Every finding on record at Optalis Health and Rehabilitation of Kingsford

This citation pertains to complaints #3072757, 3093009All times are in Eastern Daylight Time (EDT) unless otherwise notedBased on interview and record review, the facility failed to ensure sufficient nursing staff were available to promote the highest practicable level of physical, mental, and psychosocial well-being of the residents. This failure had the potential to affect all 78 residents residing in the facility. Findings include:The Centers for Medicare & Medicaid Services (CMS) Payroll-Based Journal (PBJ) Staffing Data Report, which reflects quarterly staffing submissions by nursing homes to CMS, for FY 2026 Quarter 2 (January 1 through March 31, 2026), revealed the facility triggered for excessively low weekend staffing.The Facility Assessment (FA), dated 5/14/26, established minimum CNA staffing levels necessary to meet the anticipated needs of its resident population. The FA identified a minimum staffing requirement of seven Certified Nurse Aides (CNAs) on the afternoon shift (2:00 p.m. to 10:00 p.m.) and five CNAs on the night shift (10:00 p.m. to 6:00 a.m.).Weekend staffing for the period of January 1 through March 31, 2026 was reviewed with Medical Records Coordinator G on 8/19/26 at 11:59 a.m. The review revealed the following instances in which CNA staffing fell below the facility's identified minimum staffing levels:Afternoon shift (2:00 p.m. to 10:00 p.m.): CNA staffing was below the facility's identified minimum three times: on 2/21/26, 2/22/26, and 3/15/26.Night shift (10:00 p.m. to 6:00 a.m.): CNA staffing was below the facility's identified minimum nineteen times: on 1/10/26, 1/11/26, 1/17/26, 1/18/26, 1/24/26, 2/7/26, 2/8/26, 2/14/26, 2/15/26, 2/21/26, 2/22/26, 2/28/26, 3/1/26, 3/8/26, 3/15/26, 3/21/26, 3/22/26, 3/28/26, and 3/29/26. Despite the identified staffing needs established in the FA, facility records demonstrated repeated instances of staffing below those established minimums, particularly on weekends and during the night shift.During a confidential group meeting on 8/19/26 at 10:42 a.m., two confidential residents (CR's) complained of insufficient staffing. One CR stated They are always short of staff.you don't get your showers if they don't have enough staff. They write that I refuse my shower, but why would I do that, I wouldn't.There was only one CNA on the wing on Saturday, and I didn't get my shower because they were short of staff. Another CR stated, There was only one CNA on the floor last night.It is often that I don't get my showers because there is not enough staff working.During an interview conducted on 8/19/26 at 2:42 p.m., CNA B reported, I am by myself down the wing today and over half the residents require two staff members when transferring the residents.I am doing the best I can but we are short of staff like this so often.We are short of staff and there is only one of us on a wing at least twice a week and it is worse on the weekends.During an interview conducted on 8/19/26 at 5:05 p.m., the Nursing Home Administrator (NHA) acknowledged the concern regarding insufficient staffing levels.

All times are in Eastern Daylight Time (EDT) unless otherwise notedBased on interview and record review, the facility failed to complete performance reviews for three out of five Certified Nurse's Aides (CNA's) at least every 12 months.Findings include:Review of facility personnel records revealed performance reviews were filled out but not reviewed with CNA D, CNA E, and CNA F and therefore demonstrated the following:CNA D was hired on 10/25/24 with no completed performance review.CNA E was hired on 2/19/22 with no completed performance review.CNA F was hired on 5/23/23 with no completed performance review.During an interview on 8/19/26 at 8:58 a.m., Hurman Resources Director A reported, Currently we are not doing performance reviews.there are three performance reviews for [CNA D, CNA E, and CNA F] that are filled out but have not been electronically signed by the employee.An interview was conducted with the Nursing Home Administrator on 8/19/26 at 9:06 a.m. The Nursing Home Administrator (NHA) reported, I would expect the managers to review the performance reviews with the staff, and the staff would electronically sign the performance review.the unsigned performance reviews are incomplete .During an interview on 8/19/26 at 5:05 p.m., the NHA acknowledged the concern regarding incomplete annual performance reviews.

Based on observation, interview, and record review, the facility failed to maintain general cleanliness and repair of the premise and plumbing, as well as providing adequate storage of resident items. Findings Include:On 8/17/2026 at 2:19 PM, both doors for the shared bathroom between room [ROOM NUMBER] and 215 were observed with the paint scratched and missing. On 8/17/2026 at 2:22 PM, a box of snacks was observed on the floor behind the bed for resident 222 bed B, identified as R87. During an interview at the time of this observation, R87 mentioned they would like more shelving or cabinets to store things in because there was no room left for anything else on top of the side table. A box of snacks was observed on the floor behind R87 and they stated their family was always bringing in a supply of snacks. On 8/17/2026 at 2:33 PM, the bed frame on the bed in room [ROOM NUMBER] for, identified as R86, was observed scratched and in disrepair. The bed was surrounded by an accumulation of personal belongings, and the bed was only accessible from the bottom right one quarter of the mattress. The resident stated they were comfortable with this situation, but would like some more storage units for personal items. On 8/17/2026 at 2:35 PM, the tile wall behind the hand sink in the Floor 2 Nurses station was observed with missing tiles, exposing the unfinished interior subsurface and leaving an open space into the wall, where the sink meets the wall. On 8/17/2026 at 2:42 PM, floor around the resident in 234 B, identified as R79, was noted with an accumulation of litter on the floor, and a bag of garbage behind a cabinet of drawers to the right of the bed. R39 who also resided in this room, had an open 12 pack of soda and a flat of soft drinks, and an open package of snack crackers and creamers sitting on top of the canned pop on the floor, making the floor inaccessible for cleaning. The top of the dresser was noted covered with open boxes of snack crackers and cookies, and a partially eaten cookie laying on the cabinet top with crumbs around it. On 8/17/2026 at 2:46 PM, the paint was observed missing in several areas from the door on room [ROOM NUMBER]. On 8/17/2026, the finish on multiple handrails on both sides of the hall in the 200 Wing was observed worn off, exposing bare wood below. On 8/18/2026 at 8:55 AM, the floor under the windows in room [ROOM NUMBER] A identified as R64, was observed covered with personal items. CNA I said they were aware there is too much stuff on the floor and they have been working with R64 to get stuff off the floor. However, R64 does not want to get rid of many of those items. CNA I said they are working with the activities director to get the resident more storage shelving. Activities Director (AD) K said the facility provided the resident with a cubby storage unit to the left of their bed, but R64 had trouble throwing things away, and R64 was afraid someone will take their stuff.On 8/18/2026 at 11:14 AM, the drain line from the hand sink in this bath was noted having leaked and an iron stain was noted on the wall under the sink, extending down the tile to the floor. On 8/18/2026 at 11:41 AM, The cabinet under the ice machine in the clean utility room on Floor 2 was observed with a missing door, and the lower interior shelf was observed with debris built up. On 8/18/2026 at 11:57 AM, the ice machine drain line for floor 1 was noted running through the cabinets and out the rear wall. When the drain line was found in the other room, it was noted with a slime mold buildup, with a strand of slime extending down into the bowl drain, and a buildup of slime all around the end of the pipe where it hangs above the bowl drain. On 8/18/2026 at 12:04 PM, the Maintenance Director (MD) H was unable to find the drain line air gap for the Floor 2 Ice machine in the clean utilities room. The drain line extends through the wall, and the end of the drain line is not visible beyond the wall.

Based on interview and record review, the facility failed to ensure the timely acquisition, administration, and disposition of oral targeted cancer medication for 1 Resident (R1) of 1 resident reviewed for pharmacy services. This deficient practice resulted in missed doses of an oncologist (cancer physician) prescribed medication, the potential of reduced efficacy and progression of disease, and resident dissatisfaction with care.Findings include:During an interview on 5/13/26 at 10:05 a.m., when asked about any facility concerns, Resident #1 (R1) stated, . I have been on cancer medicine for 8 years now - they used a medicine and that cancer medicine cost [thousands of dollars] a month. My [Native American] [NAME] furnishes that medicine for me . I got in here and I turned that medicine over to them. The new supply came in, and the post office reassured my provider that it reached the post office on May 1st. Now it is gone. For three days I have not had my cancer medicine. For 2,400 days before that I never missed a dose. I come to a professional health care facility and I miss three days .Review of R1's Minimum Data Set (MDS) assessment, dated 3/25/26, revealed R1 was admitted on [DATE] with active diagnoses that included prostate cancer, and secondary bone cancer. R1 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), reflective of intact cognition, and was independent with mobility, self-care, and functional cognitive tasks.Review of R1's Medication Administration Record (MAR), for May 2026, revealed Abiraterone Acetate was not administered on 5/11, 5/12, or 5/13/26. The entry was documented with nurse's initials and a Chart Code of 07 which indicated Other/See Progress Notes.Review of R1's Face Sheet, printed 5/13/26, revealed R1 was his own responsible party, able to make independent medical and financial decisions.Review of R1's Physician Order Summary on 5/13/26, revealed the following, in part: Abiraterone Acetate Oral Tablet 500 MG (Abiraterone Acetate) Give 2 tablet by mouth one time a day for Antineoplastics (drugs that inhibit or prevent the growth and spread of tumors or malignant cells). Give 2 tabs one hour prior to breakfast Phone Active 3/13/2026, 3/14/2026 Start Date.Review of R1's Care Plan, on 5/13/26, revealed the presence of a Resident has an active Cancer diagnosis prostate cancer with secondary Bone CA (cancer) care plan, which did not include any intervention related to the administration of an oral chemotherapy agent while in the facility.During an interview on 5/13/26 at 12:18 p.m., the Director of Nursing (DON) was asked about R1's missing Abiraterone Acetate which was and not administered to R1. The DON said a Resident (R2) was discharged from the facility and the medication had gone home with R2 on Sunday, 5/10/26. The plan, per the DON, was to get R1's cancer medication from their pharmacy, but their pharmacy could not send a short-day supply because they do not keep that medication in stock. The DON did not know the name or location of the specialty pharmacy that needed to be used, nor was she aware of how many pills were sent home with R2 upon their discharge from the facility with R1's cancer medication. The DON confirmed the failure to administer R2's cancer medication would be considered a medication error, and stated, There is not a med error report completed.Review of R1's Progress Notes revealed the following notes related to R1's missing abiraterone acetate which was and not administered to R1, in part: 5/11/26 11:57 a.m. [Central Standard Time (CST)] - Call out to [Oncologist E] office informing that resident (R1) will miss 2 doses of Abiraterone on 5/11-5/12. 5/13/26 10:02 a.m. CST - Provider aware of missed doses of abiraterone. Pharmacy contacted and unable to obtain this medication as it is a specialty medication. Message left with [Oncologist E's'] office to update provider, awaiting call back. In house provider notified regarding missed doses.During an interview on 5/13/26 at 1:24 p.m., when queried regarding R2's missing cancer medication which was not administered to R1, RN/Unit Manager A, said on Monday 5/11/26, Licensed Practical Nurse (LPN) D could not find the abiraterone acetate to administered to R2. RN A stated, [LPN D] said, 'I wonder if it got sent home with a resident who was discharged ?' LPN D called R2's (Resident discharged on 5/10/26) son, who confirmed R1's cancer medication had been sent home with R2 on 5/10/26. RN A said there was no medication inventory completed upon R2's discharged showing which medications were given to them upon discharge. RN A said the facility could not get R1's cancer medication from their pharmacy and the mail order pharmacy was not able to ship it until that day 5/13/26. The mail order pharmacy said it would be delivered in a couple of days - Monday, 5/18/26, at the latest. RN A did not know what method of shipment was used for the abiraterone acetate. RN A stated, I asked [the DON] if we should send someone to get it and I was told 'no'. I did not talk to the Nursing Home Administrator (NHA) about [R1's missing cancer medication not administered] .Review of a Statement obtained via phone interview on 5/13/26 at 0900 CST [10:00 Eastern Standard Time (EST)] and typed by RN A, included the following two paragraphs: Statement regarding incident occurring on 5/10/26 where a resident's medications were inadvertently sent home with another resident who discharged to home. I did not know another resident's medications were sent home with the resident who discharged . I grabbed the medications and put them in a patient belonging bag along with the residents MAR to go home with the patient at discharged . Typed signatured of LPN C. During a telephone interview on 5/13/26 at 2:40 p.m., when asked about any concern with the omission of chemotherapy medication for R1, [Health System Name] Cancer Center RN J stated, If the medication (Abiraterone Acetate ) was not taken as indicated, it's efficacy cannot be guaranteed because there is not clinical evidence to support non-compliance (with administration of) the oral-targeted chemotherapy. So theoretically the patient could be at greater risk for progression of disease if the medication was not administered as ordered.Review of the Medication Error Policy & Procedure, reviewed 2/3/26, revealed the following, in part: It is the policy of this facility to provide protection for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors . A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders . and principles of the professional(s) providing services. Examples of medication errors include: Omission - a drug is ordered but not administered . In the event of a medication error . The following information is documented in an incident report/medication error report and in the resident's clinical record: Factual description of the medication error. Actions taken and the resident's response. Physician, Resident, and Family/Representative notification and response . Each incident report/medication error report is forwarded to: Director of Nursing, Administrator, Medical Director and Consultant Pharmacist .During the Exit Conference on 5/13/26 at approximately 3:00 p.m., the NHA and DON acknowledged the identified deficiency related to pharmacy services including the timely acquisition of R1's cancer medication, the failure to administer the cancer medication to R1 as prescribed, and the facility's error in disposition of the medication to R2 upon their discharge from the facility on 5/10/26.

Based on interview and record review, the facility failed to ensure the medical record contained accurate and complete information related to the facility's loss of oral chemotherapy medication for one Resident (#1) of one resident reviewed for a complete medical record, Findings include: Resident #1 (R1)During an interview on 5/13/26 at 10:05 a.m., when asked about any facility concerns, R1 stated, . I have been on cancer medicine for 8 years now - they used a medicine and that cancer medicine cost [thousands of dollars] a month. My [Native American] [NAME] furnishes that medicine for me . I got in here and I turned that medicine over to them. Now it is gone. For three days I have not had my cancer medicine. For 2,400 days before that I never missed a dose. I come to a professional health care facility and I miss three days .Review of R1's Minimum Data Set (MDS) assessment, dated 3/25/26, revealed R1 was admitted on [DATE] with active diagnoses that included prostate cancer and secondary bone cancer. R1 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), reflective of intact cognition, and was independent with mobility, self-care, and functional cognitive tasks.Review of R1's Medication Administration Record (MAR), for May 2026, revealed Abiraterone Acetate was not administered on 5/11, 5/12, or 5/13/26.Review of R1's Physician Order Summary on 5/13/26, revealed the following, in part: Abiraterone Acetate Oral Tablet 500 MG . Give 2 tablet(s) by mouth one time a day for Antineoplastics (drugs that inhibit or prevent the growth and spread of tumors or malignant [cancer] cells). Give 2 tabs one hour prior to breakfast. Phone Active 3/13/2026, 3/14/2026 Start Date.During an interview on 5/13/26 at 12:18 p.m., the Director of Nursing (DON) was asked about R1's missing Abiraterone Acetate which was not administered to R1. The DON said a different Resident (R2) was discharged from the facility and the medication had gone home with R2 on Sunday, 5/10/26. When asked if this information was documented in R1's medical record the DON stated, No, that is not in there specifically. It was documented that the medication was not available .I don't see any documentation in the medical record that the medication went home with another resident upon discharge. I am also not sure when we identified that the med went home with another resident. When asked if the medical record documented how R1's cancer medication was going to be acquired, the DON stated, I don't have any interview or documentation yet about what we were working on for getting that (R1's abiraterone acetate cancer medication) here. The DON confirmed the failure to administer R1's cancer medication would be considered a medication error. When asked if a medication error report was completed, the DON stated, There is not a med error report completed. During an interview on 5/13/26 at 1:24 p.m., when queried regarding R1's missing cancer medication which was not administered to R1, RN/Unit Manager A confirmed R1's cancer medication had been sent home with R2 on 5/10/26. RN A said there was no medication inventory completed upon R2's discharged showing which medications were given to them upon discharge. RN A stated, .I called [the oncologist's office) Monday (5/11/26) around 9:00 a.m. (CST). I left a message. When asked if a progress note detailed the call to the oncologist on Monday, RN A stated, I did not put a note in on Monday. When asked if a medication error report was completed for the doses of R1's cancer medication not administered, RN A stated, I guess I just missed it (doing a medication error report) because I was under the impression he would be getting it from the pharmacy and that is why I didn't do a medication error report. When asked if there was any documentation of education provided to the involved nursing staff, RN A stated, No, [LPN C] has been off. I got a statement from her. I wrote it down. I will have to go find it. It was not put into any medical record. When asked if she had informed the Nursing Home Administrator (NHA) of investigation details and the medication errors, RN A stated, I did not talk to [the NHA] about this. When asked if there was documentation in R1's medical record that would show details of the loss of R1's medication and the lack of administration of that medication, RN A stated, I am pretty positive there is nothing in the medical record that would show that the medication was sent home with another Resident (R2).Review of a Statement obtained via phone interview on 5/13/26 at 0900 CST [10:00 Eastern Standard Time (EST)] and typed by RN A, included the following two paragraphs: Statement regarding incident occurring on 5/10/26 where a resident's medications were inadvertently sent home with another resident who discharged home. I did not know another resident's medications were sent home with the resident who discharged . I grabbed the medications and put them in a patient belonging bag along with the residents MAR to go home with the patient at discharged . Typed signatured of [LPN C]. Review of the Medication Error Policy & Procedure, reviewed 2/3/26, revealed the following, in part: It is the policy of this facility to provide protection for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors . A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders . and principles of the professional(s) providing services. Examples of medication errors include: Omission - a drug is ordered but not administered . In the event of a medication error . The following information is documented in an incident report/medication error report and in the resident's clinical record: Factual description of the medication error. Actions taken and the residents' response. Physician, Resident, and Family/Representative notification and response . Each incident report/medication error report is forwarded to: Director of Nursing, Administrator, Medical Director and Consultant Pharmacist .During the Exit Conference on 5/13/26 at approximately 3:00 p.m., the NHA and DON acknowledged the identified deficiency related to a complete and accurate medical record related to the absence of progress notes detailing R1's cancer medications being given to another resident upon discharge and the lack of progress notes and medication error reports.

