at 2:19pm, ADON/Infection Preventionist F reported she unable to complete all her responsibilities because she had to work as a floor nurse due to low staffing. In an interview on 08/13/26 at 11:03 am, Regional Clinical Consultant (RCC) E, reported agency staff were not completing basic day to day responsibilities for resident care. RCC E confirmed resident care needs were falling through the cracks and not being addressed in a timely manner. In an interview on 8/19/26 at 12:06pm, Assistant [NAME] President of Clinical Operations (AVPCO) V reported the facility was unaware of the need to increase nursing staffing levels until noncompliance issues were identified during this survey. AVPCO

This citation pertains to intake #'s 3063059 and 3073875.Based on interview and record review, the facility failed to prevent significant medication errors in 12 residents (Resident #91, #57, #17, #45, #68, #72, #28, #90, #34, #3, #80, and #95) of 12 residents reviewed for significant medication errors, when licensed staff failed to effectively transcribe physician orders, omitted, and/or administered medications late on multiple occasions, resulting in the potential for the worsening of health conditions of resident's.Findings include: Resident #91 (R91) Review of a Face Sheet revealed Resident #91 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: type 2 diabetes mellitus (when your body can't use insulin properly causing sugar to build up in your blood). Review of R91's Care Plan revealed a diabetic care plan was developed on 8/3/26 (3 days after admission). Review of R91's Medication Error Report dated 8/3/26 at 12:39 PM created by Registered Nurse (RN) E revealed that the resident admitted on [DATE] with discharge orders for Glargine (long-acting insulin) 32 units to be injected once daily, and Lispro (fast-acting insulin) to be injected every 6 hours and also with meals per sliding scale (dose of insulin is determined by current blood sugar level) but the orders were not transcribed, therefore R91 had not received the insulin. Review of R91's hospital discharge orders dated 7/31/26 revealed, a discharge diagnosis of uncontrolled type 2 diabetes mellitus and three orders for insulin as follows: 1). glargine 100 unit/ml (milliliter) inject 32 units nightly with the first dose to be given on 7/31/26 at 10:00 PM. 2). lispro 100 unit/ml inject 6 units every 6 hours with the first dose to be given at 6:00 PM. 3). lispro 100 unit/ml inject every 6 hours per sliding scale with the first dose to be given at 6:00 PM. Review of R91's July 2026 Medication Administration Record (MAR) revealed no orders and/or administration of insulin on 7/31/26. Review of R91's Progress Note dated 8/3/26 at 1:09 PM by RN E revealed, (Nurse Practitioner (NP) C) gave orders entered for 32 units of long-acting glargine SQ (injected into the fat layer) daily, and insulin lispro 6 units SQ, Q (every) 6 hours with sliding scale additionally. Review of R91's August 2026 MAR revealed, R91 received insulin glargine 32 units on 8/1/26 at 8:00 AM. The order was discontinued on that day and reordered with instructions changed to be administered at 9:00 PM daily. The new order was not confirmed until 8/3/26 by RN E, therefore the first dose was not available to be administered until 8/3/26 at 9:00 PM. Director of Nursing (DON) B documented in R91's MAR indicating that the 9:00 PM dose on 8/2/26 was not received and to see progress note; the documentation was time stamped 8/5/26 at 6:29 AM. Review of R91's August 2026 MAR revealed, orders for insulin lispro to be administered every 6 hours per sliding scale (administer 2 units with blood sugar result of 141-180, 4 units for 181-220, 6 units for 221-260, 8 units for 261-300, 10 units for 301-350, 12 units for 351-400) with a start date of 8/3/26 at 6:00 PM. There was a space for the nurses initials and also the blood sugar result. DON B documented in R91's MAR indicating the first dose on 8/3/26 at 6:00 PM was not administered see progress note, and the blood sugar was documented as NA. There was no blood sugar documented elsewhere in R91's record from that time frame and no progress note as to why the insulin was not administered. There was a blood sugar result of 322 entered on 8/3/26 at 3:54 PM by Assistant Director of Nursing (ADON) F. On 8/4/26 at 12:00 PM Licensed Practical Nurse (LPN) S documented a blood sugar of 154 and medication not given due to no insulin required per orders. On 8/6/26 at 6:00 PM, DON B documented the dose was not administered see progress note, the blood sugar was documented as NA, and there was not a blood sugar result elsewhere in the record from that timeframe. On 8/16/26 at 6:00 PM there was no documentation. Review of R91's August 2026 MAR revealed no orders for insulin lispro 6 units every 6 hours. In an interview on 8/19/26 at 9:25 AM, DON B reported that he did not remember documenting anything on R91's MAR. In an interview on 8/19/26 at 11:39 PM, RN E reported that on 8/3/26 it was discovered that R91's insulin orders had not been transcribed correctly and/or confirmed, therefore they were not popping up in the MAR for the nurses to administer. RN E reported that R91 did not have a blood sugar check until 8/3/26. RN E reported that DON B's documentation in R91's MAR did not make sense and confirmed that DON B's documentation in the MAR for the date of service of 8/3/25 was entered on 8/5/26. Resident #57 (R57) Review of a Face Sheet revealed Resident #57 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: polyneuropathy (nerve damage that typically causes pain in the hands and feet). During an observation on 08/12/2026 at 12:16 PM in the common area near the nurse's station, R57 was moaning and asking for help. This surveyor observed several ancillary staff consoling R57 for approximately 30 minutes. Review of R57's MAR for August revealed, Tramadol (narcotic pain medication) 50 mg give 1 tablet by mouth two times a day for pain at 7:00 AM and 5:00 PM. Start date 7/27/26. The corresponding medication administration time audit indicated that the 7:00 AM dose was administered late on the following days: at 9:36 AM on 8/8/26, at 12:46 PM on 8/12/26, at 9:11 AM on 8/14/26, and at 9:21 AM on 8/18/26. The MAR also indicated on 8/12/26, R57 received his 5:00 PM dose at 11:35 PM by RN PP. Review of R57's Controlled Substance Log for Tramadol revealed that there were no doses signed out from R57's Tramadol pill card on 8/12/26. A count of the medication was performed on 8/14/26 and revealed the count was correct. There were 3 doses signed out on 8/11/26, and one of the doses was signed out at 12:46 PM which would correlate with the Tramadol administration time audit for 8/12/26 at 12:46 PM. The log did not account for the dose that was documented on R57's MAR on 8/12/26 at 11:35 PM. In an interview on 8/18/26 at 11:12 AM, LPN J reviewed R57's controlled substance log for Tramadol and compared it to R57's MAR. LPN J confirmed the discrepancy for 8/12/26 and reported that R57 does not refuse pain medication but that it was not uncommon for medications to be administered late due to the amount of time it takes to complete the medication pass on the hall. In an interview on 8/19/26 at 10:45 AM, Unit Manager (UM) D reported that on 8/12/26 R57 was having pain in his hands. This surveyor asked if UM D had noticed that R57 had not received his pain medication that morning, to which UM D stated, no, but that would explain why he was having so much pain. UM D reported that she had not seen R57 complaining of pain prior to 8/12/26. Review of R57's Pain Level Record indicated 10 out of 10 for 8/8/26 and 0 out of 10 for 8/12/26. Resident #17 (R17) Review of a Face Sheet revealed Resident #17 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: chronic pain, type 2 diabetes, vasculitis (swelling and irritation of blood vessels that can cause aches and pains). Review of a Minimum Data Set (MDS) assessment for Resident #17, with a reference date of 7/22/26 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #17 was cognitively intact. Review of R17's Care Plan revealed, at risk for pain related to history of circulatory disease and chronic pain. In an interview and observation on 8/12/26 at 12:12 PM R17 was in the hall and reported that she was upset because she had been waiting all morning for her pain medications. R17 reported that she was supposed to have prednisone (anti-inflammatory medication for pain) early that morning but she just got it; and her Pregabalin (narcotic medication for pain) was given late. In an interview on 8/13/26 at 10:07 AM, R17 reported that she still had not received her prednisone that day and it was supposed to be given by the third shift nurse at 5:00 AM. R17 reported that she was having pain in her back, legs and hips as a result of inconsistent administration of her pain medications. R17 reported that the nurses tell her that it says she already received her pills, that the medications are not in the cart to give and/or just ignore her and refuse to administer her medications. R17 reported that this problem had been ongoing for months. In an interview on 08/13/2026 at 10:29 AM, LPN J reported that R17 never refused her medications but there were times when R17's medications were not in the cart, times when they were in the wrong spot in the cart and times when the medications must be pulled from our back up supply. LPN J reported that R17's prednisone was never in the cart and always had to be pulled from the backup supply, but agency nurses did not have a key to the locked prescription medication cabinet and may not take the time to find someone to get the medication for them. LPN J reported that when medications are not in the cart it takes longer to complete medication pass and the nurse may have to wait until after morning medication pass was finished to figure out why certain medications are not in the cart and/or contact the pharmacy and provider for assistance. LPN J reported that an extensive amount of time had been spent already that day searching for medications that should have been readily available in the medication cart. LPN J reported frustration with morning medication pass taking so long that it runs over into the afternoon medication administration times. In an observation on 8/13/26 at 10:34 AM, LPN J attempted to administered R17's prednisone 20 mg that was due to be given at 5:00 AM, but it was not available in the medication cart. LPN J retrieved prednisone 20 mg from the backup stock and administered the medication to R17. In an interview on 8/18/26 at 11:34 AM, NP C reported that she was aware R17 was not receiving her medications as prescribed the past couple weeks and that there was no explanation for it. NP C reported that R17's medications are necessary to control her pain and the resident frequently complained that medications were given late or missed. NP C confirmed that there was a known issue in June with R17 not receiving her prednisone, but she thought the issue had been dealt with. NP C reporting that she would expect to be notified of any medication that is given late and/or not available, especially pain medication, anti-seizure medication and insulin. Review of R17's MAR for August revealed, Pregabalin (medication used for nerve pain) 200 mg give one capsule two times a day for leg pain at 7:00 AM and 5:00 PM. Start date 1/30/26. The administration time audit indicated that the 7:00 AM dose was administered at 10:57 AM on 8/8/26; and at 10:17 AM on 8/12/26. Review of R17's MAR for August revealed, Prednisone 20 mg tablet give one daily for vasculitis at 5:00 AM. Start date 3/6/26. The medication was checked off as given every day, except the days that R17 was out of the facility. The administration time audit also indicated that the medication was administered on time everyday including 8/12/26, except for 8/13/26 the medication was administered at 10:47 AM by LPN J. Review of R17's MAR for July revealed, Predinsone 20 mg tablet give one daily for vasculitis at 5:00 PM. Start date 3/6/26. The medication was checked off as given every day, except the days that R17 was out of the facility. Review of R17's MAR for June 2026 revealed, Predinsone 20 mg tablet give one daily for vasculitis at 5:00 PM. Start date 3/6/26. The medication was not documented as administered on 7 of 30 days; three of those days (6/2/26, 6/7/26, 6/22/26) there was no documentation and 4 of the days (6/4/26, 6/18/26, 6/20/26, 6/21/26) were documented as see progress note. Review of R17's MAR-Progress Notes related to Predinsone revealed, 6/4/26 progress note indicated reordered; 6/17/26 indicated the medication was pulled from backup and reordered; 6/18/26 indicated on order; 6/20/26 indicated unavailable; and 6/21/26 indicated on order. Review of R17's Pharmacy Packing Slips from June, July and August, to verify that the facility ordered a sufficient supply of R17's Predinsone to be available for administration per physician orders. The packing slip revealed the facility received 10 pills on 6/4/26, 10 pills on 6/19/26 and 10 pills on 7/23/26. On 8/14/26 at 7:55 AM this surveyor requested that Nursing Home Administrator (NHA) A and or RN E provide additional information to explain the lack of Prednisone ordered, but no response was received. Review of R17's Provider Note dated 6/22/26 revealed, (R17) is seen today for follow-up to recheck pain. She accuses the staff of withholding her prednisone, and staff confirm that the prednisone was missing yesterday. Prednisone has been pulled from back up for today's dose, and accusations discussed with administration. Review of R17's Provider Note dated 6/24/26 revealed, (R17) seen today per her request for pain. She is asking for additional pain medications because her prednisone was reportedly not given related to reordering issues. Staff report that the patient does not have charted missed doses, and prednisone was added back as available. The patient reports that she has not had prednisone in several days. Resident #45 (R45) Review of a Face Sheet revealed Resident #45 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: Epilepsy (seizure disorder). Review of a Minimum Data Set (MDS) assessment for Resident #45, with a reference date of 3/27/26 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #45 was cognitively intact. Review of R45's Care Plan revealed, the resident had a seizure disorder related to head injury and interventions included: to give seizure medication as ordered by the doctor. In an interview on 8/12/26 at 2:31 PM, Family Member (FM) PPP reported R45 called her the previous weekend (8/8/26) and reported he did not get any of his morning medications until noon, including his seizure medications. FM PPP reported it was very important R45 received his seizure medications as ordered, and she was concerned he was at risk for having a seizure if the physician orders were not followed for those medications. Clobazam (anti-seizure medication): Review of R45's MAR for August 2026 revealed, Clobazam 20 mg give 1 pill twice daily at 8:00 AM and 5:00 PM. For 8/7/26, DON B marked the 5:00 PM dose as not given see progress note. For 8/8/26 the record indicated R45 received 1 dose at 12:13 PM by Agency-RN MM and the second dose was marked absent from home with meds at 6:47 PM by Agency-RN NN. On 8/12/26 the record indicated R45 received the first dose at 11:09 AM by UM D, and the second dose 5 hours later at 4:36 PM by UM D. The narcotic count sheet was reviewed to verify pill counts were accurate and revealed, 2 doses were signed out on 8/7/26 (neither of which were by DON B), 1 dose was signed out on 8/8/26, and 2 doses were signed out on 8/12/26 (9:00 AM & 5:00 PM). Review of R45's MAR-Progress Note related to Clobazam revealed, R45 refused the medication on 8/8/26 at 6:47 PM. There was no note related to the late administration of Clobazam on 8/12/26. There was no note related to the 8/7/26 5:00 PM dose. Lacosamide 100 mg (anti-seizure medication): Review of R45's MAR for August 2026 revealed, Lacosamide 100 mg give 1 tablet two times a day for Epilepsy at 8:00 AM and 5:00 PM. For 8/7/26, DON B marked the 5:00 PM dose not given see progress note. For 8/8/26 the record indicated R45 received 1 dose late at 12:09 PM by Agency-RN MM and a second dose at 6:47 PM by RN M. For 8/12/26 the record indicated R45 received 1 dose late at 11:09 AM and a second dose at 4:35 PM both given by UM D. The narcotic count sheet was reviewed to verify pill counts were accurate and revealed, 2 doses were signed out on 8/7/26 (neither of which were by DON B), 1 dose on 8/8/26, and 1 dose on 8/12/26. Review of R45's MAR-Progress Note related to Lacosamide 100mg, there was no note from 8/7/26, 8/8/26 or 8/12/26. Lacosamide 50 mg: Review of R45's MAR for August 2026 revealed, Lacosamide 50 mg give 1 in the evening in addition to the 100 mg dose to total 150mg at 5:00 PM. For 8/7/26, DON B marked the 5:00 PM dose as not given see progress note. For 8/8/26 Agency-RN NN marked medication not given, absent from home with meds. Review of R45's MAR-Progress Notes related to Lacosamide 50 mg revealed, no notes on 8/7/26 and for 8/8/26 at 6:50 PM the note indicated R45 refused the medication. Divalproex Sodium (used to treat seizures): Review of R45's MAR for August 2026 revealed, Divalproex Sodium ER extended release 500 mg give 3 tablets by mouth twice daily at 8:00 AM and 5:00 PM for seizures. For 8/7/26, DON B marked the 5:00 PM dose not given see progress note. For 8/8/26 the record indicated R45 received 1 dose at 12:09 PM by Agency-RN MM and 5:00 PM dose was marked absent from home with meds by Agency-RN NN. Review of R45's MAR-Progress Notes related to Divalproex Sodium revealed, no notes from 8/7/26, and R45 refused the medication on 8/8/26 at 6:49 PM. In an interview on 8/18/26 at 10:56 AM, LPN J reported that R45 does not refuse his medications and furthermore R45 knew exactly what medications he should be given and when he was supposed to get them. LPN J reported that morning medications were frequently administered late simply due to workload and when that happened, they would adjust the timing of R45 second dose, to avoid giving the medications too close together. LPN J reported that R45's seizure medications should be given approximately 9 hours apart per physician orders. LPN J reviewed the MAR verses the narcotic sign-out sheets for Lacosamide and Clobazam; LPN J could not explain the discrepancies in documentation and/or why DON B would be documenting in the MAR. In an interview on 8/18/26 at 11:34 AM, NP C reported that she was aware that R45's AM doses of his seizure medications were given late on 8/8/26 and the second dose should have been given much later than scheduled, to ensure the medications were not given too close together. NP C reported that she has no doubt R45 would refuse medications if the nurse tried to administer them too early, adding R45 knows exactly what medications he needs and when he needs them. Review of R45's Vital Sign Record revealed, no vital signs were obtained in August 2026. Review of R45's Progress Notes revealed, no documentation on 8/8/26 of an assessment and/or monitoring related to late and missed seizure medications. In an interview on 8/19/26 at 9:25 AM, DON B reported that he did not remember working with R45 on 8/7/26 and did not know why his initials were on the MAR. Resident #68 (R68) Review of a Face Sheet revealed Resident #68 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: epilepsy. Review of a Minimum Data Set (MDS) assessment for Resident #68, with a reference date of 8/10/26 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #68 was cognitively intact. Review of R68's Care Plan revealed, R68 had a seizure disorder and to give medications as ordered. Review of R68's MAR for August 2026 revealed, Clobazam 20 mg give 2 pills one time at day for epilepsy at 7:00 PM. The medication administration time for 8/12/26 was 11:08 PM by RN PP and subsequent review of the narcotic count sheet indicated that there were no doses pulled on 8/12/26. In an interview on 8/18/26 at 11:04 AM, LPN J reported that Clobazam was R68's only narcotic medication. LPN J reviewed the narcotic count sheet verses the MAR for 8/12/26 and reported that R68 could not have gotten the medication because the count was correct. Review of R68's Vital Signs record revealed, R68's vital signs were assessed and documented only on the following days: 7/14/26, 7/30/26 at 12:34 AM (when R68 was sent to the hospital), 8/7/26 (when R68 returned from the hospital) and then not again until 8/11/26 (when R68 was sent to the hospital again). Review of R68's Change of Condition dated 8/11/26 at 8:19 AM revealed, Respiratory arrest.resident started having difficulty breathing last night. This morning continues.send to ED (emergency department). Resident #72 (R72) Review of a Face Sheet revealed Resident #72 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: seizures. Review of R72's MAR for August 2026 revealed, Lamotrigine (anti-seizure medication) 100 mg pill to be given once a day for seizures at 8:00 PM. On 8/8/26 the medication was administered at 11:25 PM. On 8/14/26, 8/15/26 and 8/16/26 the medication was administered between 10:38 PM and 11:16 PM. Review of R72's MAR-Progress Notes related to Lamotrigine revealed one note on 8/8/26 indicating that the provider had given a verbal order to give the dose. Review of R72's MAR for August 2026 revealed, Levetiracetam (anti-seizure medication) 250 mg pill give 2 pills twice daily at 7:00 AM and 5:00 PM for seizures. On 8/8/26 the 7:00 AM dose was not given and documented as see progress note and the 5:00 PM dose was administered at 11:26 PM. Between 8/8/26 and 8/18/26 the medication was administered greater than 1 hour after the time it was due to be given in 18 of 19 opportunities. Resident #28 (R28) Review of a Face Sheet revealed Resident #28 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: seizures. Review of R28's MAR for August 2026 revealed, Lacosamide 150mg pills give 1 twice a day for seizures at 8:00 AM and 6:00 PM. There were multiple late AM doses found. On 8/8/26 the AM dose was administered at 10:20 AM, on 8/11/26 it was administered at 3:50 PM, and on 8/12/26 it was administered at 11:43 AM. When the MAR was compared to the narcotic count sheet the times did not match. In an interview on 8/18/26 at 1:57 PM, Agency-RN MM reported that 8/8/26 was the first time he had worked for the facility, the first time he had worked in long-term care, and the first time he had used the electronic health record system that the facility had in place. Agency-RN MM reported that he arrived at 6:00 AM that day but could not get into the facility until someone opened the door at 7:00 AM. Agency-RN MM reported his assignment include 35 residents, 2 medication carts and he was given report by another agency nurse who told him to do the best he could. Agency-RN MM reported that he was completely lost. Agency-RN MM reported that he had to go to another unit to find the vitals machine, was trying to prioritize medications, and keep track of the medications that he could not find in the cart, but that residents kept coming up to the cart screaming, demanding medications and saying they were in pain. Agency-RN MM reported that multiple medications were not in the cart, and he did not know where to look for them but had planned to ask another nurse when he was finished passing the medications that he had available in the cart. Agency-RN MM reported that UM D called him in the afternoon and told him not to pass anymore medications and that he needed to count narcotics with another nurse and then leave the building. In an interview on 8/18/26 at 3:12 PM, Agency-RN NN reported she was called in to work on 8/8/26 and arrived at the facility about 11:00 AM. Agency-RN NN reported that when she arrived on 8/8/26, RN M was covering 2 of the 4 halls, Agency-RN QQ was covering 1 hall but was on break and Agency-RN MM was covering 1 hall. Agency-RN NN reported that Agency-RN MM was standing at the medication cart and it was a mess. Agency-RN NN reported that later that day, RN M asked her to help Agency-RN MM because he was struggling to get medications passed. Agency-RN NN attempted to assist with medications but quickly realized the number of residents that had not received their medications was concerning. Agency-RN NN reported that there was a female resident complaining about not getting her insulin and her blood sugar had not been checked, but she noticed that an insulin pen had been left in the resident's room. Agency-RN NN reported after finding the insulin pen, she immediately contacted UM D to report her concerns; she was instructed to count narcotics with Agency-RN MM and then he would be leaving. Agency-RN NN reported that she and RN M worked together to get the medications caught up; she did not do any assessments other than blood sugar checks; and she communicated with the provider for further instructions on medications that required multiple doses a day. In an interview on 8/18/26 at 2:18 PM, UM D reported she received a call on 8/8/26 at 1:30 PM from Agency-RN NN reporting that the MAR's for the hall that Agency-RN MM was working on were all red (meaning the medications had not been administered). UM D reported that she notified NHA A and the on-call provider of the situation. UM D reported that she called Agency-RN MM to get an explanation for the missed medications, and Agency-RN MM reported that it was his first time in the building, he had trouble getting into computer system, and that he had not received any training. UM D reported that she informed the other nurses (Agency-Nurse NN, RN M and Agency-RN QQ) per the on-call providers instructions, to get vital signs on all the residents, administer one a day medication and hold twice daily medications until the next dose was due. UM D reported that the managers met the next week to discuss the issue and since then they have started to put information in the medication cart binder for agency staff related to who to contact with issues and where to find supplies. Regarding the late medications that were administered on 8/12/26, UM D reported a first shift nurse had call in that morning, and UM D took over the hall mid-morning, which resulted in medications being given late. In an interview on 8/18/26 at 2:35 PM, NHA A reported that on 8/8/26 in the afternoon, UM D notified her that the morning medication pass had not been completed by Agency-RN MM. NHA A reported that she instructed UM D to send Agency-RN MM home and to replace the nurse on the floor. NHA A reported UM D had notified the on-call provider and received instructions to hold some medications and to administer some medications. In an interview on 8/18/26 at 11:34, NP C reported on 8/8/26 the on-call provider service was called and notified that all resident's on R57's hall had medications administered late and/or not at all due to staffing issues. NP C reported the most important medications to be administered were ones for pain-relief, insulin and seizures. NP C reported that it was decided to administer all one a day doses but to hold twice daily doses due to not having enough time available between doses. NP C reported that she had met with the managers and administration on 8/10/26 and expressed her concerns about late medication administration. NP C reported that it was also brought to her attention by resident's on 8/12/26 that medications had been administered late again. Resident #90 (R90) Review of an admission Record revealed R90 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: alzheimer's disease (progressive brain disorder that slowly destroys thinking skills), generalized anxiety disorder (chronic, excessive, and hard to control worry about everyday things). Review of a Minimum Data Set(MDS) assessment for R90 with a reference date of 7/21/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 3/15, which indicated the resident was severely cognitively impaired. Review of R90's Care Plan revealed a mood care plan with intervention of administer medications as ordered. Review of R90's Medication Administration Record (MAR) revealed a physician's order Lorazepam (anti-anxiety medication) Oral tablet .5mg (milligrams), Give 1 tablet by mouth two times a day for anxiety. The medication was scheduled to be given at 7am and 7pm. R90's MAR reflected on 8/8/26 the medication was given at 4:22pm and 11:16pm. Noted 2 medication errors in which R90's Lorazepam was given more than hour after the scheduled time twice on 8/8/26. Review of R90's Controlled Drug Receipt/Record/Disposition Form (Narcotic count sheet) for August 2026 revealed R90's Lorazepam was only signed out once on 8/8/26 with a time of 10:45pm. Resident #34 (R34)Review of an admission Record revealed R34 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: bilateral (both) primary osteoarthritis of knee (wearing away of the protective cartilage causing pain and stiffness). Review of a Minimum Data Set(MDS) assessment for R34 with a reference date of 7/24/26, revealed a Brief Interview for [NAME]

Based on observation, interview, and record review the facility failed to 1.) maintain enhanced barrier precautions during wound care for 1 (Resident #4), 2.) ensure hand hygiene and glove use with medication administration including insulin injections for 1 (Resident #1) and Resident #8), and 3.) infection surveillance for 1 (Resident #8) of 20 sampled residents resulting in the potential for the spread of infection, cross contamination, and disease transmission.Findings include: Resident #1 (R1) Review of a Face Sheet revealed Resident #1 was originally admitted to the facility on [DATE]. During an observation on 8/12/26 at 8:19 AM, RN-A K prepared R1's morning medications. One of the medications was Humalog Lispro (insulin given to regulate blood sugar). RN-A K opened the vial of insulin, wiped the top with alcohol and withdrew 2 units into a syringe. RN-A K did not perform hand hygiene prior to administering the injection. RN-A K entered R1's room and administered the insulin injection to R1's left arm without wearing gloves and did not perform hand hygiene prior to exiting the resident's room. In an interview on 08/12/2026 at 8:34 AM, RN-A K reported that she does not wear gloves for insulin injections. Review of the facility policy Insulin Administration dated 2.3.26 revealed, . Aseptic (procedures to prevent contamination of resident and staff) technique is used when preparing and administering all injections .Insulin syringe injection administration procedure: .Perform hand hygiene and don (put on) clean gloves .Dispose of the needle in the sharp's container. Remove gloves and perform hand hygiene . Resident #8 (R8) Review of a Face Sheet revealed Resident #8 was originally admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #8, with a reference date of 6/4/26 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #8 was cognitively intact. In an interview on 08/11/2026 at 10:46 AM, R8 reported she had a cold since 8/7/26, with a runny nose and cough, and was waiting to have a chest x-ray. R8 reported that she saw a provider on 8/10/26 and was told she would be having a chest x-ray right away. NP C entered the room at 10:55 AM and explained to R8 that she would be prescribing medication for R8's cough as soon as the chest x-ray results came back. Review of R8's Physician Orders revealed, a STAT (immediately) chest x-ray was ordered on 8/10/26 at 1:59 PM. In an interview on 08/12/2026 at 9:22 AM, R8 reported she had not received her chest x-ray yet. R8 reported having a productive (spitting up phlegm) cough, sore throat, tiredness, and her chest felt heavy. R8 reported that she had not had her vital signs checked. Review of R8's Progress Notes related to signs, symptoms, and/or complaints of an upper respiratory issue. There was not any documentation from 8/7/26-8/12/26. Review of R8's Vital Signs Record revealed the only temperature taken was on 8/1/26. The most recent BP, pulse, and oxygen levels were from 8/8/26. In an interview on 08/12/2026 at 4:22 PM, Unit Manager (UM) D reported that she had looked into R8's chest x-ray the day before because NP C had asked about why it had not been done yet. UM D reported that there had been no vital signs checked or ordered to monitor R8's signs and symptoms. UM D reported that the nurse should have entered orders for monitoring when R8's signs and symptoms started. In an interview on 8/12/26 at 2:42 PM, ADON/IP F reported that R8 should have had her vital signs monitored from the time of her first reported signs and symptoms of an upper respiratory infection. ADON/IP F reported that her expectation would have been to check vital signs every shift until the symptoms resolved. In an interview on 08/13/2026 at 11:03 AM, RN E (Regional Clinical Consultant) reported when a resident becomes symptomatic with symptoms such as a cough and sore throat the nurse would be expected to assess, monitor, and complete vital signs at least once a shift. RN E reported that normally when testing was ordered, ADON/IP F would follow up and track the results, but she was on vacation. RN E reported that the unit managers and floor nurses would be expected to review the dashboards and to follow the resident when ADON/IP F was not in the facility, but there had been a lot of new and agency nurses therefore the basic day-to-day things are not getting done. RN E reported that the facility had been trying to ensure that the Unit Managers (UM) and Director of Nursing (DON) review the 24-hour report (that would include test results), but on 8/12/26 DON B and UM D were both working on the floor to cover short staffing. Resident #4 (R4) Review of a Face sheet revealed Resident #4 was a male who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: parkinson's disease (a neurodegenerative disease affecting the central nervous system), pressure ulcer stage 3 (full thickness skin injury that extends into the subcutaneous fat but does not expose muscles, tendons, or bone), and dysphagia (inability to swallow). Review of a Minimum Data Set (MDS) assessment for Resident #4, with a reference date of 4/8/26 revealed Section M – Skin Conditions revealed Resident #4 was assessed to have 1 stage 4 pressure ulcer and was at risk for developing pressure ulcers. Review of an Order Summary for R4 revealed on 7/21/26 orders were implemented for enhanced barrier precautions every shift. Review of a Care Plan revealed R4 requires enhanced barrier precautions, staff to wear gown and gloves with high contact care activities, related to wound care. On 8/11/26 at 10:45 am, signage on R4's door to his room indicated staff were to use a gown and gloves for enhanced barrier precautions while providing care. On 8/13/26 at 3:50 pm, Agency Registered Nurse (A-RN) W was observed providing wound care to R4. A-RN W had wound care supplies placed on R4's bed, over the bed table, and in a basin on R4's bed as well. Observed scissors lying on the blanket of R4's bed. A-RN W was not wearing a gown, and no barrier was used for any supplies. A-RN W exited R4's room to gather supplies, and when she returned, she was wearing a gown. In an interview on 8/13/26 at 4:07 pm, A-RN W confirmed she was not wearing a gown when she was observed at 3:50 pm. A-RN W reported she had removed the gown to grab a roll of tape from the medication cart outside of R4's room. No discarded gowns were observed in any trash can of R4's room at the time of the observation. In an interview on 8/13/26 at 4:24 pm, A-RN W reported R4 was in enhanced barrier precautions for wound care and that indicated staff should wear a gown and gloves while providing care to him. Review of a facility policy Enhanced Barrier Precautions with a revised date of 2/6/26 revealed enhanced barrier precautions involved the use of gown and gloves during high contact care activities, including wound care, feeding tubes, and indwelling urinary catheters.

This citation pertains to Intake #3153735Based on observation, interview, and record review, the facility failed to implement care plan interventions for 2 residents (Resident #30 & #29) of 20 residents reviewed for care planning. Findings include: Review of a Face Sheet revealed Resident #30 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: a stroke (blood clot in brain that blocks blood flow and oxygen and causes brain damage), dysphagia (difficulty speaking) from the stroke, paralysis (inability to move) on the left side of his body from the stroke and dementia. Review of a Minimum Data Set (MDS) assessment for Resident #30, with a reference date of 8/11/26 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated Resident #30 was severely impaired and never/rarely made decisions. Review of the Functional Status revealed that Resident #30 required assistance of 2 or more helpers for all mobility and hygiene. Review of R30's ADL Care Plan dated 7/19/26 revealed the following interventions: assist with daily hygiene, grooming, dressing, oral care and eating as needed, 2 assist for bed mobility (ability to move from side to side in bed), break ADL tasks into sub-task for easier patient performance, staff to assist with feeding, encourage and/or assist to reposition frequently, prefers bed bath but offer shower as well to promote good hygiene, resident is incontinent (2 assist for toileting). The care plan also indicates R30 is resistive to care, refuses ADL care including nails to be trimmed, incontinence care, and shower/bath. The interventions include allowing the resident to make decisions about treatment regimen, negotiate a time for ADLS so that the resident participates in the decision-making process, and if the resident is resistant, reassure resident and try again later. Review of R30's Skin Care Plan dated 8/28/25 revealed, R30 was at risk for alteration in skin integrity and should have an offloading pillow boot applied to his left foot. Review of R30's At Risk for Aspiration Care Plan dated 8/28/25 revealed, R30 should have close supervision due to risk of choking and 1:1 feed assist due to impulsivity. Review of R30's Enabler bar (supportive devices to help move and reposition) Care Plan dated 7/19/26 revealed that the resident used enabler bars on the bed to assist with bed mobility and repositioning. The interventions include the enabler bars are fixed to both sides of the bed at all times. Review of R30's Kardex (care guide for direct care givers) revealed the following interventions related to ADL's: staff to assist with feeding, uses enabler bar on both side of the bed, required 2 staff assistance for bed mobility, ensure placement of off-loading pillow boot to left foot, staff to assist with feeding, check for pocketing and residual food, alternate liquids and solids often, small sips, close supervision: monitor for choking, coughing, and any food or fluid being pocketed in mouth. During an observation on 08/12/2026 at 9:28 AM R30 was lying in bed, with the HOB (head of bed) raised to sitting position, and he was leaning far towards the left side of the bed. There were no enabler bars observed on the bed. R30's fingernails were long and dirty, and he had food/fluids on his face and gown. There was a partially eaten tray of food in front of R30. In an interview on 08/12/2026 at 9:44 AM, R30 reported that he wanted his fingernails short, and his hair cut close to his head (short) and all the same length. R30 reported that he would like his facial hair trimmed to a go-tee (hair only on chin and around mouth). R30 reported that no one ever helped him brush his teeth or wash his face. R30 reported that he would like someone to come in and help him get cleaned up, cut his hair and brush his teeth. In an interview on 08/12/2026 at 12:26 PM, CNA O reported that she was assigned to R30 but had not made it into the room to provide cares yet that day. CNA O reported R30 was independent for eating and was not sure who dropped off R30's breakfast. In an observation on 8/12/26 at 12:28 AM in R30's room, CNA O entered the room with clean linens and towels for a bed bath. The first thing CNA O said to R30 was, Are you gonna fight today?, but R30 did not answer. CNA O did not offer R30 a shower. Observed R30's incontinence brief soaked, and the bed linens to be wet and discolored brown underneath R30. CNA O struggled to reposition R30 multiple times and turned the resident back and forth using her own strength and the linens underneath the resident. R30 winced in pain. R30 tried to turn onto his side but could not move his body and there were no enabler bars observed on either side of the bed for him to grab. CNA O reported that R30 really needed 2 staff to complete cares and make things for comfortable for him. CNA O did not offer to put the foam boot on R30's left foot. At 1:20 PM an unknown staff member dropped off R30's lunch tray and CNA O exited the room at that time. CNA O did not attempt to wash R30's hands or assist with eating. During a subsequent observation on 08/12/2026 at 1:30 PM R30 was sitting up in bed eating and drinking from his lunch tray. The privacy curtain was pulled so that R30 was not visible from the doorway. R30 had red juice on his face and chest. R30 was not being assisted or supervised during his meal. During an observation on 08/13/2026 at 11:39 AM R30 was lying in his bed. R30's fingernails appeared trimmed on his right hand but were long and dirty. R30's hair and beard were still long and unkempt. R30 did not have the foam boot in place on his left foot, it was sitting in his chair. R30 did not have enabler bars on his bed. In an interview on 08/13/2026 at 12:40 PM, Director of Nursing (DON) B reported that staff should encourage residents to have good personal hygiene including cleaning and trimming fingernails and toenails, washing and combing hair, and trimming facial hair. DON B reported that staff should know what the resident's preferences are for hair length and it should be listed on the care plan. DON B reported that if a resident refused ADL care, the staff would be expected to encourage and offer the care at another time. When asked about the enabler bars and foam foot boot, DON B reported that R30's care plan should be an accurate reflection of his needs and if the tasks are not being done, then staff are not following the care plan. In an interview on 08/13/2026 at 3:38 PM, Registered Dietician (RD) H reported that R30 required 1:1 assistance for eating beginning on 7/20/26 and had always needed some assistance prior to that. During an observation on 08/19/2026 at 2:07 PM R30 was lying in his bed, his hair was long and unkempt and his beard had not been trimmed. R30 was not wearing the foam boot on his left foot and there were no enabler bars observed on the bed. Review of R30's Dietary Orders revealed, Regular diet, Minced & Moist texture, Mild/Nectar (thickened) consistency, straw okay, meds whole/crushed in puree, divided plate, built-up utensils, 2 handled cup. Check for pocketing/residue, alternate liquids/solids often. 1:1 feed assist given impulsivity . This was an active order since 7/20/2026. Resident #24 (R24) Review of a Face Sheet revealed R24 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: hemiplegia (paralysis on one side of the body), repeated falls and vascular dementia (decline in thinking and memory due to reduced blood flow to the brain). Review of a Minimum Data Set(MDS) assessment for R24 with a reference date of 7/2/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 6/15, which indicated the resident was severely cognitively impaired. Section J revealed R24 had 2 or more falls since his prior assessment.Review of a Care Plan for R24 with a reference date of 6/23/26 revealed a plan for Falls with interventions that included: bedside table to be placed between beds (not to be placed on side of closet), nonskid material (brand name omitted) to be placed above wheelchair cushion, ensure stop sign across doorway, make phone available. During an observation on 8/11/26 at 10:05am, R24 laid on his back in his bed. R24's bedside table was parallel to and against the wall between the head of his bed and his closet. The bedside table contained the residents' television remote, water and cell phone but was not in reach. There was nonskid material on his wheelchair cushion, and no stop sign across his door. During an observation on 8/14/26 at 3:12pm, R24 stood from the edge of his bed and reached toward his bedside table that was parallel to and against the wall between the head of his bed and his closet. R24 reported he wanted to talk to his mother. R24 sat back down on the edge of his bed momentarily then stood again and attempted to reach the cell phone on the bedside table. Nurse was alerted due to concern for R24's safety. R24's wheelchair was parked next to his bed; no nonskid material was present on the wheelchair cushion. No stop sign was across his door. During an observation and interview on 8/18/26 at 10:34am, R24 was in his wheelchair next to his bed, alone, facing the head of his bed. There was no stop sign across his door. His bedside table was parallel to and against the wall between head of his bed and his closet. R24 leaned forward in his wheelchair and reached for a disposable cup on the bedside table but could not reach it. When queried, R24 reported he was trying to reach his water because he was thirsty. Call light activated due to concern for R24's safety. During an observation on 8/18/26 at 10:37am, Certified Nursing Assistant (CNA) DDD responded to R24's call light and assisted him with transferring to his bed, then provided the resident his water. No non-skid material was present on R24's wheelchair cushion. In an interview on 8/18/26 at 10:44am, CNA DDD reported another aide left R29 alone at his bedside and should not have done so because R29 was impulsive (moved self unsafely without awareness of danger) and would try to transfer himself to bed.

This citation pertains to Intake #3063059. Based on observation, interview, and record review, the facility failed to ensure routine medications were ordered, received and administered in 2 residents (Resident #38 & #17) of 20 residents reviewed, resulting in residents not having a sufficient supply of physician ordered medications and a delay in treatment for medical conditions. Findings include:Resident #38 (R38)Review of a Face Sheet revealed R38 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: pulmonary hypertension (a type of high blood pressure that affects the lungs and heart).Review of a Minimum Data Set (MDS) assessment for R38, with a reference date of 8/6/26 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R38 was cognitively intact.Review of R38's Medication Administration Record (MAR) revealed, Sildenafil Citrate (for pulmonary hypertension) 20 mg to be given three times a day at 7:00 AM, 1:00 PM and 7:00 PM. In an interview on 08/12/26 at 8:10 AM, Registered Nurse-Agency (RN-A) K reported that R38 did not receive his Sildenafil Citrate medication that morning because the medication was not in the cart and she did not have access to the backup supply of medications. RN-A K reported that after she finished the rest of the residents, she would find someone to help her look for the medication.In an interview on 08/12/2026 at 10:36 AM, RN-A K reported that Sildenafil Citrate had been reordered from the pharmacy on 8/10/26, and that they were just waiting for it to be delivered. RN-A K reported that she did not know how many doses R38 had missed of the Sildenafil Citrate, and she had not notified the provider of the missed doses. Review of R38's Progress Notes revealed multiple notes entered by nurses between 8/5/26 and 8/13/26 indicating that Sildenafil Citrate was not available to be administered. There were no notes indicating that the provider had been notified.In an interview on 08/13/2026 at 2:14 PM, Nurse Practitioner (NP) C reported that R38 was taking Sildenafil Citrate for pulmonary hypertension, and she was not aware R38 was not getting the medication and/or of any issues getting the medication from the pharmacy, until 8/12/26. NP C reported that had she known, she could have tried to substitute the medication until it was available.Review of R38's MAR revealed R38 had received 30 of 33 doses of Sildenafil Citrate in August; 93 of 93 doses in July; and 15 of 15 doses in June.Review of R38's Pharmacy Delivery Sheets from June, July and August of 2026 revealed the facility only received 183 pills in total, which would be equal to a 20-day supply of the medication. On 8/14/26 at 7:55 AM this surveyor requested additional information to explain the lack of medication received verses the medication that was documented as administered.During an observation and interview on 8/14/26 at 8:20 AM, Director of Nursing (DON) B verified that Sildenafil Citrate was not included in the facility's backup supply of medication.Review of R38's Medication Error report dated 8/14/26 at 8:44 AM by RN E (Regional Clinical Consultant) revealed, a medication variance occurred regarding Sildenafil Citrate 20 mg oral tablets. Ordered doses were omitted on 7/5/26 at 7:00 PM, TID (three times a day) 7:00 AM, 1:00 PM, 7:00 PM on 7/11/26 through 7/13/26, and on 7/14/26 at 7:00 AM. Additionally, a charting discrepancy was noted for the 7/13/26 7:00 PM dose, which was mistakenly signed as administered when the medication was actually unavailable. It was noted that the medication error report indicated the medication variance occurred in July but should have said August.In an interview on 08/13/26 at 12:31 PM, Director of Nursing (DON) B reported that when the nurse cannot find a resident's medication, the unit manager and provider should be informed. DON B reported that he was not aware of any issues with R38's medications. DON B reported that the nurse should call the pharmacy to request immediate delivery of medications when there are none available, but due to agency staff and short staff that was falling through the cracks.Resident #17 (R17)Review of a Face Sheet revealed Resident #17 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: chronic pain, type 2 diabetes, vasculitis (swelling and irritation of blood vessels that can cause aches and pains).Review of a Minimum Data Set (MDS) assessment for Resident #17, with a reference date of 7/22/26 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #17 was cognitively intact. Review of R17's Care Plan revealed, at risk for pain related to history of circulatory (involving the blood vessels) disease and chronic pain. In an interview on 8/12/26 at 12:12 PM R17 was in the hall and reported that she was upset because she had been waiting all morning for her pain medications. R17 reported that she was supposed to have Prednisone (anti-inflammatory medication for pain) early that morning, but she had just gotten it.In an interview on 8/13/26 at 10:07 AM, R17 reported that she still had not received her Prednisone that day and it was supposed to be given by the third shift nurse at 5:00 AM. R17 reported that she was having pain in her back, legs and hips as a result of inconsistent administration of her pain medications. R17 reported that the nurses tell her that the computer says she already received her pills, that the medications are not in the cart to give and/or just ignore her and refuse to administer her medications. R17 reported that this problem had been ongoing for months.In an interview on 08/13/2026 at 10:29 AM, LPN J reported that R17 never refused her medications but there were times when R17's medications were not in the cart, times when they were in the wrong spot in the cart and times when the medications must be pulled from our back up supply. LPN J reported that R17's Prednisone was never in the cart and always had to be pulled from the backup supply, but agency nurses did not have a key to the locked prescription medication cabinet and may not take the time to find someone to get the medication for them. LPN J reported that when medications are not in the cart it takes longer to complete medication pass and the nurse may have to wait until after morning medication pass was finished to figure out why certain medications are not in the cart and/or contact the pharmacy and provider for assistance. LPN J reported that an extensive amount of time had been spent already that day searching for medications that should have been readily available in the medication cart. LPN J reported frustration with morning medication pass taking so long that it runs over into the afternoon medication administration times.In an observation on 8/13/26 at 10:34 AM, LPN J attempted to administered R17's prednisone but it was not available in the medication cart. LPN J retrieved prednisone 20 mg from the backup stock and administered the medication to R17.In an interview on 8/18/26 at 11:34 AM, NP C reported R17's medications are necessary to control her pain and the resident frequently complained that medications were given late or missed. NP C confirmed that there was a known issue in June with R17 not receiving her Prednisone, but she thought the issue had been dealt with. NP C reporting that she would expect to be notified of any medication that is given late and/or not available, especially pain medication, anti-seizure medication and insulin.Review of R17's MAR for August revealed, Prednisone 20 mg tablet give one daily for vasculitis at 5:00 AM. Start date 3/6/26. The medication was checked off as given every day, except the days that R17 was out of the facility. The administration time audit also indicated that the medication was administered on time everyday including 8/12/26, except for 8/13/26 the medication was administered at 10:47 AM by LPN J.Review of R17's MAR for July revealed, Predinsone 20 mg tablet give one daily for vasculitis at 5:00 PM. Start date 3/6/26. The medication was checked off as given every day, except the days that R17 was out of the facility.Review of R17's MAR for June 2026 revealed, Predinsone 20 mg tablet give one daily for vasculitis at 5:00 PM. Start date 3/6/26. The medication was not documented as administered on 7 of 30 days; three of those days (6/2/26, 6/7/26, 6/22/26) there was no documentation and 4 of the days (6/4/26, 6/18/26, 6/20/26, 6/21/26) were documented as see progress note. Review of R17's MAR-Progress Notes related to Predinsone revealed, 6/4/26 progress note indicated reordered; 6/17/26 indicated the medication was pulled from backup and reordered; 6/18/26 indicated on order; 6/20/26 indicated unavailable; and 6/21/26 indicated on order.Review of R17's Pharmacy Packing Slips from June, July and August, to verify that the facility ordered a sufficient supply of R17's Predinsone to be available for administration per physician orders. The packing slip revealed the facility received 10 pills on 6/4/26, 10 pills on 6/19/26 and 10 pills on 7/23/26, which was a 30-day supply. On 8/14/26 at 7:55 AM this surveyor requested that Nursing Home Administrator (NHA) A and or RN E provide additional information to explain the lack of Prednisone ordered, but no response was received.Review of R17's Provider Note dated 6/22/26 revealed, (R17) is seen today for follow-up to recheck pain. She accuses the staff of withholding her prednisone, and staff confirm that the prednisone was missing yesterday. Prednisone has been pulled from back up for today's dose, and accusations discussed with administration.Review of R17's Provider Note dated 6/24/26 revealed, (R17) seen today per her request for pain. She is asking for additional pain medications because her prednisone was reportedly not given related to reordering issues. Staff report that the patient does not have charted missed doses, and prednisone was added back as available. The patient reports that she has not had prednisone in several days.Review of a facility policy Medication Administration dated 2.3.26 revealed, .If a pharmacy supplied medication is not available, refer to the pharmacy policy and procedures related to emergency pharmacy delivery and emergency supply kit usage .

This citation pertains to intake #3095854Based on interview, and record review, the facility failed to report an incident of resident-to-resident physical abuse to the State Agency in a timely manner for 2 (Resident #6, Resident #45) of 5 residents reviewed for abuse and reporting.Findings include:Resident #6 (R6)Review of an admission Record for R6 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Alzheimer's disease (brain disorder that slowly destroys memory, thinking skills and the ability to do simple tasks), and psychotic disorder with delusions (mental health disorder in which a person has fixed, false beliefs).Review of a Minimum Data Set(MDS) assessment for R6 with a reference date of 5/8/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 2/15, which indicated the resident was severely cognitively impaired. Section E revealed R6 displayed physical, verbal and other behavioral symptoms directed toward others during 1-3 days of the 14-day assessment period.In an interview on 8/12/26 at 3:14pm, Certified Nursing Assistant (CNA) BBB reported she heard R6 yelling profanities and responded to find him banging on the medication room door early in the morning on 7/5/26. CNA BBB reported she approached R6 and provided verbal direction, and he began walking toward his room with her when he stated, I'm going to kill you! to her. CNA BBB reported after R6 said that R45 came up and shoved R6 to the ground and kicked him in the back.In an interview on 8/18/26 at 11:16am, Licensed Practical Nurse (LPN) JJ reported on 7/5/26 at approximately 6:00am she was in the medication room on the memory care unit when she heard a Certified Nursing Assistant (CNA) BBB saying loudly No, no, no (R45's name omitted) so LPN JJ responded to the situation. LPN JJ reported when she entered the hallway, she saw R6 lying on the floor on his left side approximately halfway down the hall. CNA BBB was crouched down tending to R6 and reported that R45 had come out of nowhere, pushed R6 down and kicked him in the back. LPN JJ reported she assessed R6 while he was on the floor, saw swelling in his left arm and called 911. LPN JJ reported she attempted to contact NHA A but left a voicemail and then called DON B and told DON B, We have a resident-to-resident incident, R45 threw R6 down on the ground. LPN JJ reported she did not initiate a Incident Report because NHA A preferred to complete those herself. When queried regarding what time she called NHA A and DON B, LPN JJ reported she did not know exactly but it was before R6 emergency personnel arrived to transport him to the hospital.Review of an Radiology Order Report for R6 with a reference date of 7/5/26 from a local hospital revealed Findings: suspected fracture fragments from the undersurface of the distal (situated farther away from the center of the body) left clavicle (slender s-shaped bone that connects the breastbone to the shoulder blade) .printed by (NHA A) at 7/6/26 8:49am.Review of an Incident Report completed by NHA A with a reference date of 7/6/26 at 12:23pm revealed Administrator received call from DON on 7/5/26 at 8:30am informing her of an incident that occurred at 6:30am. Resident (R45's name omitted) walked towards (R6's name omitted) and pushed resident down. In an interview on 8/14/26 at 1:47pm, Nursing Home Administrator (NHA) A reported the facility substantiated R45 physically assaulted R6 on 7/5/26. NHA A reported she was initially told by DON B on 7/5/26 at 8:30am that R45 had pushed R6 and she did not consider pushing to be physical abuse. NHA A confirmed there was a delay in reporting the resident-to-resident physical altercation to the State Agency.Review of an Abuse policy with a reference date of 2.2.26 revealed Initial Reporting: The facility will ensure that all allegations involving abuse are reported immediately to .the State Survey Agency not later than two hours after the allegation.

This citation pertains to intake #3095854Based on interview and record review, the facility failed to implement the abuse policy for reporting and response to allegations of abuse and prevent the potential for further allegations of abuse to be unreported in 1 of 5 residents (Resident #6) reviewed for abuse.Findings include: Resident #6 (R6)Review of an admission Record for R6 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Alzheimer's disease (brain disorder that slowly destroys memory, thinking skills and the ability to do simple tasks), and psychotic disorder with delusions (mental health disorder in which a person has fixed, false beliefs).Review of a Minimum Data Set(MDS) assessment for R6 with a reference date of 5/8/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 2/15, which indicated the resident was severely cognitively impaired. Section E revealed R6 displayed physical, verbal and other behavioral symptoms directed toward others during 1-3 days of the 14-day assessment period.In an interview on 8/12/26 at 3:14pm, Certified Nursing Assistant (CNA) BBB reported she heard R6 yelling profanities and responded to find him banging on the medication room door early in the morning on 7/5/26. CNA BBB reported she approached R6 and provided verbal direction, and he began walking toward his room with her when he stated, I'm going to kill you! to her. CNA BBB reported after R6 said that R45 came up and shoved R6 to the ground and kicked him in the back.In an interview on 8/18/26 at 11:16am, Licensed Practical Nurse (LPN) JJ reported on 7/5/26 at approximately 6:00am she was in the medication room on the memory care unit when she heard a Certified Nursing Assistant (CNA) BBB saying loudly No, no, no (R45's name omitted) so LPN JJ responded to the situation. LPN JJ reported when she entered the hallway, she saw R6 lying on the floor on his left side approximately halfway down the hall. CNA BBB was crouched down tending to R6 and reported that R45 had come out of nowhere, pushed R6 down and kicked him in the back. LPN JJ reported she assessed R6 while he was on the floor, saw swelling in his left arm and called 911. LPN JJ reported she attempted to contact NHA A but left a voicemail and then called DON B and told DON B, We have a resident-to-resident incident, R45 threw R6 down on the ground. LPN JJ reported she did not initiate a Incident Report because NHA A preferred to complete those herself.Review of an Radiology Order Report for R6 with a reference date of 7/5/26 from a local hospital revealed Findings: suspected fracture fragments from the undersurface of the distal (situated farther away from the center of the body) left clavicle (slender s-shaped bone that connects the breastbone to the shoulder blade) .printed by (NHA A) at 7/6/26 8:49am.Review of an Incident Report completed by NHA A with a reference date of 7/6/26 at 12:23pm revealed Administrator received call from DON on 7/5/26 at 8:30am informing her of an incident that occurred at 6:30am. Resident (R45's name omitted) walked towards (R6's name omitted) and pushed resident down. Noted the incident was not reported to NHA A, the abuse coordinator, until 2 hours after the incident.In an interview on 8/14/26 at 1:47pm, Nursing Home Administrator (NHA) A reported the facility substantiated R45 physically assaulted R6 on 7/5/26. NHA A reported she was initially told by DON B on 7/5/26 at 8:30am that R45 had pushed R6 and she did not consider pushing to be physical abuse but the following day (7/6/26) when she learned R6 was injured during the altercation, she initiated an investigation. Review of an Abuse policy with a reference date of 2.2.26 revealed The facility will develop and implement policies that include: Initial Reporting: allegations involving abuse are reported immediately to the Administrator.

This citation pertains to intakes #3153735 and 3095854.Based on observation, interview, and record review, the facility failed to: 1.) ensure a resident's power/electric wheelchair was charged in a designated safe area, and 2.) provide adequate supervision to prevent wandering in 2 (Resident #18 and Resident #6) of 5 residents reviewed for accidents/hazards. Findings include: Resident #18(R18) Review of the admission Record revealed R18 was a [AGE] year-old woman admitted to the facility on [DATE] with pertinent diagnoses including muscle weakness and fibromyalgia (chronic disorder of unknown etiology characterized by pain, stiffness, and tenderness in the muscles of neck, shoulders, back, hips, arms, and legs). R18 relied on an electric wheelchair to move throughout the facility. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R18 was cognitively intact. On 8/11/2026 at 9:59 AM, R18 was observed lying in bed and her power/electric wheelchair was in her room. A charger box was plugged into the outlet by the television, and the other end had a cord attached to her electric wheelchair for charging. During an interview on 8/11/2026 at 10:03 AM, R18 stated that she liked having her electric wheelchair in her room and being able to charge it there instead of down the hall. R18 reported that she didn't want staff to charge it in the designated area because if she wanted to go somewhere she didn't want to wait for staff to get it, so they let her charge it in her room. R18 stated that she knew the risks of a fire from charging it in her room so she was careful. During an interview on 8/12/2026 at 2:20 PM, Director of Therapy (DOT) I stated that there was a separate room to charge electric wheelchairs and they should not be charged in a resident room due to safety concerns. DOT I said that she would talk to R18 about not charging her wheelchair in her room and making sure it was done in the designated area. During an interview on 8/12/2026 at 2:42 PM, Nursing Home Administrator (NHA) A stated that electric wheelchairs should be charged in the designated area which was the spa room. NHA A stated that R18 had been educated by multiple management staff on the risk of fire and gas if she charged her electric wheelchair in her room and staff was aware that she couldn't charge her it in her room. This surveyor asked for any information related to R18 education and documentation regarding her non-compliance and NHA A stated she would provide any information she had. During an interview on 8/13/2026 at 9:48 AM, Maintenance Manager (MM) Y stated that he thought an electric power wheelchair could charge in a resident room but he wasn't aware of the regulations since he just started the position at the facility a few weeks before. During an interview on 8/13/2026 at 9:52 AM, Maintenance Director (MD) OOO reported that MM Y was new to the facility and was learning the regulations and stated that electric wheelchairs should be charged in the designated spa room located at the front of the facility. When asked if he knew why electric wheelchairs couldn't be charged in resident rooms, MD OOO stated that a gas can be expelled out of the battery in the room which was harmful to people and was a fire hazard, MD OOO reported that he would educate MM Y since he was not aware of the regulations. During an interview on 8/13/2026 at 10:02 AM, MD OOO reported that he spoke to the nurse on the hall and staff and R18 would not be charging her wheelchair in her room anymore. MD OOO stated he would tell Director of Nursing (DON) B to educate staff. During an interview on 8/13/2026 at 10:42 PM, Resident #17 (R17) who was R18's roommate stated that DON B took R18's battery for her electric wheelchair out of her room and said he would return it after the state surveyors left at the end of the day. During an observation on 8/13/2026 at 11:19 AM, DON B was seen talking to R18 in the hallway. R18 asked when she could get the battery back for her electric wheelchair in her room so she could charge her wheelchair and DON B stated that he would return her battery to her room after the surveyors left the facility. During an interview on 8/14/2026 at 9:03 AM, R17 stated that DON B went into her room after this surveyor left on 8/13/2026 and returned R18's battery for her wheelchair so she could charge it in her room. R17 also reported that DON B took the battery out that morning at 6am before the state surveyors returned to the facility. During an interview on 8/14/2026 at 9:22 AM, R18 also stated that DON B' gave her the battery for her wheelchair back the previous night and then took it out that morning. During an interview on 8/14/2026 at 10:06 AM, DON B reported that management constantly reminded R18 that her wheelchair needed to charge in the spa, and he stated that he would never give her the battery for her to charge her wheelchair in her room so other staff must have taken it to her. Facility did not have an Electric Wheelchair Charging Policy, and no additional information was received prior to exit from the facility. Resident #6 (R6) Review of an admission Record for R6 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: Alzheimer's disease (brain disorder that slowly destroys memory, thinking skills and the ability to do simple tasks), and psychotic disorder with delusions (mental health disorder in which a person has fixed, false beliefs). Review of a Minimum Data Set(MDS) assessment for R6 with a reference date of 5/8/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 2/15, which indicated the resident was severely cognitively impaired. Section E revealed R6 displayed physical, verbal and other behavioral symptoms directed toward others during 1-3 days of the 14-day assessment period. Section E also revealed R6 wandered during 4-6 days of the same assessment period. Review of a Care Plan for R6 with a reference date of 5/8/26 revealed the following focus/goal/interventions: Focus: Psychotic disorder, wandering.will go into other resident's rooms. Goal: will not leave facility. Interventions: calmly redirect as appropriate. In an interview on 8/11/26 at 2:08pm, CNA WW reported the facility did not have enough staff to keep R6 from wandering into other residents' rooms. CNA WW reported R6 wandered into other residents' rooms and those residents would get upset. In an observation and interview on 8/12/26 at 9:24am, Human Resources staff (HR) TT sat in the dining room of the memory care unit with a laptop and office supplies on the table in front of her. When queried, HR TT confirmed she was asked to sit in the dining room today to provide more supervision to the residents. HR TT confirmed she did not have dementia care training. In an interview on 8/12/26 at 9:30am, Activity Assistant (AA) SS' reported she worked full time on the memory care unit and had never seen HR TT providing supervision to the residents prior to this date. AA SS reported she was relieved to see HR TT on the unit because the residents did not receive enough supervision. AA SS confirmed R6 wandered into other residents' room regularly and was prone to swearing and threatening others. In an interview on 8/12/26 at 9:31am, CNA GGG reported she worked on the memory care unit regularly and had never seen HR T providing supervision to the residents prior to this date. In an interview on 8/13/26 at 7:04am, Licensed Practical Nurse (LPN) XXX reported the facility did not have enough staff to adequately supervise residents on the 200 hall who wandered into other residents' rooms. LPN XXX reported she often worked as the floor nurse for both 100 and 200 halls simultaneously. LPN XXX reported the 200 hall was regularly staffed with only 2 nursing assistants after 4:00pm, so when she was off the hall to provide care to a resident on the 100 hall, and 1 nursing assistant provided toileting assistance while the other nursing assistant walked with a resident, there was no other staff to prevent a resident who wandered from going into other residents' rooms. Review of the Daily Schedule revealed multiple days in which the 200 hall was staffed by a nurse who covered 100 and 200 halls and 2 CNAs. During an observation on 8/13/26 at 10:52am, R6 was escorted out of another resident's room by Physician (MD) RRR. MD RRR stated he's been laying down in the ladies' room and needed to get out of there. In an interview on 8/13/26 at 10:53am, MD RRR reported he found R6 laying on someone else's bed in a room that was occupied by 2 women. MD RRR reported ladies were all worked up now because of the situation. Review of the Daily Schedule for 8/13/26 revealed the 200-hall had 2 CNAs scheduled from 7am-11am. In an interview on 8/18/26 at 11:16am, LPN JJ reported R6. LPN JJ reported R6 was often found in his former room which was now occupied by 2 females. LPN JJ reported before staff were able to guide him out of the room, R6 often called the female residents vulgar names and both residents reported they were afraid of him.

