Every finding on record at Optalis Health and Rehabilitation of Sterling Heig

Based on observation, interview, and record review, the facility failed to follow contact precautions for one resident (R157) on contact precautions out of one resident reviewed for infection control. Findings include:On 08/26/2026 at 1:12PM, an observation from the hallway outside R157's room revealed Certified Nursing Assistant (CNA) D entering the room to deliver R157's lunch from the tray cart. Posted prominently on the front of the door was a sign reading Contact Precaution- Everyone must: clean their hands, including before entering and when leaving the room. Providers and staff must also: Put on gloves before room entry. Discard Gloves before room exit. Put on gown before room entry. Discard gown before room exit. CNA D did not put on gloves or a gown before entering the room. During this observation, R157 was leaned back in a reclining chair, and requested help to adjust it to an upright position. A second CNA, CNA M, entered the room also without donning gloves or a gown to assist CNA D adjust R157's chair. Both CNAs were observed handling the reclining chair R157 was sitting in without wearing gloves or a gown.After both CNA's left R157's room, they were interviewed about the above observation. When asked about the expectations for wearing personal protective equipment (PPE, such as gloves and gowns) when entering a room for a resident on contact precautions, CNA M confirmed they should have been wearing gloves when providing care for the resident.A review of R157's electronic medical record (EMR) revealed they were admitted into the facility on 7/15/2026 with diagnoses of Sepsis (life threatening condition caused by the immune system's reaction to an infection), muscle weakness, and neutropenia (low white blood cell count). A review of R157's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15/15, indicating intact cognition.A review of active physician orders for R157 revealed an order with a start date of 8/3/2026 for Isolation: Contact Precautions: ESBL (Extended Spectrum Beta-Lactamase) Urine (urine containing bacteria that is resistant to many antibiotics).On 08/26/2026 at 3:32 PM, an interview was conducted with the facility's Infection Preventionist (IP). The IP stated gowns and gloves should be put on every time a staff member enters a contact precaution room.On 08/27/2026 at 2:50 PM, an interview was conducted with the Director of Nursing (DON). The DON confirmed the CNAs should have been wearing PPE when providing care in R157's room. A facility policy titled Infection Control- Standard and Transmission-Based Precautions with a review date of 2/4/2026 revealed Contact Precautions include.Personal protective equipment (PPE): Gloves - apply before entering and remove before leaving the resident's room and perform hand hygiene. Gown- apply gown upon entering and before leaving the resident's room and perform hand hygiene.

Based on observation, interview, and record review, the facility failed to implement the use of a Thoracic Lumbar Sacral Orthosis (TLSO-used to limit spinal mobility to promote healing following spinal fractures) back brace per physician order for one (R38) of one resident reviewed for splints/braces. Findings include: On 08/25/2026 at 12:18 PM, R38 was observed sitting in their wheelchair near the nurse's station. A brief record review was completed during the observation which documented the resident had an active physician order dated 08/20/26 for a Thoracic Lumbar Sacral Orthosis (TLSO). The order indicated the resident was to wear the TLSO when out of bed. At this time R38 was not wearing a TLSO and did not respond to initial interview questions. A review of R38's facility electronic medical record (EMR) revealed they were admitted into the facility on [DATE] with diagnoses including Wedge Compression Fracture of the First, Second, and Third Thoracic Vertebrae secondary to a fall. The Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 09/15 indicating moderate cognitive impairment. The MDS also indicated R38 required supervision/touching assistance for upper body dressing indicating they would not be able to correctly apply the TLSO independently. On 08/26/2026 at 11:42 AM, R38 was observed sitting in their wheelchair near the nurse's station. There was no TLSO brace observed on the resident. On 08/27/2026 at 11:40 AM, R38 was observed sitting in their wheelchair near the nurse's station. There was no TLSO brace observed on the resident. On 08/27/2026 at 11:45 AM, Unit Manager (UM) O was interviewed in the dining area and asked their understanding of R38's TLSO order. UM O reviewed the record and verified the order was active since 08/20/26 and indicated the brace was to be worn when out of bed. UM O was informed the resident had been observed the past three days in the wheelchair without the TLSO on and it was not currently on the resident. UM O confirmed the resident's TLSO would be expected to be used according to the physician order. On 08/27/2026 at 1:03 PM, the facility Director of Rehab (DOR) P was interviewed in their office and asked if they were aware of any reason that R38 would not be wearing the TLSO when out of bed. DOR P reviewed the record and reported they were not aware of any reason that it would not be used as ordered. On 08/27/2026 at 2:46 PM, the facility Director of Nursing (DON) reported their expectation is the physician orders for R38's TLSO would be followed. Review of the facility policy Equipment and Assistive Devices last reviewed 02/03/2026, revealed the statement The facility maintains and supervises the use of assistive devices and equipment for residents. These may include .orthotic equipment (such as AFO's, splints, braces, etc.). The facility will provide appropriate assistance to ensure the resident can use the assistive device. This may include .set-up assistance, supervision, or physical assistance as needed.

This citation pertains to intakes: 3042492, 3046398, 3095388, 3136828 and 3180695. Based on observation, interview, and record review, the facility failed to provide timely incontinence care for two residents (R54 and R197) of two reviewed for incontinence care. Findings include: R54 On 08/25/2026 at 10:03 AM, R54 was interviewed at bedside. There was an odor of a soiled brief present in the room. When asked about any care concerns, they reported being incontinent and needing assistance to have their brief changed. R54 reported they regularly do not get checked or changed during the night if they are asleep resulting in being wet and soiled for an extended time. They reported they were currently wet and soiled, and they were last changed yesterday evening around 5pm and this happens at least a couple times a week. A review of R54's facility electronic medical record (EMR) revealed they were admitted into the facility on [DATE] with diagnoses including Right Below Knee Amputation (BKA), Muscle Weakness, and Muscle Wasting and Atrophy. The Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 15/15 indicating intact cognition and indicated R54 was dependent for toileting/incontinence care. On 08/25/2026 at 10:54 AM, R54's brief was inspected following incontinence care. The brief was observed to have feces with some portions appearing drier and other portions appearing to have been from a more recent bowel movement. The brief felt heavily saturated with urine. On 08/26/2026 at approximately 10:30 AM, R54 was interviewed at bedside asked if they had ever expressed a desire to not be woken up during the night for an incontinence check and they reported they had not and they would always want to be checked regardless of being awakened or not. Further review of R54's EMR revealed the Toileting Hygiene task completion record documenting R54 had last been changed at 5:22 PM on 08/24/2026 indicating approximately 17 hours between brief changes. On 08/27/2026 at 1:48 PM, Certified Nursing Assistant (CENA) F was interviewed in the west lounge and reported their understanding of the facility check and change procedure for incontinent residents was the resident should be checked roughly every two hours and changed as needed. CENA F reported they will not wake a resident to check them if the resident has expressed a desire to not be disturbed while sleeping and if the resident has not specifically asked not to be disturbed, they will try to gently get the residents attention so as not to startle them and complete the check and change as needed. On 08/27/2026 at 1:56 PM, CENA G was interviewed in the west lounge and reported they had worked midnight shifts. They reported they complete the check and change process on midnights every 2 to 3 hours and they do wake residents up especially if the resident is wet or soiled as the residents are often at risk for skin breakdown. On 08/27/2026 at 2:00 PM, Unit Manager (UM) H was interviewed in the west lounge and reported their expectation is residents will be checked every two hours and changed if needed including during the midnight shift. UM H reported in the specific instance of R54 not being changed between 5:30 PM 8/24/26 and 10:30 AM 08/25/26, their expectation was additional brief changes should have been completed during that time. On 08/27/2026 at 2:51 PM, the facility Director of Nursing (DON) reported their expectation is residents who are incontinent and dependent for toileting will be checked every two hours and changed as needed including during the midnight shift. R197 On 08/25/2026 at 10:09 AM, R197 was observed lying in bed and was asked about their stay in the facility. They explained they were recently admitted into the facility yesterday evening and was disappointed in the way they had been treated. R197 explained the nurse assigned to them on the midnight shift was rude to them when they asked about their prescribed medications, and when they needed assistance with ambulating to the bathroom, no one responded. R197 explained they slowly ambulated to the bathroom by themselves and didn't make it in time resulting in them wetting themselves. R197 also explained someone came into their room at 1:00am to deliver water, they reported they asked for assistance and no one came back. As a result, the resident reports they were extremely wet this morning as urine had soaked through resulting in their clothing and linens needing to be changed. On 08/25/2026 at 10:43 AM, R197's assigned Certified Nursing Assistant (CNA D) was asked about the resident's care needs this morning. CNA D explained R197's brief and linen had been saturated with urine requiring a full linen change. A review of R197's medical record revealed they were admitted into the facility on 8/28/26 with diagnosis of Cellulitis of Right Lower Limb. Further review revealed the resident was cognitively intact and required one person assist for toileting. On 08/27/2026 at 8:42 AM, an interview was completed with the Director of Nursing (DON) regarding the resident not being provided with timely incontinence care, and they explained the resident reported this to the unit manager and upon interviewing the assigned midnight CNA they reported they entered the resident's room throughout the night to provide care. A review of the concern form submitted by R197 dated 8/25/26 revealed the following, [R197 said] that [they] did not get [their] medications, [R197] put [their] call light on, and no one came. [R197] stated someone came at 1:00am and drop off water and said they would come back but no one came until 6:00am. [R197] said [they were] soak and wet . On 08/27/2026 at 10:29 AM, an attempted phone call was made to R197's assigned CNA (CNA E) on the midnight shift 8/28/26 into 8/29/26 to no avail. A review of the facility policy Activities of Daily Living (ADL) last reviewed 02/02/2026, revealed the statement Appropriate care and services will be provided for residents who are unable to carry out ADL independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Elimination (toileting).