This citation pertains to intake 2715858.Based on interview and record review, the facility failed to monitor urinary output for one Resident (#10) of three residents reviewed for standards of practice with indwelling catheters.Findings include: Resident #10 (R10)Review of the Electronic Medical Record (EMR) revealed R10 was admitted to the facility on [DATE] and had diagnoses including neurogenic bladder, diabetes, paraplegia, and Stage 4 sacral pressure ulcer. Review of the Minimum Data Set (MDS) assessment, dated 11/05/2025, revealed R10 had mild cognitive impairment and required substantial/maximal assistance with personal hygiene and was dependent on staff for toileting hygiene bed mobility and transfers. Section H (Bladder and Bowel), of the MDS assessment revealed R10 had an indwelling urinary catheter.Review of R10's progress notes revealed the following:12/17/2025 at 10:35 a.m. Called [acute, inpatient hospital] for an update on resident: Catheter was changed again at the hospital and is being monitored. Resident is in the hospital with heart flutter. UTI - put on antibiotics. Anemic - they administered 2 units of blood.12/16/2025 at 9:01 p.m. Resident have multiple issues with catheter after it was changed a few days ago. Urine continues to come out around the catheter, blood mixed with urine, catheter not patent, multiple times having to be flushed. At [1:45 p.m.] today I went in to check on the catheter and found resident soaked in blood from the catheter insertion site with no urine collected in the urine bag . permission to call 911 to have her transferred to the ED [emergency department] .Review of documentation in the EMR from 10/27/2025 until R10's transfer to the ED on 12/16/2025, revealed the following:Urology Consultation Note dated 10/27/2025: [R10] had a R PCN [tube inserted through the skin into the back of the kidney for drainage] . for sepsis and right hydro [Hydronephrosis: swelling of the kidney caused by back-up of urine due to a blockage in urinary tract] . she is currently at [respective long-term care facility] . isn't sure how much has been draining from the nephrostomy tube . per reports there was no stone. Today I advised a clamp trial . Today 10/27/25 [R10] follows up; her neph tube has been clamped ever since I shut it off last visit. There is no [urine] in the bag . no hydro noted in that right kidney . Based on this I did remove the right PCN today in clinic. It was noted there was no assessment of the indwelling urinary catheter noted in the urology consultation notes.11/04/2025 at 7:00 a.m. Past medical history . UTI (recent 6 weeks of cefepime and vancomycin [antibiotic] treatment) .12/16/2025 at 4:48 a.m. Resident has moderate to severe hematuria [blood in urine] .During an interview on 2/03/2026 at 11:40 p.m. the Director of Nursing (DON) was queried regarding standards of practice for residents with indwelling urinary catheters, specifically measurement and monitoring of urinary output. The DON reported that all residents with indwelling urinary catheters should have measured output documented every shift.On 2/3/2026 at 12:15 p.m. the DON stated, I have to correct myself on my earlier comment. The DON went on to state urinary output is only measured when there is a physician order to do so, even in the presence of indwelling urinary catheters. The DON was asked if urinary output should be measured as a standard of practice for a resident with an indwelling catheter who had a history of UTI and hydronephrosis with recent removal of a nephrostomy tube. The DON reported only if the physician ordered measurement of the urine. The DON was asked if R10's urine had been measured after the nephrostomy tube was removed to which she answered she would check and report back to this Surveyor.At 12:45 p.m., the DON reported R10 was being followed by the urology office, and they did not give an order to measure output from the indwelling catheter but to watch for fever and flank pain. The DON reported the foley was in place for wound healing not genitourinary issues, therefore the urologist wound not have provided a care order for the catheter. The DON confirmed she was aware R10 had a history of UTIs and hematuria but contended measurement of urinary output was not indicated. On 2/3/2026 at 2:50 p.m. the Nursing Home Administered (NHA) reported CNA (Certified Nursing Assistant] documentation from 10/2025 through 12/16/2025 states that [R10] has had output every shift since 10/2025 through when she went to the hospital 12/16/2025.Review of the CNA POC (point of care) documentation for 10/1/2025 through 12/16/2025, provided by the Director of Nursing (DON) on 2/3/2026 at 11:31 a.m. and again by the NHA on 2/3/2026 at 2:50 p.m., revealed the following: Bladder Elimination. Urinary Continence. Select the one category that best describes the resident: 0 - Continent. 1 - Incontinent. 2 - Did not void. 3 - Continence not rated due to indwelling catheter . Review of the documentation revealed R10 was consistently coded at 3 - Continence not rated due to indwelling catheter.It was noted in review of all CNA POC documentation for 10/01/2025 through 12/16/2025, there was no language or assessment indicating patency of the catheter or amount and description of urine output from the catheter.Further review of the EMR revealed no documented measured amounts of urine output from R10's indwelling urinary catheter.Review of R10's October, November and December 2025 Medication Administration Records (MARs) and Treatment Administration Records (TAR) revealed the following: Maintain foley catheter and provide care every shift . Diagnosis: retention . Start Date: 10/31/2025.It was noted no documentation was included on the MARs and TARS to include the measured amount of urine present or emptied from R10's indwelling urinary catheter, including after the catheter was changed as documented on 12/03/2025, 12/13/2025 and 12/15/2025 or after irrigation of the catheter for urinary issues as documented on 12/16/2025 at 4:51 a.m.Review of the facility policy titled Catheter Use, with a review date of 2/2/2026, revealed the following: If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures that include but are not limited to . Ongoing monitoring for changes in condition related to potential catheter-associated urinary tract infections, recognizing, reporting and addressing such changes. A review of the website National Library of Medicine revealed the following information for each website page: https://www.ncbi.nlm.nih.gov/books/NBK593198/table/ch21elimination.T.expected_outcomes_of_u/#:~:text=Urine%20output%20is%20at%20least,improvement%20after%20manipulating%20the%20tubing.Urine output is at least 30 mL/hr.Verifies correct catheter placement and appropriate kidney functioning. If urine output is less than 30 mL/hour, check tubing for kinking and obstruction, and notify the provider if there is no improvement after manipulating the tubing. https://www.ncbi.nlm.nih.gov/books/NBK606132/#:~:text=Urinary%20or%20urine%20output%20(UO,1.0%20mL/kg/h.Urinary or urine output (UO) is an important clinical indicator of renal physiology and function. Evaluating UO can provide insights into a patient's hydration status and guide subsequent management. A normal UO is approximately 0.5 to 1.0 mL/kg/h .

Based on interview and record review, the facility failed to provide adequate supervision for one Resident #1 (R1) of three residents reviewed for elopement. This deficient practice resulted in R1 leaving the facility unattended and the potential for falls and injury.This citation pertains to intake 2600151Findings include:Resident #1 (R1)Review of Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 7/24/24, with active diagnoses that included anxiety disorder, depression and non-Alzheimer's dementia. R1 scored a 7 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of severe cognitive impairment.Review of document titled Elopement dated 6/30/25, read in part .Resident was visualized by Admissions Director C ambulating towards [Name of business]. Resident entered the business. Admissions Director C notified staff she saw him walking outside. Registered Nurse (RN) D went to the [Name of business] and accompanied resident.Notes.wander guard(C) assessed upon return to the facility .wander guard(C) did not alarm at the entrance of the facility (where resident had exited) .During an interview on 9/16/25 at 11:23 a.m., Social Worker B reported that R1 prefers to be by himself and doesn't normally get dressed or up during the day.The day R1 eloped, I heard a message on the two-way radio from Admissions Director C that he was outside.I left my office and went outside.Registered Nurse (RN)D saw he was over at the bar and I went and sat with him.his family came and drove him back to the facility as he was tired.During an interview on 9/16/25 at 11:54 a.m., Admissions Director C reported I was just outside of the facility with another resident.I saw R1 coming out of the facility door with visitors and announced on the two-way radio to alert the staff in the facility and kept watching him. RN D came out of the facility and went to the [Name of the business].During a phone interview on 9/16/25 at 12:30 p.m., RN D reported I worked down a different wing that day but had heard he was outside of the facility.I walked to the area business (bar) and he was inside having a beer.Review of R1's care plan did not reveal any new interventions were added to the care plan following the elopement.During an interview on 9/16/25 at 12:27 p.m., The Nurse Manager E acknowledged no new interventions were added to the care plan following the elopement.During an interview on 9/16/25 at 2:50 p.m., The Nursing Home Administrator (NHA) and Director of Nursing (DON) acknowledged that the resident eloped from the facility and no interventions had been added to the care plan.Review of policy titled Elopement for Facilities with a Wander alert Bracelet System last revised 5/27/24, read in part Guidelines for when a missing resident has been located.the care plan is updated.resident s care plan and interventions that address the resident's needs.are reviewed and updated.Elopement is a situation in which a resident leaves the facility without the facilities knowledge.

Based on observation, interview, and record review, the facility failed to implement safety measures during transportation to an outside appointment for 1 Resident (#22) of 3 residents reviewed for accidents/hazards. This deficient practice resulted in harm for Resident #22 who sustained 4 fractures (both bones in lower legs broken), and a large laceration requiring sutures on right footAll times are in Eastern Daylight Time (EDT) unless otherwise notedFindings include:Resident #22 (R22)Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 3/15/18 with active diagnoses that included: dementia, depression, and type 2 diabetes mellitus. R22 scored 8 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of moderate cognitive impairment. During an interview on 6/24/25 at 3:41 p.m., R22 reported that her legs hurt and were painful.Review of Incident report titled Injury dated 2/3/25 read in part, .incident description per Registered Nurse (RN) N. Van driver had alerted this nurse that resident had fallen in the van .resident sitting on her butt with wheelchair on top of her and her feet extended out with ankles turned in against the front of the console area of van. Resident (R22) was wearing her boots when she left but those had fallen off when she fell Resident unable to give full description as she was in so much pain . R22 experienced facial grimacing, loud moaning or groaning, crying, short period of hyperventilation, and occasional labored breathing .injuries report post incident. Injury type and location: fracture to left lower leg and right lower leg . Further review of Incident report titled Injury dated 2/3/25 revealed a statement from Maintenance Worker/Van Driver (Staff) O read in part, . I was transporting [R22] to her appointment .Resident positioned upright in broda (type of high back wheelchair) chair .the chair tipped forward .the seatbelt was not placed (unbuckled). When the chair is reclined far back the seatbelt would not buckle.Review of progress notes revealed the following:2/3/25 at 8:30 PM Resident returned to facility via Emergency Medical Service (EMS) .Her legs are both wrapped with splints .She has bilateral (both legs) lower extremity fractures of the fibula/tibia with laceration under toes of right foot with 5 stitches .2/4/25 at 12:48 AM R22 returned from emergency room (ER) with new order for Norco . one or two tablets every six hours as needed for pain . Further review of the progress notes revealed that prior to surgery that was scheduled to occur on 2/12/25, R22 received Norco 18 times between 2/4/25 thru 2/10/25 at 7:24 AM for pain. Review of facility incident report titled Injury dated 2/3/25 read in part, Resident had ortho appointment on 2/7. Casting unable to be completed in office and resident was scheduled for closed reduction with casting on 2/12/25 to be completed in the Operating Room (OR) under anesthesia .Review of the facility progress notes dated 2/12/25 indicated R22 had returned from the hospital where R22 had to undergo casting under anesthesia due to her cognitive function to address the injuries sustained from the incident.Review of Document titled Operative Note dated 2/12/25 read in part, . [Orthopedic Surgeon's Name] .Operation: closed reduction and cast application of right tibia and fibula fractures. Closed reduction and cast application of left tibia and fibula fractures .[R22] .sustained injuries to bilateral lower legs when she fell out of her wheelchair during medical transport on 2/3/25. She was transported to the emergency department, where she was diagnosed with displaced oblique fractures of bilateral distal tibia shafts and roughly transverse fractures of bilateral distal fibula shafts . (bilateral lower leg fractures)During an interview on 6/26/25 at 1:57 p.m., the Nursing Home Administrator (NHA) acknowledged the seatbelt was not in place at the time of the incident and the seatbelt would have held the resident in place in the wheelchair when the brakes were applied. During an interview on 6/26/25 at approximately 2:00 p.m., the Director of Nursing (DON) reported that R22 screams out in pain quite often since the incident due to the bilateral lower leg fractures. During an interview on 6/26/25 at approximately 3:30 p.m., the NHA requested Past Non-Compliance (PNC) for the incident involving R22. The NHA reported she had provided the PNC to this surveyor including the incident report titled Injury.During an interview on 6/26/25 at 3:45 PM. Registered Nurse (RN) N. reported he was called by the driver of the van when [R22] fell forward in her wheelchair. The van driver came into the facility yelling that he needed help. I ran out there, and [R22] was in the back of the van. The wheelchair was on top of her, she was seated on the floor of the van both legs extended in front of her, her ankles and toes were turned inwards. It was difficult to get the wheelchair off her. R22 was moaning and in a lot of pain, both her boots had come off and her toes had been sliced and bleeding. We were able to finally get the wheelchair (which was a broda-high back style) off her. I noted at that time she had wet herself pretty good and defecated on herself. She was in pain, she had some scratches on her forehead, legs, and her toes were still bleeding. I made a call to the facility doctor, and R22 was sent out to the emergency room (ER). During an observation of the van with Staff O on 6/26/25 at 4:23 p.m., Staff O was interviewed and reported he was driving a short distance away from the front entrance of the facility (about 6 car lengths) and demonstrated where the van was when he applied the brakes. He then reported after he applied the brakes, R22 had come out of her chair. He backed up the van to the front entrance and went to get help. Staff O demonstrated where R22 was sitting on the floor of the van with the wheelchair tipped over. He demonstrated where her feet were up against the console. Staff O' reported the resident was yelling out in pain and he could not remember if he had applied the seat belt or if the wheelchair lock downs (tie downs) were in place.Review of the facility PNC which included the incident report titled Injury dated 2/3/25 read in part, .work order placed to have maintenance director assess functionality of the van .During a phone interview on 6/26/25 at 4:38 p.m., Maintenance Director P reported he had not completed a work order on the facility van to ensure the van was safe for resident transport after the incident and stated, the problem wasn't the van. During a follow up interview at 5:00 p.m., Maintenance Director P reported he does not have an annual in-service for maintenance staff on the use of the facility van, proof of education regarding use of seatbelts in the van, a completed checklist to ensure the safety of the van, and does not have the maintenance workers complete a checklist to ensure the safety of the van prior to using the van.

Based on observation, interview, and record review, the facility failed to: effectively date mark potentially hazardous ready-to-eat food products, effectively clean food service equipment resulting in cross-contamination, bacterial harborage, and the increased potential for resident foodborne illness.Findings include:During a dining observation on 6/25/25 at 8:27 AM., noted in the main dining room found in one of the cabinet drawers was a individual small cup of what appeared to be brown sugar uncovered, open to air. The drawer had multiple individual packages of jellies, straws, and random condiments. The inside of the drawers along the cabinet wall were noted to be soiled with food crumbs and sticky substances. In a cupboard above the refrigerator a was clear storage container of yellow popcorn kernels. The container was noted to be yellowing, sticky, and grimy/greasy to the touch there was no date or label on the popcorn. Continued observations of dining on 6/25/25 at 8:59 AM., noted multiple packages of cubed swiss cheese, cheddar cheese and pepper jack cheese, multiple packages (tubes) of summer sausage on the refrigerator shelves. In the bottom of the refrigerator right side drawer was a gallon size baggie of sliced summer sausage which was approximately half full. The baggie of summer sausage had no label, date or use by date. There was no description of food item (summer sausage), and the pieces of sliced sausage appeared dried out. Also noted in the bottom right drawer was 1 bag of each type of cubed cheese in the bottom drawer (swiss cheese, pepper jack and cheddar) were noted to have no open date or use by date on them. In an interview on 6/25/25 9:10 AM., Activity Director (AD) K reported she the summer sausages and cubed cheese was in the refrigerator in the main dining room because it was used for residents and family for a Father's Day celebration (6/15/25). AD K reported she did not know she was supposed to label and date any food item that she used and had ordered through the kitchen for activities. AD K reported she would throw away the summer sausage and cheeses that had no open date on them. On a return visit to the main dining room [ROOM NUMBER]/26/25 at 2:34 PM., noted in the bottom right drawer was 1 bag of each type of cubed cheese in the bottom drawer (swiss cheese, pepper jack and cheddar) were noted to have no open date or use by date on them. Review of a facility Policy & Procedure with a revision date of 12/26/22 revealed: Department: Food and Nutrition Services It is the policy of this facility to provide sufficient storage to keep foods safe, wholesome and appetizing, according the USDA Food Code guidelines .Compliance Guidelines It is the responsibility of the Dietary staff and supervisors to ensure that food is stored, labeled and used within the recommended time guidelines to prevent food borne illness. a. Temperatures of the food storage areas, including dry storage, refrigeration and freezers shall have thermometers and be monitored and recorded daily.b. Foods must be rotated using the FIFO method in all storage areas.c. Guidelines for food labeling and dating must be adhered to by all food service personnel and closely monitored by the food service manager. All employees who provide patient/resident assistance with meals will be trained and shall demonstrate competency in the prevention of foodborne illnesses 10. All foods removed from original packing and must have an arrival date. If food has a manufacturers expiration date, an open date will be added to the label, which includes food like: cottage cheese, bulk yogurt, sour cream etc11. All food packaging that is open for use and returned like deli meat must be labeled with arrival date and open date. 12. Leftover foods must be immediately frozen, labeled and dated for later use. If refrigerated, the food must be discarded within 72 hours .

Based on observation, interview, and record review the facility failed to maintain a clean, comfortable environment throughout the facility and maintain clean sanitary linens and shower rooms for shared resident use. This resulted in a potential decreased satisfaction of living conditions and an increased potential for a bacterial harborage for residents residing in the facility.All times are in Eastern Daylight Time (EDT) unless otherwise notedFindings include:In an observation on 6/24/25 at 12:15 PM., upon entering the facility for annual recertification it was noted walking through the main door into the main common area that a strong smell of urine and musty warm air was evident. There were multiple residents in the main common area watching TV. The carpet was noted to be heavily soiled throughout the common area and the entire 2nd floor carpeting along the corridors/units had multiple stains, and an overall dirty appearance. There were floor box fans blowing warm air through the building.During an environmental tour on 6/25/25 at 3:21 PM., prompted by initial observations on entrance and comments made during a private resident council meeting held by the survey team, residents voiced frustrations about a strong urine smell in the facility, soiled carpeting, soiled linens and overall dissatisfaction with the cleanliness of the facility. Observation of the lower 1st floor shower room noted the following: a cart with multiple random items strewn about including adult pull up briefs, soiled wash cloths, rolls of clear garbage bags, random pieces of paper. Located in the 2nd stall shower/bath area was a shelf unit with different types of adult briefs strewn about not organized to style or size of briefs. 2 shower chairs made of white PVC with blue and pink mesh backing had strong odor of urine, underneath the bottom of the shower chairs were visible yellow/dark orange discoloration in the crevasses and along the frame underneath the seats. The shower/bathroom it was noticed there were no bath towels, hand towels or washcloths. There were approximately 6 flat sheets, 6-8 pillowcases. The shower/bathroom showers had shower curtains hanging that were yellowing at the top (mesh) torn and tattered in various spots on the curtain itself. The shower curtains appeared dated and worn.Further environmental observations on 6/25/25 at 4:07 PM., the 1st floor linen room had approximately 12 bath towels, all which were noted to be dingy white/gray in color, thin in texture and heavily stained. 13 hand towels noted which were all dingy white in color, thin in texture and multiple stains were noticed during the inspection. The washcloths which were all noted to be very dingy white/gray in color, stained and could not differentiate if they were used for cleaning or resident care.Further environmental observations on 6/25/25 at 4:14 PM., the 2nd floor clean linen room inspection revealed resident clothing protectors were like bath towels in texture and were dingy white/gray in color with multiple stains observed on them. The bath towels were old in appearance, abrasive to the touch and dingy white/gray in color along with multiple stains. Hand towels inspected were all heavily used in appearance and color, dingy white/gray with stains. A stack of clean wash clothes inspected were very tattered/torn and dingy in color. This surveyor could not differentiate whether the washcloths were used for cleaning, or they were actual resident washcloths. The linens in the linen room were all in poor condition. Bed sheets, blankets and covers inspected in the linen room on the 1st floor also were noticed to be worn and old in appearance, along with the linen room having a muggy/malodorous smell to it.In an interview on 6/25/25 at 4:30 PM., Certified Nurse Aide (CNA) D reported he was unsure when new linens are ordered. CNA D reported the linens are used for all residents and they are not separated from what areas of the body wash their faces, or peri-areas. CNA D reported residents share linens including washcloths which seem quite old and dingy as well as rough/abrasive on the skin.In an interview on 6/25/25 at 4:45 PM., CNA C reported the linens which are stocked in the linen rooms/shower rooms are where the staff get towels, sheets, washcloths and other linen items. CNA C reported he has noticed many linens, towels and clothing protectors were in an older condition, he was not sure when and how often the facility gets new linens. During a second environmental inspection on 6/26/25 at 10:30 AM., the 1st floor shower room was observed again with no change. The room and equipment/resident shower chairs and shower curtains were noted to not unchanged/cleaned from the first inspection on the environmental tour on 6/25/25 at 3:21 PM. The pink mesh/PVC shower chair first noticed was now in a shower and was noted to have long dark strands of hair on the seat.Further environmental inspections conducted on 6/26/25 at 10:41 AM., noted a linen cart in the 1st floor shower room which housed multiple thin bath towels which were dingy white/gray in color, abrasive to the touch and multiple stains were noted on them. The hand towels were all noted to be dingy/stained in appearance, and the washcloths were noted to be stained, dingy and tattered/thin and abrasive to the touch.In an interview on 06/26/25 at 10:47 AM., Laundry/Housekeeping Manager (Staff) L reported she and one other housekeeping/laundry staff member put the clean linens out into the linen rooms, and shower rooms, as well as on the linen carts that are housed on the 2nd floor resident units. Staff L reported any time a towel or linen is soiled and stained it is immediately discarded, and new lines/towels are put out.On 6/26/25 at 11:12 AM., Staff L accompanied this surveyor to the shower room on the 1st floor to observe bath towels, hand towels, linens and shower curtains and the overall condition of carpets, and other environmental housekeeping areas. When this surveyor showed Staff L the multiple areas and linens that were soiled, stained tattered and torn Staff L reported the towels should not look like that and indicated they should be clean, white and stain free. Staff L reported the shower curtains should be clean and free of holes and replaced or rotated when visibly soiled. Staff L reported she herself would not want to use any of the linens this surveyor inspected with her.Review of a facility Policy Title: Terminal Cleaning and Disinfecting of Resident Rooms With a revision date of 1.10.2024 revealed: Cleaning considerations include but are not limited to: Obtain cleaning care and appropriate supplies and EPA approved disinfectants Keep the cart with supplies at the door Bring in the supplies needed for the cleaning process Change mop bucket water between rooms and when visibly dirty Clean the resident bedroom area before the resident bathroom In multi-occupancy rooms, clean each bedroom area (surfaces, furniture, etc.) separately to avoid cross-contamination Clean from top to bottom to prevent dirt and microorganisms from dripping or falling and contaminating already cleaned areas. (i.e. clean surfaces before cleaning floors) Clean low-touch surfaces before high-touch surfaces. Clean in a systematic manner to avoid missing areas - for example left to right or clockwise. Clean prior to disinfecting as recommended by the manufacturer of the product(s) being used for transmission-based precautions. Follow the manufacturer instructions for use of all cleaning and disinfection products (i.e. concentration, application method, contact time, etc.)