Based on observation, interview, and record review, the facility failed to follow professional standards of nursing for medication administration for 3 residents (Resident #38, #1 & #30) of 6 residents reviewed for medication administration, resulting in medication administered without verifying orders, medications documented prior to being administered, and lack of documentation and physician notification related to omitted medications. Findings include:Resident #38 (R38)Review of a Face Sheet revealed Resident #38 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: pulmonary hypertension (a type of high blood pressure that affects the lungs and heart).In an observation on 08/12/2026 at 8:06 AM, Registered Nurse-Agency (RN-A) K prepared R38's morning medications, signed the medications off in the Medication Administration Record (MAR) and then proceeded to administer the medications to R38.Review of R38's MAR revealed, Pantoprazole 40 mg to be given once daily at 7:00 AM for reflux (when food or drink comes back up from the stomach into the throat); and Sildenafil Citrate (for pulmonary hypertension) 20 mg to be given three times a day at 7:00 AM, 1:00 PM and 7:00 PM. In an interview on 08/12/26 at 8:10 AM, RN-A K reported that R38 did not received Pantoprazole and/or Sildenafil Citrate because the medications were not in the cart and she did not have access to the backup supply of medications. RN-A K reported that after she finished the rest of the residents, she would find someone to help her look the medication.In an interview on 08/12/2026 at 10:36 AM, RN-A K reported that she had someone pull R38's Pantoprazole from the locked backup supply and she administered the medication at about 9:00 AM. RN-A K reported that she did not know who pulled the medication, but she assumed they had gotten it from the locked backup supply. RN-A K reported that Sildenafil Citrate had been reordered from the pharmacy on 8/10/26, and that they were just waiting for it to be delivered. RN-A K reported that she did not know how many doses R38 had missed of the Sildenafil Citrate, and she had not notified the provider of the missed doses.Resident #1 (R1)Review of a Face Sheet revealed Resident #1 was originally admitted to the facility on [DATE].During an observation on 8/12/26 at 8:19 AM, RN-A K prepared R1's morning medications. RN-A K prepped 4 medications and signed them off as administered on the MAR. One of the medications was insulin lispro (fast-acting insulin given to regulate blood sugar). RN-A K opened the vial, wiped the top with alcohol and withdrew 2 units into a syringe. While holding the uncapped syringe in one hand, RN-A K poured water into a cup, grabbed an inhaler, a cup full of R1's other oral medications, walked to R1's room, and entered without knocking. RN-A K did not perform hand hygiene prior to administering medications. RN-A K administered the insulin injection to R1's left arm without wearing gloves.In an interview on 08/12/2026 at 8:34 AM, RN-A K reported that she does not wear gloves for insulin injections and always signed medications off as she was preparing the medications; if the resident refused, she would have to go back and remove the medication from the record. RN-A K reported that she was not familiar with the policies and procedures at the facility.Review of R1's MAR revealed an order for Calcium-Cholecalciferol tablet to be given daily at 7:00 AM for hypocalcemia (low calcium level). The medication was omitted during the 8/12/26 medication administration that was observed but was signed off as administered on the MAR.In a subsequent interview on 08/12/2026 at 11:51 AM, RN-A K reported that R1 did not receive his Calcium-Cholecalciferol tablet because it was not in the medication cart and she did not know where else to look. RN-A K reported she accidently documented that she had administered the medication.Resident #30 R30Review of R30's MAR revealed orders for Methocarbemol (muscle relaxer) 750 mg tablet give three times a day for pain at 9:00 AM, 1:00 PM and 9:00 PM, and Acetaminophen (pain reliever) 325 mg tablet give 2 tablets three times a day for pain at 9:00 AM, 1:00 PM, and 9:00 PM. On 8/12/26 at 1:24 PM the record indicated that the 9:00 AM doses of the medication had already been administered by Unit Manager (UM) D.During an observation on 08/12/2026 at 1:26 PM, UM D was preparing medications for R30. The computer was not open to R30's orders. UM D placed Acetaminophen 325 mg 2 pills and Methocarbemol 750 mg 1 pill in a cup, crushed the pills and administered the medication to R30. UM D reported that R30 had refused the medication earlier that day and she was just getting caught up on medication pass. UM D reported that she had marked the medications as administered prior to administering the medications and should not have done that.Review of Fundamentals of Nursing ([NAME] and [NAME]) revealed, Professional standards such as Nursing: Scope and Standards of Practice (ANA, 2010) .apply to the activity of medication administration. To prevent medication errors, follow the six rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these six rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 39307-39313). Elsevier Health Sciences. Kindle Edition.Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, After administering a medication, immediately document which medication was given on a patient's MAR per agency policy to verify that it was given as ordered .Never document that you have given a medication until you have actually given it. Document the name of the medication, the dose, the time of administration, and the route on the MAR. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 609-610). Elsevier Health Sciences. Kindle Edition.Review of the facility policy Medication Administration dated 2.3.26 revealed, .If an over-the-counter medication is not available, check the medication storage area to replenish the stock and administer the medication. If a pharmacy supplied medication is not available, refer to the pharmacy policy and procedures related to emergency pharmacy delivery and emergency supply kit usage .Perform hand hygiene. Open MAR (Medication Administration Record) to resident record and review physician medication order against medication label. Read transcribed physician order on the MAR: resident name, medication name, dosage, route, and interval ordered. Remove medication from cart. Compare MAR with medication label for accuracy . Prepare medications for administration. Administer medication: Knock on door and request entrance. Introduce self, explain medication administration need, and provide privacy . Administer medication . Sign MAR after administered .Document refusal on MAR. Notify physician of refusal as clinically indicated. Medications administered are documented following administration. Administration of PRN medications include the justification and response to administration. The licensed nurse is responsible for validating documentation is completed for any medication administered during the shift.

This citation pertains to intake 3001998.Based on observation, interview, and record review the facility failed to initiate emergency medical services (EMS) and start cardiopulmonary resuscitation (CPR; an emergency lifesaving procedure performed when a person's heartbeat or breathing has stopped) timely for 1 (Resident #302) of 5 residents reviewed for life sustaining measures, resulting in an Immediate Jeopardy when, on [DATE], Resident #302 who was a full code, was found unresponsive and staff delayed EMS initiation for approximately 34 minutes and provided limited life sustaining measures were attempted by facility staff prior to EMS arrival. Resident #302 was pronounced dead on [DATE] by EMS personnel. This deficient practice is likely to cause serious harm, injury and/or death for the additional 51 of a total of 98 residents who have been deemed to have full code status. Findings include:The Immediate Jeopardy began on [DATE] when facility staff failed to call 911 and start/attempt life sustaining measures timely for Resident #302 (R#302) after being found unresponsive at 05:59 AM. Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy on [DATE] at 2:40 PM. The surveyors confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at a scope of isolated and severity of actual harm due to not all staff having received training and sustained compliance has not been verified by the State Agency.Review of Resident #302's face sheet, dated [DATE], revealed R#302 was initially admitted to the facility on [DATE] and pertinent diagnoses of acute respiratory failure (the lungs are unable to get enough oxygen into the blood or can't remove carbon dioxide from the body adequately), congestive heart failure (progressive condition where the heart muscle is too weak/stiff to pump blood efficiently), apraxia (neurological motor disorder in which the brain struggles to coordinate and plan body movements), and cognitive communication deficit (impaired ability to speak, listen, read, write or socialize effectively).Review of R#302's physician order, dated [DATE], stated, Adv (Advanced) Directive (document outlining medical preferences during an emergency): Full code (indicated a desire for immediate CPR and life saving measures in the event one's heart or breathing stopped) Cardiopulmonary Resuscitation (CPR).Review of R#302's incident and accident report titled, #930 Unknown, dated [DATE] at 05:59 AM, stated, Resident: (R#302).Incident Location: Resident's Room.Incident Description.0559 (5:59 AM) resident (R#302) unresponsive to touch and voice, not breathing no pulse, CPR started/911 called, vital obtain no vital sign noted. EMT (emergency medical technician) arrival on unit 0606 (06:06 AM) took over CPR. EMT work on resident remain unresponsive/EMT pronounce resident dead 0710 (7:10 AM).Was this incident witnessed: N (No).Statements.Name.(Licensed Practical Nurse (LPN) C).Relation.Staff.Date.XXX[DATE].Statement.CNA (certified nurse aide; unidentified in the report) did rounds around 3:45 AM. I (LPN C) went in just before 0600 (06:00 AM) and found resident unresponsive, No respirations, no pulse. I verified code status, obtained crash cart, called code (code blue; medical emergency alert often indicating someone is experiencing cardiac arrest (heart stops) and/or respiratory arrest (breathing stops) requiring an immediate response), had staff (unidentified in the report) call 911, and began CPR. We were unable to revive him and EMS showed up and took over.Agencies / People Notified.Director of Nursing (DON B) [DATE] 06:11 (6:11 AM).Review of Emergency Medical Services/ambulance Prehospital Care Report Summary (an EMS run sheet; legal and medical document used by EMS to record every detail of a 911 call or medical transport), dated [DATE], stated, Call Received: 06:34:08 (AM).En Route: 06:34:52 (AM).On Scene: 06:38:22.Patient (R#302) Contact: 06:42:22 (AM).Dead After Arrival - Patient Dead at Scene-Resuscitation Attempted (Without Transport).Other Responding Agencies: (city name omitted) FD (Fire Department).Dispatch Reason.Cardiac or Respiratory Arrest/Death.Chief Complaint.Cardiac Arrest.06:43:22 (AM).Treatment- CPR.06:45:22 (AM).Treatment- BVM Ventilation (Bag-valve-mask; an emergency technique used to provide positive-pressure ventilation to patients who are not breathing or breathing inadequately).07:10:30 (AM).Termination of resuscitation.Was an AED (portable, electronic medical device designed to treat people experiencing sudden cardiac arrest) applied prior to EMS arrival: No.Estimated Time of Arrest: 06:00:00 (AM) - Approximate.Time of First CPR: 06:34:00 (AM).End of Event: Expired (died) in the Field.Narrative History Text:. FD was not performing compressions at that time.Pt (patient; R#302) was pulseless (no detectable pulse) and apneic (state of having stopped breathing) . Staff reported that Pt was at baseline ability and mentation at 5:59 (AM) when she did her rounds.EMS noted Pt was warm to the touch. EMS started compressions. Pt was in asystole (the complete stopping of the heart's electrical and pumping activity). PT LAST SEEN AT AND BY: (Staff) at 5:59AM this morning .Additional Assessment Notes.FD was getting good compliance with BVM.Pt was in asystole for the entirety of care.ETCO2 (end-tidal carbon dioxide; maximum carbon dioxide exhaled at the end of a breath) was at 0 for the entirety of arrest. After 20 minutes of resuscitation attempts with no changes, EMS called [Hospital Name omitted] ER (emergency room) for cease resuscitation orders.Review of the Fire Department's Detailed EMS Report, dated [DATE], stated, Incident information.Dispatch Reason: Cardiac Arrest / Death. Cardiac Arrest: Yes, Prior to EMS Arrival.Final Patient Acuity: Dead.XXX[DATE] 06:40:00 (AM) Arrived at Patient.XXX[DATE] 06:41:30 (AM) CPR.Review of the Fire Department's [NAME] (National Emergency Response Information System) Print Report, dated [DATE], stated, Initial Details.Fire Dispatch: [DATE] 06:32:52 (AM).On Scene 06:37:17 (AM).Engine (fire engine/truck) 4 and [EMS Company Name] pulling in just prior to 12's (Engine 12).Staff was delayed opening the side door for us; main entrance was oos (out of service) due to construction.During a telephone interview on [DATE] at 11:20 AM, LPN M reported when she arrived at R#302's room the morning of [DATE], LPN C and Registered Nurse (RN) I were in the room with R#302 but neither nurse had hands on the resident and were not performing CPR. LPN M reported she began CPR at that point because nobody was and stopped after a few minutes and LPN C took over CPR. LPN M reported she had received a call from DON B that staff may need help, so she ran over to assist. LPN M reported she couldn't remember what time she entered R#302's room and started CPR but reported as she left R#302's room EMS were coming into the building. LPN M reported she didn't know if anything from the crash cart (a specialized mobile cart used in medical facilities that contains lifesaving emergency equipment to treat cardiac and/or respiratory arrest allowing rapid response) was used and was focused on starting CPR.Review of R#302's [DATE] incident witness statement from LPN M, dated [DATE], stated, .Coming upon the door (R#302's room), the crash cart was sitting in the hallway right outside the resident's door. When I entered, I saw (LPN C) standing on the side of the bed near the window and RN I was standing over (R#302). No CPR was being performed.EMS was just entering the building to head to (R#302)'s room.During a telephone interview on [DATE] at 2:36 PM, LPN C reported she couldn't recall all the details of R#302's [DATE] code blue event but indicated she had made a detailed report to management and the incident report included what happened. LPN C recalled RN I had come to assist her within a minute or two of having started CPR on R#302. LPN C alleged to have started CPR after determining the code status (full code) and then yelled out for someone to call 911. LPN C reported she couldn't remember who came and called 911. LPN C reported LPN M also entered the room at one point and alleged herself, LPN C, and RN I alternated performing CPR until the fire department arrived at which point they took over.During a follow up telephone interview on [DATE] at 8:39 AM, LPN C reported she couldn't explain how the EMT arrived on [DATE] at 6:06 AM, as she had stated in the incident report, and the EMS run sheet indicated the 911 call was received at 6:34 AM. LPN C reported she had started CPR, yelled out for help, and RN I brought the crash cart. LPN C reported she couldn't remember if oxygen was administered to R#302 from the crash cart by staff. LPN C stated, Whatever I put in my note I did, when asked if a BVM was used. LPN C reported she would not answer the question of how she performed CPR. Before the surveyor could ask questions about the use of the crash cart's equipment/supplies, such as oxygen, BVM, or an AED, LPN C became audibly upset and hung up the phone.Review of R#302's progress note, dated [DATE] at 8:02 AM and written by LPN C, provided no additional details, times, or information and was the same as what was entered in the Nursing Description on R#302's incident report titled #930 Unknown.During a telephone interview on [DATE] at 9:13 AM, RN I confirmed she couldn't remember if any oxygen, BVM, or an AED was used during R#302's [DATE] code blue incident and couldn't recall any specific times. RN I indicated EMS arrived quickly and she and LPN C alternated performing CPR for a short time before EMS arrived.During an observation on [DATE] at 9:30 AM, the 300-hall crash cart was covered in a pile of clothes and dust. On the cart was a binder that had a nightly crash cart checklist for staff to review to ensure that the cart was stocked and equipment was working in the event of an emergency. April and [DATE]'s nightly crash cart log were completed on 9 of 30 days for the month of April and 12 of 27 elapsed days for the month of [DATE]. There was an unopened full oxygen tank attached to the cart with a tag attached to the tank dated [DATE] (full prior to R#302 code blue event). Review of R#302's Census report, dated [DATE]-[DATE], indicated R#302 had resided on the 300s hall for the duration of his stay at the facility.During an interview on [DATE] at 9:40 AM, Director of Nursing (DON) B reported she was not aware of how often staff were supposed to check the crash cart at the facility. DON B reviewed the nightly crash cart log and confirmed that staff were supposed to be completing the list every night per the instructions on the log. DON B confirmed the facility had missed checking the crash cart nightly. DON B reported the 300-hall crash cart was the cart that was used on [DATE] when R#302 was found unresponsive. DON B confirmed the 300-hall crash cart oxygen tank dated [DATE] had not been opened and therefore couldn't have been used on R#302 on [DATE]. DON B reported on [DATE] around 6:10 AM, she had received a call from LPN C. DON B reported that LPN C had told her that she had just found R#302 unresponsive and that he was a full code. DON B reported that she told LPN C to begin CPR on R#302, that LPN C then ended the call, then called her right back, and told her that she was going to get RN I for help. DON B confirmed that LPN C had not yet initiated CPR on R#302, and left R#302 in his room alone to go find RN I for assistance. DON B confirmed that she did not know if LPN C or anyone else in the facility had called 911 yet, and uncertain the amount of help RN I would be to LPN C, so she called LPN M and asked her to go assist LPN C. DON B confirmed that LPN C had left R#302 in his room with CNA J to go get assistance from RN I. DON B was unable to report which staff member called a code blue in the facility, which staff member called 911, if any staff members placed a board (CPR backboard; hard and flat device placed under the back to provide a solid surface necessary for effective chest compressions during CPR) under R#302 prior to allegedly beginning compressions on R#302, and/or if facility staff used an automated external defibrillator (AED). During an interview on [DATE] at 11:51 AM, LPN S reported that she arrived at the facility around 6:40 AM on [DATE] when she saw that EMS workers were in R#302's room working on him. LPN S reported that there was not a crash cart outside of R#302's room and there was no facility staff in R#302's room. LPN S reported that during shift change report, LPN C reported to her that she didn't do CPR on R#302 because she didn't know that he was a full code.Review of R#302's [DATE] incident witness statement from CNA J, dated [DATE], stated, I was on the group with R#302 on [DATE] into AM (morning) of [DATE].found him on my last round he didn't look right I was not sure if he was breathing, he never responses (sic) but he looked off to me. I went to find (LPN C) to report this and have her go back with me to check him out.I'm not sure of the exact times I was doing my last round, and it had to be very close to 6a (6:00 AM) and when we went back it was a little after. (LPN C) indicated she (sic) he (R#302) had passed. I heard someone call Code Blue, not sure who it was. (LPN C) went and got the other nurse, (RN I) to assist. Review of the facility's Cardiac Arrest Emergency Management (MICHIGAN) policy, review date [DATE], stated, .CPR is to be initiated on residents in the event of a cardiac arrest.Only EMS Personnel or a physician/practitioner can make the decision to stop CPR once it has been started.Guidelines for a resident with a full code order:.For those residents where CPR was initiated by Facility staff, 911 shall be contacted for continuation of emergency care.First person to identify emergency with resident calls for assistance.Do not leave the resident unless an immediate response is anticipated.First licensed nurse to arrive:.Directs additional staff to review the resident's medical record for the resident's code status and whether there is a Do Not Resuscitate Order in place.If the resident has a Full Code order and is without a pulse/respirations:.Begin CPR.Direct designated staff to page Code Blue to location of need.Direct designated staff to call 911 requesting emergency assistance.Staff nearest the crash cart transports it and the AED (if applicable) to the location and assists with the following:.Opens the crash cart.Sets up any needed equipment per licensed nurse instruction (i.e. Oxygen, AED, etc.).Turn on the AED as soon as it arrives to bedside and follow the prompts.After EMS services arrive and take over the resident's care, the licensed nurse should document the following in a progress note:.Occurrence and time of code called.Time EMS contacted.Step by step description of care provided: initiation of CPR, AED use (if applicable), oxygen administration.EMS arrival and transfer of care.any additional applicable information.The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy. The steps the facility took to remove the immediacy were as follows:1. The Facility's interdisciplinary Team reviewed the facility's Cardiac Emergency Policy and Advance Directive Policy on [DATE]. The policies were reviewed in detail/ accepted/and reinforced for immediate implementation.2. The Administrator and Regional Social Services Director completed an audit of all residents currently in-house to confirm code statuses are accurate on [DATE].3. The Director of Nursing and/or Designee initiated mandatory education for all licensed nurses beginning [DATE]. Education includes:- Review of the Facility's Cardiac Arrest Emergency Management Policy/including requirements for immediate initiation of CPR for residents identified as Full Code and requirements for immediate notification of emergency medical services during cardiac or respiratory emergencies/and- Review of the Facility's Advance Directive-Code Status Policy, including where to locate a resident's Code Status.- Director of Nursing and/or Designee will utilize a CPR quiz for licensed nurses to ensure that previous education has been retained. Director of Nursing and/or Designee will quiz random licensed nurses 5 times per week; any incorrect answers will be given further one-to-one education. As highlighted in the CPR quiz/crash carts must be checked nightly on 3rd shift (overnight shift). Assistant Director of Nursing and/or designee will audit crash cart signature log daily to identify any discrepancies. One-to-one education will be provided to any nurse found not to have audited the crash cart.- The education will be more interactive and competency-focused. The Director of Nursing and/or designee will conduct spontaneous/ scenario-based checks by approaching licensed nurses at random and asking/ What would you do in situation X? (X meaning; different scenarios the facility would present to staff)? This real-time questioning ensures that staff can apply CPR knowledge in practical situations, not Just in a classroom setting. Any incorrect or incomplete responses will be immediately followed by one-to-one coaching to reinforce correct actions and ensure sustained competency.4. The Director of Nursing and/or Designee initiated mandatory education for all Certified Nursing Assistants (C.N.A.s) beginning [DATE]. Education includes:- Review of the Facility's Cardiac Arrest Emergency Management Policy/ specifically highlighting; The first person to identify a resident emergency should call for assistance, not leaving the resident unattended after an emergency has been identified, and any staff member can call 911 in the event of a resident emergency.- How to utilize the Cardiac-Respiratory Arrest form- No licensed nursing staff member will be permitted to work in the facility until required education has been completed/ as validated by the Director of Nursing and/or designee. The Administrator and/or designee will maintain documentation of completed education for all licensed nursing staff.5. The facility will conduct ongoing audits to ensure compliance with emergency response procedures, including verification of code status awareness and adherence to CPR initiation protocols.6. Mock drills started [DATE], and will be conducted at minimum, weekly per shift, and will continue until compliance is established through the Facility's QAPI (Quality Assurance and Performance Improvement) Committee. Director of Nursing and/or Designee will review the facility's Cardiac-Respiratory Arrest Documentation form (attached) (attached meaning; the facility provided with the verified removal plan) during every mock de-briefing. Forms will then be passed through QAPI to identify any additional barriers.7. Facility ordered 3-D (three dimensional) AED signs that will be placed on the hallways on [DATE]. These signs will give directions as to where the AED is located on the hallway.8. Facility placed clipboards on all crash carts that contain the Cardiac Arrest Documentation form to help promote accurate documentation timelines.9. Facility filed formal complaints with [NAME] (Licensing and Regulatory Affairs; A department within the State of Michigan) regarding the licenses of (RN I) and (LPN C).According to the Fundamentals of Nursing ([NAME] and [NAME], 6th ed., 2005), Cardiac arrest is characterized by an absence of pulse and respiration. If the nurse determines that the client has had a cardiac arrest, cardiopulmonary resuscitation (CPR) must be initiated. CPR is a basic emergency procedure of artificial respirations and manual external cardiac massage.Per the American Red Cross First Aid and Safety Handbook (2011), A person in cardiac arrest is unconscious, not breathing, and has no heartbeat. The Handbook revealed that a person in cardiac arrest will have the greatest chance of survival if there is: 1). Early access to the emergency medical services (EMS) system, 2). Early CPR, 3). Early defibrillation, and 4). Early advanced medical care. The Handbook also revealed that without early CPR and defibrillation, the chance for survival is greatly reduced. According to the Handbook, once you begin CPR, do not stop except in one of these situations.another trained responder or EMS personnel take over.

Based on interview and record review the facility failed to implement its quality assurance and performance improvement policy with the potential to affect all residents of the census of 98 resulting in an adverse event not being thoroughly investigated and the potential for further repeat deficiencies and/or adverse events.Findings include:Review of the facility's Provider History Report (A Centers for Medicare and Medicaid Services' report that shows the history of deficiency citations and other related information), included repeat deficiencies for health complaint surveys, dated [DATE]-[DATE]. The citation, F0842 - Resident Records - Identifiable Information (A regulation addressing complete and accurate medical records and other medical record requirements) was cited during 4 different surveys. The two most recently cited surveys with this repeated deficiency were in the surveys dated [DATE] and [DATE]. (Note: F842 is being cited again on the survey which exited on [DATE]). The report also showed the citation, F0678 - Cardio-Pulmonary Resuscitation (CPR) (A regulation addressing cardiopulmonary resuscitation (CPR) requirements) was cited at a severity of Immediate Jeopardy (represents a situation in which noncompliance by a provider has placed the health and safety of recipients (residents) in its care at risk for serious injury, serious harm, serious impairment, or death) on a survey dated [DATE]. (Note: F678 is being cited again at the same severity and scope (how widespread the issue is) on the survey which exited on [DATE]). The report also showed, from [DATE]-[DATE], F0550 - Resident Rights/Exercise of Rights was cited 4 times and F0610 - Investigate/Prevent/Correct Alleged Violation was cited 3 times. (Note: Both F550 and F610 are being cited again on the survey which exited on [DATE]).During an interview on [DATE] at 9:40 AM, Director of Nursing (DON) B confirmed a complete and thorough investigation had not been completed when she was asked about the adverse event on [DATE] in which facility staff had a delay in starting cardiopulmonary resuscitation (CPR; an emergency lifesaving procedure performed when a person's heartbeat or breathing has stopped) and the resident (R#302) died. DON B confirmed she didn't interview any of the certified nurse aides who worked on [DATE] until [DATE]. DON B was unable to answer various investigative questions such as how often the crash cart (a specialized mobile cart used in medical facilities that contains lifesaving emergency equipment) should be checked, which staff member called 911, if an automated external defibrillator (portable electronic medical device) was used, or if any staff used oxygen on the resident. During an interview on [DATE] at 12:20 PM, Nursing Home Administrator (NHA) A reported after the adverse event on [DATE] the next QA (quality assurance)/QAPI (quality assurance and performance improvement) meeting was held on [DATE], but when asked for verification to show this adverse event was addressed at the meeting, she stated, It is not in my paperwork.I'll be honest, I can't find it in here (the QA/QAPI meeting documentation). (Note: No documentation was provided to the surveyor before the end of survey to prove the facility addressed the [DATE] adverse event in a QA/QAPI meeting following the event). NHA A reported the next QAPI meeting that would have addressed the adverse event was scheduled for [DATE], but they did not conduct the meeting because surveyors were in the building. NHA A reported the facility used two programs to track adverse events, and the adverse event on [DATE] was documented as Incident #930. NHA A confirmed the date the incident was opened (started) on [DATE]. NHA A reported the facility ended their mock (structured/simulated practice exercise often used to prepare staff to respond to a real situation) code blue (medical emergency alert often indicating someone is experiencing cardiac arrest (heart stops) and/or respiratory arrest (breathing stops) requiring an immediate response) audits that QAPI was monitoring around the end of [DATE]/Beginning of [DATE] (Note: The date of the last audit was requested from NHA A at time of interview, but was not provided before survey exit).Review of the facility's Quality Assurance and Performance Improvement (QAPI) policy, revised date [DATE], stated, .It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program. Adverse Event is an untoward, undesirable and usually unanticipated event that causes death or serious injury, or risk thereof.The facility will maintain documentation and demonstrate evidence of its ongoing QAPI program. Documentation may include, but is not limited to:.Systems and reports demonstrate systematic (refers to a step by step process that is structured, so that it can be replicated) identification.investigation, analysis, and prevention of adverse events.Program Activities.adverse events are routinely tracked.An investigation will be conducted on each identified.adverse event to analyze causes.Preventive actions and mechanisms will be implemented to prevent.adverse events, including feedback and education.Monitoring will be conducted to ensure desired outcomes are achieved and sustained.

Based on observation, interview, and record review, the facility failed to ensure adequate staffing to promote the physical, mental, and psychosocial well-being in 2 of 13 residents (Resident #306 and Resident #309) reviewed for staffing, resulting in unmet care needs and the potential for physical and psychosocial harm for all residents in the facility. Findings include: Resident #306Review of an admission Record revealed Resident #306 was originally admitted to the facility on [DATE] with pertinent diagnoses which included depression, muscle weakness, and repeated falls. Review of a Minimum Data Set (MDS) assessment for Resident #306, with a reference date of 4/17/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #306 was cognitively intact. In an observation and interview on 5/27/26 at 10:01 AM, Resident #306 was lying in her bed talking to this writer and Wound Care Licensed Practical Nurse (WCLPN) T. Resident #306 reported feeling frustrated with the care that she received at the facility. Resident #306 reported that staff at the facility would frequently ignore her call light when she would activate it to ask for help with care, or they would enter her room and turn off her call light before addressing her needs. Resident #306 reported that most of the staff at the facility seemed stressed and burned out, and that they were always running late with cares. During an observation on 5/29/26 at 8:33 AM, This writer noted that Resident #306's call light had been activated since 7:46 AM (47 minutes). It was also noted that there were 4 other call lights activated on the same hall as Resident #306. In an observation and interview on 5/29/26 at 8:55 AM, Resident #306 confirmed that her call light had been activated for assistance since 7:46 AM. Resident #306 reported it was common for her to have to wait for over an hour for her call light to be answered. Resident #306 voiced frustration regarding the long call light wait times, and reported feeling like the staff just could care less about what we (residents at the facility) need. They make me feel like I am bothering them every time I ask for help. On 5/29/26 at 9:00 AM, Certified Nursing Assistant (CNA) R entered Resident #306's room and turned off her call light. Noted that Resident #306's call light had been activated (1 hour and 27 minutes after Resident #306 activated her call light). Resident #309Review of an admission Record revealed Resident #309 was originally admitted to the facility on [DATE] with pertinent diagnoses which included major depressive disorder, generalized anxiety disorder, muscle weakness, and debility (physical weakness as a result of illness). Review of a Minimum Data Set (MDS) assessment for Resident #309, with a reference date of 6/2/26 revealed a Brief Interview for Mental Status (BIMS) score of 9/15 which indicated Resident #309 was moderately cognitively impaired. Review of Section GG: Functional Abilities revealed that Resident #309 required substantial/maximum assistance (resident requires more than half of the effort to complete an activity, and a helper (caregiver or staff) is doing the rest) with toileting. Review of Resident #309's Care Plan revealed, Focus: (Resident #309) is at risk for changes in behavior and mood r/t (related to) major depressive disorder . date initiated: 12/12/24. Interventions: Evaluate for physical needs; hunger, thirst, positioning, toileting, pain, cold/warm, etc Date initiated: 1/16/25 Focus: Alteration in elimination-incontinence of bladder and bowel r/t (related to) debility . Start date: 12/12/24. Interventions: Incontinence care per facility protocol. Date initiated: 12/12/24 .During an observation on 5/29/26 at 10:36 AM, this writer noted that the facility's call light board at the 300-hall nursing station indicated that Resident #309's call light was activated at 8:51 AM. As this writer was looking at the call light board, Certified Nursing Assistant (CNA) R looked at the call light board and then went to Resident #309's room at 10:41 AM. At 10:43 AM, CNA R exited Resident #309's room. It was noted that Resident #309's call light had been turned off. During an interview on 5/29/256 at 10:40 AM: Licensed Practical Nurse (LPN) S reported that the unit was not working short staffed that day. LPN S reported that the facility used to staff three nurses on the 300 and 400 hall, and they would typically have 5 aides between the 300 and 400 hall. LPN S reported that the residents on the 300-hall were very high acuity, and it was common for the aides to struggle to keep up with resident care. LPN S reported that the nurses on the 300 and 400 hall each had over 30 residents, so they were usually also running behind and not able to assist the CNA's with resident care. During an observation on 5/29/26 at 10:43 AM, this writer entered Resident #309's room and noted a strong smell of urine. Resident #309 was lying in his bed in a soiled gown and brief, with a soiled pad and sheet under him. Resident #309 reported he turned his call light on to get help with being changed more than an hour prior to when CNA R entered his room. Resident #309 reported he was lying in a soiled brief, and that he had turned his call light on several times throughout the night and morning to get changed, but staff just turned off the light, said they would come back, but never did. Resident confirmed that he had asked CNA R to change him, and she said she would get his aide and be back, and then she left his room. Resident #309 reported that it was common for the staff to ignore him all night and day because they don't like me or care. Review of Resident #309's toileting task on 5/29/26 at 10:50 AM indicated that staff had last documented incontinence care on 5/28/26 at 20:50 (8:50 PM). At 5/29/26 at 12:02 PM, This writer and CNA NN entered Resident #309's room to assist with incontinence care. CNA NN removed Resident #309's blanket from him and confirmed that Resident #309 was lying in a soiled brief. CNA NN stated to Resident #309 You definitely have not been changed since last night. Resident #309 again confirmed to this writer and CNA NN that he had not received care since the evening before. In an interview on 5/29/26 at 1:34 PM, CNA NN confirmed that she was the staff member assigned to take care of Resident #309 that day, and that 12:02 PM was the first time that she had been in Resident #309's room to provide care to him. CNA NN reported that she was new to the unit, and that the residents on that hall required a lot of assistance, and she had been trying to catch up all morning. CNA NN reported that it was common for residents at the facility to go several hours without care, especially on nights. CNA NN reported that it felt impossible to keep up with the care needs of the residents on the 300-hall, even when the facility was staffed at their usual staffing numbers. CNA NN reported that she did not feel like the nurses and nurse management had taken her concerns seriously regarding resident care. CNA NN reported that she was new to the facility, but already feeling burned out because she did not feel like staff were able to meet the residents' basic care needs. In an interview on 5/29/26 at 1:43 PM, CNA MM reported she had voiced concerns to facility management about night staff leaving residents wet and soiled for extended periods of time. CNA MM reported that the aides were not able to get to everyone right away in the morning, and she did not feel that first shift was staffed well enough for the aides to get to all residents in the morning to complete morning care timely. CNA MM reported that she felt like the aides were doing everything they could to provide good care, and it was frustrating that management ignored concerns brought forth that could improve resident care. CNA MM reported that the 300-hall had several residents that required two staff members for cares, high fall risks, behaviors, and assistance with eating, so there was hardly any time to get any other care done. CNA MM reported that residents were frequently missing care because the staff were not able to get to all of the residents on the unit during their shifts. CNA MM Reported that the facility typically staffed 4-5 CNA's on the 300 and 400 halls (The Coast Unit.)In an interview on 5/29/26 at 1:57 PM, LPN S reported she was the nurse assigned to care for Resident #309 that day. LPN S reported the acuity of the residents on the unit was very high; she had over 30 patients to pass medications and complete treatments for and she felt that she was not able to help the aides with resident care. LPN S reported that the nurses and aides on the 300 and 400 halls were always running behind because the resident acuity of those units was not manageable with the number of staff that they had. LPN S reported that residents were frequently getting their medications and treatments late, if at all. LPN S reported the facility used to staff 3 nurses between the 300 and 400 hall, but they recently dropped down to two nurses. Review of Resident #309's Advocate Rounding forms from 4/20/26 to 6/2/26 revealed, 2. Do you feel safe with the care you are receiving here? Resident stated no to this question 8 out of 24 times. 3. Has your call light been answered timely since the last time you were asked? Resident stated no to this question 8 out of 24 times . Is room (Resident #309's room) free of odors? This was answered as no 23 out of 24 times . Is resident up and dressed? This was answered No 24 out of 24 times .Review of Resident #309's Call Log report log from 5/1/26 to 6/2/26 indicated that Resident #309's average to room elapsed time (time it takes for staff to enter resident room and turn off an activated call light) was 37:09. The highest to room elapsed time was 7:10:41. Noted 70 occasions where Resident #309's call light had been activated for over 30 minutes, 42 occasions where the call light was activated for over 1 hour, 15 occasions where the call light had been activated for more than 2 hours, 8 occasions where the call light was activated for over 3 hours, 4 occasions where the call light was activated for more than 4 hours, 3 occasions where the call light was activated for more than 5 hours and one occasion where the call light was activated for more than 7 hours. During an interview on 6/2/26 at 4:16 PM, Registered Nurse (RN) FF reported that staffing at the facility had been an ongoing concern for her. RN FF reported that she had worked the night before and had almost 30 residents to care for, and she was running behind most of the night. RN FF reported that the nighttime medication pass for the 300 hall was very heavy, and it was a challenge to get medications and treatments administered timely. RN FF reported that the facility often had to work short staffed, and that they had recently only had two CNAs on the 300 and 400 halls for an entire night shift. During an interview on 6/2/26 at 10:47 AM, LPN BB reported that he would not comment on staffing at the facility because I feel like every time I have voiced concerns it just comes back on me and the facility never does anything to improve the staffing and nothing comes of it, so I will just say that the facility had told us they are meeting state staffing requirements, and that is good enough. You can see how the resident care is from being there. LPN BB then reported that when he voiced staffing concerns before, facility management had said that they should be fine because they have the 100 hall staff members to help them, but they never come to the 300 and 400 to hall to help. Review of the Facility's Facility Assessment last reviewed on 5/29/26 revealed, . Staffing guidelines: The facility's staffing is based on resident population and acuity. The following generally represents the daily staffing at the facility utilizing the number of employees: . Nursing Assistants (23-33.5), Licensed Nurses (10-12.5). Noted that the next page of the facility assessment included a typical daily schedule of 2 nurses on the bay unit, 2 nurses in the harbor unit, and 2 nurses on the coast unit in a 24-hour period. CNA's: The bay 1-2 each shift, The Harbor: 3 each shift, and the Coast: 5-6 each shift. Noted this conflicted with the previous page which noted the typical staffing guidelines included 10-12.5 nurses in a 24-hour period- but the typical schedule reflected 8 nurses and 23-33.5 CNAs in a 24-hour period- but the typical schedule reflected 22 CNAs. It was noted that the facility assessment had based their staffing off an average of 91 residents, but the census at survey entrance was 98. For further information, see F600 and F550.

Based on interview and record review, the facility failed to maintain accurate medical records for 6 (Resident #301, #306, #309 #311, #312 and #313) residents out of a total of 13 residents reviewed for complete and accurate medical record documentation, resulting in the potential for staff and providers mismanaging care for residents. Findings include: Resident #301 Review of an admission Record revealed Resident #301 was originally admitted to the facility on [DATE] with pertinent diagnoses which included adult failure to thrive (syndrome of progressive decline in weight, physical function, nutrition, and cognitive or psychosocial health, often seen in older adults), muscle weakness, and parkinsons disease (neurological disorder that affects movement.) Review of Resident #301's Treatment Administration Record (TAR) for May 2026 revealed, Order: Enteral Feed (Delivery of nutrition directly though the gastrointestinal tract for those that cannot eat by mouth) one time a day via G- tube free water flushes . start date: 5/26/26. Noted missing documentation to indicate if the treatment was completed on the following date: 5/26/26. Review of Resident #301's Medication Administration Record (MAR) for May 2026 revealed, Order: Fluad Quadrivalent (Influenza vaccine) . inject 0.5 ml (milliliters) intramuscularly everyday shift for 1 day . start date: 5/29/26. Noted missing documentation to indicate if the vaccine was administered on the following date: 5/29/26. Review of Resident #301's MAR for May 2026 revealed, Order: Vital signs every shift x3 days and then daily every shift for monitoring. Start date: 5/26/26. Noted missing documentation to indicate if the treatment was completed on the following date: 5/29/26. Review of Resident #301's MAR for May 2026 revealed, Order: Ammonium lactate 12% lotion. Apply to bilateral legs (both legs) topically every shift for dry skin. Start date:5/12/26. Noted missing documentation to indicate if the treatment was completed on the following date: 5/29/26. Review of Resident #301's TAR for May 2026 revealed, Order: Monitor for signs and symptoms of anaphylaxis (severe allergic reaction that can be life threatening), temp, chills, fever, muscle aches/pains, check injection site for edema and redness and notify Dr. (Doctor) of any abnormalities. Please indicate yes or no every shift for vaccine administration for 3 days. Start date: 5/29/26. Noted missing documentation to indicate if the treatment was completed on the following date: 5/30/26. Review of Resident #301's MAR for May 2026 revealed, Order: Carbidopa Levodopa (medication primarily used to treat parkinson's disease symptoms) Oral tablet 20-100 MG (milligrams). Give 2 tablets via G-tube every 6 hours for parkinsons. Start date: 5/25/26. Noted missing documentation to indicate if the medication was administered on the following date: 5/29/26. Review of Resident #301's MAR for May 2026 revealed, Order: Nystatin Suspension (antifungal medications used to treat yeast infections) Give 5 ml by mouth four times a day for oral thrush (fungal infection) for 14 days . start date: 5/26/26. Noted missing documentation to indicate if the medication was administered on the following dates: 5/29/26. Review of Resident #301's TAR for May 2026 revealed, Order: Suprapubic, foley, or condom (types of catheters) catheter output amount every shift. Start date: 5/28/26. Noted missing documentation to indicate if the treatment was completed on the following dates: 5/28/26, 5/29/26, and 5/20/26. Review of Resident #301's TAR for May 2026 revealed, Order: Wound care: Cleanse affected area on sacrum (area of lower back) with generic wound cleanser . start date: 5/27/26. Noted missing documentation to indicate if the treatment was completed on the following dates: 5/29/26. Resident #306 Review of an admission Record revealed Resident #306 was originally admitted to the facility on [DATE] with pertinent diagnoses which included depression and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #306, with a reference date of 4/17/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #306 was cognitively intact. During an interview on 5/27/26 at 3:52 PM, Resident #306 reported concerns with nursing staff missing medications and treatments. Resident #306 reported that she felt like the nurses were inconsistent in medications and treatments that were ordered for her, and she felt like she was not always getting all of her medications and treatments. Review of Resident #306's MAR for May 2026 revealed, Order: Levothyroxine (hormone replacement medication) oral tablet. 100 mg. Give 1 tablet by mouth one time a day for hypothyroidism (condition where the thyroid does not produce enough thyroid hormones) . start date: 4/8/26. Noted that missing documentation to indicate if medication was administered on the following dates: 5/18/26, and 5/26/26. Review of Resident #306's MAR for May 2026 revealed, Order: House liquid protein (medical grade protein supplement designed for rapid absorption and high density nutritional support) three times a day. Start date: 4/13/26. Noted missing documentation to indicate if the medication was administered on the following dates: 5/26/26. Review of Resident #306's MAR for May 2026 revealed, Check blood sugar before meals and at HS (At bedtime) for DM 11 (Diabetes Mellitus Type 2). Start date: 4/8/26. Noted missing documentation to indicate if the treatment was completed on the following dates: 5/18/26, 5/24/26, and 5/26/26. Review of Resident #306's TAR for May 2026 revealed, Order: Ensure abdominal dressing placement Q (every) shift. Change per order if not in place two times a day for abdominal wound. Start date: 4/8/26. Noted missing documentation to indicate if the treatment was completed on the following dates: 5/18/26, 5/20/26, 5/22/26, 5/25/26 and 5/29/26. Review of Resident #306's TAR for May 2026 revealed, Order: Menthol (Topical Analgesic) external gel 5%. Apply to knees bilaterally topically two times a day for pain. Order: 5/20/26. Noted missing documentation to indicate if the treatment was completed on the following dates: 5/20/26, 5/21/26, 5/22/26, 5/25/26, 5/26/26, 5/27/26, and 5/30/26. Review of Resident #306's TAR for May 2026 revealed, Order: Wound care: Irrigate RLQ (right lower quadrant) abdominal wound with saline and pat dry . two times a day for wound care. Start date: 5/19/26. Noted missing documentation to indicate if the treatment was completed on the following dates: 5/22/26 and 5/26/26. Review of Resident #306's TAR for May 2026 revealed, Order: Wash with soap and water, rinse, pat dry bilateral inner thighs and labia every shift for red blanchable (sic) until healed. Start date: 4/16/26. Noted missing documentation to indicate if the treatment was completed on the following dates: 5/18/26, 5/20/26, 5/22/26, 5/25/26, and 5/26/26. Resident #309 Review of an admission Record revealed Resident #309 was originally admitted to the facility on [DATE] with pertinent diagnoses which included major depressive disorder, generalized anxiety disorder, and muscle weakness. Review of Resident #309's TAR for May 2026 revealed, Order: Ammonium Lactate External Lotion 12%. Apply to feet/heels topically every day for dry skin. Start date: 2/28/26. Noted missing documentation to indicate if the treatment was completed on the following dates: 5/18/26, 5/19/26. Review of Resident #309's TAR for My 2026 revealed, Order: Orthosis (external medical device used to correct alignment or provide support)/splint to be applied to: Left resting hand splint on for 8 hours as tolerated. Perform skin assessment upon removal. Every morning and at bedtime. On in the evening, off in the morning. Start date: 11/20/25. Noted missing documentation to indicate if the treatment was completed on the following dates: 5/18/26. Resident #311 Review of an admission Record revealed Resident #311 was originally admitted to the facility on [DATE] with pertinent diagnoses which included pressure ulcer of right heel and muscle weakness. Review of Resident #311's TAR for May 2026 revealed, Order: Check placement of wound dressing on right heel. If soiled/missing perform wound care two times a day for wound care. Start date: 2/13/26. Noted missing documentation to indicate if the treatment was completed on the following dates: 5/18/26 and 5/25/26. Review of Resident #311's TAR for May 2026 revealed, Order: Foam heel suspension boots to be worn at all times as tolerated every shift for PI (pressure injury). Start date: 11/20/25. Noted missing documentation to indicate if the treatment was completed on the following dates: 5/18/26. Review of Resident #311's TAR for May 2026 revealed, Order: Place alternating pressure mattress on bed for pressure reduction. Monitor alternating pressure mattress function and check that the settings are appropriate for the patient every shift . Start date: 11/20/25. Noted missing documentation to indicate if the treatment was completed on the following dates: 5/18/26. Resident #312 Review of an admission Record revealed Resident #312 was originally admitted to the facility on [DATE] with pertinent diagnoses which included major depressive disorder and repeated falls. Review of Resident #312's MAR for May 2026 revealed, Order: Aquaphor external Ointment. Apply to feet topically one time a day for diabetic neuropathy (complication of diabetes, characterized as nerve damage). Start date: 12/30/25. Noted missing documentation to indicate if the treatment was completed on the following dates: 5/29/26 and 5/31/26. Review of Resident #312's MAR for May 2026 revealed, Order: Obtain blood glucose level one time a day for blood glucose monitoring. Start date: 4/24/26. Noted missing documentation to indicate if the treatment was completed on the following dates: 5/16/26. Review of Resident #312's MAR for May 2026 revealed, Order: Assess resident for pain every shift. Start date: 11/20/25. Noted missing documentation to indicate if the treatment was completed on the following dates: 5/29/26. Review of Resident #312's MAR for May 2026 revealed, Order: Effexor (antidepressant medication): Monitor for side effects of antidepressant use . start date: 4/20/26. Noted missing documentation to indicate if the treatment was completed on the following dates: 5/29/26. Review of Resident #312's MAR for May 2026 revealed, Order: Olanzapine (antipsychotic medication). For those residents on psychoactive medications, please identify targeted behaviors to monitor .document adverse reactions in progress note and notify physician every shift. Start date: 1/20/26. Noted missing documentation to indicate if the treatment was completed on the following dates: 5/29/26. Review of Resident #312's MAR for May 2026 revealed, Order: Gabapentin (medication used to treat seizures and nerve pain) 300 mg. Give 4 tablets by mouth three times a day for chronic pain. Start date: 4/7/26. Noted missing documentation to indicate if the medication was administered on the following dates: 5/29/26. Review of Resident #312's MAR for May 2026 revealed, Order: Insulin lispro (medication used to control blood sugar levels in people with diabetes) inject per sliding scale . before meals and at bedtime for type 2 diabetes. Start date: 4/30/26.Noted missing documentation to indicate if the medication was administered on the following dates: 5/29/26. Review of Resident #312's TAR for May 2026 revealed, Order: Shower/Bath Friday AM. Complete weekly skin check . skin assessment and vital signs on bath day . ensure shower form is completed. Start date: 5/15/26. Noted missing documentation to indicate if the treatment was completed on the following dates: 5/15/26 and 5/23/26. Review of Resident #312's TAR for May 2026 revealed, Order: Wound Care: Left heel. Cleanse heel with generic wound cleanser two times a day for wound care. Start date: 5/19/26. Noted missing documentation to indicate if the treatment was completed on the following dates: 5/20/26 and 5/22/26 and 5/27/26. Review of Resident #312's TAR for May 2026 revealed, Order: Monitor right eye cataract (clouding of the lens of the eye) every shift for right eye cataract. Start date: 5/21/26. Noted missing documentation to indicate if the treatment was completed on the following dates: 5/15/26, 5/19/26 and 5/20/26. During an interview on 5/28/26 at 9:40 AM, Director of Nursing (DON) B confirmed that the facility was cited for noncompliance of complete and accurate medical records in April 2026, and she felt that the facility nursing staff had improved on ensuring that they were completing documentation of all medications and treatments administered, or indicating why they were missed if they were not completed. DON B reported that the facility management had been auditing resident records, and she was unaware of current concerns with nursing staff missing documentation of medications and treatments administered. Resident #313: Review of Resident 313's physician progress note dated 5/28/26, stated, (Resident #313).admitted to the skilled nursing facility for long-term care on May 26, 2026.has a chronic indwelling Foley catheter (tube inserted into the bladder to drain urine). Review of Resident #313's TAR, dated 5/1-5/31/26, included the order, Communication Order: Please open and complete sepsis (life-threatening reaction to an infection) screen in assessments every shift for sepsis screening for 7 days., start date 5/26/26, and the TAR was blank (the treatment/care was not marked as having been completed) on 5/29/26 for the section labeled, 7AM-. Review of Resident #313's TAR, dated 5/1-5/31/26, included the order, Maintain Foley Catheter and provide care every shift., start date 5/26/26, and the TAR was blank on 5/29/26 for the section labeled, 7AM-.

Based on observation, interview, and record review, the facility failed to implement policies and procedures of reporting an allegation of neglect in 1 (Resident #309) of 11 residents reviewed for abuse and neglect timely to the State Agency resulting in the allegation not being thoroughly investigated and the potential of further occurrences of neglect to continue. Findings include: Resident #309Review of a Minimum Data Set (MDS) assessment for Resident #309, with a reference date of 6/2/26 revealed Section GG: Functional Abilities revealed that Resident #309 required substantial/maximum assistance with toileting. During an observation on 5/29/26 at 10:36 AM, this writer noted that the facility's call light board at the 300-hall nursing station indicated that Resident #309's call light was activated on at 8:51 AM. As this writer was looking at the call light board, Certified Nursing Assistant (CNA) R looked at the call light board and then went to Resident #309's room at 10:41 AM. At 10:43 AM, CNA R exited Resident #309's room. It was noted that Resident #309's call light had been turned off. During an observation on 5/29/26 at 10:43 AM, this writer entered Resident #309's room and noted a strong smell of urine. Resident #309 was lying in his bed in a soiled hospital gown, with a soiled brief, pad, and sheets. Resident #309 yelled out as this writer entered his room, I need to be changed! Resident #309 reported he turned his call on to get help with being changed more than an hour prior to when CNA R entered his room. Resident #309 reported he was lying in a soiled brief, and that he had turned his call light on several times throughout the night and morning to get changed, but staff just turned off the light, said they would come back, but never did. Resident confirmed that he had asked CNA R to change him, and she said she would get his aide and be back, and then she left his room. Resident #309 voiced frustration about being left wet and soiled overnight. Resident #309 reported he felt embarrassed that he had to lay in soaked briefs, and he felt like the staff did not care about him, and he was so angry that the facility treated him so poorly. Resident #309 reported that it was common for the staff to ignore him all night and day because they don't like me or care. It was noted that Resident #309's call light was attached to his bed, and out of his hand. At 5/29/26 at 12:02 PM, This writer and CNA NN entered Resident #309's room to assist with incontinence care. CNA NN removed Resident #309's blanket from him and confirmed that Resident #309 was lying in a soiled brief. CNA NN stated to Resident #309 You definitely have not been changed since last night. Resident #309 again confirmed to this writer and CNA NN that he had not received care since the evening before. In an interview on 5/29/26 at 1:34 PM, CNA NN confirmed that she was the staff member assigned to take care of Resident #309 that day, and that 12:02 PM was the first time that she had been in Resident #309's room to provide care to him. CNA NN reported that she was new to the unit, and that the residents on that hall required a lot of assistance, and she had been trying to catch up all morning. CNA NN reported that it was common for residents at the facility to go several hours without care, especially on nights. CNA NN reported that it was common for the night shift staff to not complete care on residents throughout the night, so she would often find residents wet and soiled in the morning. CNA NN reported that she had reported those concerns several times to the nursing staff and management, but care had not improved. CNA NN reported that she had also found residents being double briefed on multiple occasions, which she had also reported to nursing staff. CNA NN reported that she had observed Resident #309 wearing double briefs on multiple occasions. CNA NN reported that it felt impossible to keep up with the care needs of the residents on the 300-hall, even when the facility was staffed at their usual staffing numbers. CNA NN reported that she did not feel like the nurses and nurse management had taken her concerns seriously regarding resident care. CNA NN reported that she hated seeing residents in these kinds of conditions and that Nobody should have to lay in a soiled brief that long. In an interview on 5/29/26 at 1:43 PM, CNA MM reported she had voiced concerns to facility management about night staff leaving residents wet and soiled for extended periods of time. CNA MM reported that the aides were not able to get to everyone right away in the morning, and she did not feel that first shift was staffed well enough for the aides to get to all residents in the morning to complete morning care timely. CNA MM reported that she had observed residents being double briefed by night shift, and even though she reported it to management, it continued to happen. CNA MM reported that Resident #309 was often found in soiled briefs. CNA MM reported that she recently had to Scrape bowel movement off of a resident's buttocks because it had been stuck on them for so long. CNA MM reported that she felt like the aides were doing everything they could to provide good care, and it was frustrating that management ignored concerns brought forth that could improve resident care. During an interview on 5/29/26 at 2:33 PM, this writer informed Nursing Home Administrator (NHA) A who was the designated abuse coordinator of the facility, of the concern that Resident #309 had not received incontinence care from 8:50 PM on 5/27/26 to 12:02 PM on 5/28.26.During an interview on 6/3/26 at 1:36 PM, Nursing NHA A reported that she did not report the allegation of neglect for Resident #309 to the State Agency because she looked into the concern and discovered that the staff caring for Resident #309 had not received adequate training, and that Resident #309 had reported that he was checked on at 3:00 AM on 5/27/26, so she did not think that concern reported was neglect. NHA A did not indicate why staffs' failure to provide care and services from the reported 3:00 am on 5/27/26 to 12:02 PM 5/28/26 occurred. On 6/2/26 at 2:35 PM, this writer requested the facility's Abuse/Neglect policy. The facility did not provide the policy by survey exit. For further information, please see F600.

Based on observation and interview, the facility failed to properly secure medications in two of five medication carts resulting in the potential for the compromise of medications, accidental indigestion, and/or misappropriation of medications. Findings include:During an observation on 5/29/26 at 6:33 AM, a medication cup containing 4 loose pills was sitting on top of the 100-hall medication cart which was unlocked and sitting next to the nurses' station. No staff were present near the nurses' station, in the 100-hall, nor within sight of the 100-hall medication cart.During an interview 5/28/26 at 8:04 AM, Licensed Practical Nurse (LPN) F confirmed she was assigned to the 100-hall, and that she had not locked her medication cart when she went to assess a resident in their room. LPN F was unable to report why she had left the medications on top of the unlocked cart unsupervised, and reported that she had a busy night and was working over because a staff member had called in. During an observation on 5/29/26 at 10:32 AM, The 300-hall medication was observed unlocked without a nurse in view of the cart.

Based on observation, interview, and record review, the facility failed to provide care and services to promote dignity and respect in 2 (Resident #306 and Resident #309) of 5 residents reviewed for dignity resulting in unmet care needs, feelings of diminished self-worth, sadness, and frustration. Findings include: Resident #306Review of an admission Record revealed Resident #306 was originally admitted to the facility on [DATE] with pertinent diagnoses which included depression, muscle weakness, and repeated falls. Review of a Minimum Data Set (MDS) assessment for Resident #306, with a reference date of 4/17/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #306 was cognitively intact. In an observation and interview on 5/27/26 at 10:01 AM, Resident #306 was lying in her bed talking to this writer and Wound Care Licensed Practical Nurse (WCLPN) T. Resident #306 reported feeling frustrated with the care that she received at the facility. Resident #306 reported that staff at the facility would frequently ignore her call light when she would activate it to ask for help with care, or they would enter her room and turn off her call light before addressing her needs. During an observation on 5/29/26 at 8:33 AM, This writer noted that Resident #306's call light had been activated since 7:46 AM (47 minutes). It was also noted that there were 4 other call lights on the same hall as Resident #306. In an observation and interview on 5/29/26 at 8:55 AM, Resident #306 confirmed that her call light had been activated for assistance since 7:46 AM. Resident #306 reported it was common for her to have to wait for over an hour for her call light to be answered. Resident #306 voiced frustration regarding the long call light wait times, and reported feeling like the staff just could care less about what we (residents at the facility) need. They make me feel like I am bothering them every time I ask for help. On 5/29/26 at 9:00 AM, Certified Nursing Assistant (CNA) R entered Resident #306's room and turned off her call light. Noted that Resident #306's call light had been activated (1 hour and 27 minutes after Resident #306 activated her call light). Resident #309Review of an admission Record revealed Resident #309 was originally admitted to the facility on [DATE] with pertinent diagnoses which included major depressive disorder, generalized anxiety disorder, and muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #309, with a reference date of 6/2/26 revealed a Brief Interview for Mental Status (BIMS) score of 9/15 which indicated Resident #309 was moderately cognitively impaired. Review of Section GG: Functional Abilities revealed that Resident #309 required substantial/maximum assistance with toileting. During an observation on 5/29/26 at 10:36 AM, this writer noted that the facility's call light board at the 300-hall nursing station indicated that Resident #309's call light was activated on 8:51 AM. As this writer was looking at the call light board, Certified Nursing Assistant (CNA) R looked at the call light board and then went to Resident #309's room at 10:41 AM. At 10:43 AM, CNA R exited Resident #309's room. It was noted that Resident #309's call light had been turned off. During an observation on 5/29/26 at 10:43 AM, this writer entered Resident #309's room and noted a strong smell of urine. Resident #309 was lying in his bed in a soiled hospital gown, with a soiled brief, pad, and sheets. Resident #309 yelled out as this writer entered his room, I need to be changed! Resident #309 reported he turned his call on to get help with being changed more than an hour prior to when CNA R entered his room. Resident #309 reported he was lying in a soiled brief, and that he had turned his call light on several times throughout the night and morning to get changed, but staff just turned off the light, said they would come back, but never did. Resident confirmed that he had asked CNA R to change him, and she said she would get his aide and be back, and then she left his room. Resident #309 voiced frustration about being left wet and soiled overnight. Resident #309 reported he felt embarrassed that he had to lay in soaked briefs, and he felt like the staff did not care about him, and he was so angry that the facility treated him so poorly. Resident #309 reported that it was common for the staff to ignore him all night and day because they don't like me or care. It was noted that Resident #309's call light was attached to his bed, and out of his hand. Review of Resident #309's toileting task on 5/29/26 at 10:50 AM indicated that staff had last documented incontinence care on 5/28/26 at 20:50 (8:50 PM). During an observation on 5/29/26 at 10:56 AM, CNA R returned to the 300 hall with 3 students that she was instructing to check on residents. CNA R went into the room next to Resident #309 and then two rooms across from Resident #309 to check in with the residents. CNA R then instructed the students to follow her to the other end of the hall to complete resident checks. Noted that CNA R did not enter Resident #309's room to complete a resident check. During an observation on 5/29/26 at 11:03 AM, Scheduler/CNA KK entered Resident #309's room and was overheard asking Resident #309 if she could complete her advocate rounds with Resident #309. Scheduler/CNA KK asked Resident #309 if staff had been kind, courteous and friendly? Resident #309 stated no. Scheduler/CNA KK then asked Resident #309 if his call light had been answered timely since the last time he was asked? Resident #309 stated no. Resident #309 was then overheard stating that he needed to be changed. Scheduler KK exited Resident #309's room after asking all of the advocate round questions. It was noted that she did not provide incontinence care to Resident #309. In an interview on 5/29/26 at 11:13 AM, Scheduler/CNA KK reported that Resident #309 did not report any care concerns to her. Scheduler/CNA KK then reported Resident #309's liked to hold on to his call light in his hand and would refuse to let staff remove the call light, which is why Resident #309's call light had been activated for over an hour earlier that morning. Noted that this writer did not ask Scheduler/CNA KK about Resident #309's call light being activated earlier that morning for over an hour. Scheduler/CNA KK reported that Resident #309 did not report that he needed assistance. During an observation on 5/29/26 at 11:23 AM, Resident #309 began yelling out help! repeatedly. Each time Resident #309 yelled out for help, his tone got louder. Noted that this surveyor could hear Resident #309 yelling out for help at the opposite end of the hall. At 11:23 AM, CNA R returned to the 300 hall and went into another resident room and did not respond to Resident #309's calls for help. During an observation and interview on 5/29/26 at 11:24 AM, Licensed Practical Nurse (LPN) S entered Resident #309's room and then exited his room at 11:25 AM. As LPN S was exiting Resident #309's room, this writer queried as to what Resident #309 was yelling out for, and she reported He does this all the time, he will say he wants to be changed, but he won't even be wet, he has a lot of behaviors. When asked if LPN S checked Resident #309's brief to see if he was soiled, she stated that she did not check Resident #309's brief.During an observation and interview on 5/29/26 at 11:31 AM, Certified Nursing Assistant (CNA) NN entered Resident #309's room with care supplies and then exited his room at 11:33 AM. CNA NN reported that she went into Resident #309's room to set everything up so that she could provide care to Resident #309 when she was done providing care for another resident. During an observation on 5/29/26 at 11:52 AM, Resident #309 activated his call light. At 11:58 AM, This writer entered Resident #309's room and noted a new brief that was sitting on his tray table with an incontinence pad inside the brief. Resident #309 reported that he had been told by CNA NN she would return to change him as soon as she could. Resident #309 again reported feelings of humiliation and anger towards the facility staff for the way that they treated him. Resident #309 reported if he didn't yell out for help, that they would never come to help me. They don't like me, it makes me feel like crap. On 5/29/26 at 12:02 PM, CNA NN entered Resident #309's room to assist with incontinence care. CNA NN removed Resident #309's blanket from him and confirmed that Resident #309 was lying in a soiled brief. CNA NN stated to Resident #309 You definitely have not been changed since last night. Resident #309 again confirmed to this writer and CNA NN that he had not received care since the evening before. As CNA NN provided perineal care (peri care-is the hygienic cleaning and maintenance of the genital and anal areas to prevent infection, skin breakdown, and maintain comfort) to Resident #309, he reported a burning and itching on his buttocks area. CNA NN cleaned Resident #309's buttocks area and it was noted that Resident #309's skin looked red and irritated. In an interview on 5/29/26 at 1:34 PM, CNA NN confirmed that she was the staff member assigned to take care of Resident #309 that day, and that 12:02 PM was the first time that she had been in Resident #309's room to provide care to him. CNA NN reported that she was new to the unit, and that the residents on that hall required a lot of assistance, and she had been trying to catch up all morning. CNA NN reported that it was common for residents at the facility to go several hours without care, especially on nights. CNA NN reported that it was common for the night shift staff to not complete care on residents throughout the night, so she would often find residents wet and soiled in the morning. CNA NN reported that she had reported those concerns several times to the nursing staff and management, but care had not improved. CNA NN reported that she had also found residents being double briefed on multiple occasions, which she had also reported to nursing staff. CNA NN reported that she had observed Resident #309 wearing double briefs on multiple occasions. CNA NN reported that it felt impossible to keep up with the care needs of the residents on the 300-hall, even when the facility was staffed at their usual staffing numbers. CNA NN reported that she did not feel like the nurses and nurse management had taken her concerns seriously regarding resident care. CNA NN reported that she hated seeing residents in these kinds of conditions and that Nobody should have to lay in a soiled brief that long. In an interview on 5/29/26 at 1:43 PM, CNA MM reported she had voiced concerns to facility management about night staff leaving residents wet and soiled for extended periods of time. CNA MM reported that the aides were not able to get to everyone right away in the morning, and she did not feel that first shift was staffed well enough for the aides to get to all residents in the morning to complete morning care timely. CNA MM reported that she had observed residents being double briefed by night shift, and even though she reported it to management, it continued to happen. CNA MM reported that Resident #309 was often found in soiled briefs. CNA MM reported that she recently had to Scrape bowel movement off of a resident's buttocks because it had been stuck on them for so long. CNA MM reported that she felt like the aides were doing everything they could to provide good care, and it was frustrating that management ignored concerns brought forth that could improve resident care. In an interview on 5/29/26 at 1:57 PM, LPN S reported she was the nurse assigned to care for Resident #309 that day. LPN S reported that she went to check on Resident #309 when he was yelling earlier that morning, that Resident #309 had told her that his aide told him she would be back after breakfast to help him, and he was still waiting for her. LPN S reported that she was unaware that Resident #309 had not received any care from staff that day until 12:06 PM. LPN S reported the acuity of the residents on the unit was very high; she had over 30 patients to pass medications and complete treatments for and she felt that she was not able to help the aides with resident care. LPN S reported the staff that worked on the rehab unit were supposed to come assist staff on the 300 hall, but they never did. Review of Resident #309's Advocate Rounding forms from 4/20/26 to 6/2/26 revealed, Open ended Questions: 1. Has staff been kind, courteous, and friendly? Resident stated no to this question 21 out of 24 times. 2. Do you feel safe with the care you are receiving here? Resident stated no to this question 8 out of 24 times. 3. Has your call light been answered timely since the last time you were asked? Resident stated no to this question 8 out of 24 times . Is room (Resident #309's room) free of odors? This was answered as no 23 out of 24 times . Is resident up and dressed? This was answered No 24 out of 24 times .Review of Resident #309's Call Log report log from 5/1/26 to 6/2/26 indicated that Resident #309's average to room elapsed time (time it takes for staff to enter resident room and turn off an activated call light) was 37:09. The highest to room elapsed time was 7:10:41. Noted 70 occasions where Resident #309's call light had been activated for over 30 minutes, 42 occasions where the call light was activated for over 1 hour, 15 occasions where the call light had been activated for more than 2 hours, 8 occasions where the call light was activated for over 3 hours, 4 occasions where the call light was activated for more than 4 hours, 3 occasions where the call light was activated for more than 5 hours and one occasion where the call light was activated for more than 7 hours. Review of the facility's Dignity policy last reviewed 2/3/26 revealed, Policy Overview: It is the policy of this facility that each resident will be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth, and self-esteem. General Guidelines: Residents will be treated with dignity and respect at all times, the facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values, and beliefs . Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents, for example: helping the resident to keep urinary catheter bags covered, promptly responding to a resident's request for assistance . Staff are expected to treat cognitively impaired residents with dignity and sensitivity, for example: addressing the underlying motives or root causes for behavior .