Based on observation, interview, and record review, the facility failed to ensure one resident (R131) remained free from a physical restraint (lap tray), failed to complete an assessment and evaluation, obtain informed consent and a physician's order, develop a restraint-specific care plan, and conduct a quarterly evaluations for restraint use of five residents reviewed for restraints. Findings Include: R131 A review of R131 Electronic Medical Record (EMR) revealed R131 was admitted to the facility on [DATE] with diagnoses of dementia, polyneuropathy, and repeated falls. According to the Minimum Data Set (MDS) assessment dated [DATE], R131's Brief Interview for Mental Status (BIMS) score was 0 out of 15, indicating severe cognitive impairment and was dependent on staff for all acitivites of daily living. Documents revealed, R131 has a legally appointed Power of Attorney (POA) since 2020. The R131's fall care plan included using the geriatric chair in a reclining position and placing R131 near the nurses' station or in a high-traffic area. On 8/25/26 at 2:26 PM, R131 was observed seated in a geriatric chair with a lap tray positioned across the chest and abdomen. Licensed Practical Nurse (LPN) Q when queried at this time about R131 and stated the purpose of the lap tray and geriatric chair was because R131 had a history of wandering, attempt to get up and walk, and would fall. During observation on 8/25/26 at 2:30 PM, Certified Nurse Assistant (CNA) R stated R131 was unable to remove the lap tray on their own and was used during meals. At the time of the observation, no meal was being served. R131 appeared restless. CNA R stated R131 was kept at the nurses' station because R131 would get out of the geriatric chair and wander. A review of R131's EMR revealed the geriatric chair had been obtained for R131 in December 2024. The medical record did not contain evidence the facility staff had completed a restraint assessment, evaluation, obtained informed consent from the resident or designated representative, obtained a physician's order, or developed a restraint-specific care plan. There was also no evidence of ongoing quarterly restraint evaluations from initiation in 2024 through the first quarter of 2026. On 8/26/26 at 4:15 PM, Interim Therapy/Rehab Director T stated residents whose geriatric chairs were provided by hospice or family were not routinely assessed by therapy for use of the equipment. Director T stated R131's geriatric chair had been provided through hospice and referred questions regarding the resident's assessment to nursing or to R131's hospice agency. During interview with the Unit Manager, Registered Nurse (RN) I, on 8/27/26 at 11:21 AM, they confirmed that no restraint assessment upon initiation (2024), no informed consent by the DPOA (Durable Power of Attorney), no physician's order, no specific care plan for restraint, and no ongoing quarterly evaluations since December 2024 per the facility restraint policy. On 8/27/26 at 1:30 PM, the Director of Nursing (DON) confirmed that R131 had not received a restraint assessment and evaluation for the geriatric chair and lap tray. The DON also confirmed there was no physician's order or evidence of quarterly restraint evaluations since the equipment was initiated in 2024. On 8/27/26 at 3:15 PM, the DON provided a progress note informing R131 son by the hospice nurse for use of the geriatric chair dated in 12/2/2024. However, no informed consent form was signed. No assessment was performed, and no quarterly monitoring was done, documented, or updated since its initiation in 2024. On 8/27/26 at 10:04 AM, documentation related to R131's geriatric chair and lap tray was requested. The facility did not provide evidence of informed consent from the time the equipment was initiated in December 2024. The facility's policy entitled: Physical Restraint Policy was reviewed, revised on 5/8/24 and revised on 2/3/26, revealed that prior to placing a resident in a restraint, the facility was to:1. complete an evaluation; 2. inform the resident or responsible party; 3. obtain and document informed consent or refusal; 4. obtain a written order from the medical practitioner; 5. develop a care plan for restraint use and; 6. have an ongoing evaluation at least quarterly, with a significant change in condition, or as needed.

This citation pertains to intake: 2719896Based on observation, interview, and record review, the facility failed to provide two-person assistance with bed mobility for one resident (R701) out of three reviewed for falls, resulting in a right leg femur fracture requiring surgery. Findings include:1/21/2026 at 11:00 AM, R701 was observed lying in bed. R701 was noted to have a right leg immobilizer in place, as well as a perimeter mattress. R701 was noted to be sleeping.A review of the medical record revealed R701 was admitted into the facility on [DATE] with the following medical diagnoses, Cervical Fracture and Muscle Wasting and Atrophy. A review of the most recent Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental status (BIMS) score of 3/15, indicating an impaired cognition. R701 was dependent on staff for bed mobility on an MDS assessment dated [DATE].A review of an Incident and Accident (IA) report dated 12/31/2025 noted the following, Description: Writer did head to toe assessment, resident was able to move all extremities except right lower leg. Assisted back to bed x 2. Resident vital signs taken.resident complains of Right leg pain, ice pack applied, PRN (as needed), STAT (as soon as possible) X-Ray right leg ordered. Date: 1/1/2026. Statement: Patient was receiving perineal care by aid (CNA-certified nursing assistant) when re-positioned towards the aid, the resident was moving during care and rolled out of the bed.A review of the Activities of daily living (ADL) care plan dated 11//14/2025 noted the following, Bed Mobility: Two Person Assist.On 1/21/2026 at 1:07 PM, an interview was conducted with the Director of Rehabilitation (DOR). The DOR reported R701 is currently on the case load for physical therapy and occupational therapy. The DOR was asked what it means if R701 was coded on the MDS for dependent and care planned as a two person assist for bed mobility since admission. The DOR reported R701 required two people during care for safety, not only for the residents but for staff as well. The DOR reported R701 remains a two person assist for bed mobility.On 1/21/20276 at 1:44 PM, a phone interview was conducted with Licensed Practical Nurse (LPN) E. LPN E reported they were the nurse on duty when R701 had their fall, CNA F was providing care alone and the resident rolled out of bed. LPN E reported R701 is very antsy. LPN E reported R701 was sent to the hospital due to increased swelling and pain to the right leg.Two attempts to contact CNA F by phone call was made with message indicating not available.Further review of a physician readmission note dated 1/15/2026 revealed the following, .Patient sent back to hospital for possible trauma. Patient found of right femur fracture. Patient taken to the OR (Operating Room) .On 1/21/2026 at 3:14 PM, an interview was conducted with the Director of Nursing (DON). The DON reported that their expectation is that when someone is care planned as a two person assist, there are two people in the room.A review of a facility policy titled, Fall Management Guidelines noted the following, The resident's care plan and interventions will be reviewed and revised as indicated for the individual needs of the resident and effectiveness of interventions.

This citation pertains to intake: 2716778Based on interview and record review, the facility failed to initiate psychiatry services for one resident (R700) out of one reviewed for behaviors. Findings include:A review of the medical record revealed R700 was admitted into the facility on 9/7/2024 with the following medical diagnoses, Alzheimer's Disease, restlessness and agitation. A review of the most recent Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status score of 0/15 indicating a severely impaired cognition. R700 also required staff assistance with bed mobility and transfers.Further review of the current physician's orders revealed the following, Olanzapine Oral Tablet 5 MG (Milligrams).Give one tablet by mouth every 12 hours for Anti-Psychotic. Start date: 9/7/2024 Psych (Psychiatric) consult. Start Date: 9/9/2024. Psych consult r/t (related to) aggression towards staff. Throwing water at staff and refusing care. Start date:10/13/2024Further review of the medical record revealed a consent to receive psychiatric services dated 12/12/2024, 3 months after initial admission into the facility.A request for R700 psychiatric visit notes were made and not received by the end of survey.On 1/21/2026 at 2:22 PM, an interview was conducted with Social Worker (SW) A. SW A reported the usual process when someone comes into the facility on an anti-psychotic being used regularly, the consent for psychiatric services is obtained upon admission and have the referral sent over to their psychiatric provider for the resident to be seen. SW A reported they could not comment as to why it was not done because they were not employed in with the facility at that time.On 1/21/2026 at 2:25 PM, an interview was conducted with SW D. SW D reported R700 should have been seen by psychiatric services during their time in the facility and they were unsure why the consent was obtained three months after R700's admission into the facility.A review of a facility policy titled, Behavioral Health and Management noted the following, It is the policy of the facility to provide necessary behavioral health care and services to attain or maintain the highest practicable physical. Mental, and psychosocial well-being of the residents in accordance with their plan of care.