Based on observation, interview, and record review the facility failed to appropriately assess one (Resident #60) out of four residents reviewed for safe self-administration of medication clinically appropriate. Findings include:All times are in Eastern Daylight Time (EDT) unless otherwise notedResident #60 (R60)On 6/24/25 at 2:37 PM, an observation and interview were conducted with R60 in their room. R60 was asked if they had any pain and R60 responded, Yes, normally at night and I take aspirin at night because of the pain from my recent shingles. R60 stated that she keeps the medication in her purse that her daughter brought in for her. R60 then showed this surveyor the medications that they had in their purse which contained acetaminophen 500 mg (milligrams), a stool softener, and a laxative. R60 then stated that she could take the acetaminophen every four hours if she wanted, and their clothing often irritated her skin where the shingles had been. On 6/25/25 at 9:10 AM, during an interview with R60 who was asked how their pain was today, replied, During the night the whole side of my body just aches. I take two acetaminophen's every four hours just to get some sleep. R60 was asked what her pain level was currently and replied, It is a 5. On 6/25/25 at 10:00 AM, an interview was conducted with Registered Nurse (RN) T who was asked if R60 had an order or assessment to self-administer medication or if RN T was aware R60 had medication in their room and replied, No. I was not aware that the resident (R60) had medication in their room. R60 lacked an assessment to self-administer medications for the acetaminophen, bisacodyl (stool softener), and bismuth subsalicylate (stomach and diarrhea relief) they were in possession of. Review of R60's physician order, dated 1/17/25, revealed an order for acetaminophen 325 mg, give 650 mg by mouth every 4 hours as needed for pain, and do not exceed 3 grams/day. Review of R60's medication administration record, dated 6/1/25 through 6/26/27, revealed acetaminophen 650 mg was administered on 6/5/25 at 7:44 AM and no other administrations were recorded.On 6/26/25 at 12:35 PM, an interview was conducted with the Nursing Home Administrator (NHA) who was asked if residents were able to self-administer medications and replied, Yes, but they need an assessment, a physician order and it also needs to be care planned. Review of policy titled, Medication Self-Administration, dated 6/25/24, read in part, Policy Overview: Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Guidelines: Each resident is offered the opportunity to self-administer medications. If the resident requests to do so, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident .The Medication Self-Administration Safety Screen in (computer electronic medical record name) will be completed by the licensed nurse .If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the physician orders, medical record, and the care plan .Self-administered medications are stored in a safe and secure place, which is not possible in the resident's room, (i.e. locked box, lockable drawer, lockable cabinet, etc.) .Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party .

All times are in Eastern Daylight Time (EDT) unless otherwise noted.Based on interview and record review, the facility failed to ensure three Residents (#14, #18, & #57) of four residents reviewed for hospitalizations were provided with written notification of the bed hold policy when the residents were transferred to the hospital. Findings include:Resident #18 (R18) During an interview on 6/25/25 at 11:17 AM, R18 indicated they had been out to the local hospital during their stay at the facility a couple times, however they were not sure of the exact date.The medical record for R18 revealed a transfer to the hospital on 1/31/25 with a readmission on [DATE] and a second transfer to the hospital on 5/1/25 with a readmission on [DATE]. The medical record did not indicate a bed hold policy for either transfer was provided to R18 or their responsible party.Resident #57 (R57) During an interview on 6/24/25 at 12:54 PM, R57 indicated they had been out to the local hospital during their stay at the facility a few times, however they were unsure of the exact date.The medical record for R57 revealed a transfer to the hospital on 1/8/25 with a readmission on [DATE] and a second transfer to the hospital on [DATE] with a readmission on [DATE]. The medical record did not indicate a bed hold policy for either transfer was provided to R57 or their responsible party.Review of the policy titled, Transfers and Discharges, dated 4/18/25, read in part, Policy Overview: The purpose of this policy is to provide guidelines for the safe transfer and discharge of a resident across the continuums of care. General Guidelines .If the resident is admitted to the hospital the Admissions Director or designee will send the resident's representative a copy of the bed hold policy and transfer notice . Resident #14 (R14) R14 was admitted to the facility 11/13/24. The medical record revealed R14 was transferred to the hospital on 2/16/25, 3/20/25, and 6/9/25. The medical record did not indicate the facility provided written notice of the bed hold policy, including the duration of the bed hold, to R14 or the Resident Representative (RR) of R14 at the time of transfer to the hospital.

All times are in Eastern Daylight Time (EDT) unless otherwise noted.Based on observation, interview, and record review, the facility failed to provide grooming and hand hygiene to one Resident (R30) of two residents reviewed for Activities of Daily Living (ADL). Findings include: All times are in Eastern Daylight Time (EDT) unless otherwise noted.Resident #30 (R30) was admitted to the facility 1/23/25 with diagnoses that included but were not limited to: metabolic encephalopathy (brain dysfunction), liver cancer, and muscle weakness.On 6/24/25 at 2:20 PM, R30 was observed sleeping in a recliner next to his bed. R30 was noted with visibly soiled hands with a brown-colored substance encrusted under the fingernails of each finger of both hands. The brown substance was embedded around the edges of each fingernail on both hands. A Minimum Data Set (MDS) assessment dated [DATE] documented R30 had impaired functional range of motion to both upper extremities and both lower extremities. The MDS indicated a Brief Interview for Mental Status (BIMS) score of 12 indicating R30 had moderate cognitive impairment. Further review of the MDS revealed R30 received chemotherapy for cancer treatment and required moderate assistance with personal hygiene tasks. The MDS documented R30 was frequently incontinent of bowel and bladder.The care plans for R30 included a care plan for ADLs. The care plan disclosed R30 had an ADL self-care performance deficit related to weakness, decreased mobility, fall with lower back strain and left ankle sprain resulting in altered mobility and pain. The care plan indicated R30 refused assistance at times with transfers, ambulation, wound treatments, and incontinence care and brief changes. The ADL care plan documented R30 required one-person staff assistance with personal hygiene. An intervention for bathing and showering read: BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. R30's Kardex (a summary of information provided to Certified Nurse Aides (CNA) to direct resident-care needs, including ADL needs) also documented BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. The Electronic Medical Record (EMR) of R30 was reviewed on 6/24/25 and disclosed a form dated 6/18/24 that documented a skin assessment. Section 3 of the form read: Bathing/Shower offered and the documented response was yes. The following portion read Bathing/Shower response and the answer was received. The form did not include documentation of fingernail appearance or hygiene. CNA Tasks in the EMR did not include documentation of fingernail hygiene. Progress notes in the EMR did not document regarding hand or fingernail hygiene.Behavior documentation tasks in the EMR of R30 were reviewed. There were no documentation entries of R30 refusing care. The documentation response was none of the above observed for each entry including the rejection of care section. R30 was interviewed on 6/25/25 at 2:37 PM. Both hands and all fingernails remained visibly soiled with the brown-colored substance remaining under the nails of both hands and around the nail perimeter of each nail of both hands. R30 was asked if he was provided hand hygiene prior to eating meals or when needed. R30 said, No, they don't help me much. R30 was agreeable when asked if he would like his hands and fingernails cleaned. CNA C was outside R30's room in the hallway. CNA C was asked on 6/25/25 at approximately 2:45 PM if R30 refused to allow staff to clean his hands and fingernails. CNA C said R30 refused care at times, but did not recall R30 ever refusing hand and fingernail hygiene. CNA C was asked when R30 last had his hands and fingernails cleaned. CNA C said he did not know. CNA C was requested to visualize the hands of R30. CNA C said they had not noticed how dirty R30's hands and nails were and said the hands and fingernails of R30 would be cleaned immediately.On 6/26/25 at 11:36 AM, the hands and fingernails of R30 appeared to be clean. R30's hands were no longer visibly soiled, and the brown substance under and around his nail beds was no longer visualized.06/26/25 12:47 PM DON interviewed. She said nail care should be provided during showers and PRN when soiled or nails are long. said shower sheet documents if nail care was provided. The policy Activities of Daily Living (ADL) dated as revised 12/7/23 read, in part: .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, personal, and oral hygiene.Appropriate care and services will be provided for residents who are unable to carry out ADL independently. The amount of assistance the resident needs to complete their ADL care will be documented in the resident's care plan and on the resident's Kardex.

Based on observation, interview, and record review the facility failed to ensure intravenous (IV) site procedure was documented, dated when initiated and orders were in place to ensure the site was changed per standards of practice for one (Resident #18) of one resident reviewed for quality of care. All times are in Eastern Daylight Time (EDT) unless otherwise notedFindings include: Resident #18 (R18)Review of R18's electronic medical record (EMR) revealed initial admission to the facility on 4/30/25 with diagnoses including diabetes mellitus, dementia, urinary tract infection with indwelling urinary catheter, and heart failure. On 6/25/25 at 3:13 PM, an observation was made of R18 during medication pass. R18 was observed to have an IV site in their left lower extremity in their forearm that had a dressing that was not dated. On 6/25/25 3:20 PM, an interview was conducted with Licensed Practical Nurse (LPN) U who was asked if the IV site needed to be dated and replied, Yes, and the current one needs to be replaced if there is no date because I don't know how long it has been there. Review of progress note, dated 6/22/25 at 12:27 AM, read in part, Resident peripheral IV placed in left forearm by integrity . The progress note lacked the size, attempts, and resident comfort of the IV placement process. Review of R18's physician orders, dated June 2025, revealed the lack of an order to change the IV site every 72 hours. On 6/26/25 at 12:30 PM, an interview was conducted with the Nursing Home Administrator (NHA) who was asked what their expectations were for IV management and replied, The dressings needed to be dated and the IV site should be changed every 72 hours or sooner if it appears infected or is not flushing properly. Review of the policy titled, Catheter Insertion and Care, date revised July 2016, read in part, Policy: Administration sets and tubing will be changed at specific intervals in order to prevent infections associated with contaminated IV therapy equipment. General Guidelines .

Based on observation, interview, and record review the facility failed to appropriately maintain and store respiratory equipment in a sanitary manner for one (Resident #31) of one resident reviewed for respiratory care. All times are in Eastern Daylight Time (EDT) unless otherwise noted.Findings include:Resident #31 (R31)Review of R31's electronic medical record (EMR) revealed initial admission to the facility on 1/7/25 with diagnoses including dementia, respiratory failure, depression, and heart failure. On 6/24/25 at 2:17 PM, an observation was made of R31 lying in their room in their bed. R31 was wearing a nasal cannula (soft plastic tubing to deliver oxygen to the nose) delivering oxygen from a concentrator at two liters and had a humidifier connected that was empty and not dated. R31 had a nebulizer lying on their bed with condensation and a small amount of medication in the cup.On 6/24/25 at 2:20 PM, an interview was conducted with R31 who was asked if the staff rinse out their nebulizer and replied, The nurse just comes in and puts the medication in it and turns it on and leaves. R31 was asked how long their humidifier had been empty and replied, I am not sure. Yesterday I had a couple drops of blood on my pillow. R31 was asked if they had a bloody nose and replied, Yes. On 6/24/25 at 2:27 PM, an interview was conducted with Registered Nurse (RN) T who was asked how often the humidifiers are replaced on the oxygen concentrators and replied, Once a week. On 6/24/25 at 3:35 PM, an observation was made of R31's respiratory equipment. R31's humidifier was not dated when the last time it was replaced, and their nebulizer was left intact with visible condensation in the medication cup on their bedside table. Review of R31's physician order, dated 6/21/25, revealed ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg(milligrams)/3 ml(milliliter), 1 vial inhale orally four times a day for dyspnea (shortness of breath), 0800, 1200, 1700, and 2100. Review of R31's physician order, dated 3/10/25, revealed oxygen delivered via NC (nasal cannula), liter flow: 2 liters, duration: continuous, every shift for breathing.On 6/26/25 at 9:45 AM, an observation was made of R31's respiratory equipment. R31's nebulizer was left intact with visible condensation in the medication cup on their bedside table. On 6/26/25 at 12:30 PM, an observation was made of R31's respiratory equipment. R31's nebulizer was left intact with visible condensation in the medication cup on their bedside table. On 6/26/25 at 12:35 PM, an interview was conducted with the Nursing Home Administrator (NHA) who was asked what their expectation were for respiratory equipment sanitation and maintenance and replied, The bubblers should be inspected every shift, and the nebulizers should be rinsed out after every use and set to dry and then stored in a bag for sanitation. Review of policy titled, Oxygen Equipment: Cleaning, Masks, Updraft/Nebulizer, Oxygen Concentrator Filter and Tubing, dated 8/8/22, read in part, Policy: It is the policy of the Facility to maintain oxygen concentrator equipment in a clean manner. Compliance Guidelines .3. Oxygen humidifiers will be checked daily and replaced weekly and PRN (as needed). All humidifiers shall be dated .Cleaning updraft nebulizer: 1. After each use, remove nebulizer T-piece and mouthpiece or mask. Disassemble nebulizer chamber by turning clockwise. 2. Rinse T-piece and mouthpiece or mask with clear hot tap water. Air-dry on clean towel at bedside .

All times are in Eastern Daylight Time (EDT) unless otherwise noted.Based on observation, interview, and record review the facility failed to appropriately maintain and store respiratory equipment in a sanitary manner for one (Resident #31) of one resident reviewed for respiratory care. All times are in Eastern Daylight Time (EDT) unless otherwise notedFindings include:Based on observation, interview, and record review the facility failed to appropriately assess one (Resident #60) out of three residents reviewed for pain management. Findings include:Resident #60 (R60) On 6/24/25 at 2:37 PM, an observation and interview were conducted with R60 in their room. R60 was asked if they had any pain and R60 responded, Yes, normally at night and I take aspirin at night because of the pain from my recent shingles. R60 stated that she keeps the medication in her purse that her daughter brought in for her. R60 then showed this surveyor the medications that they had in their purse which contained acetaminophen 500 mg (milligrams), a stool softener, and a laxative. R60 then stated that she could take the acetaminophen every four hours if she wanted, and their clothing often irritated her skin where the shingles had been. On 6/25/25 at 9:10 AM during an interview with R60 who was asked how their pain was today and replied, During the night the whole side of my body just aches. I take two acetaminophens every four hours just to get some sleep. R60 was asked what her pain level was currently and replied, It is a 5. On 6/25/25 at 10:00 AM, an interview was conducted with Registered Nurse (RN) T who was asked if R60 had an order for to assess for pain each shift and if staff were monitoring R60's pain related to their recent shingles outbreak and replied, Each resident is assessed for pain each shift and R60 should have a pain assessment at least once a day. RN T was asked if they were aware that R60 had pain from their shingles that made it difficult for them to fall asleep at night and their clothing irritated their skin and replied, No, but I will go and check on them now. Review of progress note, dated 6/4/25 at 11:11 AM (Central time), read in part .res (resident) reports ‘terrible' pain in shingles areas. Areas located on chest and upper back. Review of progress note, dated 6/17/25 at 3:51 PM (Central time), read in part .stated that she if feeling better and has pain. The area is now scabbed over. Review of progress note, dated 6/25/25 at 4:16 PM (Central time), read in part .Resident is alert and oriented, with a Brief Interview for Mental Status (BIMS) score of 15. Resident is asking that she be able to keep the following meds at bedside and self-administer: [name brand acetaminophen]. Review of progress note, dated 6/26/25 at 6:37 AM (Central time), read in part, Resident reports having pain from her shingles.She requests to only take ES (extra strength) [name brand acetaminophen] and scheduled Aspirin for pain relief . Review of progress note, dated 6/26/25 at 6:41 AM (Central time), read in part, .My rash (points to the shingles area on chest) hurts, especially at night and the [name brand acetaminophen] helps me sleep. Review of R60's physician order, dated 1/17/25, revealed an order for acetaminophen 325 mg, give 650 mg by mouth every 4 hours as needed for pain, and do not exceed 3 grams/day. Review of R60's physician order, dated 5/27/25, revealed an order for valacyclovir, give 500 mg by mouth two times a day for Shingles for 7 days. Review of R60's medication administration record, dated 5/1/25 through 6/26/27, revealed administered acetaminophen 650 mg on 5/27/25 at 7:02 PM, 5/31/25 at 7:59 AM, 6/5/25 at 7:44 AM and no other administrations. Review of R60's pain level, dated 5/27/25 through 6/5/25 revealed the following: 6/5/2025 11:14 0 Numerical 6/5/2025 07:44 4 Numerical 5/31/2025 10:06 0 Numerical 5/31/2025 07:59 4 Numerical 5/27/2025 20:41 2 Numerical 5/27/2025 19:02 7 Numerical No other pain evaluations recorded and R60 continued to experience pain. Review of R60's physician order, dated 5/24/25, revealed an order for pain evaluation, but under order type indicted no documentation was required. Review of R60's care plan, dated 7/15/24, read in part, .Focus: At risk for pain r/t (related to) impaired mobility. Goal: Pain goal is a zero until next review. Target date: 7/21/25. Interventions: Administer pain medication as ordered. Monitor for effectiveness. Review of R60's care plan, dated 5/27/24, read in part, .Focus: The resident has Shingles. Goal: The resident will be free from complications related to infection through the review date. Interventions: Administer anti-viral as per MD (medical doctor) orders. R60's care plan lacked any interventions or acknowledgment of pain from having shingles. Review of policy titled, Pain Management, dated 4/18/24, read in part Policy: The purpose of this policy is to provide guidelines to prevent and/or manage both acute and chronic pain. General Information: Pain is a highly subjective and personal experience which is impacted by one's previous experiences with pain.Recognition and Evaluation of Pain: Pain is evaluated and documented.When the resident has a new pain or worsening of existing pain utilizing the Pain Evaluation UDA within the resident's electronic health record.Treatment and Management: The individualized comprehensive care plan addresses the pain management program.Monitoring and Modifying Approaches: Licensed nurses will routinely evaluate the resident's pain using the appropriate standardized pain scale.