This citation pertains to intake 3026395.Based on interview and record review the facility failed to release medical records upon request for 1 (Resident #302) of 3 residents reviewed for access of resident records resulting in being unable to obtain and review requested records.Findings include:Review of Resident #302's (R#302) Census report, dated 1/14/26-4/18/26, indicated R#302 was admitted on [DATE] and discharged on 4/18/26.Review of R#302's Profile report, undated, indicated R#302's Family Member (FM) QQ was Emergency Contact #1.Responsible Party (bills).Guardian and FM RR was Emergency Contact #3.During an interview on 5/29/26 at 1:17 PM, Nursing Home Administrator (NHA) A confirmed FM QQ was R#302's guardian, Family Member QQ requested medical records for R#302 on 3/24/26 from DON B, those records were never provided to FM QQ, and the documents requested were not compiled to be able to be released until 4/14/26. NHA A reported R#302's FM RR, prior to 3/24/26, had come to the facility, obtained a medical record request, FM RR returned it the next day, and it had a signature from FM QQ. NHA A confirmed R#302's Family Lawyer (FL) OO had requested medical records for R#302 by postal mail, dated 4/9/26 and received date 4/14/26. NHA A reported the request was sent to the facility/company's legal team on 4/14/26 but they had not finished reviewing it yet. NHA A reported she contacted the legal team on 5/15/26 and 5/20/26 for an update but had not received a response back.Review of R#302's FL OO's medical record request, dated 4/9/26, stated, .April 9, 2026.VIA CERTIFIED MAIL.This firm represents (FM QQ) as guardian of (R#302).pressure wounds that developed while he (R#302) was a patient at your facility.Please note that (FM QQ) has previously requested the medical records of (R#302) from your facility, and we hereby demand that they be immediately produced and sent to my attention at [Contact information omitted], according to the request of his guardian.including any and all investigative reports, statements made by staff members, photos, videotapes and recordings, taken or made before, during and/or after his admission.Review of an email from NHA A, dated 6/2/26 at 1:08 PM, included the request from the surveyor for the medical record request FM RR submitted with FM QQ's signature, and NHA A stated, The request was never scanned into the medical record so I'm unable to locate. During a follow up interview on 6/3/26 at 1:18 PM, NHA A reported she had misunderstood direction she received previously regarding release of records. NHA A reported she had thought their legal team had to approve the release of the records but confirmed the release of records can be done after review by NHA and regional clinical consultant. NHA A reported the requested records would be sent to R#302's FL OO today. Review of the facility's Release of Health Information policy, dated 5/1/2022, stated, .a patient or his or her authorized representative has the right to examine or obtain the patient's Health Record.

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect for 1 (Resident #309) of 11 residents reviewed for abuse and neglect resulting in Resident #309 being left in a soiled brief for several hours, experiencing feelings of humiliation and dehumanization, and having his repeated verbal expressions for help go unanswered. Findings include: Resident #309Review of an admission Record revealed Resident #309 was originally admitted to the facility on [DATE] with pertinent diagnoses which included major depressive disorder, generalized anxiety disorder, muscle weakness, and debility (physical weakness as a result of illness). Review of a Minimum Data Set (MDS) assessment for Resident #309, with a reference date of 6/2/26 revealed a Brief Interview for Mental Status (BIMS) score of 9/15 which indicated Resident #309 was moderately cognitively impaired. Review of Section GG: Functional Abilities revealed that Resident #309 required substantial/maximum assistance (resident requires more than half of the effort to complete an activity, and a helper (caregiver or staff) is doing the rest) with toileting. Review of Resident #309's Care Plan revealed, Focus: (Resident #309) is at risk for changes in behavior and mood r/t (related to) major depressive disorder . date initiated: 12/12/24. Interventions: Evaluate for physical needs; hunger, thirst, positioning, toileting, pain, cold/warm, etc Date initiated: 1/16/25 Focus: Alteration in elimination-incontinence of bladder and bowel r/t (related to) debility . Start date: 12/12/24. Interventions: Incontinence care per facility protocol. Date initiated: 12/12/24 .During an observation on 5/29/26 at 10:36 AM, this writer noted that the facility's call light board at the 300-hall nursing station indicated that Resident #309's call light was activated on at 8:51 AM. As this writer was looking at the call light board, Certified Nursing Assistant (CNA) R looked at the call light board and then went to Resident #309's room at 10:41 AM. At 10:43 AM, CNA R exited Resident #309's room. It was noted that Resident #309's call light had been turned off. During an observation on 5/29/26 at 10:43 AM, this writer entered Resident #309's room and noted a strong smell of urine. Resident #309 was lying in his bed in a soiled hospital gown, with a soiled brief, pad, and sheets. Resident #309 yelled out as this writer entered his room, I need to be changed! Resident #309 reported he turned his call light on to get help with being changed more than an hour prior to when CNA R entered his room. Resident #309 reported he was lying in a soiled brief, and that he had turned his call light on several times throughout the night and morning to get changed, but staff just turned off the light, said they would come back, but never did. Resident confirmed that he had asked CNA R to change him, and she said she would get his aide and be back, and then she left his room. Resident #309 voiced frustration about being left wet and soiled overnight. Resident #309 reported he felt embarrassed that he had to lay in soaked briefs, he felt like the staff did not care about him, and he was angry that the facility treated him so poorly. Resident #309 reported that it was common for the staff to ignore him all night and day because they don't like me or care. Review of Resident #309's toileting task on 5/29/26 at 10:50 AM indicated that staff had last documented incontinence care on 5/28/26 at 20:50 (8:50 PM). During an observation on 5/29/26 at 10:56 AM, CNA R returned to the 300 hall with 3 students that she was instructing to check on residents. CNA R went into the room next to Resident #309 and then two rooms across from Resident #309 to check in with the residents. CNA R then instructed the students to follow her to the other end of the hall to complete resident checks. Noted that CNA R did not enter Resident #309's room to complete a resident check. During an observation on 5/29/26 at 11:03 AM, Scheduler/CNA KK entered Resident #309's room and was overheard asking Resident #309 if she could complete her advocate rounds with Resident #309. Scheduler/CNA KK asked Resident #309 if staff had been kind, courteous and friendly? Resident #309 stated no. Scheduler/CNA KK then asked Resident #309 if his call light had been answered timely since the last time he was asked? Resident #309 stated no. Resident #309 was then overheard stating that he needed to be changed. Scheduler/CNA KK exited Resident #309's room after asking all of the advocate round questions. It was noted that she did not provide incontinence care to Resident #309. In an interview on 5/29/26 at 11:13 AM, Scheduler/CNA KK reported that Resident #309 did not report any care concerns to her. Scheduler/CNA KK reported that Resident #309 did not report that he needed assistance. During an observation 5/29/26 at 11:23 AM, Resident #309 began yelling out help! repeatedly. Each time Resident #309 yelled out for help, his tone got louder. Noted that this surveyor could hear Resident #309 yelling out for help at the opposite end of the hall. At 11:23 AM, CNA R returned to the 300 hall and went into another resident room and did not respond to Resident #309's calls for help. During an observation and interview on 5/29/26 at 11:24 AM, Licensed Practical Nurse (LPN) S entered Resident #309's room and then exited his room at 11:25 AM. As LPN S was exiting Resident #309's room, this writer queried as to what Resident #309 was yelling out for, and she reported He does this all the time, he will say he wants to be changed, but he won't even be wet, he has a lot of behaviors. When asked if LPN S checked Resident #309's brief to see if he was soiled, she stated that she did not check Resident #309's brief.During an observation and interview on 5/29/26 at 11:31 AM, Certified Nursing Assistant (CNA) NN entered Resident #309's room with care supplies and then exited his room at 11:33 AM. CNA NN reported that she went into Resident #309's room to set everything up so that she could provide care to Resident #309 when she was done providing care for another resident. During an observation on 5/29/26 at 11:52 AM, Resident #309's activated his call light. At 11:58 AM, This writer entered Resident #309's room and noted a new brief that was sitting on his tray table with an incontinence pad inside the brief. Resident #309 reported that he had been told by CNA NN she would return to change him as soon as she could. Resident #309 again reported feelings of humiliation and anger towards the facility staff for the way that they treated him. Resident #309 reported if he didn't yell out for help, that they would never come to help me. They don't like me, it makes me feel like crap. At 5/29/26 at 12:02 PM, This writer accompanied CNA NN entered Resident #309's room as she prepared to assist Resident #309 with incontinence care. CNA NN removed Resident #309's blanket from him and confirmed that Resident #309 was lying in a soiled brief. CNA NN stated to Resident #309 You definitely have not been changed since last night. Resident #309 again confirmed to this writer and CNA NN that he had not received care since the evening before. As CNA NN provided perineal care (peri care-is the hygienic cleaning and maintenance of the genital and anal areas to prevent infection, skin breakdown, and maintain comfort) to Resident #309, he reported a burning and itching on his buttocks area. CNA NN cleaned Resident #309's buttocks area and it was noted that Resident #309's skin looked red and irritated. In an interview on 5/29/26 at 1:34 PM, CNA NN confirmed that she was the staff member assigned to take care of Resident #309 that day, and that 12:02 PM was the first time that she had been in Resident #309's room to provide care to him. CNA NN reported that she was new to the unit, and that the residents on that hall required a lot of assistance, and she had been trying to catch up all morning. CNA NN reported that it was common for residents at the facility to go several hours without care, especially on nights. CNA NN reported that it was common for the night shift staff to not complete care on residents throughout the night, so she would often find residents wet and soiled in the morning. CNA NN reported that she had reported those concerns several times to the nursing staff and management, but care had not improved. CNA NN reported that she had also found residents being double briefed on multiple occasions, which she had also reported to nursing staff. CNA NN reported that she had observed Resident #309 wearing double briefs on multiple occasions. CNA NN reported that it felt impossible to keep up with the care needs of the residents on the 300-hall, even when the facility was staffed at their usual staffing numbers. CNA NN reported that she did not feel like the nurses and nurse management had taken her concerns seriously regarding resident care. CNA NN reported that she hated seeing residents in these kinds of conditions and that Nobody should have to lay in a soiled brief that long. In an interview on 5/29/26 at 1:43 PM, CNA MM reported she had voiced concerns to facility management about night staff leaving residents wet and soiled for extended periods of time. CNA MM reported that the aides were not able to get to everyone right away in the morning, and she did not feel that first shift was staffed well enough for the aides to get to all residents in the morning to complete morning care timely. CNA MM reported that she had observed residents being double briefed by night shift, and even though she reported it to management, it continued to happen. CNA MM reported that Resident #309 was often found in soiled briefs. CNA MM reported that she recently had to Scrape bowel movement off of a resident's buttocks because it had been stuck on them for so long. CNA MM reported that she felt like the aides were doing everything they could to provide good care, and it was frustrating that management ignored concerns brought forth that could improve resident care. In an interview on 5/29/26 at 1:57 PM, LPN S reported she was the nurse assigned to care for Resident #309 that day. LPN S reported that she went to check on Resident #309 when he was yelling earlier that morning, that Resident #309 had told her that his aide told him she would be back after breakfast to help him, and he was still waiting for her. LPN S reported that she was unaware that Resident #309 had not received any care from staff that day until 12:06 PM. LPN S reported the acuity of the residents on the unit was very high; she had over 30 patients to pass medications and complete treatments for and she felt that she was not able to help the aides with resident care. LPN S reported the staff that worked on the rehab unit were supposed to come assist staff on the 300 hall, but they never did. Review of Resident #309's Advocate Rounding forms from 4/20/26 to 6/2/26 revealed, Open ended Questions: 1. Has staff been kind, courteous, and friendly? Resident stated no to this question 21 out of 24 times. 2. Do you feel safe with the care you are receiving here? Resident stated no to this question 8 out of 24 times. 3. Has your call light been answered timely since the last time you were asked? Resident stated no to this question 8 out of 24 times . Is room (Resident #309's room) free of odors? This was answered as no 23 out of 24 times . Is resident up and dressed? This was answered No 24 out of 24 times .Review of Resident #309's Progress Note dated 5/29/26 at 3:02 PM and documented by LPN S revealed, Pt (patient) states that he was checked/changed at 0300 and his CNA checked him at shift change and at that time his brief was dry. Pt states he consumed more liquids this morning than usual and experienced heavy urination which caused his brief and padding to become saturated. Pt yelled out for staff to (sic) and turned his call light on. Nurse answered call light and Pt asked for his CNA. Nurse located CNA and she went to pt's room. Pt stated he needed to be changed, and she was able to provide cares shortly after. Soon after Pt turned his call on x2 and was checked and changed again . Noted that this progress note conflicts the interviews and observations completed by this writer on 5/29/26. Review of Resident #309's Progress Note dated 6/1/26 at 1:14 PM and documented by Regional Social Worker (RSW) PP revealed, Regional MSW (Masters Social Worker) approached resident after hearing him call out for help in his room. Upon entering room, resident was laying in bed with his call light in reach . Resident states that he was hoping to have an aide come down and help change him as well. RSW PP assisted Resident in hitting his call light and stopped at the nurse's station to report resident desire to have an aide check on him. Floor staff state that he has been yelling out for help frequently today and will send staff away upon entering his room., as well as him recently being checked on and being dry. Resident has a history of this behavior, and presentation is not atypical. Review of Resident #309's Call light log revealed that Resident #309's call light had been activated twice on 6/1/26 at 1:36 AM and 3:20 AM. Noted that Resident #309's call light log does not reflect that Resident #309's call light was activated around 1:14 PM as documented in RSW PPs progress note dated 6/1/26. Review of Resident #309's Toileting Task dated 6/1/26 revealed that staff had documented that Resident #309 was incontinent twice on 6/1/26 at 6:46 AM and 11:52 AM. Noted that Resident #309's toileting task did not reflect the report of staff frequently checking on Resident #309 throughout day as noted in RSW PP's progress note on 6/1/26. On 6/2/26 at 2:35 PM, this writer requested the facility's Abuse/Neglect policy. The facility did not provide the policy by survey exit.

Based on observation, interview, and record review, the facility failed to identify and thoroughly investigate an allegation of neglect for 1 (Resident #309) of 11 residents reviewed for abuse and neglect resulting in an allegation of neglect going unaddressed and the potential for ongoing neglect due to an incomplete investigation. Findings include:Resident #309During an observation on 5/29/26 at 10:36 AM, this writer noted that the facility's call light board at the 300-hall nursing station indicated that Resident #309's call light was activated on at 8:51 AM. As this writer was looking at the call light board, Certified Nursing Assistant (CNA) R looked at the call light board and then went to Resident #309's room at 10:41 AM. At 10:43 AM, CNA R exited Resident #309's room. It was noted that Resident #309's call light had been turned off. During an observation on 5/29/26 at 10:43 AM, this writer entered Resident #309's room and noted a strong smell of urine. Resident #309 was lying in his bed in a soiled hospital gown, with a soiled brief, pad, and sheets. Resident #309 yelled out as this writer entered his room, I need to be changed! Resident #309 reported he turned his call on to get help with being changed more than an hour prior to when CNA R entered his room. Resident #309 reported he was lying in a soiled brief, and that he had turned his call light on several times throughout the night and morning to get changed, but staff just turned off the light, said they would come back, but never did. Resident confirmed that he had asked CNA R to change him, and she said she would get his aide and be back, and then she left his room. Resident #309 voiced frustration about being left wet and soiled overnight. Resident #309 reported he felt embarrassed that he had to lay in soaked briefs, and he felt like the staff did not care about him, and he was so angry that the facility treated him so poorly. Resident #309 reported that it was common for the staff to ignore him all night and day because they don't like me or care. It was noted that Resident #309's call light was attached to his bed, and out of his hand. At 5/29/26 at 12:02 PM, CNA NN entered Resident #309's room to assist with incontinence care. CNA NN removed Resident #309's blanket from him and confirmed that Resident #309 was lying in a soiled brief. Resident #309 again confirmed to this writer and CNA NN that he had not received care since the evening before. In an interview on 5/29/26 at 1:34 PM, CNA NN confirmed that she was the staff member assigned to take care of Resident #309 that day, and that 12:02 PM was the first time that she had been in Resident #309's room to provide care to him. CNA NN reported that it was common for the night shift staff to not complete care on residents throughout the night, so she would often find residents wet and soiled in the morning. CNA NN reported that she had reported those concerns several times to the nursing staff and management, but care had not improved. CNA NN reported that she had also found residents being double briefed on multiple occasions, which she had also reported to nursing staff. In an interview on 5/29/26 at 1:43 PM, CNA MM reported she had voiced concerns to facility management about night staff leaving residents wet and soiled for extended periods of time. CNA MM reported that she had observed residents being double briefed by night shift, and even though she reported it to management, it continued to happen. CNA MM reported that Resident #309 was often found in soiled briefs. CNA MM reported that she recently had to Scrape bowel movement off of a resident's buttocks because it had been stuck on them for so long. CNA MM reported that she felt like the aides were doing everything they could to provide good care, and it was frustrating that management ignored concerns brought forth that could improve resident care. During an interview on 5/29/26 at 2:33 PM, this writer informed Nursing Home Administrator (NHA) A who was the designated abuse coordinator of the facility, of the concern that Resident #309 had not received incontinence care from 8:50 PM on 5/27/26 to 12:02 PM on 5/28.26.During an interview on 6/3/26 at 1:36 PM, Nursing NHA A reported that the Assistant Director of Nursing (ADON) AA had looked into the concern. NHA A reported that Resident #309 had reported that he had been checked on at 3:00 AM, and that the staff caring for Resident #309 on 5/28/26 had not been trained, so she felt that ADON AA had addressed the concern. When this writer queried NHA A if she or ADON AA had any documentation to verify what they completed for the investigation, NHA A reported that she would provide information for this writer to review. On 6/4/26 at 11:47 AM, NHA A provided a One on one in service record dated 5/30/26 that indicated that CNA NN had received a verbal review of Kardex (care plan sheet that aides use to follow resident care plans), every 2-hour checks, check all residents on rounds and report refusals. This was signed by ADON AA and CNA NN on 5/30/26. Noted that there was no further information to review and no indication or documentation of a thorough investigation per exhibit 369 in the State Operations Manual Appendix PP. On 6/2/26 at 2:35 PM, this writer requested the facility's Abuse/Neglect policy. The facility did not provide the policy by survey exit. For further information, please see F600.

This citation pertains to intake #2740840 and #2788540.Based on interview and record review, the facility failed to prevent the worsening of pressure injuries in 2 residents (Resident #104 & #101) of 5 residents reviewed for pressure ulcers, resulting in harm to Resident #104 when staff did not transcribe and enter hospital wound instructions, did not perform an initial wound assessment, and did not ensure measures were in place to promote healing of an Unstageable pressure injury (a full-thickness wound where the true depth and extent of tissue damage cannot be determined because the wound bed is covered by slough (moist dead tissue), eschar (crusty dead tissue), or both) on sacrum (tailbone) which led to hospitalization for sepsis (life threatening condition due to infection) due to wound infection. Resident #101 did not receive consistent wound care for an Unstageable pressure injury to the right heel, resulting in worsening of the wound and infection that required antibiotic (medication to treat infection) interventions. Findings include: Resident #104Review of an admission Record revealed Resident #104 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: metabolic encephalopathy (altered mental status). Review of a Minimum Data Set (MDS) assessment for Resident #104, with a reference date of 2/12/26 revealed a Brief Interview for Mental Status (BIMS) score of 5, out of a total possible score of 15, which indicated Resident #104 was cognitively impaired. Review of the Functional Status revealed that Resident #104 was dependent on staff for bed mobility and toileting.Review of Resident #104's Skin Care Plan revealed, Focus: At risk for alteration in skin integrity related to pressure ulcer right hip, history of scrotum and gluteal cleft wounds, diabetes mellitus, incontinence associated dermatitis.Date initiated: 2/6/26, Revision on: 2/20/26.Will refuse showers, will refuse cares and positioning. Interventions: .Barrier cream to peri area/buttocks as needed. Date initiated: 2/6/26 .Elevate heels as able. Date initiated: 2/10/26 .Incontinence care as needed. Date initiated: 2/10/26 . It was noted that the care plan did not identify a wound on the sacrum and there were no interventions created to address the revision on 2/20/26 for refusal of care. Review of Resident #104's Pressure Ulcer Care Plan created on 2/20/26 revealed, Focus: Resident admitted to facility with a pressure ulcer of sacrum unstageable related to impaired mobility, incontinence, refusal of care, refuses to be repositioned, and will refuse to get out of bed . Interventions: .Administer treatments per physician orders.APM (alternating pressure mattress) .Incontinence management .Date initiated 2/20/26. It was noted that the pressure ulcer care plan was developed on 2/20/26 (14 days after admission) and all interventions were developed on 2/20/26. Review of Resident #104's Incontinence Care Plan revealed, Focus: Urinary incontinence and urinary retention. Date initiated: 2/10/26. It was noted that the care plan did not indicate that the resident refused incontinence care and/or that the resident required frequent incontinence care. Review of Resident #104's Hospital Discharge Summary dated 2/6/26 at 12:44 PM obtained from Resident #104's facility records revealed, .Hospital problem list: .skin ulcer right hip with fat layer exposed, incontinence associated dermatitis (skin condition caused by contact with urine or stool, leading to redness, rash, erosion, and increased risk of infection and pressure ulcers). There was a handwritten note attached that included admission information obtained via phone call between hospital staff and an unknown facility staff that indicated, .hard to turn, very stiff.open spots to bottom, sore right hip Monday, Wednesday, Friday change xeroform/mepilex (bandage). This information was not transcribed to Resident #104's facility records.Review of Resident #104's Hospital Patient After-Visit Summary (Discharge Instructions) dated 2/6/26 obtained from Resident #104's facility records revealed, .Wound care instructions: Right hip wound: cleanse with wound cleanser or normal saline and gauze, apply single layer Xeroform (a non-stick anit-bacterial bandage) to wound bed, cover with bordered foam dressing. Change every M/W/F (Monday, Wednesday, Friday) and as needed. Turn and reposition frequently to offload wound. Twice a day and after toileting, cleanse buttocks and scrotum gently and dry. Apply thin layer zinc barrier (like desitin or over the counter diaper rash cream with zinc oxide) to denuded skin (when the outer layer of skin is removed, exposing the sensitive underlying tissue, making it vulnerable to injury and infection) and peri-area (genitals and buttocks) to protect from incontinence (urine and stool). Avoid friction and shear with transfers and repositioning in chair/bed. Goal: to protect denuded skin and keep skin folds clean and dry. If your wound does not heal within 2 weeks of discharge, we recommend that you follow up with your primary care physician for wound check as you may need a referral.Pressure prevention measures are very important, including offloading wounds. Turn side to side to side every 2 hours when in bed. Float heels. Please discuss wound healing need for high protein diet and vitamin supplements with your primary care provider . There was extensive printed information related to the prevention of a pressure ulcer attached to the after-visit summary. The wound care instructions were not transcribed to the resident's treatment orders and/or care plan upon admission.Review of Resident #104's Admissions Assessment-Total Body Evaluation documented by Licensed Practical Nurse (LPN) L dated 2/6/26 at 9:59 PM revealed, . Describe abnormalities: Right trochanter (hip) surgical site 35 cm (centimeter) x 6 cm. There was no documentation of any open wounds and/or refusals for skin assessment.Attempts were made to contact LPN L for an interview with no return call prior to survey exit.Review of Resident #104's Physician Orders revealed, no orders related to wounds or skin on the sacrum in the resident's record from admission on [DATE] through 2/12/26.Review of Resident #104's Treatment Administration Order (TAR) for February 2026) revealed, no skin treatments were administered to Resident #104's from admission on [DATE] through 2/12/26.Review of Resident #104's Facility Provider Visit Note dated 2/9/26 did not include documentation that the provider assessed Resident #104's wounds, and the assessment/plan did not include any skin related diagnoses and/or treatment orders.Review of Resident #104's Skin/Wound Note dated 2/9/26 at 2:45 PM created by Assistant Director of Nursing (ADON) C revealed, Attempted to assess the resident for skin issues. It is documented in his admission eval that he has a surgical incision on his right hip. Resident denies having a surgical incision on his hip. He would not allow me to assess his skin by moving him.Review of Resident #104's Facility Provider Visit Note dated 2/11/26 revealed, .follow up after admission to facility on 2/6/26. He reports his back is hurting. Physical exam: .Skin-no masses, no rashes, no lesion on exposed skin. The assessment/plan did not include any skin related diagnoses and/or treatment orders.Review of Resident #104's Nursing Note dated 2/11/26 revealed, discussed resident during weekly Medicare meeting. He admitted on [DATE] with an admitting dx (diagnosis) of Metabolic Encephalopathy (change in mental status) .Barriers to d/c (discharge): little participation from resident to participate in therapy sessions, resident c/o (complains of) pain in bilateral legs at times. There was no documentation related to skin wounds or the resident refusing care.Review of Resident #104's Progress Notes written on 2/11/26 by LPN W revealed, Resident incontinent of bowel and bladder. Refuses to get out of bed d/t (due to) BL (bilateral) IE (lower extremity). Able to make needs known. Refuses therapy at this time. There were 4 separate, identical notes created on 2/11/26 but they were given effective dates of 2/7/26, 2/8/26, 2/9/26 and 2/10/26.In a subsequent interview on 3/3/26 at 4:39 PM, LPN W reported that she did not normally work on Resident #104's unit and did not remember caring for the resident.Review of Resident #104's Nutrition/Dietary note dated 2/12/26 (6 days after admission) revealed, .Skin: surgical incision. There was no documentation related to skin wounds or a need to increase protein in diet due to wounds.Review of Resident #104's Skin/Wound Note dated 2/13/26 at 11:15 AM revealed, New skin issue, location: sacrum. Issue type: pressure ulcer/injury . Pressure ulcer staging: Stage 3 pressure ulcer/injury-full thickness skin loss. Wound was present on admission. Exact date: 2/13/26 .length: 7.92 (cm) Width: 8.1 (cm) Depth: 0.2 (cm) . granulation: 100%. Exudate (drainage) amount: moderate. The information related to how long the wound had been present was noted to be inconsistently documented. The attached photo was reviewed and showed multiple open areas on the buttocks where the top layer of skin was missing. The skin between the open areas and directly surrounding the wound was dark black. Review of Resident #104's Physician Orders revealed, Start date: 2/14/26: Wound Care: Cleanse affected area on sacral region with generic wound cleanser and pat dry. Apply a cut to fit collagen sheet (promotes healing) only to the wound bed and cover with a 5x5 bordered foam dressing in the evening every other day for wound care.Review of Resident #104's Nursing Note dated 2/15/26 at 1:25 PM revealed, Resident A&Ox4 (alert and oriented), able to make needs known.Requires extensive assist x 2 with turning and repositioning, incontinence care. Total dependent with transfers. Is incontinent of bowel and bladder. Dressing to bilateral buttocks intact. There was no documentation related to Resident #104 refusing care.Review of Resident #104's Nursing Note dated 2/16/26 at 2:49 PM revealed, Resident A&Ox4, able to make needs known.Requires extensive assist x 2 with turning and repositioning, incontinence care. Total dependent with transfers. Is incontinent of bowel and bladder. Dressing to bilateral buttocks intact. It was noted that this documentation was identical to the day before.Review of Resident #104's Wound Provider Rounds dated 2/17/26 at 11:11 AM revealed, .Unstageable Sacral Pressure Ulcer.Noted in hospital records it was gluteal stage 2. Patient presently in a regular bed. No heel protectors. Wound measurements 7.5 cm x 9.9 cm x 0.2 cm (depth). 60% granulation, 40% slough. Wound pink. Heavy serosanguineous drainage. Edges intact. Surrounding tissue pink, fragile. Assessments/Plans: Pressure ulcer of sacral region, unstageable. Recommendations cleanse with generic wound cleanser/normal saline, pat dry, apply sheet of honey coated absorbent dressing Manuka (protects against bacteria and maintains moist environment to promote healing) and cover with two 6 x 6 silicone foam super absorbent dressings since 1 on each buttock. CHANGE EVERY DAY. Recommend APM (alternating pressure mattress) bed. Recommend heel protectors. Recommend offloading. Frequent incontinence changes. Noted below the orders were entered inaccurately for every other day, instead of every day as written above, and the resident did not have pressure ulcer interventions (heel protectors and APM bed) in place during the provider's visit. Review of Resident #104's Physician Orders revealed, Start date: 2/17/26: Wound Care: Cleanse affected area on sacral region with generic wound cleanser and pat dry. Apply a sheet of Manuka to the wound bed and cover with two 5x5 bordered foam dressings (one on each buttock) in the evening every other day for wound care. It was noted that the wound care was entered incorrectly, to be completed every other day instead of every day as ordered by the wound provider on 2/17/26 which resulted in the next wound care due 2/19/26. The administration record indicated that LPN X performed the wound care on 2/19/26, and there was no documentation that the care was performed on 2/21/26. There was no other documentation in progress notes that any additional wound care was performed and/or attempted. There was no order for PRN (as needed) wound care. In an interview on 3/4/26 at 1:41, LPN X reported that she did not remember Resident #104 and could not recall the wound care that had her initials on it.Review of Resident #104's Physician Orders revealed, Start date: 2/17/26: House liquid protein, two times a day Pro Stat 30 cc (about 1 ounce) for wound healing. The administration record indicated that Resident #104 missed 2 of 9 opportunities due to the treatment not available. In an interview on 3/4/26 at 12:58 PM, Certified Nursing Assistant (CNA) Z reported that Resident #104 was very hard to roll and reposition and required at least 2 people at all times, but he did not refuse cares. CNA Z reported that Resident #104 was incontinent and would press his call light if he needed incontinence care. CNA Z reported that Resident #104 had developed a very bad wound after he admitted .Review of Resident #104's Toileting and Incontinence Care Record completed by the CNA's from 2/6/26-2/22/26 revealed that the resident did not have any refusals of care.In an interview on 3/4/26 at 2:56 PM, CNA F reported that when Resident #104 first admitted to the facility he was very alert and had a lot of pain when staff would perform incontinence care and repositioning. CNA F reported that towards the end of her shift on Saturday 2/21/26 at approximately 6:45 AM she had noticed Resident #104 had a large bandage covering his sacrum that smelled badly and was soiled with urine. CNA F reported that Resident #104 was not talking to staff or eating/drinking like normal. CNA F notified LPN K about the concern with Resident #104's mental status and that his bandage needed to be changed. LPN K brought in a new bandage and sat it on the table but said she would come back later to change it. CNA F reported that she left for the day around 7:00 AM and then returned at 7:00 PM for her next shift and found that Resident #104's bandage was still on the table. CNA F reported that Resident #104 was staring off into space and could not hold a cup to take a drink. CNA F notified LPN K again regarding the concerns about Resident #104 change in mental status and that his dressing was still completely soiled and smelled bad. CNA F reported that several hours later LPN L (a nurse from the other unit) walked over to assess Resident #104 and change the bandage. CNA F reported that LPN L quickly replaced Resident #104's bandage with a clean one but did not cleanse the wound. CNA F reported that soon afterwards on 2/22/26 (early AM) Resident #104 was sent to the hospital. In an interview on 3/5/26 at 8:22 PM, LPN K reported that on 2/21/26 around 7:00 AM the CNA's reported that Resident #104 was not acting like himself, and LPN K knew that the provider was suspecting a wound infection but did not call the provider regarding Resident #104's condition until 2/22/26 at approximately 1:00 AM (18 hours later). LPN K reported that Resident #104's wound looked very bad, had a lot of drainage and smelled awful prior to the resident being sent to the hospital. LPN K reported that the wound dressing order was just to clean the wound and put a new bandage on it, and she had never heard of a sheet of Manuka to be applied to the wound bed. LPN K reported that she had asked LPN L to help with the wound care on 2/21/26; LPN L reported that she not received any wound care training except for what she learned in school and rarely saw management on the night shift.Review of Resident #104's Change of Condition documented by LPN K dated 2/22/26 at 1:28 AM revealed, .Altered mental status, seems different than usual .Possible sepsis from coccyx wound .send to ER (emergency room) .Review of Resident #104's Hospital records dated 2/22/26 revealed, .Patient comes from (skilled nursing facility) first noticed fever and low oxygen saturation yesterday .Of note, the patient was just discharged approximately 2 weeks. has chronic wounds to the sacrum and right hip.The ulcer on his sacrum is deep, foul-smelling and dark in color questioning necrosis (dead tissue). has been evaluated by general surgery and plastic surgery, with plan for possible OR (operating room) for debridement (removal of dead tissue) tomorrow. Positive blood cultures (indicate an infection in the bloodstream). He is being treated with Rocephin (antibiotic) and flagyl (antibiotic). Assessment and Plan: .Sepsis secondary to sacral decubitus ulcer. Surgery Consultation Note: .Sacral pressure sore: 13 cm x 8 cm unstageable pressure sore with black eschar .anticipate the wound extends deeper beneath the eschar. Wound images were attached that indicated an Unstageable pressure wound on the sacrum and Deep Tissue Injuries (a serious form of pressure injury where underlying tissue is damaged causing a dark colored area without an open lesion) to the right and left heel.In an interview on 3/4/26 at 11:24 AM, Unit Manager (UM) P reported that she was aware of the concerns about wound care not being performed as ordered and had been trying to monitor the reports in the computer to identify missed treatments. UM P reported that it was her understanding that ADON C was planning to complete re-education to nursing staff.In an interview on 3/5/26 at 10:25 AM, ADON C reported that she managed wounds for the facility. ADON C reported that when she assessed Resident #104 on 2/9/26 she was not aware of a wound on his sacrum but was trying to follow up on the right hip surgical incision that was noted on his admission assessment by LPN L which she determined was a healed surgical scar. ADON C reported that she did not know about the wound orders on Resident #104's hospital paperwork and was not aware of any concerns related to the sacrum until the resident's nurse brought it to her attention on 2/13/26. ADON C reported that she had not reviewed Resident #104's hospital paperwork until she had reviewed it that day with this surveyor. ADON C reported that based on the written note attached to the discharge summary, it appeared a facility staff member, likely LPN L had received wound information verbally from the hospital prior to the resident's admission on [DATE] but did not document an assessment of the wound and/or wound care orders in the resident's record. ADON C reported that Resident #104's hospital after-visit summary also included wound care instructions, but they were not transcribed into the resident's record. ADON C reported that Resident #104's wound orders should have been entered into the resident's physician orders at the facility on 2/6/26. ADON C reported that she initiated wound dressing/treatment orders for Resident #104's wound on 2/13/26 and then followed up along with the wound care provider on 2/17/26. ADON C reported that on 2/17/26 the provider changed the wound dressing orders and ordered a culture of the wound. ADON C reported that she first discovered in December (3 months ago) that other residents were not getting their wound dressings changed and she was working with UM P to ensure that the wound care was being performed as ordered. ADON C reported that there were no refusals documented for incontinence care, skin checks and/or wound care except for one time on 2/9/26 when the resident would not move his body for ADON C to assess his surgical scar. In an interview on 3/5/26 at 2:50 PM, Director of Nursing (DON) B reported that nursing staff had not documented any refusals for incontinence care and/or wound care for Resident #104. DON B reported that she had been aware of wound care not being completed for other residents in the past and along with ADON C they were monitoring staff and orders closely.In an interview on 3/5/26 at 2:44 PM, Nursing Home Administrator (NHA) A reported that she was not aware of any issues related to wound care and dressing changes not being completed. NHA A reviewed her QAPI (Quality Assurance and Performance Improvement) book and reported that the only wound related discussions during the meetings had been the number of wounds that the facility had.Review of Resident #104's Braden Scale for Predicting Pressure Ulcer Risk Evaluation dated 2/6/26 at 8:10 PM revealed, Sensory perception: slightly limited. Moisture: occasionally moist. Activity: chairfast, resident is completely immobile, does not make even slight changes in body or extremity position without assistance. Nutrition: adequate. Friction and shear problem. Braden Score: 13. There was a subsequent evaluation on 2/14/26 with a score of 14 and on 2/21/26 the score was 15. (a score of 18 or higher: Low risk, 15-17: Moderate risk, 13-14: High risk and 12 or lower: Very high risk.) The assessments indicated the resident's risk for pressure ulcers improved. Resident #101Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: weakness and falls. Review of Resident #101's Pressure Ulcer Care Plan revealed, .has pressure injury, with risk for delayed wound healing.Right heel.Last Revision: 11/8/25. Interventions: .Provide wound care as ordered by physician.Skin evaluations weekly.In an interview on 3/4/26 at 11:24 PM, UM P reported that she was aware of Resident #101's right heel wound and was aware of issues in December and again in January with wound dressings not getting changed and incomplete documentation. Reviewing the current treatments and assessments, UM P reported that Resident #101 did not normally refuse wound care but had 6 documented refusals for wound care in February (2/5, 2/7, 2/16, 2/17, 2/21, 2/22, and 2/26). UM P would expect the nurses to enter a progress note recording the refusal and documenting an attempt to perform the wound care at another time but there was no documentation of either. In addition to that, UM P reported that Resident #101 had missed several weekly full skin checks the past couple months (2/17/26, 1/27/26, 1/6/26).In an interview on 3/4/26 at 10:50 AM, Nurse Practitioner (NP) DD reported that on 12/17/25 when she first assessed Resident #101's right heel wound, the dressing was grossly soiled, dated 12/11/25 (6 days old) and the dressing in place was not consistent with the orders on record at that time. NP DD reported that she was concerned about cellulitis and ordered an oral antibiotic. NP DD discussed her concerns to the nursing managers related to the dressing not being changed every other day as ordered. When NP DD followed up on 1/13/26 the wound was deteriorating, therefore NP DD changed the orders every day and added a topical antibiotic. Then NP DD returned on 1/27/26 the wound had not improved and again the dressing was soiled and dated 1/22/26 (5 days old). NP DD reported her concerns to the nursing managers related to the dressing not being changed daily as ordered and the facility not having the topical antibiotic available. That was the last time NP DD saw the resident.Review of Resident #101's Wound Provider Rounds dated 12/17/26 revealed, .Wound consult for right heel ulcer.Most recent dressing dated 12/11/25 without honey fiber present.Assessment/Plan: Pressure ulcer of right heel unstageable.Wound nurse notified and aware of lack of dressing change. Unable to debride due to adherent eschar.Concerns for cellulitis (skin infection). Recommend Clindamycin (oral antibiotic).Review of Resident #101's Wound Provider Rounds dated 1/6/26 revealed, Wound consult for right heel ulcer.Wrong wound dressing.wound care nurse aware.Review of Resident #101's Wound Provider Rounds dated 1/13/26 revealed, Wound consult for right heel ulcer.Deteriorating.Review of Resident #101's Wound Provider Rounds dated 1/27/26 revealed, Wound consult for right heel ulcer.notes painful heel.Mupirocin not started. Last dressing changed 1/22. Concern for infection.strong odor .Review of Resident #101's Physician Orders for February revealed, Wound care: Right heel.Cover the wound bed with cut to fit xeroform gauze and cover with a super absorbent foam border dressing daily and PRN. Start date 2/11/26. It was noted that from 2/11/26 through 2/28/26 Resident #104 missed 1 treatment (2/12) and refused 4 treatments (2/16, 2/21, 2/22 and 2/26). There were no progress notes and/or PRN wound care documented for these days.Review of Resident #101's Physician Orders for January revealed Wound care: Right heel: Cleanse right heel with 3% acetic acid and pat dry. Apply mupirocin 2% (antibiotic) ointment into wound bed. Cover the affected area with dermablue foam (bandage used for wound with heavy drainage) then cover with silicone super absorbent dressing daily and PRN, Start date 1/13/26 It was noted that from 1/13/26 through 2/10/26 Resident #101 missed 4 treatments (1/14, 1/17, 1/22, and 1/24) and refused 4 treatments (1/27, 1/30, 2/5 and 2/7). There were no progress notes and/or PRN wound care documented for these days. There was also an oral antibiotic started 1/27/26, Doxycycline tablet 100 mg give 1 tablet two times a day for RIGHT HEEL INFECTION for 10 days. It was noted that Resident #101 received 19 of 20 doses. This record is consistent with NP DD's recollection of events.Review of Resident #102 Physician Orders for December revealed Wound care: Right heel.cut honey fiber to fit wound bed.cover with silicone super absorbent dressing every other day and PRN. Start date 12/1/26. It was noted that from 12/1/25 through 12/31/25 Resident #101 missed 7 treatments (12/3, 12/15, 12/17, 12/18, 12/20, 12/24, and 12/28.) There was also an oral antibiotic started 12/17/25, Clindamycin capsule 300 mg give 1 capsule.three times a day for WOUND INFECTION for 7 days. It was noted that Resident #101 received 20 of 21 doses. This record was consistent with NP DD's recollection of events.In an interview on 3/4/26 at 12:17 PM, LPN S reported he worked with Resident #101 often and he was not aware of the resident having any wounds or dressing change orders for a long time and reported that he did not see a dressing on the resident on 3/3/26. LPN S noted that normally dressing changes are completed on the night shift. LPN S reported that Resident #101 does not normally refuse and overall, the facility doesn't have many residents that refuse dressing changes. LPN S reported that there have been times when agency nurses will not complete wound dressing changes.In an interview on 3/4/26 at 12:24 PM, LPN H, who was assigned to Resident #101 that day, reported that she was not aware of a wound dressing on the resident and had been in the room that morning to administer medications. It was noted that LPN H had documented checking placement of Resident #101's right heel dressing that morning.In an interview and observation on 3/4/26 at 12:53 PM, CNA Z reported that Resident #101 still complains that his heel is sore but reported that she did not remove his socks that morning when she got him out of bed. Resident #101 was in his wheelchair in the TV room and allowed CNA Z to remove his sock and this surveyor observed a large bandage on Resident #101's heel.In an interview on 3/5/26 at 10:25 AM, ADON C reported that she had found Resident #101's dressing not changed and the documentation was missing and/or the documentation indicated the dressing had been changed more than one time in the past. ADON C reported that she was aware the wound care provider had been upset about finding dressing not being changed a couple months ago. ADON C reported that they had determined that most of the issues were with agency nurses and/or because first shift nurses didn't have time to do the dressing changes. ADON C reported that they have since changed all wound care orders to the night shift.

This citation pertains to intakes: 2694470 and 2685061Based on interview and record review the facility failed to perform cardiopulmonary resuscitation (CPR) on [DATE] for 1 (Resident #13) of 1 resident reviewed for code status (medical orders that indicate a resident's preference for treatment in a medical emergency) orders, resulting in an immediate jeopardy when Resident #13 was found unresponsive and subsequently died.Findings include:Interviews and record reviews verified that Agency Registered Nurse (RN) AA did not perform CPR on Resident #13, who was a full code, and was found unresponsive on [DATE] at approximately 5:02 am and subsequently died.The immediate jeopardy began on [DATE] when staff did not perform CPR on a full code resident (Resident #13). On [DATE] at 3:20 PM, the Nursing Home Administrator was verbally notified and received written notification of the immediate jeopardy. This surveyor confirmed by observation, interview, and record review, the immediate jeopardy was removed on [DATE], but noncompliance remains at a scope of isolated and severity of actual harm due to the fact that all staff including agency had not been educated and sustained compliance had not yet been verified by the State Agency.According to the 2025 American Heart Association Guidelines for CPR and ECC (CPR and ECC Guidelines | American Heart Association CPR & First Aid), Healthcare Professionals (HCPs) have a prima facie obligation to follow institutional policies regarding ethical issues in resuscitation in addition to the guidelines in this document. In turn, institutions have an obligation to develop ethically sound policies, educate HCPs on both policies and ethical guidelines, and provide the resources necessary to adhere to these standards and resolve difficult issues when they arise.Once initiated, resuscitation can be discontinued, but the decision not to initiate treatment is often irrevocable. Thus, HCPs should generally err on the side of providing resuscitation when uncertainty exists.focusing on the special circumstances as etiologies of cardiac arrest, provide and evaluate specific treatment options meant to be administered in addition to, and alongside, traditional resuscitation care. Unless otherwise specified, all patients should receive standard airway management, support of breathing, and treatment of hypotension, arrhythmias, and cardiac arrest consistent with local protocols and the resources available at the site of treatment.Resident #13Review of an admission Record revealed Resident #13 was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: hereditary ataxias (poor muscle control and clumsy movements), dysphagia following cerebral infarction (difficulty swallowing after a stroke), and Parkinson's disease (a movement disorder of the nervous system of the body that worsens over time).Review of Order Summary for Resident #13 revealed .admitted to (Name Omitted) hospice services.Adv Directive (advance directive-code status) Full Cardiopulmonary Resuscitation (CPR) with start dates of [DATE].Review of Care Plan for Resident #13 revealed no care plan documentation regarding code status, advance directives, or preference related to medical emergency treatment.Review of Nursing Progress Note for Resident #13 dated [DATE] at 05:18 (5:18 am) authored by Agency Registered Nurse (RN) AA revealed Staff reported resident was unresponsive at 0502 [DATE] (5:02 am) pt (patient) heart and lungs sounds were examined there were no heart or lung sounds present. No spontaneous cardiac or respiratory activity present in response to verbal or painful stimuli no capillary reflex present pupils are fixed and dilatated, resident was pronounced dead at [DATE] at 0508 (5:08 am) pt was presently Hospice with (Name Omitted).In a telephone interview on [DATE] at 11:08 AM Hospice Supervisor (HS) OO reported Resident #13 was originally admitted to hospice services in December of 2024. HS OO reported Resident #13 was on and off services a couple of times during the last year. HS OO reported Resident #13, and her family, had made the decision for Resident #13 to remain a full code while on hospice services. HS OO stated Resident #13 was a full code the entire time she was on our services, including the most recent re-admission to hospice on [DATE] until her death. In an interview on [DATE] at 11:35 AM, CNA I and CNA D reported a resident's code status was in their record, in their care plan, and on the Kardex (medical patient information system that stores information regarding patient needs for nursing staff to access quickly). CNA I and CNA D reported if a resident was found unresponsive and was a full code the nurse would have to start a code. CNA I and CNA D reported CNAs cannot assist with CPR, they are not certified, but they can be instructed by the nurse to do other things during a code.In an interview on [DATE] at 1:05 PM, Attending Physician (AP) MM reported a resident's code status requires a physician order. AP MM reported if a resident was a full code, and there was a medical emergency, CPR should be initiated and continue until EMS (emergency medical services/911) arrives.In a telephone interview on [DATE] at 1:13 PM, Agency RN AA reported on [DATE] she was the assigned nurse for Resident #13. Agency RN AA reported at about 5:00 AM on [DATE] a CNA came to her and asked her to look at Resident #13. Agency RN AA reported when she observed Resident #13 at about 5:00 AM on [DATE] she could clearly see that Resident #13 had her eyes open, mouth open and that she had died. Agency RN AA stated they told me she was on hospice. When queried, Agency RN AA stated she did not recall Resident #13's code status. When further queried, Agency RN AA stated She did not perform CPR when Resident #13 was found unresponsive on [DATE] at about 5:00AM.In a telephone interview on [DATE] at 1:52 PM, CNA QQ reported she was working on [DATE], assigned to the same hall where Resident #13 resided, but not assigned to Resident #13. CNA QQ reported CNA W was assigned to Resident #13 the night she passed away. CNA QQ reported CNA W came to her during last rounds, about 5:20 AM and asked for her help with Resident #13's postmortem care. CNA QQ reported she went to Agency RN AA and told her Resident #13 was a full code, and Agency RN AA did nothing. CNA QQ reported CPR was not started and EMS was not called. CNA QQ reported she knew Resident #13 was a full code even though she was on hospice services.In an interview on [DATE] at 3:06 PM, Nursing Home Administrator (NHA) A reported she had investigated staff not performing CPR for Resident #13 on [DATE]. Review of documented interview of Agency RN AA completed by Director of Nursing (DON) B and NHA A provided by NHA A on [DATE] revealed On [DATE].This writer (NHA A) asked Agency RN AA to describe the event that transpired, and she stated she was alerted by a CNA that Resident #13 was unresponsive and it was determined that the resident had passed away.This writer asked whether CPR was started and Agency RN AA stated, She's on hospice. They told me she was on hospice. I then informed the nurse that being on hospice doesn't automatically make a resident a DNR and that they were hospice companies that allowed residents to remain a full code. I then asked, So is it safe to state that you did not start CPR on this resident? and Agency RN AA stated Yes. But the hospice company didn't even tell me she wasn't a DNR. There's no paperwork on it! Not anything printed that she was a full code.In a telephone interview on [DATE] at 7:43 PM, CNA W reported she was assigned to Resident #13 the night she passed away. CNA W reported she assisted Resident #13 to bed about 1 or 1:30 AM on [DATE]. CNA W Reported Resident #13 was a high fall risk, and she had observed Resident #13 from the hallway after she assisted her to bed but did not go back into her room until last rounds about 5:00 AM. CNA W reported the door to Resident #13's room was left slightly open so Resident #13 could be observed to make sure she was not on the floor. CNA W reported Resident #13 was incontinent and check and changes should be done every 2 hours, but Resident #13 was not a heavy wetter, and she typically did not check and change Resident #13 between her being put to bed and being the first one up about 5:00 AM. When queried, CNA W reported it was typical that she did not physically disturb Resident #13 for 4 hours or more when she was in bed sleeping. CNA W reported her typical routine was to assist Resident #13 to bed between 12:00 - 1:00 AM and not check on her other than walking past the door to observe her, again until 4:00-5:00 AM. CNA W stated on [DATE] I went into Resident #13's room about 4:30 or 5:00 AM, I went to the sink and turned on the water, I was talking to Resident #13, asking how she slept, and she did not respond. I went to her and touched her and she felt cold. I panicked and yelled for the nurse. I stood in the doorway, watching. A different nurse came into the room then went to the medication cart in the hallway to get a stethoscope. Then the nurse told me she (Resident #13) was dead and to clean her up and prepare her for the family. CNA W stated No one did anything. No one got the crash cart. No one did CPR. No one called 911. Someone called hospice. CNA W reported a resident's code status was in their record. CNA W reported if a resident was a DNR staff did not have to do anything, and if a resident was a full code, staff should do CPR. In an interview on [DATE] at 7:52 AM, DON B reported on [DATE] she was notified via telephone Resident #13 had passed way, she was a hospice patient, and they had been notified. DON B reported she discovered when she arrived at the building later that morning that Resident #13 was a full code. DON B stated I was shocked and began education immediately. DON B reported she completed immediate education for staff in the moment of inquiry, a completed education for all staff the week of [DATE], she completed mock codes, reviewed the policy, reviewed the medical record system, educated CNAs where to find resident code statuses. DON B reported check and changes should be completed minimally every 2-3 hours, that was standard of care, and residents could be care planned for something different more specific. DON B reported code statuses should be in every resident's care plan as well.Review of facility policy Advance Directives- Code Status with a revised date of [DATE] revealed .the resident has the right to formulate an advance directive.advance directives related to code status are honored in accordance with state law and facility policy.Full Code - indicates that if a person's heart has stopped beating and/or they have stopped breathing resuscitation procedures will be provided to keep them alive. This process can include chest compressions and defibrillation and is referred to as CPR.Review of facility policy Cardiac Arrest Emergency Management (Michigan) with an issue date of [DATE] revealed .Policy overview: to provide guidelines for the car of resident who have a cardiac arrest. General guidelines CPR is to be initiated on resident in the event of a cardiac arrest unless the resident has a Do Not Resuscitate order and is properly documented in the medical record.Guidelines for a resident with a full code order:. first licensed nurse to arrive. directs additional staff to review the resident's medical record for the resident's code status.if the resident has a full code order and is without a pulse/respiration: begin CPR.direct designated staff to page Code Blue to location needed.direct designated staff to call 911 requesting emergency assistance.staff nearest the crash cart transports it and the AED (automated external defibrillator- a portable device used to treat individuals experiencing sudden cardiac arrest by delivering an electric shock to restore normal heart rhythm) to the location.The immediate jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy and correct the non-compliance.1. All resident charts were audited to confirm code status based on Resident/POA (power of attorney) wishes. Audits were completed on [DATE].2. Facility licensed staff were provided with an in-service education starting on [DATE]. Education included ensuring CPR was initiated for residents identified as full codes, a resident on hospice does not mean DNR (do not resuscitate) code status, location of code status preference in resident records, and review of facility cardiac arrest emergency management policy.3. Agency licensed staff were provided with in-service education starting on [DATE]. Education included ensuring CPR was initiated for residents identified as full codes, a resident on hospice does not mean DNR (do not resuscitate) code status, location of code status preference in resident records, and review of facility cardiac arrest emergency management policy.4. The Director of Nursing will ensure that all staff received in-service education and completed education was documented prior to working their next assigned shift.5. The Director of Nursing/Designee will monitor all booked shifts for Agency licensed staff for completion of assigned required in-service education and completed education was documented prior to working the scheduled shift.6. The medical director was notified on [DATE]. The Director of Nursing held mock CPR drills with nursing staff on each shift starting on [DATE]. Director of Nursing will conduct mock CPR drills monthly on each shift.8. Information from the drills will be reviewed for recommendations at QA&A committee meetings monthly.9. An Ad-Hoc (unscheduled) QAPI (quality assurance performance improvement) meeting was held on [DATE] to review findings and action plan.