This citation pertains to Intake: 2574739Based on observation, interview, record review facility failed to implement interventions (alternating pressure mattress) as ordered to prevent worsening of pressure ulcer for one (R901) of two residents reviewed for pressure ulcer prevention/management. Findings include:R901R901 was originally admitted to the facility on [DATE] for skilled rehabilitation and nursing care. R 901 was readmitted to hospital on [DATE] and returned to the facility on 7/24/25. R901's diagnoses included stroke with right side weakness, heart failure, stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle) of the sacrum (a triangular bone at the base of your spine, located between your two hip bones) and aphasia (language disorder that affects a person's ability to communicate) and wound debridement while they were at the hospital. R901 was receiving nutrition through Percutaneous Endoscopic Gastrostomy (PEG) tube (A soft, flexible tube inserted through the abdominal wall directly into the stomach to provide nutrition and hydration for patients with trouble swallowing or unable to eat enough to get the nutrients they need).A complaint received by the State Agency alleged R901 did not receive adequate/appropriate and timely staff assistance with repositioning needs and incontinence episodes.An initial observation was completed on 8/5/25 at approximately 9:30 AM. R901 was observed in their bed on their back. A few minutes later two staff members went into R901's room to provide care and the door was closed. At approximately 10:05 AM the door was open, and a follow-up observation was completed. R901 was receiving their nutrition through PEG tube, and they were also receiving antibiotics through a PICC (A peripherally inserted central catheter [PICC] is a long, thin tube that goes into the body through a vein in the upper arm. The end of this catheter goes into a large vein near the heart.) line. R901 was laying on a regular mattress. When asked how they were doing R901 nodded their head up and down and mumbled Ok. Review of R901's discharge summary and orders from hospital dated 7/24/25 read, continue with low air loss therapy specialty bed. patient will needs specialty bed. Review of R901's facility admission orders revealed an order dated 7/25/25 that read Place Alternating Pressure Mattress (APM) on for pressure reduction. Monitor alternating pressure mattress functioning and check that the settings are appropriate for the patient. The order also read check every shift for pressure reduction. Check for proper function, replace if malfunctioning.On 8/5/25 at approximately 2:10 PM. R901 was observed laying on their back. When asked how they were doing R901 nodded the head up and down. There were no other positioning devices on R901's bed. The mattress R901 was using was a foam mattress with no other low air loss therapy mechanism attached.Review of wound assessment dated [DATE] revealed the following: Exudate (drainage): moderate. Wound measurements: Area: 9.3 cm (centimeters); Length: 4.6 cm; Width 3.3 cm; depth 2.5 cm; undermining 2.0 cm. Nursing wound care progress note read in part, Resident remains at risk for further skin breakdown related to medical modalities.plan of care up to date and resident and physician aware and in agreement with plan of care.Review of R901's care plan for alteration in skin integrity revealed, pressure redistributing device on bed' dated 7/25/25.In an interview with the Unit Manager A completed on 8/5/25 at approximately 2:20 PM, they were queried about R901's interventions that were ordered for pressure ulcer prevention/management. Unit Manager A reviewed the Electronic Medical Record (EMR) and read all the interventions to minimize the skin break down risk which included Alternating Pressure Mattress (APM) on the bed. They were asked about the mattress R901 was currently using and they confirmed that it was regular mattress. When questioned further why R901 was not an APM mattress ordered on 7/25/25 (11 days ago), Unit Manager A reported they were unsure. When queried about the process they added the wound care nurse completes weekly wound rounds, adds the orders to the EMR, notifies the unit manager, and they would notify maintenance via their electronic notification system to install the mattress. When notified of the air mattress concern, Unit Manager A confirmed R901 needed that mattress for their wound healing and would follow up.On 8/5/25 at approximately 2:40 PM the facility Administrator was notified of the observations and concern and reported they would follow up with the Director of Nursing (DON).An interview with the DON was completed on 8/5/25 at approximately 3:30 PM. The DON was notified of the observations and queried why R901 did not have the APM that was ordered several days ago with a stage 4 pressure ulcer. DON reported that there was a process breakdown at the facility's end.On 8/6/25 at approximately 12:30 PM an interview with the facility Administrator was completed. They were queried about the facility process for following up on the specialty mattresses. The administrator reported the wound care nurse placed the order and initiated the electronic maintenance request. Maintenance followed up on the request and the nursing team ensured that the appropriate equipment was in place and it was reviewed during daily interdisciplinary team meeting.Review of (evidence based) Clinical Practice Guidelines from National Pressure Injury Advisory Panel (NPIAP) on Full Body Support Surfaces for Prevention of Pressure Ulcers revealed that alternating pressure surfaces are clinically more effective for prevention of prevention injuries (Source: NPIAP: Clinical Practice Guidelines: Full Body Support Surfaces)

Based on observation, interview, and record review, the facility failed to maintain the exterior trash refuse area in a clean manner. This deficient practice had the potential to affect all residents, staff, and visitors. Findings include: On 6/23/25 at 9:10 AM, the exterior dumpster area was observed. The ground surrounding both dumpsters was observed to be soiled with grease and sludge, and there was a milky liquid pooled on the ground. In addition, there was a foul, sour odor in the dumpster vicinity. Dietary Manager B stated Maintenance was responsible for cleaning the dumpster area. On 6/23/25 at 1:30 PM, Maintenance Supervisor S was queried about the dumpster area, and stated that they try to clean it monthly. Maintenance Supervisor S stated, It's probably due for cleaning again. According to the 2022 FDA Food Code section 5-501.115 Maintaining Refuse Areas and Enclosures, A storage area and enclosure for refuse, recyclables, or returnables shall be maintained free of unnecessary items, as specified under § 6-501.114, and clean.

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: On 6/23/25 between 8:30 AM-9:15 AM, during an initial observation of the kitchen with Dietary Manager (DM) B, the following observations were made: There was a buildup of a black, mold-like substance on the backsplash located on the soiled side of the dish machine, and the faucet assembly for the hose sprayer was continuously leaking water. According to the 2022 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions, (A) Physical facilities shall be cleaned as often as necessary to keep them clean. According to the 2022 FDA Food Code section 5-205.15 System Maintained in Good Repair, A plumbing system shall be: (A) Repaired according to law; P and (B) Maintained in good repair. In the walk-in cooler, there was an opened, undated 1 gallon container of ranch dressing and Greek dressing, and a container of cut carrots and celery dated 6/16-6/18, which appeared to be dried out. DM B confirmed the dressings should have been dated when opened, and stated the carrots and celery needed to be discarded. According to the 2022 FDA Food Code section 3-501.17: Ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days. Refrigerated, ready-to- eat, potentially hazardous food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. Dietary Staff was observed washing soiled dishware at the dish machine. The dish machine was tested by this surveyor with a paper thermometer test strip, and the strip did not change color to denote the surface temperature of the dishware was reaching 160 degrees Fahrenheit, to ensure adequate sanitization. A plate simulating dishwasher tester was sent through the dish machine, and noted a maximum temperature of 150 degrees Fahrenheit. DM B stated there have been issues with the dish machine, and that they have purchased a new dish machine, but are waiting for it to be installed. According to the 2022 FDA Food Code section 4-501.110 Mechanical Warewashing Equipment, Wash Solution Temperature. (A) The temperature of the wash solution in spray type warewashers that use hot water to SANITIZE may not be less than: (1) For a stationary rack, single temperature machine, 74°C (165°F); Pf (2) For a stationary rack, dual temperature machine, 66°C (150°F); Pf (3) For a single tank, conveyor, dual temperature machine, 71°C (160°F); Pf or (4) For a multitank, conveyor, multitemperature machine, 66°C (150°F). Pf (B) The temperature of the wash solution in spray-type warewashers that use chemicals to SANITIZE may not be less than 49°C (120°F) On 6/23/25 at 9:15 AM, the filter for the ice machine in the main kitchen was observed with a handwritten date of 1/23/24. DM B stated that Maintenance was responsible for changing the filters, and stated she was unaware if the date written on the filter was the date it was changed, or the date it expired. On 6/23/25 at 9:20 AM, the filter for the ice machine on the 1 [NAME] unit was observed with a handwritten date of 9/20/23. On 6/23/25 at 9:25 AM, the filter for the ice machine on the 1 East unit was observed with a handwritten date of 1/23/24. On 6/23/25 at 2:30 PM, Maintenance Supervisor S was queried about the ice machine filters, and confirmed that they should be replaced annually. Maintenance Supervisor S further stated, They're expired. On 6/23/25 at approximately 12:10 PM, Dietary Staff R was observed entering the kitchen to begin working. Dietary Staff R did not perform handwashing after entering the kitchen. Dietary Staff R went immediately to the lunch trayline, and began handling the resident lunch tray items. When queried at that time, DM B stated Dietary Staff R should have performed handwashing after entering the kitchen. According to the 2022 FDA Food Code section 2-301.14 When to Wash, Food employees shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles P.

This citation has two deficient practice statements. Deficient Practice #1 Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility. Findings include: Review of the facility's Water Management Program Plan (WMPP) updated 4/29/23 noted: Each facility must establish a Water Management Team. The Team is responsible for implementing policies and procedures presented in this WMPP including: .Implement water management policies and procedures .monitor and document performance improvement .review elements of the water management program at least annually . The team consists of the following: Facility Administrator, Maintenance Director, Infection Preventionist . In addition, the plan notes that Point of Use Residual Disinfectant will be monitored monthly, and Fixture Flushing Log will be done twice per week. On 6/23/25 at 3:10 PM, the facility Infection Preventionist was queried regarding their involvement on the facility's water management team, and stated that Maintenance does it all. On 6/23/25 at 3:15 PM, the Administrator was queried regarding his involvement in the facility's water management program and stated that the Maintenance Supervisor is responsible for their water management program. When queried about the components of the plan that were not being completed, and that the plan had not been updated since 4/29/23, the Administrator apologized but provided no further explanation. On 6/23/25 at 3:20 PM, Maintenance Supervisor S was queried about the facility's water management plan. When queried about why the plan had not been updated since 4/29/23, Maintenance Supervisor S provided no explanation. When queried about any Point of Use Residual Disinfectant logs or fixture flushing logs, Maintenance Supervisor S stated, Am I supposed to be doing that? This citation pertains to MI00153659. Deficient practice statement number two: Based on observation, interview and record review the facility failed to ensure, the appropriate Personal Protective equipment (PPE) was worn for isolation precautions during patient care activities for one resident (R152) of four reviewed for isolation and failed to complete departmental infection control surveillance. Findings include: On 06/23/25 at 1:43 PM, R152 was observed to have a sign on their door which indicated, Enhanced Barrier Precautions (EBP) and that a gown and gloves were required for high contact resident care activities. Certified Nursing Assistant (CNA) M and CNA N were observed to give R152 a bath and a brief change. R152's brief was observed to be saturated with urine and slightly soiled with stool. The CNAs were observed to only wear gloves and not the gown as indicated by the EBP sign on the door. On 06/24/25 at 11:36 AM, Registered Nurse (RN) D was observed to change the tube feeding formula bag, flush the PEG (Percutaneous Endoscopic Gastrostomy tube-through which feeding, water and medications are administered) with 30 mililiters (ML) of water, and connect to R152's PEG tube while wearing only gloves and not the gown as indicated by the EBP sign on the door. A review of the record for R152 revealed R152 was admitted into the facility on [DATE]. Diagnoses included Non traumatic Brain Dysfunction, Stroke and High Blood Pressure. The Minimum Data Set (MDS) assessment dated [DATE], indicated severely impaired cognition, impaired range of motion of the extremities, and R152 was dependent on staff for all activities of daily living including eating, bed mobility, bathing and personal hygiene. A review of physician order dated 06/23/25 revealed Enhanced Barrier Precautions: PEG Tube every shift. On 06/24/25 at 11:37 AM, during a medication pass observation for insulin administration, Licensed Practical Nurse (LPN) W, was observed to don and doff gloves without hand hygiene. On 06/24/25 at 1:30 PM, the infection control program was reviewed with the Infection Control Preventionist. The ICP reported Enhanced Barrier precautions (EBP) are used for any resident with tube feeding via a PEG (tube inserted into stomach), an indwelling urinary catheter, Peripherally Inserted Central Catheters and any stage three and stage four wounds. Resident R152 was noted by the ICP to have entered the facility on contact precautions for a stool borne pathogen and was switched to EBP. It was noted the order indicated both types of isolation and subsequently the ICP discontinued the order for contact isolation. The EBP remained for the residents PEG tube feeding. The ICP confirmed on query that the two staff who gave R152 a bath and the nurse who connected the tube feeding should be wearing a gown and gloves. A review of the monthly documentation for the infection control program revealed no documentation of departmental surveillance for appropriate infection control practices. On 06/24/25 at 4:05 PM, the Infection Control Preventionist was asked if they had any documentation of monthly departmental infection control surveillance and reported they did not have any documentation and was provided prior to survey exit. On 06/25/24 at 1:42 PM, the identified concerns were reviewed with the Director of Nursing (DON) who reported precautions should be followed as per the signage on the door for all care activities listed on the signage. The DON further noted the current isolation precautions for the resident should be reflected in the care plan and physician orders. A review of the facility policy titled, Infection Surveillance revised 09/25/24 revealed, .The Infection Control Preventionist or designee will analyze the monthly data to identify trends and present to the QAPI (Quality Assurance) committee for review and potential recommendations to minimize risk and control to spread of infection and multidrug resistant organisms, and improve outcomes through education, skills validation or other initiatives as warranted.