All times are in Eastern Daylight Time (EDT) unless otherwise noted Based on observation, interview, and record review the facility failed to store medication in a secure and safe manner and ensure expired medication was disposed of in the active medication cart for three (Residents #33, Resident #57, and Resident #60) of 18 reviewed and one of two medication carts reviewed for medication storage.Findings include:Resident #33 (R33) Review of R33's medication administration record (MAR), dated June 2025, revealed a physician order for insulin glargine subcutaneous solution pen-injector 100 units/ml (milliliter), inject 14 units subcutaneously at bedtime for DMII (diabetes mellitus type 2), start date 3/10/25 at 1900 (7:00 PM), and administered on 6/24/25 at 7:00 PM. On 6/25/25 at 10:15 AM, a review of the medication cart for the South second floor end, revealed an insulin glargine subcutaneous solution pen-injector 100 units/ml with an opened date of 5/26/25 and an expiration date of 6/23/25 in the active medication cart. This insulin pen should have been discarded and was used on 6/24/25 for R33 at 7:00 PM. The medication cart for the South second floor end also had one loose pill that was round, orange, and with imprint of 20 that was unable to be identified and three small pieces of a white pill that were broken and lying in the base of the second drawer. On 6/25/25 at 10:20 AM, an interview was conducted with Registered Nurse (RN) T who was asked if any loose medications or outdated medications should be left in the medication carts and replied, No, the night shift nurse should have cleaned and discarded any loose or expired medications. RN T confirmed that R33 received the insulin glargine 14 units on 6/24/25 when the pen should have been discarded and replaced. On 6/26/25 at 12:00 PM, a follow-up review of the medication cart for the South second floor end was conducted and found to still contain the insulin glargine subcutaneous solution pen-injector 100 units/ml with an opened date of 5/26/25 and an expiration date of 6/23/25 in the active medication cart. RN T was asked if R33 had another insulin pen and why the expired insulin pen remained in the cart and replied, I don't know, but I am throwing this out and will see if there is another pen. RN T confirmed that R33 received the insulin glargine 14 units on 6/25/25 again when the pen should have been discarded and replaced. Resident #57 (R57) On 6/24/25 at 12:54 PM, an observation was made of R57 lying in their bed resting. R57's room was observed to have a small bottle of Nystatin powder on the dresser with their name on the bottle. R57 was unable to recall why the bottle was there. Review of R57's order recapitulation, dated 1/30/25 through 6/25/25, revealed an order for Nystatin powder, apply to groin topically every shift for incontinence; rash, dated 2/6/25 and discontinued on 2/7/25. Another order for Nystatin powder on 2/7/25 to be applied topically every evening shift for fungal/yeast and to discontinue once resolved and apply to groin topically every day shift for fungal/yeast and to discontinue once resolved and discontinued on 3/11/25. A third order for Nystatin powder started on 3/14/25 for the same reason and discontinued on 3/27/25. R57 did not have any further orders for the Nystatin powder and should have been discarded and not left in their room. Resident #60 (R60) On 6/24/25 at 2:37 PM, an observation and interview were conducted with R60 in their room. R60 was asked if they had any pain and R60 responded, Yes, normally at night and I take aspirin at night because of the pain from my recent shingles. R60 stated that she keeps the medication in her purse that her daughter brought in for her. R60 then showed this surveyor the medications that they had in their purse which contained acetaminophen 500 mg (milligrams), a stool softener, and a laxative. R60 then stated that she could take the acetaminophen every four hours if she wanted, and their clothing often irritated her skin where the shingles had been. On 6/25/25 at 9:10 AM during an interview with R60 who was asked how their pain was today and replied, During the night the whole side of my body just aches. I take two acetaminophens every four hours just to get some sleep. R60 was asked what her pain level was currently and replied, It is a 5. On 6/25/25 at 10:00 AM, an interview was conducted with Registered Nurse (RN) T who was asked if R60 had an order to self-administer medication or had an assessment to self-administer medication or if they were aware that R60 had medication in their room and replied, No. I was not aware that the resident (R60) had medication in their room. R60 lacked an assessment to self-administer medications for acetaminophen, stool softener, and laxative. Review of R60's physician order, dated 1/17/25, revealed an order for acetaminophen 325 mg, give 650 mg by mouth every 4 hours as needed for pain, and do not exceed 3 grams/day. Review of R60's medication administration record, dated 6/1/25 through 6/26/27, revealed administered acetaminophen 650 mg on 6/5/25 at 7:44 AM and no other administrations. On 6/26/25 at 12:35 PM, an interview was conducted with the Nursing Home Administrator (NHA) who was asked if medications should be stored in resident rooms and if expired medication should be left in the active medication cart supply and replied, No, expired medications are to be discarded and no medications should be left in resident rooms unless they are able to self-administer and have proper assessment and order to do so. Review of policy titled, Medication and Treatment Storage, dated 8/7/23, read in part, Policy Overview: It is the policy of this facility to ensure accurate labeling and dating of medications and treatments for safe administration and safe and secure storage (including proper temperature controls, appropriate humidity and light controls, limited access, and mechanisms to minimize loss or diversion) of all medication and treatments. General Guidelines: All medications and biologicals will be stored in locked compartments.Expired, discontinued, or deteriorated drugs or biologicals will be returned or destroyed per pharmacy return/destruction guidelines.

This deficiency pertains to Intake MI00151603. Based on interview and record review, the facility failed to promptly resolve grievances for one Resident (R6) of three residents reviewed for grievances. This deficient practice resulted in resident frustration and dissatisfaction when missing personal items were not found or replaced. Findings include: All times noted are Eastern Daylight Savings Time (EDST). Review of R6's Minimum Data Set (MDS) assessment, dated 1/16/25, revealed R6 was admitted to the facility on [DATE] with diagnoses that included: cancer, neurogenic bladder, anxiety disorder, depression, and unspecified mood disorder. R6 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition. During an interview on 4/30/25 at approximately 11:30 a.m., R6 reported the following items were missing and had not been located by the facility: a small pouch, mother's engagement and wedding rings, two mother's rings, a ring her brother made for her, a tennis bracelet, a golden girls blanket, a light jacket, a sweater, a shirt, and a pair of sweat pants. R6 stated, I would guess it (jewelry) disappeared a couple of months ago. They (facility staff) tore this room apart, so I don't know what would have happened to it. When asked about the clothing, R6 stated, I distinctly remember the aide walking out (of the room) with it (clothing), and the laundry said it never came down . They took the blanket, jacket, sweater, and my pants. They were all together. R6 said she filed three complaints (Concern/Grievance Forms) and was told they (facility) was going to replace the things. On 5/1/25 at 9:36 a.m., the Social Services Coordinator (Staff) F provided two Concern Forms completed for R6 regarding missing items on the following dates: 12/17/24: [R6] states items are missing from her room. Golden girls blanket with cartoon gold girls, black velvet jacket with red polka dots down the sleeves, Golden girls pouch - has her mother's wedding rings in it. [NAME] spiral notebook. She said these items have been missing for about a week. Spoke to laundry and looked around in laundry. [Laundry] says they never came down. 3 sports bras - also missing pink slipper with strap across the front. 1/20/25 Replaced slippers. Signed by Staff F. 1/18/25: Missing her Golden Girls blanket, nightgown - blue with seahorses is missing. Golden Girls makeup bag and contents of parents' wedding rings, tennis bracelet, hair pick etc. all missing and black polka dot jacket. Resolution: Yes - Describe resolution: 1/20/25: Looked in laundry and patient room. Could not locate. Laundry never saw the stuff. 1;30/25: [R6] told to pick out items and let Staff F know and facility will purchase items on her patient inventory list including, 1 night gown, 1 jacket, Golden girls blanket and pouch, hair pick, 3 sports bras. 4/30/25: [Staff F] reminded [R6] about picking out items so facility can purchase for her. The method used to notify the complainant of resolution, date of resolution, and documentation of whether the complainant was satisfied with the resolution were all absent completion details. On 5/1/25 at 10:45 a.m., Staff F provided the Resident Personal Effect Inventory for R6, dated 1/20/25, Review of R6's complete medical record by Staff F, ADON/RN B and this Surveyor failed to locate any Personal Effect Inventory completed at the time of admission (10/14/24). R6's Resident Personal Effect Inventory was completed following the submission of two missing items concern forms to the facility. Review of the Resident Missing Items policy, dated 10/1/2007, revealed the following, in part: All missing items will be investigated . A report of loss will be filled out by the person who receives a complaint of loss from a resident or family member at the time it is reported . The Department Manager/Director is required to move the process towards resolution within the designated time frame of two weeks. During an interview on 5/1/25 at approximately 12:00 p.m., the NHA was asked about R6's missing items and concern forms. The NHA stated, If I get a concern form, I send it out to the department that it affects. It is up to each one of them (department heads) to investigate and resolve the concern form. Generally, if they are missing items they go to Staff F. R6's Concern Forms were reviewed with the NHA in relation to the facilities' Resident Missing Items policy. The NHA expressed understanding of this Surveyors concerns with the lack of resolution to R6's written concerns/grievances/missing items.

Based on observation, interview, and record review, the facility failed to ensure a urinary nephrostomy drainage bag was maintained to prevent contact with contaminated surfaces or garbage for one Resident (R6) of one resident reviewed for catheter care. This deficient practice resulted in the increased risk of contamination of the urinary drainage bag and increased risk of urinary tract infection (UTI) for R6. Findings include: This deficiency pertains to Intake MI00152512. All times noted are Eastern Daylight Savings Time (EDST). During an interview and observation on 4/30.25 at 11:28 a.m., R6's nephrostomy urinary drainage bag was observed clipped to the bed linen on the right (exit) side of R6's bed, with the urinary drainage bag hanging down into R6's garbage can which contained various garbage items. No privacy/dignity cover was observed on the urinary drainage bag and the weight of the urine looked as though it continued to lower the bag into the garbage. When R6 was asked about the urinary drainage bag from their nephrostomy being in the garbage can, R6 stated, No, it should not be in there. When asked about UTI's, R6 stated, Oh God. I can't tell you how many I have had. I had one recently that was so bad that I had to have an IV (for antibiotics). Review of R6's Minimum Data Set (MDS) assessment, dated 1/16/25, revealed admission to the facility on [DATE], with diagnoses that included: cancer, neurogenic bladder, anxiety disorder, depression, and unspecified mood disorder. R6 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition. During an interview on 4/30/25 at 12:45 p.m., the Nursing Home Administrator (NHA) was advised of this Surveyors' observation of the nephrostomy urinary drainage bag being in R6's garbage can. The NHA acknowledged it would be an infection control concern as R6 was easily susceptible to UTI's. Assistant Director of Nursing (ADON)/Registered Nurse (RN) I entered the NHA's office and instructed RN I to go to R6's room and remove the nephrostomy urine drainage bag from the garbage can. RN I acknowledge this concern and indicated it would be an infection control problem. During an interview on 5/1/25 at 12:14 p.m., RN I confirmed they had gone into R6's room and the nephrostomy bag was placed in a dignity cover so it would lower into the cover instead of into the garbage can. RN I confirmed the bag was clipped to a sheet, but with the weight of the urine it had lowered into the garbage can. Review of R6's Altered Elimination Care Plans revealed the following interventions: .Be mindful of presence of nephrostomy tubes with cares . Dated 8/12/2024, .Ensure nephrostomy tubes are fully closed following flushing . Date Initiated: 10/10/2024. .Provide a collection bag cover at all times . Date Initiated: 7/25/2024.

Based on observation, interview, and record review the facility failed to ensure medications were administered under nursing observation for one Resident (R6) of one resident reviewed for medication administration. This deficient practice resulted in the potential for delayed or non-administration of medications left unsupervised at bedside. Findings include: This deficiency pertains to Intake MI00152512. All times noted are Eastern Daylight Savings Time (EDST). Review of R6's Minimum Data Set (MDS) assessment, dated 1/16/25, revealed R6 was admitted to the facility on [DATE] with diagnoses that included: cancer, neurogenic bladder, anxiety disorder, depression, and unspecified mood disorder. R6 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition. During an interview/observation on 4/30/25 at 11:28 a.m., R6 was observed lying in bed with a plastic cup of red and orange gummies on the overbed table in front of them. Licensed Practical Nurse (LPN) A entered the room, per R6's request, and R6 told LPN A that she only had one red Vitamin D3 gummy in the cup, and yesterday she had three. R6 stated, I didn't want to eat them before I showed you. LPN A exited the room, with the cup, and returned with three red Vitamin D3 gummies in the cup. LPN A stayed in the room and said she needed to watch R6 eat the gummies. R6 stated, Why do you have to observe me? You have never observed me eat them before. During an interview on 4/30/25 at approximately 11:40 a.m., LPN A acknowledged R6 did not have a physician order for self-administration, and no Self-Administration of Medication Assessment was completed showing R6 had the capability and safety to administer their own medications. During an interview on 4/30/25 at 12:45 p.m., in the presence of the Nursing Home Administrator (NHA) and Assistant Director of Nursing (ADON)/Registered Nurse (RN) I, RN I reported LPN A had left R6's medications at the bedside without a physician order for self-administration of medication by R6. When asked if the self-administration of medication assessment and physician order had been implemented after this Surveyor's observation of R6's medications being left at the bedside, RN I confirmed the physician order and care plan had just been update today and no order or care plan intervention had been in place at the time of this Surveyor's observation on 4/30/25 at 11:38 a.m. Review of R6s' Physician Order Summary, retrieved 5/1/25 at 11:53 CT (Central Time), revealed the following orders: 1. Give one Vitamin B 3000 mg Gummy (Resident supplies), may hold if unavailable one time a day for supplement. Start Date: 3/11/20245 2. Start Date: 5/1/2025. Per Resident's request it is acceptable to leave her supplemental Gummies for her to take at her pace every shift. Review of R6s' initial Medication Self-Administration Safety Screen, with a lock date of 4/30/25 at 16:48 (4:48 p.m. CT) revealed the following instructions: Complete this assessment prior to resident initiating self-administration of medication and with any medication order changes . Ongoing assessment should occur at a minimum or quarterly .

This citation pertains to intake(s): MI00151324, MI00151372 Based on observation, interview and record review the facility failed to provide sufficient staffing to ensure resident needs were met timely for three Residents (#4, #5, & #3) of five residents reviewed for staffing concerns. This deficient practice resulted in Resident #4 being left wet and soiled for extended periods of time and unmet care needs including oral care, and grooming with the potential to affect all 75 residents. Findings include: Resident #4 (R4) On 3/26/25 at 2:35 PM., Registered Nurse (RN) B was interviewed and reported R4 needs assistance to get in and out of bed, take showers, perform oral care and to be provided overall daily grooming (ADLs). RN B reported Certified Nurse Aides (CNA's) are extremely short staffed. RN B reported many residents do not get their grooming daily. RN B reported there are a lot of agency staff that don't show up, call in and/or cut corners on care for residents. RN B reported there were several times in the mornings where CNA staff have reported residents have been left wet and soiled, and that their night cares have not been completed. RN B reported R4 often reports to staff that he has not been helped, and residents are not getting their showers. RN B stated, this morning, CNA J reported R3 was heard crying out for help when walking into the facility to punch in (6:00 AM). RN B stated CNA J checked on R3 and found she was left wet and soiled. RN B stated they went with CNA J to assess R3, and when they entered R3's room, she was completely soaked from her upper thighs to the upper mid back. RN B stated, R3's bedding was wet and smelled of urine and her clothing appeared to be the clothing she had on the day before. RN B stated, they instructed CNA J to inform the unit manager. RN B stated, CNA J immediately cleaned R3 up and changed her linens. RN B stated, R3 was visibly upset when he entered the room, she appeared cold, and was crying that no one came for a long time. RN B stated, this occurs because the night staff will not stay over and do walking rounds with oncoming day staff. RN B reported some of these staff are agency staff and they walk out the door as soon as the morning shift comes in. On 3/26/25 at 3:00 PM., Agency Staff LPN E was interviewed and reported she works 50-60 hours a week at the facility. LPN E reported the facility is very short staffed. LPN E reported the schedule is always changing and staff are constantly being reassigned to different units than previously assigned for the day. LPN E stated staff are often pulled in many directions, filling holes wherever needed, and staff have to cut corners and are forced to prioritize what must be done versus what can wait. LPN E stated, earlier today there was only 1 CNA until 10:00 am for her unit which is a heavy unit and reported it was impossible to give all these residents 100% good quality care when everyone is constantly rushing between getting residents up for meals, showered, and changed. LPN E reported documentation and other things that come up such as emergencies, falls, admissions, and discharges are not able to be kept up either. LPN E reported there were no consequence for the agency staff who cancel, or no call/no show and they are still allowed to pick up the next day as if nothing happened. When asked about care not being able to be consistently provided, LPN E stated, . absolutely residents are missing their showers, ADL care, restorative ROM, oral care and genuine quality care that is not rushed. LPN E reported the facility admission department keeps admitting residents with high needs, including residents who required 2-person assist and mechanical lift assistance which always take 2 staff. LPN E stated it is nearly impossible to keep up. On 3/27/25 at 8:15 AM., in the main dining room was observed with approximately 16 residents seated at tables. No drinks, utensil or coffee were observed on the tables. CNA F was observed preparing juice, water and other drinks on a counter but was not passing any of the drinks out to residents. There were multiple residents observed appearing disheveled. Family Member (FM) N was observed coming into the dining room and looking around the cabinets/cupboards. FM N was then observed proceeding to enter the east unit looking for staff and asking where the clothing protectors were. Aat 8:32 AM., FM N was observed returning to the dining room with a stack of clean clothing protectors, went to his (mother-unsampled resident) and placed a clothing protector on her, then began putting clothing protectors on other residents in the dining room. At 8:45 AM., residents were observed remaining seated at the tables with no drinks or meals yet, and several residents were observed looking around, with some talking to one another asking, what is taking so long. At 8:52 AM., a meal cart was observed delivered to the dining room, and staff began to pass the trays. No residents were observed having coffee prior to the meal trays being passed at approximately 9:01 AM. On 3/27/25 at 9:10 AM., FM N was interviewed and reported the facility is very short staffed. FM N stated he comes in daily to assist with his mother's breakfast and help feed her because she is dependent on staff for meal assistance. FM N reported the staff are very nice and do the best they can, but with being short some corners get cut. FM N reported being aware many agency staff do not show up, or they call in last minute which leaves the staff working short with facility staff having to stay over to help out. FM N reported at times he does see some residents in the dining room who appear to not have had grooming and care completed. On 3/27/25 at 9:17 AM., CNA F was interviewed and reported the facility is very short staffed, especially in regard to CNAs. CNA F stated a lot of resident care is not completed to the standard the residents deserve, as well as her not being able to provide what she would like to be able to give. CNA F reported the shifts are typically 6:00 AM-2:00 PM, 2:00 PM-10:00 PM, and 10:00 PM -6:00 PM, and stated there were some shifts that currently are all over the place, such as 2:00 AM-2:00 PM to attempt to cover gaps. CNA F acknowledged agency staff do call/cancel last minute, no show and regular staff have been taking some days off because they have picked up so much overtime they are feeling burned out. CNA F reported the west unit is the heaviest (majority of residents-approximately 30 require 2 staff assist for care). CNA F stated, about 2-3 weeks ago she was working the late-night shift 2:00 AM-2:00 PM., and CNA J came in to help at 3:00 AM. CNA F reported her and (CNA J) started to do their rounds, and they found 9 of 15 residents on the west unit that were completely soaked in urine, and a couple residents who had BM (Bowel Movements). CNA F stated it was very sad to see, and deal with. CNA F reported 2 of the residents had to be showered in the middle of the night because of how soiled they were. CNA F stated there were only 2 CNAs prior to them coming in for the entire facility because agency staff didn't show up. CNA F reported, the hardest part was that so many residents are 2 person assists, and without enough staff, they are always behind, which directly affects resident care. On 3/27/25 at 9:38 AM., an observation and interview revealed R4 in a wheelchair self-propelling downstairs via the elevator to go to the therapy gym. R4 was noted to have food particles on her shirt and her hair was not brushed. R4's lips were observed dry, red and chapped. R4 was observed with what appeared to be dried crusted substances around her mouth. R4's overall appearance was disheveled. R4's hands had visibly soiled fingers, and her fingernails were chipped, and some broken off with varied lengths. R4's fingernail tips were observed with heavy buildup of grime/dark substances and reported the staff do not always help her clean up so well. R4 stated, it was difficult for her to brush her own hair and teeth, among other things independently because she had a stroke. On 3/27/25 at 11:52 PM., Physical Therapist Technician (PTT) I reported R4 is often disheveled and at times smells of stale urine. PTT I stated R4 comes to the therapy gym often and will work out with little supervision. PTT I reported the facility was very short staffed and stated it most definitely affects the care of the residents. On 3/27/25 at 2:00 PM., CNA J was interviewed and reported when she arrived at the facility yesterday morning for her shift, she overhead R4 crying out. CNA J stated, she was not assigned to R4 but has worked with R4 for years. CNA J reported the cry sounded different and more concerning from what she normally sounded like. CNA J stated, she went into R4's room and found her crying out that she was wet and cold. CNA J reported, she calmed R4 down and let her know she would be staying to help her get clean and warm. CNA J reported, at first, she didn't think it was that bad. CNA J indicated R4's linens were found damp when she pulled back the covers to assist R4 with rolling over. CNA J reported, at that time, she got an immediately noticeable odor of urine and realized that most of the linen was wet. CNA J stated some of the linen had noticeable areas which were previously wet and had dried urine-stained areas. CNA J reported, she knew R4 had been laying in her urine a while just by the smell of it and stated, the urine has a much more pungent smell when its damp/drying. CNA J stated she informed RN B and then assisted R4 with getting cleaned up. CNA J stated she felt the staffing problems were why R4 was left wet. CNA J stated, either agency staff just don't show up, or they call and cancel last minute. CNA J reported a few weeks ago she came into a shift from 3:00 am- 2:00 pm., that she had picked up because the facility was short. CNA J reported when she arrived, about 9 out of 15 residents were wet and soiled on the west unit, which CNA J stated is a heavy unit. CNA J reported, almost all of the residents on the west unit are a 2 person assist. CNA J stated, overall, most of the residents in the facility needed 2-person assist for one aspect of their care or another. CNA J reported residents often don't get their 2 showers a week, and many times staff have to cut corners with items such as nail care and grooming. CNA J reported both nurses and CNA staffing are very short handed, and it directly affects the quality of care provided to the residents. Review of an Admission Record revealed R4 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: dementia. Review of a Minimum Data Set (MDS) assessment for R4, with a reference date of 1/20/25 revealed a Brief Interview for Mental Status (BIMS) score of 9/15 which indicated R4 was cognitively intact. Review of R4's Care Plans revealed: Focus: (R4) ALTERATION IN ELIMINATION r/t: decreased mobility/risk for constipation, diuretic use, incontinence . Date Initiated: 09/13/2024 .(R4) has an ADL self-care performance deficit related to: left hemiplegia post (stroke) Date Initiated: 09/13/2024 .INTERVENTIONS: TOILET USE: 2 persons assist Date Initiated: 09/13/2024 . Further review of R4's care plan and progress notes did not reveal a history of refusing ADL care. Resident #5 (R5) Review of an Admission Record revealed R5 was originally admitted to the facility on [DATE] with diagnoses including aphasia/dysphasia (difficulty with speech and comprehension) following a CVA/Stroke. Review of a Minimum Data Set (MDS) assessment for R5, with a reference date of 2/26/25 revealed a BIMS score of 99/15, indicating cognition was severely impaired and unable to be assessed. Review of R5's Care Plan revealed: Focus: (R5) has an (Activity of Daily Living) ADL self-care performance deficit related to weakness, unsteady gait, previous CVA/Stroke, aphasia, urinary frequency . noted to drool frequently when up in wheelchair Date Initiated: 12/10/2024 . Further review of R3's care plan and progress notes did not reveal a history of refusing ADL care. Review of R5's Kardex (Certified Nurse Aide [CNA] Care Guide) revealed: Resident Care Clothing protector at all times when up in wheelchair. Change when soiled and as needed for dignity PERSONAL HYGIENE/ORAL CARE: 1 person assist . Eating/Nutrition: Monitor for choking, coughing, any food or fluid being pocketed in mouth s/p each meal. Pt should be 100% eyes on supervision. Use tactile cueing, as needed, to cease rapid rate of feeding. If cueing does not word (work [sic]) , staff are encouraged to move food item away to help indicate need to: wait-swallow food/clear oral cavity. On 3/27/25 at 11:52 PM., PTT I was interview and reported she works with many of the residents residing in the facility on a regular basis. PTT I reported R5 was not getting his oral care completed, and indicated his mouth is very dry with saliva buildup. PTT I stated, when she cares for him, she notices his mouth is rarely clean and often has dried saliva and/or food left around his mouth and in his teeth. On 3/27/25 at 2:55 PM., R5 was observed near a nurse's station on the main unit. When R5 was asked to open his mouth, there was dried food observed around his lips and mouth. R5's teeth had observed buildup of plaque and/or food stuck in and around his teeth. R5's mouth also appeared dry, with an accumulation of dried white saliva in the corners of his mouth and had an overall appearance of being disheveled. Resident #3 (R3) Review of an Admission Record revealed R3 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: hemiplegia-stroke affecting the left side. Review of an MDS assessment for R3, with a reference date of 3/6/25 revealed a Brief Interview for Mental Status (BIMS) score of 15/15, indicating cognition was intact. Review of R3's Care Plan revealed: Focus: (R3) has an (Activity of Daily Living) ADL self-care performance deficit related to: historical stroke .impaired mobility Date Initiated: 12/10/2024. The resident had a cerebral vascular accident (CVA/Stroke) and has a diagnosis of vascular dementia affecting movement . Further review of R3's care plan and progress notes did not reveal a history of refusing ADL care. Review of R3's Kardex (Certified Nurse Aide [CNA] Care Guide) revealed: PERSONAL HYGIENE/ORAL CARE: 1 person assist. BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary . On 3/25/25 at 4:10 PM., R3 was observed/interviewed and reported the staff at the facility is very short handed. R3 reported the shortage is bad on 2nd shift and weekends. R3 reported he has waited over an hour to get help to get up and out of bed. R3 added that his catheter has not been emptied to the point it has leaked and left him wet and soiled. R3 reported many of the staff are agency and those staff will either not show up or call in and cancel their shift minutes before they are supposed to be at the facility. R3 reported the staff who are employed by the facility that pick up, stay over and work are very nice, and apologetic, but their hands are tied, and they have to cut corners. R3 reported he feels bad when this happens to other residents who cannot speak up about the issue or do anything for themselves. R3 reported he has no use of his left side of his body, so he needs assistance with showering, getting in and out of bed, and some help with brushing his dentures. R3 reported it has been 3 days since his dentures were brushed good and soaked overnight as they should be. R3 reported he often sees other residents who are put up in their wheelchairs placed in front of the nurse's station and left there all day, except for meals. R3 reports many of them do not get any attention, nor do they get cleaned up properly after meals and he notices their faces which at times still would have food dried and stuck on. R3 reported he does not always get his 2 showers a week, and sometimes he refuses his care so that other residents who cannot speak up get the time slot to be showed and assisted. R3 reports some of the agency staff will not help him with his dentures at all and will say you can do it yourself. R3 reported he can do some things himself, but with the use of only one arm/hand (right side) it is very difficult to clean his dentures thoroughly. It was noted R3's fingernails needed to be trimmed and cleaned; his left-hand fingernails were visibly soiled. R3 reported he cannot trim his own fingernails or lift his left arm to wash his hands in the sink. R3 reported he has mentioned many of these issues in Resident Council at the monthly meetings, but it does not seem to make anything better. On 3/25/25 at approximately 5:20 PM., concern and grievance forms from R4 were requested related to care not given, and/or the above-mentioned concerns. A request was also made for Resident Council meeting minutes for the past 90 days. Review of Resident Council Meeting Minutes (RCMM) from 1/6/25 -3/3/25 revealed: An RCMM form dated 1/6/25 had no account of how many residents attended and showed a Discussion of Old Business: Area identified for Improvement . (Resident-name omitted) was in lift 2 hours. Action/Resolution: Speak with DON DON will come to next meeting. (2/2025) Miscellaneous: snack cart not seen in 3 days on west hall . Discussion of New Business: Nursing . 1/6/25 Nursing: Staffing not doing the job they signed up for. Action/Resolution: Speak with DON. Further review of 1/6/25 RCMM revealed no management signatures on the form. RCMM dated 2/3/25-11 residents attended including R4. Discussion of New Business: Nursing. Discussion of New Business: Administration: CNA's not completing jobs say they will be back and don't come back. Nursing: recommendations: more workers . Is there anything you would like to resolve? west on night only 1 aide (CNA) why can't there be 2 (two). Further review of 1/6/25 RCMM revealed no management signatures on the form. RCMM dated 3/3/25-12 residents attended including R4. Discussion of Old Business: Area identified for Improvement .CNA's not completing jobs, saying they will be right back and don't come back Issue Resolution: Still an issue Issue Resolved? . NO .Discussion of New Business: Nursing. Why is there no training for travelers (agency staff). Why is there only 1 CNA on the floor. Hire more people . Further review of RCMM's dated 1/6/25 -3/3/25 revealed no management signatures on any of the forms. On 3/27/25 at 3:00 PM., the Director of Nursing (DON) was interviewed and reported there are open staffing positions on all shifts for both nurses and CNA's. The DON confirmed there has been some difficulty with some of the agency staffing who do not show up and cancel at the last minute. DON reported she was unsure exactly how many staffing positions the facility had open, but stated she would provide that information. Review of the requested information titled, Nurse-CNA Staff open positions dated 3/27/25 revealed: CNA's . 3 open (Full time) FT 6am-2pm, 1 open FT 6-2pm, 4 open FT 2pm-10pm, 2 open (Part time) PT 2pm-10pm, 2 open PT 10pm-6am, (Currently Open CNA positions being filled by (Staffing Agency name omitted) Agency. A review of the open facility Nursing staffing shifts needed dated 3/27/25 revealed: Nurses: 3 open FT 6am-2pm 2 open FT 2pm-10pm 1 open FT 10pm-6am 2 open PT 10pm-6am Nursing positions currently filled by (Facility Name Flex staff) Licensed Practical Nurse (LPN) 2 LPNs and agency nurses 2 RNs Review of a facility Policy titled Staffing with a date of 4/13/22 revealed: POLICY It is the policy of this facility to ensure appropriate staffing levels to meet resident needs at all times 2.0 Compliance Guidelines 1. All employees of the facility are responsible for Residents and required to report to work when scheduled and to remain at work until replaced by someone else. 2. Regular staffing call-in policy remains in effect unless otherwise indicated by the Administrator. 3. There will be a designated staff member listed at the front desk who is responsible to always ensure appropriate staffing at all times. 4. Designated staff member will ensure that there is staff appropriate to care for all residents in the facility.