This citation pertains to intake 2648348 and 2640731.Based on interview and record review, the facility failed to ensure residents were free from significant medication errors in 1 of 6 residents (Resident #101) reviewed for medication administration resulting in an Immediate Jeopardy beginning on 10/9/25 at approximately 9:00 AM when Resident #101 received another resident's medications which were administered by an agency nurse and nursing student. Resident #101 was found approximately one hour later and was noted to be lethargic and was hospitalized from [DATE]-[DATE] where she was diagnosed with acute metabolic encephalopathy (significant decline in brain function due to an underlying metabolic disturbance) and iatrogenic polypharmacy (harm caused by the administration of multiple medications). This deficient practice placed all residents residing in the facility at risk for significant medication errors. Findings include: The immediate jeopardy began on 10/9/25 when Resident #101 was administered another resident's medications and was sent to the hospital, where she was hospitalized from [DATE]-[DATE]. Resident #101 returned from the hospital on hospice services. Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy on 10/22/25 at 9:00 AM. The surveyor confirmed by observation, interview, and record review that the immediacy was removed on 10/11/25 and the deficient practice was corrected on 10/21/25 prior to the start of the survey. Resident #101Review of an admission Record revealed Resident # 101 was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness and essential hypertension (high blood pressure). Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 8/14/25 revealed a Brief Interview for Mental Status (BIMS) score of 10/15 which indicated Resident #101 was moderately cognitively impaired. Review of Resident #101's Hospital Records dated 10/9/25 revealed, . Assessment and plan: Acute metabolic encephalopathy and iatrogenic polypharmacy . History of present illness: . (Resident #101) presents with somnolence (abnormal drowsiness) after taking another resident's medication. (Resident #101) will respond to verbal stimuli but does not engage in conversation. She is able to follow simple commands with squeezing fingers/wiggling toes. Per report, the patient (Resident #101) was in her usual state of health today when she was given another resident's medications. These included Bupropion 450 mg (antidepressant medication), Dronedarone 400 mg (antiarrhythmic medication used to treat certain heart dysrhythmias), Eliquis 5 mg (anticoagulant medication used to treat and prevent blood clots), Fluconazole 200 mg (antifungal medication used to treat fungal infections), Fludrocortisone 0.1 mg (corticosteroid medication used to manage the body's sodium and fluid balance), Gabapentin 900 mg (anticonvulsant medication used to treat seizures and nerve pain), Norco 5-325 mg (opioid pain medication), Synthroid 112 mcg (thyroid hormone medication used to treat hypothyroidism), Metoprolol 25 mg (beta blocker medication used to treat high blood pressure and chest pain), Midodrine 10 mg (vasopressor medication used to treat low blood pressure), Pantoprazole 40 mg (proton pump inhibitor used to reduce stomach acid), Torsemide 20 mg (diuretic used to treat high blood pressure and reduce edema (swelling) in the body . Assessment and plan dated 10/13/25: Interval history: Over the weekend was reportedly mostly normal on 10/11, 10/12 family reports that she (Resident #101) was hallucinating about cats and insects in the room. Subjective: Somnolent, does not awaken easily, quite confused per daughter at bedside . Neurological: Mental Status: She is lethargic. 10/13: pt. (Resident #101) is somnolent today and not able to participate with cares. SLP (Speech Language Pathology) ordered for concern regarding issues with swallowing over the weekend, but she isn't able to participate in the evaluation. Palliative care (specialized medical care for people with serious or life-threatening illnesses) following . 10/14: (Resident #101's family member) and (local hospice facility) met and intends to sign Resident #101 up for hospice . Review of the facility Incident Report dated 10/9/25 revealed, Nursing Description: At 9:39 AM, the nurse, accompanied by two student nurses, prepared medications for the patient. Both student nurses verified and pulled the medications while the nurse rechecked each before placing them into the medication cup. Vital signs were obtained prior to administration, and the medications were given to the patient. While continuing the medication pass, it was noted that another patient had not yet received her medications, though the MAR (medication administration record) indicated they had been administered. Upon review, it was discovered that the medications for that patient had been given to the first patient in error. Resident Description: Resident Unable to give Description. Description: The nurse immediately assessed the affected patient (Resident #101), who was found to be lethargic. Vital signs were BP (blood pressure) 99/54, HR (heart rate) 72, RR (respiration rate) 16, SpO (oxygen saturation) 92%. The Director of Nursing (DON) and Nurse Practitioner (NP) were notified promptly. The NP reviewed the medications administered, consulted with medical support, and recommended hospital transfer for further evaluation. The patient's daughter was notified of the situation and transfer. The patient was transported via MMS (sic) to (local hospital) in stable condition. Level of Consciousness: Lethargic (Drowsy). Notes: patient responded appropriately oriented to person and disoriented to situation and time . Review of Resident #101's Progress Note dated 10/9/25 and documented by Nurse Practitioner (NP) BB revealed, . Nursing approached requesting my immediate attention due to the fact that Pt (Resident #101) received someone else's medications. The nurse reported that she was assisting a student nurse to administer the pt. her medication, not realizing that the other pt. who has a remarkably similar name and only one room away from pt, medications were inadvertently mixed up and given to pt. by mistake. A medication review of what pt. received revealed the following medications along with several vitamins and supplements were given: Zoloft 150 mg (antidepressant medication), dronedarone 400 mg, gabapentin 900 mg, Norco 5-325 mg, Robaxin 500 mg (muscle relaxant medication), Eliquis 5 mg, Fludrocortisone 0.1 mg, midodrine 10 mg, pantoprazole 40 mg, Wellbutrin (antidepressant) XL 450 mg, Diflucan 200 mg. Pt examined and Pt expressed she was terrified. Pt informed that we are sending her to the hospital to receive treatment and that I would stay with her until the ambulance arrives. Phoned Pt's daughter while at pt.'s bedside to report what incident and determine which hospital is preferred .Exam findings . Positive: Anxiety. Notes: Pt kept eyes closed and tried not to move while expressing her fear . Assessment and plan: F43.0- Acute stress reaction: pt. is experiencing an acute stress reaction to learning she received the wrong medications and the implications that may have to her health and life . Z77.9 Other contact with and (suspected) exposures hazardous to health: pt. received a tremendous amount of medications not intended for her. Her life depends on immediate transport to the hospital for treatment . In an interview on 10/20/25 at 2:17 PM, NP BB reported that she was notified by agency Licensed Practical Nurse (LPN) J on 10/9/25 that Resident #101 had received the wrong resident medications. NP BB reported that she immediately went to assess Resident #101 who she found to be lying in bed with her eyes closed. NP BB reported that Resident #101 was able to open her eyes and talk, but she did not want to because she was scared. NP BB confirmed that was very concerned about the number of medications that she had received and the various conditions that the medications were used to treat. NP BB reported that she had concerns that Resident #101 had the potential to experience serotonin syndrome (A serious drug reaction. It is caused by medications that build up high levels of serotonin in the body) and the potential for cardiac complications due to the large doses of antiarrhythmicmedication and cardiac medications that she received. NP BB reported that she was also concerned about the large dose of gabapentin that Resident #101 received. NP BB confirmed that Resident #101 had an allergy to Norco, and that she had also received Norco during this medication error. NP BB reported that she ordered Resident #101 be sent to the hospital because of her concerns with the potential harm caused to Resident #101 from receiving large doses of medications not ordered for her. In an interview on 10/20/25 at 2:45 PM, Family Member (FM) D reported she was notified by NP BB on 10/9/25 that Resident #101 was given the wrong resident's medications, and that the facility was sending Resident #101 to the hospital. FM D reported that she met Resident #101 at the hospital, where she noted Resident #101 to be non-responsive. FM D reported that Resident #101 slowly became more arousable during her stay in the hospital, but she also became much more confused, and the decision was made to activate Resident #101's durable power of attorney, which was followed by Resident #101 being enrolled into hospice services due to her decline. FM D reported that prior to the medication error incident on 10/9/25, Resident #101 was able to communicate well and was alert and oriented x3, able to feed herself, and required one person assistance from staff with activities of daily living (ADL) care. FM D reported that Resident #101 was discharged from the hospital on [DATE], but that she was still incredibly weak, and that the goal was to provide comfort care to Resident #101. FM D voiced concerns that the facility should have identified the potential for a medication error to happen, as Resident #101's room was next to a resident with the same first and middle name, and that their last names started with the same initial and were similar in sound, FM D reported that there had been multiple occurrences of staff mixing up Resident #101 and the other resident, and she had voiced concern about the residents being so close together with similar names. In an interview on 10/20/25 at 10:28 AM, LPN J confirmed she was the nurse that oversaw Resident #101 receiving the wrong resident medications. LPN J reported that she was an agency nurse at the facility, and she had not worked on Resident #101's unit prior to the 10/9/25. LPN J reported that she was assigned to have two nursing students with her, and that she was allowing the nursing students to prepare medications and dispense the medications to the residents. LPN J reported that one of the nursing students reviewed the medication orders for the resident in the room next to Resident #101 as they dispensed them, and then LPN J and the second nursing student were checking the medications to ensure that they were correct. LPN J reported that after the medications were prepped, she and the two nursing students went into Resident #101's room and asked her to confirm her name. LPN J reported that Resident #101 did state her first and last name, and then nursing student (NS) P administered the medications to her. LPN J reported that Resident #101 was able to engage in a casual conversation and would have been able to state her birthdate if she had been asked. LPN J confirmed that she or the nursing students did not notice that Resident #101 had said a different last name. LPN J reported that she did not verify Resident #101's birthdate, room number, or the picture in the MAR (medication administration record). LPN J confirmed that she was not familiar with Resident #101 or the resident that medications were given to Resident #101. LPN J reported that about an hour after Resident#101 received the wrong medications, she went to give the other resident her medications and noticed that they were already documented as administered. LPN J reported that she realized that she and the nursing students had administered the wrong medications to Resident #101 and she went to assess Resident #101 where she found her to be very lethargic. LPN J reported that she notified the Director of Nursing (DON) B and NP BB immediately, and they took over the care of Resident #101 after that. LPN J reported that she thought it was an accident waiting to happen to have two residents next to each other with the same first and middle name, and very similar last names in room next to each other. LPN J reported that she had never had nursing students follow her before, and that the facility and the nursing students did not give her any instruction on what the nursing students were allowed to do with her. LPN J reported that she had worked at the facility a few times, but she had never worked on the unit that Resident #101 was on. In an interview on 10/9/25 at 3:19 PM, LPN W reported he had cared for Resident #101 for several years, and that he was very familiar with her. LPN W reported Resident #101 was cognitively intact, and able to communicate with staff. LPN W confirmed that Resident #101 was able to communicate her name and date of birth . In an interview on 10/20/25 at 11:16 AM, NHA A and DON B reported they were both made aware of the medication incident on 10/9/25 right after it was discovered. DON B confirmed that a nursing student had administered the medications to Resident #101 under the supervision of LPN J. DON B and NHA A confirmed that Resident #101 was in a room right next to a resident that had the same first and middle name, and that Resident #101 and the other resident had very similar last names. NHA A and DON B also confirmed that they did not have a facility policy for student nurses at the time of the incident, and that they were no longer allowing agency nurses to work with nursing students. In an interview on 10/20/25 at 12:01 PM, Clinical Instructor (CI) K reported she had been made aware of Resident #101 receiving the wrong medications on 10/9/25. CI K reported the educational institution's policy was that nursing students were not supposed to administer medications with a nurse at the facility, and that they were only allowed to dispense and administer medications under the supervision of a clinical instructor. CI K reported that she could not confirm or deny if one of the nursing students had administered the medications because she was not present to observe. This writer asked for the contact information for the two nursing students that were involved in the incident. On 10/20/25 at 4:12 PM, this writer received a call from the Nursing School (name redacted) Faculty Director (FD) HH. FD HH reported that he wanted to present during this writer's interviews with the nursing students, and he arranged meetings with this writer and the nursing students. In an interview on 10/21/25 at 12:25 PM, Nursing Student (NS) II reported she did not recall the medication error, and that she could not remember any details of the medication administration for Resident #101. NS II was unable to report if LPN J had asked Resident #101 for her name prior to administering her medications. NS II reported she did not administer or dispense any medications. In an interview on 10/21/25 at 12:53 PM, NS P reported she had mostly observed LPN J on 10/9/25. NS P reported she did not dispense or administer medications under the supervision of LPN J. When asked by this writer why LPN J, DON B and the facility incident report indicated that she had prepared and administered the medications to Resident #101, NS P reported that did not know why. NS P reported she did not recall if LPN J had asked Resident #101 her name prior to giving her medications. In a follow up interview on 10/21/25 at 12:45 PM, FD HH reported he had met with the nursing students prior to this writer's interviews but stated that I did not coach them on what they were allowed to say or not say. It was noted that this writer had not queried FD HH about coaching the nursing students. In an interview on 10/21/25 at 12:30 PM, DON B reported she had been told on 10/9/25 by LPN J and NS P that NS P had dispensed and administered the medication that was given to Resident #101. DON B confirmed that she reported that NS P had administered the medications to Resident #101 to CI K. DON B confirmed that she was not aware that the nursing students were not supposed to administer medications without their clinical instructor present. DON B confirmed that the facility did not have a policy for how to navigate nursing students at the facility.In an interview on 10/20/25 at 12:29 PM, Facility Pharmacist (FP) L reported that as a pharmacist, she would have concerns with Resident #101 receiving such a high dose of Bupropion because that type of medication takes time to build up in the system, and there was a potential for lethargy (unusually tired), seizures. mild to moderate tachycardia (abnormally fast heart rate), neurological disturbances (wide range of conditions such as sensory changes, motor problems, cognitive impairment, and behavioral changes), tremors (rhythmic movement of body part that is out of control), dry mouth, headache and insomnia (restlessness). FP L reported that Resident #101 taking Fluconazole also increased her risk of seizures, and other expected side effects included nausea and vomiting. FP L reported that Resident #101 had the potential to experience sleeplessness, nervousness and anxiety from taking Levothyroxine 112 mcg. FP L reported that Resident #101 had the potential to experience electrolyte imbalances, hypotension (low blood pressure), dehydration, tachycardia, and headache from taking the Torsemide 20 mg. FP L reported that Resident #101 had the potential to experience QT prolongation (problem with the electrical system in your heart taking too long to recharge. This issue can lead to a life-threatening type of abnormal heart rhythm), lethargy, somnolence, and tachycardia from taking Zoloft 75 mg. FP L reported that Resident #101 had the potential to experience increased creatinine levels (waste from protein and muscle breakdown), diarrhea, nausea and vomiting from taking Dronedarone 400 mg. FP L reported that Resident #101 had the potential for increased bleeding and bruising from taking Eliquis 5 mg, and she had the potential for arrythmias and seizures due to taking Flu cortisone 0.1 mg. FP L reported that Resident #101 had the potential for hypotension, nausea, vomiting, and tachycardia from taking Methocarbamol 500 mg. FP L reported that Resident #101 had the potential to experience elevated blood pressure and reflex bradycardia (low heart rate) from taking Midodrine 10 mg. FP L reported that Resident #101 had the potential for nausea, vomiting, drowsiness, bradycardia, and hypotension from taking Norco. FP L did confirm that Resident #101 was allergic to Norco, but it was not known what type of reaction Resident #101 had experienced from taking Norco. Lastly, FP L reported that she had major concerns for Resident #101 taking such a large dose (900 mg) of Gabapentin because this medication needs to be built up to. FP L reported that she would consider the amount of Gabapentin that Resident #101 had received to be a mild overdose, which had the potential to cause sedation, ataxia (poor muscle control that causes clumsy movements. It can affect walking and balance, hand coordination, speech and swallowing, and eye movements), diplopia (double vision), nausea, vomiting, movement disorder, dizziness, and fatigue. FP L reported that Resident #101 was at risk for multiple adverse reactions from taking so many medications at large doses that were not ordered for her. The Immediate Jeopardy that began on 10/9/25 was removed on 10/11/25, and the surveyor confirmed the deficient practice corrected on 10/21/25 when the facility took the following actions to remove the Immediacy and correct the noncompliance prior to the start of the survey. A. Immediacy Removal:1. On October 9, 2025, staff identified that (Resident #101) received medication intended for name redacted. 2. LPN J was immediately removed from medication administration duties pending investigation into the incident. Education was provided to the name redacted student nurse program on the facility's medication administration policy, including the Five Rights of Medication. 3. Resident #101 was assessed for any adverse effects by the facility's Nurse Practitioner. Nurse Practitioner recommended the resident be transferred to the hospital for further evaluation. 4. Resident for whom the medication was intended for, received her medications as ordered. 5. The responsible party for Resident #101 was notified by the nurse practitioner. 6. An audit was completed for the medication administration for all residents residing on the 400 Hall by the Director of Nursing. No other residents received incorrect medications. 7. Medication Error in Risk Management was initiated and completed. 8. An audit of all resident photos were verified on each eMAR for proper identification. Photos are present and appropriate. 9. All licensed nurses received immediate re-education on the facility's medication administration policy, which includes the Five Rights - right resident, right drug, right dose, right route, right time - with emphasis on proper resident identification verification using two identifiers (name and photo). 10. Resident photos on eMAR were reviewed and verified by the facility's Admissions Coordinator. 11. All licensed nurses and (Nursing College) student nurses for Rotation 1 (October 6th, 7th, 9th, and 10th) in attendance were re-educated on October 9, 2025, by the DON and/or Designee on: Medication Administration policy.and Verification of resident identity prior to medication administration utilizing name verification and/or resident photo.12. Medication Skills Checklists were completed with all licensed nurses, including agency nurses. 13. Education was started with all licensed nurses were educated on BSN436: Concepts of Nursing III on October 21, 2025. No licensed nurse will work without completion of this education. 14. Attendance was documented via an in-service log. An audit was conducted of all licensed nurses to verify completion of education. 15. New hires will receive the same education prior to assuming independent medication administration responsibilities. Agency nurses booking future shifts with the facility will be educated on the facility's Medication Administration policy and BSN436: Concepts of Nursing III. Per interviews on 10/22/25, the facility has been completing this. B. Plan of Correction1. The Director of Nursing and/or Designee will conduct direct observation of medication passes for 5 nurses weekly for four weeks then monthly until substantial compliance is met. 2. Daily audits of MAR documentation will be completed by the DON and/or Designee for thirty days. 3. All medication errors will be reviewed in daily clinical stand-up and QAPI meetings to identify patterns and prevent recurrence.4. (Nursing College) nursing students who attended Rotation 2 (October 20th, 21st, 23rd, and 24th) were educated on the facility's Medication Administration policy on October 20, 2025. 5. Inter-Disciplinary Team met for an ad-HOC QAPI to review the facility's Intern and Student Nurse policy as well as BSN436: Concepts of Nursing III and Medication Rights weekly audits completed between October 12, 2025, through October 17, 2025, and October 20, 2025, through October 22, 2025. Physicians with (name redacted- local group) also reviewed the facility's Intern and Student Nurse policy as well as BSN436: Concepts of Nursing III. 6. Additional communication was completed with (Facility Nursing College) representatives (name redacted), Strategic Engagement Liaison III, Partnerships, and (name redacted), (Nursing College) Placement Coordinator. Review of the facility's Medication Administration policy dated, 8/7/23 revealed, General Instructions: 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, and right clinical indication . Prepare medications for administration. Administer medication: Knock on door and request entrance. Introduce self, explain medication administration need, and provide privacy. Identify resident by calling name and referring to photo .

This citation pertains to intake 2597303.Based on observation, interview, and record review the facility failed to ensure appropriate supervision and assistance was provided during toileting for 1 (Resident #503) of 3 residents reviewed for falls resulting in a head injury, fracture of a patella (kneecap), and pain.Findings include:Resident #503:Review of the facility's facility reported incident report for Resident #503 (R#503), submitted 7/30/2025, stated, .Incident Summary. Staff entered resident's (R#503) bathroom and observed resident on the floor; resident sent to emergency room.Investigation Summary. Individual(s) Involved: (R#503) (Resident) A [AGE] year-old female.has diagnoses of Alzheimer's (form of dementia; brain disorder that destroys memory/thinking skills).abnormalities of gait (manner of walking or moving on foot) and mobility, unsteadiness on feet.chronic pain.history of falls, dementia (unspecified severity; without behavioral/psychotic/mood disturbance; without anxiety). restlessness and agitation.anxiety.She is dependent on staff x2 (two staff members) for all Activities of Daily Living (ADLs) and is unable to make her needs known. A BIMS (Brief Interview for Mental Status) score was attempted on July 1, 2025 but was unable to be completed due to (R#503) cognitive decline (This reflected R#503 had severe cognitive impairment). Summary of Events On July 29, 2025, (Registered Nurse (RN) R) was administering medications when she heard a loud noise coming from (R#503's room number). Upon entering the resident's room, (R#503) was observed lying sideways on the floor in front of her bedside commode. (R#503) was transferred to [Hospital Name] for evaluation. (R#503) re-admitted to the [Nursing Facility] on July 30, 2025 where it was revealed she suffered a fracture of her left patella (kneecap). Statements (Certified Nurse Aide (CNA) H) was requested by R#503's Guardian (family member responsible for making decisions due to the resident's inability to do so), (R#503)'s daughter, to place the resident on her bedside commode and then transfer her back to her recliner when toileting was completed. (R#503) had not successfully voided (evacuated urine and/or feces) by the time CNA H completed her shift, so information was exchanged during shift rounding that (R#503) remained on the toilet until voided was successful. As (RN R) was completing her medication administration, she heard a loud noise coming from (R#503's) room and upon arrival, observed (R#503) lying sideways on the floor.On-call physician was notified who ordered resident be transferred to the emergency room for evaluation.When (date and time) did the problem occur? 07/29/2025 10:00 PM (other facility documentation included below indicated the fall was at 6:50 PM or 7:00 PM).During an observation on 9/3/25 at 10:16 AM, Resident #503 was in her room, lying in her bed flat on her back, and was non-verbal.During an interview on 9/3/25 at 09:00 AM, Director of Nursing B reported Resident #503 had been left alone on the bed side commode (toilet) prior to the fall incident on 7/29/25 and should not have been.During an interview on 9/4/25 at 9:31 AM, Resident #503's Guardian X reported she had never wanted her mom (Resident #503) left alone on the commode. Guardian X confirmed her mom had been confused and was confused and non-verbal during her stay at the facility. Guardian X reported her mom is unable to use a call light and felt had someone been in the room with Resident #503 while she was on the bed side commode she would not have fallen.During an interview on 9/4/25 at 11:40 AM, Certified Nurse Aide (CNA) H was asked if Resident #503 should have been left on the bed side commode alone and stated, No. CNA H reported she didn't feel Resident #503 was left unattended because the door was open while she was on the commode and staff were huddled outside Resident #503's room for shift change report. CNA H confirmed no one was within arm's reach of Resident #503 while she was on the bed side commode on 7/29/25 before the fall happened.During an interview on 9/4/25 at 8:52 AM, Certified Nurse Aide (CNA) K reported she would never leave Resident #503 alone on the bed side commode if she had been caring for her. CNA K reported Resident #503 required two staff assistance for toileting and once transferred onto the commode one staff member should have stayed with the resident to prevent a fall. CNA K confirmed Resident #503 had dementia, was unable to use her call light to request help, and there was no reason a nurse or CNA shouldn't have been with #503 during toileting on the commode.During an interview on 9/4/25 at 8:58 AM, Certified Nurse Aide (CNA) N reported she would never leave a cognitively impaired resident, which she confirmed Resident #503 was, alone on a commode (toilet). Review of Resident #503's Investigation Report (a packet/file of information) for the 7/29/25 fall with fracture stated, Fall with injury events and conclusion: Resident Information.Cognitive Status: Severely impaired cognition.Safety Awareness: Poor; high fall risk.Location: Resident's (Resident #503) room.Type of Incident: Unwitnessed fall.Activity at Time of Fall: Using bedside commode.Description of Event.During routine medication administration, the nurse (Registered Nurse R) heard a loud noise from (Resident #503's) room.Upon entering, (Resident #503) was found lying sideways on the floor, face down.Hematoma (closed wound where blood collects in a space) observed on the right side of forehead.Findings: Fractured left patella (kneecap).Closed head injury.Root Cause Analysis.(Resident #503) attempted to move forward on the BSC (bed side commode) without staff assistance.Her (Resident #503) cognitive impairment and poor safety awareness contributed to the fall.Date/Time Incident Occurred: 7/29/2025 07:00 PM.Witness Statement.Name and Title of person being Interviewed: (Certified Nurse Aide (CNA) H).Date and time of Interview: 7/30/25 0800 (8 AM).Statement.(Resident #503's Guardian X) was in too see her mother (Resident #503) and requested that I put on the commode and let sit and then place her in her recliner and feed her dinner. Requested (CNA H) if can't finish to have the next shift complete the task. Myself (CNA H) and (CNA N) placed (Resident #503) on the commode and repositioned her. I (CNA H) gave report to (Registered Nurse R) reported not to leave her (Resident #503) alone. We were trying figure out staffing and I went back and gave report to all the staff present for follow up.Review of Resident #503's post (after) fall hospital paperwork, dated 7/29/25, stated, Chief Complaint: FALL.DIAGNOSIS.1. Closed (broken bone that doesn't break through the skin) nondisplaced (fracture occurs to the bone but it says in normal position/alignment) comminuted (bone that is broken in at least two places) fracture (break) of left patella (kneecap).2. Closed head injury.Female (Resident #503) presents for unwitnessed fall.She does have a hematoma to the right forehead.There is tenderness to the left knee with some erythema (redness of skin) and swelling.Daughter at bedside indicates that patient (Resident #503), her mother is nonverbal due to advanced dementia.XR (x-ray) Left Knee.Indication: left knee pain/swelling, unwitnessed fall off toilet. Review of Resident #503's progress note, dated 7/30/25 at 06:03 AM, stated, (Resident #503) returned to facility.Patellar (kneecap) fracture to left leg, knee mobilizer in placed. 1 week follow-up appointment recommended.Review of Resident #503's progress note, dated 7/30/25 at 08:06 AM, stated, Acetaminophen Extra Strength (pain relief medication).Give 2 tablet by mouth every 8 hours as needed for Pain.Review of Resident #503's Pain Level Summary, dated 7/1/25-8/2/25, indicated a pain level of zero (0-10 point scale; 0 meaning no pain and 10 meaning highest level of pain) consistently from 7/1/25 through 7/28/25 (day before the fall). On 7/30/25 (after the fall) Resident #503's pain score was noted to be a 3 at 08:06 AM, a 5 at 4:45 PM on 8/1/25, a 3 at 5:12 PM on 8/1/25, a 2 at 1:15 AM on 8/2/25, and 1 at 7:34 AM on 8/2/25.Review of Resident #503's Nursing: Fall Checklist, dated 7/30/25, stated, Date of Fall: 7/30/2025.Time of Fall: 18:50 (6:50 PM).What did the guest/resident say they were trying to do just before they fell? .Aphasia (communication disorder) Mumbles.Time last toileted and/or changed: 6:50 PM.Root Cause of this Fall:.Toileting Status. Review of Resident #503's fall risk assessment, dated 7/1/25, stated, .Confusion most/all of the time.Routinely incontinent (bowel and/or bladder).Moderate/severe unsteadiness - requires physical assist.Safety Awareness: .Lack of understanding of physical and cognitive limitations.Review of Resident #503's cognition care plan, revised 07/02/2025, stated, The resident (Resident #503) has impaired cognitive function/dementia or impaired thought process r/t (related to) Alzheimer's, Dementia.Staff to anticipate her (Resident #503) needs aeb (as evidenced by) non-verbal communication, provide safety and comfort. Review of the facility's Activities of Daily Living (ADL) policy, revised 12/7/2023, stated, Appropriate care and services will be provided for residents who are unable to carry out ADL independently.including appropriate support and assistance with.Elimination (toileting).

This citation pertains to intake MI00150232. Based on interview and record review, the facility failed to ensure residents received quality care based on professional standards for 1 (Resident #103) of 3 residents reviewed for unwitnessed falls, resulting in a delay in identifying a change in condition and treatment for multicompartmental acute intracranial hemorrhage (brain bleed). Findings include: Resident #103 Review of an Admission Record revealed Resident #103 was originally admitted to the facility on [DATE] with pertinent diagnoses which included history of falling. Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 10/16/24, revealed a Brief Interview for Mental Status (BIMS) score of 9/15 which indicated Resident #103 was moderately cognitively impaired. Review of Resident #103's Care Plan revealed, (Resident #103) is at risk for falls r/t (related to ) dementia, requires assist with ADL's (activities of daily living), skin impairment to heel with recommended cushion boots, new environment, seizure disorder, psychoactive medication use, hx (history) of falls, hx of intracranial hemorrhage, hx of alcohol abuse. (Resident #103) becomes restless while in bed, at times, attempting to stand. Date initiated: 8/14/24. Interventions: Anticipate needs. Date initiated: 8/14/24 . Bed in low position when resident is in bed. Date initiated: 9/25/24 .Call light within reach. Date initiated: 8/14/24 .Encourage Resident to remain in common areas while awake. Date initiated: 8/16/24. Encourage resident to stay out in common area until HS (night time) meds given. Date initiated: 9/25/24. Have commonly used articles within easy reach. Date initiated: 8/14/24. Keep bed at transfer height. Date initiated: 9/30/24. Low bed at all times. Date initiated: 8/14/24 .Offer resident frequent reminders to use call light during interactions. Date initiated: 8/14/24 . Offer toileting frequently throughout the day. Date initiated: 9/20/24 . Review of Resident #103's Fall Risk Evaluation dated 12/26/24 indicated that Resident #103 was confused most/all of the time, had a history of 3 or more falls within the last 3 months, was routinely incontinent, had adequate vision, was moderate/severely unsteady and required physical assistance. Resident #103 was impulsive, lacked understanding of physical and cognitive limitations and forgot or did not always use assistive devices. Resident #103 took three or more medications which increased risks for falls and Resident #103 had 3 or more predisposing diseases and conditions which increased risk for falls . Review of an Incident Report submitted by Nursing Home Administrator (NHA) A dated 1/12/25 revealed, . Details: (Resident #103) was seen in the bathroom laying on his back with an abrasion on his forehead, he was able to tell staff that he didn't hit his head, but he had a change in condition and staff notified on-call physician and an order was to send to local hospital. (Resident #103) returned with a hemorrhage. A full investigation will follow . Review of Resident #103's Progress Note dated 1/10/2025 and documented by Registered Nurse (RN) HH revealed, Patient(Resident #103) was observed laying on the floor in restroom/ bedroom. This nurse was informed by CNA (Certified Nursing Assistant) that patient fell . Patient wheelchair was in the hallway. Patient was observed in a supine position (lying on back) face upward. Patient was assessed for injury and vital signs obtained. Patient has abrasion noted to bil (bilateral) elbows, and abrasion noted to left knee x2. Patient was transferred from floor to bed via hoyer. Patient is denying hitting head and pain and discomfort at this time. Provider notified of this fall along with DON (Director of Nursing). This nurse attempted to reach out to patient family unable to reach. Patient was treated with schedule pain medication. Patient appears to be in no pain or discomfort at this time. Provider gave orders to dress the abrasion with xerofoam (type of sterile gauze) and cover with Mepliex (type of dressing) foam change QOD (every other day) until Monday when wound staff can follow up. Review of Resident #103 Progress Note dated 1/11/24 at 07:54 AM revealed, eMAR - Administration Note. Note Text: Assess Resident for Pain Every Shift every shift for Pain. Facial grimacing, he stated I hurt all over . Review of Resident #103 Progress Note dated 1/11/2025 at 9:27 AM and documented by Licensed Practical Nurse (LPN) EE revealed, Incident Note: Note Text: Res had a fall yesterday on second shift, he was complaining of generalized pain this morning, routine Tylenol and Ultram given as ordered, but he is denying pain at this time but facial grimacing, BP (blood pressure) is high 184/67, will retake, he normally eats breakfast and drinks his coffee, but he refused. DPOA (durable power of attorney) notified via phone call. Review of Resident #103's Progress Note dated 1/11/2025 at 9:28 AM and documented by LPN EE, revealed , Incident Note: Note Text: Abrasions noted to his forehead, and some blood on the carpet by his bed. Review of Resident #103's Progress Note dated 1/11/2025 at 11:01 AM and documented by LPN EE revealed, Note Text: still facial grimacing but denying pain, routine Tylenol and Ultram is coming up soon, BP is still high 159/84. Review of Resident #103's Progress Note dated 1/11/2025 at 12:23 PM and documented by LPN EE revealed, Note Text: 170/80, staff had to assist him with eating, this is new, he normally will get himself out of bed but has not done that either since the start of shift. He continues to deny pain but facial grimacing and frowning noted. Review of Resident #103's Progress Note dated 1/11/2025 at 1:51 PM and documented by LPN EE revealed, Note Text: spoke to his DPOA again for recent updates, not able to feed himself at lunch, did try to get of bed but staff helped him back quickly, he ate poorly at lunch with full staff assistance. continues to rest in bed. Review of Resident #103's Progress Note dated 1/12/2025 at 8:04 AM and documented by LPN EE revealed, Note Text: . resident is not alert as usual, bp is still high 173/68, he is sleeping a lot, total care now, this quite a change, eating less and coughing with meals and drinks. Review of Resident #103's Progress Note dated 1/12/2025 at 10:39 AM and documented by LPN EE revealed, Note Text: Hey (Name redacted- Facility Physician Assistant C, running a low-grade fever of 99.3, cold compress applied. 157/67, P-88, O2-93%RA (oxygen saturation on room air), res (respirations) is 20, occasional coughing noted as well. Family is asking for some tests. Review of Resident #103's Progress Note dated 1/12/2025 at 10:59 AM and documented by LPN EE revealed, Note Text: On call provider (Physician Assistant C), ordered stat chest x-rays to views, order placed . Review of Resident #103 Progress Note dated 1/12/2025 at 12:12 PM, and documented by LPN EE revealed, Note Text: ADON (Former Assistant Director of Nursing) D asked for him to be sent out, and family agrees, sending out to (local hospital) Review of Resident #103's Progress Note dated 1/12/2025 11:11 PM and documented by LPN EE revealed, Note Text: The ER discharging nurse reported that res (Resident #103) has significant brain bleed, family declined treatment and want Hospice/comfort, (local hospice) Hospice nurse is coming in early in the morning to meet with family. Review of Resident #103's Hospital Records dated 1/12/25 revealed, . Chief Complaint: Fall Injury (Unwitnessed fall on Friday evening, did not seek medical attention at that time. Staff reports that patient is more somnolent (drowsy) since either yesterday or this morning, is normally confused but alert and conversative.) . Treatment Plan: Patient seen and examined by myself as well as my attending physician for a chief complaint of a fall on Friday for which he did not seek medical attention with increased somnolence/decreased mentation over the last 24 to 48 hours. At bedside patient Semi-Fowler's (lying on back with head of bed elevated) in bed, nontoxic-appearing, mumbling, not answering questions appropriately, not following commands. Vital signs assessed and patient was mildly hypertensive 180/100 . Physical exam findings did reveal a contusion over patient's left and right forehead with no deformity or crepitus or overlying laceration. Patient also had a significant number of bandages over all major joints with various dates from multiple falls over the last couple weeks no evidence of joint instability in extremities .Based on patient's initial presentation my initial clinical suspicion included intracranial hemorrhage from recent fall .I independently interpreted patient's head CT (computed tomography scan) and did appreciate what appears to be a significant intracerebral hemorrhage with no obvious fracture or dislocation . Given the protracted nature of time since the onset of symptoms and unsure disposition, patient's DPOA( durable power of attorney)contacted who is his eldest daughter and states the patient is currently a DNR (Do Not Resuscitate) and that she would like to discuss the case with her younger sibling to decide how to proceed whether or not to bring patient home for comfort care or if they would like patient admitted with more aggressive measures .Patient's DPOA/eldest daughter did contact me and states after discussing the case with her sister they do believe that they would like to have patient brought back to the sending facility and would be contacting hospice . Shortly after updating patient's daughter on the plan nursing alerted me that patient had fallen out of bed and landed on his face resulting in a significant laceration to the forehead and bridge of the nose. Patient was cleaned up and assisted back to bed by nursing. Given the goals of care as well as known intracranial hemorrhage no repeat imaging was performed based on goals of care wishes. Patient's lacerations were closed without complication; . During an interview on 2/19/25 at 12:52 PM, CNA Z reported that she was the staff member that had found Resident #103 after his fall on 1/10/25. CNA Z reported that she had gone to check on Resident #103 when he had not arrived in the dining area for dinner and she found him lying on the bathroom floor. CNA Z was unable to report the last time that she had checked on Resident #103, so she did not have any idea how long Resident #103 had been lying on the floor. CNA Z reported that she recalled Resident #103 had some blood on both of his legs, but she did not remember if he had any abrasions or bumps on his head. During an interview on 2/19/25 at 9:10 AM, RN HH reported that she was the nurse caring for Resident #103 the night that he fell . RN HH reported that she was notified by CNA Z that Resident #103 was on the floor and she went to assess him. RN HH reported that she did not notice any abrasions on Resident #103's head (as found in the hospital report). RN HH reported that she notified the provider on call, and the Director of Nursing (DON) about Resident #103's fall. RN HH reported that she had not noticed any changes with Resident #103 after his fall, but that she had never worked with him before, so she was not familiar with his baseline. During an interview on 2/19/25 at 1:17 PM, CNA BB reported that she had cared for Resident #103 after his fall on 1/10/25 and that Resident #103's assistance needs had increased to requiring total assistance from staff. CNA BB confirmed that Resident #103 was independent with tasks such as eating and dressing prior to his fall. CNA BB reported that this was a significant change for Resident #103. During an interview on 2/19/25 at 11:23 AM, LPN EE reported that she was the nurse that cared for Resident #103 on 1/11/25 and 1/12/25 after his fall. LPN EE reported that she had noted that Resident #103 appeared to be in pain, and she noticed an abrasion on his head near his hairline. LPN EE confirmed that Resident #103's blood pressure had increased since his fall, he was not eating, and requiring total assistance from staff, which was a change in condition for him. LPN EE reported that she had notified the on call provider, Physician Assistant (PA) C of the changes she had noticed with Resident #103. LPN EE reported that PA C had instructed her to order a chest x-ray since Resident #103 had a cough, and continue to monitor Resident #103. LPN EE reported that she was not sure if Resident #103's change in condition was related to his fall, but she did feel like Resident #103 would have benefited from going to hospital. LPN EE reported that she did not advocate to PA C for Resident #103 to be sent to the hospital, because he was the provider and she felt like she could trust his judgement. LPN EE reported that she did not know if PA C was aware that Resident #103 had an unwitnessed fall. LPN EE confirmed that PA C was not at the facility to assess Resident #103, and that the provider relied on nursing assessments and communication to make treatment decisions. During an interview on 2/19/25 at 10:56 AM, Former Assistant Director of Nursing (ADON) D reported that she was the staff member that instructed LPN EE' to send Resident #103 to the hospital on 1/12/25. Former ADON D reported that since she was the nursing manager, she had been included on all communication messages between nurses and PA C. Former ADON D reported that on 1/12/25 she had checked the messages from her home and when she read the communication between LPN EE' and PA C' about Resident #103, she was shocked that Resident #103 had not been sent out to the hospital yet. Former ADON D reported that from the messages she had read it was clear that Resident #103 was experiencing a change in condition and likely a closed head injury based on the symptoms. Former ADON D reported the symptoms she felt were likely related to a closed head injury included increased blood pressure, decline in ADL's, sleepiness, and an increased temperature. Former ADON D reported that she immediately called LPN EE and told her to send Resident #103 to the hospital. Former ADON D reported that she felt that LPN EE and PA C missed the change in condition for Resident #103, and that he should have been sent to the hospital as soon as changes were noted since Resident #103's fall was unwitnessed and he had an abrasion on his forehead, so it was likely that he had hit his head. During an interview on 2/19/25 at 2:13 PM, PA C reported that he was the provider on call on 1/11/25 and 1/12/25. PA C confirmed that he had been made aware that Resident #103 had a fall on 1/10/25, and that Resident #103 had an abrasion on his head and he did not eat breakfast. PA C reported that he was not aware of Resident #103's increased blood pressure. PA C' reported that he had not been contacted on 1/12/25. This writer read LPN EE's progress notes from 1/11/25 and 1/12/25 to PA C and queried as to what his clinical judgement was for the symptoms noted in the progress notes. PA C reported that the symptoms noted in LPN EE 's progress notes on 1/11/25 and 1/12/25 were all potential symptoms of a closed head injury. PA C reported that if he had been aware that Resident #103 was experiencing a change in condition and decline after a fall, he would have requested a virtual health visit to assess Resident #103, and then send him to the emergency department if he felt like it was necessary. PA C reported that he relied on the nurse's communication of changes to make treatment decisions because he was not in the facility to assess residents. On 2/19/25 at 1:11 PM, this writer requested a copy of the messages sent between LPN EE and PA C. NHA A reported that the messages were not available, and were deleted after 14 days.

This citation pertains to intake MI00150232. Based on interview and record review, the facility failed to 1.) Provide adequate supervision and assistance to prevent falls with injury for 2 (Resident #103 and Resident #101) of 3 residents; 2.) implement and revise care plan interventions to prevent falls for 2 (Resident #103 and #108) resulting in Resident #103 falling and sustaining a multicompartmental acute intracranial hemorrhage (brain bleed), Resident #101 falling and sustaining T3 and T8 (spine locations) fractures, and the potential for a fall with injury for Resident #108. Findings include: Resident #103 Review of Admission Record revealed Resident #103 was originally admitted to the facility on [DATE] with pertinent diagnoses which included history of falling. Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of ,d+[DATE] which indicated Resident #103 was moderately cognitively impaired. Review of Resident #103's Care Plan revealed, (Resident #103) is at risk for falls r/t (related to ) dementia, requires assist with ADL's (activities of daily living), skin impairment to heel with recommended cushion boots, new environment, seizure disorder, psychoactive medication use, hx (history) of falls, hx of intracranial hemorrhage, hx of alcohol abuse. (Resident #103) becomes restless while in bed, at times, attempting to stand. Date initiated: [DATE]. Interventions: Anticipate needs. Date initiated: [DATE] . Bed in low position when resident is in bed. Date initiated: [DATE] .Call light within reach. Date initiated: [DATE] .Encourage Resident to remain in common areas while awake. Date initiated: [DATE]. Encourage resident to stay out in common area until HS (night time) meds given. Date initiated: [DATE]. Have commonly used articles within easy reach. Date initiated: [DATE]. Keep bed at transfer height. Date initiated: [DATE]. Low bed at all times. Date initiated: [DATE] .Offer resident frequent reminders to use call light during interactions. Date initiated: [DATE] . Offer toileting frequently throughout the day. Date initiated: [DATE] . Review of Resident #103's Fall Risk Evaluation dated [DATE] indicated that Resident #103 was confused most/all of the time, had a history of 3 or more falls within the last 3 months, was routinely incontinent, had adequate vision, was moderate/severely unsteady and required physical assistance. Resident #103 was impulsive, lacked understanding of physical and cognitive limitations and forgot or did not always use assistive devices. Resident #103 took three or more medications which increased risks for falls and Resident #103 had 3or more predisposing diseases and conditions which increased risk for falls . Review of an Incident Report submitted by Nursing Home Administrator (NHA) A dated [DATE] revealed, . Details: (Resident #103) was seen in the bathroom laying on his back with an abrasion on his forehead, he was able to tell staff that he didn't hit his head, but he had a change in condition and staff notified on-call physician and an order was to send to local hospital. (Resident #103) returned with a hemorrhage. A full investigation will follow . Review of Resident #103's Progress Notes dated [DATE] and documented by Registered Nurse (RN) HH revealed, Patient (Resident #103) was observed laying on the floor in restroom/ bedroom. This nurse was informed by CNA (Certified Nursing Assistant) that patient fell . Patient wheelchair was in the hallway. Patient was observed in a supine position face upward. Patient was assessed for injury and vital signs obtained. Patient has abrasion noted to bil (bilateral) elbows, and abrasion noted to left knee x2. Patient was transferred from floor to bed via hoyer. Patient is denying hitting head and pain and discomfort at this time. Provider notified of this fall along with DON (Director of Nursing). This nurse attempted to reach out to patient family unable to reach. Patient was treated with schedule pain medication. Patient appears to be in no pain or discomfort at this time. Provider gave orders to dress the abrasion with xerofoam (type of sterile gauze) and cover with Mepliex (type of dressing) foam change QOD (every other day) until Monday when wound staff can follow up. Review of Resident #103's Hospital Records dated [DATE] revealed, . Chief Complaint: Fall Injury (Unwitnessed fall on Friday evening, did not seek medical attention at that time. Staff reports that patient is more somnolent (drowsy) since either yesterday or this morning, is normally confused but alert and conversative.) . Treatment Plan: Patient seen and examined by myself as well as my attending physician for a chief complaint of a fall on Friday for which he did not seek medical attention with increased somnolence/decreased mentation over the last 24 to 48 hours. At bedside patient Semi-Fowler's (lying on back with head of bed elevated) in bed, nontoxic-appearing, mumbling, not answering questions appropriately, not following commands. Vital signs assessed and patient was mildly hypertensive ,d+[DATE] . Physical exam findings did reveal a contusion over patient's left and right forehead with no deformity or crepitus or overlying laceration. Patient also had a significant number of bandages over all major joints with various dates from multiple falls over the last couple weeks no evidence of joint instability in extremities .Based on patient's initial presentation my initial clinical suspicion included intracranial hemorrhage from recent fall .I independently interpreted patient's head CT (computed tomography scan) and did appreciate what appears to be a significant intracerebral hemorrhage with no obvious fracture or dislocation . Given the protracted nature of time since the onset of symptoms and unsure disposition, patient's DPOA( durable power of attorney)contacted who is his eldest daughter and states the patient is currently a DNR (Do Not Resuscitate) and that she would like to discuss the case with her younger sibling to decide how to proceed whether or not to bring patient home for comfort care or if they would like patient admitted with more aggressive measures .Patient's DPOA/eldest daughter did contact me and states after discussing the case with her sister they do believe that they would like to have patient brought back to the sending facility and would be contacting hospice . Shortly after updating patient's daughter on the plan nursing alerted me that patient had fallen out of bed and landed on his face resulting in a significant laceration to the forehead and bridge of the nose. Patient was cleaned up and assisted back to bed by nursing. Given the goals of care as well as known intracranial hemorrhage no repeat imaging was performed based on goals of care wishes. Patient's lacerations were closed without complication; . It was noted that there were no care plan interventions added to Resident #103's Care Plan after his falls on [DATE] or [DATE]. Review of Resident #103's Progress Not dated [DATE] revealed, Note Text: (Resident #103) was noted on the floor mat next to his bed by a CNA (Certified Nursing Assistant) assigned to the unit. (Resident #103) was alert and talkative upon assessment. Zero injury noted . He stated that he was trying to get himself to the bathroom because he had to urinate. This Nurse explained to him that there was a catheter in place to catch his urine . During an interview on [DATE] at 12:52 PM, CNA Z reported that she was the staff member that found Resident #103 on his bathroom floor after an unwitnessed fall on [DATE]. CNA Z reported that Resident #103 was found on his bathroom floor, and that he had reported to her that he was trying to get up to go to the bathroom. CNA Z was unable to report the last time she had checked on Resident #103. CNA Z was unable to report how often staff were supposed to check on Resident #103. CNA Z confirmed that Resident #103 was supposed to be assisted to the restroom every two hours. CNA Z reported that she had no clue when Resident #103 had last been assisted to the toilet. CNA Z reported that Resident #103 would sometimes use his call light, but that he was also impulsive, and would frequently self transfer without asking for assistance. CNA Z did not know other care plan interventions that were in place to decrease Resident #103's risks for falls. During an interview on [DATE] at 9:10 AM, Registered Nurse (RN) HH reported that she was the staff member that assessed Resident #103 after his fall on [DATE]. RN HH reported that she had never cared for Resident #103 before, and was not aware that he was a high fall risk. RN HH reported that she had reached out to the Director of Nursing (DON) for assistance after Resident #103's fall for assistance, and she was told that the DON would complete the incident report and create new care plan interventions to reduce Resident #103's risks for more falls. RN HH confirmed that she did not implement any immediate interventions to reduce Resident #103's risks more falls. During an interview on [DATE] at 11:23 AM, Licensed Practical Nurse (LPN) EE reported that Resident #103 was a fall risk. LPN EE reported that Resident #103 would frequently attempt to self-transfer. LPN EE reported that Resident #103 would occasionally use a call light, but he often would try to do things himself. LPN EE reported that the only fall prevention interventions in place for Resident #103 that she could recall were a fall mat in his room, and grippy socks. During an interview on [DATE] at 4:21 PM, LPN GG reported that Resident #103 was frequently restless and confused, and would often try to self transfer. LPN GG confirmed that Resident #103 had fallen frequently at the facility. LPN GG reported that she did not think that Resident #103 was on a toileting schedule, or how often staff were supposed to check on him. This writer queried what frequently was defined as for Resident #103's care plan intervention which stated Offer toileting frequently throughout the day. Date initiated: [DATE]. LPN GG reported that she did not know what frequently was defined as, and confirmed that Resident #103's care plan intervention was not descriptive enough for staff to follow. LPN GG reported that the facility had struggled with staffing, and the unit that Resident #103 resided on required more staffing to provide adequate supervision of all of the residents, which they did not always have. During an interview on [DATE] at 9:42 AM, Unit Manager (UM) DD reviewed Resident #103's care plan with this writer and confirmed that Resident #103's care plan was not descriptive enough for staff to follow. During an interview on [DATE] at 10:56 AM, Former Assistant Director of Nursing (ADON) D reported that staffing at the facility had been a major issue, and it had affected resident care, including staff being able to provide adequate supervision. ADON D reported that the facility was wildly out of control and residents were frequently falling. ADON D confirmed that the facility did not have IDT (interdisciplinary) meetings after resident falls to review the fall and implement new care plan interventions to reduce further falls. During an interview on [DATE] at 10:47 AM, DON B reviewed Resident #103's care plan with this writer and confirmed that the care plan interventions were too broad and not easy for staff to follow. During an interview on [DATE] at 1:40 PM, Nursing Home Administrator (NHA) A reported that she was responsible for investigating Resident #103's fall on [DATE]. NHA A was unable to report the findings from her investigation as to why Resident #103 fell , and what changes the facility made to decrease further falls. NHA A confirmed that the facility IDT team had not met after Resident #103's falls on [DATE] and [DATE] to implement new interventions to reduce further falls. NHA A reported that Resident #103 had last been assisted to the toilet around 11:00 AM, and she thought that Resident #103 had fallen around 8:00 PM. NHA A confirmed that she did not know how long it had been since Resident #103 had been checked on by staff. NHA A reported that she did not review Resident #103's hospital records from his fall on [DATE], and she was unaware that Resident #103 had been diagnosed with multicompartmental acute intracranial hemorrhage prior to his fall at the hospital. NHA A confirmed that Resident #103 fell on [DATE] after he returned from the hospital. Review of the facility's Fall Policy dated [DATE] revealed, Policy Overview: The purpose of this policy is to provide guidelines to assist with a fall risk identification and fall management of residents in the facility .Care Planning: The facility staff, with input from the attending physician, will implement a resident centered comprehensive care plan that addresses the fall management program, the goal for fall management, individualized interventions to address the residents modifiable risk factors, interventions to try to minimize the consequences of risk factors that are not modifiable, and the plan for reduction of risk or risk for injury related to falls .The resident's care plan and interventions will be revived and revised as indicated for the individual needs of the resident and effectiveness of of interventions .Post fall evaluation: . if there is evidence of injury, provide appropriate first aide and/or obtain medical treatment immediately .IDT review: The interdisciplinary team will review the resident's fall including: the circumstances surrounding the resident's fall and any changes in the resident's risk factors, conditions, and/or functional status to validate/determine the root cause of the fall. The interdisciplinary team will review the resident's care plan and interventions to ensure the interventions are appropriate for the resident's post-fall interventions correlate to the root cause of the fall in an attempt to prevent future falls . 41424 Resident #101: Review of an Admission Record revealed Resident #101 was a male with pertinent diagnoses which included Alzheimer's disease, heart failure, muscle weakness, repeated falls, difficulty in walking, spinal stenosis (narrowing of one or more spaces within your spinal canal), and dislocation of T,d+[DATE] thoracic vertebra (middle segment of the spine have moved out of their normal position). Review of current Care Plan for Resident #101, revised on [DATE], revealed the focus, .At risk for falls and safety risks due to Alzheimer's disease with impaired cognition, history of repeated falls, impaired balance, weakness, potential medication side effects, visual impairment related to glaucoma, congestive heart failure, cardiomyopathy ( ), anemia (low iron in the blood), protein calorie malnutrition, hx (history) syncope (fainting). (Resident #101) has impaired safety awareness and frequently attempts to self-transfer without assistance . with the intervention .Assist to chair and high traffic area when awake as resident allows .bed in low position when resident is in bed .call light within reach .Encourage to transfer and change positions slowly .Have commonly used article within easy reach .Provide assist to transfer and ambulate as needed .Reinforce need to call for assistance .Therapy evaluation and treatment per orders . Review of Admission Evaluation dated [DATE] at 4:06 PM, revealed, Resident #101 had occasional confusion, ,d+[DATE] falls in the last 3 months, balance/unsteady while standing, transferring and/or walking - moderate/severe unsteadiness - required physical assist. Resident #101's safety awareness was attempts to self-transfer or ambulate when not recommended to do so, impulsive, lack of understanding of physical and cognitive limitations. The baseline care plan for Resident #101 was minimize risk for falls. Resident #101 was screened for transfers which revealed resident was not able to stand pivot transfer with contact guard assist or less, was not able to move from supine to sitting, and required manual, supervised transfers with a gait belt. Requested and reviewed a list of falls for the last 30 days which revealed, Resident #101 had 4 unwitnessed falls. Review of Incident Reports dated ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE] revealed immediate interventions were not implemented for Resident #101's safety as he was considered a high fall risk and required additional supervision to prevent further falls Review of Resident #101's care plan revealed the care plan was not updated after each fall incident to aid in the prevention of further falls. Review of History and Physical dated [DATE] at 00:00 AM, revealed, .Patient required sitter during hospital admission due to impulsivity, confusion, and behaviors . Review of No Type Specified note dated [DATE] at 11:08 AM, revealed, .Attempting to stand up, looking for his car, lots of redirections, called his significant other, they are currently talking on the phone . Note: This was not included as an intervention for Resident #101's care plan. Review of Nursing -Progress Note dated [DATE] at 11:54 PM, .Patients' roommate put on call light for assistance. Staff went into room to answer call light and observed patient on the floor sitting on his buttocks with feet in front of him and back against the wall next to the bathroom door. Patient was barefoot and walker still next to bed. Patient stated he had just gone to the bathroom and lost his balance and fell . Nursing assessment completed, no injuries or bruises noted. Neuro checks implemented, Vss (vitals) BP,d+[DATE] P (pulse) 88 R(respirations)16 T (temperature) 97.60296% rm air. On call provider and nursing team notified. Patient is currently resting in bed with no known concerns at this time . Note: No intervention to provide frequent rounding, signage to remind resident to use his walker, or staff increased requests to assist to restroom were not included as interventions for Resident #101's care plan. Review of Resident #101's care plan did not include an intervention for grippy non-slip socks or footwear. Review of Fall-Risk Evaluation dated [DATE] at 00:22 AM, revealed, Resident #101 had occasional confusion, ,d+[DATE] falls in the last 3 months, poor/impaired vision, and he was impulsive, forgets or does not always use assistive devices, lack of understanding of physical and cognitive limitations, and attempted to self-transfer. Review of Nursing -Progress Note dated [DATE] 02:05 AM, revealed, .Patient continues to try and self-transfer out of bed throughout the night. Patient was asked what he needs. Patient stated, I don't know I was trying to get a sheet!! Patient had sheet and blanket covering him. Staff asked patient was he cold and needed extra blankets? patient begin to yell at staff saying, leave me alone! Patient reminded once again to use call light and to not get up without assistance . Review of Nursing -Progress Note dated [DATE] at 01:15 AM, revealed, .At 2300 (11:00 PM) Assigned Nurse went to do rounds, Patient was observed lying on the floor next to his sink and bathroom door. The bathroom door was halfway open with lightbulb on. Patient's Head was against the bottom of the bathroom door, legs out in front of him, sitting on his buttocks. Patient bed was in the low position did not see walker in room. Wheelchair was on the other side of room. Patient had on pjs with regular socks. Patient stated that he doesn't remember what he was doing and asked me to go get the neighbors with the truck to help him up. nursing assessment completed patient complained of pain in his lower back. Patient stated that he cannot sit up and kept falling over could not sit straight up. On Call provider notified and patient sent out to (Local Hospital) for further eval. VSS BP,d+[DATE] P80 R18 0296% rm air. Neuro checks implemented . Review of Nursing -Progress Note dated [DATE] at 06:47 AM, revealed, .This nurse received report from ER (emergency room ) Nurse (First Name) stating that resident is on his way back from (Local Hospital) ER. ER Nurse stated that resident has a T3 & T8 fracture. ER Nurse states that patient has a follow up appointment in a few weeks but at this time it is nothing they can do for the fractures and will let them heal on their own and have patient continue therapy . Review of Progress Note for (Local Hospital) Emergency Department dated [DATE] revealed, .HPI: The patient is a [AGE] year-old male presents emergency depart chief complaint of fall . States that today he was found down in the bathroom. Unsure of the mechanism. The patient is altered at baseline but able to answer basic questions. States that he does not remember any of the symptoms prior to the fall. Does not remember if he hit his head or not. Not on any blood thinners. Main complaint is lower back pain .Musculoskeletal: Comments: Lower back tenderness. Full range motion of upper and lower extremities. No reproducible tenderness over extremities .Assessment/Plan: DIAGNOSIS at time of disposition: 1. Fall, initial encounter .2. Closed fracture of third thoracic vertebra, unspecified fracture morphology, initial encounter (HCC) .3. Closed fracture of eighth thoracic vertebra, unspecified fracture morphology, initial encounter (HCC) .CT scans .The scans revealed fractures of the T3 and T8 vertebrae . Review of No Type Specified dated [DATE] at 08:02 AM, revealed, .CNA observed res standing and walking in his room unassisted, staff assisted him to his wheelchair and back into the dining room . Review of Nursing -Progress Note dated [DATE] at 11:12 PM, revealed, .Res is attempting to transfer himself all the time, not using the call light for help . Review of No Type Specified dated [DATE] at 06:50 AM, revealed, .(Resident #101) was alert and restless during the evening. He wheeled himself from the common area of the unit back and forth to his room several times.(Resident #101) was noted transferring himself from his wheelchair and standing in his room. He was redirected by staff and encouraged to ask for help many times during the evening.(Resident #101) would not wait for staff to assist him. He continued to take himself back to his room each time staff tried to keep him within sight for the purpose of his safety due to his poor safety awareness .(Resident #101) continued to attempt to self- transfer late during the night. Staff had to visit his room frequently to check to make sure he was safe. VSS. Neurological assessment is WNL (within normal limits) .(Resident #101) did not complain of pain. This Nurse suggests placing a tab alarm on Resident due to his restlessness, poor safety awareness, and frequent falls . Review of Incident Note dated [DATE] at 2:06 PM, revealed, .Resident was observed laying on the floor in his room. He was laying on his right side, and he was holding his head up. No injury noted as of now. Voice message left for significant other, on call supervisor notified via phone call, on call provider notified via tiger text message. Alert charting and neurological assessment initiated . Review of Incident Report dated [DATE] at 9:30 PM, revealed, .At about 9:30 PM, res was observed laying on floormat by his bedside .Level of pain: 4 . Review of Nursing - Progress Note dated [DATE] at 06:05 AM, revealed, .Patient continued to self-transfer out of bed during the night. Patient is impulsive and does not put on call light to have staff assist him to the bathroom. Patient was given a urinal to keep at bedside but often forgets to use it and stills try to self-transfer himself out of bed . Review of Nursing - Progress Note dated [DATE] at 11:22 PM, revealed, .Urine sample obtained, called (Local Hospital) lab for pick up . Review of Incident Report dated [DATE] at 11:43 AM, revealed, .At 1130, (Resident #101) was observed sitting in the hallway with legs stretched out with his back leaning against the wall. He was next to his wheelchair. Had grippy socks on .Res. stated help me please . Review of IDT dated [DATE] at 11:18 AM, revealed, .Pt (patient) was observed on the matt next to his bed laying on the floor. Resident had on his gripper socks . Note: Fall mat was not included as an intervention in Resident #101's care plan. In an interview on [DATE] at 12:15 PM, Registered Nurse (RN) CC reported when a resident had a fall, she would go to them to assess, take vitals, perform ROM (if necessary), ask if the resident had pain or hit their head, if necessary start neuro checks on the resident. RN CC reported then you would try to determine why the fall occurred and create interventions to assist with preventing the incident from happening again. RN CC reviewed the green folder for Falls at the nurse's station, which contained a document named Falls Risk management checklist .3. Immediate interventions to ensure they don't fall again? When queried RN CC reported Try to come up an intervention so they don't repeat with the same cause of the fall. In an interview on [DATE] at 12:36 PM, Unit Manager (UM) DD reported the nurse would create a risk management report for an incident and the nurse reviewed the care plan, update it with an intervention, and if there was not a focus already one would be created with interventions. UM DD reported an immediate intervention would be created with each fall. UM DD reported when a risk management report was generated additional tabs would be opened for additional assessments such as a fall risk evaluation. She indicated there was a point in the risk management report where the nurse was able to add witness statements from the staff present. UM DD reported the care plan were able to be updated by the nurses. UM DD reported for residents who were impulsive and had multiple falls, the facility would develop interventions to help keep that individual safe such as, possibly the resident needed a different chair. For example, when a resident utilized a broda chair, they may not be comfortable in it and attempt to get out of it. For residents who wander, they may need a lot of redirection, for those who forget to use their walkers -reminders to use their walkers. The staff on the floor needed to continue re-orienting the residents, keep reinforcing the use of the walker. Staff would need to have eyes on the floor, and when residents were in their rooms as well by looking in on them frequently. The staff should be walking the hallway, laying eyes on the residents, redirecting them, possibly have the residents come out and participate in activities, encourage them to come out of their rooms, do activities with the residents or give them something to work on like a puzzle, cards, or just talking with the residents. UM DD reported the staff should be making rounds on the floors, monitoring residents as they were the first line on the floor. In an interview on [DATE] at 11:09 AM, Director of Nursing (DON) B reviewed Resident #101's care plan and reported the first intervention noted in the care plan was dated [DATE]. DON B reported there were not interventions developed for Resident #101 following each fall. She reported an immediate intervention was to be created after each fall to ensure the resident's safety and minimize the risk for injury. DON B reported the falls were reviewed each morning during the morning meeting with all the disciplines involved for different perspectives for possible reasons for falls, and they would review the interventions to determine if the immediate intervention was a good intervention or revise the care plan. On [DATE] at 11:42 AM, DON B reported antitippers was the initial intervention for Resident #101 at entry for a baseline care plan. Resident #108: Review of an Admission Record revealed Resident #108 was a female with pertinent diagnoses which included right artificial hip joint, joint replacement surgery, muscle weakness, difficulty in walking, necrosis of the bone (loss of blood supply to the bone causing it to die) and history of falling. Review of current Care Plan for Resident #108, revised on [DATE], revealed the focus, .At risk for falls due to total right hip replacement . with the intervention .Provide assist to transfer and ambulate as needed . Review of current Care Plan for Resident #108, initiated on [DATE], revealed the focus, .Resident has an ADL self-care performance deficit related to: activity intolerance, ADL abilities will fluctuate with therapy staff and nursing staff, limited mobility . with the intervention .Locomotion: x1 assist x 100' with fww (four wheeled walker) .Toilet Use: 1 person assist with fww .Transfer: 1 person assist with fww . Review of Physical Therapy: PT Evaluation & Plan of Treatment dated [DATE], revealed, .Reason for Therapy: chronic h/o (history of) arthritis underwent s/p R THA (total hip arthroplasty), presents with R (right) LE (lower extremity) weakness, poor dynamic balance (ability to maintain stability while moving your body), difficulty standing, walking and cannot walk for any length of time .Fall Predictors: Inadequate postural control, inadequate ankle dorsiflexion (movement of the ankle joint where the foot is raised towards the shin), reduced quad strength (thigh muscles) and weak trunk and hip extensors . In an interview on [DATE] at 12:57 PM, Resident #108 reported when she called staff for assistance to use the restroom, Certified Nursing Assistant (CNA) E responded to her request. Resident #108 reported asked her for assistance to get to the bathroom and Resident #108 reported CNA E informed her she was here for therapy, she needed to learn to be independent, and she just stood there watched her struggle. Resident #108 reported she just needed a little help with her leg and she needed to get to the bathroom. Resident #108 reported she did not assist her with transferring out of her bed either. Resident #108 reported she was in pain and she was concerned for her safety. In an interview on [DATE] at 09:15 AM, Director of Therapy O reported Resident #108 came in as a one assist with ambulation, transfers, toileting. Director of Therapy O reported one assist was with one staff member with a gait belt for ambulation, transfers, and toileting with contact and steady hand to stabilize Resident #108 if she needed it. In an interview on [DATE] at 10:35 AM, Licensed Practical Nurse (LPN) II reported the resident's information - how they transfer, ambulation, the basics of to care for them was on the communication board. LPN II reported the information was entered prior to the resident coming, also the nurse at the hospital gives a nurse to nurse report. LPN II reported all staff have access to the communication board and she would also speak to the CNAs to share information with them as well. CNA R was present, and she reported the CNAs would also look at the Kardex as that would tell them how to care of the resident. In an interview on [DATE] at 11:09 AM, Director of Nursing (DON) B reported the admission process was a current work in progress. DON B reported the baseline care plan was created from the admission assessment. DON B reported the care plan created a Kardex for the staff to refer to. DON B reported the nurse created the care plan, she would give report to the CNA, after that can review the Kardex and update that form for them. In an interview on [DATE] at 11:09 AM, Director of Nursing (DON) B reported a one person assist would require the staff to provide support or supervision to the resident. DON B reported with a resident who had a recent join surgery the expectation was for staff to provide support to the resident for safety. This writer attempted to contact CNA E who did not reach back prior to exit from the facili [TRUNCATED]