On 6/24/25 at 2:12 PM, five of the 14 residents that attended the group reported the food did not taste good. They went on to say the food is sometimes cold when it reaches them. A review of the facility's policy titled Food Palatability dated 4/4/25 noted, Food is prepared by methods that conserve nutritive values, flavor, and appearance. Food and drink should be palatable, attractive, and at a safe and appetizing temperature for the general population This citation pertains to Intake: MI00153364 Based on observation, interview, and record review, the facility failed to ensure that food was served in a palatable manner and at the preferred temperature for four residents (R31, R33, R51, R95) and five confidential group residents of twenty reviewed for food palatability. Findings include: R31 On 6/23/25 at 10:26 AM, R31 was interviewed regarding the care and services they were receiving at the facility. R31 indicated the food didn't taste good and was frequently cold when served to them. A review of R31's electronic medical record revealed that R31 was admitted to the facility on [DATE] with diagnoses that included Cellulitis (bacterial skin infection) and Heart disease. A review of R31's most recent minimum data set assessment (MDS) dated [DATE] revealed that R31 had an intact cognition. R51 On 6/23/25 at 10:56 AM, R51 was interviewed regarding the care and services they were receiving at the facility. R51 indicated the food was frequently cold when served to them. A review of R51's electronic medical record revealed that R51 was admitted to the facility on [DATE] with diagnoses that included Fracture of right lower leg and Muscle weakness. A review of R51's most recent minimum data set assessment (MDS) dated [DATE] revealed that R51 had an intact cognition. R95 On 6/23/25 at 1:20 PM, R95 was interviewed regarding the care and services they were receiving at the facility. R95 indicated the food was frequently cold and didn't taste good. A review of R95's electronic medicate record revealed that R95 was admitted to the facility on [DATE] with diagnoses that included Spondylolisthesis lumbar region (spinal condition) and Heart failure. A review of R95's most recent minimum data set assessment (MDS) dated [DATE] revealed that R95 had an intact cognition. R33 On 6/23/25 at 1:23 PM, R33 was interviewed regarding the care and services that they were receiving at the facility. R95 indicated the food was frequently cold and didn't taste good. A review of R33's electronic medical record revealed R33 was admitted to the facility on [DATE] with diagnoses that included Heart failure and Depressive disorder. A review of R33's most recent minimum data set assessment (MDS) dated [DATE] revealed that R33 had an intact cognition. On 6/25/25 at 8:52 AM, a breakfast tray was pulled from a food cart on the one hundred unit of the facility and temperature tested by Dietary manager (DM) B. The food was observed to be contained in white foam containers. DM B was asked about the containers and indicated the facility dishwasher was currently broken. The results of the food temperature test was; Pancakes: 105 degrees Fahrenheit; Turkey sausage: 103 degrees Fahrenheit. DM B was asked what the preferred temperature was for the pancakes and sausage and indicated they liked to see the temperature at 130 degrees Fahrenheit or greater. DM A acknowledged the white foam containers did not maintain the temperature of the food very well. On 6/25/25 at 8:58 AM, the food was taste tested by members of the survey team and revealed the pancakes and sausage tasted cold, which negatively impacted the palatability of the food. A review of resident council meeting minutes for the months of January 2025-June 2025 revealed the following, Food is horrible. Meals are cold. Overall food needs improving. On 6/25/25 at 2:00 PM, the Administrator (NHA) was interviewed regarding their expectations for food palatability and temperature at the facility. The NHA indicated the food should meet all standards of temperature. Hot food should be hot and cold food should be cold.

Based on observation, interview, and record review the facility failed to provide appropriate and meaningful activities for two (R57 and R152) of three residents reviewed for activites. Findings include: R57 On 06/23/25, 06/24/25, and 06/25/25 during the hours of 9:00 am and 4:00 PM, R57 was observed to be in bed in their room. The TV was not on nor was there any device observed to play music. A review of the record for R57 revealed R57 was admitted into the facility 03/19/2025. Diagnoses included Alzheimer's Anxiety and Depression. The Minimum Data Set (MDS) assessment dated [DATE] documented severely impaired cognition and the need for assistance with all activities of daily living and was dependent or required maximal assistance for all except eating. Section F: Preference for Customary Routine and Activities documented it was very important or somewhat important for R57 to choose what to wear, listen to music, keep up on the news, do things with groups of people, go outside, do favorite activities . A review of the At risk for changes in behavior and mood related to Alzheimer's care plan dated 03/20/2025, revealed, Encourage resident to attend activities of choice . A review of the Activities/Recreation care plan initiated 03/29/2025 revealed, assist resident off the unit for strolls, special events or entertainers . A review of the Activities Task documentation from 6/9/25 to 6/22/25, revealed no Independent, Intellectual, Physical, Social, and Spiritual activities had been provided to R57. R152 On 06/23/25, 06/24/25, and 06/25/25 during the hours of 9:00 am and 4:00 PM, R152 was observed to be in bed in their room the TV was not on nor was there any device observed to play music. A review of the record for R152 revealed R152 was admitted into the facility on [DATE]. Diagnoses included Non traumatic Brain Dysfunction, Stroke and High Blood Pressure. The Minimum Data Set (MDS) assessment dated [DATE], indicated severely impaired cognition, impaired range of motion of the extremities, and R152 was dependent on staff for all activities of daily living including bed mobility, bathing and personal hygiene. Section F: Preference for Customary Routine and Activities documented it was very important or somewhat important for R57 to .listen to music, be around animals, keep up on the news, do things with groups of people, do favorite activities . The primary respondent was documented as R152. A review of the Activities Task documentation from 6/9/25 to 6/22/25, revealed no Independent, Intellectual, Physical, Social, and Spiritual activities had been provided to R152. On 06/25/25 at 11:49 AM, the identified concerns were reviewed with the Activity/Recreation Director. The Activities Director reported they were responsible for completion of the Recreational Therapy assessment and section F in the MDS. The Activities Director was asked about room visits and reported room visits are for resident who are bed bound or do not come out of their rooms. The activity documentation for R57 and R152 was reviewed with the Activities Director who confirmed there was no documentation of any activities provided for R57 nor R152. On 06/25/25 at 1:42 PM, the Director of Nursing (DON) was interviewed and confirmed care activities should be provided and documented. A review of the facility policy titled, Activities dated 04/01/22 revealed, It is the policy of this facility to provide an ongoing program of activities designed to meet the interest, choice and preferences as well as to meet the interest of and support the physical, mental, and psychosocial well being of each resident . A review of the facility policy titled Resident Rights issued 11/12/24 revealed, .Right to Self Determination to: Participate in activities programs of their choice .

A review of the record for R152 revealed R152 was admitted into the facility on [DATE]. Diagnoses included Non traumatic Brain Dysfunction, Stroke and High Blood Pressure. The Minimum Data Set (MDS) assessment dated [DATE], indicated severely impaired cognition, impaired range of motion of the extremities, and R152 was dependent on staff for all activities of daily living including bed mobility, bathing and personal hygiene. A review of the policy, Care Plan - Comprehensive and Revision, revised 8/25/2023, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident .Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. The IDT (Interdisciplinary Team) reviews and updates the care plan when there has been a significant change in the resident's condition . Based on observation, interview, and record review, the facility failed to update a care plan for one (R152) of four residents reviewed for plans of care. Findings include: On 6/23/25 at 8:53AM, the room door of R152 was observed with an Enhanced Barrier Precautions (EBP) signage on it. The sign identified what personal protective equipment was to be used when entering the room and remained in place for the duration of the survey which ended on 6/25/25. A review of medical records revealed R152 was admitted into the facility on 5/22/25 and was placed on Contact Isolation Precautions (to prevent the spread of infections through direct and indirect contact) on 5/23/25 for C. Difficile (C-Diff, a contagious infection in the bowel). A review of the active Physician's order dated 6/23/25, (R152) was placed on EBP every shift related to their tube feeding. A review of R152's care plan (revised 5/23/25) revealed the resident was currently on Contact Isolation Precautions. R152's care plan did not reflect the current Physican's order for EBP. On 6/24/25 at 1:33 PM, the Infection Preventionist (IP) was interviewed regarding care plans and explained the care plans should be updated immediately (when the resident was placed on EBP precautions). The IP continued to explained the resident was supposed to be on EBP only and the C-Diff precautions were discontinued. On 6/25/25 at 1:40 PM, the Director of Nursing (DON) was interviewed regarding the revision of care plans and explained the care plans should be updated immediately to reflect the changes of care and also reflect on the Kardex (the care plan for the nurse aides).