This deficiency pertains to Intake #MI00147846. Based on interview and record review, the facility failed to timely obtain and process physician orders for respiratory assessment, treatment, and radiology diagnostics for one Resident (R1) of three residents reviewed for quality of care. This deficient practice resulted in harm when R1 was hospitalized related to severe respiratory distress and fluid volume overload. Findings include: All times documented are Eastern Standard Time (EST) unless otherwise noted. Review of R1's Minimum Data Set (MDS) Admission assessment, dated 10/15/24, revealed R1 was admitted to the facility on [DATE] with active diagnoses that included heart failure, renal insufficiency, diabetes mellitus, anxiety disorder, and encounter for surgical aftercare following surgery on the circulatory system. R1 was documented as having had a major surgical procedure in the 100 days prior to admission that required active care during the SNF (skilled nursing facility) stay. R1's noted admission weight was 141 pounds, and they were not documented as having received a diuretic (medication for removal of excess fluids) upon admission. R1 scored 14 of 15 on the Brief Interview for Mental Status (BIMS) assessment, reflective of intact cognition and R1 was their own responsible party for health care. R1 was able to make their needs known. During a telephone interview on 11/12/24 at 11:13 a.m., Complainant D said R1 was very cognitively intact. Complainant D stated, I know [R1] had been coughing and it (the cough) had continued to progress. They [Nurse Practitioner (NP) F] put in an order for the (chest x-ray), and it never got done. It was the weekend, and [NP F] had put [R1] on lasix (diuretic) for three days. [R1] continued to retain fluid, and they chalked it up to [R1's] congestive heart failure. Fluid retention had never been a part of that (R1's physical concerns) since the heart valve had been replaced. The following Monday, [R1] asked [NP F] about the x-ray . and [NP F] was surprised that it had not been done. [R1] asked about blood work, and the NP said they only do blood work if there is something unusual. I told [R1] the cough and the fluid retention were unusual. Overnight on Monday and Tuesday [R1] got pretty sick. They sent [them] to the ED (emergency department) because [their] O2 (oxygen saturation in the blood) was in the 80's . Complainant D said staff should have listened to R1's lung sounds, or the chest x-ray should have been performed prior to R1's significant decline in condition requiring hospitalization . Complainant D stated, [R1] was very close to dying. Review of R1's Progress Notes revealed the following documentation related to their 13- day stay in the facility, in part: Effective Date 10/9/24, Date of Service 10/10/24, Visit Type: Acute . CHIEF COMPLAINT: Admission . I saw the patient, (R1) who has no acute pain or distress. She is alert and oriented . We discussed the treatment plan and hopefully wean off the use of oxygen . Respiratory Negative: Respiratory distress . Authored by NP F. No weight was documented within this initial admission provider visit. Effective Date 10/11/24, Date of Service 10/11/24, Visit Type: Acute. No weight was documented. Effective Date: 10/12/24 04:07 a.m. [Central Standard Time (CST)]- Resident (R1) awoke and felt like [they were] choking causing [them] to experience a panic attack with high respiration and heart rate (108). SpO2 (measurement of the percentage of oxygen in your blood relative to its' maximum capacity) 92% with O2 continuous at 3 L(liters)/min (minute) via mask . Effective Date 10/15/24 23:00 (11:00 p.m. CST) - Date of Service: 10/16/24. Visit Type: Follow Up . [R1] says [they are] congested and has had phlegm that [they] cannot get rid of quickly . REVIEW OF SYSTEMS: . Respiratory Positive: Cough . PHYSICAL EXAM Findings: Respiratory Positive: Respiratory distress . Authored by NP F. Effective Date 10/17/24 23:00 (11:00 p.m. CST) - Date of Service 10/18/24. Visit Type: Follow Up . [R1] said [they] would like to know daily weight due to CHF (congestive heart failure). I will check her weight daily . Significantly diminished lung sounds on continuous oxygen, with CHF chest congestion. I will send her for x-rays of the chest for chest congestion . Respiratory Positive: Shortness of Breath (SOB) . Weight: 140.6 (this weight measured on 10/14/24) . PHYSICAL EXAM: Respiratory Positive: Respiratory distress . Authored by NP F. Effective Date: 10/20/24 23:00 (22:00 p.m. CST) - Date of Service 10/21/24, Visit Type: Follow Up . I saw the patient for a follow-up. [R1] complained of edema in [their] legs/feet. I advised [them] to elevate [their] legs in the chair. Also, use compression stockings for comfort . Chest X-ray for chest congestion is pending . PHYSICAL EXAM: Vital Signs Heart Rate 53 bpm (beats per minute) . Edema Positive: non-pitting, Edema in lower left extremities, Edema in lower right extremities, Respiratory Positive: Respiratory Distress .ASSESSMENTS and PLANS: Chronic Systolic (Congestive) heart failure: Check daily weight in the morning. Will give her Lasix 40 mg daily with K (Potassium)10 mEq (milliequivalents) daily . X-ray of chest for chest congestion pending . Authored by NP F. 10/22/24 10:43 a.m. CST - Resident (R1) very anxious this AM. Received PRN (as needed) alprazolam (anti-anxiety medication) with no relief . nothing effective at this time, oxygen saturation 70% on room air, oxygen mask applied on 3 L saturation brought up to 93%. Pulse 118, crackles throughout lungs, using accessory muscles to breathe. Notified provider and received telephone orders to send to ED for eval (evaluation)/treat (treatment) . Authored by RN/Wound Care Nurse H. 10/22/24 10:44 a.m. CST - Resident (R1) noted to be hypoxic 78% on 2-liter N/C (nasal cannula). Lung sounds rhonchi and crackle throughout. Resident placed on 4 liters per simple mask. MD (Doctor of Medicine) updated will send to ED for CXRAY (chest X-ray) and eval (evaluate) . Authored by RN/ADON (Assistant Director of Nursing) G. 10/22/24 11:18 a.m. CST - Resident exited the facility via ambulance. 10/22/24 23:21 (11:21 p.m.) CST - Resident was admitted to the . hospital for, respiratory distress, fluid volume overload, and Covid. Resident is being treated with Bi pap (non-invasive breathing machine used by individuals who find it hard to breathe.) and bumetanide (diuretic medication) . No weights were documented in the Weight Summary documentation between 10/14/24 and 10/21/24. Review of R1's October 2024 EMAR (electronic medication administration record) and ETAR (electronic treatment administration record) on 11/12/24 at 12:03 p.m., revealed no physician orders for daily weights, supplemental oxygen therapy, or a chest x-ray for R1. Review of a handwritten Telephone Order dated 10/21/24, on 11/12/24 at approximately 1:05 p.m., revealed the following physician order: X-ray of chest for clarification: 2 views for DX (diagnosis) R09.89 (Other specified symptoms and signs involving the circulatory and respiratory systems). Physician/Prescriber was NP F. The physician order was signed by RN (Nurse Manager) I. This handwritten telephone order prepared by RN I was never added onto R1's ETAR, leaving nursing staff and appointment/transportation scheduling staff unaware of any physician order for the chest x-ray ordered for R1. Review of the Radiology and Diagnostic Services Policy & Procedure, issued 9/7/2023, revealed the following, in part: The facility will obtain radiology and other diagnostic services to meet the needs of its' residents . Review of R1's Weight Summary on 1/12/24 at 1:20 p.m., documented weights taken during their entire 13-day stay (from 10/9/24 through 10/22/24) in the facility included weights on the following dates: 10/13/24, 10/14/24, and 10/21/24. No weights were documented on the Certified Nurse Aide (CNA) Task - Weights in the EMR between 10/14/24 and 10/21/24. R1 was prescribed [furosemide] (diuretic medication) 40 mg, BID (twice daily) with a Start Date of 10/16/24, for three days for CHF. No weights were documented during this time period to show efficacy of the treatment. Review of R1's October 2024 EMAR and ETAR on 1/12/24 at approximately 1:25 p.m., revealed the following physician orders and associated documentation of completion/administration, in part: Daily weight every day shift. Start Date: 10/20/24 0600, D/C (discontinue) date 10/23/24 10:29. Documented as completed on 10/20/24, and absent nursing initials on the ETAR on 10/21/24 and 10/22/24. R1 had requested the performance of daily weight as documented with NP F on the 10/17/24 (Effective Date) Provider Visit Note. During an interview on 11/12/24 at 1:35 p.m., Confidential Staff A was asked to review R1's EMR and provide the location of a physician order for a chest x-ray for R1. Staff A said there was not a physician order for a chest x-ray in R1's EMR. Staff A stated, It (physician order for R1's chest x-ray) was not in the EMAR (or ETAR), and added that specifications related to a chest x-ray for R1 were also not present. Staff A stated, There was a miscommunication . As far as I can see it, we never put it (chest x-ray order) in the EMAR, and it was marked 'No further documentation needed', so no action was needed by the nurse. When asked about R1's decreased heart rate of 53 on 10/20/24 at 4:50 a.m., Staff A stated, Heart rate at 53 should have been a send to the ED right there. She was compensating . I think they (facility staff) waited too long .If it (physician order for R1's chest x-ray) had gotten on the EMAR the nurse would have been responsible (to ensure it was performed), and the scheduler would have set it up for the van and the driver . It should have been on the ETAR. How does a nurse know if it is not in there? It doesn't come up automatically . It is just a quick run to the hospital. We did not have a mobile x-ray unit at that time, (but) .[R1] would have been able to go out (for the x-ray). When asked about daily weights for a resident with a CHF diagnosis, Staff A stated, There should have been daily weights X (times) 3 (days) upon admission. Staff A reviewed R1's EMAR and said daily weights (per physician order) started on the 20th . (They) should have listened to [R1's] lungs every shift. On 11/12/24 at 2:23 p.m., the Nursing Home Administrator (NHA) and Director of Nursing (DON) were interviewed. The DON was asked for evidence of a physician order for a chest x-ray as specified in NP F's Provider Visit Notes dated 10/17/24 and 10/21/24. The DON reviewed R1's EMR and said there was no physician order present in R1's EMAR or ETAR. The DON noted a telephone order was written and noted on 10/21/24 but acknowledged the physician order was never placed in R1's ETAR for nursing and scheduling staff to complete. When asked about the lack of routine lung sound assessments for R1, the DON stated, I definitely would have listened to her lungs if she was having issues. During an interview on 11/12/24 at 3:35 p.m., Therapy Staff B said [they were] concerned about R1's respiratory status and had documented respiratory concerns in therapy notes and on the Eagle Daily Interdisciplinary Room Report. Therapy Staff B confirmed they had discussed the possibility of a chest x-ray with R1, validating R1's similar report to this Surveyor. On 11/12/24 at approximately 3:40 p.m., review of the Daily Interdisciplinary Room Report revealed the following line item, dated 10/17/24: [R1's Name] - Just wondering if pt (patient R1) should get chest x-ray. Aware [they are] going on mucinex, but [they] got SOB (shortness of breath) all the time. Spitting up thick secretions w (with)/bloody tint. Worried there's something more happening. On 11/12/24 at approximately 3:45 p.m., review of . Therapy Treatment Encounter Note (s) provided by Staff B included the following regarding R1, in part: 10/15/24 signed 12:59 p.m. (CST); .baseline breathing is clavicular. Breaths are extremely shallow and weak . 10/16/24 signed 12:56 p.m. (CST): . Pt (patient) was already exhibiting SOB and short shallow breathing that would lead to hyperventilating. 10/18/24 signed 1:28 p.m. (CST): .Intervention also being provided atom (sic) improved expiratory strength needed for ability (to) create a productive cough to clear airway of secretions. 10/22/24 signed 1:24 p.m. (CST): .Clinical (staff) found patient R1) in distress. Slumped down in bed. Hyperventilating. [Therapy Staff B] gained assistance to prop [R1] up. [Took their] O2, (saturation level) it was at 70% on 3 L. Notified RN immediately. Retrieved a face mask. Instructed [R1] in slow and controlled breathing. Pt tried to be comply (sic) but could not regain control. O2 (saturation) raised to 86% but no higher. Staff B waiting for response from nursing. Had to seek out admin (administrative) nursing staff during morning meeting to get attention. [When] proper staff was retrieved, [Staff B] removed self from situation. Response to TX (treatment): Decline in general health and well-being. Required hospitalization . Review of R1's Care Plans revealed the following, in part: FOCUS: Altered cardiovascular status r/t (related to) CHF, mitral valve insufficiency, CAD (coronary artery disease), aortic stenosis, HLD (high density lipoprotein), ischemic cardiomyopathy (heart muscle that can't pump well because of damage from a lack of blood supply to the muscle), murmur, a-fib (atrial fibrillation), hx (history) of MI [myocardial infarction (heart attack)] and recent cardiac surgery, Date Initiated: 10/14/24, Created by RN (Nurse Manager) I. A GOAL of The resident will be free from s/sx of complications of cardiac problems through the review date, was initiated on 10/14/22, however all Interventions/Tasks including the following, in part, were initiated on 10/22/24 (date of transfer to ED/Hospital). Monitor/report to MD changes in lung sounds on auscultation (i.e. crackles), edema and changes in weight . Monitor/report to MD s/sx (signs/symptoms) of CAD: chest pain or pressure especially with activity, heartburn, nausea and vomiting, shortness of breath, excessive sweating, dependent edema . and Obtain vital signs and notify physician as needed. Focus: The resident has altered respiratory status/Difficulty Breathing r/t decreased oxygenation d/t cardiac insufficiency, OSA (obstructive sleep apnea), Date Initiated: 10/14/24. Created by RN (Nurse Manager) I. Goal: The resident will have no complications related to SOB. Date Initiated: 10/14/24 by RN (Nurse Manager) I. All of the following interventions were initiated and created by RN C on 10/22/24; date of R1's transfer to ED/Hospital: Evaluate lung sounds and vital signs . Monitor changes in orientation, increased restlessness, anxiety, and air hunger. Monitor for s/sx of respiratory distress and report to MD PRN: Increased Respirations, Decreased Pulse oximetry; Increased heart rate (Tachycardia); Restlessness; . Hemoptysis (bloody sputum); Cough; Pleuritic pain; Accessory muscle usage . Monitor/report abnormal breathing patterns to MD: increased rate, decreased rate, periods of apnea (absence of breathing), prolonged inhalation, prolonged exhalation, prolonged shallow breathing prolonged deep breathing, use of accessory muscles, pursed-lip breathing, nasal flaring. O2 at 3 Liters via nasal cannula or mask. (Lack of physician order for intervention) Obtain labs as ordered. Position resident with proper body alignment for optimal breathing pattern. Review of R1's Pulse Summary report on 11/12/24 at 1:21 p.m., revealed the following heart rates outside of the normal range (60-100 beats per minute [bpm]): 10/10/24 21:18 (9:18 p.m.) CST - 46 bpm. 10/11/24 00:53 (12:53 a.m.) CST - 5 bpm. (Sic) 10/11/24 02:58 (2:58 a.m.) CST - 50 bpm. 10/11/24 10:24 a.m. CST - 106 bpm. 10/11/24 12:30 p.m. CST - 106 bpm. 10/11/24 20:50 p.m. CST - 102 bpm. 10/12/24 01:15 (1:15 a.m.) CST - 102 bpm. 10/12/24 13:39 (1:39 p.m.) CST - 101 bpm. 10/12/24 19:36 (7:36 p.m.) CST - 108 bpm. 10/13/24 12:43 p.m. CST - 105 bpm. 10/20/24 04:50 (4:50 a.m.) CST - 53 bpm. 10/20/24 21:59 (9:59 p.m.) CST - 58 bpm. 10/22/24 10:54 a.m. CST - 118 bpm. Review of the Radiology and Diagnostic Services Policy & Procedure, issued 9/7/2023, revealed the following, in part: The facility will obtain radiology and other diagnostic services to meet the needs of its' residents . During a telephone interview with R1 on 11/12/24 at 3:05 p.m., R1 was asked to describe their stay in the facility. R1 stated, I was not happy while I was there at all . One of the OT (Occupational Therapy) people had first suggested a chest x-ray. She said it would be a good idea to get a chest x-ray because of the cough and things that were going on (with my lungs). [Therapy Staff B)]was going to relay it (concern for need for x-ray) to someone else. I spoke to [NP F] a couple of times, and it (chest x-ray) was never taken care of. It was close to a week later when I talked to [NP F] who said, 'Hasn't it been taken care of yet.' At that time my pneumonia was starting .My clothes were not fitting me. I believe I started swelling up, and it didn't register (with me then) . (The 22nd) I had been having some panic/anxiety attacks. When I woke up that morning, I felt like I could not breathe. I thought it was a panic attack, but it just wouldn't go away . I had called for a xanax, and it was over an hour before the nurse finally came, and by that time I was in a full-blown attack. That is when she (the nurse) called the ambulance, and they rushed me to the hospital. Once I got to the hospital, they were very concerned. I could not breathe. The doctor told me that you really couldn't breathe (because my lungs were filled with fluid) . I know he was very concerned because he questioned me about resuscitation and what my wishes were. That was really scary . I had filled up completely with fluid and the pneumonia and COVID set in .If they would have done the x-ray when the first OT person suggested it, I think they would have caught the lung issues . During the Exit Conference on 11/12/24 at approximately 4:45 p.m., the NHA and DON acknowledged R1's EMR documentation revealed NP F had not completed a physician order, prior to 10/20/24 for daily weights although R1's request for daily weights was noted within the 10/17/24 (effective date) provider progress note. The NHA and DON confirmed NP F did not complete a physician order for a chest x-ray for R1, prior to 10/20/24, and no order (including the 10/20/24 order) was ever added to the ETAR for completion to evaluate R1's worsening chest congestion and potential fluid volume overload based on R1's progression of symptoms.