This citation pertains to Intake # MI00147580, MI00147822, MI00147838, & MI00149046. This citation has two deficient practice statements, A & B. Deficient Practice Statement A Based on interview, and record review, the facility failed to protect the residents' right to be free from neglect in 7 of 15 residents (Resident #103, #104, #113, #120, #124, #125, #126) reviewed for neglect, resulting in an Immediate Jeopardy when on 10/12/24, 10/18/24, 10/19/24, and 10/26/24 licensed nursing staff did not accept responsibility for the care and supervision of residents on portions of the 300 and 400 Halls, which led to missed medications, significant medication errors (Resident #103 missed seizure medication on 10/18/24, Resident #113 missed insulin on 10/12/24, Resident #124 missed a blood thinner on 10/18/24, and Resident #125 missed insulin on 10/18/24 and 10/19/24), and a lack of overall supervision. On 10/12/24 a total of 30 out of 32 residents on the 400 Hall missed medications. On 10/18/24 a total of 30 out of 30 residents on the 300 Hall missed medications. On 10/19/24 a total of 6 out of 30 residents on the 300 Hall missed medications. On 10/26/24 a total of 24 out of 29 residents on the 300 Hall missed medications. This deficient practice placed all residents on the 300 and 400 Hall at risk and resulted in the likelihood for serious harm, injury, and/or death. Findings include: The Immediate Jeopardy began on 10/12/24 when licensed nursing staff did not accept responsibility for the care and supervision of residents on portions of the 300 and 400 Halls, resulting in missed medications, significant medication errors, and a lack of overall supervision. Administrator A was notified of the Immediate Jeopardy on 1/9/25 at 4:02 PM. The surveyor confirmed by observation, interview, and record review, that the Immediate Jeopardy was removed on 10/28/24, but noncompliance remains at a scope of pattern and severity of no actual harm with the potential for minimal harm that is not Immediate Jeopardy due to sustained compliance that has not been verified by the State Agency. In an interview on 1/6/25 at 3:48 PM, Licensed Practical Nurse (LPN) QQ reported staffing was a major issue in September/October 2024 after the change in facility ownership. LPN QQ reported at times they were the only nurse on the 300/400 Hall, or there was no oncoming nurse at the end of their shift. LPN QQ stated .I was exhausted . LPN QQ reported on 10/18/24 the Agency nurse scheduled to relieve them at 6:30 PM on the 300 Hall did not show up for the shift. LPN QQ reported that evening there was only one nurse on the 400 Hall, and no nurse on the 300 Hall. LPN QQ reported the evening of 10/18/24 on the 300 Hall, no residents received scheduled medications. LPN QQ reported on 10/18/24 between 7:00 PM-11:00 PM one resident from the 300 Hall attempted to elope from the facility and was found in the parking lot after setting off a door alarm. LPN QQ reported with Agency staff, the nurses working have no notification when a scheduled Agency staff member calls in or cancels a shift, and stated .we have no idea if they will show up or not . LPN QQ reported after the change in ownership, only two nurses were scheduled on the 300/400 Halls, when previously they had three, and stated .that is how we ended up with this mess . LPN QQ reported when short-staffed, they are unable to pass medications timely or provide quality care. In an interview on 1/8/25 at 9:15 AM, Registered Nurse (RN) LLL reported they were assigned the 400 Hall on 10/18/24 from 6:30 PM-7:00 AM. RN LLL reported they could not recall who was responsible for the 300 Hall that night (10/18/24 between 6:30 PM-11:00 PM). RN LLL recalled a resident on the 300 Hall attempted to elope from the facility between 7:00 PM-11:00 PM. RN LLL stated in regard to staffing .We were always short. (Staffing) was definitely an issue that night . RN LLL reported they had issues getting medications administered timely when short-staffed. RN LLL reported they stopped working at the facility shortly after that night, and stated .That was one of the reasons I left .safety . RN LLL reported management was .fully aware . of the staffing concerns but would not come into the facility to assist when short-staffed. In an interview on 1/8/25 at 9:32 AM, Certified Nursing Assistant (CNA) J reported there was no nurse assigned to the 300 Hall on 10/18/24 between 6:30 PM-11:00 PM) and one nurse on the 400 Hall (Registered Nurse (RN) LLL). In an interview on 1/8/25 at 9:52 AM, Former Assistant Director of Nursing (ADON) MMM reported they were contacted by staff on 10/18/24 between 7:00 PM-11:00 PM in regard to an attempted elopement (Resident #103). Former ADON MMM reported a CNA responded to a door alarm and found Resident #103 outside in the parking lot. ADON MMM reported no issues with staffing that evening and stated .we were at State minimums . ADON MMM reported they were aware that multiple residents missed medications the evening of 10/18/24 and stated .we did look into that . In an interview on 1/8/25 at 10:07 AM, Agency Licensed Practical Nurse (LPN) JJJ reported they worked on the 100 Hall the evening of 10/18/24 at the time of Resident #103's attempted elopement from the facility. Agency LPN JJJ reported they heard the alarm going off and began to search/check doors to identify a cause. Agency LPN JJJ reported an Agency CNA found Resident #103 outside in the parking lot. Agency LPN JJJ reported they notified the nurse on-call of the attempted elopement, along with the Administrator at the time. Agency LPN JJJ reported that evening there was no nurse assigned to the section of the building (the 300 Hall) where Resident #103 resided. Agency LPN JJJ reported there was only a nurse on the 400 Hall. Agency LPN JJJ reported they took over some of the rooms on the 300 Hall after 11:00 PM, but from 6:30 PM-11:00 PM on 10/18/24 there was no nurse assigned to the residents on the 300 Hall. Agency LPN JJJ reported the evening of 10/18/24 was not the first time where no nurse was assigned to a section of residents, and stated .I canceled all my shifts after that. (I) did not feel safe working there . Agency LPN JJJ reported they spoke with the on-call manager that evening (Former ADON MMM) about the staffing concerns, and reported there were only three nurses in the building when there should have been four. In an interview on 1/8/25 at 10:44 AM, LPN OOO reported concerns with staffing at the facility. LPN OOO reported at times there would be one nurse assigned to over 50 residents. LPN OOO stated .They were telling me I had to work like that. I told them there are people who are a fall risk, people with mental health issues .I told them it's not safe .I am not going to put these people's lives in jeopardy . LPN OOO reported they worked one shift with a 56 resident assignment and stated .it was too dangerous .It was the most nerve-wracking night of my life . LPN OOO reported they spoke with Former Assistant Director of Nursing (ADON) MMM at the time about the staffing concerns and no assistance/guidance or direction was provided. LPN OOO reported Former ADON MMM often did not answer the phone and stated .if you had an issue at night that was your issue .(Former ADON MMM) wouldn't come in and get on a cart or help at all . LPN OOO reported the evening when she worked with a 56 resident assignment, she was not aware until a CNA came and asked her to get a pain medication for a resident. LPN OOO reported the offgoing nurses that night had locked the keys in the medication cart and left at the end of their shift. LPN OOO stated .I never got report or nothing about that hall or any of those patients . In an interview on 1/8/25 at 11:49 AM, RN PPP reported they worked at the facility on 10/19/24 and stated .they were short on nurses that morning . RN PPP recalled going over to the 300 Hall to assist with passing morning medications. RN PPP reported there was no nurse responsible for the 300 Hall at that time. RN PPP stated .It was horrible because a lot of people did not get their medications . on 10/18/24 and 10/19/24. RN PPP reported in each instance, the offgoing nurse locked the keys in the medication cart and left the facility without giving verbal report. RN PPP reported the nurse on the 400 Hall that day (10/19/24) had been calling management for help, and no plan was in place to assist staff when there was a shortage of nurses. RN PPP reported the on-call nurse manager at the time stopped responding to phone calls. In an interview on 1/8/25 at 12:40 PM, Agency CNA QQQ reported they responded to a door alarm the evening of 10/18/24 and found Resident #103 outside the facility in the parking lot. Agency CNA QQQ reported they redirected Resident #103 back into the facility and brought him back to his room on the 300 Hall. Agency CNA QQQ could not recall which nurse was assigned to Resident #103 at the time of his attempted elopement, and stated .they were short-staffed that whole day .It was so busy. They had days with no nurse on the hall . Agency CNA QQQ reported when there was no nurse assigned to a hall, there would be an additional CNA added to help monitor until a nurse could come in and take the assignment. In an interview on 1/8/25 at 1:22 PM, with Director of Nursing (DON) B and Assistant Director of Nursing (ADON) C, DON B reported the facility recognized an issue related to the 300 Hall and missed medications on 10/18/24. DON B reported a nurse came in late on 10/19/24 to assist with medication administration on the 300 Hall and help get everything caught up. In an interview on 1/8/25 at 3:40 PM, LPN QQ reported at shift change the evening of 10/18/24, no nurse showed up for the 300 Hall. LPN QQ reported they counted the controlled substances with the other day shift nurse and locked the keys in the medication cart before leaving the facility. LPN QQ reported they wrote a shift-to-shift report on a piece of paper and left it at the desk. LPN QQ stated .(With Agency staff) you don't know who will show up . LPN QQ reported RN LLL was on the 400 Hall that night and refused to take responsibility for the 300 hall because .it was too many people . LPN QQ reported the same thing happened on 10/26/24 on day shift, where no nurse took responsibility for the 300 Hall resulting in residents not receiving their ordered medications. LPN QQ reported at times when working day shift, some residents would ask the nurses to give them their scheduled evening medications before going home because they were anxious and worried that their medications would be missed. LPN QQ stated calling management or the on-call nurse was .a waste of your time . LPN QQ reported there were multiple days with missed medications and management .didn't do anything . LPN QQ reported residents on the 400 Hall missed medications and had no nurse the evening of 10/12/24. LPN QQ reported that night (10/12/24) the Agency nurse on the schedule arrived and refused the assignment, saying she wasn't going to put her license at risk. In an interview on 1/14/25 at 12:36 PM, CNA RRR reported they were assigned to Resident #103 the evening of his attempted elopement on 10/18/24. CNA RRR reported that evening, the facility was short-staffed and there was no nurse caring for the residents on the 300 Hall. CNA RRR reported at the time of Resident #103's attempted elopement, they were in a room caring for a different resident. CNA RRR reported there was a nurse on the 400 Hall, but when they asked the 400 Hall nurse for assistance they would say they were busy. CNA RRR stated .I was like, then who should I ask? CNA RRR reported they were unsure if any residents received their evening medications on 10/18/24. Review of the policy/procedure Medication Administration, dated 8/7/23, revealed .Administer medication in accordance with frequency prescribed by physician and standards of practice . Resident #103 Review of an Admission Record revealed Resident #103 was a male, with pertinent diagnoses which included stroke, anxiety, muscle weakness, depression, high blood pressure, and a history of falls. Review of the October 2024 Medication Administration Record (MAR) for Resident #103 revealed no documentation (missed medications) on 10/18/24 in the evening for the following physician orders: -Latanoprost Ophthalmic Solution 0.005 % (Latanoprost) Instill 1 drop in both eyes one time a day for Glaucoma -Losartan Potassium Oral Tablet 25 MG (Losartan Potassium) Give 1 tablet by mouth one time a day for HTN (hypertension - high blood pressure) -Rosuvastatin Calcium Oral Tablet 5 MG (Rosuvastatin Calcium) Give 1 tablet by mouth one time a day for Hyperlipidemia -Thiamine HCl Oral Tablet 100 MG (Thiamine HCl) Give 1 tablet by mouth one time a day -traZODone HCl Oral Tablet 50 MG (Trazodone HCl) Give 75 mg by mouth at bedtime for depression -levETIRAcetam Oral Tablet 500 MG (Levetiracetam) Give 1 tablet by mouth two times a day for Seizures -traMADol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 8 hours for Pain -Acetaminophen Tablet 325 MG Give 2 tablet by mouth four times a day for discomfort Resident #104 Review of an Admission Record revealed Resident #104 was a female, with pertinent diagnoses which included dementia, Alzheimer's disease, depression, anxiety, insomnia (difficulty sleeping), chronic pain, and high blood pressure. Review of the October 2024 Medication Administration Record (MAR) for Resident #104 revealed no documentation (missed medications) on 10/18/24 in the evening for the following physician orders: -Melatonin Oral Tablet 3 MG (Melatonin) Give 2 tablet by mouth one time a day for Sleep Review of the October 2024 Medication Administration Record (MAR) for Resident #104 revealed no documentation (missed medications) on 10/26/24 in the morning for the following physician orders: -Aspirin Oral Tablet Chewable 81 MG (Aspirin) Give 1 tablet by mouth one time a day for blood thinner -Cyanocobalamin Oral Tablet 100 MCG (Cyanocobalamin) Give 1 tablet by mouth one time a day for supplement -Lisinopril Oral Tablet 5 MG (Lisinopril) Give 1 tablet by mouth one time a day for HTN (hypertension - high blood pressure) -Polyethylene Glycol 3350 Powder (Polyethylene Glycol 3350) Give 17 gram by mouth one time a day for Constipation -clonazePAM Oral Tablet 0.5 MG (Clonazepam) Give 1 tablet by mouth two times a day related to anxiety Resident #113 Review of an Admission Record revealed Resident #113 was a female, with pertinent diagnoses which included diabetes, epilepsy (seizure disorder), hypothyroidism, bipolar disorder, depression, and a history of falls. Review of the October 2024 Medication Administration Record (MAR) for Resident #113 revealed no documentation (missed medications) on 10/12/24 in the evening for the following physician orders: -Gabapentin Oral Capsule 300 MG (Gabapentin) Give 1 capsule by mouth one time a day related to neuropathy (nerve pain) -Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 61 unit subcutaneously one time a day for diabetes -Levothyroxine Sodium Oral Tablet 75 MCG (Levothyroxine Sodium) Give 1 tablet by mouth one time a day related to hypothyroidism -Colace Oral Capsule 100 MG (Docusate Sodium) Give 1 capsule by mouth two times a day for constipation -QUEtiapine Fumarate Oral Tablet 50 MG (Quetiapine Fumarate) Give 1 tablet by mouth two times a day related to bipolar disorder -Refresh Plus Ophthalmic Solution 0.5 % (Carboxymethylcellulose Sodium) Instill 2 drop in both eyes two times a day for Dry eyes -Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen) Give 2 tablet by mouth three times a day for Pain Resident #120 Review of an Admission Record revealed Resident #120 was a male, with pertinent diagnoses which included dementia, atrial fibrillation (an irregular heart rate that results in poor blood flow), depression, anxiety, schizoaffective disorder (a mental health condition), Wernicke's encephalopathy (neurological disorder), hyperlipidemia, insomnia, diabetes, and hypotension (low blood pressure). Review of the October 2024 Medication Administration Record (MAR) for Resident #120 revealed no documentation (missed medications) on 10/12/24 in the evening for the following physician orders: -Atorvastatin Calcium Oral Tablet 10 MG (Atorvastatin Calcium) Give 1 tablet by mouth one time a day related to hyperlipidemia -Melatonin Oral Tablet 3 MG (Melatonin) Give 1 tablet by mouth one time a day for Sleep -OLANZapine Oral Tablet 20 MG (Olanzapine) Give 1 tablet by mouth one time a day related to schizoaffective disorder -traZODone HCl Oral Tablet 50 MG (Trazodone HCl) Give 1 tablet by mouth one time a day related to depression -Sotalol HCl Oral Tablet 160 MG (Sotalol HCl) Give 1 tablet by mouth two times a day related to atrial fibrillation -Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) Give 4 capsule by mouth three times a day related to dementia -Lactulose Oral Solution 10 GM/15 ML (Lactulose) Give 30 ml by mouth three times a day related to Wernicke's encephalopathy -Midodrine HCl Oral Tablet 10 MG (Midodrine HCl) Give 1 tablet by mouth three times a day related to hypotension -Haloperidol Oral Tablet 5 MG (Haloperidol) Give 1 tablet by mouth four times a day related to schizoaffective disorder Resident #124 Review of an Admission Record revealed Resident #124 was a male, with pertinent diagnoses which included heart disease, hyperlipidemia (high levels of fat in the blood), seizure disorder, high blood pressure, atrial fibrillation (an irregular heart rate that results in poor blood flow), and BPH (an enlarged prostate that can cause difficulty urinating). Review of the October 2024 Medication Administration Record (MAR) for Resident #124 revealed no documentation (missed medications) on 10/18/24 in the evening for the following physician orders: -Atorvastatin Calcium Oral Tablet 40 MG (Atorvastatin Calcium) Give 1 tablet by mouth one time a day for hyperlipidemia -Tamsulosin HCl Oral Capsule 0.4 MG (Tamsulosin HCl) Give 1 capsule by mouth one time day for BPH -Eliquis Oral Tablet 5 MG Apixaban) Give 1 tablet by mouth two times a day related to heart disease/atrial fibrillation -Gabapentin Oral Capsule 100 MG Give 2 capsule by mouth two times a day for Pain -Lacosamide Oral Tablet 100 MG (Lacosamide) Give 1 tablet by mouth two times a day for seizure -Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen) Give 2 tablet by mouth every 8 hours for pain Review of the October 2024 Medication Administration Record (MAR) for Resident #124 revealed no documentation (missed medications) on 10/26/24 in the morning for the following physician orders: -Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate) Give 1 tablet by mouth one time a day for heart failure/atrial fibrillation -Senna Oral Tablet 8.6 MG (Sennosides) Give 2 tablet by mouth one time a day for bowels -Eliquis Oral Tablet 5 MG Apixaban) Give 1 tablet by mouth two times a day related to heart disease/atrial fibrillation -Gabapentin Oral Capsule 100 MG Give 2 capsule by mouth two times a day for Pain -Lacosamide Oral Tablet 100 MG (Lacosamide) Give 1 tablet by mouth two times a day for seizure -Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen) Give 2 tablet by mouth every 8 hours for pain Resident #125 Review of an Admission Record revealed Resident #125 was a male, with pertinent diagnoses which included diabetes. Review of the October 2024 Medication Administration Record (MAR) for Resident #125 revealed no documentation (missed medications) on 10/18/24 in the evening for the following physician orders: -Lantus Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 10 unit subcutaneously one time a day for diabetes -traZODone HCl Oral Tablet 50 MG (Trazodone HCl) Give 1 tablet by mouth one time a day for Depression Review of the October 2024 Medication Administration Record (MAR) for Resident #125 revealed no documentation (missed medications) on 10/19/24 in the morning for the following physician orders: -NovoLOG FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject 10 unit subcutaneously three times a day for diabetes -NovoLOG FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale three times a day for diabetes Resident #126 Review of an Admission Record revealed Resident #126 was a female, with pertinent diagnoses which included depression, anxiety, and diabetes. Review of a Minimum Data Set (MDS) assessment for Resident #126, with a reference date of 11/15/24, revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated she was cognitively intact. In an interview on 1/9/25 at 12:21 PM, Resident #126 recalled several nights in October 2024 where no nurse was assigned to her hall. Resident #126 stated .I guess (the nurse) just didn't show up. I think that is what the excuse was . Resident #126 reported she missed some medications and others were administered late. Resident #126 stated .I was kind of worried because I didn't know. I have sugar (diabetes). I didn't know then if I would have a reaction . Resident #126 reported she was worried about how long she could go without medication. Resident #126 reported issues with anxiety and stated .The anxiety got to be so bad .nobody (was) handing out meds (medications) .there was no one . In an email on 1/9/25 at 3:47 PM, DON B reported 30 of 32 residents on the 400 Hall missed medication on 10/12/24, 30 of 30 residents on the 300 Hall missed medication on 10/18/24, 6 of 30 residents on the 300 Hall missed medication on 10/19/24, and 24 of 29 residents on the 300 Hall missed medication on 10/26/24. The Immediate Jeopardy that began on 10/12/24 was removed on 10/28/24 when the facility took the following actions to remove the immediacy: 1) Staff involved in the incidents were disciplined including termination. 2) All missed medications were addressed with physician orders reviewed and implemented. Families and responsible parties were notified of the incidents and corrective actions taken. Beginning 10/21/24, morning meetings now include reviews of missed medications for immediate investigation and follow-up. Medication errors are documented, with physicians, residents, and responsible parties notified. 3) Facility policies on Medication Administration and Controlled Medication Guidelines were reviewed and all licensed nurses were re-educated. All licensed nursing staff received additional and/or re-education on Medication Administration and Error Prevention and Reporting Shortages and Advocating for Residents on 11/1/24. Additional in-service education provided to all nursing and CNA staff on 11/5/24 and 11/7/24. 4) Beginning 10/28/24, nursing leadership on-call with an identified cell phone for staff to call if needed for any reason. Nursing remains on-call 24/7. An additional process was added for calling at the start of each shift to ensure all scheduled staff have arrived. 5) In situations where coverage is needed, the on-call staff will prioritize ensuring clinical supervision and assistance with medication pass. Management staff to review the current staffing matrix and identify available resources including but not limited to agency use through two contracted vendors, PRN (as needed) staff and current staff working overtime. Identify on-call staff to come in as well as beginning to cross-train existing personnel to cover immediate needs. 6) DON/Designee and Administrator will meet daily to discuss any calls from the previous day/night to ensure continuity of care throughout all departments and ensuring all needs have been met. 41982 DPS Statement B: Based on interview and record review, the facility failed to protect the residents' right to be free from physical/verbal abuse by staff and physical abuse by a resident in 3 of 15 residents reviewed for abuse, resulting in staff-to-resident physical and verbal abuse by CNA UU toward Resident #114 on 11/20/24 and resident-to-resident physical abuse by Resident #106 toward Resident #108 on 9/29/24 and Resident #109 on 10/3/24. Findings include: Staff-to-Resident Abuse: Review of a Facility Reported Incident (FRI) Intake Information Report revealed, .Facility incident report received via online submission on: 11/20/24, 1:30 PM .Incident Summary Staff members (Certified Nurse Aide (CNA) M) & (CNA N) reported to (Assistant Director of Nursing (ADON) C) that (CNA UU) while washing resident (Resident #114) up, resident hit (CNA UU) in the arm. The assigned CNA (CNA UU) hit resident back .Investigation Summary Title of Incident: Resident Abuse Date/Time of Incident: 11/20/24 11:30 am .Statement of Incident: Three CNAs were providing care to (Resident #114) around 11:30 am. The assigned CNA (CNA UU) was standing to the left side of the resident. The resident reached up and grabbed at the CNAs (CNA UU) shoulders. The CNA (CNA UU) began smacking her with an open palm to (Resident #114)'s back. It was reported by the two other CNAs (CNA M & N) that (CNA UU) and (Resident #114) continued hitting each other back and forth. Per CNA (CNA UU) she grabbed the residents arm to stop her from hitting her. Per CNAs (CNA M & N), CNA (CNA UU) had pushed it down and they felt she had twisted it and continued to hit each other with an open hand. There is a discrepancy in the number of times that the resident was hit, however statements of both CNAs (CNA M & N) state that it was approximately 10-20 times 911 was called. (CNA UU) was kept in an office with oversight until the police arrived. When they arrived, they talked with (CNA UU), and she admitted to them what she had just done to Resident #114. They immediately arrested her and escorted her out of the facility .A skin assessment was completed, and redness was identified immediately to the left shoulder and arm .Pain assessment was completed and pain meds (medications) given post incident . Resident #114 Review of an Admission Record revealed Resident #114 was a female, with pertinent diagnoses which included: cognitive communication deficit, major depressive disorder, muscle weakness (generalized). Review of a Minimum Data Set (MDS) assessment for Resident #114, with a reference date of 10/10/24 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated Resident #114 was severely cognitively impaired. Review of Resident #114's current Care Plan revealed the focus, Resident has a past potentially traumatic event related to being physical assault (being slapped multiple times) with a date initiated of 11/21/24 and care planned interventions which included, Encourage resident to talk about traumatic event at their own pace .Monitor for changes in cognition and behavior and report observation to services/nursing .Offer reassurance of safety and security with date initiated of 11/21/24. (It should be noted that this care plan was developed following the staff to resident abuse incident.) Review of a witness statement from CNA M (not dated) revealed, We were wrapping up the bed bath. Assigned CNA (CNA UU) washed up arm pits. Resident had hit assigned CNA (CNA UU) in the arm. The assigned CNA (CNA UU) hit resident with substantial force. They hit each other back and forth over 10 times. During the situation the CNA (CNA UU) said, I fight back multiple times. Resident called assigned CNA (CNA UU) an A**hole the assigned CNA (CNA UU) responded by saying, your mom is an a**hole. The area of injury is upper arm, shoulder, twisting the wrist. In an interview on 1/2/25 at 2:23 PM, CNA M reported that he and 2 other staff (CNA N and CNA UU) went in to provide Resident #114 care. CNA M reported CNA N was a unit aide at the time and was there to watch and learn. CNA M reported Resident #114 got combative during her care and began to swat and swing at CNA UU. CNA M reported CNA UU began swatting and swinging back at Resident #114 and when Resident #114 told CNA UU that her mom was an a**hole, CNA UU then told Resident #114 that her mom was an a**hole. CNA M reported CNA UU also told Resident #114 that she fought back. CNA M reported he wasn't sure when, but at one point CNA UU grabbed Resident #114's hand and twisted her arm. CNA M reported Resident #114 and CNA UU continued to hit each other back and forth. CNA M reported that doing anything back to a resident was excessive and that Resident #114's arm from the elbow up was red where CNA UU had hit her. CNA M reported it wasn't just a slap, but rather, CNA UU had moved her hand back over her head and then hit the resident with open hand multiple times. Review of a witness statement from CNA N (not dated) revealed, Around 1130-1140am, I (CNA N), (CNA M), (CNA UU) went to give a resident to give her a bed bath. I was standing at the foot of the bed and (CNA UU) was on the left side of the resident. The resident grabbed (CNA UU)'s shoulder and (CNA UU) started smacking the resident saying, I hit back and smacked the resident's hand again. The resident began crying and they started hitting each other back and forth. (CNA UU) then twisted the resident's arm. Me and (CNA M) walked out. As we were walking down the hall, I could still hear (CNA UU) and resident yelling at each other and another loud slap. I texted (ADON C) to talk and told her everything. Resident got hit at least over 20 times on her left upper side of her body and back of the head and upper back. In an interview on 1/2/25 at 3:46 PM, CNA N reported on the day of the incident, she had been training at the time and had gone in Resident #114's room with CNA M and CNA U to observe them provide Resident #114 with a bed bath. CNA N reported when CNA UU started washing Resident #114 up, Resident #114 grabbed CNA UU's clothing. CNA N reported then CNA UU decided to turn around and started slapping Resident #114. CNA N reported Resident #114 started yelling and crying at that point to which CNA UU yelled back at Resident #114 and reportedly said f*ck you, f*uck your mom, you hit me and I will hit you back. CNA N reported at that time CNA UU started hitting Resident #114 repeatedly. CNA N reported the slapping happened for approximately 3-5 minutes, but that it seemed like forever. CNA N reported CNA UU then told CNA M to give her the brief for Resident #114 so they could put it on her. CNA N reported after CNA M gave CNA UU the brief (incontinence underwear) and put it on Resident #114, they (CNA N and CNA M) walked out of the room. CNA N reported that is when she realized that CNA UU was still in the room with Resident #114 and heard a loud slap, like a clapping sound. CNA N reported hearing the slap down the hallway. CNA N reported she then text messaged ADON C to report the incident. In an interview on 1/3/25 at 9:30 AM, ADON C reported CNA N had texted her and said she needed to speak with her because she had just seen something real bad. ADON C reported when she approached CNA N, CNA N started crying and reported to ADON C that she had just seen CNA UU beat a resident. ADON C reported she went and found CNA UU (who was out of Resident #114's room at this point) and CNA UU openly admitted that she had hit Resident #114. ADON C reported CNA UU, CNA M, and CNA N were placed in separate rooms to give statements and the police [TRUNCATED]

This citation pertains to Intake # MI00147580, MI00149295, & MI00149428. Based on interview, and record review, the facility failed to ensure residents are free from significant medication errors in 5 of 14 residents (Resident #118, #103, #113, #124, & #125) reviewed for medication administration, resulting in a significant change in condition and hospitalization for Resident #118, and the potential for adverse effects due to missed medications. Findings include: The health care provider (physician or advanced practice nurse) is responsible for directing medical treatment. Nurses follow health care providers' orders unless they believe that the orders are in error, violate agency policy, or are harmful to the patient. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 20717-20719). Elsevier Health Sciences. Kindle Edition. Resident #118 Review of an Admission Record revealed Resident #118 was a male, with pertinent diagnoses which included heart failure, atrial fibrillation (an irregular heart rate that results in poor blood flow), respiratory failure, kidney disease, stroke, and high blood pressure. Review of a Minimum Data Set (MDS) assessment for Resident #118, with a reference date of 12/17/24, revealed a Brief Interview for Mental Status (BIMS) score of 0, out of a total possible score of 15, which indicated severe cognitive impairment. Review of a Nursing - Transfer to Hospital Summary for Resident #118, dated 12/30/24 at 6:37 PM, revealed .Resident was in bed alert with prompting .Resident brother at bedside during the morning. Medications reviewed with brother .Brother was concerned resident was not staying awake during visit .VS (Vital Signs) obtained (oxygen via nasal cannula) increased to 5 (Liters) .to maintain (oxygen) above 90%. NP (Nurse Practitioner) called .brother wanted to send patient to ED (Emergency Department) . In an interview on 1/6/25 at 12:15 PM, Unit Manager LL reported they assessed Resident #118 prior to his hospitalization on [DATE]. Unit Manager LL reported they were working on a different unit when Resident #118's nurse came to get them for a second opinion. Unit Manager LL reported Resident #118's family member had been in earlier asking about Resident #118's ordered medications. Unit Manager LL reported Resident #118's oxygen saturation had been low and the assigned nurse had increased his oxygen to keep his saturation above 90%. Unit Manager LL reported Resident #118 appeared calm and did make eye contact and respond to his name. Unit Manager LL reported Resident #118's family member was concerned, and wanted Resident #118 to be sent to the hospital since he seemed more sleepy/tired than usual. In an interview on 1/6/25 at 12:23 PM, Agency Licensed Practical Nurse (LPN) DDD reported they were the nurse assigned to Resident #118 at the time of his hospitalization on [DATE]. Agency LPN DDD reported Resident #118 was awake but appeared to have labored breathing. Agency LPN DDD reported since they were not sure of Resident #118's baseline, they requested Unit Manager LL to assess Resident #118. Agency LPN DDD reported they checked on him several times and he would respond and make eye contact. Agency LPN DDD stated .the breathing was my concern . and reported both Resident #118's pulse and respiration rate were high. Agency LPN DDD reported Resident #118's family member was concerned that Resident #118 was not his usual self, and wanted him sent to the hospital for further evaluation. Agency LPN DDD reported Resident #118 had a PRN (as needed) medication ordered for anxiety, but no doses were administered on their shift. Review of an Emergency Department (ED) Physician Note for Resident #118, dated 12/30/24, revealed .presented from nursing facility with acute Encephalopathy, un arousable, only arousing to sternal rub .Drug screen pending .Upper and lower extremities are cold to touch .Concerned if he is in cardiogenic shock .QTC is very prolonged >600s, holding amiodarone .Avoid QT prolonging (medications) .transferred to the intensive care unit (ICU) . Review of a Hospital Physician Note for Resident #118, dated 12/31/24, revealed .Presented this admission from LTC (Long-Term Care) for change in mentation and abnormal breathing .Amiodarone started last admission .EKG upon admission demonstrated prolonged QTc. Agree with holding at this time .Per ICU notes - may be related to Trazodone use .Monitor QTc and rhythm . Review of a Hospital Physician Note for Resident #118, dated 1/1/25, revealed .Patient was brought in from his long-term care facility to emergency department with acute encephalopathy leading to worsening acute hypoxic respiratory failure. He was difficult to arouse in the emergency department so he was admitted to intensive care unit for close monitoring .suspected to be medication related: Drug screen was positive for trazodone (not on facility med (medication) list, so unclear how he received this medication), but also had been on Xanax but this did not show on drug screen . Review of a Hospital Physician Note for Resident #118, dated 1/2/25, revealed .Drug Screen .Trazodone .Facility was contacted, and there was no record of trazodone administration .there is report that the patient did receive Vistaril and Xanax on the days leading up to admission. There was no benzodiazapines identified on screens .It is felt that the altered mental status may have been related to trazodone (found) on a drug screen, there is no documentation of this ever being given at the facility . In an interview on 1/7/25 at 9:30 AM, Agency Registered Nurse (RN) BBB reported Resident #118 had a PRN medication for anxiety and recalled administering the medication to Resident #118. Agency RN BBB stated .(Resident #118) had a lot of anxiety. (He) wouldn't keep his oxygen (nasal cannula) on (and) would have episodes of rapid breathing . Agency RN BBB reported Resident #118 took all his medication via a PEG (Percutaneous Endoscopic Gastrostomy) tube (a feeding tube placed through the abdominal wall). Review of an Order Summary Report for Resident #118 revealed the physician order .Xanax Oral Tablet 0.5 MG (Alprazolam) Give 0.5 mg via G-Tube (feeding tube) every 8 hours as needed for Anxiety . with a start date of 12/19/24. Note this order was discontinued on 12/26/24. Review of an Order Summary Report for Resident #118 revealed the physician order .Xanax Oral Tablet 0.5 MG (Alprazolam) Give 1 tablet via PEG-Tube (feeding tube) every 8 hours as needed for Anxiety . with a start date of 12/29/24. Review of a Controlled Drug Receipt/Record/Disposition Form for Resident #118 revealed one Alprazolam 0.5 MG Tablet was pulled from Resident #118's medication supply for administration on 12/19/24 at 7:00 AM, one on 12/19/24 at 7:00 PM, one on 12/28/24 at 9:00 PM, and one on 12/29/24 at 12:22 PM. Note there was no active physician order for Alprazolam 0.5 MG Tablet for Resident #118 on 12/28/24. Review of the December 2024 Medication Administration Record (MAR) for Resident #118 revealed the medication Alprazolam 0.5 MG Tablet was documented as administered only one time, on 12/29/24 at 12:22 PM. No administration documentation noted in the December 2024 MAR related to the Alprazolam 0.5 MG Tablets pulled from Resident #118's medication supply on 12/19/24 (two doses) and 12/28/24 (one dose). Review of an Order Summary Report for Resident #118 revealed the physician order .Amiodarone HCl Oral Tablet 200 MG (Amiodarone HCl) Give 1 tablet .one time a day . with a start date of 12/28/24. Review of an Order Summary Report for Resident #118 revealed no physician order for Trazodone. In an interview on 1/9/25 at 1:42 PM, Assistant Director of Nursing (ADON) C reported Resident #118 was sent to the hospital on 12/30/24 and a drug screen revealed trazodone (an antidepressant) in his system, which he was not prescribed. ADON C reported the drug screen also indicated no alprazolam in his system, which he did have a prescription for and per the facility medication administration records had been given two doses prior to his hospitalization . ADON C reported Resident #118 was prescribed amiodarone which cannot be taken simultaneously with trazodone, due to the potential for drug interactions. Resident #103 Review of an Admission Record revealed Resident #103 was a male, with pertinent diagnoses which included stroke and a seizure disorder. Review of a current Care Plan for Resident #103 revealed the focus .The resident has a seizure disorder r/t (related to) hx (history) intracerebral hemorrhage (stroke) . with interventions which included .Give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness . both initiated 8/14/24. Review of the October 2024 Medication Administration Record (MAR) for Resident #103 revealed no documentation (missed medication) on 10/18/24 in the evening for the physician order .levETIRAcetam Oral Tablet 500 MG (Levetiracetam) Give 1 tablet by mouth two times a day for Seizures . Review of an article titled Missed Medicines as a Seizure Trigger, dated 2024, revealed .Missing doses of seizure medicine is the most common cause of breakthrough seizures. Missed medicines can trigger seizures in people with both well-controlled and poorly controlled epilepsy. Seizures can happen more often than normal, be more intense or develop into long seizures called status epilepticus. Status epilepticus is a medical emergency and can lead to death if the seizures aren't stopped. Missing doses of medicine can also lead to falls, injuries and other problems from seizures and changes in medicine levels . Retrieved from https://www.epilepsy.com/what-is-epilepsy/seizure-triggers/missed-medicines Resident #113 Review of an Admission Record revealed Resident #113 was a female, with pertinent diagnoses which included diabetes. Review of a current Care Plan for Resident #113 revealed the focus .Risk (for) adverse outcomes from potential hypoglycemic (low blood sugar) or hyperglycemic (high blood sugar) episodes (diagnosis of diabetes) . initiated 8/14/24. Review of the October 2024 Medication Administration Record (MAR) for Resident #113 revealed no documentation (missed medication) on 10/12/24 in the evening for the physician order .Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 61 unit subcutaneously one time a day for diabetes . Resident #124 Review of an Admission Record revealed Resident #124 was a male, with pertinent diagnoses which included heart disease, high blood pressure, and atrial fibrillation (an irregular heart rate that results in poor blood flow). Review of a current Care Plan for Resident #124 revealed the focus .The resident is on anticoagulant therapy r/t (related to) Atrial fibrillation, history of PE (pulmonary embolism) . with interventions which included .Administer medications as ordered by physician. Monitor for side effects . both initiated 8/13/24. Review of the October 2024 Medication Administration Record (MAR) for Resident #124 revealed no documentation (missed medication) on 10/18/24 in the evening for the physician order .Eliquis (an anticoagulant) Oral Tablet 5 MG Apixaban) Give 1 tablet by mouth two times a day related to heart disease/atrial fibrillation . Review of the October 2024 Medication Administration Record (MAR) for Resident #124 revealed no documentation (missed medication) on 10/26/24 in the morning for the physician order .Eliquis Oral Tablet 5 MG Apixaban) Give 1 tablet by mouth two times a day related to heart disease/atrial fibrillation . Review of a Cleveland Clinic page titled Anticoagulants, last reviewed/updated 1/10/22, revealed .Anticoagulants are a family of medications that stop your blood from clotting too easily. They can break down existing clots or prevent clots from forming in the first place. These medications can help stop life-threatening conditions like strokes, heart attacks and pulmonary embolisms, all of which can happen because of blood clots . Retrieved from https://my.clevelandclinic.org/health/treatments/22288-anticoagulants Resident #125 Review of an Admission Record revealed Resident #125 was a male, with pertinent diagnoses which included diabetes. Review of a current Care Plan for Resident #125 revealed the focus .The resident has Diabetes Mellitus . with interventions which included .Administer medication as ordered by the physician . both initiated 8/13/24. Review of the October 2024 Medication Administration Record (MAR) for Resident #125 revealed no documentation (missed medication) on 10/18/24 in the evening for the physician order .Lantus Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 10 unit subcutaneously one time a day for diabetes . Review of the October 2024 Medication Administration Record (MAR) for Resident #125 revealed no documentation (missed medications) on 10/19/24 in the morning for the physician orders .NovoLOG FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject 10 unit subcutaneously three times a day for diabetes . and .NovoLOG FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale three times a day for diabetes . Review of a Cleveland Clinic page titled Insulin, last reviewed/updated 1/17/24, revealed .Insulin is an essential hormone. It helps your body turn food into energy and manages your blood sugar levels. If you have diabetes, your body can't make enough insulin or can't use it properly. Your healthcare provider can prescribe manufactured insulin that you take through an injection (shot), injectable pen or pump .Insulin is a naturally occurring hormone your pancreas makes that's essential for allowing your body to use sugar (glucose) for energy. If your pancreas doesn't make enough insulin or your body doesn't use insulin properly, it leads to high blood sugar levels (hyperglycemia). This results in diabetes .There are also manufactured types of insulin that people with diabetes use to manage the condition .Regular insulin (or short-acting insulin) .They begin working about 30 to 45 minutes after injection and wear off after about five to eight hours. Regular insulin peaks about two to four hours after injection .Long-lasting insulin: It takes about an hour for this type of insulin to reach your bloodstream and start working. It peaks between three and 14 hours after injection. It lasts up to a day. Types include insulin glargine .Follow your provider's instructions carefully . Retrieved from https://my.clevelandclinic.org/health/body/22601-insulin In an interview on 1/6/25 at 3:48 PM, Licensed Practical Nurse (LPN) QQ reported the evening of 10/18/24 on the 300 Hall, no residents received scheduled medications. In an interview on 1/8/25 at 9:52 AM, Former Assistant Director of Nursing (ADON) MMM reported they were aware that multiple residents missed medications the evening of 10/18/24 and stated .we did look into that . In an interview on 1/8/25 at 10:07 AM, Agency Licensed Practical Nurse (LPN) JJJ reported they worked on the 100 Hall the evening of 10/18/24. Agency LPN JJJ reported that evening there was no nurse assigned to the 300 Hall from 6:30 PM-11:00 PM. In an interview on 1/8/25 at 11:49 AM, RN PPP reported they worked at the facility on 10/19/24 and stated .they were short on nurses that morning . RN PPP recalled going over to the 300 Hall to assist with passing morning medications. RN PPP reported there was no nurse responsible for the 300 Hall at that time. RN PPP stated .It was horrible because a lot of people did not get their medications . on 10/18/24 and 10/19/24. In an interview on 1/8/25 at 1:22 PM, with Director of Nursing (DON) B and Assistant Director of Nursing (ADON) C, DON B reported the facility recognized an issue related to the 300 Hall and missed medications on 10/18/24. DON B reported a nurse came in late on 10/19/24 to assist with medication administration on the 300 Hall and help get everything caught up. In an interview on 1/8/25 at 3:40 PM, LPN QQ reported at shift change the evening of 10/18/24, no nurse showed up for the 300 Hall. LPN QQ reported they counted the controlled substances with the other day shift nurse and locked the keys in the medication cart before leaving the facility. LPN QQ reported they wrote a shift-to-shift report on a piece of paper and left it at the desk. LPN QQ stated .(With Agency staff) you don't know who will show up . LPN QQ reported RN LLL was on the 400 Hall that night and refused to take responsibility for the 300 hall because .it was too many people . LPN QQ reported the same thing happened on 10/26/24 on day shift, where no nurse took responsibility for the 300 Hall resulting in residents not receiving their ordered medications. LPN QQ reported residents on the 400 Hall missed medications and had no nurse the evening of 10/12/24. LPN QQ reported that night (10/12/24) the Agency nurse on the schedule arrived and refused the assignment, saying she wasn't going to put her license at risk.

This citation pertains to Intake # MI00141034. Based on interview, and record review, the facility failed to perform Cardiopulmonary Resuscitation (CPR) on a resident with a Full Code status, in 1 of 5 residents (Resident #105) reviewed for code status/CPR, resulting in an Immediate Jeopardy when on [DATE] at approximately 9:00 AM Resident #105, who was designated as a Full Code, was found to be non-responsive (no respirations/heart beat). Licensed Nursing staff did not initiate CPR per physician order and facility policy, and Resident #105 passed away. This deficient practice placed all residents, who are designated as a Full Code and who suffer cardiac arrest, or are found non-responsive, at risk for serious harm and/or death. Findings include: Review of an Admission Record revealed Resident #105 was a female, with pertinent diagnoses which included stroke, diabetes, dementia, high blood pressure, right tibia fracture, vascular disease, and muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #105, with a reference date of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated she was cognitively intact. Review of a Request to Limit Treatment form for Resident #105, dated [DATE], revealed the statement .In the event of cardiopulmonary arrest, I wish to be given CPR . had a check mark in the section which stated .I DO . Further review of this form revealed the statement .You will remain a full code until this form and an order is obtained by the physician . This form was signed by Resident #105 on [DATE]. Review of an Order Summary Report for Resident #105 revealed the physician order .CPR-Full Code . with a start date of [DATE] and no end date. Review of a Care Plan for Resident #105 revealed the focus .(Resident #105) admitted to facility as her own responsible party. Request to limit treatment form filled out indicating (Resident #105's) wishes . with interventions which included .CODE STATUS: FULL CODE . both initiated [DATE]. Review of a Nurse's Note for Resident #105, dated [DATE] at 1:17 PM, revealed .Resident expired this morning (at) approximately (9:10 AM). No carotid or peripheral pulse. Pupils fixed and nonreactive (sic). No response to tactile stimuli. No respirations for full minute. Verified with second nurse and unit manager. DPOA (Durable Power of Attorney) notified (at) approximately (9:20 AM) . In an interview on [DATE] at 10:39 AM, Licensed Practical Nurse (LPN) S reported on [DATE], at approximately 9:00 AM, she was passing medications on the hall when she was approached by Registered Nurse (RN) L, who asked if she had a stethoscope and could come with her to verify Resident #105 had expired. LPN S reported Resident #105 did not have a pulse and was not breathing. LPN S reported RN L never discussed or mentioned Resident #105's code status. LPN S reported after she verified Resident #105's death she returned to her hall to continue with medication pass. LPN S reported CPR was not initiated on Resident #105. In an interview on [DATE] at 11:02 AM, Resident Care Assistant (RCA) F reported she was assisting Resident #105's roommate on [DATE] at approximately 9:00 AM, with the curtain pulled, when Physical Therapy Assistant (PTA) II requested her assistance with Resident #105. RCA F reported she went over to assist PTA II and observed that Resident #105 was not breathing. RCA F reported she and PTA II notified RN L, who was right outside the doorway, to come and assess Resident #105. In an interview on [DATE] at 11:24 AM, PTA II reported she initially approached Resident #105 for therapy on [DATE] at approximately 8:30 AM. PTA II reported at that time Resident #105 appeared to be asleep with her eyes closed, and was breathing. PTA II reported she left, and when she returned to Resident #105's room at approximately 9:00 AM, Resident #105 was non-responsive and .was clearly gray (in color) . and not breathing. PTA II reported she requested RCA F to assist because .I just wanted to make sure. Am I seeing what I'm seeing . PTA II reported after RCA F came over to Resident #105's side of the room, they immediately notified RN L who .was right outside the door . PTA II reported she asked RN L about Resident #105's code status, and RN L reported she wasn't sure. PTA II reported she also went down to notify Unit Manager M that Resident #105 was non-responsive and not breathing. PTA II stated when RN L and Unit Manager M were in Resident #105's room .they were questioning how long she had been deceased . PTA II reported CPR was not initiated on Resident #105. In an interview on [DATE] at 11:41 AM, RN L reported she was Resident #105's assigned nurse on [DATE]. RN L reported she was approached by PTA II at approximately 9:00 AM while at her medication cart. RN L reported PTA II told her she believed Resident #105 had expired. RN L reported Unit Manager M and LPN S came into Resident #105's room with her to assess the situation. RN L reported she listed to Resident #105's heart and lungs and didn't hear a heartbeat or note any respirations for a full minute. RN L reported this observation was verified by LPN S. RN L reported at that time they pronounced Resident #105's death. RN L reported she could not recall if Resident #105's code status was discussed. RN L reported she checked Resident #105's code status on her paper report sheet when PTA II notified her of Resident #105's status and stated .She was a Full Code . but reported she would need to verify in the computer. RN L reported she did not check the computer to verify Resident #105's code status. RN L stated she did not initiate CPR on Resident #105 because .I saw (Resident #105) and how pale she was (She) appeared to have been dead for a while . RN L reported she used her .nursing judgement . and .realized CPR would have done more harm than good . In an interview on [DATE] at 12:29 PM, LPN Y reported if a resident is found non-responsive (no breathing/no heart beat), nursing staff should quickly check the resident's code status in the electronic medical record. LPN Y reported if the resident is a Full Code, staff are to announce a Code Blue overhead, and initiate CPR. LPN Y reported CPR was not initiated on Resident #105 on [DATE]. In an interview on [DATE] at 12:55 PM, Director of Nursing (DON) B reported she was notified that Resident #105 had expired during morning meeting on [DATE]. DON B reported she left the meeting and went down to Resident #105's room to .just see the situation . DON B reported when she arrived, Resident #105 was covered up and postmortem care had already been completed. DON B reported she interviewed RN L, who explained what had happened. DON B reported she asked about Resident #105's code status, and discovered Resident #105 was a Full Code. DON B reported she asked RN L if CPR had been initiated and .She said no . DON B reported she asked Unit Manager M why CPR wasn't initiated when Resident #105 was a Full Code, and was told that Resident #105 had expressed a desire to be on Hospice. DON B stated .(Resident #105) wasn't yet on Hospice and there was no documentation of her transition to Hospice . DON B reported CPR should have been initiated when Resident #105 was found non-responsive on [DATE]. In an interview on [DATE] at 1:41 PM, Unit Manager M reported she was notified by a therapist on [DATE] at approximately 9:00 AM that there was an issue with Resident #105. Unit Manager M reported she responded with RN L and LPN S to Resident #105's room. Unit Manager M reported RN L and LPN S pronounced Resident #105's death, and she (Unit Manager M) notified DON B of her passing. Unit Manager M reported she did not recall a discussion with RN L or LPN S about code status, and stated .I didn't know the code status . Unit Manager M reported CPR was not initiated on Resident #105. Review of the policy/procedure Cardiopulmonary Resuscitation, dated [DATE], revealed .It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement guidelines regarding cardiopulmonary resuscitation (CPR) .The facility will follow current American Heart Association (AHA) guidelines regarding CPR .If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and: a. In accordance with the resident's advance directives, or b. In the absence of advance directives or a Do Not Resuscitate order; and c. If the resident does not show obvious signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) . On [DATE], Administrator A was notified of an Immediate Jeopardy that began on [DATE] when the facility failed to perform CPR on a resident with a Full Code status (Resident #105) upon identifying that the resident was non-responsive (no respirations/heart beat). On [DATE], this surveyor verified the facility completed the following to remove the Immediate Jeopardy: 1) Resident #105 is deceased as of [DATE]. 2) On [DATE] the facility Medical Director was notified of the incident. 3) On [DATE] deaths that occurred within the last 90 days were reviewed to ensure advance directives were adhered to. Audit identified no concerns. 4) On [DATE] Registered Nurse who did not perform CPR on the full code status resident was immediately re-educated. 5) On [DATE] Education for all facility and agency nurses was initiated on the Cardiopulmonary Resuscitation (CPR) and the Do Not Resuscitate Policies. Any nurse not educated before [DATE] has been educated prior to returning to work. As of [DATE], 17 out of 24 actively working facility nurses were re-educated; those not educated by [DATE] have been re-educated prior to starting their next shift. As of [DATE], 23 out of 23 actively working facility nurses have been re-educated. As of [DATE] 100% of agency nurses have been educated prior to start of shift. 6) The Director of Nursing or Designee will complete audits on random nurses to determine if they are aware of the DNR and CPR policy. Audits will be done on 5 nurses weekly for 4 weeks, Biweekly for the next 4 weeks and once the following month. Any concerns related to code status documentation will be addressed immediately and reported to the Director of Nursing. The Director of Nursing will report results to QAPI monthly x3 months and then as directed by the QAPI committee. On [DATE] and [DATE] weekly audits were conducted. 7) The Director of Nursing or Designee will perform one code blue drill weekly on random shifts for 4 weeks to ensure all shifts have been evaluated, biweekly for the next 4 weeks, and then monthly going forward. Findings will be reviewed at the monthly QAPI meeting. On [DATE] and [DATE] code blue drills were conducted. 8) Audit results will be reviewed by QAPI until such time consistent substantial compliance has been achieved as determined by the QAPI committee. On [DATE], the QAPI committee reviewed the facility abatement plan, past non-compliance, and accompanying audits. 9) The Director of Nursing is responsible for attaining and sustaining overall compliance with this plan of correction. Date of Compliance with this regulation is by [DATE]. The facility was granted a Past Non-Compliance at the time of exit due to no further like incidents had occurred, the facility re-trained pertinent staff, the Cardiopulmonary Resuscitation (CPR) and Do Not Resuscitate policies were reviewed and deemed appropriate, and the facility had achieved sustained compliance. Therefore, no plan of correction will be required.

This citation pertains to intake #MI00134978. Based on observation, interview, and record review, the facility failed to safely transfer 1 of 3 residents (Resident #100) reviewed for accident hazards, resulting in Resident #100's avoidable fall and sustaining a left rami (pelvic bone) fracture. Findings include: Review of an Admission Record revealed Resident #100 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: osteoporosis (condition when bone strength weakens and is susceptible to fracture. It usually affects hip, wrist or spine) and osteoarthritis (degenerative joint disease). Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 2/9/23 revealed a Brief Interview for Mental Status (BIMS) score of 8, out of a total possible score of 15, which indicated Resident #100 was cognitively impaired. Review of the Functional Status revealed that Resident #100 was totally dependent and required 2 person assistance for transfers. Review of Resident #100's Care Plan that was in place at the time of the fall on 2/18/23 .has ADL (activities of daily living) self-care deficit related to cognitive impairment, weakness/debility .Date initiated 11/12/20 .INTERVENTIONS: .TRANSFER: Dependent mechanical full body lift (hoyer) with 2 staff assist. Date Initiated: 11/12/2020. The transfer intervention was revised on 03/01/2023 and revealed, TRANSFER: Dependent mechanical hoyer lift with 2 staff assist. Recommended to use full body sling. Review of a Facility Reported Incident (FRI) received on 2/20/22 at 11:33 P.M. revealed, .On 2/18/23, (Resident #100) had a fall which resulted in no external injury. On 2/20/23, Physician sent resident out to (hospital) due to report of pain. X-ray results showed suspected fracture of the left inferior pubic ramus (hip bone) . INVESTIGATION: .No injury was identified at the time of the fall. (Licensed Practical Nurse (LPN) F) reported fall to on call provider (Nurse Practitioner (NP) M). No new orders were given. Per (NP M) (Doctor of Osteopathic Medicine (DO) U) would be notified on Monday (2/20/23). (Resident #100) was monitored post fall with Vital signs and neurological checks. No concerns were noted at the time .(Resident #100) slid out of the hoyer while she was being transferred .On 2/19/23 at 7:11am, (Registered Nurse (RN) O) noted that (Resident #100) had pain with repositioning. Resident was not able to state where exactly she hurt but said yes when asked if her lower back hurt and yes when asked if legs hurt. No swelling noted or any abnormal findings at that time. Will continue to monitor. On 2/19/23 at 1:34pm, (LPN F), .noted that she stayed in bed for the shift (7-3) .Neuro checks were WNL (within normal limits). She complained of pain during repositioning of her left knee and mid back, however, resident has history of chronic pain. Scheduled pain medication was administered and it was effective in relieving pain .On 2/20/23 around 3:58pm .physician came in to assess resident post fall and placed orders for (Resident #100) to be sent out to (emergency department) to perform x-ray due to continued discomfort in her lower back. On 2/20/23 around 11:30pm .hospital report showed that (Resident #100) had a suspected fracture of the left inferior pubic ramus .On 2/21/23 at 3:16am .(Resident #100) had returned to facility with no new orders, as the fracture just needed to heal per ER (emergency room ) provider . In an interview on 3/14/23 at 5:01 P.M., Director of Nursing (DON) reported that Resident #100 fell on [DATE] due to staff not being knowledgeable about the use of a hoyer. DON reported that Resident #100 should have been safe to transfer in the U shaped sling or the full body sling, as long as it was hooked up right and stated, .now (Resident #100) was care planned for the full body sling just to simplify the expectations for staff . In a phone interview on 3/14/23 at 10:58 A.M., Certified Nursing Assistant-Agency (CNA-A) J reported the day of Resident #100's fall that it was a very busy day and she was in a hurry. CNA-A J reported she had hooked the hoyer sling up to the hoyer lift like she always had, but that during the transfer Resident #100 slid out of the sling and landed on the floor. CNA-A J reported that Resident #100 hit the floor hard, and that she stayed with the resident while CNA-A K left to get Licensed Practical Nurse (LPN) F. CNA-A J reported that LPN F came into the room, along with other CNA's, and we got her back into bed, and LPN F told me that I had used the wrong type of sling to do the transfer. CNA-A J reported that Resident #100 complained of pain with the transfer into bed and with position changes while in bed, which was a new complaint. CNA-A J reported that DON called her a couple days later to inform of Resident #100's injury due to the fall and requested that CNA-A J come in to the facility to further discuss the incident. CNA-A J reported that she and CNA-A K reenacted that scenario for DON to observe, were briefly educated, and it was determined that CNA-A J had hooked the hoyer sling up wrong. CNA-A J reported that she was told that she was supposed to criss-crossed the leg straps prior to hooking the sling onto the hoyer lift and stated, .I had no idea .I always did it that way .no one had ever corrected me .I didn't even know she was supposed to have a full body sling .I am still confused to this day . CNA-A J reported that the sheet of paper that the facility had given her only indicated that Resident #100 used the hoyer lift, but did not specify a specific sling and stated, .I had never used the type of hoyer that the facility had until I worked there .as an agency CNA you have to figure it our for yourself .I don't know how to look at the care plan .I didn't know anything about her .it was very unorganized . CNA-A J reported that she had only worked in the facility 2 or 3 shifts, because she had called off several times and stated, .after that I canceled all my shifts .I was not comfortable working there . In a phone interview on 3/14/23 at 11:24 A.M., CNA-A K reported that she assisted CNA-A J with Resident #100's hoyer transfer on 2/18/23. CNA-A K reported that when Resident #100 was lifted up, she slipped right out of the sling and fell on the floor, landing on her bottom and stated, .(CNA-A J) didn't cross the leg straps .I didn't notice until (Resident #100) started sliding out of the sling .it happened so fast . CNA-A K reported that it was her one and only time working at the facility and stated, .I did not get any training .no help with anything .no welcoming or nothing .no one even showed me around .I had to figure things out myself . In an interview on 3/14/23 at 12:17 P.M., LPN F reported that the day that Resident #100 fell there were 2 agency CNA's working on the hall and stated, .I was told that one of them had been here twice . LPN F reported that he was called into Resident #100's room by CNA-A K. LPN F reported that Resident #100 was on the floor and complained of back pain with ROM (range of motion). LPN F reported that he did not perform ROM on Resident #100's left leg due to her known chronic pain in the knee. LPN F reported that when they got her back in bed she continued to complain of pain in her middle back and had increased pain when she was rolled on her side. LPN F reported that he called the on-call person and they said to give her Tylenol, continue to monitor and that they would see her on Monday (2 days later). LPN F reported that there are a lot of agency CNA's working in the facility and they do not know the residents, and that he educated the agency CNA's involved afterwards about using a full body hoyer pad for Resident #100 due to her weight and her body being limp. LPN F reported that he reminded the agency CNA's to check the resident's Kardex (direct care-givers care guide) prior to providing care, and that CNA-A J told him that she had checked the Kardex and that it did not indicate the type of hoyer sling that the resident required. During an observation and interview on 3/14/23 at 1:00 P.M. Resident #100 was lying in bed on her back with the HOB at approximately 30 degrees. CNA G came in to assist the resident with lunch. CNA G reported that she had to raise the HOB very slow otherwise Resident #100 will scream and stated, .I think she hurt her leg .she doesn't want to get up .but before she would get up into her chair with no problem . Resident #100 reported that she had pain in her hips and stated, .it's really bad . In an interview on 3/14/23 at 3:32 P.M., CNA Q reported that Resident #100 used to get up in her chair everyday and now she is in bed all of the time. In an interview on 3/15/23 at 12:32 P.M., Nurse Practitioner (NP) M reported that she had received a secure text from the facility on 2/18/22 in the afternoon and she called back but had to leave a message, and then LPN F called back shortly after that, reporting that Resident #100 had fallen due to improper use of the hoyer lift, that she was having back pain, but that she was back in bed and comfortable. NP M reported that she gave instructions to LPN F to do every 2 hours neuro (neurological) checks and call us back if Resident #100 was not improving and stated, .we did not get any calls .my expectation from a skilled facility is that they know the resident and when to call . NP M reported that Doctor of Osteopathic Medicine (DO) T was scheduled to see Resident #100 on 2/20/23, and DO T made the decision at that time to send Resident #100 out to the hospital for evaluation due to the amount of pain she was having. Review of On-Call Communication from NP M dated 2/18/23 revealed, Received a secure text .regarding (Resident #100) reporting that she had a fall while transferring with Hoyer lift and having back pain. 1357 (1:57 P.M.) - called and left voicemail in the number provided to call back with further concerns. 1400 (2:00 P.M.) - received a call back from (LPN F) that reported (Resident #100) slipped out of the Hoyer and was guided to the floor during transfer. Her vitals were checked and stable .she did report some pain in her mid back with any movement or palpation, but otherwise denies pain and is comfortable in bed. She has not had any pain medication provided at this time. She did not remember hitting her head. Staff was vague with a report of the fall, he (LPN F)will look further into this. Gave orders to provide Tylenol now and every eight hours over the weekend, perform Neuro checks every four hours, and call if there is any worsening of symptoms, change in vitals, or altered mental status .Will forward to care team for discussion and follow up on Monday. Review of Resident #100's Medication Administration Record (MAR) from February indicated in addition to regularly scheduled Gabapentin (for chronic pain syndrome), Resident #100 had an order for Acetaminophen Tablet 500mg give 2 tablets by mouth every 8 hours as needed for pain, start date 1/6/23, and received the medication a total of 3 times following her fall on 2/18/23. Indicating administration on 2/18/23 at 2:28 P.M. for pain level of 7 out of 10, on 2/21/23 at 12:40 P.M. for a pain level of 5 out of 10, and on 2/27/23 at 6:09 P.M. for a pain level of 5 out of 10. Also Buprenorphine transdermal patch (pain medication administered through a patch placed on the skin) applied once weekly starting on 2/22/23. This record indicates that Resident #100 received only 2 doses of pain medication after her fall and prior to returning from the hospital on 2/21/23. Review of Resident #100's MAR from February revealed, Ask Resident if they are having pain and Document two times a day for evaluation. Start Date 01/29/2023. And indicated that Resident #100 had 0/10 pain level up until the day of the fall, except for 2/6/23 indicated 2/10 pain level. Following the fall on 2/18/23 pain levels were noted in 14 of 20 evaluations, ranging from 1-6 pain level. Review of Resident #100's Emergency Department Summary dated 2/21/22 revealed, .Arrival Date/Time: 02/20/2023 2055 (8:55 P.M.) .The patient presents to the emergency department with concerns of left hip pain. In route she was noted to be febrile .She does not have a true fever here but slightly elevated body temperature .Given the fall with mild left-sided greater trochanteric (upper leg/hip) tenderness, x-ray left hip was obtained .Pelvic x-ray however does show a pubic rami fracture (pelvic bone) .No surgery is needed. They will reach out to her for follow-up .discharge date /Time: 02/21/2023 0116 (12:16 A.M.) .