Based on interview and record review, the facility failed to ensure the completion of 12-hours of annual in-service trainings of two Certified Nursing Assistants (CNA O and CNA P), of five reviewed for the completion of 12-hours of annual in-service training. Findings include: On 6/25/25 at 8:43 AM, 12-hours of annual in-service training was requested from the facility for CNA O and CNA P. On 6/25/25 at 11:44 AM, the facility provided documentation the 12-hours of annual training was requested from the vendor the facility uses for CNAs that work on an as needed basis and are not hired directly through the facility. A review of a document titled, CNA skills competency checklist was provided for CNA P however, it did not reveal the number of training hours, nor did it reveal that dementia management training and resident abuse prevention was provided. Training documentation for CNA O was not received by the end of the survey. On 6/25/25 at 4:18 PM, In-service Director Q was interviewed regarding training for agency CNAs, and explained the facility has a contract with a vendor that is to provide trainings through an app. In addition, huddles and education is on-going while they are working in the facility. A review of the facility's Staffing policy did not address the required 12-hours of in-service training for CNAs.

Based on observation, interview, and record review, the facility failed to ensure resident medications were not left at the bedside for one resident (R74) of one resident reviewed for medication storage. Findings include: On 6/23/25 at 3:32 PM, R74 was observed lying in their bed. A medication cup with 2 pills were observed sitting on the resident's overbed table. The resident was asked about the medications and explained they didn't realize they were there, and didn't know how long they had been sitting there. On 6/23/25 at 3:34 PM, during an interview with Licensed Practical Nurse (LPN) G, assigned nurse to R74, who explained they had gone into the room to provide services to R74's roommate and in doing so provided the medications to the R74. LPN G confirmed they didn't know why the resident hadn't taken them. LPN G then entered R74's room and watched the resident take the medication. LPN G indicated the medications in the medication cup were, Robaxin (muscle relaxer) and (R74's) blood pressure medication because their blood pressure runs high.' A review of R74's medical record revealed they were admitted into the facility on 5/17/25 with diagnoses that included Cerebral Infarction, Hypertension, and Muscle Weakness. Further review revealed the resident was cognitively intact and required minimal assistance for activities of daily living. Further review of the medical record did not reveal an assessment for the self-administration of medications. On 6/25/25 at 3:44 PM, the Director of Nursing (DON) was asked for the expectations regarding medications left at the bedside, and explained medications should not be left at the bedside, and the nurse should have watched the resident take them. A review of the facility's Storing Drugs and Biologicals-Storage and Maintenance of Medication did not address medications being left at the bedside.

Based on observation, interview, and record review the facility failed to label, date, and provide tube feeding (nutrition infused directly into the stomach via a tube) as ordered for one resident (R152) of three residents reviewed for tube feeding. Findings include: A review of the record for R152 revealed R152 was admitted into the facility on [DATE]. Diagnoses which included Non traumatic Brain Dysfunction, Stroke and High Blood Pressure. The Minimum Data Set (MDS) assessment dated [DATE], indicated severely inmpaired cognition, impaired range of motion of the extremities, and R152 was dependent on staff for all activities of daily living including eating, bed mobility, bathing and personal hygiene. On 06/23/25 at 8:53 AM, 3:45 PM and on 06/24/25 at 8:33 AM, R152's was observed to be in bed with the tube feeding actively running at 40 milliliters(ml) per hour (ml/hr), with the formula bag dated 6/22 5:30 PM. A review of the active Physician's order R152's tube feeding rate revealed the feeding should have been set at 45 ml per hour. No indication for the rate to be at 40 ml/hr was noted in the progress notes or discontinued tube feeding orders. On 06/24/25 at 11:36 AM, Registered Nurse (RN) D was interviewed regarding the tube feeding orders, the labeling and dating of the tube feeding bags. RN D stated the policy is to change the bag every 24 hours. On 06/25/25 at 1:40 PM , the Director of Nursing (DON) was interviewed regarding tube feeding policy for orders, label and dating. The DON explained the policy was to change the bag every 24 hours, date it the day they hang it and follow the physician orders. A review of the facility policy titled, Tube Feeding-Overview dated issued 08/09/23 revealed, .A resident will be fed via feeding tubes when their clinical condition demonstrates that enteral feeding is clinically indicated . Feeding tubes (nasogastric, gastrostomy, jejunostomy) will be utilized in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible . Feeding tubes will be utilized according to physician orders, which typically include: the kind of feeding and its caloric value, volume, duration, mechanism of administration, and frequency of flush .

Based on observation, interview, and record review the facility failed to prevent a fall for one resident (R143) of four residents reviewed for falls resulting in pain. Findings include: On 6/23/25 at 9:28 AM, R143 was observed in bed, unable to move their right arm. R143 was asked about their care in the facility and explained they've had concerns regarding transfers and bed mobility as they recently sustained a fall. A review of R143's medical record revealed they were admitted into the facility on 4/18/25 with diagnoses which included, nontraumatic intracerebral hemorrhage in brain stem, Diabetes, and Heart Failure. Further review revealed the resident was cognitively intact and required 1-2 person assist with transfers, bed mobility, and grooming. Further review of the medical record revealed the following progress notes: 6/11/2025 21:21 (9:21pm) . Note Text: Resident is A&Ox3-4. (alert and oriented to person, place, and time) Assist x1-2 (persons) with adl's (activities of daily living), bed mobility, and transfers. Incont (incontinent) of bowel and bladder with incontinence care given as needed during shift. Hard of hearing. In bed with call light and personals within reach. 6/12/2025 05:47 (5:47am) Note Text: While charting at nursing station loud noise was heard where staff entered room to observe pt (patient) on the floor .Pt transferred back to bed via (name of mechainical lift) with assist x3-4. C/o (complain of) pain to RUE/RLE (right upper extremity/right lower extremity) In bed at this time with call light and personals within reach. 6/12/2025 07:30 (7:30am) Note Text: Spoke to [physician] X-rays ordered to RUE and RLE. Logged to be seen today. 6/13/2025 13:47 (1:47pm) .Details: Chief Complaint: Fall incident 6/12/2025 .Review of Systems: patient was seen and examined today in [their] room, [they are] laying comfortably in bed in no acute distress. Was called to evaluate patient today because of nurse report of a fall incident yesterday. Per patient, chart review and staff, patient fell off the bed in the early morning of 6/12/2025 when [they were] receiving care; patient reports continued pain to right shoulder A review of Incident and Accident report dated for 6/12/25 revealed, heard loud noise from pts room with aide noted in room. Pt notes on floor lying on right side near window against wall. Resident states [they] fell out of bed and complains of pain to RUE and RLE. Pt. states [they] may of hit [their] head. [R143] states that the impact was to [their] R (right) side which broke the fall .Description: Staff reports that during care pt was getting clean and pt rolled out of bed to the floor .Level of pain: 8 . On 6/25/25 at 1:33 PM, the Assistance Director of Nursing (ADON) was asked about the incident and said she thought the CNA had rolled the resident the wrong way during care. On 6/25/25 at 1:50 PM, R143 was interviewed further regarding their fall, and explained at approximately 5am, a CNA came into their room to change them, and at that time expressed concern because they were working by themselves and appeared small in stature. R143 explained while providing incontinence care, the CNA was standing behind them, and in the process of rolling them over, pushed them away and onto the floor saying they remained on the floor for approximately 30-45 minutes naked while staff went to locate a mechanical lift to lift them off the floor. R143 explained many x-rays were completed due to pain, and explained they had bruising to their right kneecap, and right elbow. On 6/25/25 at 3:09 PM, an attempt to contact CNA E was to no avail. On 6/25/25 at 3:44 PM, the Director of Nursing (DON) was asked about R143's fall and acknowledged CNA E rolled the resident the wrong way, away from her and not toward her causing the fall. On 6/25/25 at 4:01 PM, a request for the facility's fall policy was made, and a policy titled Accident and Incident Report was provided, however, it did not address fall interventions and/or prevention.