This citation pertains to intake MI00142093 and MI00142802. Based on observation, interview and record review, the facility failed to implement a comprehensive wound care program which resulted in Immediate Jeopardy with identification of the development of multiple facility acquired stage III/IV/Unstageable facility acquired pressure injuries and/or worsening of existing pressure injuries for four Residents (R4, R19, R38, and R48) of five Residents reviewed for pressure injuries. Findings include: All times recorded in Eastern Daylight Time (EDT), unless otherwise noted. R4 developed two facility-acquired unstageable/Stage 3 pressure injuries. R19 developed a right heel wound infection requiring surgical debridement and administration of IV (intravenous) antibiotics, and developed a new, facility-acquired left heel deep tissue injury (intact skin with damage of underlying soft tissue from pressure) without implementation of interventions to prevent worsening of the wound. R38 developed a facility-acquired pressure injury which deteriorated from Moisture Associated Skin Damage (MASD) [Inaccurately identified] which deteriorated to a Stage 4 pressure injury to the coccyx (tailbone)[Inaccurately identified as unstageable] requiring the use of antibiotics for a subsequent wound infection. R48 lacked essential skin care interventions to prevent the development of additional facility-acquired pressure injuries, experienced worsening of a Stage IV sacral injury, and was observed being provided with inadequate wound care technique to prevent wound infection. The Immediate Jeopardy identified on 5/20/2024, began on 3/08/2024 when R38 was assessed with a facility-acquired Stage 4 pressure injury (wound covered with extensive dead tissue, if removed would reveal a full-thickness wound) to the coccyx following incomplete assessments and inaccurate identification of the wound as moisture-associate skin damage (MASD). All times are recorded in Eastern Daylight Time (EDT), unless otherwise noted. Resident #19 (R19) A review of the Electronic Medical Record (EMR) revealed R19 was admitted on [DATE] with diagnoses including coronary artery disease, diabetes, peripheral vascular disease, and osteoarthritis. Review of R19's quarterly Minimum Data Set (MDS) assessment, dated 3/14/2024, revealed he was dependent (Helper does all the effort. Resident does none of the effort to complete the activity) on staff for dressing, putting on/taking off footwear, and all mobility including rolling left to right, sitting to lying, lying to sitting, transfers and wheelchair mobility. Further review of the MDS assessment revealed R19 was assessed as experiencing pain that interfered with day-to-day activities almost constantly and had one unhealed, unstageable (not stageable due to the coverage of the wound bed by necrotic tissue) pressure ulcer. R19 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he was cognitively intact. An observation on 5/19/2024 at 2:49 p.m., revealed R19 lying in bed with his hips and upper body leaning to the left side of the bed wearing a blue foam heel protection boot on his right foot. R19 was not wearing footwear on his left foot, and his left heel was observed to be resting completely on the mattress. A pillow was observed to be under R19's lower legs. It was noted the pillow was flat and did not elevate R19's heels from the surface of the bed. On 5/19/2024 at approximately 2:54 p.m., immediately following the initial observation, R19 could be heard in the hallway yelling out for help. Certified Nurse Aide (CNA) N and CNA W entered R19's room and closed the door. Upon entering the room, CNA N reported they were preparing to reposition R19 in bed per his request. After repositioning R19 on his right side, CNA N replaced the flattened pillow under R19's lower legs. R19 was wearing a blue, heel protection boot on his right foot and his left foot was bare. R19's left foot was observed to be turned inward, with the medial aspect of his heel and ankle resting directly on the mattress. Registered Nurse (RN) X entered the room at that time and was observed standing on the left side of R19's bed, speaking with R19. RN X was in full view of R19's heels resting directly on the bed and did not attempt to reposition R19 or instruct CNA N and CNA W to reposition R19, so his heels were not resting directly on the bed. RN X, CNA N and CNA W left the room without elevating R19's heels. An observation on 5/20/2024 at 8:40 a.m. revealed R19 lying in bed, tilted to his left side with the head of the bed at approximately 45 degrees. The blue heel protection boot was on R19's right foot. R19 was not wearing footwear on his left foot and his left heel was observed to be resting fully on top of a flattened pillow positioned directly under his feet. An observation on 5/20/2024 at 11:30 a.m. revealed CNA N and two unidentified students enter R19's room. CNA N informed R19 they were going to prepare him for transport to an outside appointment with his Urologist. Upon removal of R19's sheet, he was observed to be wearing a blue heel protection boot on his right foot. R19 was not wearing footwear on his left foot and his left heel was observed to be resting directly on the bed. CNA N removed the blue heel protection boot from R19's right foot revealing an elastic material wrap on R19's foot extending from the base of his toes and over R19's heel and ankle. During repositioning, CNA N lifted R19's left leg, revealing an area approximately 1.5 in. (inch) by 1 in. of dark purple discoloration on the medial aspect of R19's left heel. Further observation revealed a black spot near the center of the dark purple area and the skin surrounding the discoloration appeared reddened. CNA N stated R19 was supposed to have a heel protector boot on his left foot. When asked where the boot was and why it had not been observed on R19, CNA N stated, we keep telling them (nurses/managers) he needs one, but we still don't have one. Further observation revealed CNA N and a student position a lift sling under R19 and began lifting R19 over the bed. Upon lifting R19 was observed yelling out it hurts, it hurts, I can't take it! R19 was lowered back onto the mattress. CNA N then asked R19, do you want to cancel your appointment? R19 reported he did not think he could take it. Review of R19's May 2024 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed the following physician orders: Change bandage to right heel, cleanse with normal saline, apply silverderm 7 and cover with heel foam adhesive, comparable bandages may be used. Every evening shift every Tue [Tuesday], Thu [Thursday], Sat [Saturday] for wound. Order Status: Active . Order Date: 4/23/2024 . Start Date: 4/25/2025. Heel protection boots to bilateral feet every shift. Order Status: Active . Order Date: 5/16/2024 . Start Date: 5/16/2024. It was noted in review of R19's May 2024 MAR and TAR, nursing staff documented heels boots were in place on both of R19's feet for the 6:00 a.m. - 2:00 p.m. shift on 5/19/2024 and 5/20/204, contrary to CNA N reporting no heel protection boot available for R19 and the observations of R19's left heel resting directly on the bed on 5/19/2024 and 5/20/2024. Offload heels while in bed to prevent ulcers. Every shift for prevent pressure [sic]. Order Status: Active . Order Date: 4/18/2024 . Start Date: 4/18/2024. It was noted in review of R19's May 2024 MAR and TAR, nursing staff documented R19's heels were offloaded on 5/19/2024 and 5/20/2024, contrary to the observations on 5/19/2024 and 5/20/2024, of R19's left bare heel and right heel with a heel protection boot resting directly on the bed. Immediately following the observation, Unit Manager and Registered Nurse (RN) L entered R19's room and asked the Resident if he wanted to cancel his appointment. R19 explained to RN L the pain in his back was severe and he did not think he could handle the pain from the movement involved in transport. R19 asked why can't they give me something [for the pain] before [appointments]? RN L told R19 she could speak to the physician about pain medication prior to outside appointments but would cancel his appointment for that day. No education was provided to R19 related to the importance of keeping the appointment or offer made for pain relief medication at that time so R19 could attend the appointment. During an interview on 5/20/2024 at 4:00 p.m., R19 reported he was aware he had a wound on his right heel. R19 reported his right heel had healed after admission to the facility but since that time opened back up and worsened. R19 reported being recently hospitalized due to an infection of the right heel wound. R19 reported no injury to his right or left heels and was unaware of the area of discoloration found on the medial aspect of his left heel. R19 reported his feel always rested directly on the mattress or directly on a pillow, never floated above the mattress, and he had never been provided a heel protection boot for his left foot. R19 pulled up his sheet at which time his left foot was without footwear and his left heel was observed to be resting directly on the bed. R19's right foot, in the blue heel protection boot, was observed to be resting on top of his left foot, pushing his left heel into the bed. R19 reported the right heel protection boot was in place off and on since he returned from being hospitalized although he could not remember when the hospitalization occurred. R19 reported constant, severe pain from arthritis in his lower back that made it difficult for him to move his lower body without assistance. A review of R19's Medication MARs and Tars from March 2024 through May 20, 2024 at 2:16 p.m., revealed no order for medication to be administered or pain relief interventions to be implemented in addition to R19's scheduled medications, prior to R19's scheduled appointments with outside providers. R19's May 2024 MAR and TAR also revealed an order for acetaminophen . give 650 mg [milligrams] by mouth every 4 hours as needed for pain. No dose was recorded as administered on 5/20/2024. Review of R19's General Progress Note, dated 4/13/2024 at 6:19 p.m. (Central Daylight Time, CDT) revealed the following: 1700 (5:00 p.m. CDT) Resident noted to be very lethargic with decreased level of consciousness throughout day . skin cool to touch and extremities cold. Feet are mottled . 911 called and will send transport . 1755 (5:55 p.m. CDT) Ambulance here 1809 (6:09 p.m. CDT) Resident has left facility . Review of R19's hospital progress note, dated 4/15/2024 at 8:40 a.m. CDT, revealed the following, in part: Chief Complaint: unresponsive episode . 4/14/2024 upon evaluation of [R19] this a.m. noted to be mumbling, yelling at times and moving about the bed without following directions. Evaluated [R19's] work up and noted right heel ulcer with a very foul odor . [preliminary] right wound heel positive for gram [positive] and gram [negative] bacilli [bacteria] . 4/15/2024 spoke with [podiatrist] this a.m.: [R19] NPO [nothing by mouth] for surgical debridement [removal of dead tissue] . no seizure activity since admission . Physical Exam . Skin: malodorous right heel wound, although covered odor emits entire bed area . Review of R19's Discharge Summary [acute care facility], dated 4/18/2024 (no time provided), revealed the following, in part: Date of Admission: 13-Apr-2024; Date of Discharge: 19-Apr-2024 . History of Present Illness . noted right heel wound with very foul odor . concern for infection causing his leukocytosis (elevated white blood cell count, indicating infection) and mental status changes. 1 of 2 [blood cultures] returned positive for gram [positive] cocci [bacteria] in clusters: on Iv [intravenous] vancomycin [antibiotic often used to treat multi-drug resistant organisms] with IV zosyn [antibiotic commonly used for broad antimicrobial coverage and in early sepsis and critically ill patients] . Hospital Course: . 1. Seizure-like activity: CT head without acute abnormality . 2. Unresponsive episode: Prior to arrival; altered mental status and drowsy . thought to be more likely to polypharmacy . 3. Leukocytosis with right heel ulcer: Right heel likely cause of leukocytosis due to foul odor . WBC: 22.7 [normal range is 4-11] . Lactic 1.1 . Wound [culture] proteus mirabilis [bacteria spread through contaminated objects and surfaces] . 11. Meningioma (brain tumor} CT of head . essentially unchanged from prior . Discharge Instructions: . Pt needs the following follow-ups which can be arranged by nursing home based on available transportation: F/U with [Podiatrist] . in 7-14 days . See wound care orders as written by [Podiatrist] . Review of R19's podiatrist consultation note, dated 4/15/2024 and signed 4/16/2024 at 11:57 a.m. CDT, revealed the following, in part: Assessment: Mixed etiology diabetic [injuries resistant to healing]/pressure ulcer on the right heel . Infected ulcer, right heel . I recommend surgical debridement of the ulceration on the right heel in the operating room with sedation and local anesthesia . The son decided to go ahead and sign the consent for the patient to have a surgical debridement of the ulceration on the right heel later today . Review of the Podiatrist's written Physician Orders, for R19, dated 4/15/2024, revealed the following: Orders for nursing home: . Monitor for infections and call wound clinic if signs of infection occur . Offload heels while in bed to prevent ulcers . [follow up] with [Podiatrist] at wound clinic in 1 month on 5-14-24 [at] 9:30 [a.m. CDT]. A review of R19's EMR revealed no documentation for the wound clinic appointment scheduled for 5/14/2024 at 9:30 a.m. (CST) per the Podiatrist's written order. Further review of the R19's EMR revealed no visit notes from the wound care clinic related to R19's care to include wound assessments, change in condition, or procedures conducted for any of R19's visits to the wound care clinic since admission to the facility on [DATE]. Review of R19's progress note dated 5/16/2024 at 12:27 p.m. (CDT) revealed the following: Resident noted with suspect deep tissue injury to left heel. Skin discolored, non-blanchable [discoloration of the skin that does not turn white when pressed, abnormal finding] and intact. Unit Manager aware. Fax to [physician]. [New order] for barrier cream to left heel every shift and heel protecting boots to bilateral [right and left] feet. A request was made on 5/20/2024 at 4:15 p.m. to the Director of Nursing (DON) for this Surveyor to observe R19's wound care scheduled for 5/21/2024. The DON reported R19's wound care would be completed on the afternoon shift on 5/21/2024 and he would alert nursing staff to inform the survey team when R19's wound care would be provided to allow for the observation. During an interview on 5/21/2024 at 1:55 p.m., the Director of Nursing (DON) was asked if nursing was informed of the request to observe R19's wound care scheduled for that day. The DON reported R19 was out of the building for a previously scheduled appointment at the wound clinic, therefore there would be no opportunity for a wound care observation as previously discussed. The DON reported R19 had refused to go to his previously scheduled appointment on 5/14/2024. The DON was asked where the visit notes from R19's wound clinic visits could be located and reported all documentation from the wound clinic was scanned into the EMR under the miscellaneous section. A review of R19's record was conduceted with the DON during this interview which revealed no wound clinic documentation including wound assessments, change in condition, or treatments provided. The only documents found were the Physician Order Details, for R19's visits on 12/6/2023, 2/7/2024, 3/13/2024, and 3/25/2024. The DON reported he was unaware the wound clinic visit notes were not received by the facility. The DON confirmed it was important to have documentation from outside appointments to ensure continuity of care. The DON reported R19 often refused care and refused to be transported to his wound clinic appointments and all refusals should be documented in the Resident's EMR. Review of R19's May 2024 point of care documentation revealed no documentation for turning and repositioning or offloading heels. Review of the May 2024 documentation for the task Behavior Monitoring & Interventions, revealed R19 had no documented refusal of care from May 1, 2024 through May 27, 2024. Review of R19's progress notes for May 2024 revealed one documented refusal of care related to medication administration on 5/13/2024 at 8:34 (CDT). Review of R19's Progress Note Details, received from the wound care clinic and dated 5/21/2024 revealed the following, in part: Wound #5 Right posterior heel . [NAME] Grade 3 diabetic ulcer . measurements 4.5 cm length x 1.7 cm width x 0.3 cm depth with an area of 1.65 sq cm [cm2]. Necrotic muscle exposed . The wound is deteriorating . The ulceration on the posterior aspect of the right heel is necrotic and covered with leathery eschar . The ulceration is fairly large . Procedures: Wound #5 . A skin/subcutaneous tissue/muscle/fascia level excisional/surgical debridement with a total area debrided of 8.46 sq cm [cm2] . An observation on 5/28/2024 at 4:00 p.m. revealed RN PP emerging from R19's closed door. RN PP was asked if the DON alerted her to this Surveyors request to observe R19's wound care. RN PP reported she was aware. RN PP then walked down the hall to the treatment cart and reported the supplies needed for R19's wound care were not in the cart. RN PP left the hall to gather the needed supplies. On 5/28/2024 at 4:11 p.m. R19 was observed lying supine in bed with a blue foam heel protection boot on his right foot and a white foam heel protection boot on his left foot. R19 was not wearing socks on his right or left foot. Further observation of R19's right foot revealed no wound dressing in place, with R19's right heel and wound resting directly against the surface of the boot with no barrier in between his heel and the foam boot. R19's left heel was observed to be resting on a stack of brown paper towels positioned between his heel and the foam boot. RN PP reported she removed R19's old dressing prior to this Surveyors arrival to R19's room at 4:00 p.m. Further observation revealed RN PP set the wound care supplies on top of R19's over bed table, without a barrier between the supplies and the table. RN PP removed R19's belongings from the table, including a Styrofoam cup with a straw and a half-empty plastic bottle of diet cola. RN PP then entered the bathroom, retrieved brown paper towels from the dispenser and proceeded to wet the towels with water from the sink faucet, and returned to move the supplies to the furthest side of the over bed table. RN PP then wiped down the portion of the table opposite the supplies with the wet paper towel, discarded the paper towel. RN PP then retrieved more paper towel from the dispenser in the bathroom to place on the overbed table where she had just wiped, and moved the wound care supplies to that area, including a can of saline wound cleanser, a foil packet of medihoney, a stack of unpackaged four in. (inch) by four in. (4 x 4) gauze pads and a 2 in. x 2 in. (2x2) adhesive foam dressing. Continuing the wound care observation revealed CNA QQ entered R19's room to assist with R19's positioning during wound care. RN PP positioned the over bed table with the wound care supplies on the right side of R19's bed and instructed CNA QQ, positioned on the left side of the bed, to lift the R19's right leg up out of the foam boot and off the bed. R19's right heel was observed to have a wound extending from the posterior portion of his heel extending to the lateral portion of the heel. The posterior portion was covered with black eschar with the lateral portion of the wound was observed to have a round appearance that was completely covered with shiny, yellow slough. The entire wound was approximately 5 cm long (posterior to lateral) by 2 cm wide. RN PP then sprayed the wound with the saline wound cleanser at which time CNA QQ was observed moving her face back and closing her eyes. RN PP commented to CNA QQ, don't worry, it got me too. Neither RN PP or CNA QQ were wearing eye protection or a protective gown during the observation. After cleansing the wound, RN PP used two of the uncovered, 4 in. x 4 in. gauze pads to pat R19's wound dry then opened the packet of medihoney and squeezed the contents onto a stack of the uncovered 4x4 gauze pads. RN PP proceeded to smear the medihoney over the entire wound bed of R19 and continued to move outward to the surrounding tissue and continued to spread the substance on the healthy tissue surrounding the wound before applying the adhesive, 2x2 foam dressing to cover the wound. It was noted RN PP did not change gloves after cleaning the wound and prior to application of the medihoney and adhesive foam dressing. RN PP was asked if there was a treatment ordered for R19's left heel to which she looked at R19's left foot positioned in the foam heel boot with the brown paper towel between the Resident's heel and the foam boot fully visible before stating there was no treatment ordered for R19's left heel. CNA QQ then lifted R19's left foot out of the foam boot and the Resident's left heel was observed covered with an orange/brown substance. On the medial portion of R19's left heel was observed to have a round area of purple discoloration with a black center. CNA QQ repositioned R19's left foot inside the foam boot, on top of the brown paper towels previously observed. RN PP was then observed removing and discarding her gloves and exiting the room without performing hand hygiene. In an interview immediately following the observation, RN PP and CNA QQ were queried regarding a sign observed to be adhered to R19's doorway referencing the use of Enhanced Barrier Precautions (EBP). CNA QQ stated she forgot EBP was to be used with all close contact care of R19. RN PP reported EBP was only used during catheter care, it's because he has a catheter. Review of physician orders for R19 revealed the following: Enhanced Barrier Precautions [related to] chronic heel wound and foley catheter every shift. Start Date: 5/06/2024. Order Status: Active. Left heel DTI, paint [with] betadine daily, keep open to air, continue protective padded boot, notify MD if opens, develops eryothemia [sic] . every evening shift for wound dressing. Start Date: 5/21/2024. Order Status: Active. R19's EMR documentation prior to the hospitalization on [DATE], revealed the following: Further review of the EMR revealed the following wound care clinic Physician Order Details: 12/6/2024: Wound #5 Right Heel . Allevyn [special heel shaped, foam dressing] heel dressing or comparable foam . Return Appointment in 4 weeks with the physician - return sooner with new concerns or deterioration of ulcers/wounds, cancel if healed. 2/7/2024 at 10:45 a.m. (CST): Wound #5 Right Heel . Other Orders: Use/Wear off-loading when in bed - keep heels free from pressure at all times, be careful when using lift sling that he does not bang his shins . Turn every 2 hours. Avoid position directing pressure to wound site. Limit side lying to 30 degree tilt. Limit [head of bed] to 30 degrees in bed . 3/13/2024 at 4:04 p.m. (CDT): Wound #5 Right Heel. Primary Wound Dressing: Hydrofera Blue. Secondary Wound Dressing: Tegaderm Foam Adhesive 5.5 x 5.5 [inches] (round) or other adhesive foam . Return appointment in 2 weeks with the physician . Wound Cleansing & Dressing Frequency: . Change dressing(s) BIW [twice per week] . keep heels from pressure at all times . He has difficulty wearing the blue boot at night; I said that he can use pillows at night but wear boot during the day. Turn every 2 hours. Avoid position directing pressure to wound site. Limit side lying to 30 degree tilt. Limit HOB elevation to 30 degrees in bed . The orders were noted by the facility on 3/14/2024 (CDT). 3/25/2024 at 2:21 p.m. (CDT): Wound #5 Right Heel . Return appointment in 2 weeks with the physician . Information included on the order was identical to the Physician Order Details from 3/13/2024. Review of R19's Order Recap Report, dated 11/01/2024 through 5/31/2024, revealed no orders to elevate the resident's heels while in bed or for the use of heel protection boots, prior to the order on 4/18/2023, after R19 returned from hospitalization . Further review of the report revealed an order dated 11/19/2023 to Monitor bed position while sleeping, reposition as needed per care plan every shift for safety. Review of R19's progress notes revealed a General Progress Noted, dated 11/19/2024 at 5:43 a.m. (CST), corresponding to the order, as follows: Resident yelling out in middle of shift and writer observed resident head and shoulders hanging off head of bed. Resident midsection and bottom half of body securely on bed . There was no language in the order referring to the relief of pressure from R19's heels. Review of R19's care plan, including revisions, accessed on 5/19/2024 at 4:49 p.m., revealed the following: Focus: At risk for alteration in skin integrity [related to] antiplatelet therapy, diabetes, impaired mobility, refuses incontinence cares/repositioning at times, refusals of treatments, elevating heels, repositioning. Reviewed 5/8/24 - No changes. Date Initiated: 11/08/2023. Goal: Decrease/minimize skin breakdown risks. Date Initiated: 11/21/2023. Interventions: . Elevate heels as able. Keep off pressure points as much as possible. Date Initiated: 11/21/2023 . Reapproach if refuses incontinence cares/repositioning - alert nurse. Date Initiated: 12/01/2023 . Focus: Resident has pressure ulcer to right heel. Reviewed 5/8/24 - no changes. Date Initiated: 11/09/2023. Goal: Free from odor . Free from [signs and symptoms] of infection (such as increased drainage/pain/periwound erythema). Date Initiated: 11/09/2023 . Interventions: Administer analgesics as needed . Administer treatment per physician orders . It was noted in review of the care plan, there were no interventions listed to correspond with the recommendations made by the wound care physician to use/wear off-loading when in bed, keep heels free from pressure at all times, be careful when using lift sling that he does not bang his shins . Turn every 2 hours. Avoid positioning direct pressure to wound site. Limit side lying to 30 degree tilt. Limit [head of bed] to 30 degrees in bed . Review of R19's January 2024 point of care documentation revealed no Intervention/Task for turning and repositioning or floating heels and monitoring bed position. Review of the January 2024 documentation for the task Behavior Monitoring & Interventions, revealed R19 was documented as refusing care on 1/1/2024. No other refusals of care were documented for January 2024. Review of R19's February 2024 point of care documentation revealed no Intervention/Task for turning and repositioning or floating heels and monitoring bed position. Review of the February 2024 documentation for the task Behavior Monitoring & Interventions, revealed R19 was documented as refusing care on 2/16/2024, 2/18/2024 and 2/22/2024. No other refusals of care were documented for February 2024. Review of R19's March 2024 point of care documentation revealed no Intervention/Task for turning and repositioning or floating heels and monitoring bed position. Review of the March 2024 documentation for the task Behavior Monitoring & Interventions, revealed R19 was documented as refusing care on 3/1/2024. No other refusals of care were documented for March 2024. Review of R19's April 2024 point of care documentation revealed no Intervention/Task for turning and repositioning or floating heels and monitoring bed position. Review of the April 2024 documentation for the task Behavior Monitoring & Interventions, revealed R19 had no documented refusals of care for April 2024. Review of R19's MARs and TARs for January 2024 through April 2024 revealed no scheduled task or documentation of offloading R19's heels while in bed to prevent ulcers until R19 returned from the hospital on April 18, 2024. During an interview on 5/29/2024 at 12:20 p.m., Unit Manager, RN O reported using water and paper towel to wipe down a surface (action performed by RN PP during a wound care observation on 5/28/2024 at 4:11 p.m.) did not provide required disinfection of the overbed table used to hold R19's wound care supplies. RN O stated staff should use an approved disinfectant and for reference pointed to a purple-topped tube of Sani-cloth Germacidal Disposable Wipes, sitting on the desk behind him. During an interview on 5/28/2024 at 4:50 p.m., the DON, reported EBP should be used for all R19's close contact care, including wound care and catheter care. When discussing R19's right heel wound, the DON reported there was a miscommunication regarding the type of wound the Resident had. The DON agreed the wound could be both diabetic and pressure related. When asked if an order for offloading pressure from R19's heels was ordered prior to R19's return from the hospital on 4/18/2024, the DON stated the order was not placed until after R19's return. Review of the Centers for Disease Control and Prevention (CDC) guideline titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organism (MDROs), dated 4/2/2024, revealed the following, in part: Enhanced Barrier Precautions: Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident to resident during these high contact care activities. Nursing home resident with wound and indwelling medical devices are especially high risk of both acquisition of and colonization with MDROs . An Admission & Re-Admission Evaluation, dated 11/8/2024 at 4:12 p.m. CST (Central Savings Time) accessed on 5/20/2024 at 1:43 p.m., revealed under section XIX. Clinical Evaluation Integumentary (Skin) R19 was assessed as having a right heel open pressure ulcer. Review of R19's initial Skin & Wound Evaluation V7.0, dated 11/9/2023 at 12:52 p.m. CST and accessed on 5/20/2024 at 1:11 p.m., revealed the following: Wound Measurements. Area 0.5 cm2 (centimeters squared). Length 0.5 cm. Width 1.2 cm . Periwound. Edges: Attached: Edge appears flush with wound bed or as a sloping edge . Treatment . Cleansing Solution: Normal Saline . Primary Dressing: Foam . Progress: New . There was no description of the location of the wound, the type of wound, the wound bed or surrounding tissue. It was noted under section H. Treatment. Additional Care no additional care had been marked including the choices of 4. Customized shoe wear . 7. Heel Suspension/Protection Device . 15. Positioning wedge . 17. Turning/reposition program. Review of the photograph attached to the Skin and Wound Evaluation, of R19's right heel revealed an open wound located on the lateral and posterior section of the heel with a red and pink cobblestone appearance to the wound bed that appeared to be granulated tissue (fragile, healing tissue). The area surrounding the wound appeared pink and smooth with a small amount of dry, peeling skin. The evaluation corresponded with the 11/9/2024 evaluation provided by the facility on 5/28/2024. Further review of R19's Skin & Wound Evaluation(s) V7.0, revealed the following: Date: 1/26/2024 at 2:54 p.m. CST, accessed on 5/20/2024 at 1:11 p.m., Type: Pressure. Stage: Deep Tissue Injury: Persistent non-blanchable deep red, maroon, or purple discoloration, Location: Rear Right Malleolus [ankle], Medial [t [TRUNCATED]