This citation pertains to intake #MI00134978. Based on interview, and record review, the facility failed to address an acute change of condition and notify the physician of persistent pain and a decline in ADL (activity of daily living) (getting out of bed) following a fall in 1 of 3 residents (Resident #100) reviewed for quality of care, resulting in a delay in pain interventions and a delay in the diagnosis of left pubic rami (pelvic bone) fracture. Findings include: Review of an Admission Record revealed Resident #100 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: osteoporosis (condition when bone strength weakens and is susceptible to fracture. It usually affects hip, wrist or spine) and osteoarthritis (breakdown of joint cartilage and underlying bone). Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 2/9/23 revealed a Brief Interview for Mental Status (BIMS) score of 8, out of a total possible score of 15, which indicated Resident #100 was cognitively impaired. Review of the Functional Status revealed that Resident #100 was totally dependent and required 2 person assistance for transfers. Review of Resident #100's Care Plan that was in place at the time of the fall on 2/18/23 .INTERVENTIONS: Give analgesic (medication to relieve pain) PRN (as needed) for pain. Resident may complain of pain, stiffness, or weakness, document complaints .Monitor/document/report to MD (medical doctor), PRN s/sx (signs and symptoms) or complications related to osteoporosis: acute fracture, compression fractures .pain, especially back pain .Date Initiated 2/28/22 . In a phone interview on 3/14/23 at 10:58 A.M., Certified Nursing Assistant-Agency (CNA-A) J reported the day of Resident #100's fall that it was a very busy day and she was in a hurry. CNA-A J reported she had hooked the hoyer sling up to the hoyer lift like she always had, but that during the transfer Resident #100 slid out of the sling and landed on the floor. CNA-A J reported that Resident #100 hit the floor hard and that Resident #100 complained of pain with the transfer back into bed and with position changes while in bed, which was a new complaint. In an interview on 3/14/23 at 12:17 P.M., LPN F reported that he was called into Resident #100's room by CNA-A K on 2/18/23 due to Resident #100 falling. LPN F reported that Resident #100 was on the floor and complained of back pain with ROM (range of motion). LPN F reported that he did not perform ROM on Resident #100's left leg due to her known chronic pain in the knee. LPN F reported that when they got her back in bed she continued to complain of pain in her middle back and had increased pain when she was rolled on her side. LPN F reported that he called the on-call person and they said to give her Tylenol (over the counter pain medication), continue to monitor and that they would see her on Monday (2 days later). LPN F reported that Resident #100 continued to have pain with any movements in bed, would verbally moan when the HOB (head of bed) was raised, would yell out during repositioning and stated, .if she wasn't touched she was fine .as long as she wasn't moving she was fine . LPN F reported that Resident #100 normally got out of bed and into her chair for all meals and stated, .we did not get her up after that .because every time we moved her she would yell in pain .we fed her in bed .she was more comfortable there . LPN F reported that he administered PRN Tylenol that day, but that her routine pain medications (Gabapentin) appeared to be controlling the pain. LPN F reported that he did not follow up with the physician later that day or the next day either, because he thought they just wanted Resident #100 monitored until they came in on Monday (2 days later) and stated, .her complaints of pain were very concerning to me .we limited her movement and kept her in bed .we were very careful with her . LPN F reported that to this day Resident #100 has not been out of her bed and stated, .we haven't even tried .we don't want her to be uncomfortable .she is still complaining of pain when they (CNA's) change her . During an observation and interview on 3/14/23 at 1:00 P.M. Resident #100 was lying in bed on her back with the HOB at approximately 30 degrees. CNA G came in to assist the resident with lunch. CNA G reported that she had to raise the HOB very slow otherwise Resident #100 would scream and stated, .I think she hurt her leg .she doesn't want to get up .but before she would get up into her chair with no problem . Resident #100 reported that she had pain in her hips and stated, .it's really bad . In an interview on 3/15/23 at 11:00 A.M., Registered Nurse (RN) O reported that she had received report at the start of shift from LPN F who indicated that Resident #100 had fallen earlier in the day, and that the physician was aware and did not want anything done at that time. RN O reported that Resident #100 was uncomfortable during during repositioning and stated, .she was grimacing and saying ouch .and that was not normal for her . RN O reported that she did not follow up with the physician, because she was told that the physician was planning to see Resident #100 in a couple days. RN O reported that she would have contacted the physician if the resident had increased pain or not able to perform ROM and stated, .I focused ROM on her legs because it was painful when she moved or twisted . In an interview on 3/15/23 at 12:32 P.M., Nurse Practitioner (NP) M reported that she had received a secure text from the facility on 2/18/22 in the afternoon and she called back but had to leave a message, and then LPN F called back shortly after that reporting that Resident #100 had fallen due to improper use of the hoyer lift, that (Resident #100) was having back pain, but that she was back in bed and comfortable. NP M reported that she gave instructions to LPN F to do neuro (neurological) checks and call us back if Resident #100 was not improving and stated, .we did not get any calls that weekend .my expectation from a skilled facility is that they know the resident and when to call . NP M reported that Doctor of Osteopathic Medicine (DO) T was scheduled to see Resident #100 on 2/20/23, and during that visit, DO T made the decision to send Resident #100 out to the hospital for evaluation. Review of On-Call Communication from NP M dated 2/18/23 revealed, Received a secure text .regarding (Resident #100) reporting that she had a fall while transferring with Hoyer lift and having back pain. 1357 (1:57 P.M.) - called and left voicemail in the number provided to call back with further concerns. 1400 (2:00 P.M.) - received a call back from (LPN F) that reported (Resident #100) slipped out of the Hoyer and was guided to the floor during transfer. Her vitals were checked and stable .she did report some pain in her mid back with any movement or palpation, but otherwise denies pain and is comfortable in bed. She has not had any pain medication provided at this time. She did not remember hitting her head. Staff was vague with a report of the fall, he will look further into this. Gave orders to provide Tylenol now and EVERY EIGHT HOURS over the weekend, perform Neuro checks every four hours, and call if there is any worsening of symptoms, change in vitals, or altered mental status .Will forward to care team for discussion and follow up on Monday. Review of Resident #100's Medication Administration Record (MAR) from February indicated in addition to regularly scheduled Gabapentin (for chronic pain syndrome), Resident #100 had an order for Acetaminophen Tablet 500mg give 2 tablets by mouth every 8 hours as needed for pain, start date 1/6/23, and had received the medication a total of 3 times following her fall on 2/18/23. Indicating administration on 2/18/23 at 2:28 P.M. for pain level of 7 out of 10, on 2/21/23 at 12:40 P.M. for a pain level of 5 out of 10, and on 2/27/23 at 6:09 P.M. for a pain level of 5 out of 10. There was also an order placed after Resident #100 returned from the hospital on 2/21/22 for Buprenorphine transdermal patch (pain medication administered through a patch placed on the skin) to be applied once weekly starting on 2/22/23. This record indicates that Resident #100 received only 2 doses of PRN pain medication after her fall and prior to returning from the hospital on 2/21/23. Review of Resident #100's MAR from February revealed, Ask Resident if they are having pain and Document two times a day for evaluation. Start Date 01/29/2023. The record indicated that Resident #100 had 0/10 pain level up until the day of the fall, except for 2/6/23 indicated 2/10 pain level. Following the fall on 2/18/23 pain levels were noted in 14 of 20 evaluations, ranging from 1-6 pain level. Review of a Facility Reported Incident (FRI) received on 2/20/22 at 11:33 P.M. revealed, .On 2/18/23, (Resident #100) had a fall which resulted in no external injury. On 2/20/23, Physician sent resident out to (hospital) due to report of pain. X-ray results showed suspected fracture of the left inferior pubic ramus (pelvic bone) . Review of Resident #100's Emergency Department Summary revealed, .Arrival Date/Time: 02/20/2023 2055 (8:55 P.M.) .The patient presents to the emergency department with concerns of left hip pain. In route she was noted to be febrile .She does not have a true fever here but slightly elevated body temperature .Given the fall with mild left-sided greater trochanteric (upper leg/hip) tenderness, x-ray left hip was obtained .Pelvic x-ray however does show a pubic rami fracture .No surgery is needed. They will reach out to her for follow-up .discharge date /Time: 02/21/2023 0116 (12:16 A.M.) .

This citation pertains to Intake #MI00134395 Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 24 residents (Resident #79 ) reviewed for care planning, resulting in unmet incontinence care needs contributing to the worsening of a pressure ulcer for Resident #79. Findings include: Resident #79 Review of an Admission Record revealed Resident #79 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: Pressure ulcer of sacral (tail bone) region, Stage 3. Review of a Minimum Data Set (MDS) assessment for Resident #79, with a reference date of 12/15/22 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #79 was cognitively intact. Review of the Functional Status revealed that Resident #79 was completely dependent on 2 staff members for toileting. Review of Resident #79's Care Plan revealed, .FOCUS: Foley Catheter (tube inserted into penis to drain urine from the body) for the treatment of sacral wound. INTERVENTIONS: Catheter: The resident has indwelling foley catheter, size 18 french, position catheter bag and tubing below the level of the bladder and away from entrance room door. Monitor/document for pain and discomfort due to catheter. Monitor/record/report to MD for s/sx (signs and symptoms) of UTI (urinary tract infection) . FOCUS: .at risk for impaired skin integrity r/t (related to) diabetes mellitus, malignant neoplasm (cancer) prostate, impaired mobility, current pressure ulcer. Date initiated 9/19/22. There was no record of Resident #79 being incontinent or interventions related to incontinence care. Review of Resident #79's Kardex (care guide for CNA's) revealed, .Toileting - needs extensive assist x 2 with toileting .Bowel/Bladder - Catheter: the resident has indwelling foley catheter .Record bowel movements . There was no record of Resident #79's needs for incontinence care. During an observation and interview on 02/13/23 at 09:26 A.M. Resident #79 was lying in bed on his back. Resident #79 reported that he does not get out of bed, was incontinent of bowel and bladder, and that the reason that he had a foley catheter was because of his urinary incontinence. During an observation of wound care for Resident #79 on 02/15/23 at 09:46 A.M. Physician Assistant (PA) F, Registered Dietician (RD) JJ and Nurse Supervisor (NS) L entered the residents room with supplies to complete wound care, and Resident #79 was observed lying on his back in bed. Resident #79 was turned onto his right side, revealing his incontinence brief that was completely saturated and heavy with urine. The brief was removed and Resident #79 had also had a BM (bowel movement). NS L reported that Resident #79's urine catheter must have been leaking. A tan colored bandage, approximately 3 x 3 inches was observed on Resident #79's sacral area (tailbone), partially detached and wet with urine. Resident #79 reported that the last time his brief was changed was the night before and that he was not able to feel when he was wet or if he had a BM. Review of Resident #79's Wound Visit Note dated 2/9/23 revealed, .sacrum .Present on admission .Pressure .Wound Assessment: .Stage 3 Pressure Injury Pressure ulcer .not healed .measurements are 1.5 cm length x 0.6 cm width x 0.3 cm depth . Review of Resident #79's Wound Visit dated 2/15/23 revealed, .sacrum .Present on admission .Pressure .Wound Assessment: .Stage 3 Pressure Injury Pressure ulcer .not healed .measurements are 1.8 cm length x 0.7 cm width x 0.3 cm depth .moderate amount of serous (clear) drainage noted .The periwound (surrounding area) skin exhibited: Denuded (loss of epidermis caused by exposure to urine, feces, body fluids, wound exudate (drainage) or friction) .SA (surface area) Slightly increased . In an interview on 02/15/23 at 10:12 A.M., CNA BB reported that Resident #79 was her responsibility that day and that she had not checked Resident #79's brief yet. In an interview on 02/15/23 at 01:51 P.M., ADON reported that Resident #79 was incontinent of bowel and bladder and should receive incontinence care every 2 hours to maintain skin integrity. ADON reported that Resident #79 did not have a care plan or interventions for his incontinence, but that he should have. 46999

Based on observation, interview and record review the facility failed to ensure residents consistently received treatment and services to prevent the worsening of a pressure ulcers for 3 residents (Resident #79, #39 and #28) of 3 residents reviewed for pressure ulcers, resulting in the worsening of a Stage 3 pressure ulcer for Resident #79 and a potential for worsening of facility acquired pressure ulcers for Resident #39 and #28. Findings include: Resident #79 Review of an Admission Record revealed Resident #79 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: Pressure ulcer of sacral (tail bone) region, Stage 3. Review of a Minimum Data Set (MDS) assessment for Resident #79, with a reference date of 12/15/22 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #79 was cognitively intact. Review of the Functional Status revealed that Resident #79 required extensive assistance of 2 staff members for positioning in bed, and was completely dependent on 2 staff members for toileting. During an observation and interview on 02/13/23 at 09:26 A.M. Resident #79 was lying in bed on his back with his legs propped up on a wedge and the HOB (head of bed) at approximately 30 degrees. Resident #79 reported that he put his call light on 45 minutes ago because he had not received his breakfast and stated, .it should have been here an hour ago .I just eat cereal because the other food is always cold .I don't complain, I just won't eat it .eggs are like ice .buttered toast has been sitting too long . Resident #79 reported that his room was at the end of the hall and that if he ate in the dining room the food was better. At 09:48 A.M. Resident #79 reported that he does not get out of bed and was incontinent of bowel and bladder and that the incontinence was the reason that he had a urinary catheter. Resident #79's catheter drainage bag was observed at the bedside. Resident #79's visitor exited Resident #79's room and collected his breakfast tray from the meal cart on the hall, and then turned the call light off. Review of Resident #79's Care Plan revealed, .FOCUS: stage 3 pressure ulcer on his coccyx. Date initiated 9/19/22 .INTERVENTIONS: .Assist with bed mobility/turning and repositioning on or about every 2 hours and PRN (as needed) .FOCUS: Foley Catheter (tube inserted into penis to drain urine from the body) for the treatment of sacral wound .FOCUS: .at risk for impaired skin integrity r/t (related to) diabetes mellitus, malignant neoplasm (cancer) prostate, impaired mobility, current pressure ulcer. Date initiated 9/19/22. There was no record of Resident #79 being incontinent or interventions related to incontinence care. During an observation and interview on 02/15/23 at 08:42 A.M. Resident #79 was lying in bed on his back and his breakfast tray was observed untouched. Certified Nursing Assistant (CNA) BB picked up the breakfast tray, but did not provide cares for Resident #79. Resident #79 reported that he had a bedsore on his bottom that was painful to touch. During an observation of wound care for Resident #79 on 02/15/23 at 09:46 A.M. Physician Assistant (PA) F, Registered Dietician (RD) JJ and Nurse Supervisor (NS) L entered the residents room with supplies to complete wound care, and Resident #79 was observed lying on his back in bed. Resident #79 was turned onto his right side, revealing his incontinence brief that was completely saturated with urine. The brief was removed and Resident #79 had also had a BM (bowel movement). NS L reported that Resident #79's urine catheter must have been leaking. A tan colored bandage, approximately 3 x 3 inches was observed on the sacral area, partially detached and wet with urine. After the bandage was removed the wound was observed with approximately 1 inch of open wound with bright red active bleeding, and the surrounding skin was lighter in color and wrinkly (macerated: occurs when skin is in contact with moisture for too long). NS L was holding pressure to the wound with guauze. PA F reported the wound measurement was 1.8 cm x 0.7 cm x 0.3 cm and stated, .the surface area has slightly increased. Resident #79 reported that the last time his brief was changed was last night and that he was not able to feel when he was wet or if he had a BM. Resident #79 reported that when staff ask him if he needs his brief changed and he tells them that he is ok. NS L applied topical medihoney (assists in wound healing), a sheet of Silver Alginate (antibacterial), and a large padded bandage to cover the entire sacral area. In an interview on 02/15/23 at 10:09 A.M., PA L reported that being wet and soiled can negatively effect Resident #79's wound healing progress and that due to Resident #79's inability to recognize when he urinates or has a BM, incontinence care should be provided every 2 hours. In an interview on 02/15/23 at 10:12 A.M., CNA BB reported that Resident #79 was her responsibility and that she had not checked Resident #79's brief yet that day. CNA BB reported that 3rd shift CNA T had reported that Resident #79 was done during shift change report at 6:30 A.M. that morning. CNA BB then reported that she had gotten caught up passing breakfast trays this morning and could not leave the meal cart until all the trays were served, and that was the reason she had not checked Resident #79's brief. This surveyor attempted to contact CNA T by phone on 02/15/23 at 11:22 A.M., but no return call was received. Review of Resident #79's Wound Visit dated 2/15/23 revealed, .sacrum .Present on admission .Pressure .Wound Assessment: .Stage 3 Pressure Injury Pressure ulcer .not healed .measurements are 1.8 cm length x 0.7 cm width x 0.3 cm depth .moderate amount of serous (clear) drainage noted .The periwound (surrounding area) skin exhibited: Denuded (loss of epidermis caused by exposure to urine, feces, body fluids, wound exudate (drainage) or friction) .SA (surface area) Slightly increased .Wound goals: healing . Review of Resident #79's Wound Visit Note dated 2/9/23 revealed, .sacrum .Present on admission .Pressure .Wound Assessment: .Stage 3 Pressure Injury Pressure ulcer .not healed .measurements are 1.5 cm length x 0.6 cm width x 0.3 cm depth .Wound goals: healing . Resident #39 Review of an Admission Record revealed Resident #39 was originally admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #39, with a reference date of 1/24/23 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #39 was cognitively intact. Review of the Functional Status revealed that Resident #39 required extensive assistance of 1 staff member for positioning in bed, and extensive assistance on 2 staff members for toileting. Review of Resident #39's Care Plan revealed, .at risk for pressure injuries, related to weakness/debility, impaired mobility, in bed or chair all day .h/o (history of) pressure injuries. Date initiated: 7/15/2020 . Interventions: .heels up, pillows, offloading, boots . Reposition or cue to reposition on or about Q2 hours (every two hours). Date initiated: 7/15/2020 .(Resident #39) has actual impairment to skin integrity, r/t (related to) edema, fragile skin, and leaning to his right. He has an unstageable pressure ulcer on his left heel. Date initiated: 4/20/2020. Interventions: . encourage to elevate his legs when sitting . During an observation and interview on 02/13/23 at 10:00 A.M. Resident #39 was lying in bed on his back with the HOB at approximately 90 degrees. Resident #39 was slouched down in bed and his legs were bent and both feet were pressed firmly against the footboard of the bed. Resident #39 had a blue pressure reducing boot on his left foot. Resident #39 reported that he had a deep sore on the bottom of his left foot and stated, .yeah it hurts .I am actually pushing my foot against the end of the bed .I am slouched down too far .they don't want me to move around by myself . During an observation on 02/14/23 at 08:53 A.M. Resident #39 was lying in bed on his back with the HOB at approximately 90 degrees. Resident #39 was position like the day before, slouched down in bed and his legs were bent and both feet were pressed firmly against the footboard of the bed. Resident #39 reported that he was uncomfortable. During an observation and interview on 02/15/23 at 09:25 A.M. of Resident #39's wound care to his left foot, NS L removed the dressing, revealing an open wound that measured 1.8 cm x 2.1 cm x 0.1 cm and NS L reported that it had improved. NP F reported that it was a pressure wound that presented as a large blister. NS L and NP F reported unsure of what caused the pressure. In an interview on 02/15/23 at 01:36 P.M. ADON reported that when Resident #39's pressure wound on his left foot was first discovered, he was sleeping in his recliner all the time and when he was ambulating in his wheelchair his foot would drag. Review of Resident #39's Wound Visit Note dated 2/15/23 revealed, .HPI (history of present illness) Left heel .Date of onset: April 2022 .Pressure .developed a blood filled blister to the left heel that has evolved .Wound Assessment: left heal Stage 3 Pressure Injury Pressure Ulcer .not healed .measurements are 1.8 cm length x 2.1 cm width x 0.1 cm depth .there is a moderate amount of sero-sanguineous (bloody) drainage noted .Pressure relief/Offloading: .float heels while in bed .offload heels .bed extender in place . 41982 Resident #28 Review of a Face Sheet revealed Resident #28 was a male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia; hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side; pressure ulcer of unspecified buttock, Stage 3; unspecified abnormalities of gait (walking) and mobility. Review of a Minimum Data Set (MDS) assessment for Resident #28, with a reference date of 12/22/22 revealed a Brief Interview for Mental Status (BIMS) score of 9, out of a total possible score of 15, which indicated Resident #28 was cognitively impaired. Review of Resident #28's assessed Functional Status of said MDS revealed Resident #28 required extensive, 1-person physical assist with bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed); extensive, 2-person physical assist with transfers (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position); and extensive, 1-person physical assist with locomotion on unit (how resident moves between locations in his/her room and adjacent corridor on same floor). Review of Resident #28's current Care Plan revealed a focus of (Resident #28) has a stage 3 pressure ulcer on his left buttock with care planned interventions which included Assist with turning and repositioning on or about every two hours and prn (as needed) with a date initiated of 12/21/22. In an interview on 2/15/23 at 10:59 AM, Certified Nurse Aide (CNA) X reported has cared for Resident #28 and knew he had a pressure ulcer on his bottom. CNA X was queried regarding when Resident #28 should be repositioned according to his current Care Plan. CNA X reported did not think Resident #28 was on the list to be repositioned and that he preferred to be in his wheelchair. CNA X reported staff was supposed to walk with Resident #28 to meals and that was considered his repositioning/offloading (take the weight off/relieve pressure from affected area). CNA X reported Resident #28 did not always get walked to meals because needed two staff to assist him and there were not always 2 staff available to do so. In an interview on 2/15/23 at 2:24 PM, Director of Nursing (DON) B reported if a resident was supposed to be walked to meals, it would be documented in the Electronic Medical Record under the Task when the task was completed or if the resident refused. Review of a Task report detailing Resident #28's Task: Walk to dine with walker, gait belt and 1 assist Look Back: 30 days (1/17/23-2/15/23) .Question 2 .Support Provided revealed: out of 90 walk to dine opportunities (3 meals per day for 30 day look back), there was 1 entry that Resident #28 refused, 27 entries of response not required, and 32 entries indicating Resident #28 had received either 1-person or 2-person assistance to walk to dine.

Based on interviews and record review the facility failed to prevent falls for 1 (Resident #336) of 4 Residents reviewed for falls, resulting in a fall with fracture. Findings include: A review of a Face Sheet revealed Resident #336 was admitted on [DATE] with pertinent diagnoses that included: Dementia, Anxiety Disorder, Urinary Tract Infection (infection in the urinary system characterized by frequent urination and potential for increased confusion in the elderly), Weakness, Seizure Disorder, and Osteoporosis (medical condition resulting in brittle bones). A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #336 required partial assistance (helper provides less than half the effort) to transfer from the bed to a chair and supervising or touching assistance to safely ambulate up to 50 feet. A review of a Physical Therapy Evaluation dated 1/31/23 with Resident #336's medical complexities listed as: poor historian, dementia, depression, frequent falls, unsteadiness on feet. Physical Therapy Evaluation identified the following fall predictors: delayed anticipatory reactions, impulsive ambulation, high attentional demands/conditions and unable to apply learned skills to difficult situations. Physical therapy assessment summary indicated Resident #336 had limited cognitive awareness to lock and unlock assisted device and decreased reactive balance. Review of a Fall Risk Evaluation dated 1/30/23 revealed Resident #336 had intermittent confusion,1-2 falls in the past 3 months, a balance problem while walking, required an assistive device to ambulate, was prescribed 1-2 medications known to increase fall risk and had 3 or more medication changes in the last 5 days. Resident #336's total score on this assessment was 18, indicating the Resident was at risk for falling. A review of a Care Plan dated 1/31/23 revealed the focus/goal/interventions as follows: (Resident #336) is at risk for falls related to deconditioning, gait and balance problems, Goal: The Resident will not sustain serious injury. Interventions included: Anticipate and meet resident needs, be sure Resident's call light is within reach and encourage use . educate Resident what to do if fall occurs . In an interview on 2/14/23 at 2:15pm, Certified Nursing Assistant (CENA) DD reported she arrived for work in the memory care unit at 6:30am on 2/2/23, received a little report from the night staff which did not include anything about Resident #336 other than all Resident needs were met at 5:00 am. During her initial rounding, CENA DD reported she found Resident #336 sitting on the floor in her room, leaning against the bed, and facing the head of the bed at approximately 6:50am. CENA DD indicated it appeared Resident #336 had taken self to the restroom and fell as she returned to bed. CENA DD reported there was no fall mat or position change alarm in place and Resident #336's call light had not been activated when the Resident was found on the floor. In an interview on 2/14/23 at 2:02pm, Licensed Practical Nurse (LPN) P reported she assessed Resident #336 as she (Resident #336) was on the floor. LPN P noted symptoms of a potential fracture and the staff lifted Resident #336 into bed. LPN P indicated she did not know Resident #336 well but was aware that Resident #336 was admitted to the memory care unit due to cognitive deficits. LPN P reported the physician ordered a stat Xray. Review of a Radiology Report dated 2/2/23 for Resident #336, contained results: There is a right acetabular fracture (break in the socket portion of the ball and socket hip joint) which appears to involve both the anterior and posterior columns (front and back of the bone or area around the bony rim). A review of an Emergency Department Provider Note dated 2/2/23 revealed Resident #336 was diagnosed with: Markedly comminuted fractures of the right acetabulum and right superior and inferior pubic rami with medial protrusion of the right proximal femur through the acetabular wall and a focal defect within the superolateral femoral head secondary to an acetabular bone fragment. There is significant surrounding hematoma involving the retroperitoneum, iliacus muscle, and surrounding proximal thigh muscles. The note indicated Resident #336 required critical care at this time due to the severity of the injuries. A review of a Fall Investigation document for Resident #336's fall on 2/2/23 revealed Resident #336 was admitted to the facility with bruising from recent falls and was documented as confused, disoriented and with short term memory loss. Staff reported Resident #336 got up out of bed multiple times throughout the night, at one point was taken to the dining area but then returned to bed where she only stayed for a few minutes. Resident #336 voiced multiple needs during the night, including a need to use the restroom, feeling sick and at times calling out, help me. In an interview on 2/15/23 at 3:46 p.m., CNA W reported Resident #336 would not sleep on the night of 2/1/23-2/2/23. CNA W reported that Resident #336 kept getting up independently without her walker. CNA W stated, I had to hold her up to her walker for her to use it. I told the nurse that she kept getting up and down and wouldn't stay in her bed or wheelchair, but I didn't get any further instructions on how to keep her safe. The nurse told me it had been a problem on the previous shift too. As soon as I would walk out of the room, she'd get right back up and be right behind me as I walked out of the room door. I didn't know anything about her, the resident was new. I did was I could. CNA W reported she tried to check on her more frequently, but the resident also would not use her call light consistently to let her know when she needed something. CNA W reported it was only her and a nurse on duty that night in the memory care unit and she had 11-12 residents who needed care. CNA W stated, I just couldn't be everywhere I needed to be at one time. I had to care for the other residents and (Resident #336) needed more time and attention than I could give.

This citation pertains to Intake # MI 031. Based on interview, and record review, the facility failed to ensure physician ordered laboratory diagnostic services were obtained and completed in a timely manner in 1 of 4 residents (Resident #101) reviewed for laboratory services, resulting in delayed treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the policy/procedure Laboratory Services and Reporting, dated ,d+[DATE], revealed .The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law .The facility must provide or obtain laboratory services to meet the needs of its residents .The facility is responsible for the timeliness of the services . Review of the Nursing Facility Laboratory Agreement, with an effective date of [DATE], revealed .Responsibilities of (Laboratory Name) .will provide diagnostic laboratory testing services to Facility in accordance with the Facility's policies, accepted professional standards, and all applicable federal, state and local laws and regulations .All testing will be provided based only on the written order of a patient's attending physician or other authorized professional .Common tests will be reported the same afternoon and most other tests will be reported within a 24-hour period. For those tests that cannot reasonably be reported in the time frames listed above, (Laboratory Name) will report results as soon as possible and in a time consistent with industry leading standards .(Laboratory Name) provides STAT (life threatening situation) service 24 hours per day, 365 days per year. Laboratory STAT testing will be reported within 5 hours .(Laboratory Name) provides routine lab days Monday through Friday, excluding holidays . Review of an Admission Record revealed Resident #101 was a female, with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated she was cognitively intact. In an interview on [DATE] at 12:27 p.m., Family Member II reported Resident #101 had a .very uncomfortable night . at the beginning of January, and lab work was ordered. Family Member II reported the facility was contacted to find out the results of the lab work around [DATE] or [DATE], however, the nurse assigned to Resident #101 (Agency Registered Nurse (RN) GG) could not find any evidence that the labs or the urinalysis (UA) had been completed. Family Member II reported Agency RN GG indicated the lab services staff did not come to the facility as scheduled on Wednesday [DATE] to draw labs and pick up the urine sample for the UA. Family Member II reported Agency Nurse GG obtained another urine sample at that time for the UA. Family Member II reported the facility was contacted again around [DATE], and Licensed Practical Nurse (LPN) L indicated there were no lab results related to the ordered blood tests/UA for Resident #101. Family Member II reported the facility was again contacted on [DATE] and LPN X indicated there were still no results related to the ordered blood tests/UA for Resident #101. Family Member II reported LPN X indicated a sample for a UA was obtained on [DATE], however it was .refused from the lab . Family Member II stated Resident #101 had .suffered for the last year from [CONDITION(S)]'s (Urinary Tract Infections) . Family Member II stated .(Resident #101) suffered unduly because (the facility) couldn't figure out how to care for the patient in a speedy manner . Review of a nursing Progress Note for Resident #101, dated [DATE] at 8:00 a.m., revealed .Provider updated on report of resident having increased confusion and yelling in the night. New orders for UA and CBC (Complete Blood Count) with diff (Differential) and CMP (Complete Metabolic Panel) to be drawn on Wed. (Wednesday) [DATE] . Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .CHIEF COMPLAINT .Dysuria (painful/difficult urination), confusion .Resident seen for increased confusion and dysuria. Upon assessment, resident reports flank pain and burning sensation when urinating .Discomfort affects mood .ASSESSMENTS AND PLANS .Dysuria: Urinalysis ordered. Follow up when results received . Review of an Order Summary Report for Resident #101 revealed .CBC with diff, CMP one time only for 1 day . ordered [DATE], with a start date of [DATE] and an end date of [DATE]. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . had missed documentation (no initials to indicate the lab draw had been completed) on [DATE] and [DATE]. Review of an Order Summary Report for Resident #101 revealed .Obtain UA one time only for increased confusion/frequent [CONDITION(S)] for 3 Days . ordered [DATE], with a start date of [DATE] and an end date of [DATE]. Review of the MAR for Resident #101, dated [DATE], revealed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . had initials (indicating the sample had been obtained by the nursing staff) on [DATE] at 10:48 p.m. Review of the nursing Progress Notes for Resident #101, from [DATE] to [DATE], revealed no documentation related to issues with the lab services, or what became of the urine sample obtained on [DATE] at 10:48 p.m. Review of Resident #101's medical record revealed no documented lab results for the urine sample obtained on [DATE] at 10:48 p.m. Review of an Order Summary Report for Resident #101 revealed .Collect UA one time only for Collect UA and send to lab as STAT urinalysis for 2 Days . ordered [DATE], with a start date of [DATE] and an end date of [DATE]. Review of the MAR for Resident #101, dated [DATE], revealed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . had initials (indicating the sample had been collected by the nursing staff) on [DATE] at 7:51 p.m. Review of a nursing Progress Note for Resident #101, dated [DATE] at 7:36 p.m., revealed .UA obtained via straight cath. Urine bloody. Lab contacted for pick up . Review of Resident #101's medical record revealed no documented lab results for the urine sample obtained on [DATE] at 7:51 p.m. Review of a nursing Progress Note for Resident #101, dated [DATE] at 3:52 p.m., revealed .Urine sample obtained d/t (due to) lab rejecting previous sample. Urine in fridge awaiting for lab representative to pick up and deliver . Review of Resident #101's medical record revealed no documented lab results for the urine sample obtained on [DATE]. Review of a nursing Progress Note for Resident #101, dated [DATE] at 1:31 p.m., revealed .(Family Member II) called with concerns and spoke with this nurse. She was upset that her mother keeps getting UAs done with no results from the lab Informed unit manager about these family concerns. Tried to explain to family that the lab isn't picking up labs that are ordered and completed, but staff is there for her mom and doing the orders from the doctors. Family also requested that UAs to not be done through a straight cathed (sic) again if lab is going to continue to not pick up specimen. Told family that we would notified (sic) the doctor and that nursing staff is trying to use nonmedical interventions on top of medication to help with pain . Review of a nursing Progress Note for Resident #101, dated [DATE] at 7:00 p.m., revealed .Res (Resident) resting in bed, refused to eat diner (sic) stating; I just want to sleep. Urine sample obtained to rule out [CONDITION(S)], sample placed in fridge pending pick up . Review of the UA results for Resident #101, for the sample collected on [DATE], revealed .URINE CULTURE - Results Pending . with the following out of range results .Clarity Turbid .Blood 3+ .Protein 3+ .Leukocytes 1 + .RBC (Red Blood Cells) ,d+[DATE] .WBC (White Blood Cells) TNTC (too numerous to count) .Bacteria Moderate . Note more than two weeks had passed since the original UA order was placed (on [DATE]). Review of the CBC and CMP lab results for Resident #101, collected [DATE], revealed the following out of range results .Carbon [MEDICATION(S)] 16 (Low) .Anion Gap 21.0 (High) .Glucose 62 (Low) .BUN 121 (Critical High Reference Range ,d+[DATE]) .Creatinine 2.62 (High) .B/C Ratio 46.18 (High) .Calcium 8.2 (Low) .AST 12 (Low) .Total Protein 5.5 (Low) .[MEDICATION(S)] 3.02 (Low) .GFR Caucasian 17 (Low) .GFR Reference Range .[CONDITION(S)] .Stage IV Severe Decrease in GFR ,d+[DATE] .WBC 13.6 (High) .Hemoglobin 11.4 (Low) .Hematocrit 35.4 (Low) .Neutrophil# 7.8 (High) .Monocyte# 1.1 (High) . Note more than two weeks had passed since the original orders for a CBC with diff and CMP were placed (on [DATE]). Review of a physician telehealth Progress Note for Resident #101, dated [DATE], revealed .Notified by nursing (of) residents labs result. There is a critical level of the BUN of 121. Creatinine was 2.62. Previous creatinine was 1.1. Urinalysis was positive with culture pending. Will begin with subqfluids (subcutaneous fluids) for hydration due to elevated BUN/creatinine. Will await culture results before starting antibiotics . Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .CHIEF COMPLAINT .Follow up for elevated BUN and Creatinine .Resident is seen for follow up with (recent elevated) BUN and Creatinine. Upon assessment, resident continues with lower back pain. Continues with increasing confusion. Currently tolerating increased fluids via Hypodermoclysis (subcutaneous fluids). Currently await C&S (Culture and Sensitivity) . Review of an Order Summary Report for Resident #101 revealed .[MEDICATION(S)] Solution 500 MG/2ML Inject 250 mg intramuscularly every 12 hours for [CONDITION(S)]/ increased confusion for 7 Days Pharmacy to dose . with a start date of [DATE] and an end date of [DATE]. Review of the UA C&S results for Resident #101, reported [DATE], revealed a sensitivity to [MEDICATION(S)], which indicated the chosen antibiotic was effective against the bacteria. In an interview on [DATE] at 10:49 a.m., RN P reported there were issues with the lab in regard to an ordered urinalysis (UA) for Resident #101. RN P reported staff had collected the sample for the UA, and stated .for some reason the lab lost it . RN P stated in regard to Resident #101 .She was in pain and just seemed uncomfortable . RN P reported the family was notified of the situation and opted for Resident #101 to remain at the facility. RN P reported previous issues with lab services, and stated .They are not easy to work with. They are not willing to come out when we need them .They are pretty rude . In an interview on [DATE] at 10:59 a.m., LPN L stated .we struggle with the lab quite a bit. Part of it is the lab techs tend to be very rude. There are times where they don't come in and pick up the specimens when we call them and tell them to . LPN L reported there had been times where lab specimens were picked up so late they were expired and had to be redrawn. LPN L reported Wednesdays are the scheduled lab days, and stated .If we call and need a STAT (urgent) lab (we) are supposed to be able to get (the lab services staff) to come in . however, the lab staff .don't always come in same day . In an interview on [DATE] at 2:56 p.m., LPN Y reported concerns with the lab services at the facility, and stated .sometimes we call them to come pick up the lab. When you check the urine is still there (in the fridge). Then they say it was past due and we cannot run it . LPN Y reported the lab provider is .not reliable . and stated .even routine labs we are waiting for someone to show up and nobody shows up. You call them and another day passes . In an interview on [DATE] at 8:40 a.m., Agency RN GG reported labs and a UA were ordered for Resident #101 at the beginning of January. Agency RN GG reported she did not draw the labs, and they were scheduled to be completed on the next lab day (Wednesday [DATE]). Agency RN GG reported in regard to the UA order on [DATE] .I did not obtain the UA, but I did pass it on . Agency RN GG reported she collected a sample for the UA on [DATE], and was unsure if the ordered labs had been drawn. Agency RN GG reported when an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .as soon as we can . Agency RN GG reported Resident #101 had some confusion and a history of frequent urinary tract infections, and stated .that's why the labs were ordered . Agency RN GG reported concerns with the lab services at the facility and reported the lab staff do not consistently come to the facility on scheduled days. In an interview on [DATE] at 9:39 a.m., LPN X reported in regard to lab services at the facility .we do everything we can . LPN X stated .We collect the (samples for UA's). (Lab services staff) would pick (the samples) up and say they weren't good enough .I know we have trouble with the blood draws too . LPN X reported in regard to Resident #101 .I was always honest . with the family about the issues with the labs, and stated the entire situation was .very frustrating . In an interview on [DATE] at 9:57 a.m., Nursing Supervisor S stated in regard to Resident #101's lab orders .(the nurses) got a (sample for a UA) and they called the lab to have them pick it up .(The lab services staff) didn't collect it before it was expired . Nursing Supervisor S reported urine specimens are good for 24 hours in the fridge. Nursing Supervisor S reported when an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .that day . Nursing Supervisor S stated in regard to the delayed labs/UA for Resident #101 .We've had a lot of trouble with this lab .I don't know why they weren't ordered STAT .We can order (the labs) STAT but (the lab services) don't always have STAT coverage . Nursing Supervisor S reported the regular draw days for lab services are Wednesdays, and stated .there were a few weeks where we did not have a phlebotomist come out . Nursing Supervisor S reported she was unsure why the CBC and CMP labs ordered to be drawn on [DATE] were not completed until [DATE]. In an interview on [DATE] at 2:27 p.m. with Administrator A and Director of Nursing (DON) B, DON B reported Resident #101's ordered labs were discussed daily during morning meetings. DON B reported the lab services were scheduled to draw on Wednesdays, however, around the time of the delayed labs for Resident #101 the facility .had issues with (the lab services staff) not drawing the lab twice in a row .

This citation pertains to Intake # MI 031. Based on interview, and record review, the facility failed to obtain ordered labs in a timely manner in 1 of 4 residents (Resident #101) reviewed for quality of care, resulting in delayed treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of an Admission Record revealed Resident #101 was a female, with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated she was cognitively intact. In an interview on [DATE] at 12:27 p.m., Family Member II reported Resident #101 had a .very uncomfortable night . at the beginning of January, and lab work was ordered. Family Member II reported the facility was contacted to find out the results of the lab work around [DATE] or [DATE], however, the nurse assigned to Resident #101 (Agency Registered Nurse (RN) GG) could not find any evidence that the labs or the urinalysis (UA) had been completed. Family Member II reported Agency RN GG indicated the lab services staff did not come to the facility as scheduled on Wednesday [DATE] to draw labs and pick up the urine sample for the UA. Family Member II reported Agency Nurse GG obtained another urine sample at that time for the UA. Family Member II reported the facility was contacted again around [DATE], and Licensed Practical Nurse (LPN) L indicated there were no lab results related to the ordered blood tests/UA for Resident #101. Family Member II reported the facility was again contacted on [DATE] and LPN X indicated there were still no results related to the ordered blood tests/UA for Resident #101. Family Member II reported LPN X indicated a sample for a UA was obtained on [DATE], however it was .refused from the lab . Family Member II stated Resident #101 had .suffered for the last year from [CONDITION(S)]'s (Urinary Tract Infections) . Family Member II stated .(Resident #101) suffered unduly because (the facility) couldn't figure out how to care for the patient in a speedy manner . Review of a nursing Progress Note for Resident #101, dated [DATE] at 8:00 a.m., revealed .Provider updated on report of resident having increased confusion and yelling in the night. New orders for UA and CBC (Complete Blood Count) with diff (Differential) and CMP (Complete Metabolic Panel) to be drawn on Wed. (Wednesday) [DATE] . Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .CHIEF COMPLAINT .Dysuria (painful/difficult urination), confusion .Resident seen for increased confusion and dysuria. Upon assessment, resident reports flank pain and burning sensation when urinating .Discomfort affects mood .ASSESSMENTS AND PLANS .Dysuria: Urinalysis ordered. Follow up when results received . Review of an Order Summary Report for Resident #101 revealed .CBC with diff, CMP one time only for 1 day . ordered [DATE], with a start date of [DATE] and an end date of [DATE]. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . had missed documentation (no initials to indicate the lab draw had been completed) on [DATE] and [DATE]. Review of an Order Summary Report for Resident #101 revealed .Obtain UA one time only for increased confusion/frequent [CONDITION(S)] for 3 Days . ordered [DATE], with a start date of [DATE] and an end date of [DATE]. Review of the MAR for Resident #101, dated [DATE], revealed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . had initials (indicating the sample had been obtained by the nursing staff) on [DATE] at 10:48 p.m. Review of the nursing Progress Notes for Resident #101, from [DATE] to [DATE], revealed no documentation related to issues with the lab services, or what became of the urine sample obtained on [DATE] at 10:48 p.m. Review of Resident #101's medical record revealed no documented lab results for the urine sample obtained on [DATE] at 10:48 p.m. Review of an Order Summary Report for Resident #101 revealed .Collect UA one time only for Collect UA and send to lab as STAT urinalysis for 2 Days . ordered [DATE], with a start date of [DATE] and an end date of [DATE]. Review of the MAR for Resident #101, dated [DATE], revealed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . had initials (indicating the sample had been collected by the nursing staff) on [DATE] at 7:51 p.m. Review of a nursing Progress Note for Resident #101, dated [DATE] at 7:36 p.m., revealed .UA obtained via straight cath. Urine bloody. Lab contacted for pick up . Review of Resident #101's medical record revealed no documented lab results for the urine sample obtained on [DATE] at 7:51 p.m. Review of a nursing Progress Note for Resident #101, dated [DATE] at 3:52 p.m., revealed .Urine sample obtained d/t (due to) lab rejecting previous sample. Urine in fridge awaiting for lab representative to pick up and deliver . Review of Resident #101's medical record revealed no documented lab results for the urine sample obtained on [DATE]. Review of a nursing Progress Note for Resident #101, dated [DATE] at 1:31 p.m., revealed .(Family Member II) called with concerns and spoke with this nurse. She was upset that her mother keeps getting UAs done with no results from the lab Informed unit manager about these family concerns. Tried to explain to family that the lab isn't picking up labs that are ordered and completed, but staff is there for her mom and doing the orders from the doctors. Family also requested that UAs to not be done through a straight cathed (sic) again if lab is going to continue to not pick up specimen. Told family that we would notified (sic) the doctor and that nursing staff is trying to use nonmedical interventions on top of medication to help with pain . Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .CHIEF COMPLAINT .Increased confusion .Resident is seen for increased confusion .Resident has history of intermittent confusion [MEDICATION(S)] more than one year . Review of a nursing Progress Note for Resident #101, dated [DATE] at 7:00 p.m., revealed .Res (Resident) resting in bed, refused to eat diner (sic) stating; I just want to sleep. Urine sample obtained to rule out [CONDITION(S)], sample placed in fridge pending pick up . Review of the UA results for Resident #101, for the sample collected on [DATE], revealed .URINE CULTURE - Results Pending . with the following out of range results .Clarity Turbid .Blood 3+ .Protein 3+ .Leukocytes 1 + .RBC (Red Blood Cells) ,d+[DATE] .WBC (White Blood Cells) TNTC (too numerous to count) .Bacteria Moderate . Note more than two weeks had passed since the original UA order was placed (on [DATE]). Review of the CBC and CMP lab results for Resident #101, collected [DATE], revealed the following out of range results .Carbon [MEDICATION(S)] 16 (Low) .Anion Gap 21.0 (High) .Glucose 62 (Low) .BUN 121 (Critical High Reference Range ,d+[DATE]) .Creatinine 2.62 (High) .B/C Ratio 46.18 (High) .Calcium 8.2 (Low) .AST 12 (Low) .Total Protein 5.5 (Low) .[MEDICATION(S)] 3.02 (Low) .GFR Caucasian 17 (Low) .GFR Reference Range .[CONDITION(S)] .Stage IV Severe Decrease in GFR ,d+[DATE] .WBC 13.6 (High) .Hemoglobin 11.4 (Low) .Hematocrit 35.4 (Low) .Neutrophil# 7.8 (High) .Monocyte# 1.1 (High) . Note more than two weeks had passed since the original orders for a CBC with diff and CMP were placed (on [DATE]). Review of a physician telehealth Progress Note for Resident #101, dated [DATE], revealed .Notified by nursing (of) residents labs result. There is a critical level of the BUN of 121. Creatinine was 2.62. Previous creatinine was 1.1. Urinalysis was positive with culture pending. Will begin with subqfluids (subcutaneous fluids) for hydration due to elevated BUN/creatinine. Will await culture results before starting antibiotics . Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .CHIEF COMPLAINT .Elevated BUN and Creatinine, lower back pain .Resident seen for elevated BUN 121, Creatinine 2.62. NP (Nurse Practitioner) recommend send resident to ED (Emergency Department). Family declines at this time. Resident with frequent complicated urinary tract infections . Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .CHIEF COMPLAINT .Follow up for elevated BUN and Creatinine .Resident is seen for follow up with (recent elevated) BUN and Creatinine. Upon assessment, resident continues with lower back pain. Continues with increasing confusion. Currently tolerating increased fluids via Hypodermoclysis (subcutaneous fluids). Currently await C&S (Culture and Sensitivity) . Review of a Care Plan for Resident #101 revealed the focus .(Resident #101) has impaired cognitive function . initiated [DATE]. Review of a Care Plan for Resident #101 revealed the focus .(Resident #101) has Urinary Tract Infection . initiated [DATE], with interventions which included .Give antibiotic therapy as ordered. Monitor/document for side effects and effectiveness . and .Obtain and monitor lab/ diagnostic work as ordered. Report results to MD (Physician) and follow up as indicated . both initiated [DATE]. Review of an Order Summary Report for Resident #101 revealed .[MEDICATION(S)] Solution 500 MG/2ML Inject 250 mg intramuscularly every 12 hours for [CONDITION(S)]/ increased confusion for 7 Days Pharmacy to dose . with a start date of [DATE] and an end date of [DATE]. Review of the UA C&S results for Resident #101, reported [DATE], revealed a sensitivity to [MEDICATION(S)], which indicated the chosen antibiotic was effective against the bacteria. Review of a nursing Progress Note for Resident #101, dated [DATE] at 3:20 a.m., revealed .resident is very confused this shift .not making much sense when talking with staff .she does have a [CONDITION(S)] and is on (an) antibiotic . In an interview on [DATE] at 10:49 a.m., RN P reported there were issues with the lab in regard to an ordered urinalysis (UA) for Resident #101. RN P reported staff had collected the sample for the UA, and stated .for some reason the lab lost it . RN P stated in regard to Resident #101 .She was in pain and just seemed uncomfortable . RN P reported the family was notified of the situation and opted for Resident #101 to remain at the facility. RN P reported previous issues with lab services, and stated .They are not easy to work with. They are not willing to come out when we need them .They are pretty rude . In an interview on [DATE] at 10:59 a.m., LPN L stated .we struggle with the lab quite a bit. Part of it is the lab techs tend to be very rude. There are times where they don't come in and pick up the specimens when we call them and tell them to . LPN L reported there had been times where lab specimens were picked up so late they were expired and had to be redrawn. LPN L reported Wednesdays are the scheduled lab days, and stated .If we call and need a STAT (urgent) lab (we) are supposed to be able to get (the lab services staff) to come in . however, the lab staff .don't always come in same day . In an interview on [DATE] at 2:56 p.m., LPN Y reported concerns with the lab services at the facility, and stated .sometimes we call them to come pick up the lab. When you check the urine is still there (in the fridge). Then they say it was past due and we cannot run it . LPN Y reported the lab provider is .not reliable . and stated .even routine labs we are waiting for someone to show up and nobody shows up. You call them and another day passes . In an interview on [DATE] at 8:40 a.m., Agency RN GG reported labs and a UA were ordered for Resident #101 at the beginning of January. Agency RN GG reported she did not draw the labs, and they were scheduled to be completed on the next lab day (Wednesday [DATE]). Agency RN GG reported in regard to the UA order on [DATE] .I did not obtain the UA, but I did pass it on . Agency RN GG reported she collected a sample for the UA on [DATE], and was unsure if the ordered labs had been drawn. Agency RN GG reported when an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .as soon as we can . Agency RN GG reported Resident #101 had some confusion and a history of frequent urinary tract infections, and stated .that's why the labs were ordered . Agency RN GG reported concerns with the lab services at the facility and reported the lab staff do not consistently come to the facility on scheduled days. In an interview on [DATE] at 9:39 a.m., LPN X reported in regard to lab services at the facility .we do everything we can . LPN X stated .We collect the (samples for UA's). (Lab services staff) would pick (the samples) up and say they weren't good enough .I know we have trouble with the blood draws too . LPN X reported in regard to Resident #101 .I was always honest . with the family about the issues with the labs, and stated the entire situation was .very frustrating . In an interview on [DATE] at 9:57 a.m., Nursing Supervisor S stated in regard to Resident #101's lab orders .(the nurses) got a (sample for a UA) and they called the lab to have them pick it up .(The lab services staff) didn't collect it before it was expired . Nursing Supervisor S reported urine specimens are good for 24 hours in the fridge. Nursing Supervisor S reported when an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .that day . Nursing Supervisor S stated in regard to the delayed labs/UA for Resident #101 .We've had a lot of trouble with this lab .I don't know why they weren't ordered STAT .We can order (the labs) STAT but (the lab services) don't always have STAT coverage . Nursing Supervisor S reported the regular draw days for lab services are Wednesdays, and stated .there were a few weeks where we did not have a phlebotomist come out . Nursing Supervisor S reported she was unsure why the CBC and CMP labs ordered to be drawn on [DATE] were not completed until [DATE]. In an interview on [DATE] at 12:15 p.m., Nurse Practitioner MM reported a urine sample should be obtained on the ordered lab day. Nurse Practitioner MM reported Resident #101 had multiple co-morbidities, including a history of kidney disease and urinary tract infections. In an interview on [DATE] at 2:27 p.m. with Administrator A and Director of Nursing (DON) B, DON B reported Resident #101's ordered labs were discussed daily during morning meetings. DON B reported the lab services were scheduled to draw on Wednesdays, however, around the time of the delayed labs for Resident #101 the facility .had issues with (the lab services staff) not drawing the lab twice in a row . Review of the policy/procedure Laboratory Services and Reporting, dated ,d+[DATE], revealed .The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law .The facility must provide or obtain laboratory services to meet the needs of its residents .The facility is responsible for the timeliness of the services . Review of the Nursing Facility Laboratory Agreement, with an effective date of [DATE], revealed .Responsibilities of (Laboratory Name) .will provide diagnostic laboratory testing services to Facility in accordance with the Facility's policies, accepted professional standards, and all applicable federal, state and local laws and regulations .All testing will be provided based only on the written order of a patient's attending physician or other authorized professional .Common tests will be reported the same afternoon and most other tests will be reported within a 24-hour period. For those tests that cannot reasonably be reported in the time frames listed above, (Laboratory Name) will report results as soon as possible and in a time consistent with industry leading standards .(Laboratory Name) provides STAT (life threatening situation) service 24 hours per day, 365 days per year. Laboratory STAT testing will be reported within 5 hours .(Laboratory Name) provides routine lab days Monday through Friday, excluding holidays .

Based on observation, interview, and record review, the facility failed to ensure safe transfers and bed mobility were completed per facility policy and plan of care in 2 of 6 residents (Resident #30 & #35) reviewed for accidents/falls, resulting in a right periprosthetic femur fracture for Resident #30 with the potential for further injury, and the potential for falls due to unsafe transfers. Findings include: Review of the policy/procedure Transfer/Lift, revised 1/21, revealed .It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines .All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be used .The interdisciplinary team or designee will evaluate and assess each resident's individual mobility needs, taking into account other factors as well, such as weight and cognitive status .Mechanical lifts may include equipment such as full body lifts, sit to stand lifts, or ceiling track mounted lifts .Two staff members must be utilized when transferring residents with a mechanical lift .Resident lifting and transferring will be performed according to the resident's individual plan of care . Resident #30 Review of an Admission Record revealed Resident #30 was a female, with pertinent diagnoses which included prosthetic right hip joint fracture, dementia with behaviors, depression, diabetes, muscle weakness, anxiety, arthritis, bone density disorder, difficulty walking, stroke, and high blood pressure. Review of a Minimum Data Set (MDS) assessment for Resident #30, with a reference date of 8/18/21, revealed a Brief Interview for Mental Status (BIMS) score of 2, out of a total possible score of 15, which indicated severe cognitive impairment. Further review of this MDS assessment, dated 8/18/21, revealed Resident #30 was totally dependent on two staff for bed mobility and transfers. Review of a current Care Plan for Resident #30 revealed the focus .(Resident #30) is at risk for bruising d/t (due to) Dementia with behavioral disturbance, cognitive deficits, and aspirin use aeb (as evidenced by) resistance and combativeness with cares, flailing and swinging of arms, throwing food and drinks at staff and other residents . with interventions which included .All cares for (Resident #30) require 2 staff members . initiated 9/27/21. Review of a current Care Plan for Resident #30 revealed the focus .(Resident #30) has an ADL (Activities of Daily Living) Self Care Performance Deficit r/t (related to) dementia w/ (with) behavioral disturbances, delusional d/o (disorder), [CONDITION(S)], impaired mobility, weakness/debility, and h/o (history of) fractures . with interventions which included .BED MOBILITY: Extensive assist x2 for bed mobility for all care, rolling and repositioning . revised 10/15/21 and .TOILETING: DOES NOT TOILET .Dependent x2 for brief changes . revised 3/19/21. Review of a Visual/Bedside Kardex Report (a document used by Certified Nursing Assistant (CNA) staff to provide care) for Resident #30, dated 10/21/21, revealed .All cares for (Resident #30) require 2 staff members .BED MOBILITY: Extensive assist x2 for bed mobility for all care, rolling and repositioning .Dependent x2 for brief changes . In an observation on 10/20/21 at 2:35 p.m., observed CNA E provide care to Resident #30 in her room. Noted a surgical wound dressing on Resident #30's right hip, with some dark purple bruising on her right thigh. Observed CNA E turn Resident #30 in bed onto her left side to perform perineal care, and hold her in position with a hand on her right hip. Observed Resident #30 pinching and swatting at CNA E's hand throughout care. CNA E placed a new brief on Resident #30, and positioned Resident #30 on her back in bed. Note only one staff member was present for Resident #30's care. In an interview on 10/20/21 at 2:45 p.m., CNA E reported Resident #30 is .usually a two-person transfer . and a one-staff assist for bed mobility. CNA E reported staff check the Kardex to determine how much assistance a resident requires with care. CNA E went to the nurses desk to verify the amount of assistance Resident #30 requires with care. CNA E reported Resident #30 should be a two-staff assist for bed mobility and care and stated .it must have just changed . Review of an Incident Report for Resident #30, dated 10/8/21, revealed .CNA came to Nursing station with concerns of a possible broken leg. Stating that when she was turning (Resident #30) during cares she heard a cracking sound! Two nurses assessed resident and no abnormal swelling or discoloration noted .Nurse put an order for STAT xray to ensure there were no Fractures/breaks. On call manager notified .Resident was stating to nurse assessing her leg my leg, my leg! be careful of my leg! .Injuries Report Post Incident .Fracture . Review of an Investigation Summary for Resident #30, for her fracture on 10/8/21, revealed .On Friday, October 8, 2021, at approximately 8:00pm (CNA FF) approached (Agency Licensed Practical Nurse (LPN) GG) stating that while she was changing (Resident #30's) brief and attempting to position her on her left side to be better able to exchange dirty for dry brief, she put one of her hands on resident's right upper shoulder and the other hand on residents right upper thigh. With her hands in place (CNA FF) stated she attempted to turn resident and heard a pop noise. (CNA FF) stated that resident did not say anything, make any noises and when (CNA FF) asked resident if she was in pain resident gave no reply. (CNA FF) then stated she went to nurses on unit to report situation. (Agency LPN GG) stated that (CNA FF) approach her and stated, I think I broke resident's leg and heard a pop. (Agency LPN GG) immediately went to resident's room. Nurse stated resident was on her back in bed. Nurse attempted range of motion to right leg and resident resisted. Nurse then attempted range of motion on her left leg and resident allowed PROM (Passive Range of Motion). Nurse stated resident was fighting and smacking as in (sic) her general demeanor. Nurse stated no [CONDITION(S)] noted and leg remained warm to touch. (Agency LPN GG) then asked second Nurse (LPN J) to assess resident. (LPN J) stated that she went to assess (Resident #30) after (Agency LPN GG) and (CNA FF) were in resident's room. (LPN J) states that (Resident #30) was attempting to point to her right leg and said my leg, my leg be careful. (LPN J) noted no new bruising or [CONDITION(S)] .(LPN J) stated when asked that she did not see anyone else assisting (CNA FF) with resident's transfer .(Agency LPN GG) ordered STAT Xray for resident. Xray results came back abnormal, resident sent to hospital for further evaluation. Upon arrival to hospital, addition (sic) Xray taken showing Right B1 Periprosthetic hip fracture and [CONDITION(S)] with s/p (status post) fragility fracture .ORIF (Open Reduction Internal Fixation) Surgery performed on resident 10.9.2021 . Review of a Radiology Report for Resident #30, dated 10/8/21 at 10:22 p.m., revealed .HIP UNI W OR W/O PELVIS 2-3 V, RIGHT .Conclusion: Periprosthetic fracture at the inferior femoral stem .FEMUR MIN 2 VIEWS, RIGHT .Conclusion: Acute periprosthetic fracture of the proximal femur . Review of an Investigation Summary for Resident #30, for her fracture on 10/8/21, revealed .Director of Nursing (DON) and Nurse Manager invited (CNA FF) back into building to conduct a re-enactment of incident. (DON B) played resident in re-enactment while (Interim Nurse Manager DD) observed and took note and (CNA FF) acted as self .(CNA FF) admitted to nurse leadership during re-enactment that she was in a rush and did not ask for help. She admitted that she knew resident was a two-person transfer and bed mobility . In an interview on 10/20/21 at 2:59 p.m., Interim Nurse Manager DD reported Resident #30 was a two-person assist for transfers and care prior to her fracture on 10/8/21. Interim Unit Manager DD reported this was reflected in the Care Plan. In an interview on 10/21/21 at 11:39 a.m., Administrator A reported she was notified of Resident #30's femur fracture on 10/8/21 via phone. Administrator A reported she was involved in the investigation into the fracture, and stated .(CNA FF) did not look at the care guide (Kardex) for bed mobility before repositioning (Resident #30) . In an interview on 10/21/21 at 12:37 p.m., Agency LPN GG reported on 10/8/21 in the evening, CNA FF approached her in the hallway and said .I think I broke her leg . referencing Resident #30. Agency LPN GG reported she went to Resident #30's room to assess her, and did not identify any changes. Agency LPN GG reported she was not as familiar with the residents, so she requested another nurse assess Resident #30. Agency LPN GG reported X-rays were ordered for Resident #30 and .the results did show a fracture . Agency LPN GG reported she interviewed CNA FF after the incident and stated .she knew better .she knew she was wrong and should have had a second person .(The Kardex) definitely said (Resident #30) was a two person assist with ADL's and transfers . Agency LPN GG reported two staff members are required to care for Resident #30 because Resident #30 can be aggressive and combative. In an interview on 10/21/21 at 12:59 p.m., CNA Q reported she worked second shift on 10/8/21, the evening of Resident #30's femur fracture. CNA Q reported CNA FF did not ask for assistance with transfers or care for Resident #30. CNA Q reported Resident #30 needed two staff for transfers and care, and this information was noted in the Kardex. In an interview on 10/21/21 at 2:23 p.m., CNA FF reported Resident #30's fracture occurred on 10/8/21 on second shift. CNA FF reported per the Kardex, Resident #30 required two staff for transfers and bed mobility/care and stated .but I was in a hurry and there weren't any other staff available .(I) just picked (Resident #30) up and transferred her myself. I was changing her brief when I heard the pop . CNA FF reported she notified Agency LPN GG to assess Resident #30. CNA FF reported she had previously provided one-person assistance with bed mobility and brief changes for Resident #30 without difficulty. CNA FF stated for mechanical lift transfers .I know it should be two people . and reported if she can't find another person she completes lift transfers by herself because she is .confident . CNA FF stated .Due to time constraints I often just let it go because I need to get a job done and I don't have time to wait for another staff to be available to help me . In an interview on 10/21/21 at 3:02 p.m., LPN J reported she and Agency LPN GG assessed Resident #30 after CNA FF reported her concern about a possible fracture on 10/8/21. LPN J reported Resident #30 was vocalizing and pointing to her leg. LPN J reported CNA FF was the only staff member in Resident #30's room at the time of the incident. Resident #35 Review of an Admission Record revealed Resident #35 was a male, with pertinent diagnoses which included anxiety, diabetes, [CONDITION(S)] disorder, high blood pressure, heart failure, kidney disease, vascular disease, bilateral leg amputations, right upper [CONDITION(S)], muscle weakness, and a history of falls. Review of a Minimum Data Set (MDS) assessment for Resident #35, with a reference date of 8/26/21, revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, which indicated moderate cognitive impairment. Further review of this MDS assessment, dated 8/26/21, revealed Resident #35 was totally dependent on two staff for transfers. Review of a current Care Plan for Resident #35 revealed the focus .(Resident #35) has an ADL (Activities of Daily Living) Self Care Deficit r/t (related to) functional deficits secondary to bilateral lower extremities amputation, amputation of right upper limb below elbow aeb (as evidenced by) weakness, pain, (dependent) lift . with interventions which included .Transfers-(Dependent Lift) with 2 assist . revised 8/11/21. Review of a Visual/Bedside Kardex Report (a document used by Certified Nursing Assistant (CNA) staff to provide care) for Resident #35, dated 10/20/21, revealed .Uses Mechanical Lift .Transfers-(Dependent Lift) with 2 assist . In an observation on 10/19/21 at 12:58 p.m., CNA E assisted Resident #35 with a transfer from his wheelchair to his bed, in the resident's room. Observed CNA E enter Resident #35's room with a dependent mechanical lift. CNA E attached the straps from the lift sling to the clips on the dependent mechanical lift, and lifted Resident #35 out of his wheelchair and into his bed. Note only one staff member (CNA E) was present for the dependent mechanical lift transfer. In an interview on 10/19/21 at 12:58 p.m., CNA E reported Resident #35 is a one staff assist for transfers with the dependent mechanical lift. Note this information contradicts policy, and the transfer status identified in Resident #35's Care Plan and Kardex. In an observation on 10/20/21 at 11:05 a.m., CNA E assisted Resident #35 with a transfer from his bed to his wheelchair, in the resident's room. Observed CNA E enter Resident #35's room with a dependent mechanical lift. CNA E positioned a lift sling below Resident #35, and attached the straps from the sling to the dependent lift. CNA E lifted Resident #35 from bed with the dependent lift, and lowered him into his wheelchair. Note only one staff member (CNA E) was present for the dependent mechanical lift transfer. In an interview on 10/20/21 at 11:33 a.m., CNA H reported per facility policy, there should always be at least two staff present for any mechanical lift transfer. In an interview on 10/20/21 at 2:05 p.m., CNA C reported all mechanical lift transfers require two staff. CNA C reported the number of staff needed for care is noted in the Care Plan/Kardex.