Based on interview and record review, the facility failed to provide gynecological care in a timely manner for one resident (R25) of one reviewed for a delay in treatment. Findings include: On 6/23/25 at 10:39 AM, R25 explained since June 2024, they had been having post-menopause vaginal bleeding and was unable to be seen by a gynecologist until May 2025, in which they were ultimately diagnosed with uterine and cervical cancer. R25 explained the facility nurse practitioner initially thought they had a urinary tract infection however, after the results came back negative, nothing more was done to further investigate the cause of the bleeding. R25 explained the vaginal bleeding would become heavy and at times become painful. R25 explained they were provided with menstrual pads. R25 also explained there had also been issues related to transportation resulting in missed appointments. A review of R25's medical record revealed they were admitted into the facility on 7/7/2017 with diagnoses which included Paraplegia, Adjustment Disorder, and Hypertension. Further review revealed the resident was cognitively intact and required extensive assistance for transfers and bed mobility. Further review of R25's medical record revealed the resident underwent a pap smear, Hysteroscopy and D&C (dilation and curettage, a procedure that surgically removes tissue from the lining of the uterus to diagnose abnormal uterine bleeding) on 5/2/25. A pathology report dated 5/9/25 revealed the following, Mixed high-grade endometrial carcinoma (cancer). Further review of R25's medical record revealed the following progress notes: Encounter Date: 06-11-2024. Chief Complaint: Vaginal bleeding. Patient seen today resting in bed. (resident) reports intermittent vaginal bleeding . (Resident) does have a history of abnormal intrauterine bleeding in several years ago underwent D&C for this. It has been a long time since (resident) has followed up with GYN (gynecologist). (Resident) denies any cramping. Bleeding is not heavy and is essentially spotting and is intermittent. Blood pressure has been stable, patient is afebrile. Bleeding is not suspected to be related to (residents) urine. (Resident) denies any dysuria .Assessments/Plans: Abnormal uterine bleeding Patient reports intermittent pink spotting, denies any pain complaints or cramping History of previous abnormal uterine bleeding several years ago status post D&C with hormone regulation. Recommend follow-up with GYN (gynecologist). Will check CBC (complete blood count) . Date of Service: 07/02/2024, Visit Type: 1. Acute/Follow-Up Plan: Abnormal uterine and vaginal bleeding, unspecified: Intermittent, spotting. Stable. CBC (complete blood count) is stable. Recommended follow-up with GYN per PCP (primary care physician). [insurance]care [NAME] assisting in finding GYN for resident and setting up apt.(appointment) . 7/26/2024 16:47 (4:47pm) Note Text: Resident is A&Ox3 (alert and oriented to person, place and time) and able to make needs known. Resident had small vaginal bleeding, MD (medical doctor) and Nurse manager aware, waiting for gynecologist follow up. No complain of pain and discomfort . 8/21/2024 00:00 (12:00am) Date of Service: 08/21/2024. Visit Type: 1. Acute/Follow-Up Plan: Abnormal uterine and vaginal bleeding, unspecified: Intermittent, spotting. Stable. CBC is stable. Recommended follow-up with GYN per PCP. [Insurance] care [NAME] assisting in finding GYN for resident and setting up apt. 9/3/2024 16:20 (4:20pm) Physician Team - Progress Note Assessments/Plans: Abnormal uterine bleeding Patient reports intermittent pink spotting, denies any pain complaints or cramping. History of previous abnormal uterine bleeding several years ago status post D&C with hormone regulation. Recommend follow-up with GYN. 9/14/2024 19:06 (7:06 PM). Note Text: Patient is paraplegia, alertx4 and able to makes needs known .Patient c/o (complains of) bleeding of the vagina with menstruation symptoms. Patients mention it happens often. Management aware and NP (nurse practitioner), but patient says they are waiting for follow up of gynecologist . 9/17/2024 00:00 (12:00am) Date of Service: 09/17/2024. Visit Type: 1. Acute/Follow-Up History of Present Illness: .(Resident) has a history of abnormal intrauterine bleeding, underwent D & C several years ago. The bleeding has unchanged since visit from PCP. It is spotting, not heavy, intermittent. Patient requests follow-up with GYN and [insurance] care [NAME] is assisting building to find a local GYN- the problem is that resident prefers in house GYN eval which has been difficult to find. (Resident) is aware of the difficulty in finding a traveling GYN to come to building. [Physician] was also notified of resident request. GYN appt requested by resident, PCP and [insurance] care [NAME] is assisting to find GYN to accommodate resident. 9/19/2024 20:31 (8:31pm) Social Work. Note Text: Resident has been bleeding from Vagina, (resident) has also pain associated with the bleeding, [physician] and Regeistered Nurses (RNs) were both informed. SW (social work) is working on setting up an appointment so resident can be eaminate (examined). 11/5/2024 00:00 Plan: Abnormal uterine and vaginal bleeding, unspecified: Intermittent, spotting. Stable. CBC is stable. Resident requesting follow-up with GYN and PCP aware: difficulty finding GYN to accommodate resident weight and bedbound status-app rescheduled. Date is undetermined. 12/2/2024 13:33 (1:33pm) Physician Team - Progress Note Assessments/Plans: Abnormal uterine bleeding Hemoglobin has been stable. No gross bleeding at this time. Continue to monitor. Did consult GYN. Patient will benefit from evaluation but not having any emergency needs. 12/3/2024 00:00. Plan: Abnormal uterine and vaginal bleeding, unspecified: Intermittent, spotting. Stable. CBC is stable. Resident requesting follow-up with GYN and PCP aware: difficulty finding GYN to accommodate resident weight and bedbound status-app rescheduled. Date is rescheduled for 12/19/2024 at 10:45 at [local hospital]. 1/7/2025 00:00 (12:00am) Chief Complaint / Nature of Presenting Problem: Routine folllow-up for multiple chronic conditions. History Of Present Illness: Patient has a history of abnormal intrauterine bleeding, underwent D&C in 2016. The bleeding has unchanged since visit from PCP. It is spotting, not heavy, intermittent, none today. Patient was scheduled for appointment with GYN on 12/19/2024 at 10:45 at [local hospital]. Discussed care with unit clerk, [unit clerk H]. The appointment was canceled, rescheduled for 01/16/2025 at 2:00 at [local hospital]. There are no changes since last visit. Discussed care with nursing staff, there are no concerns at this time. Effective Date: 02/10/2025 15:01 (3:01pm). Chief Complaint: Vaginal bleeding .Patient was seen and examined today in room, (resident) is sitting comfortably up in bed in no acute distress. Was called to evaluate patient today because of nursing concern of recurrent vaginal bleeding. Patient reports history of D&C in 2017 because of recurrent bleeding. (Resident) was prescribed hormones which (they) took for 3 months. Bleeding did resolve but recurred recently in the last 3 to 5 months. According to patient, they have a scheduled follow-up appointment with gynecology on Friday, 2/14/2025 for a vaginal ultrasound . Date of Service: 2025-02-19 .Details: Chief Complaint: monthly follow-up, chronic deconditioning, intermittent vaginal bleeding. Review Of Systems: Patient was seen and examined today in room; (Resident) is sitting comfortably up in bed in no acute distress. Patient had a couple appointments and both fell through. Patient has not had ultrasound or lab work done recently. Patient requires stretcher transport for outpatient labs tests, visit. Has had a lot of complications with arranging all the steps necessary for this. Patient is frustrated specially (especially) since (resident) is still having significant decline. Has been stable and vital signs obtaining lab draw in our facility. Assessments/Plans: Abnormal uterine bleeding-Check CBC. Patient has a scheduled follow-up appointment with GYN at the end of this week but unable to be attended (attend) due to requiring stretcher transportation. Patient continues to have periodic bleeding and spotting. Has not had GYN follow-up yet scheduling constraints . On 6/25/25 at 8:55 AM, R25 was asked additional information about the missed appointments, and denies they ever asked for a traveling gynecologist, and the vaginal bleeding started off as light spotting that progressed to heavy bleeding.The resident further reported when they had their first appointment on 3/4/25 with the gynecologist and was unable to get on the exam table and bend their leg, so they attempted an ultrasound which was unsuccessful. As a result, they had an exam on 5/2/25 in which they were placed under anesthesia and a D&C was performed. R25 also explained they spoke to NP J about going to emergency room for an exam, and was advised they did not have emergent needs. On 6/25/25 at 10:54 AM, an interview was completed with Unit Clerk H regarding R25's appointments, and they explained the resident had to be transported to outside appointments via stretcher, so they must contact two local Emergency Medical Services for transportation. Unit Clerk H explained after an appointment is made, they provide a window of time to the transportation company however, due to priority calls being made for emergencies, the resident would miss their appointments. Unit Clerk H was asked how many appointments had been missed, and said, two. Unit Clerk H was asked when they started working on gynecology appointments for R25 and explained they were not aware of the need for the resident to be scheduled for gynecology appointments until March 2025. Unit Clerk H was asked if there was a care [NAME] that worked in the building and they explained that a care [NAME] would assist with appointments and insurance. The process includes sending a form to the care [NAME] regarding a resident when an appointment is being made, they then in turn approve and return the form within 2 days. On 6/25/25 at 11:58 AM, an interview was completed with CNA I, who cares for R25 regularly, and was asked about the vaginal bleeding. The CNA explained they have been working with the resident for about 8 months, and during time has observed vaginal bleeding which ranged from spotting to blood clots. CNA I explained they informed the nurses and the bleeding persisted. On 6/25/25 at 12:19 PM, an interview was completed with Social Worker K who was asked about R25's gynecology appointments, and they explained the social work department informed the resident's physician of the resident's concerns however, their department only sets up ancillary services (dental, vision, and podiatry, and all other medical appointments are set up by nursing and the unit clerk. On 6/25/25 at 12:48 PM, Nurse Practitioner J (NP J) was interviewed about the treatment provided to R25 regarding vaginal bleeding. NP J explained they no longer work with the resident, and hasn't done so since the end of January (2025), but did explain the resident had some bleeding which they ruled out as a urinary tract infection (UTI). NP J explained the facility had some difficulty locating a gynecologist that could accommodate the resident and acknowledged delays as a result however, in the meantime the resident's hemoglobin was monitored. NP J was asked what would have made circumstances emergent for the resident's vaginal bleeding and explained that if the resident was steadily bleeding with a heavy flow and lasting more than a day. On 6/25/25 at 2:13 PM, a phone interview was completed with the resident's current NP, NP L regarding the delay in R25 being seen for gynecological care. NP L referred the surveyor to a progress note dated 2/12/25 and explained it was not easy to locate a gynecologist for a bedbound resident who needs appropriate transportation. On 6/25/25 at 3:44 PM, the Director of Nursing (DON) was asked about the delay in R25's gynecological care and explained they were not familiar with the concern and was unable to speak to the topic at that time. A review of the facility's Change in Condition policy revealed the following, It is the policy of this facility that residents will be routinely monitored and evaluated by all staff members to determine the need for additional health services monitoring of chronic, unstable, or changes in condition. Results of additional monitoring will be routinely evaluated for appropriateness and effectiveness.