MI 460 Based on observation, interview, and record review, the facility failed to utilize proper transfer equipment for one Resident (#1) from three residents reviewed for safe transfers which caused harm. This deficient practice resulted in a humerus fracture, increased pain, and risk for deterioration of overall health. Findings include: (Times reflect Eastern Standard Time) Review of Resident #1's Minimum Data Set (MDS) assessment, dated 9/16/21, reflected the following diagnoses: sarcopenia (loss of muscle tissue as a natural part of aging), muscle wasting and atrophy, weakness, [CONDITION(S)], and depression. Resident #1 required two-person assistance with bed mobility, transfers, dressing, and toilet use and was non-ambulatory. The Brief Interview for Mental Status (BIMS) score was 15 out of 15 reflective of intact cognition. Review of Resident #1's imaging report, dated 11/19/21, read in part, Oblique and slightly vertical fracture of the right humerus neck and proximal shaft of the right humerus. Review of Resident #1's orthopedic consult, 12/2/21, read in part, has a displaced right humeral neck fracture, which is approximately 10 days post injury. Optimal outcome would be with surgery intervention, but after discussion with (Family Member U), . feels that surgical intervention should not be performed and I agree due, to the patient's age and medical history .Caution with transfers and use a Hoyer lift . During an observation on 12/7/21 at 9:58 a.m., Resident #1 was found on top of an air-mattress in bed. She was positioned on her left side with her right arm in a sling on top of a pillow. Resident #1 did not open her eyes to this Surveyor's voice. RN I entered the room and placed a hand on Resident #1 and asked if she was experiencing any pain. Resident #1 opened her eyes and with a groggy voice responded, No. Resident #1 immediately closed her eyes after she spoke. Review of Resident #1's Care Plan, print date 12/7/21, read in part, [NAME] lift (transfer equipment which requires the absence of weight bearing support from the resident) with staff assist of 2 (Revision 9/20/21). Risk for pain related to history of lumbar fracture, arthritis, possible [CONDITION(S)] (stroke) with left sided weakness and increased pain to LLE (left lower extremity) Created on: 2/20/18 . Notify physician if pain frequency/intensity is worsening . Revised 9/20/21. Review of Resident #1's Witness Statement dated 11/19/21, read in part, .they used the machine that my feet went on the ground. I had pain in my right arm . Review of CNA B typed statement, dated 11/24/21, read in part, On November 17, 2021 (CNA A) and I provided care to (Resident #1) .We got (Resident #1) up for supper .I put the sling around her .(Resident #1) said, 'This isn't the right lift.' .We stood her up with the sit to stand lift .Once up in the lift, (Resident #1) said, 'Stop, my arm, my foot.' I (CNA B) heard a pop like sound .We sat her down in the wheelchair . The facility confirmed a Witness Statement relating to Resident #1's improper transfer on 11/17/21 was not completed for CNA B. During a telephone interview on 12/7/21 at 7:12 p.m., CNA B acknowledged she had not checked the Kardex (care plan used by CNAs) to identify the type of transfer equipment needed before Resident #1's transfer on 11/17/21 before supper. CNA B said, .the new girl (CNA A) was making me nervous and trying to hurry me . CNA B confirmed (Resident #1) told them (CNA A and CNA B) it was the wrong transfer equipment. CNA B said that the remark was disregarded, and she proceeded to use the sit-to-stand for transfer from bed to wheelchair. CNA B said Resident #1 told her to stop repeatedly but she continued with the transfer. CNA B said Resident #1, kept saying ow, ow and voiced pain to her arm and foot. CNA B said she heard a pop sound and knew something was wrong. When asked if the nurse was notified about what transpired with the transfer, CNA B said, No, I did not. It was a mistake. Review of Certified Nurse Aide (CNA) A Witness Statement, dated 11/19/21, read in part, On 11/17/21 me (CNA A) and (CNA B) transferred (Resident #1) using a chorus lift (medical equipment which enables a single caregiver to raise a patient to a standing position for transfers-also known as a sit-to-stand). She c/o (complained of) pain to right arm, elbow and right foot before, during and after the transfer . Unsuccessful telephone interview attempts were made to CNA A on 12/7/21 at 4:54 p.m. and on 12/8/21 at 9:00 a.m. The voicemail box indicated it was full; therefore, additional messages could not be placed. Review of CNA C Witness Statement dated 11/22/21 (time of interview was left blank) read in part, worked 11/18/21 . I slid my hand under her R (right) elbow to take her vital signs and before I even moved her arm (Resident #1) yelled 'Don't touch it, it's broken. Review of Registered Nurse Supervisor (RN) D Witness Statement dated 11/22/21 at 2:30 p.m., read in part, worked 11/17 & 11/18 NOC (night shift) . I know (Resident #1) had increased pain all over & got an order for (over the counter pain reliver). 11/18/21-11/19/21 I noticed her R arm was swollen . Review of CNA E Witness Statement dated 11/22/21 (time of interview was left blank) read in part, worked 11/18/21 . (Resident #1) stated she hurt. Her right arm . Review of CNA F Witness Statement dated 11/22/21 (time of the interview was left blank) read in part, worked 11/18/21 . Yes her legs and right (hurt) . Review of CNA G Witness Statement dated 11/22/21 (time of the interview was left blank) read in part, worked 11/17/21 . (Resident #1) c/o left arm pain and requested (over-the-counter pain reliver). Unsure if it was the left arm . Review of CNA H Witness Statement dated 11/22/21 (time of the interview was blank) read in part, worked 11/17/21, 11/18/21, 11/19/21 . (Resident #1) c/o right arm and right ankle pain when I came in on 11/18/21. The 10-6 CENA reported (Resident #1) was having pain right arm & right leg . Review of CNA M Witness Statement undated and the time of the interview was blank, read in part, worked 11/19/21 (Resident #1) (pain) right arm and right ankle. Nurse alerted . Review of RN Supervisor (RN) I first of two Witness Statement dated 11/19/21 (time of interview left blank) read in part, worked on 11/18/21 (Resident #1) c/o right leg, right ankle and right shoulder (pain) . Review of RN I second Witness Statement dated 11/22/21 (time of interview left blank) read in part, I did not assist with cares. No one reported anything to me . Review of CNA J Witness Statement dated 11/22/21 at 11:00 a.m. read in part, worked 11/17/21 & 11/18/21 . (Resident #1) stated 'everything hurt' at one time, then stated right shoulder . Review of Staff K Witness Statement dated 11/22/21 at 11:00 a.m., read in part, (Resident #1) verb (verbalized) pain to R arm with touch & movement. right arm was bruising . Review of Resident #1's Progress Notes beginning on 11/1/21 revealed the first indication of pain was on 11/18/21 at 11:26 a.m., .noted with increased pain . pain is all over knee, ankle, leg, shoulder. When not moving resident no pain/discomfort. When turning resident in bed pain starts, new orders received to schedule (over-the-counter pain medication four times per day). Review of Resident #1's Medication Administration Record (MAR) for November 2021 showed Resident #1's Pain Evaluation scores were zero (indicative of the absence of pain) every single day until 11/18/21 (the day after the improper transfer on 11/17/21). Further review of Resident #1's Progress Notes revealed the following: On 11/19/21 at 11:09 (a.m.) read in part, MD updated on pain to right arm with swelling. new order to obtain and (sic) xray. On 11/19/21 at 17:09 (5:09 p.m.) read in part, Increase (narcotic pain medication) to QID (four times per day). On 11/19/21 at 18:06 (6:06 p.m.) read in part, MD updated on xray .new orders received for sling to right arm, orthopedic consult, . (An additional narcotic pain medication ordered) QID. On 11/20/21 at 04:51 (a.m.) read in part, right arm remains swollen with discoloration to lateral AC (antecubital) area, right arm remains in sling . On 11/20/21 at 13:50 (1:50 p.m.) read in part, moderate discomfort noted . stayed in bed today . On 11/20/21 at 20:26 (8:26 p.m.) read in part, stayed in bed during shift .noted with increased pain/discomfort to arm . On 11/21/21 at 20:14 (8:14 p.m.) read in part, arm continues with swelling and bruising .did not want to get out of bed this afternoon .buttock started to get soft, barrier cream applied .only took bites of supper . On 11/21/21 at 20:51 (8:51) read in part, noted with increased pain/discomfort to right arm/shoulder . On 11/22/21 at 13:43 ((1:43 p.m.) read in part, in bed this shift, appetite is poor . On 11/25/21 at 21:31 (9:31 p.m.) read in part, took only liquids and her pain medication . sleepy most of the shift . On 11/26/21 at 13:28 (1:28 p.m.) read in part, continues to be lethargic and refused meals today . On 11/28/21 at 16:52 (4:52 p.m.) read in part, spoonfed supper and ate 25% of meal . During a telephone interview on 12/8/21 at 9:02 a.m., FM U confirmed the facility had notified him of Resident #1's humerus fracture. FM U said, They're tight-lipped about it and didn't explain what happened . FM U said he hadn't been able to really talk with (Resident #1) due to all the pain medication (side effects). During a telephone interview on 12/8/21 at 9:14 a.m., Unit Manager (Staff) Q and the Director of Nursing (DON) confirmed they completed the investigation involving Resident #1's humerus fracture. When asked why the facility's Investigation Report conclusion read in part, Unable to identify if the transfer was cause of fracture and was dated 11/19/21 which was prior to the end of the facility's investigation on 11/23/21 and five days before the interview with CNA B on 11/24/21 from the person who was responsible for the improper transfer. Staff Q said she must have written the wrong date. Staff Q then said, (Resident #1's) fracture did not prove it was caused from the transfer. When asked what other possibilities were considered, no response was received by Staff Q nor the DON. During a telephone interview on 12/8/21 at 12:14 p.m., the Nursing Home Administrator (NHA) confirmed CNAs were expected to immediately report residents' complaints of pain to the nurse. When asked if the facility had concerns when CNA B did not listen and respond to Resident #1 when she voiced the wrong transfer equipment was being used, when Resident #1 told CNA B to stop and she didn't, when Resident #1 cried out in pain, when CNA B heard a pop, and lastly did not immediately report what had happened, the NHA responded, We totally recognize what happened. Review of Resident #1's last primary physician visit was on 11/4/21 prior to the facility's exit date on 12/8/21. A request for the facility's transfer policy/procedure was emailed on 12/8/21 at 10:01 a.m. to the Nursing Home Administrator (NHA) and the DON. The transfer policy was never received.