This citation pertains to intakes #: MI 289 Based on interview and record review, the facility failed to implement care plan interventions to prevent a fall for 1 of 5 sampled residents (Resident #101) reviewed for falls, resulting in injuries sustained from the fall. Findings include: Review of Resident #101's Admission Record revealed that Resident #101 was an [AGE] year old female originally admitted to the facility on [DATE] with pertinent diagnoses which included: dementia and [CONDITION(S)]. Review of Resident #101's Care Plan reveaed, (Resident #101) has a self care deficit r/t (related to) advanced dementia .Bed Mobility: Extensive 2 assist for all cares, turns, and repositioning. Date initiated: 10/03/2019 Revision on: 8/10/2021 . Review of Resident #101's Nurse's Note dated 8/10/21 at 11:02 revealed, Res(ident) on observed laying on the floor with face down with bleeding to the face/head. staff attempted to get Vitals but res kept moving her arms, so the machine couldn't read her BP/P (blood pressure/pulse). Administrator, unit manager and family notified. 911 called and res was taken to (name omitted) hospital for further evaluation/treatment/examination. Review of Resident #101's Hospital Record dated 8/10/2021 revealed, CHIEF COMPLAINT: FALL .CNA (Certified Nursing Assistant) was rolling the patient and patient rolled out of bed. patient hit head on nightstand. bleeding to forehead, L (left) elbow skin tear. dementia at baseline, nonverbal) XXX[AGE] year-old female with severe dementia nonverbal at baseline presenting with head injury after being accidentally rolled into her nightstand. Patient is at her neurologic baseline according to family member at bedside. On exam, she has 2 facial lacerations on the forehead and a skin tear on her left elbow. Lacerations were repaired at bedside, details as below . Review of the 5 Day Investigation Summary revealed, August 10, 2021 8:00 am-Incident: (Certified Nursing Assistant CNA R) was in room (number omitted) on the Harbor Unit at approximately 8:00 am caring for (REsident #101). (CNA R) was providing cares to get (Resident #101) up in her wheelchair, she rolled the resident in bed to pull up the resident's pants and place a Hoyer pad under her for transfer. (Resident #101) began to roll too far over, immediately (CNA R) attempted to keep control of (Resident #101) and was unable. (Resident #101) rolled off the side of the bed onto the floor on the right side of the bed. Nursing staff immediately responded, 911 was called and the resident was sent to ER for evaluation .Sequence of events: August 10, 2021 8:00 am (CNA R) is providing care to (Resident #101). (CNA R) was standing on the left side of the bed, rolling (Resident #101) away from her, she was attempting to pull the residents pants up and slide the Hoyer pad underneath her to prepare for Hoyer transfer. When she rolled the resident (Resident #101) went over to far, (CNA R) attempted to control her but the resident is heavy and she then rolled off the right side of the bed hitting her head on the small bedside dresser. (Resident E101) was on the floor, (CNAR) immediately ran from the room to obtain help, yelling loudly for assist to the room. Floor Nurse (Licensed Practical Nurse LPN P) responded to the room immediately, she saw the resident laying on her stomach, with bleeding from her forehead. (LPN P) states (Resident #101) was alert. 911 was alerted .(Previous Director of Nursing PDON V) re-educated the CNA regarding following the Kardex for care and define Bed Mobility as for all care, rolling and repositioning must have 2 care givers present for safety. DON identified any like residents that need 2 assist with Bed Mobility .2:14 pm (Resident #101) returned from the hospital with 2 forehead lacerations with sutures, bruising to face, laceration to left forearm and bruising, bilateral knee abrasions and a bruised left great toe .Conclusion: The facility conducted an investigation; the staff (CNA R) involved was interviewed and re-educated immediately. All post-incident reviews and monitoring for (Resident #101) have occurred. It was immediately identified root-cause of (Resident #101's) fall was related to the CNA not following the care directive on the Kardex. This failure to follow the Kardex resulted in a resident to fall with injury. The staff (CNA R) was immediately re-educated and received final disciplinary action. Interventions were placed post fall to further define care directives for bed cares for (Resident #101) to prevent further occurrences. The resident continues to reside at (facility) she is doing well and being monitored until all injuries are healed. All like residents have been identified, their care plans and Kardex's have been reviewed and revised. All nursing staff will be re-educated regarding caring for residents with bed Mobility deficits and process to reviewed the Care Plan and Kardex daily for any updates or changes. (Facility) substantiates the event. Review of the interview conducted with CNA R revealed, DON requested to speak with (CNA R) who is working today on the Harbor Unit. (CNA R) was providing am care to (Resident #101) in her room. CNA R was standing on the left side of the bed, rolling (Resident #101) away from her, she was attempting to pull the residents pants up and slide the Hoyer pad underneath her to prepare for Hoyer transfer. When she rolled the resident (Resident #101) went over too far, (CNA R) attempted to control her but the resident is heavy and she then rolled off the right side of the bed hitting her head on the small bedside dresser. (Resident #101) was on the floor, (CNA R) immediately ran from the room to obtain help, yelling loudly for assist to the room. I asked (CNA R) if she provides care to the resident often, she states yes. I reviewed the plan of care with her that was hanging on the back of the doorway. (CNA R) states she normally looks at the kardex on the computer. She states she did not realize she needed 2 persons to roll the resident despite there is directions that (Resident #101) is to have 2 caregivers for Bed Mobility. (CNA R) was re-educated regarding the meaning of bed mobility and staff assistance to include bed cares, rolling and repositioning. Having caregiver on either side of the bed while rolling prevents the resident to all. (CNA R) verbalized understanding. During an interview on 09/08/2021 at 1:27 P.M., LPN P reported that she was the nurse that worked the day that Resident #101 fell out of bed. LPN P reported that on the date of the incident the unit was staffed with 2 CNA's and not 3 which was required. LPN P reported that the fall out of bed was upsetting and Resident #101 ended up with lacerations on her face and was face down. LPN P reported that she believed being short staffed directly played a roll in Resident #101's fall. LPN P reported that Resident #101 required 2 staff assist for bed mobility and the CNA should not have attempted to care for the resident without an additional staff person. During an interview on 09/09/2021 at 3:30 P.M., CNA R reported that on the day of the incident there were 2 CNA's and not 3 working on the unit. CNA R reported that there were many 2 assist residents on the unit and working short staffed made it difficult to meet the needs of the residents. CNA R reported that there were no available staff to assist her with Resident #101 on 8/10/21 which was the reason why Resident #101 had a fall from her bed. Review of the Staff Schedule dated 8/10/21 revealed that the unit that Resident #101 resided on had 2 CNA's and 1 nurse scheduled for the first shift (an additional staff members name was crossed off). On 9/9/21, this surveyor confirmed that the facility implemented the following: On 8/10/21-8/20/21 all nursing staff were educated on Care Plan/Kardex Review Expectations. (The plan of care is a working tool to guide resident care. The plan of care should reflect the needs of the resident from day to day, it may be changed often depending on the resident's condition, level of assist required, and any special needs or preferences. Certain items on the plan of care specifically flow out to the Kardex to alert caregivers how to care for each resident. The nurse has the ability to update and revise the plan of care as needed, this means that each day it's important to review the kardex to make sure you have the most recent information on your residents. Following the Care Plan and Kardex ensures we keep our residents safe from incidents and accidents, and they receive the support they need from us from day to day.) Additionally, an audit of all like residents residing in the building was completed to ensure a complete and accurate Care Plan/Kardex was in place. During the onsite survey, no concerns were identified regarding the citation.

This citation pertains to intake #: MI 257 and MI 290 Based on observation, interview, and record review the facility failed to follow professional standards of practice in the prevention and care of pressure ulcers for 1 of 9 sampled residents (Resident #109) reviewed for pressure ulcer care resulting in the formation of pressure ulcers and a delay in wound healing with the potential for infection and overall deterioration in health status. Findings include: Review of the facility policy Pressure Ulcer Prevention and Management revised 08/2020 revealed, OBJECTIVE-Is a system for the prevention and management of pressure ulcers, based on the regulatory requirements set by Center Medicare and Medicaid (CMS) . PROVISION 1. Physicians/designee will identify and document type of injury and apply staging criterion if characterized as a pressure injury. The classification of pressure injury includes consideration of other etiologies of [MEDICAL CONDITION] (e.g., arterial ulcer, venous ulcer, neuropathic ulcer, moisture, and incontinence associated [MEDICAL CONDITIONS], medical adhesive related skin injury, allergic response). Nursing documentation will include characteristics of the injury . Prevention/Risk 1. The Braden Scale is the primary screening tool used to assess a resident's risk for the development of pressure ulcer, and initiate interventions as applicable to risk. 2. A Braden shall be completed with every resident upon admission/readmission, weekly for the first four weeks, monthly, with new pressure injury and PRN (as needed) by the Nurse. 3. After reviewing the skin condition, determination of injury type shall be made distinguishing pressure injuries from other [MEDICAL CONDITION] by a MD/designee. The MD/designee will document the wound characteristics and treatment orders (and assess stage if a pressure injury). 4. A weekly Skin Assessment is completed by clinical staff and verified by charge nurse. All currently documented and new [MEDICAL CONDITION] are indicated on Weekly Assessment form. Charge nurse to assess and document on new skin conditions/injuries, and as needed. Letter of Unavoidability 1. The Letter of Unavoidability may be used to provide physician certification of unavoidable wounds due to resident condition despite proper implementation of care interventions. Weekly Documentation 1. Documentation shall be completed utilizing current assessment forms or the electronic medical record. 2. The charge nurse shall complete a skin assessment on all residents weekly 3. Treatment shall be initiated when appropriate physician orders have been obtained. 4. The characteristics of existing pressure injuries, and periwound tissue, inclusive of measurement and comparison to the preceding week, shall be described and documented by the charge nurse/designee on a weekly basis using the skin/wound progress note in the electronic medical record. 5. Record the assessment and presence of signs of infection and pain. Document the resident's responses to the interventions. 6. The characteristics of existing pressure injuries and periwound tissue, exclusive of measurement shall be described and documented by the charge nurse during daily or prn dressing change. Assessment of soiled dressing to determine strikethrough of drainage or adequacy of treatment/dressing is also documented. 7. If no progress is seen within 2 weeks, treatment and/or interventions shall be re-evaluated and documented. Care Planning 1. Comprehensive Assessment Care plan shall be completed at admission/quarterly for residents at risk for skin breakdown based on history, Braden Scale score and interventions, and disease process. 2. Acute care planning for present skin breakdown based on identification, treatment and/or healing and preventative measures. Tracking 1. Skin Integrity/Pressure Ulcer shall be analysis for trends and patterns and reviewed at the monthly quality assurance performance improvement (QAPI) meeting. Treatment 1. Treatments shall be completed using established guidelines within the community and orders received from the physician. Review of the Fundamentals of Nursing 9th edition revealed, Nutrition. For patients weakened or debilitated by illness, nutritional therapy is especially important .Normal wound healing requires proper nutrition (Table 48-4). Deficiencies in any of the nutrients result in impaired or delayed healing. Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations - ). Elsevier Health Sciences. Kindle Edition. Review of the Fundamentals of Nursing revealed, The health care provider (physician or advanced practice nurse) is responsible for directing medical treatment. Nurses follow health care providers' orders unless they believe that the orders are in error, violate agency policy, or are harmful to the patient. Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations - ). Elsevier Health Sciences. Kindle Edition. Resident #109 Review of a Face Sheet revealed Resident #109 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #109, with a reference date of 11/20/20 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated Resident #109 was severely cognitively impaired. Review of the Functional Status revealed that Resident #109 required extensive 2 person assist with bed mobility, transferring, dressing and personal hygiene. Review of Resident #109's Care Plan revealed, Focus-(Resident #109) has cognitive deficits r/t (related to) dementia w/ (with) delusional features. (Resident #109) is able to make her needs known. (Resident #109) often requires cues and reminders for time based events. (Resident #109) has significant disturbances in thought, conduct, and judgment. She has a hx (history) of refusing to let staff assist with cares, showers, changing her clothes even with staff encouragement. (Resident #109) refuses to wear fanny pack to store items instead of the waistband of her pants. She frequently says b**** or b****es or swearing not necessarily to a person but states it at times of frustration and non frustration. At times she talks to & swears at an unseen person in her room and the DR (Dining Room). (Resident #109) has also hidden medications in a towel she keeps near her bed instead of swallowing the medications. Date Initiated: 08/25/2014 Revision on: 03/26/2019 (Note the focus had not been revised since 2019) Goals-(Resident #109) will be able to communicate basic needs on a daily basis through the review date Initiated: 08/25/2014 Revision on: 11/23/2020 Target Date: 02/15/2021 (Note a past goal date) Interventions-*Approach in a caring, helpful manner. *(Resident #109) does not respond well if she feels she is being ordered to do something Date Initiated: 08/25/2014 *CNA (Certified Nursing Assistant) to notify nurses if noted increase change in behavior that is disruptive and affects pt's (patients) overall well being. Nurse to notify physician of these changes. Date Initiated: 08/25/2014 Revision on: 03/11/2016 *Communicate with (Resident #109)/family/caregivers regarding her capabilities and needs. Date Initiated: 08/28/2014 Revision on: 10/18/2016 *Introduce self and explain all procedures. Date Initiated: 08/20/2013 *Offer choices and encourage me to respond. Date Initiated: 08/28/2013 *Prompt and remind as needed. Date Initiated: 08/28/2013 *Use task segmentation to support short term memory deficits. Date Initiated: 08/25/2014 Revision on: 06/02/2016. (Note the interventions had not been revised since 2016) Review of Resident #109's Care Plan revealed, Focus-(Resident #109) is at risk for impaired skin integrity r/t (related to) impaired mobility, cognitive deficits and combative with care d/t (due to) dementia, poor PO (oral) intake, h/o (history of) significant weight loss, h/o (history of) pressure ulcer to coccyx, occasionally refuses incontinence cares, combative with cares, fragile skin. Date Initiated: 08/29/2014 Revision on: 07/16/2020 (Note focus not revised for current pressure ulcer) Goal-(Resident #109) will be free from major impairments to her skin daily, through the review date. Date Initiated: 08/29/2014 Revision on: 08/18/2020 Target Date: 02/15/2021 (Note a past goal date) Interventions-*Assist with Repositioning Q2hrs (every 2 hours) and PRN (as needed) as allowed by (Resident #109). *Use pillows to rotate from left to center to right side to offload. Use skin barrier cream BID (twice a day) and PRN Date Initiated: 12/21/2016 Revision on: 02/15/2021 *Avoid scratching try to Keep fingernails short as much as resident will allow Date Initiated: 08/29/2014 Revision on: 12/22/2020 *During care use caution with (Resident #109's) arms, she may swing out or she may injure herself. Date Initiated: 11/02/2019 *Encourage good nutrition and hydration in order to promote healthier skin. Date Initiated: 08/29/2014 Revision on: 08/29/2014 *NO SOAKER PAD UNDER (Resident #109) while she is on an APM (Alternating Pressure Mattress) Date Initiated: 01/22/2021. Review of Resident #109's Care Plan revealed, Focus-(Resident #109) has an ADL (Activities of Daily Living) Self Care Performance Deficit r/t (related to) Confusion. Resident does not accept assistance with ADLs. Offers to assist creates agitation and anger. Refuses labs when needed. Date Initiated: 08/28/2014 Revision on: 04/14/2015 Goal-(Resident #109) will improve self care abilities with ADLs by the review date. Date Initiated: 08/28/2014 Revision on: 08/18/2020 Target Date: 02/15/2021. (Note a past goal date) Interventions .BED MOBILITY: (Resident #109) is extensive assist x2 for bed mobility. Date Initiated: 08/09/2017 Revision on: 11/28/2017 .(Resident #109) can become combative agitated and combative with care, if agitated re approach when (Resident #109) has calmed down. (Resident #109) enjoys speaking about her family. At times of resistance speak to (Resident #109) in a gentle tone about her daughter and granddaughter. Date Initiated: 10/11/2018 Revision on: 11/29/2018 .PRECAUTIONS: Provide (Resident #109) assistance as tolerated as (Resident #109) displays increased agitation often during cares and assistance which increases risk for injury. Date Initiated: 08/11/2017 .(Indicating Resident #109's bed mobility and behaviors were not new) . Review of Resident #109's Kardex (form to communicate resident needs) revealed, Resident Care-*Assist with Repositioning Q2hrs and PRN as allowed by (Resident #109). Use pillows to rotate from left to center to right side to offload. Use skin barrier cream BID and PRN . *If (Resident #109) is not accepting cares, engage in conversation about her family. She particularly enjoys talking about her grandchildren . *NO SOAKER PAD UNDER (Resident #109) while she is on an APM (alternating pressure mattress) .Safety-*Approach client with transfers to bed with calm soothing encouragement for falls prevention and resident to increase trust with transfers *Bed in low position. *During care use caution with (Resident #109's) arms, she may swing out or she may injure herself . *PRECAUTIONS: Provide (Resident #109) assistance as tolerated as (Resident #109) displays increased agitation often during cares and assistance which increases risk for injury .Behavior/Mood- * Document refusals of care, and combative behavior *(Resident #109) can become combative agitated and combative with care, if agitated re approach when (Resident #109) has calmed down. (Resident #109) enjoys speaking about her family. At times of resistance speak to (Resident #109) in a gentle tone about her daughter and granddaughter . *(Resident #109) refuses assistance with cares, hates when her feet are touched, but can sometimes be persuaded when engaged in discussion about either flowers, the weather, or her grandchildren . Review of Resident #109's Care Record for the month of March 2021 revealed, NO SOAKER PAD UNDER (Resident #109) while she is on an APM . Review of Resident #109's Braden Scale for Predicting Pressure Sore Risk dated 11/19/20 revealed Resident #109 was High Risk. Review of Resident #109's Braden Scale for Predicting Pressure Sore Risk dated 2/19/21 revealed Resident #109 was High Risk. Review of Resident #109's Weekly Skin assessment dated [DATE] revealed, 1. Skin Assessment .Excoriation (skin breakdown) to coccyx .Coccyx-red area .Resident has been behavioral, throwing food, resistive to care, combative with staff, Refusing medications. (Chamosyn) (ointment used for skin/barrier cream) applied bottom. (Note that Resident #109's Care Plan was not updated to reflect excoriation to her coccyx.) Review of Resident #109's Weekly Skin assessment dated [DATE] revealed, 1. Skin Assessment .Chamosyn (ointment used for skin irritations/protective barrier) lotion applied to pink area on coccyx. Repositioning used to try to get pressure off coccyx .Coccyx-Some pink/light redness noted on bottom area. Chamosyn applied. Repositioning used to remove some pressure from bottom. (Note that Resident #109's Care Plan was not updated to reflect redness to her coccyx.) Review of Resident #109's Weekly Skin assessment dated [DATE] revealed, 1. Skin Assessment .light redness/pinkness noted on coccyx area. Chamosyn cream applied to area. Repositioned her off area .Coccyx-pink/light redness noted. Chamosyn and repositioning in place. (Note that Resident #109's Care Plan was not updated to reflect redness to her coccyx.) Review of Resident #109's Weekly Skin assessment dated [DATE] revealed no skin impairment. Review of Resident #109's Weekly Skin assessment dated [DATE] revealed, 1. Skin Assessment .Chamosyn order in place, applied q (every) shift .Coccyx (Description Blank)-Sacrum (Description Blank) . Review of Resident #109's Weekly Skin/Wound Note dated 12/31/20 revealed, Late Entry: Type of Wound: [MEDICATION NAME] (rash with blisters) .upper left and upper inner buttock .slightly red, painful, tender .Date of Origin: 12/31/2020. Review of Resident #109's Weekly Skin assessment dated [DATE] revealed, 1. Skin Assessment .shingles to buttocks, tx (treatment) in place .Coccyx (Description Blank)-Sacrum (Description Blank) .Continue to apply chamosyn as ordered. Review of Resident #109's Weekly Skin/Wound Note dated 1/8/21 revealed, Type of Wound: Pressure (previously suspected to be [MEDICATION NAME])-Skin condition: open, 2 areas-Stage, location, and size (length, width, depth): STAGE 2; Coccyx; 2.6cm x 1.4cm- STAGE 2; Left upper buttock; 0.9cm x 0.2cm .Coccyx - Distal medial aspect with small area of necrotic (dead) tissue, remaining wound with 80% yellow slough (mass of dead tissue breaking off of pressure ulcer)-Left upper buttock - pink and moist-Current treatment: [MEDICATION NAME] ointment-Progress of the wound: worsened-Order for change in treatment : D/C [MEDICATION NAME] ointment Start Chamosyn BID and PRN-Date of Origin: 12/31/2020. Review of Resident #109's Physician Order dated 1/8/21 revealed, [MEDICATION NAME] Ointment (chamosyn) 0.44-20.6 % (Menthol-Zinc Oxide) Apply to Coccyx, LT upper buttock topically two times a day for stage 2 pressure injury AND Apply to coccyx, LT upper buttock topically as needed for as needed. Review of Resident #109's Weekly Skin assessment dated [DATE] revealed, 1. Skin Assessment .no new issues .Coccyx-Stage II; [MEDICATION NAME] BID (twice a day)-Left buttock Stage II, [MEDICATION NAME] BID . Review of Resident #109's physician progress notes [REDACTED]. Meds rev (reviewed) vss (vital signs stable), patient cannot participate (sic) in ros (Review of Symptoms) due to advanced dementia . Skin: Left coccyx reveals a 2.6 cm x 1.4 cm stage 2 wound, distal medical (sic) aspect small area of necrosis, 80% yellow slough other portion of wound bed Left buttock there is a .9 cm x 0.2 cm wound, wound bed is pink and (moist) .Plan: Dc (discontinue) [MEDICATION NAME] ([MEDICAL CONDITION]), add chamosyn cream bid and prn to both wounds, turn in bed if patient will allow, hx dementia with (combative) behavior and anxiety, may be (resistive) to turning frequently. Discussed with staff. Review of Resident #109's Weekly Skin/Wound Note dated 1/15/21 revealed, Type of Wound: Pressure-Skin condition: Open-Stage, location, and size (length, width, depth): 1) Stage 2; Left Coccyx; 2cm x 0.8cm 2) DTI; Left Buttock; 0.6cm x 0.7cm-Description of the wound bed (beefy red, eschar, slough, drainage, and odor): 1) Pink, distal aspect slightly necrotic, light exudate - 2) N/A, closed DTI -Current treatment: Chamosyn BID and PRN Progress of the wound: improving-Order for change in treatment: no change-Date of Origin: (Blank)-Date Resolved: (Blank). Review of Resident #109's physician progress notes [REDACTED]. Patient is agitated and confused, in bed. She is cooperative with exam however. Medications reviewed and vital signs are stable. Patient overall with advanced debility and dementia . Skin: Left proximal 6 wound stage II, measures 2.0 cm x 0.8 cm, the wound bed is pink. The distal aspect there is a slight Lee necrotic area, this is small and pinpoint in nature. Left buttock wound is now closed, there is a purple deep tissue injury over the old wound that measures 0.6 cm x 0.7 cm . Continue chamosyn twice daily and as needed, continue offloading. Patient needs good Roho cushion (cushion designed to decrease the amount of pressure on the sitting area) in her wheelchair. Patient with poor oral intake and poor nutrition, protein calorie malnutrition related to advancing dementia and debility. Resident dietitian is following, she is offered supplements. Review of Resident #109's Weekly Skin assessment dated [DATE] revealed, 1. Skin Assessment .Open area to coccyx with chamosyn order in place, applied q shift .Sacrum-Open area to coccyx with chamosyn in place, applied q shift . No Weekly Skin/Wound Note for 1/22/21. Review of Resident #109's physician progress notes [REDACTED]. Patient is in bed, staff assist with turns, patient is slightly anxious but she does cooperate with turns. Medications reviewed and vital signs are stable. ROS cannot be performed due to dementia . Skin: Left coccyx there is a stage II wound present, right over the bony prominence, measures 3.0 cm x 1.7 cm, the wound bed is 20% slough with irregular borders blanchable tissue surrounding. The left buttock reveals a 0.6 cm x 0.5 cm wound, there is no deep tissue injury surrounding, the wound bed is 90% slough, the rest is pink granulation . Plan: Wound unavoidable and patient with bony skeleton, [MEDICAL CONDITION], failure to thrive, protein, malnutrition, weight loss and advanced dementia. We will continue chamosyn twice daily and as needed, continue offloading. Patient needs a Roho cushion for her chair I discussed this with nursing staff. Resident dietitian is present for exam and will be adding Juven or protein supplement. Review of Resident #109's Weekly Skin assessment dated [DATE] revealed, 1. Skin Assessment .Open area to coccyx with chamosyn order in place, applied q shift .Sacrum-Open area to coccyx with chamosyn in place, applied q shift . Review of Resident #109's Weekly Skin/Wound Note dated 1/29/21 revealed, Type of Wound: pressure-Skin condition: (Blank) Stage, location, and size (length, width, depth): stage II left coccyx and buttock left 3.0x1.0 right 0.5x0.4-Description of the wound bed (beefy red, eschar, slough, drainage, and odor): left superior aspect purple surrounding = purple DTI (deep tissue injury)- right pink moist slightly raised macerated-Current treatment: Chamosyn BID and PRN-Progress of the wound: (Blank) Order for change in treatment: (Blank)-Date of Origin: (Blank)-Date Resolved: (Blank)-Comments: (Blank). Review of Resident #109's physician progress notes [REDACTED]. Patient is in bed, she is slightly combative with cares. Medications reviewed and vital signs stable . Patient with poor oral intake, resident dietitian is following as well, continue supplements. Patient with advancing dementia and decreased appetite, increasing debility. All contribute to poor wound healing. Patient is noncompliant with turns in bed, continue chamosyn twice daily and as needed as well as offloading. Review of Resident #109's Weekly Skin assessment dated [DATE] revealed, 1. Skin Assessment .Coccyx (Description Blank) .coccyx has an open area. Tx (treatment) in place. Review of Resident #109's Weekly Skin/Wound Note dated 2/5/21 revealed, Type of Wound: stage II -Skin condition: (Blank)-Stage, location, and size (length, width, depth): Left coccyx 2.8x1.0- left buttock (sic) 0.9x0.9 Description of the wound bed (beefy red, eschar, slough, drainage, and odor): Yellow slough left buttock left coccyx slough-Current treatment: Chamosyn BID and PRN-Progress of the wound: (Blank)-Order for change in treatment: (Blank)-Date of Origin: (Blank)-Date Resolved: (Blank)-Comments: (Blank) Review of Resident #109's Weekly Skin assessment dated [DATE] revealed, 1. Skin Assessment .Open area to coccyx with chamosyn order in place, applied q shift .Sacrum-Open area to coccyx with chamosyn in place, applied q shift . Review of Resident #109's Federal Regulatory Visit dated 2/10/21 revealed, .Reviewed resident's total program of care, including mediations and treatment plan. Patient continues to require skilled nursing care for general well-being, and help with ADLs (Activities of Daily Living) and IADLs (Instrumental Activities of Daily Living). (No documentation of Pressure Ulcer) No Weekly Skin/Wound Note for 2/12/21 Review of Resident #109's Weekly Skin assessment dated [DATE] revealed, 1. Skin Assessment .Open area to coccyx with chamosyn order in place, applied q shift .Sacrum-Open area to coccyx with chamosyn in place, applied q shift . Review of Resident #109's Weekly Skin/Wound Note dated 2/19/21 revealed, Type of Wound: pressure unstageable-Skin condition: (Blank)-Stage, location, and size (length, width, depth): left coccyx and buttock LT coccyx 3.5x1.4 -LT buttock 0.7x1.0-necrosis 0.9x0.6-Description of the wound bed (beefy red, eschar, slough, drainage, and odor): central essential area necrosis .pink granulated 100% slough Current treatment: chamysin (sic) BID and PRN-Progress of the wound: (Blank)-Order for change in treatment : cover with [MEDICATION NAME] (type of wound dressing)-Date of Origin: (Blank)-Date Resolved: (Blank)-Comments: (Blank). Review of Resident #109's physician progress notes [REDACTED]. Patient has had no change in diet, is on no bowel meds. Patient w/o sssx (sic) (without signs and symptoms) of infection (sic), no recent abx (antibiotic) use. Pateints (sic) meds reviewed in detail, bowels reviewed in (electronic health record) as well, several loose stools documented daily. Meds (reviewed) (vital signs stable) . [MEDICATION NAME] (blood sugar medication), blood sugars are being obtained only once a month, last blood sugars 132, 114, 126. Patient is on 500 mg of [MEDICATION NAME] may contribute to loose stools again will DC (discontinue) and continue to monitor blood sugars. Will consider adding [MEDICATION NAME] or Questran to help with bowels as well if this is not effective, I discussed this with resident dietitian in great detail. Patient overall is declining, she has advanced dementia. Medications reviewed . Review of Resident #109's Weekly Skin assessment dated [DATE] revealed, 1. Skin Assessment .[MEDICATION NAME] L (left) upper buttocks .left buttock open area . Review of Resident #109's Weekly Skin/Wound Note dated 2/26/21 revealed, Type of Wound: pressure-Skin condition: (Blank)-Stage, location, and size (length, width, depth): left coccyx and buttock #1 lt (left) coccyx 2.6x1.0 with central area tunneling=0.5x0.5x0.5 #2 lt buttock 1.3x2.0 Description of the wound bed (beefy red, eschar, slough, drainage, and odor): #1 100% slough except the tunneling area #2 WB pink granulation tissue- Current treatment: #1 Chamosyn BID and prn- #2 Cover with [MEDICATION NAME]-Progress of the wound: (Blank)-Order for change in treatment : none-Date of Origin: (Blank)-Date Resolved: (Blank)Comments: appears less painful. Review of Resident #109's physician progress notes [REDACTED]. Patient is seen in bed, she is slighty (sic) aggitated (sic) today, hx dementia and behaviors as well. Meds rev vss, now on zinc, vit c, mvi (multivitamin) for wound helaing (sic), she is laying on her back and appears to be comfortable . Wound of sacral region, subsequent encounter Coccyx wound now with area of central tunneling, necrosis is healed, cont (continue) [MEDICATION NAME] to keep covered with frequent stooling , cont off loading, has air mattress Left buttock wound , although slightly larger, is improving, no slough, pink wound bed, cont chamosyn . Review of Resident #109's Physician Order dated 6/20/20 revealed, Offloading Boots-on while in bed. Repositioning and Interventions During an observation on 03/01/2021 at 8:48 A.M., (Resident #109) was in her room, in bed on her back. Resident #109 was feeding herself breakfast alone in her room. The meal tray was on the tray table level with her eyes. Resident #109 was not properly positioned and was approximately 12 inches from the top of her bed. Resident #109 did not have any offloading boots on her feet. During an observation on 03/01/2021 at 9:20 A.M., (Resident #109) was lying in bed on her back. Resident #109 did not have any offloading boots on her feet. During an observation on 03/01/2021 at 9:27 A.M., (Resident #109) was lying in bed on her back. Resident #109 did not have any offloading boots on her feet. During an observation on 03/01/2021 at 10:22 A.M., (Resident #109) was lying in bed on her back. Resident #109 did not have any offloading boots on her feet. Resident #109 had a soaker pad underneath her body. During an observation on 03/01/2021 at 11:08 A.M., (Resident #109) was lying in bed on her back. Resident #109 did not have any offloading boots on her feet. Resident #109 had a soaker pad underneath her body. During an observation on 03/01/2021 at 11:46 A.M., (Resident #109) was lying in bed on her back. Resident #109 did not have any offloading boots on her feet. Resident #109 had a soaker pad underneath her body. During an observation on 03/01/2021 at 12:15 P.M., (Resident #109) was lying in bed on her back. Resident #109 did not have any offloading boots on her feet. Resident #109 had a soaker pad underneath her body. During an observation on 03/01/2021 at 12:39 P.M., (Resident #109) was lying in bed on her back. Resident #109 did not have any offloading boots on her feet. Resident #109 had a soaker pad underneath her body. During an observation on 03/01/2021 at 1:05 P.M., (Resident #109) was lying in bed on her back. Resident #109 did not have any offloading boots on her feet. Resident #109 had a soaker pad underneath her body. During an observation on 03/02/2021 at 9:30 A.M., (Resident #109) was lying in bed with a pillow under her left side. Resident #109 did not have any offloading boots on her feet. During an observation on 03/02/2021 at 11:18 A.M., (Resident #109) was lying in bed with a pillow under her left side. Resident #109 did not have any offloading boots on her feet. During an interview on 03/02/2021 at 1:55 P.M., (Certified Nursing Assistant) CNA G reported that Resident #109 should be repositioned at least every 2 hours to offload pressure on her buttocks and assist with wound healing. CNA G reported that Resident #109 should not have a soaker pad underneath her body at any time. CNA G reported that Resident #109 would get agitated during cares but repositioning Resident #109 was still able to be completed. During an observation on 03/02/2021 at 4:06 P.M., Resident #109 was in her bed and did not have any offloading boots on her feet. During an interview on 03/03/2021 at 10:06 A.M., CNA J reported that Resident #109 should be repositioned at least every 2 hours to offload and get the pressure off her bottom. CNA J reported that Resident #109 does get aggravated but does allow repositioning to be completed. CNA J reported that staff should always follow the residents' care plans and/or kardex. During an interview on 03/02/2021 at 9:44 A.M., Registered Nurse (RN) L reported that residents should be repositioned every 2 hours or more if they have a pressure injury. RN L reported that Unit Managers should be updating care plans with any new interventions. RN L reported that after the physician assesses a wound and orders new interventions the Unit Manger should immediately update the care plan to reflect the new intervention. During an interview on 03/02/2021 at 1:45 P.M., LPN M reported that unit managers update resident Care Plans when there are changes. LPN M reported that a new order for a Roho mattress or offloading heals should be placed on the resident Care Plan. Wound Treatment Review of Resident #109's Physician Order dated 2/20/21 revealed, [MEDICATION NAME] Ointment 0.44-20.6 % (Menthol-Zinc Oxide) Apply to Coccyx, LT(left) upper buttock topically two times a day for stage 2 pressure injury cover with [MEDICATION NAME] AND Apply to coccyx, LT upper buttock topically as needed. During an interview and observation on 03/01/2021 at 1:40 P.M., CNA C was assisting Resident #109 with incontinence care. Resident #109's brief was saturated. Resident #109 did not have a [MEDICATION NAME] dressing over her pressure ulcer. CNA C reported that she had not seen a dressing on Resident #109's buttocks during her shift. Resident #109 had 2 large wounds on her buttocks/coccyx and bright red blood was noted. CNA C reported that during her shift she changes Resident #109 2 times. CNA C then placed a soaker pad under Resident #109. Resident #109 swore at CNA C but no other behaviors noted. CNA C reported that Resident #109 does have some behaviors but ultimately Resident #109 is compliant with care. During an interview on 03/01/2021 at 3:32 P.M., Licensed Practical Nurse (LPN) E reported that she had cared for Resident #109 since the beginning of her shift at 6:30 A.M. LPN E reported that Resident #109 did not have wound ordered wound care and she had not performed wound care on 3/1/21. (Review of Resident #109's March 2021 Medication Administration Record [REDACTED].) During an observation and interview on 03/02/2021 at 2:00 P.M., Resident #109 was receiving her wound treatment. Resident #109 did not have a [MEDICATION NAME] in place. LPN I reported that he did not know why Resident #109 did not have a [MEDICATION NAME] on her wound but reported that she should because it was an ordered treatment. During an interview on 03/02/2021 at 2:08 P.M., Physician Assistant (PA) N (responsible for Resident #109's wound care) reported that Resident #109 is combative at baseline. PA N reported that the staff should be repositioning Resident #109 every 2 hours and providing the wound care she ordered. Review of Resident #109's Electronic Health Record revealed no Letter of Unavioidability. Behaviors Review of Resident #109's Monthly Nursing Summary dated 10/11/20 revealed, (TRUNCATED)

This citation pertains to intake MI 909 Based on observation, interview, and record review, the facility failed to ensure a safe environment for 1 of 3 residents (Resident #101) reviewed for accidents and hazards, resulting in serious injury for Resident #101. Findings include: Review of facility policy Fall Prevention, Analysis and Follow-up revision date: 11/17, revealed, OBJECTIVE: The objective of this policy is to assess the risk of falls of all residents, analyze why a fall has occurred and determine what intervention(s) are needed to prevent falls from occurring .POLICY The Community shall ensure that a system is in place for managing falls and identifying interventions related to residents at risk for falls. The goal of the community is to ensure that the residents environment remains as free from accident hazards as possible and that each resident receives adequate supervision and assistance to prevent accidents. DEFINITIONS Fall: Unintentional change in position coming to rest on the ground, floor or onto the next lower surface (e.g., onto a bed, chair, or bedside mat). The fall may be witnessed, reported by the resident or an observer or identified when a resident is found on the floor or ground. Falls are not always a result of an overwhelming external force (e.g., a resident pushes another resident), An intercepted fall occurs when the resident would have fallen if he or she had not caught him/herself or had not been intercepted by another person -this is still considered a fall. PROVISIONS .4. Safety devices including, but not limited to, an alarm, motion detector, mat on the floor or low bed will be provided on admission and as needed when a resident is at risk for a fall. 5. A care plan will be developed or revised based on the assessment and possible interventions. All interventions will be included on the care plan .When A Resident Has Fallen Previously:[NAME] If the initial intervention based on systematic evaluation does not prevent another fall, other interventions will be initiated based on further identified or suspected causes . Review of the facility reported incident submitted to the State Agency on 8/14/19 at 3:35 PM revealed, Incident Summary CNA had been providing incontinence care to resident just prior to fall from bed to mat at 0450am. In the course of providing care, CNA had raised the entire bed from 12 inches (low bed height) to approximately 24 inches, as re-demonstrated by CN[NAME] CNA had completed care when resident became incontinent again, thereby soiling the clean linens. The CNA then left the bedside (without lowering bed) to obtain a fitted sheet and upon return the room, resident was lying on the floor next to the bed on the floor mat. Review of a Face Sheet revealed Resident #101 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of Resident #101's Care Plan with a date initiated of 3/24/18, a revision date of 9/4/19, and target date of 11/20/19, revealed a Focus of resident being at .risk for falls d/t (due to) poor balance, poor safety awareness, and desire to maintain independence, aeb hx (as evidenced by history) of falls with no injury stating she does not need help and can do things her self . The Goal of the Care Plan was to .have no major injury from the result of a fall through the review date . with Interventions for staff to provide care and treatment of [REDACTED]. with a date initiated on 4/23/19. Resident #101's focused Risk for Falls Care Plan revealed no updated interventions had been made since 4/23/19. Previous revisions to this particular care plan to prevent falls and provide safety measures for staff to follow were revised on 11/21/18 that indicated Ensure that (Resident #101) is wearing gripper socks or proper footwear . Resident #101's Kardex (a medical information system used by nursing staff as a way to communicate important information on their patients) revealed, Safety .Keep (Resident #101's) bed low when she is in it . Review of an Incident Report indicated Resident #101 had a fall on 8/13/19 at 4:50 AM revealing, .Nurse was alerted by staff that resident was on the floor. She was previously lying in the bed receiving care from caregiver. Bed was at regular height. Nurse entered room and observed resident laying on fall mat with left arm and leg under body .Resident was assessed for injuries and c/o severe pain to the right arm and leg .Orders received from physician to transfer resident to hospital .Resident bed was left elevated by CNA while CNA went to get new bed linen while providing care . Injuries documetned post incident were: 1.) fracture right trochanter (hip) and 2.) fracture right shoulder (rear). Review of the ER Preliminary Report dated 8/13/19 2:41 PM indicated Resident #101 had sustained a fracture to right arm (humerus) and her right femur (thigh bone) and required surgical repair. Review of Resident #101's Progress Note dated 8/13/2019 05:29 (5:29 AM) revealed, .Nurse was alerted by staff that resident was on the floor. Nurse entered room and observed resident laying fall mat with left arm and leg under body. Resident was unable to tell nurse what happened for sure. Resident was assessed for injuries and c/o severe pain to the right arm and leg .Orders received from physician to transfer resident to hospital . Resident transferred by (ambulance) to .hospital. On call manager, and administrator notified. During an interview on 9/11/19 at 12:03 PM CNA B stated, I worked for an agency (that supplied CNAs to the facility) as a CNA and was assigned to the facility on and off for about 3 years. The morning of the incident I was rushing and doing my rounds. I changed (Resident #101) and she peed again. I put the clean brief under her and put her on her back. I left the bed up. It was between my waist and knees and I'm 5'3. I ran down to the clean linen room about 3 doors away from her room. It only took me about 3 minutes. When I came back she had fallen off the bed. She did have an alarm on so I knew she was a fall risk. I was rushing because I was 3rd shift and the group I was on had a lot of alarms. They (referring to the motion alarms) were constantly going off and there was only the two of us CNAs. It was also the time for my last rounds and get-ups (assisting residents to get up for the morning). The Kardex is to know of resident needs and care; it was on the wall. When I first came in to the room to change her she was trying to get up on the side of the bed. She had tried that all night. I was just trying to get a clean pad under her and change her. During an interview on 9/10/19 at 9:50 AM, Certified Nursing Assistant (CNA) D stated, The resident's will have on their care plans and Kardex if they are to have a low bed. A low bed is one that is to be all the way down to the floor. When care is being provided the bed can be raised to make if easier to provide care. When care is done, the bed must be lowered down. The kardex will tell us what position to put the bed in. If the resident is a fall precaution they should have mats on floor next to the bed also. (Resident #101) has to have mats next to the bed on the floor, a low bed and a bed alarm. We are never to leave the resident in bed with the bed raised. Observed on 9/10/10 at 12:39 PM Resident #101 supine in bed with eyes closed. Mat on floor to left side side of HOB (head-of-bed). Bed not lowered to floor; approximately 10-12 from floor to bottom of bed. Observed on 9/10/19 at 1:25 PM Resident #101 in bed, supine, eyes open, visiting with family member. Bottom of bed approximately 10-12 off of floor. During an interview and observation on 9/10/10 at 1:57 PM with Unit Manager (UM) F, stated, When a bed is care planned to be low the bed should be positioned down to the floor. Observed Resident #101's bottom of bed approximately 10-12 of of floor with UM F present. UM F used bed control to lower bed to floor position. UM F stated, The bed moved about 5-6 down, I don't know the exact distance it went down. It was not in the low position. UM F reviewed Resident #101's Care Plan and Kardex with surveyor and stated, (Resident #101's) Care Plan says Keep (Resident #101's) bed low when she is in it and a fall mat next to the bed. The Kardex that the CNAs (Certified Nursing Assistant) use comes right from the Care Plan. (Resident #101's) Kardex says the same thing; bed low when she is in it.'. During an observation and interview on 9/10/19 at 2:45 PM, Family Member (FM) H stated, When I came in around 1:20 (PM) this afternoon, (Resident #101) was in bed. The bed was not low to the ground as it should be. During an interview on 9/11/19 at 3:25 PM, the Director of Nursing (DON) stated, Care Plans are for staff to understand and direct the care of residents. It is very important that a care plan is developed and followed by staff. We (referring to facility) work very hard to make care plans person-centered. Our facility CNAs are trained at orientation of their job duties. The facility sends the Agency a power-point of job duties and the staff gets it from the agency they work for.

This pertains to intake M 5154 Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent elopement and ensure the safety in 1 of 4 residents (Resident #101) reviewed for safety and supervision, from a total sample of 6, resulting in an Immediate Jeopardy when on 4/23/18, Resident #101 exited the facility at 8:37 p.m., unbeknownst to facility staff, and was found in the parking lot approximately 50 to 75 feet away from the door at 8:53 p.m. This deficient practice placed 27 residents, identified as risk for elopement, at risk for serious harm, injury, and/or death. Findings include: Review of a Policy titled Elopements and Wandering Residents last revised 11/17 revealed: Objective: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Review of a Face Sheet revealed Resident #101 was an [AGE] year-old male admitted on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) revealed Resident #101 had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately cognitively impaired, and extensive assist of 1 staff for transfers. Review of an Elopement Care Plan for Resident #101 created on 6/6/17 revealed: Resident #101 is an elopement risk aeb (as evidenced by) making statements of wanting to find his car so he can leave. Resident #101 is not oriented to place. Resident #101 asks to go outside when the weather is nice, but is able to be redirected and wait so staff can accompany him. Review of Nurse's Notes dated 2/14/18 at 10:31 p.m. for Resident #101 revealed: CENA called this nurse to hallway near front lobby because of Resident #101 on the floor .Doctor was called . Review of Nurse's Notes dated 3/6/18 at 6:09 p.m. for Resident #101 revealed: was agitated and was constantly asking to go home and asking where family is, denies any pain, was given [MEDICATION NAME] and has been quiet after, states feels comfortable. Review of Stand up meeting notes dated 3/16/18 revealed: Resident #101 not wandering, likes to be up at reception. Review of Nurse's Notes dated 3/20/18 at 3:04 p.m. for Resident #101 revealed: Wander Guard discontinued due to non-exit seeking behavior. Care plan updated, Wander Guard order discontinued. Review of the documented incident dated 4/23/18 for Resident #101 revealed: II. On (MONTH) 23, (YEAR) resident (Resident #101) was observed in the driveway out front of the building at 8:50 p.m. by staff. Upon review of the camera footage, the exit door opens at approximately 8:44 p.m. and then (Resident #101) is seen on the camera propelling in his wheelchair along the parking lot approximately 50 feet when staff observe him and then assist him back into the building. Resident deemed an elopement risk on (MONTH) (YEAR). On (MONTH) 20,2018 his wanderguard was discontinued as the IDT (interdisciplinary team) no longer saw or heard elopement tendencies . Review of a surveillance video on 5/9/18 revealed that on 4/23/18 at 8:35 p.m., door 25 (the door Resident #101 eloped from) opened and stayed opened until the camera moved at 8:37 p.m. to a view of the grass. The camera moved back to door 25 at 8:38 and the door was still opened at 8:39 p.m. The camera only viewed the top half of door 25. The camera then moved to the view of the parking lot for a moment then to the side with grass, no one was visible in camera system. At 8:40, door 25 was halfway open then the camera moved to the parking lot with no one visible in the parking lot. At 8:42 p.m. door 25 was viewed opened and then closed, then the camera viewed the parking and then the grass on the side and no one was there. At 8:44 p.m. the camera viewed Resident #101 in a wheelchair moving out by the circle drive of the parking lot. There were headlights from the steady traffic of cars passing on the road adjacent to the parking lot where Resident #101 was visible. At 8:50 p.m., Resident #101 was still rolling in his wheelchair when a car approached him near the circle drive of the parking lot. At 8:51 p.m., a visitor was seen entering door 25. At 8:53 p.m, Resident #101 was viewed near the drivers' door of the car that had pulled up to next to him, then 2 staff were seen walking out the front door of the facility towards Resident #101 and the car. Review of a Nurse's Note dated 4/24/18 at 1:15 a.m. for Resident #101 revealed: The nurse from the Bay came over and told me that Resident #101 was out in the parking lot. I went to the front and a couple CNAs were helping him through the main front door. I assessed for injuries (there were none) and tried to figure what lead him to go outside. I called IPC and the on-call manager. I then called security and asked them to look at the tapes to see what happened. When they called me back they told me Resident #101 went out the side door in front (where the human resources offices are) around 2037 (8:37) and was out there until about 2050 (8:50). Wander Guard placed on resident, will continue to monitor.) In an interview on 5/10/18 at 1:44 p.m., CNA E reported she originally had Resident #101 that night but switched with CNA J at the beginning of the shift. CNA E reported that she did not know Resident #101 had left the building until about a ½ hour after Resident #101 returned. CNA E reported she last saw Resident #101 around 8:00 p.m. and he was talking to one of the nurses. CNA E reported she remembered the fire alarm going off around dinner time, but not the door alarm to the door that Resident #101 left out of. In an interview on 5/10/18 at 3:00 p.m., License Practical Nurse (LPN) G reported he last saw Resident #101 between 8-8:30 p.m. Another nurse told him that Resident #101 was outside and had been seen by another staff who was on break. LPN G then reported he went to get him and then called security. Security told LPN G that Resident #101 got out of door on far-left side of the building (door 25) around 8:37 p.m. until about 8:52 p.m. LPN G then reported Resident #101 had a Wander Guard until a few days prior to the elopement, which then it had been removed. When Resident #101 returned to the building, LPN G immediately placed the Wander Guard back on him. LPN reported the door was not working as it was supposed to and thought the door did not reset when the fire alarm was pulled earlier in the day. Review of a written statement regarding the elopement of Resident #101 on 4/23/18, CNA J reported: .the last time I checked on (Resident #101) was about 8:15 p.m. right before I laid another resident down for bed. I was charting when I was informed that (Resident #101) were outside in the parking lot. (sic) Review of a written statement regarding the elopement of Resident #101 on 4/23/18, CNA O reported: The previous time I saw (Resident #101) was around 8:10-8:15 p.m. when I was doing my charting by the 400 hall shower room. He had been with me for around 20 minutes and the headed up the hall. The next time I saw him was when we were alerted by (visitor) that there was a man in a wheelchair outside. It was then that the custodian went outside and retrieved him. This was around 8:45 p.m. In an interview on 5/9/18 at 4:07 p.m., CNA X reported he was coming back from his break on 4/23/18 when she was driving down 32nd street and looked at the building and saw Resident #101 in the parking lot. CNA X then reported she turned around, entered the parking lot and pulled up next to Resident #101 and started talking to him. CNA X reported she called the nurse at the facility and then 2 staff members had come out to take Resident #101 back inside. CNA X could not remember the time. In an interview on 5/9/18 at 4:07 p.m., CNA O reported he was assigned to the back end of the 400 hall on 4/23/18 and Resident #101's room was down hall 300. CNA O reported Resident #101 was near him around 8:10 p.m. while CNA O was charting. CNA O reported Resident #101 was looking for his car all day that day and thought that when Resident #101 went to the parking lot, that was what he may have been doing. CNA O reported that previously, Resident #101 would go to the front lobby many times and set off the Wander Guard alarm and the staff would have to go and get him. CNA O reported he was unaware of Resident #101 having his Wander Guard removed until after the elopement and did not think it was a good idea to remove it since Resident #101 was always wandering around. CNA O reported the managers did not ask him and was unaware of other staff members being asked about removing Resident #101's Wander Guard. CNA O reported the alarm to the door Resident #101 went out was going off but he did not hear it until he walked down that hall. CNA O reported he was notified by visitors that Resident #101 was outside. CNA O reported the front doorbell goes off to the pagers of the staff but the door alarms did not. During an observation and an interview on 5/9/19 at 10:14 a.m., Plant Operations Manager (POM) M reported that the Wander Guards activated when the doors opened, and if a resident is in the area of the door, it will alarm. The day Resident #101 went out the door, he did not have a Wander Guard on. Door 25 had a delayed egress (a locking feature that delays the opening of a door) of 15 seconds, once the door opens it alarms loudly. Outside door 25 was a driving circle with a parking lot on the other side. The parking lot sat adjacent to 32nd street which had heavy traffic with motor vehicles. In an interview on 5/10/18 at 10:00, Director of Nursing (DON) B reported that another resident had pulled the fire alarm on 4/23/18 at around 6:00 to 7:00 p.m. and after the fire alarm, the fire department came out. DON B then reported that door #25 did not reengaged after the alarm happened, but now that the facility was aware of this, CNA's were assigned to check the doors after the fire alarms Review of a Late Entry Nurse's Notes dated 4/23/18 at 7:00 p.m. for Resident #101 revealed: After Resident #101 eloped, I spoke with Physician Assistant (PA) V who gave the ok to place a wonder guard back on Resident #101. (sic) Review of an Order Summary Report for Resident #101 dated 4/24/18 revealed: Wander Guard to right ankle. Check for placement every shift by CENA. Check function on 3rd shift by nurse. One time a day for elopement risk. Review of an alarm log for 4/23/18 at 6:06 p.m. revealed Fire alarms acknowledged. Review of an invoice dated 5/3/18 revealed: This billing is for a service call on 4/2/18 for the double doors by Physical Therapy not relocking after a Fire Alarm. We found that, upon resetting the Fire Alarm system the door opener was being activated slightly prior to the locks being re-armed; causing the locks to unlock (after 15 seconds) in delayed egress mode. We eliminated the interconnection between the auto opener and the lock control units, eliminating the problem. Review of an invoice dated 5/3/18 revealed: This billing is for a Saturday (4/28/18) not re-locking after an authorized exit. The system was working as it was supposed to; however, it had been set- up with a very long by-pass time (75 seconds & 10 seconds). We changed the by-pass time on both the locks and keypads, and adjusted lock's sensitivity, as needed. On 5/9/18, Administrator A was notified of an Immediate Jeopardy that began on 4/23/18 when Resident #101, who was identified as an elopement risk, eloped from the facility, unbeknownst to facility staff. On 5/10/18, this surveyor verified the facility staff implement the following to remove the Immediate Jeopardy: 1. On 4/23/18 Resident #101's care plan was reviewed and updated and a wander guard was placed immediately. 2. On 4/24/18 each exit was assessed for function and for function of the Wander Guard with the door safety system. Issues were identified on 4/24/18. Interventions to keep people safe until the final resolution occurred on 4/28/18. There were 27 resident identified to have had the potential to be affected by this practice. 3. On 4/23/18 a head count for all residents was done immediately. 4. On 4/24/18 all residents were assessed for elopement and the need for Wander Guards. This was done by doing elopement assessments on 4/24/18. Records were reviewed since the last elopement assessment on all people residing at the Lodge. Discussions with floor staff were conducted on 4/24/18. 5. On 4/24/18 all care plans were reviewed and the 27 residents who were identified as an elopement risk had their care plans updated. 6. Starting 4/25/18 to 5/7/18, 165 out of 167 staff were educated. Education was given to all staff except for 2 whom cannot work without the education at the Lodge. 7. Each resident who had a wander guard had their alarm checked for function and placement. This occurs nightly on third shift. 8. On 4/26/18, the Elopement Risk Process was updated by the IDT ( interdisciplinary team) Social Workers, Recreational Therapy Director, Dietician, Maintenance, Laundry Supervisor, Therapy Director and Assistant, Nursing Managers, and DON. The new process states that the IDT team will review progress notes since last elopement assessment and interview staff to identify need for wander guard prior to removing a wanderguard and deeming a resident no longer an elopement risk. 9. On 4/25/18 the Fire Safety Plan was updated and staff educated on the new plan. The new plan was placed in the Emergency site books in the building. 10. On 4/25/18 all the exit doors were numbered and checked nightly for function. The floor plan was updated and is displayed in the facility with numbered doors. 11. On 4/24/18 the Elopement Policy and Missing Resident Procedure were reviewed. 12. The Director of Nursing or Designee will randomly audit 5 staff members weekly to ensure they understand the education of doing a head count after a fire drill and having all exit doors checked for re-engagement. The Director of Plant Operations will hold a fire drill weekly for 4 weeks checking the re-engagement of the exit doors when the system is re-engaged. Results will be reviewed at QAPI monthly. 13. Findings of the audits will be reported to the QAPI meeting quarterly and any follow up action as appropriate will be recommended by the committee. Need for continued monitoring will be based on QAPI committee recommendations. The immediate jeopardy was removed on 4/26/18. The facility completed all items necessary to achieve compliance including education of all staff as well as completing ongoing monitoring, by 5/7/18. A past non-compliance was granted at this citation.