A review of the record for R152 revealed R152 was admitted into the facility on [DATE]. Diagnoses included Non traumatic Brain Dysfunction, Stroke and High Blood Pressure. The Minimum Data Set (MDS) assessment dated [DATE], indicated severely impaired cognition, impaired range of motion of the extremities, and R152 was dependent on staff for all activities of daily living including bed mobility, bathing and personal hygiene. Resident #57 On 06/23/25 at 9:01 AM, R57 was observed to be supine in bed, with their heels on the bed, and and dressed in a hospital style gown. R57's breakfast tray was observed on the over bed table which was over the waist area of R57. R57 had not eaten or drank any items. The mighty shake (for calorie/nutrition assistance) was not opened. The call light was in the top drawer of the night stand away from R57. On 06/23/25 R57 was not observed to be out of bed during the hours of the survey. On 06/24/25 at 8:16 AM, R57 was observed to be laying on their back (supine) in bed. The head of the bed was flat. The arm for trapeze (device to assist bed mobility) extended over the upper portion of the bed with the handle hooked over the end of the arm. The call light button was observed to be in the top and mostly closed, drawer of the night stand at the right side of the bed. The bed control was at the foot of the bed. R57 wore a hospital style gown. R57 confirmed they would like to be out of bed at times during the day. On 06/24/25 at 12:59 PM, CNA N was asked about R57 and reported they had care for R57 three times in the last month and R57 will answer when asked directly but will not ask for care needs to be met such as to get out of bed, or use the call light. CNA N further noted R57 required a Hoyer lift (two persons) for transfers. On 06/24/25 at 4:19 PM, R57 appeared as before but with the head of the bed up around 30-45 degrees. R57 was not observed to have been out of bed or repositioned. No devices for for repositioning such as an extra pillow or a foam wedge were observed. On 06/25/25 at 9:51 AM, R57 was observed to be in bed, supine, feet/heels on bed, and dressed in a hospital style gown. The call light was in the slightly open top drawer of the night stand. On 06/25/25 at 10:17 AM and 12:05 PM, R57 was on their back in bed, slumped down slightly, with the head of bed around 30-45 degrees. The call light in the top drawer of the night stand. R57 reported on query that they had not been out of bed the day before but does like to be out of bed at times. R57 was not sure if staff had checked on them. The TV was off and their roommate was dressed and out of bed. On 06/25/25 at 12:08 PM, Licensed Practical Nurse (LPN) T was asked to observed R57 and the location of the call light in the top drawer of the night set and reported it should be in reach of R57. On 06/25/25 at 12:14 PM, CNA U reported they offer to get residents out of bed and noted they had noted worked with R57 since they moved from the second floor and reported R57 was more aware now and no longer had an indwelling urinary catheter. On 06/25/25 at 1:40 PM, the Director of Nursing (DON) was asked what is the expectations of repositioning, brief change, and call light use. DON replied repositioning, brief change every two hours and as needed, and the call lights are to be within reach. A review of the record for R57 revealed R57 was admitted into the facility 03/19/2025. Diagnoses included Alzheimer's Anxiety and Depression. The Minimum Data Set (MDS) assessment dated [DATE] documented severely impaired cognition and the need for assistance with all activities of daily living and was dependent or required maximal assistance for all except eating. A review of the facility policy titled Call light accessibility and Timely Response issued 08/16/23, revealed, .Staff will ensure the call light is plugged in, functioning, within reach of resident and secured as needed . Staff members who see or hear and activated call light are responsible for responding regardless of assignment . Turn off call light when resident's request's is met . This citation pertains to Intakes: MI00152680, MI00152773, MI00153364, and MI00153659. Based on observation, interview, and record review, the facility failed to ensure that brief changes and repositioning were provided in a timely manner for three dependent residents (R57, R152, and R271) of eight reviewed for activities of daily living (ADL) care. Findings include: R271 On 6/24/25 at 9:15 AM, R271's call light was observed to be activated and R271 was heard to say, I need a brief change. At 9:21 AM, Certified Nursing Assistant (CNA) C entered R271's room, deactivated their call light and exited the room. At 9:25 AM, R271 reactivated their call light. At 9:33 AM, CNA F who was observed walking down R271's hallway, entered R271's room, deactivated their call light, exited, and proceeded to enter another resident's room. On 6/24/25 at 9:38 AM, CNA C was interviewed regarding the policy regarding responding to activated call lights for residents and was asked if a residents' call light should be deactivated prior to the residents' care need being met. CNA C indicated they were, agency staff and admitted they didn't know the call light policy. On 6/24/25 at 3:30 PM, R271 was interviewed about their care and call light response at the facility. R271 was unable to respond coherently to any questions. A review of R271's electronic medical record (EMR) revealed that they were admitted to the facility on [DATE] with diagnoses that included Fracture of right side of pelvis and Dementia. R271's most recent minimum data set assessment (MDS) dated [DATE] revealed R271 had a severely impaired cognition and was frequently incontinent of bowel. A review of R271's Kardex (guide to care for CNA) revealed R271 required two person assistance for all ADL care other than eating. A review of resident council meeting minutes for the months of January 2025-June 2025 revealed the following, Call lights not being answered in a timely manner. Staff not being present or responding in a timely manner. Why is there a lack of care? On 6/25/25 at 10:35 AM, the Assistant Director of Nursing (ADON) A was interviewed and asked about their expectations for resident care and call light response to which they responded staff should respond to call lights in a timely manner and the call light should remain on until the care need has been met. On 6/25/25 at 10:42 AM, the Director of Nursing (DON) was interviewed and asked about their expectations for resident care and call light and indicated call lights should be answered as quickly as possible and the care need should be met prior to the call light being turned off. R152 On 6/23/25 at 8:53 AM, 11:50 AM, and 1:40 PM, R152 was observed in supine position in bed with of the bed elevated around 30-45 degrees. The call light was in the top drawer of the nightstand and two briefs were stacked on the over bed table on the left side of the bed. R152's fingernails were long appeared to have dirt under the nails and extended an eigth to a quarter inch beyond the tip of the fingers. On 06/23/25 at 1:40 PM, R152 was asked if they had been changed or repositioned recently and R152 nodded their head no. On 06/23/25 at 1:43 PM, Certified Nursing Assistant (CNA) M and another CNA N were observed to give R152's a bath and a brief change. R152's brief was observed to be saturated with urine and slightly soiled with stool. On 06/23/25 at 3:19 PM, CNA M interviewed and asked if they knew the facility policy for brief change, repositioning, and call lights. CNA M stated, every two hours and call lights need to be within reach. On 06/23/25 at 3:45 PM, R152 was observed to be supine in bed with the head of the bed elevated 30-45 degrees and dressed in hospital style gown. On 06/24/25 at 8:33 AM, and 11:00 AM and 12:10 PM, R152 was observed supine in bed with the head of the bed around 30-45 degrees. The call light was in the top draw of the nightstand. A single brief was observed on their dresser. At 12:10 PM a vague odor of bowel movement (BM) was noted.

This citation pertains to Intake MI00151526 Based on interview and record review, the facility failed ensure timely assess a pressure ulcer for one resident (R703) out of two reviewed for pressure ulcers. Findings include: A review of the medical record revealed that R703 admitted into the facility on [DATE] with the following medical diagnoses, Severe Protein-Calorie Malnutrition and Urinary Tract Infection. A review of the Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status assessment score of 3/15 indicating an impaired cognition. The MDS also did not note any unhealed pressure ulcers/injuries at the time of assessment. R702 also required staff assistance with bed mobility and transfers. Further review of the progress notes revealed the following, 2/27/2025 at (4:20 PM) .Wound Rounds Note: WCC (Wound Care Consultant) and WCNP (Wound Care Nurse Practitioner) to room for admission skin assessment during IDT (Interdisciplinary Team) rounds .Skin intact, sacrum with darker shade of skin but intact, buttocks pink, blanchable and intact, Bilateral heels pink and intact .No open areas or area of concern. Resident with decreased mobility due to weakness. Discussed with resident and staff the need to turn side to side with assistance while in bed and sit up in chair as tolerated to decrease pressure on boney prominences. Care plan updated. Comfort care mattress on bed for pressure reduction. 3/14/2025 at (5:54 PM) .Nursing-Progress Note .CNA (Certified Nursing Assistant) made writer aware that patient has open area to coccyx and groin area. Writer cleanse area, pat dry and applied medihoney and applied foam dressing. Wound care consult/wound care orders made, and MD (Medical Doctor) made aware. A request for wound care notes were requested but not received by end of survey. On 4/7/2025 at 1:39 PM, an interview was conducted with the Director of Nursing (DON) and Wound Care Nurse (WCN) B. The DON reported R703 did not enter the facility with any open areas, but preventative measures were put in place by WCN B. The DON reported when the open area was observed they put an order in and was waiting for the Wound Care Nurse Practitioner (WCNP) to come and assess. WCN B was queried as to if the area was ever staged or measured. WCN B stated they were waiting for the WCNP to come in and they come in weekly, but did not make in to see R703 prior to their transfer from the hospital. A review of a facility policy titled, Skin and Wound Guidelines noted the following, .Weekly evaluation of the pressure injury in the resident's medical record by the wound team or licensed nurse per state and federal guidelines .