Based on interview and record review, the facility failed to provide adequate supervision and assistance to prevent accidents for one Resident (#301) of three Residents ( #301, #302 and #303) in a total sample of three residents reviewed for falls. This deficient practice resulted in Resident #301 falling and sustaining a fractured hip and surgical repair. Findings include: All times recorded were at Central Standard Time (CST). An investigation took place at the facility regarding a facility reported incident dated 2/10/15, regarding an unwitnessed fall sustained by Resident #301, in the lobby area in front of the women's restroom on that date at 7:30 p.m., resulting in a fractured right hip. A review of the local hospital "Healthcare System Discharge Summary" records dated 2/16/15 for Resident #310 revealed, "Displaced Right Femoral Neck Fracture" resulting in an "Open Right Hip cemented with hemiarthroplasty under spinal anesthesia" for Resident #301 following her fall. A review of Resident #301's Minimum Data Set (MDS) quarterly assessment prior to her fall, dated 12/11/14, documented Resident #301 as a [AGE] year old female admitted on [DATE], with [DIAGNOSES REDACTED]. The MDS showed she demonstrated minor cognitive impairment as evidenced by Brief Interview of Mental Status (BIMS) score of 12, she was high risk for falls and had experienced 1 fall in the previous 3 months. A review of Resident #301's plan of care prior to her fall with injury, revealed the following interventions: Needs assistance with cares/toileting (initiated 10/28/2014), transfer with A1 (assist of 1) (initiated 12/02/14), and Encourage/take to toilet in am, before and after meals, at hs (bedtime), and as needed, perform incontinent cares as needed/needs assistance (initiated 9/26/14 and revised 12/10/2014). An interview was conducted with Physical Therapist (PT) "C" at the facility on 3/5/2015 at 9:30 a.m. She stated Resident #301 was on a walking program (prior to her fall) with the nurses and was "supervision" for walking because her right knee had been buckling sometimes. Record review of the "Facility Incident Report- Patient Involved" for Resident #301 dated 2/10/2015 documented that Resident #301 said she was trying to get to the lobby bathroom, was incontinent of bladder and fell . She was last toileted at 1620 (4:20 p.m.). She was last seen after supper at 6:30 p.m. by Certified Nursing Assistant (CNA) "B" and at 7:15 p.m. by CNA "G" and Licensed Practical Nurse (LPN) "F". Nursing progress notes dated 2/11/2015 (late entry), recorded Resident #301 as last toileted at 16:10 (4:10 p.m.) before supper on 2/10/2015. An interview with Resident #301 was conducted in her room at the facility on 3/3/15 at 1:35 p.m. Resident #301 was requested to recall the incident leading to her fall. She stated it had been too long ago to remember, but she said she was now afraid of falling, so doesn't walk much. She said she still has pain in that (right) hip. Review of the "Facility Occupational Therapy Summary" dated 12/30/2014, documents Resident #301 as requiring supervision/assist for higher level care tasks with cueing to maintain toileting schedule, and she would benefit from staff assistance for following 2 hour toileting schedule. An interview with CNA Team Leader "B" was conducted at the facility on 3/4/2015 at 2:26 p.m. She stated the resident care plans are reviewed for any changes on the computer kiosks at the beginning of every shift. An interview with CNA "A" was conducted at the facility on 3/4/2015 at 3:23 p.m. CNA "A" was requested to recall the incident on 2/10/2015. She stated the dining room closes at 6:30 p.m. She thought her coworker toileted Resident #301 before supper. She stated she was fairly new and was not aware of Resident #301 being on a toileting schedule. She stated she couldn't recall when she last saw Resident #301 on 2/10/15, but knew it was before supper. ( )

Based on interviews and record reviews, the facility failed to provide medications as prescribed by a physician, then failed to protect from potential undue adverse medication consequences (by administering additional medications before notifying the physician) for one (Resident #100) of six residents reviewed for medication errors out of a facility population of 105 residents. Resident #100 did not have a [DIAGNOSES REDACTED].#100. The immediate jeopardy was identified on 3/13/14 and began on 3/11/14 at 7:30 a.m., when significant medication errors were made by Registered Nurse (RN) "B", who failed to adhere to accepted professional standards of medication administration practice, when she administered insulin, anti-hypertensive, and non-steroidal medications to Resident #100, which were not in accordance with physician orders. Then, when the medication errors were realized and without awaiting specific physician direction, RN "A" proceeded with administrating Resident #100 his prescribed medications, which are known to have multiple interactions with the medications given to him in error by RN "B". The National Coordinating Council for Medication Error Reporting and Prevention (found at website www.nccmerp.org) lists the definition: "Medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional...". According to the Institute for Safe Medication Practices (ISMP), found at website www.ismp.org, "High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error...the consequences of an error are clearly more devastating to patients..." The ISMP identifies all formulations of insulin as a "high-alert medication". All times reflected in this report are on Central Daylight Time. The Nursing Home Administrator was notified of the immediate jeopardy at 3:44 p.m. on 3/13/14. The immediate jeopardy was removed on 3/14/14, when Surveyor verification demonstrated the facility had implemented the following: 1. Resident #100's blood pressure and blood glucose levels were being monitored. 2. Other residents with orders to receive insulin were reviewed and verified the medication was given correctly and no evidence of adverse medication actions were noted. 3. Nurses who administered medications on the morning of 3/11/14 on noted unit were interviewed regarding any other potential medication errors, which revealed none existed. 4. Education on Medication Administration: Medication Pass policy, Medication Administration: Injections, and five rights of medication administration occurred for all licensed nursing staff on 3/12/14. 5. Additional education took place 3/13/14 - 3/16/14 and included Medication Management Guidelines: Errors and Significant Medication Errors. Interview with facility Administrator on 3/14/14 at 10:55 a.m., verified the written supplemental attachment to the facility policy titled Medication Management Guidelines: Errors (dated 8/11/06) directed licensed nurses to notify the physician prior to proceeding with any further medication administration for the affected resident. Interview with facility Administrator on 3/17/14 at approximately 10:45 a.m., verified that all licensed nurses (with the exception of one on medical leave) had been educated as of 3/16/14. 6. Medication administration audits will be conducted three times per week for three months with any findings to be immediately corrected per policy and procedure. Report of findings will be given to the Administrator weekly and reviewed by the QA&A (Quality Assessment & Assurance) committee monthly for further recommendations as needed. The Administrator will be responsible for assuring that compliance is attained and maintained. Although the immediate jeopardy was removed, non-compliance remained at a lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy until the following has occurred: - The State Agency validates the facility's ability to maintain substantial compliance with ensuring residents are free of any significant medication error. Findings include: A partial extended survey was conducted from 3/12/14 - 3/17/14 in response to the facility reported incident involving the health and safety of Resident #100. A record review of intake number MI 078 read, "Insulin and [MEDICATION NAME] intended for 112A (Resident #201) given to resident (112B) (Resident #100). Resident remains at facility." A review of Resident #100's medical file revealed on his Admitting Record printed 3/12/14, that he is a [AGE] year old man admitted to the facility on [DATE], hospitalized [DATE] - 3/10/14, and readmitted to the facility on [DATE]. Resident #100's [DIAGNOSES REDACTED]. Resident #100's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed he scored an 8 out of 15 on his Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. An attempt to interview Resident #100 on 3/13/14 at 8:00 a.m. regarding the medication error incident was unsuccessful, as Resident #100 had no recollection of receiving an injection at the facility within the last couple of days. During an interview with RN "A" on 3/12/14 at 1:18 p.m., she stated, "One of the day shift nurses had called in (on the morning of 3/11/14). We (midnight shift nurses RN "A", RN "B" and RN "C") stayed over to do the meds (medications). We were taking turns (alternating) passing meds to one resident at a time. I had gotten (Resident #201's) insulin ready and put his [MEDICATION NAME] and [MEDICATION NAME] in a cup. I crushed the three pills and mixed them with applesauce. I sat them on the med cart. I turned to address one of the CNAs (Certified Nurse Aides). When I turned back around, the insulin syringe and pills were gone from the med cart. (RN "B") was in room [ROOM NUMBER]; she was taking the spoon out of (Resident #100's) mouth. I didn't see her administer the meds; I just saw her take the spoon out of his mouth. I said, '(RN "B"), those aren't his meds.' She had already given the meds in applesauce and the insulin (to Resident #100). I can't recall what she said. She took (Resident #201's) med sheets so she could call the doctor. No, I don't know why she thought they were (Resident #100's) meds. (RN "B") reported it to (Assistant Director of Nursing (ADON) "D") while (RN "C") and I were still passing meds. I gave (Resident #100) his regular scheduled meds before (RN "B") talked to the doctor." Attempts to contact RN "B" by telephone on 3/12/14 and 3/13/14 were unsuccessful. A review of Resident #201's physician's orders [REDACTED]. A review of Resident #201's Medication Observation Record for the period 3/1/14 - 3/31/14, revealed these four medications were scheduled to be given to Resident #201 at 7:00 a.m. Per interview with RN "A" on 3/12/14 at 1:18 p.m., RN "B" administered the medications listed above which were ordered for Resident #201 to Resident #100, without the medications being prescribed for Resident #100 by a physician. During a second interview with RN "A" on 3/13/14 at 7:25 a.m, she was asked if it occurred to her to withhold Resident #100's blood pressure medications, knowing he had already received Resident #201's blood pressure medications, until orders were received from the physician. RN "A" stated, "Not until afterwards. (The physician's) office was aware that (Resident #100) received both (Resident #201's) and his own blood pressure medications. I was the one that took the call when the doctor's office called back. The doctor said to monitor (Resident #100) for signs or symptoms of low blood pressure and gave an order for [REDACTED]." A review of Resident #100's March 2014 Medication Observation Record revealed RN "A" administered to Resident #100 all of his medications scheduled for 7:00 a.m. on 3/11/14 which included, but were not limited to: [MEDICATION NAME] 10 mg (also known as an ACE (angiotensin converting enzyme) inhibitor used for the treatment of [REDACTED]. [MEDICATION NAME] 10 mg (used for the treatment of [REDACTED]. [MEDICATION NAME] 20 mg (used for the treatment of [REDACTED]. Aspirin 81 mg (used to treat pain and reduce fever or inflammation, sometimes used to treat [MEDICAL CONDITIONS] and chest pain), [MEDICATION NAME] 5 mg (a corticosteroid used as an anti-[MEDICAL CONDITION]), Pantoprazole 40 mg (also known as a proton pump inhibitor used for treatment of [REDACTED]. According to the reference resource "Drugs.com" found at website http://www.drugs.com, the significant medication errors administered by RN "B" on 3/11/14 at 7:30 a.m. and followed by RN "A" administering Resident #100's prescribed medications, placed Resident #100 at risk for multiple moderate drug interactions. This resource defines a moderate drug interaction as being moderately clinically significant, usually avoid combinations; use it only under special circumstances. The following identifies the potential undue adverse effects between the medications given to Resident #100 in error and the medications which were physician prescribed: [MEDICATION NAME] and [MEDICATION NAME]; [MEDICATION NAME] may increase the effects of insulin and cause the blood sugar levels to get too low potentially resulting in dizziness, drowsiness, nausea, tremor, weakness, sweating, and fast or pounding heartbeats. [MEDICATION NAME] and [MEDICATION NAME]; the combined use may lower blood pressure and slow the heart rate. [MEDICATION NAME] ([MEDICATION NAME]) and [MEDICATION NAME]; [MEDICATION NAME] may adversely affect renal function, cause sodium and water retention which may increase the risk of [MEDICAL CONDITION]. [MEDICATION NAME] and Aspirin; [MEDICATION NAME] may reduce the effectiveness of Aspirin when prescribed to prevent [MEDICAL CONDITION] or [MEDICAL CONDITION]. In addition, combining these medications may increase the risk of developing gastrointestinal ulcers and bleeding. [MEDICATION NAME] and [MEDICATION NAME]; the combined use may increase the potential for serious gastrointestinal toxicity, including inflammation, bleeding, ulceration, and perforation. [MEDICATION NAME] and [MEDICATION NAME]; the combined use may lower blood pressure when obtaining a standing position potentially resulting in [MEDICAL CONDITION] and/or loss of balance with possible subsequent fall. During an interview with ADON "D" on 3/13/14 at 7:15 a.m, he stated, "I wasn't here yet (at the time of the medication error)....At approximately 7:30-7:40 a.m., I got a phone call...It was (RN "B"). She said, 'We have a med error. (Resident #100) ended up getting (Resident #201's) [MEDICATION NAME] and [MEDICATION NAME].' I asked how that happened. It's hard to recall what she said, exactly, but she said that she did give it. When I got here (to the facility), (RN "B") was at the desk. She said, '(RN "A") had the meds on the cart; I grabbed it and gave it to him (Resident #100).' I told her that's not Standards of Practice. She (RN "B") said, 'I just gave him the [MEDICATION NAME] and the [MEDICATION NAME]. I tried paging the doctor twice.' They had checked (Resident #100's) blood sugar. The doctor did call back. He gave orders to check (Resident #100's) blood sugar three times daily and give him orange juice for a blood sugar of less than 80. Later, I found out that (Resident #100) had actually received (Resident #201's) [MEDICATION NAME], and [MEDICATION NAME]." An Incident Report, dated and signed by ADON "D" on 3/11/14, read in part, "(Resident #100) received roommates [MEDICATION NAME] 50 units and [MEDICATION NAME] 50 mg...physician notified (at) 9:12 AM...Nurse took medications off cart that other nurse had set up and had given to wrong patient...Corrective Action: Verbally edeucated (sic) nurse on medication administration, never giving medications that another nurse had setup, verifying correct meds for correct patient." An attached statement, given by RN "B" read, "(RN "A") pull med & drew up med, placed on cart, she turned her back & I took med & insulin without her knol (knowledge) & gave med to wrong pt (patient)." An Employee Warning Notice (signed by the Administrator and RN "B" on 3/14/14 (erroneously) and verified by the Administrator to have actually been written on 3/12/14) read, "On 3/11 (RN "B") administered p.o. (oral) medication and insulin to a pt (patient) other than who it was intended for. Insulin was drawn up by other nurse. Disregard for med pass standards." This Notice revealed RN "B" was discharged from employment. Information from the website mayoclinic.org revealed the following: "Insulin [MEDICATION NAME] ([MEDICATION NAME]) is a long-acting insulin that works slowly over about 24 hours...Too much insulin [MEDICATION NAME] can cause [DIAGNOSES REDACTED] (low blood sugar)...Symptoms of low blood sugar must be treated before they lead to unconsciousness (passing out)... Symptoms of low blood sugar include anxiety; behavior change similar to being drunk; blurred vision; cold sweats; confusion; difficulty in thinking; dizziness or lightheadedness; drowsiness; excessive hunger; fast heartbeat; headache; irritability or abnormal behavior; nervousness; nightmares; restless sleep; shakiness; slurred speech; and tingling in the hands, feet, lips, or tongue. If symptoms of low blood sugar occur, eat glucose tablets or gel, corn syrup, honey, or sugar cubes; or drink fruit juice, nondiet soft drink, or sugar dissolved in water to relieve the symptoms... call for emergency help immediately if severe symptoms such as convulsions ([MEDICAL CONDITION]) or unconsciousness occur. Have a [MEDICATION NAME] kit available, along with a syringe and needle, and know how to use it..." Additionally, the website mayoclinic.org described diabetic [DIAGNOSES REDACTED] as follows: "Low blood sugar ([DIAGNOSES REDACTED])... occurs when there's too much insulin and not enough sugar (glucose) in your blood. [DIAGNOSES REDACTED] is defined as blood sugar below 70 milligrams per deciliter (mg/dl) or 4 millimoles per liter (mmol/L). Several factors can cause [DIAGNOSES REDACTED]... including taking too much insulin or other diabetes medications, skipping a meal, or exercising harder than usual... Left untreated, diabetic [DIAGNOSES REDACTED] can lead to [MEDICAL CONDITION] and loss of consciousness. This is considered a medical emergency." Immediately following the medication error incident, the facility began monitoring Resident #100's blood glucose level. A physician's Telephone Order dated 3/11/14 read, "Monitor blood sugar TID (three times daily) today. Give OJ (orange juice) if <80 (less than 80 mg/dl)." The same Vital Sign Record that contained Resident #100's blood pressure readings also included four blood glucose readings on 3/11/14 and eight blood glucose readings on 3/12/14. According to this record, Resident #100's blood glucose remained above 80 mg/dl until 1:30 a.m. on 3/12/14, when it dropped to 63 mg/dl and then to 57 mg/dl at 1:40 a.m. A Change of Condition progress note dated 3/12/14 at 2:35 a.m. and found in Resident #100's medical record, showed a decline in Resident #100's blood glucose levels and alertness. This progress note read, "Res (Resident #100) accu check at 2330 (11:30 p.m.) strable (sic) at 115. At 2430 (12:30 a.m.) =102. Res. was self transfering (sic) at 0100 (1:00 a.m.) and noted to be drooling. Accu check at that time was 82. Attempted to have res. intake fluids/snack but he refused to accept. At 0130 accu check = 63. Phys. (physician) contacted and N.O.s (new orders) obtained. Attempted glucose oral gel however res. swalowed (sic) once and remainder ran out of mouth. At 0140 accu check = 57 and Glucogen hypokit was administered. Res. was becoming lethargic at that time and was difficult to arouse. At 0200 accu check = 86. At 0220 = 138. At this time oral intake being encouraged. Res is increasingly alert however cont. (continues) to decline fluids/snacks." A physician's Telephone Order dated 3/12/14 at 0200 (2:00 a.m.) and found in Resident #100's medical record read, "Give Glucose Gel PO now. If gel ineffective or unable to take give Gluco-gen hypokit. Indication-Dx (diagnosis) acute [DIAGNOSES REDACTED]." Additional information from the website mayoclinic.org revealed, under "Precautions" following the use of [MEDICATION NAME]: "When the patient is conscious and can swallow, give him or her some form of sugar. [MEDICATION NAME] is not effective for much longer than 1? hours and is used only until the patient is able to swallow. Fruit juice, corn syrup, honey, and sugar cubes or table sugar (dissolved in water) all work quickly. Then, if a snack or meal is not scheduled for an hour or more, the patient should also eat some crackers and cheese or half a sandwich, or drink a glass of milk. This will prevent [DIAGNOSES REDACTED] from occurring again before the next meal or snack. The patient or caregiver should continue to monitor the patient's blood sugar. For about 3 to 4 hours after the patient regains consciousness, the blood sugar should be checked every hour." Physician "E" was interviewed by telephone on 3/17/14 at 11:45 a.m. He was asked if he recalled the facility reporting a medication error to him on 3/11/14 involving Resident #100. Physician "E" stated, "Yes. They told me they had given (Resident #100) [MEDICATION NAME] and [MEDICATION NAME] in addition to his own medications." Physician "E" was informed by this Surveyor that during the investigation, it was found Resident #100 had actually received his roommate's [MEDICATION NAME], and [MEDICATION NAME] in addition to his own medications. Physician "E" was asked if the facility had contacted him after the medication error but before Resident #100's own medications were administered to him, would he have held any of Resident #100's medications. Physician "E" stated, "I would have asked them what medications he was taking before telling them to go ahead with his own medications." This Surveyor then gave Physician "E" a complete list of Resident #100's medications he received after receiving his roommate's medications. Physician "E" then stated, "The [MEDICATION NAME], I would not have been so worried about. I probably would have told them to hold (Resident #100's) [MEDICATION NAME] and [MEDICATION NAME]." Physician "E" was then asked if he had been aware of all medications that had been given to Resident #100 when the facility reported the medication error to him, would he have given any other orders than the ones he did. Physician "E" stated, "I might have had (Resident #100's) renal function checked." ( )