Based on interview and record review, the facility failed to ensure appropriate and timely dental services for 2 residents (Resident #2 and #8), of 2 reviewed for dental services out of a total sample of 24 residents, resulting in pain and the potential for infection. Resident #8 Findings include: According to the facility Admission Record, dated 10/25/17 at 12:05 PM, Resident #8 was a [AGE] year old male, admitted to the facility 4/5/17, with [DIAGNOSES REDACTED]. During an interview with Resident #8 on 10/26/17 at 2:06 PM, he stated that he had an upper and lower tooth on the left side of his mouth that needed attention. He reported that he had pain while eating and when not eating. Resident #8 stated it felt like he was biting metal. He further stated that if he had his teeth taken care of, he would have been able to eat properly. He also expressed that he wished they would get the problem solved and, that he was eating less because his teeth hurt. Review of progress notes in the medical record reflected the following: -Resident #8 was seen by Physician's Assistant (PA) DD on 9/21/17 for a cracked tooth. Documentation for the oral cavity reflected that the left upper tooth was broken off at the root, two of them I can see. The note also indicated that [MEDICATION NAME] was added, the dentist was to see the resident and that he likely needed an extraction (tooth pulled). -A note on 9/22/17 at 1:04 PM reflected that Resident #8 complained of mouth pain and was eating 75 percent (%) of his meals. -A note on 9/28/17 at 2:14 PM reflected Resident #8 complained of tenderness to gum area. -A note on 9/25/17 at 12:04 PM reflected the resident complained of tenderness to his mouth and was eating 85% of meals. The resident said it hurt when drinking cold water. -A note on 10/4/17 at 2:11 PM reflected that the resident complained of pain to teeth with cold water and ate 50% of meals. -A quarterly dietary note on 10/6/17 at 8:56 AM reflected that the resident's tooth was bothering him, and at times, it had impacted his chewing. He was awaiting a dental procedure. -A note on 10/8/17 at 5:34 AM reflected that the resident was given medication for mouth pain. -A note on 10/8/17 at 1:44 PM reflected that the resident refused to go to the dining room for meals due to complaints of a toothache. -A progress note by PA DD on 10/9/17 reflected, .Chief Complaint(s): gums swollen and painful .Patient seen for swollen gums . The note mentioned that the resident had gingivitis (a form of gum disease), dental plaques on all teeth and tooth decay. -A dietary progress note on 10/15/17 at 11:16 AM reflected that the resident had an 11.1 pound and 5.4% significant weight loss x 30 days (in last 30 days). The note also reflected that appetite and PO (oral) intake have been variable depending on mood, sleep pattern, tooth pain, per FAR (food acceptance record) PO intake refusals to > (greater than) 76% - A dietary note on 10/18/17 at 10:08 AM reflected that the resident had a 21 pound and 10.2% significant weight decline since 9/19. The resident had been sleeping more and had tooth pain. A review of an exam note from (name of dental provider), dated 9/29/17 and for a date of service of 9/26/17 reflected, .Patient presented for a problem focused exam regarding concerns with tooth number(s) #19, #20. Patient's symptoms included the following Pain on upper and lower left side when eating, Pain Scale 6 Discussed patients concern(s) and suggested the following course of treatment need necessary x-rays to determine if (name of dental provider) can do the extractions or refer out to oral surgeon for extractions for #19, #20 . In an interview on 10/26/17 at 12:53 PM, Licensed Practical Nurse (LPN) CC reported that in order for an emergency extraction by an oral surgeon, the resident would have to have had swelling and pain. LPN CC reported that the resident was looked at for this (pain and swelling) in the facility and did not present with both (refer to PA DD note for 10/9/17). He stated that (name of dental provider) came in to see the resident and made recommendations on 9/29/17. On 10/26/17 at 4:51 PM, Director of Nursing (DON) B reported that she was unsure based on the note from (name of dental provider) on 9/29/17 if Resident #8 already had x-rays done, if they would be done on the next visit in the facility or if the resident would have needed to go to (name of a different dental provider). Findings: Review of the Profile Face Sheet and Minimum Data Set (MDS) revealed Resident #2 was an [AGE] year old male originally admitted to the facility on [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) score was noted to be 11 out of 15 indicating moderately impaired cognition. Resident #2 was assessed to require extensive assistance for activities of daily life (ADLs). Observation and interview on 10/24/2017 at 2:20 p.m., Resident #2 has multiple upper and lower teeth missing, states, My teeth need pulled, about 4 of them, they hurt sometimes. Review on 10/25/2017 of the facility's Kardex, indicating specific care for Resident #2 to be followed by all nursing staff providing care, revealed, Monitoring: Monitor/document/report to MD PRN for s/s of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. Review on 10/26/2017 of a Clinical Summary of Care from a hospital visit Resident #2 returned from on 9/6/2017, revealed, Follow Up Information: .Coments: Follow up with oral surgeon regarding dental abscsesses. Add'l Instructions For Rcving Facility: .Resident #2 is to be seen by Oral Surgery given tooth abscesses found on CT. Review on 10/26/2017 of Resident #2's in Progress Notes, a late entry Medical Staff Narrative by Medical Director P on 9/8/2017 at 16:58 (4:58 p.m.), from Resident #2's admit of (9/6/2017) from a hospital visit, revealed, Details .also oral surgeon d/t multiple dental absecesses as well. Interview on 10/26/2017 at 10:25 a.m., with Licensed Practical Nurse (LPN) Unit Manager (UM) CC stated, I placed a note in the Communication Book about 3 weeks ago to the Physician's Assistant (PA) about Resident #2's teeth, I'll have to find the note. The facility could not find the note that was written by LPN-UM CC to the PA. LPN-UM CC stated, yesterday (10/25/2017) I spoke with Resident #2 regarding resident's teeth. Resident #2 stated resident popped out own tooth and about 4 more may come out. An oral surgeon was recommended by the hospital, but the facility's physician didn't see a need prior to you asking. I called him (Medical Director P) today and he said did not feel Resident #2 needed to see an oral surgeon. I can have him call you to verify. Medical Director P did not return call to this surveyor. Interview on 10/26/2017 at 12:45 p.m., LPN-UM CC stated, I didn't write a note in the Communication Book to the PA, I gave a verbal communication to PA DD. Medical Director P did not feel Resident #2 needed to see an oral surgeon. We have 3 other residents that have dental issues. Interview on 10/26/2017 at 1:25 p.m., this surveyor requested progress notes regarding Resident #2 dental condition, LPN-UM CC stated regarding Resident #2, I think there is nothing in Resident #2's chart or notes about teeth from anyone. Record review on 10/26/207 of Resident #2 Progress Notes of 10/25/2017 at 17:16 (5:16 p.m.) by LPN-UM CC revealed, LATE ENTRY: 9/12/2017 Unit Manager (UM) spoke to resident about his teeth and if they are painful. Resident stated yeah, they hurt .Note left for PA/MD to f/u. Record review on 10/26/2017 of Resident #2 Progress Notes of 10/25/2017 at 17:20 (5:20 p.m.) by LPN-UM CC revealed, UM spoke with resident about .teeth and if they have been painful. Resident stated it was till I pulled it out when asked how .pulled it out res stated I just pushed on the bottom of the tooth (as .pointed to .upper left teeth) and it just popped out and I threw it away when asked if he was still having pain .stated sometimes, I think I need about 4 more taken out PA notified .

This citation pertains to intake MI 385 Past non-compliance was accepted for this citation. Plan identified below. Based on observation, interview and record review the facility failed to prevent the elopement of 1 of 3 residents reviewed for elopement (Resident #101) from a total of 6 sampled residents resulting in an Immediate Jeopardy when (Resident #101) who had been assessed as an elopement risk and wore a WanderGuard bracelet, and who eloped from the facility, unbeknownst to staff, after an unknown staff person deactivated an audible WanderGuard door alarm, allowing Resident #101 to elope from the facility on 7/29/16 at 10:34 a.m. and was brought back to the facility about an hour later when a family member of the resident called the facility staff to make them aware that the resident had eloped. This deficient practice placed Resident #101 and 18 other residents who were assessed as being at risk for elopement at risk for serious harm, injury and or death from hazards outside the facility. Findings: Resident #101 was a [AGE] year old man admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #101 was severely cognitively impaired and needed supervision and one person to assist with transfers, supervision and one person to assist with ambulation on and off the unit and was not steady on his feet but able to stabilize without staff assistance. Resident #101 ambulated with a walker and required supplemental oxygen to be delivered via nasal cannula at 2 liters per minute. Review of an elopement risk assessment dated [DATE] indicated Resident #101 was at risk for elopement as evidenced by an elopement risk assessment score of 6. A WanderGuard device was applied to Resident #101 ' s ankle and checked daily for placement and function starting on 7/6/16. Review of a Care Plan for Resident #101 indicated he was at risk for elopement as evidenced by impaired safety awareness and, disorientation to place and exit seeks to where his wife lives. During an observation on 8/16/16 at 9:40 a.m. the route Resident #101 may have taken to get from the long term care facility to the assisted living facility was walked. Many hazards were identified such as hills, curbs and a three lane 35 mile-per-hour road and driveway in addition to those hazards present in the independent living center. Review of a facility Incident Report dated 7/29/16 indicated Resident #101 was noted missing at 11:40 a.m., sign out log checked and Code Green was called immediately. Head count was done inside and outside building. Unit Manager was informed he is over at his wife ' s room at the (Independent Living) facility by daughter. Resident #101's wife called daughter and daughter called unit manager. Everyone continued to search until unit manager texted Director of Nursing stating resident was found in his wife ' s room. Unit manager got to him at 11:41 a.m. All clear called at 11:47 a.m. Review of a Facility Reported Incident-5 Day Report summary indicated the following: Upon review of the cameras at the front door, Resident #101 exited the building after 2 visitors entered. Review of the wander guard system indicates that the alarm did sound and it was silenced. Two staff members were at the front desk at the time of the incident. Both indicate that they did not hear an alarm go off or observe Resident #101 exit the building. That said, given the alarm did sound per the electronic system and the code was entered, we know that the system was functioning and a staff member did respond. Review of the WanderGuard system indicates that the program is working. Resident #101 ' s WanderGuard was on him and activated at the time of the incident. It was determined that the alarm did go off, and someone entered the code to turn off the alarm, but we have been unable to identify what staff member turned off the code but did not notice Resident #101 leave the building. During an interview on 8/16/16 at 9:10 a.m., Nursing Home Administrator (NHA) A reported she knew Resident #101 got out of the building and should not have, but due to staff error was able to elope. The Nursing Home Administrator (NHA) and Director of Nursing (DON) were informed on 8/16/16 at 3:00 p.m. Immediate Jeopardy (IJ) had been identified at F-323 starting on 7/29/16 at 10:34 a.m. for the facility's failing to prevent the elopement of 1 resident (Resident #101) who was a known elopement risk and wore a WanderGuard bracelet and still, unbeknownst to staff, eloped from the facility after an unknown staff person deactivated an audible WanderGuard door alarm, allowing Resident #101 to elope from the facility on 7/29/16 at 10:34 a.m. This deficient practice has the potential to affect all 19 residents who are assessed as being at risk for elopement at risk for serious harm, injury and or death from hazards outside the facility. On 8/17/16 the surveyor verified the following interventions had been put into place and were effective to remove the immediacy: July 29, 2016: 11:38 AM- (Resident #101) was identified as missing, staff unable to locate. 11:38 AM- Code Green Called. 11:41 AM- Resident found at wife's apartment in independent living on campus. Immediately assessed for change in condition, which was not found. 11:47 AM- Code Green was all cleared. All residents currently admitted at the Lodge were present and/or accounted for. This includes all 19 residents identified as an increase elopement/wander risk. Post Code Green cleared, all exit doors were tested for function. All wander guards in use, were checked for placement and tested for function. (Resident #101) was assisted back to the (facility) via walker. On return Assistant Director of Nursing (ADON) attempted to perform skin assessment, however, resident declined and insisted on eating lunch. 12:45 PM- Post completion of (Resident #101's) lunch, a head to toe skin assessment was performed. No injuries noted. Reception staff and other facility staff whom were in the lobby around the times of incident were immediately educated. No other residents were identified as an increased risk for elopement/wandering. The following was implemented for (Resident #101) on 7/29/16 post incident: · 15 minutes checks · Encourage to sit in alternate locations, rather than at the front lobby. · When (Resident #101) is experiencing exit seeking behavior, attempt to call daughter to assist in directing. · When (Resident #101) is exit seeking, facilitate taking him outside for a walk. · Offer preferences such as ice cream was placed on care plan. August 1, 2016 The Following was implemented for (Resident #101) on 8/1/16: · Wife agreed to visit resident at (Facility) Mondays Wednesdays and Fridays · Daughter brought in resident's television that will assist (Resident #101) in watching golf and give him the ability to navigate. Refreshments previously kept in the lobby area were moved out of the space to decrease the desire for residents to visit in the lobby and instead use a social space within the building away from the exits. Began staff education to utilize alternate exit when exiting the building. The front desk was rearranged to provide better view of the front door. August 2, 2016: The Egress and WanderGuard code to each exit was changed. Clipboard was placed at each exit for staff to document when the WanderGuard went off to provide more supervision/monitoring of elopement risk. Education was initiated for all employees on elopement prevention on July 29. This was formalized on August 2 with a due date of August 12. All staff will be trained prior to their next shift after August 12. On 8/17/16 this surveyor reviewed documentation, conducted interviews and made observations the preceding interventions were completed prior to the abbreviated survey. A determination of past non-compliance was approved by the state agency as of 8/12/16.

This citation pertains to MI 169 Based on observation, interview, and record review, the facility failed to prevent a fall with multiple injuries for 1 (Resident #1) of 1 reviewed for falls, from a total sample of 3, resulting in Resident #1 eloping from the facility and sustaining a fall with 2 fractures and a facial laceration requiring sutures. Findings include: Review of the incident report submitted by the facility to the state agency on 6/12/16, revealed that on June 12, 2016, (Resident #1) excited the (Facility) at 5:15pm via the front door when a group of visitors had entered the building. While (Resident #1) was outside, she sustained a fall. (Resident #1) sustained a right knee avulsion fracture due to mechanical fall and a right wrist triquetral avulsion fracture. She was admitted to the hospital. Review of the Face Sheet and the quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #1 was a [AGE] year old female, admitted the facility on 1/20/16 with [DIAGNOSES REDACTED]. The MDS revealed Resident #1 scored 4 out of 15 (severe cognitive impairment) on the Brief Interview of Mental Status (BIMS), required supervision with physical assist of 1 staff member for transfers and ambulation, and used a walker for ambulation. Review of the Fall Risk assessment dated [DATE], revealed Resident #1 was at moderate risk for falls. Review of the Falls Care Plan initiated 1/20/16, revealed Resident #1 was at risk for falls and had decreased safety awareness. Review of the Recreational and Restorative Therapy Communication dated 5/20/16, revealed Resident #1 required stand by assist with a 4 wheel walker for ambulation. In a telephone interview on 6/29/16 at 2:43 pm, Certified Nursing Assistant (CNA) C reported she was assigned to care for Resident #1 on 6/12/16. CNA C reported on 6/12/16, at dinner time, she observed Resident #1 sitting in the TV room and then observed her walking toward the dining room. CNA C stated I didn't pay much more attention to her. CNA C reported she was then serving dinner trays and realized Resident #1 was no longer in the dining room or the TV room. CNA C reported she searched Resident #1's room and all of 400 hall and could not locate Resident #1. CNA C reported she then notified Licensed Practical Nurse (LPN) E who assisted CNA C and CNA H to search the building. CNA C reported Resident #1 was not found in the building, therefore an outside search was initiated. CNA C reported a visitor walking by the back of the building found Resident #1 and notified staff. CNA C reported a code green (for a missing resident) was not paged overhead in the building and reported that it was approximately 20 minutes between the time Resident #1 was identified as missing and then found. In an observation and interview on 6/29/16 at 11:40 am, Nursing Home Administrator (NHA) A reported she spoke with Receptionist D over the phone at 4:09 pm on 6/12/16 to educate her about being more vigilant in watching who was exiting and entering the building, due to an elopement of another resident on 6/12/16 at 3:22 pm. NHA A and Director of Nursing (DON) B reported that they determined, after review of surveillance footage, on 6/12/16 at approximately 5:15 pm, 6 visitors entered the facility and signed in at the front desk. During that time, Resident #1 walked out the front door, with her walker, unbeknownst to staff. NHA A and DON B reported that Resident #1 turned right and walked toward the parking lot, at which point she was no longer visible on the surveillance footage. NHA A and DON B walked the surveyors around to the back of the building, where Resident #1 was found by a visitor on the ground, near the generator. NHA A and DON B reported the visitor knocked on the back door to get staff's attention, at which time a staff member was leaving for the day. NHA A and DON B reported their review of surveillance footage revealed staff exited out the back door at 5:31 pm (16 minutes after Resident #1 left the building). The surveillance footage was only available for 14 days and therefore, not available for review by the surveyors. Observation of the possible path that Resident #1 walked to the back of the building revealed a sidewalk between the building and the staff parking lot, grass, a marsh-like area, and a wooded area. Review of the hospital History/Physical Physician dated 6/13/16, revealed At 5 pm yesterday, patient was found on the ground outside of her assisted living facility. The fall was unwitnessed, but suspected to be mechanical and she was down approximately 30 minutes .The patient suffered a laceration to her upper lip and injury to her wrist and knee. XR (xray) showed triquetral avulsion fracture (wrist) and likely avulsion fracture of the knee .General: Eye: patient's periorbital region and eyebrow area is swollen bilaterally and bruising under right eye .There is an abrasion over the bridge of the nose. There is a small laceration at the vermilion border and midline of the upper lip that has been sutured . Review of the medical record revealed Resident #1 returned to the facility on [DATE] and was admitted into hospice care on 6/19/16. Review of the Interdisciplinary Resident Screen dated 6/27/16, revealed Resident #1 had a change in condition with balance, bed mobility, transfers, dressing, toilet use, bathing, and mode of locomotion. Review of the Therapeutic Recreation Participation Review note dated 6/27/16, revealed .Resident's group participation has declined since re-admission r/t (related to) decline. She has been spending more time resting in bed . An observation on 6/29/16 at 2:10 pm, revealed Resident #1 sitting in a wheelchair in the dining room, being fed by a staff member. ( ) In an interview on 6/29/16 at 12:20 p.m., Director of Nursing B stated that before Resident #1's fall with 2 fractures and a facial laceration requiring sutures, Resident #1, Ambulated with her walker independently, and now she is dependent in her wheelchair. ( )

Based on observation, interview and record review, the facility failed to routinely assess and implement interventions to prevent pressure ulcers for 4 of 4 residents reviewed for pressure ulcers (#1, #2, #4 and #5) out of a total sample of 7 resulting in a stage IV pressure ulcer to the coccyx for Resident #2 and avoidable pressure ulcers for Residents #1, #4 and #5. Findings include: According to the August 2014 monthly physician orders, Resident #4 was a [AGE] year old female who was admitted to the facility on [DATE]. The 5-day Minimum Data Set (MDS) assessment dated [DATE] listed [DIAGNOSES REDACTED]. The facility's progress notes dated 8/11/14 reflected Resident #4 was admitted post fall with left upper extremity fracture. That Resident #4 was alert and oriented to self and family. Resident #4 spoke Polish, staff anticipated needs, required one person assistance with transfers and a one person assistance with activities of daily living including eating. The Initial Admission assessment dated [DATE] had a Braden Scale portion (9 a) in which it was determined that Resident #4's ability to respond meaningfully to pressure-related discomfort was very limited, that her skin was very moist and that her linen needed to be changed once a shift, that Resident #4's ability to walk was severely limited or non-existent, that Resident #4 was very limited in her ability to change body position and that Resident #4 ate over 50% of most meals. This section identified that the problem areas "require moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. [DIAGNOSES REDACTED], contractures or agitation leads to almost constant friction." After this assessment, no pressure ulcer care plan was initiated until after a pressure ulcer was found on 8/1/14. The facility's progress notes dated 8/1/14 reflected resident #4 had a "new intact moist discoloration noted to coccyx. 2 cm x 1.8 cm..." and treatment was applied. Progress notes dated 8/4/14 reflected Resident #4's responsible party was "here aware of new changes in resident buttock." Resident #4's pressure ulcer care plan was initiated on 8/2/14 and revised on 8/4/14. One of the interventions on the pressure ulcer care plan instructed staff to "monitor/document/report to MD (medical doctor) PRN (as needed) changes in skin status: appearance, color, wound healing, s/sx (signs and symptoms) of infection, wound size (length X width X depth), stage." On 8/14/14 at about 10:30 am, Resident #4 skin assessments and wound measurements were requested. The Director of Nursing (DON) returned at 11:00 and stated there were no measurements found because "we didn't do any." The DON also returned at 11:12 am and could not find an updated Braden assessment. On 8/14/14 at about 11:50 am, RN "H" stated Resident #4 was at risk for developing a pressure ulcer, and showed where the Braden assessment was done on the initial admission assessment. When RN "H" was asked should an updated Braden assessment be done since a pressure ulcer developed, RN "H" replied "yes". The facility's "Unplanned Occurrences" Policy dated 2/10/04 and revised 6/2014 reflected under "Prevention" that "Residents will be screened on admission, quarterly, and with significant change in condition for safety risk 2) This will include (at a minimum) b. Braden Scale.." This same policy described an "unplanned event: anything that is outside the ordinary." On 8/13/14 all incident and accident reports were requested, two were received, but none included documentation of a pressure ulcer. Without a pressure ulcer care plan, the nurse aides would not know what interventions were needed to prevent a pressure ulcer for Resident #4. According to the progress notes, there was a "weekly skin/wound note" dated 7/24/14 which reflected Resident #4's "skin pale warm and dry intact n (no) changes noted." The facility's progress notes dated 8/1/14 reflected resident #4 had a "new intact moist discoloration noted to coccyx. 2 cm x 1.8 cm..." On 8/14/14 at 11:12 am, the DON stated the root cause of the development of Resident #4's pressure ulcer was unknown. Resident #4's pressure ulcer was not discovered until 8/1/14 and a care plan to treat and prevent pressure ulcers was not initiated until 8/2/14, reflecting that pressure ulcer was avoidable. ( ) Review of the facility policy/procedure "Pressure Ulcer" dated 12/24/09 last revised 7/2011 reflected the following: "This policy provides guidelines for the assessment, diagnosis, treatment and monitoring of pressure ulcers...CNA's (certified nurse assistant) will complete skin assessment during routine care and report any abnormalities to the licensed nurse. The licensed nurse and or skin nurse will complete a skin assessment on all residents weekly. Abnormalities will be documented and treatment started when appropriate...Documentation: A. Exact body location, B. Ulcer Characteristics, 1. length, width, and depth in centimeters, 2. stage, 3. presence of undermining/tunneling, 4. exudate/drainage (type and amount), 5. type of tissue present (necrotic, granulation, or [MEDICATION NAME] tissue), C. Skin surrounding the ulcer ([DIAGNOSES REDACTED] or inflammation, induration, heat, tenderness)...Diagnosis/cause Identification: Ulcers not pressure related...will have documentation to support that conclusion...Pressure ulcers will be managed in the following manner per stage. The Charge Nurse will initiate the following treatment as needed: Stage I...reposition every 1-2 hours...observe area every shift...Stage II, III or IV or unstageable...notify Physician for any recommendations...assess and document wound characteristics with each dressing change... charge nurse will measure wound initially and weekly until healed depending on timing of treatment...Monitoring: Ulcers will be reassessed weekly using the PUSH Tool (Pressure Ulcer Scale for Healing). The treatment protocol will be reviewed and changed as needed. Generally, if no progress is seen within 2 weeks, treatment and/or interventions should be re-evaluated. Provide a report weekly to the Director of Nursing or Designee on the number, stages, facility acquired and the progress of all pressure, venous, arterial and diabetic ulcers. Non-healing wounds will be assessed for factors which might impede healing, and adjust interventions according or explain why the current interventions continue to be the most appropriate." Resident #2 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], reflected Resident #2 was a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #2 had moderate cognitive impairment and required staff assistance for all activities of daily living, including turning/repositioning and incontinence care. In an interview on 8/14/14 at 1:30 PM, Registered Nurse (RN) "A" stated that when Resident #2 was originally admitted on [DATE], Resident #2 had two small pressure sores to the buttock and sacrum area but was noted to be healed on 8/8/13. RN "A" stated that on 12/23/13 Resident #2 developed a facility acquired pressure sore to the right buttock and on 12/26/13 developed another pressure ulcer to the left buttock. The surveyor asked what the root cause of the pressure ulcer development was and RN "A" stated, "I was not able to locate that information." When asked if the pressure ulcers were avoidable or unavoidable, RN "A" stated, "That is unknown." Review of the nursing notes dated 12/26/13 revealed two, stage II pressure Ulcers, one to the right buttock that measured 1.5 cm x 2.3 cm, and one to the left buttock that measured 0.8 cm x 0.3 cm. The physician order dated 12/23/13 reflected a dressing change and treatment to be applied to the right buttock every day (there was no treatment ordered for the left buttock). The nurses notes dated 12/24/13 and 12/25/13 were reviewed and did not contain a note or description of the wounds (per facility policy) until 12/26/13 and following that entry there were no other dressing change notes with a description of the wounds until 1/2/14 (6 days later), at which time the wounds had increased in size (right buttock 4 cm x 4.5 cm and left buttock 3 cm x 1.5 cm). Review of the physician orders dated 1/2/14 reflected a change in the treatment/dressing order to the right buttock to be changed daily and an order for [REDACTED]. 1, 2, 4, 5, 7, 8, 10, 11, 13, 16, 17, and 19, 2014. The nursing notes did not reflect a treatment/dressing change or description of the pressure ulcers on the following days, 1/24/14 - 2/7/14 (15 days), and 2/14/14 -2/19/14 (5 days). The nurses note on 2/20/14 reflected, Resident #2's wound to the coccyx was unstageable 2.0 cm x 2.5 cm covered with eschar and the tendon was noted. The left buttock stage II measured 1 cm x 1.5 cm. No dressing change assessments or notes were found for 2/21/14 - 2/26/14 (6 days). Review of the physician progress notes [REDACTED]. No treatment/dressing changes were noted within the nursing notes from 3/14/14 - 3/19/14 (6 days). The coccyx wound increased in size and according to the nurses note dated 3/20/14 the wound measured 3 cm x 2.5 cm with a depth of 2 cm and tunneling (opening into the body) of 2 cm. The wound was noted to have had a foul odor and antibiotics were ordered for the wound infection which the physician noted, "coccyx wound, stage IV likely [DIAGNOSES REDACTED] (infection that has gone into the bone)." According to the nurses notes there were no wound measurements from 3/27/14 until 4/5/14 (9 days later) and the stage IV coccyx wound had increased in size to 2.7 cm x 2.0 cm x 2.4 with two tunneling spots that measured 5 cm deep in both areas. The treatment/dressing order was changed to a [DEVICE] (a device that drains the wound) on 3/31/14. The next wound assessment was documented on 4/17/14 (12 days later) and not again until 5/1/14 (14 days later). Review of the nursing notes dated 6/6/14 - 7/18/14 revealed no skin assessments were documented for 6 weeks. During a continued interview on 8/14/14 at 1:30 PM, RN "A" stated, "The nurses are initialling the TAR and are suppose to document (the skin/wound assessment) in the progress notes." According to the physician notes dated 8/15/14 the stage IV coccyx wound measures 5 cm x 3.5 cm x 1.4 cm with tunneling at 9 o'clock (measurement not documented) and tunneling at 12 o'clock at 1.1 cm. According to the MDS assessment review no significant change assessments were noted from 12/3/14 (date of readmission from the hospital for resolving pneumonia) through 7/18/14. Resident #1 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], reflected Resident #1 was a [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #1 had moderate cognitive impairment and required staff assistance for all activities of daily living, including turning and repositioning in bed and incontinence care. According to the Unusual Occurrence form dated 6/24/14 at 1:00 AM, Resident #1 was noted to have had a new open area on his tailbone (coccyx). This same form also reflected that the Physician was notified (via notification left in Physician folder) on 6/26/14 (2 days after the discover of the stage II pressure ulcer), the policy indicates the physician will be notified for any recommendations. According to the physician progress notes [REDACTED]. The treatment/dressing order (dated 7/17/14) was to be changed every 3 days. Review of the nursing notes dated 6/24/14 at 1:13 PM reflected the wound was a stage II pressure ulcer to the coccyx that measured 1.0 cm x 0.5 cm x 0.5 cm and "Resident has an alternating air mattress in place and is repositioned frequently." Review of the nursing notes dated 7/18/14 at 12:47 PM reflected the stage II pressure ulcer to the coccyx measurement of 1.0 cm x 0.5 cm x 0.5 cm, continue dressing change every 3 days and "Resident has alternating air mattress, turned frequently throughout shift...". Review of the physician progress notes [REDACTED]. The treatment/dressing order was changed and new order was written for the dressing to be changed every other day. Review of the nursing notes dated 8/11/14 at 3:49 PM reflected the stage II pressure ulcer to the coccyx measurement of 1.9 cm x 0.8 cm x 1.0 cm (increased in size), "Will continue to reposition frequently. Alternating air mattress in place as well...". Review of the nursing notes reflected no documented weekly skin assessments (per facility policy) for the following periods: 5/15/14 - 5/29/14 (14 days), 5/30/14 - 6/11/14 (12 days) and 7/2/14 - 7/18/14 (16 days). Review of the nursing notes reflected no documented dressing changes with wound assessments (per facility policy) for the following dates that were scheduled: 7/20/14, 7/27/14, 7/29/14, 8/3/14 and 8/13/14. Review of the care plan for the stage II coccyx wound reflected that the care plan was initiated on 7/16/14 (22 days after the the stage II pressure ulcer was discovered on 6/24/14). The interventions of the alternating air mattress and turning/repositioning frequently (as mentioned in nursing notes on 6/24/14, 7/18/14 and 8/11/14) were not implemented on the care plan. The care plans reflected that Resident #1 was totally dependent on staff for turning and repositioning but did not state the frequency of this task and reflected a pressure relieving mattress and cushion to the wheel chair (not an alternating air mattress). In an observation on 8/14/14 at 2:35 PM, with the Director of Nursing (DON), Resident #1 was observed in bed laying in bed. The DON stated, "The mattress is a pressure relieving not an alternating air mattress." In an observation on 8/15/14 at 11:30 AM, Physician "I" was observed evaluating and changing Resident #1's dressing to the coccyx. Physician "I" washed and donned gloves, removed the soiled cover dressing and soiled packing from within the wound, discarded the soiled dressing, cleansed the wound with gauze and swabs, measured the wound length, width, and depth (1.4 cm x 1.0 cm x 1.0 cm), packed the wound with a dressing, covered the wound with a flat dressing, taped around the boarders of the dressing, removed the gloves and washed hands. In an interview on 8/15/14 at 12:50 PM, Physician "I" was asked when he does he typically hand washes during the wound dressing change process and Physician "I" stated, "I did before and after the dressing change, and on the smaller ones (wounds) like his (Resident #1's) wound, which wasn't real messy, so I don't during." In an interview on 8/19/14 at 9:45 AM, the DON stated the facility had a current hand washing policy but did not have a current dressing change policy. The DON stated that the facility staff had recently had an inservice regarding hand washing but Physician "I" was not included in that inservice. When the DON was asked at what point during a wound dressing change do you expect the staff to hand wash and don clean gloves(to prevent the spread of infection), the DON stated after the soiled dressing was removed and before touching and applying the clean treatment/dressing. When the DON was asked if the stage II pressure ulcer for Resident #1 was avoidable or unavoidable, the DON stated that it was not known and could not locate documentation regarding it. According to the MDS review no significant change assessments were noted from 3/25/14 to 8/15/14. Resident #5 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], reflected Resident #5 was a [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, Resident #5 was cognitively intact and required staff assistance for all activities of daily living. According to the list of residents with pressure ulcers, that was provided after the entrance conference on 8/12/14, Resident #5 had a facility acquired pressure ulcer to the left buttock. Review of the nursing note dated 8/11/14 at 9:20 PM, reflected Resident #5 had a dressing to the left buttocks. There was no measurement or description of the wound found within the nurses notes. Review of the Physician Orders dated 8/11/14 (untimed) reflected a new treatment/dressing order for the open area to the left buttock to be changed every three days. During an interview on 8/15/14 at 9:45 PM, the DON stated that there was no care plan initiated for the wound that was discovered on 8/11/14 on Resident #5's left buttock. (# )

This citation pertains to MI 800. Based on observation, interview, and record review, the facility failed to implement interventions to reduce risk for falls (Resident #101) and provide adequate supervision and assistive devices to prevent falls for 2 residents reviewed for falls (Resident #102 and #103), from a total of 4 sampled residents, resulting in an unwitnessed fall resulting in fracture for Resident #101, and falls with the potential for harm for Resident #102 and Resident #103. Findings include: Resident #101 According to Resident #101's care plan, dated [DATE], "Focus: The resident has an ADL (Activity of Daily Living) Self Care Performance Deficit r/t (related to) Disease Process Adult failure to thrive...Interventions: Resident has bed alarm". According to physician progress notes [REDACTED]. S/P (status [REDACTED]. S/P ARF (acute/sudden) renal (kidney) failure..." According to Resident #101's nurse's notes, dated [DATE], "(Resident #101) admitted post fall, with adult failure to thrive. A & O (alert and oriented) x 2; able to communicate some needs to staff, staff to anticipate pt (patient's) needs...Pt incontinent of bowel and bladder most of the time..." According to Resident #101's nurse's notes, dated [DATE] at 11:42 PM, "(Resident #101) admitted post fall for rehab. Ambulates on unit with 4 www (wheeled walker), x 1 assist for transfers. TAB's alarm placed on resident. Resident was trying to self- transfer in evening, noted confusion at this time...Does notify staff of toileting needs, but can be incontinent at times." According to the facility's Unplanned Occurrence Investigation, dated [DATE], "(On [DATE] at 11:00 PM) (Resident #101) observed to be on buttocks with legs straight out in front of her in bathroom...Immediate Action & Plan to Prevent Reoccurrence: Resident to continue with therapy to increase strength...Summary of Root Cause Assessment: (Resident #101) has unsteady gait and is confused. Got up without help and didn't use walker. Additional Interventions recommended by Committee to Prevent Subsequent Falls or Injury: (blank)". According to Resident #101's nurse's notes, dated [DATE] at 11:23 PM, "(Resident #101) observed on floor at 11 PM with legs straight out in front of her facing the door of the bathroom... According to Resident #101's nurse's notes, dated [DATE] at 7:43 AM, "(Resident #101) began complaining of pain at 1 AM due to fall. Stated whole L (left) leg hurt with pain of ,[DATE]...(Resident #101) able to move leg with PROM (passive range of motion) with pain of ,[DATE], but upon placing pressure, pain increased to ,[DATE]..." According to the MDS/Minimum Data Set, dated dated [DATE], Resident #101 was admitted to the facility from the hospital on [DATE]; she scored 5 on the Brief Interview for Mental Status (indicating she had severe cognitive impairment), needed extensive assistance with transfers, and 2 person assistance with ambulation. According to Resident #101's MDS she was not on a toileting program and needed extensive assistance with personal hygiene. According to Resident #101's CAAs (Care Assessment Areas), dated [DATE], she was at risk for falls due to taking psychotropic medications, had gait impairments due to straying off the straight path of walking, and she had decreased muscle coordination. According to Resident #101's imaging report, dated [DATE], "History: Fall, with left hip pain. Findings: There are essentially non-displaced fractures through the left inferior and superior pubic rami..." According to an Addendum, dated [DATE], "The fracture lines are clearly visible and relatively sharp...The age of the fractures is...likely are either acute or early sub-acute, probably in the range of several days to several weeks old". On [DATE] at 11:15 AM, in the presence of Unit Manager "B", Resident #101 was observed sitting in a wheelchair in the dining room with a TAB alarm on. Unit Manager "B" examined the alarm and surveyor observed the alarm was set on "low". Unit Manager "B" unplugged the alarm and it sounded with a barely audible sound. Unit Manager "B" immediately turned the alarm to "high" and stated, "It should be on high". In an interview, on [DATE] at 11:30 AM, Nurse Aide "A" identified herself as being the nurse aide assigned on a first shift/full time basis to Resident #101. Nurse Aide "A" reported she had reported to the nurses on a daily basis that Resident #101 was setting off her alarm approximately 2 times each day on her shift seeking the bathroom, and began having loose stools "a couple of weeks after being admitted to the facility" and she continued to have the loose stools. Nurse Aide "A" stated, "They put her on a new medication 1 week ago". Nurse Aide "A" stated, "She would set off the alarm, and I would find her in the bathroom". Nurse aide "A" reported Resident #101 was not on a toileting program and often refused when asked if she needed to use the bathroom. In a telephone interview, on [DATE] at 12:15 PM, Nurse Aide "C" addressed herself as a second shift, full time, nurse aide that "always" cared for Resident #101. Nurse Aide "C" reported she was on the way out of the building to go home for the night (approximately 11:00 PM) when another nurse aide "yelled to me that (Resident #101) was on the floor". Nurse aide "C" reported the call light was not on, and there was a pressure alarm on Resident #101's bed, but it was not sounding. Nurse Aide "C" stated, "I didn't hear the alarm going off". Nurse Aide "C" reported she had last toileted Resident #101 at 9:00 PM, and observed Resident #101 in bed at approximately 10:35 PM. On [DATE] at 1:05 PM, DON/Director of Nursing reported, "There is not a Fall care plans for (Resident #101). We should have a Fall care plan specifically for falls for her". On [DATE] at 2:00 PM, Unit Manager "B" said, "The (Interdisciplinary) Team doesn't review care plans after a fall. Unit Manager "B" also stated, ""We should have had a bowel and bladder care plan for (Resident #101) in light of what has happened. She was having ongoing loose stools. There are a lot of alarms. I didn't know she was setting off her alarm". In an interview, on [DATE] at 10:32 AM, Restorative/In service Nurse/LPN/Licensed Practical Nurse "D" reported the Restorative Team checked the alarms for proper functioning every Thursday. LPN "D" stated, "The volume of the alarm is not care planned, but it is typically on high...We are not currently checking the batteries to see if they are expired. When they aren't working, it ' s too late". On [DATE] at 12:40 PM, LPN "E" reported she changed the batteries in Resident #101's alarm because it failed to alarm at the time of the fall. LPN "E" reported she did not check to see if the battery had expired before she discarded them, and stated, "That would be a good intervention". Review of Resident #101's Care Plans revealed the facility failed to initiate a Fall prevention care plan upon admission, and after she sustained a fall on [DATE]. There was no Fall prevention care plan in Resident #101's medical record on [DATE]. ( )/( ) Resident #102 According to the MDS, dated [DATE], Resident #102 scored 6 on the Brief Interview for Mental Status, indicating she had cognitive impairments. According to Resident #102's care plan, dated [DATE], "Focus: (Resident #102) has h/o (history of) falls. (Resident #102) has chronic UTIs (urinary tract infections) and has falls when increased confusion noted from UTIs. (Resident #102) is forgetful, but able to make needs known...do not leave unattended in the bathroom...sensor alarm to bed and w/c - check for placement and function q (every) shift". According to nursing progress notes, dated [DATE] at 2:47 PM, "...some confusion...PO (oxygen level in blood) 72% at room air. (Resident #102) was put in on 2 L (liters) NC (oxygen by nose). PO2 95%...Will continue to monitor". According to the facility's Unplanned Occurrence Investigation, dated [DATE] at 9:40 PM, "Chair alarm was on; did not func (function). Observed (Resident #102) in seated position next to bed...(Resident #102) unable to state what occurred. Immediate Action & Plan to Prevent Reoccurrence: Assessment complete, assisted (Resident #102) to bed. Alarm replaced. Order to straight cath (place a tube in bladder to empty urine)". On [DATE] at 11:15 AM, Resident #102 was observed sitting in the dining room in a wheelchair, with an alarm noted to be in place, and an oxygen tank. In an interview, on [DATE] at 3:15 PM, Nurse Aide "C" reported she was caring for Resident #102 on [DATE], and stated, "When (Resident #102) has a UTI she becomes incoherent; not her normal self. She wouldn't let us put her to bed and wouldn't let us do cares that night. We let her sit in her wheelchair and watch TV. I turned on Animal Planet and left the room around 9:00 PM. The alarm was intact on wheelchair but not sounding when we found her hollering 'Mama' on the floor. There is no schedule to change the batteries in the alarms. A lot of times we find out they are not working too late". Resident #103 According to the Face Sheet, Resident #103 had a [DIAGNOSES REDACTED]. On [DATE] at 11:00 AM. Resident #103 was observed sitting in a wheelchair in the dining room unattended. Resident #103 was leaning forward in the wheelchair touching the floor with his hand; there was no alarm on the wheelchair. According to a facility's Unplanned Occurrence Investigation, dated [DATE] at 7:30 PM, "Describe Incident: (Resident #103) self-transferring from w/c (wheelchair) to bed, was not completely on the bed & had to be lowered to the floor...Resident's Account of how incident occurred: "I couldn't make it all the way & couldn't push myself up." There was no mention of whether call light or alarms were sounding. However, the "Immediate Action & Plan to Prevent Reoccurrence" was, "Bed/chair alarms". According to Resident #103's MDS, dated [DATE], he scored ,[DATE] on a Brief Interview for Mental Status (indicating he had memory problems), needed assistance with transfers, and had a fall prior to reentry to the facility on [DATE]. According to Resident #103's care plan, dated [DATE], "Focus: (Resident #103) is at risk for falls r/t self care deficit and limited mobility; decreased safety awareness...Interventions: Bed to side of wall for safety (initiated [DATE]); Bolsters on mattress to prevent falls (initiated [DATE])...Check placement and function of bed and wheelchair alarms each shift (initiated [DATE]); Extensive assist with 4 ww (wheeled walker) for transfers bed to wheelchair (initiated [DATE])..." Review of Resident #103's progress notes revealed no information regarding the decision to place bolsters on Resident #103's bed. In an interview, on [DATE] at 11:00 AM, the Rehab Director reported the Rehab Department did not do an assessment for the use of , or recommend bolsters, for Resident #103. In an interview, on [DATE] at 2:59 PM, Resident #103 was observed lying in bed; there were 12 inch high rigid bolsters in position under his covers extending the nearly the entire length of both sides of the sides of the bed. Resident #103 reported he was waiting for pain medication and said, "I've put the light on 3 times already. They come in and tell me someone will be back. It's been 30 minutes. I need my pain pill". In an interview, on [DATE], Nurse Aide "C" noted herself to be the nurse aide assigned to Resident #103. Nurse Aide "C" reported she did not know why Resident #103 had bolsters on his bed. Nurse Aide "C' stated, "I have no clue why has large bolsters on his bed. I had no idea he fell until I talked to you earlier. Now, he has a pressure alarm on his bed only. I didn't see one on his chair. Yes, he uses his call light". In an interview, on [DATE] at 10:00 AM, the Administrator reported he did not know why bolsters were being used on Resident #103's bed. The Administrator stated, "I'd have to know the case. If he wanted to, he could climb out the end of the bed". In an interview, on [DATE] at 10:10 AM, the nurse assigned to Resident #103, LPN/Licensed Practical Nurse was asked why Resident #103 had bolsters on his bed and if there was a signed consent for the bolsters. LPN "F" replied, "It's okay. We don't need signed consent. They are not restraints if used to keep you from falling out or climbing out of bed." In an interview, on [DATE] at 10:15 AM, Resident #103 reported he need assistance, "99% chance I need help to get up. That's what we're working on. I need patience to wait for someone. The day I fell , I waited an hour. I was whipped and wanted to get into bed. The aide said we didn't forget you; they never come back...I tried to get from the wheelchair into bed. They picked me up before I got on the floor; I was strattling the bed". ( )

This citation pertains to intake MI 365. Based on interview and record review the facility failed to prevent staff to resident abuse for 1 (#106) of 6 sampled residents of a total sample of 6 resulting in physical and verbal abuse, pain and fear for resident #106. Findings include:. Review of resident #106's medical record revealed an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her Minimum Data Set ((MDS) dated [DATE], documented that she is moderately impaired with cognitive skills for daily living, and required maximum assistance of one person for transfers and bathing. Facility incident report dated 9/6/11 documented that resident #106 stated she didn't want to shower because the girl that will give her a shower tomorrow told her to shut up and that the girl does it all the time, especially on shower day. In an interview in the facility Chapel on 9/30/11 at 9:50 am, resident #106 stated that CNA #14 gave her a shower every other week, and after her shower, when she tries to get up at the bar, sometimes she can do it and sometimes she can't, because she had "[MEDICAL CONDITION] arthritis". Resident #106 stated CNA #14 will yell at her to "stand up" and she will tell CNA #14 that she needs more help. Resident #106 stated CNA #14 will tell her she isn't getting anymore help, and yells at her again to "stand up". Resident #14 stated after the last shower CNA #14 gave her, she (resident #106) was trying to put her hands on the grab bar, and it took her (Resident #106) a little longer than CNA #14 wanted, so CNA #14 grabbed her arm and put her hand on the bar real rough and said, "I said stand up". Resident #106 stated, "It hurt real bad. Look at my hands. They're all crippled." At this point during the interview, the surveyor observed Resident #106 start to cry. Resident #106 stated she doesn't have CNA #14 take care of her anymore, but does see her in the hallway. Resident #106 stated most of the staff are real nice, but CNA #14 is not, and she didn't want CNA #14 to ever take care of her again. Resident #106 stated, "They are supposed to take care of us, but sometimes it is the other way around and we do what they say." During the interview, Resident #106 was able to correctly identify the year, the name of the facility and the President of the United States. Resident #106 stated she knew why the surveyor was asking her those questions, and that she hadn't lost her mind, just the ability to care for herself. In an interview on 9/30/11 at 3:00 pm, RN #7 stated that Resident #106 was very upset when she (resident #106) reported to her that she didn't like the way CNA #14 treated her and that she (resident #106) dreaded shower day when CNA # 14 was on because resident #106 didn't know what CNA #14 was going to do. RN #7 stated that resident #106 told her that CNA #14 yelled at her to stand up, and even when she (resident #106) can't, CNA #14 pushes her and that CNA #14 slammed her hand on the bar and that it hurt because she had arthritis. RN#7 stated that resident #106 stated she was concerned about what might happen next and seemed scared. In an interview on 9/30/11 at 12:45 pm, Social Worker (SW) #9 stated that resident #106 told her an aide had been rough with her and was able to identify CNA #14. SW #9 stated resident #106 was able to describe CNA#14 and identify what shift she worked. SW #9 stated that resident #106 stated CNA #14 was the only staff member she had a problem with. SW #9 said that resident #106 told her that CNA #14 forced her hands on the grab bar in the shower after she told CNA #14 she could not stand. SW #9 stated resident #106 repeatedly stated she did not want CNA #14 to care for her anymore. SW #9 stated that for the most part resident #106 is alert and oriented and does not complain about much. SW #9 stated when she interviewed resident #106 regarding her allegations against CNA #14, she asked the same questions in multiple ways, and resident #106 gave consistent answers. SW #9 stated that resident #106 reported to her that it was painful and hurt when CNA#14 put her hands on that bar. In an interview on 9/30/11 at 11:20 am, CNA #14 denied any problems with resident #106. At the beginning of the interview, CNA #14 looked down at the table, gave short, one word answers and crossed her arms over her chest. CNA #14 stated when she came to work on Friday, the unit manager told her she had to clock out because resident #106 told the third shift nurse that whoever did her showers on Wednesdays is mean to her and hits her. CNA #14 stated she didn't know what resident #106 was talking about, and that sometimes resident #106 will say she can't stand, but she can, and when her husband is here visiting, resident #106 will refuse to leave the lobby to even be toileted. CNA #14 stated resident #106 can actually stand, and if she (CNA #14) gets somebody to help and comes back to resident #106, the resident will stand. CNA #14 stated she was suspended during the investigation, and came back to work two weeks later. CNA #14 stated she was written up and given a one to one inservice by the Director of Nursing on Abuse just a few hours prior to the interview with the surveyor. Review of CNA #14 personnel record revealed a Corrective Action report dated 9/27/11 which documented the violation to be "Failure to follow company policies" and description of incident documented: On 9/6/11, a resident alleged CNA #14 rudely spoke to her and roughly placed her hands on a metal bar. The resident verbalized fear of CNA #14 to another CNA and the Social Worker. The resident also consistently maintained the alleged incident. This incident was reported to the State of Michigan for investigation. Effects are documented as: Puts the facility and residents at risk, cause anxiety among residents and staff, and interferes with our ability to provide care to the resident. In an interview on 10/4/11 at 12:30 pm, the Director of Nursing stated that CNA #14 was written up for the allegations of abuse against her by resident #106. The Director of Nursing was given the written corrective action for CNA #14, which was dated 9/27/11 to review. The Director of Nursing admitted that CNA #14 was not educated or given her written corrective action on 9/27/11, but on 9/30/11. ( )

Complaint Intake Number: MI 038 Based on observation, interview and record review the Facility failed to provide adequate and appropriate supervision and assistance devices (wheelchair) for 3 of 4 residents with falls (#101, #103 & #104) in the sample of 5 resulting in actual harm (Resident #101-fractured arm & Resident #104 large bruises) and minor injury with the potential for greater injury (small bruises for Resident #103). Findings include: Resident #101 Per the Incident Report dated 5/18/11 Resident #101 was observed sitting on her buttocks on the floor in her room. Resident #101 complained of shoulder pain and said she hit her head. Per the x-ray report dated 5/18/11 Resident #101 sustained a fractured right humeral neck (upper end of the top bone in the right arm). In an observation on 6/2/11 at 12:30 p.m. Resident #101 was seated in an upholstered recliner chair in her room with her right arm in a sling and a fall alarm clipped to her dress. Resident #101 said she fell and hit her head and broke her arm. Resident #101 gestured from her shoulder to her fingertips and said, "It hurts from here down." Review of the June 2011 physician's orders [REDACTED]. Per the Minimum (MDS) data set [DATE] Resident #101 had memory loss (scored 9 out of possible 15 on the memory assessment) and was independent with transfers and ambulation. Resident #101 had a history of [REDACTED]. 1. Per review of the "Resident Information Sheet for Physician" which revealed on 2/16/11 Resident #101 fell from a standing position and hit her forehead. 2. Review of the Nurses' Notes dated 5/6/11 at 5:10 a.m. revealed Resident #101 was found sitting on the floor in front of the recliner saying she "slid out" of the chair. The Nurses' Notes dated 5/6/11 at 7:30 a.m. stated Resident #101 said she activated the electric recliner chair to lift her to a standing position and "slid out of the recliner, she did not have shoes on. I suggested a grip (sic) socks but said no (sic)." 3. Review of the Nurses' Notes dated 5/10/11 at 2:50 a.m. revealed Resident #101 was again found sitting on the floor in front of the recliner having "slid out" of the chair. 4. Review of the Nurses' Notes dated 5/16/11 revealed Resident #101 was found sitting on the floor at the foot of her bed and sustained a skin tear to her right elbow after trying to help her roommate change clothing (tipped over backwards). Per Resident #101's Falls Risk Care Plan dated 5/10/10 Resident #101 slept in the recliner (did not use her bed) and interventions dated 5/10/10 instructed staff to "remind her to keep her shoes on until she is ready to go to bed for the night for safety r/t (related to) previous fall" and she was to have "proper footwear on daily." On 2/16/11 the interventions were updated to include the instruction "not to wear slippers." Per Resident #101's Episodic/Acute Care Plan dated 5/6/11 interventions included "encourage to wear non slid (sic) footwear (sic)." Per Resident #101's Episodic/Acute Care Plan dated 5/10/11 interventions included "encourage to wear nonslid (sic) foot wear." In an interview on 6/2/11 at 2:12 p.m. Nurse Aide #12 stated Resident #101 was not wearing "grippy socks" when she fell on [DATE] or when she fell on [DATE]. Nurse Aide #12 said Resident #101 was wearing "her own socks. She didn't think the grippy socks were fashionable. She took them off and put her own on." Nurse Aide #12 admitted she was given no instruction to increase supervision of Resident #101 in light of the increasing number of falls and Resident #101's refusal to wear appropriate footwear while up. In an interview on 6/2/11 at 12:25 p.m. Nurse #13 said on 5/18/11 Resident #101, "said she was reaching for her control and lost her footing and fell on her bottom. She was standing and she fell backwards and hit her arm on the cabinet." In an interview on 6/2/11 at 12:22 p.m. Resident #101's roommate, Resident #102, said on 5/18/11 she saw Resident #101 "trip on the cord and she fell on the chest. Her leg was under. I called for help." In an interview on 5/18/11 at 12:37 p.m. Resident #102 said on 5/18/11 Resident #101 "fell hard. She had an awful fall." There was no documented evidence found in the investigation file notes or in the Nurses' Notes as to what footwear was or was not worn by Resident #101 at the time of her fall on 5/18/11. ( ) Resident #104 Per the Incident Report dated 5/26/11 Resident #104 fell while walking outside and sustained bruises to her left knee and left elbow and abrasions to the left elbow. In an observation on 6/2/11 at 4:30 p.m. Resident #104 was seated in an upholstered recliner in her room with her feet elevated. Resident #104 stated she was walking on the sidewalk to a vehicle for transportation to a medical appointment on 5/26/11 when she "stubbed my toe and tripped" and let go of her wheeled walker. As the sidewalk had a slight decline the walker "ran away" and Resident #104 fell forward onto the sidewalk. Resident #104 stated the caregiver who was transporting her to the appointment was not at her side but rather was at the vehicle opening the door. Observation revealed Resident #104's left knee was extensively bruised purple and grossly swollen and red. Resident #104's left lateral hand and left pinkie finger were bruised purple. There was a small bruise on Resident #104's left elbow. Review of Resident #104's Fall Risk Prevention Care Plan revealed she had a history of [REDACTED]. 1. 1/18/11 Use wheelchair for longer distances. 2. 3/14/11 Activity to assist when getting in and out of the bus related to a fall on 3/12/11. Review of the Incident Report and investigation dated 5/10/11 revealed Resident #104 had fallen in her room on 5/10/11 when she attempted to turn her oxygen off and she lost her balance. It was noted Resident #104 was "blind in left eye." Review of the Incident Report and investigation dated 5/25/11 revealed Resident #104 "started trying to walk out of room and fell back and landed in a sitting position on the floor." Resident #104 sustained "red area on the back of head." Per the Minimum (MDS) data set [DATE] Resident #104 had mild cognitive deficits (score of 13 out of 15 on the exam) and required assistance with ambulation off the unit. Per the June 2011 physician's orders [REDACTED]. Resident #103 Per the Incident Report dated 5/25/11 at 12:00 a.m. Resident #103 reported to the staff that she had "lost her balance after getting out of bed and fell on the floor." No injuries were noted at that time. The Plan of Correction placed the onus of responsibility on the Resident as she was told to use her walker when up. Per the Incident Report dated 5/27/11 Resident #103 was heard calling out and was found sitting on the floor in her room; Resident #103 hit her head on the room door. No injury was noted. The Plan of Correction again placed the onus of responsibility on the Resident as she was told to "slow down when getting up." Per the Incident Report dated 5/28/11 at 7:25 p.m. Resident #103 was found on her knees in front of her walker outside the doorway to her room. She sustained a 4.5 cm x 3.5 cm bruise on her right leg. Resident #103 reportedly said she was returning from bingo and "she felt like her knees gave out & felt dizzy & stated she fell ." The Plan of Correction stated to "encourage resident to rest in room after meals..." In an observation on 6/2/11 at 12:15 p.m. Resident #103 was observed exiting her bathroom without benefit of walker. Resident #103 said she "lost my balance and sat down hard..." In an observation on 6/6/11 at 10:20 a.m. Resident #103 was seated in a chair in her room reading a book. Resident #103 jumped up to a standing position upon this Surveyor's entry into the room. With the assistance of Nurse #14, Resident #103's buttocks and legs were observed. A bruise approximately 25 cent piece sized was noted on Resident #103's left buttock. No bruises were noted to either leg. Per the Minimum (MDS) data set [DATE] Resident #103 had extensive cognitive deficits (score of 4 out of 15 on the exam) and required supervision with ambulation. Per the June 2011 physician's orders [REDACTED]. ( )

Complaint Intake Number: MI 695 Based on observations, interviews and records review the Facility failed to provide adequate supervision when the care plan was not followed and there was an avoidable fall for 1 of 6 residents in the sample (#105) which resulted in actual harm-fractured vertebrae and ribs. Findings include: Per the Incident Report dated 11/5/10 prepared by the Administrator, on 11/4/10 at 1:00 p.m. Resident #105 "got up from dining room table, using her walker when she lost balance and fell with back against wall..there were no obstacles in her path...x-rays were ordered...CT scan to be ordered. Initial results could not determine ancient or recent fracture." Per the CT scan dated 11/6/10 Resident #105 had an acute (new) fracture of the T-11 vertebrae (thoracic or mid back) and acute (new) fractures to right posterior (back) of the 7 th and 8 th ribs and the right lateral (side) 7 th rib. Per the statement dated 11/8/10 Dietary Aide #15 saw Resident #105 "falling out of the corner of her eye. (Dietary Aide #15) said the resident got out out of her chair and was trying to walk through the people that were near her and fell ..." In an interview on 11/9/10 at 3:15 p.m. the Administrator said the statement by Dietary Aide #15 that Resident #105 was trying to walk between 2 people when she fell had come to his attention after he began the investigation on 11/8/10. In a telephone interview on 11/9/10 at 6:30 p.m. and in a telephone interview on 11/15/10 at 8:15 a.m. Dietary Aide #15 described the scene of the incident on 11/4/10. Dietary Aide #15 said Resident #105 had been eating while seated at the dining room table in the chair on the side of the table "closest to the window" wall. Dietary Aide #15 said she saw Resident #105 "standing with her walker and 2 or 3 other residents were in front of her." Dietary Aide #15 said Resident #105 was attempting to walk forward between the two residents who were seated back-to-back, one in a chair at Resident #105's table and the other at the neighboring table. Dietary Aide #15 said, "Her walker got hung up" on one or both of the chairs as Resident #105 tried to push her way forward between the two seated residents. Dietary Aide #15 said Resident #105 "fell and hit her back or her head on the register. She was still holding onto her walker" as she lay on the floor and the walker was partially under the chair of the resident seated at the neighboring table. Per the Fall Prevention Care Plan dated 6/9/10 Resident #105 had "difficulty getting away from the dining room table because of other residents being seated there with their walkers. Change position at dining room table to make it easier to exit the table/dining room." In a telephone interview on 11/10/10 at 3:30 p.m. Nurse #18 said on 11/4/10 Resident #105 was "sitting at the wrong table. She had been up and down all shift." Nurse #18 said she was aware that the care plan instructed staff to ensure Resident #105 was seated on the side of the table closest to the main walkway between the 2 rows of tables in the dining room to prevent her from tripping while trying to walk between residents seated at adjacent tables in the dining room. Nurse #18 said when the evening meal was served on 11/4/10 Resident #105 was not seated in a chair on the proper side of the table but rather was seated in a chair on the opposite side of the table closest to the window wall and another resident was seated in Resident #105's assigned seat. Nurse #18 said she "decided not to move (Resident #105) and the other person" because both residents were eating when she made the observation. Nurse #18 admitted she did not ensure Resident #105 was closely supervised to prevent her from falling when she completed her meal and attempted to walk with her walker through the narrow space between her table and the neighboring table. Nurse #18 said "all the other nights" she had made sure that Resident #105 sat in her assigned seat. Per the Incident Report dated 6/8/10 Resident #105 "was sitting in dining room...stood up to leave...while Resident was trying to get out around the table, she tripped and fell to the floor on her right side. No injury or bruise noted at this time." Per the Face Sheet dated 7/31/07 Resident #105 was a [AGE] year-old female. Per the Minimum (MDS) data set [DATE] Resident #105 was diagnosed with [REDACTED]. In an observation on 11/15/10 at 7:55 a.m. Nurse Aide #16 toured this Surveyor through the dining room in the secure unit. Nurse Aide #16 stated Resident #105 was a resident on the secure unit on 11/4/10. Nurse Aide #16 obtained a seating chart from the inside of a cupboard door in the dining room of the secure unit and explained that Resident #105 was assigned different seats on the first and second shifts. Review of both sides of the seating chart paper revealed she was assigned a seat on the side of a table with her back to the resident's back at the neighboring table on the "6:30 a.m.-3:00 p.m. shift" and was assigned a seat on the side of the table closest to the open walkway between the 2 rows of tables on the side of the seating chart dated "10/15/10." Nurse Aide #16 identified the side of the seating chart dated 10/15/10 as the seating chart used on the 3:00 p.m.-11:00 p.m. shift. Per the Nurses' Notes dated 11/8/10 Resident #105 was admitted to the hospital. Per an interview on the morning of 11/9/10 with the Administer and the Director of Nursing Resident #105 was in the hospital and the plan was for her to be fitted with a "turtle shell" brace to stabilize her fractures and eventually return to this facility. Nurse Aide #16 said in the interview on 11/15/10 at 7:55 a.m. that Resident #105 was "supposed to come back (from the hospital) yesterday but she didn't." ( )

This citation pertains to MI 266. Based on observations, interviews, and records review, the facility failed to provide supervision to prevent 1 of 7 sampled residents (#101) from eloping from the facility, resulting in immediate jeopardy when resident #101 was found outside the facility walking toward a busy street without the knowledge of staff. Findings include: Resident #101 was admitted to the facility on [DATE]. Resident #101 was identified as high risk for elopement based on an "Assessment Elopement Risk Upon Admission," dated [DATE]. Per the "Treatment Record" for resident #101, a "Wanderguard on right ankle at all times" was initiated [DATE]. According to the 24 Hour Facility Incident Report, on [DATE], administrator #1 recorded, "Resident was observed walking on the sidewalk outside of the facility after dinner. Resident ambulates independently throughout the facility however was outside unattended. Resident was redirected to the facility without incident and was assessed by nursing with no injuries noted. Resident does wear a Wanderguard alarm (device that sends radio waves through a transmitter). The facility immediately began an investigation." On [DATE] at 3:30 PM, administrator #1, stated he believed resident #101 exited the building by following a visitor through an open door. He stated staff had checked resident #101's Wanderguard alarm numerous times without fail since the occurrence and presented video and alarm reports to substantiate his theory that the incident was an unusual event. On [DATE] at 10:20 AM, surveyors tested the functionality of the Wanderguard bracelet that was worn by resident #101 on [DATE]. It did not lock the door or sound the alarm as intended on two of the four trials. In an interview conducted on [DATE] at 11:35 AM, social worker #13 stated she had no record of the expiration date for resident #101's Wanderguard bracelet and did not have expiration dates for any of the Wanderguard bracelets used in the facility. In an interview conducted on [DATE] at 3:05 PM, the contracted security specialist #10 stated that although the battery could be working, the Wanderguards' transmitters were only warranted for three years. He suggested the facility replace them after 2 ? years after purchase. He verified, by calling the distributor of the Wanderguard bracelets, the bracelet that was worn by resident #101 on [DATE] had expired on [DATE]. Two other Wanderguards, thought to be operating properly because the batteries tested as functioning, were also confirmed as expired. Administrator #1 was notified on [DATE] at 4:15 PM of the immediate jeopardy that began on [DATE] at 6:14 PM when resident #101, who was identified as a high risk for elopement, eloped without the knowledge of staff and was found walking toward a busy thoroughfare. The deficient practice placed 13 other residents, who were identified as high risks for elopement, at high risk for elopement and possible physical harm or death. On [DATE], the surveyors confirmed that the facility implemented the following to remove the immediate jeopardy: 1. On [DATE] at 5:00 PM, administrator #1 positioned staff to monitor the Wanderguard exit doors 24 hours/day. Per documents entitled "Sign In for service door" and "Sign in for rehab/front lobby doors," dated [DATE] - [DATE], staff were in place to prevent residents from eloping. 2. On [DATE], the facility ordered new Watchlets (Wanderguards) to replace all current devices being used. These were received at the facility in the evening of [DATE]. On [DATE], the new Watchlet devices were tested . Testing results indicated that the new devices were not consistently reliable. The Watchlet devices, therefore, were not distributed to residents based on these results. The facility has contracted with a different wander prevention vendor to install by [DATE] a new system replacing the current system. Twenty-four hour monitoring of the identified exit doors will continue until it is certain that the new system is working properly. 3. In an interview on [DATE] at 8:30 AM, administrator #1 stated that the new wander prevention vendor had been contacted and inspected the facility on [DATE]. On [DATE], at 3:10 PM, installer #37 stated he had completed the installation of the new wander prevention system and demonstrated it working properly. 4. On [DATE] at 3:17 PM, director of environmental services #9 stated she would be testing the Wanderguards on a monthly basis. Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity of no actual harm but potential for more than minimal harm not immediate jeopardy due to the permanent elopement prevention alarm system had not been installed and sustained compliance had not been verified by the state agency. and