This citation has two deficient practices. Deficient practice #1. This citation pertains to Intake MI00134465. Based on interview and record review, the facility failed to adequately assess and monitor a skin alteration for one resident (R283) of two reviewed for quality of care, resulting in an unmonitored infection, gangrene, and ultimately, amputation of the right great toe. Findings include: A complaint filed to the State Agency was reviewed and included the following: .On 01/25/23 a podiatrist came to clip [R283's] toe nails. He had an ingrown toe nail that was infected on his right foot, big toe. Antibiotic cream was use (sic) and a dressing applied. On 02/04/23 the resident's [family] visited .[R283's] big toe was blue and dark black .On 02/08/23 the resident had his big toe amputated because he had gangrene. A review of R283's record revealed that the resident was admitted into the facility on [DATE] and discharged on [DATE]. A review of R283's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was cognitively intact and required extensive assistance from staff for activities of daily living (ADLs). R283's medical diagnoses included Right Femur Fracture, Cerebrovascular Disease, Peripheral Vascular Disease, Hemiplegia/Hemiparesis Affecting Left Side, and Type 2 Diabetes Mellitus. A review of R283's medical record revealed a photo taken on 2/5/23 of the resident's right toe, along with an incomplete (unsigned) skin assessment. The photo showed R283's right foot with the top of the right toe discolored black/purple and appearing leathery (indicating gangrene) down to the bottom of the nail bed. A review of R283's hard copy chart from the facility revealed documentation from a podiatry visit at the facility on 1/25/23. The podiatrist documented the following: -Chief Complaint: Painful dystrophic toenails, Painful lesion - R (right) hallux nail . R Hallux (R1, or Right Great Toe)- medial border - Erythema, Incurvation, Painful Nail Boarder (sic), Breakdown, Paronychia (an infection of the skin that surrounds a toenail or fingernail) . Treatment: Podiatic E/M (evaluation/management) & Hx (history), Debrided mycotic toenails 1-5 B, I & D (incision and drainage) of infected toe - R1, Antibiotic Ointment and Dsg (dressing) applied - R1. A review of R283's electronic medical record and progress notes did not reveal any documentation related to the visit from the podiatrist, nor indicate that there was an issue with R283's feet/toes prior to the podiatry visit. A review of R283's physician orders did not reveal any related to the treatment of the resident's right foot/toe until 2/4/23, and did not reveal an order to send R283 to the hospital at any point for further evaluation of the toe. Continued review of R283's progress notes revealed the following: -2/4/2023 19:01 (7:01 PM) General Progress Note Note Text: Resident observed with redness to upper back, swelling and discoloration to right big toe during shower. MD (Physician), Unit Manager, and son informed of finding. Daughter admitted to cutting residents toe nails multiple times since January 23rd. Family very rude to nurse and unit manager on phone. Family demanded resident be sent out 911. Residents family then changed their mind. Writer inserted order of TOA (topical antibiotic) and dry dressing BID . Written by Licensed Practical Nurse (LPN) H. -2/4/23 19:40 (7:40 PM) General Progress Note Text: .writer was informed by nurse on duty with family concerns to residents right great toe, resident is seen and followed by outside podiatrist and was seen recently, daughter .admitted to cutting residents toe nails several times during the residents stay without having staff awareness. Talked to son on phone about concerns, he was rude, verbally aggressive, and upset the physician would not sent resident out 911, resident and family refused to leave and remained at the hospital. TX (treatment) order was applied to toe by nurse, resident will be followed by wound NP (Nurse Practitioner) on 2-6-2023. Physician aware of current plan of care. Written by LPN I. -2/5/2023 11:04 (AM) General Progress Note Text: Yesterday (2/4/23) medical doctor (MD) gave order to go to hospital, pt (patient) refused to leave, Transportation offered and set up, PT taken by family out of facility, instructed to go straight to emergency room . All risks discussed and understood. Written by Licensed Practical Nurse (LPN) H. A review of the facility provided, hard-copy Skin Worksheets for R283 revealed: -1/11/23 worksheet, marked as abnormal, with the right foot/leg circled and two areas on the resident's back marked as abnormal. No details regarding the skin concern circled on the right foot/leg were present on the sheet, nor in the resident's medical record upon review. No corresponding progress note to the skin worksheet dated 1/11/23 was found, however, a progress note for a body audit on 1/12/23 noted, No new skin concerns. No Skin Worksheets for R283 were provided by the facility after 1/18/23, although the resident remained in the facility until 2/5/23. A review of R283's medication/treatment administration records (MAR/TAR) revealed the order, Body Audit every night shift every Wednesday, Saturday for Body Audit. There was no documentation present indicating that the body audit was completed per the order on Saturday, 1/28/23, and no corresponding progress note was found. It was documented that a body audit was completed on Wednesday, 2/1/23, however, no corresponding progress note nor skin assessment/worksheet was found. A review of R283's hard copy chart from the facility revealed that the resident's family member signed the resident out AMA (against medical advice) on 2/5/23 at 11:00 AM. On 3/6/23 at 2:13 PM and 3/7/23 at 10:38 AM, Confidential Witness J was interviewed via phone. When queried regarding what occurred over the weekend prior to R283 leaving the facility, Witness J explained, February 4th my [family member] was visiting [R283] . [The resident's] toe was completely black - not bruised - it was black. Ten days prior, a podiatrist had come in per the facility and clipped [R283's] toenails, he had an ingrown toenail - the paperwork went into a binder and didn't get put into the computer system. No one was paying attention to [R283's] feet. [R283] has bad blood circulation to his feet and diabetes. Witness J explained that photos were sent to the supervising nurse of the toe LPN I (who was not working in the building when the issue with the toe was discovered, but was corresponding over the phone). Witness J stated, The nurse (LPN I) said the doctor was saying just to put cream on it and would have someone look at it on Monday. We were telling them [R283] needed to go to the hospital. When asked if family had cut the resident's toenails, Witness J stated that family cut the resident's toenails on the smaller toes but, Not the big toes, because there was an ingrown toenail .We asked the facility if they could do it and they said they would get podiatry set up. Witness J explained that is why R283 ended up being seen by the podiatrist in the facility in the first place. Witness J stated the resident's family wanted R283 to go to the hospital on 2/4/23 but the facility would not send him out. When asked if any of the family or R283 ever changed their mind about wanting to send the resident to the hospital, Witness J stated, No. Witness J continued and stated, I went there on Sunday (2/5/23) morning and looked at the toe myself and talked to the nurses and supervisors. They said it's okay, someone will look at it tomorrow (2/6/23). I asked them to override the doctor. When queried regarding the documentation in R283's record by LPN H and LPN I from 2/4/23 and 2/5/23, Witness J stated it was incorrect. Witness J stated that R283's family was adamant on the resident needing to be sent to the hospital, and added, That's absolutely not what happened at all. Why would [family] sign AMA paperwork if the doctor had given an order to send [R283] to the hospital? They did absolutely nothing for [R283] as it related to that toe .We saw the toe on the 4th (February), and it was done on the 25th (January) .[R283] supposedly had four showers between those two dates, no one was paying attention during his showers as to having an open wound on his toe and no one said anything to us. R283's hospital documentation was obtained, reviewed, and revealed the following: -Note From Your Admission on 02/05/23 .ED (Emergency Department) Provider Notes .Chief Complaint: Foot discoloration . Physical Exam: .Skin: .Right great toe has partial nail evulsion with necrotic region around right first toe distal nail bed. Right dorsal foot erythema. +1 bilateral lower extremity edema . Medical Decision Making: I am concerned about osteomyelitis and necrosis of the patient's right great toe. Patient will be given vancomycin and Zosyn (antibiotics) and will admit for podiatry evaluation and IV (intraveneous) antibiotics. X-ray indicates no fracture. -OR (Operating Room) Brief Operative Note .Date of Surgery: 2/8/2023 11:07 AM .Preoperative Diagnosis: gangrene right great toe, Postoperative Diagnosis: Same, Procedure(s): amputation of the great right toe . On 3/8/23 at 8:32 AM, Licensed Practical Nurse (LPN) H was interviewed regarding her involvement in the discovery of the deterioration of R283's right great toe. When queried regarding conflicting information about whether the resident was ordered to be sent to the hospital versus being signed out AMA, LPN H stated that R283's family wanted the resident to be sent out. LPN H further explained that R283's [family member], Was rude and didn't want to talk to me because I'm not a RN (Registered Nurse) .and was upset there was no RN in the building. [R283's family member] was talking with the Unit Manager (LPN I) on the phone but she wasn't here to see it, she just talked to [family member], it was after hours .[Family] signed [the resident] out AMA the next day. LPN H explained that she and the aide on duty on 2/4/23 did what they were supposed to do by noticing the toe when taking the resident for a shower and completing a skin assessment. LPN H stated that she didn't work for days before the condition of R283's toe was noticed so, Can't say what happened between then because I wasn't here. When queried regarding a treatment being in place for R283's right great toe after the podiatrist had seen the resident on 1/25/23, LPN H explained that doctors are, Supposed to put orders in a book and flag it so the nurses can see it on the rack and it can get put in .But I don't believe the podiatrist put an order in .He treated the toe but we looked for an order and couldn't find one. On 3/8/23 at 9:53 AM, the Director of Nursing (DON) was interviewed. The DON was asked to review the podiatry note for R283 dated 1/25/23 that noted the I&D, inflammation, and skin breakdown of the resident's right great toe. When asked about orders being put into place to treat the toe after said visit, the DON stated she didn't believe the podiatrist put any orders in, To do anything extra at that point .[The] nurses didn't know anything concerning about the toe until days later. When asked about how R283's toe was being monitored after the visit from podiatry, the DON explained that staff does body audits and is confident that staff reports things that they see. The DON stated, For it to not be noticed .I'm not sure if [R283] had a shower in-between. When queried regarding the skin worksheet dated 1/11/23 with the circled area on the right foot/leg, the DON responded that there was a 1/12/23 note indicating no new skin issues. The DON reviewed a 1/25/23 practitioner note and stated she was hoping it would have acknowledged the podiatry visit, however, it did not. When queried regarding the missing MAR/TAR body audit documentation on 1/28/23, the DON acknowledged the missing information. The DON was unable to locate an accompanying note to the documented 2/1/23 body audit checked off on the MAR/TAR. A review of the facility's policy/procedure titled, Skin Management Guidelines, dated 03/2022, revealed, .Skin alterations and pressure injuries are evaluated and documented by the licensed nurse: .Using the Skin Alteration Record or Skin/wound application in PCC (if enabled) weekly by the licensed nurse for non-pressure injuries - Whenever there is a significant change in condition or clinically indicated .Body audits are completed: By the licensed nurse daily for patients with pressure injuries and documented on the eTAR; new findings are documented in a progress note; By the licensed nurse weekly for patients without pressure injuries and documented on the eTAR; new findings are documented in a progress note; By the nursing assistant during scheduled baths/showers, and if indicated during routine daily care and documented on the Skin Worksheet .The Skin Worksheet is used by the nursing assistant to document skin observations. The worksheet is completed at least twice/week with the patient ' s bath/shower. Completed worksheets are given to the licensed nurse for validation and action planning as indicated . A review of the facility's policy/procedure titled, Change of Condition Protocol, dated 06/2021, revealed Purpose: To provide guidance in the identification of clinical changes that may constitute a change in condition and require intervention and notifications .Nurse ' s Responsibility: .Identify the resident involved and the issue - ask when the incident/change began and/or when was it identified? Is the resident known to the nurse? Has this occurred before .Review previous condition and current medication orders .Decision Phase: Determine whether this is an unusual incident for this resident; Evaluate whether additional information is needed; Evaluate the seriousness of the issue; Determine whether a call to 911 is indicated; Determine whether the physician needs to be consulted; Determine whether the issue is within the confines of the Nurse Practice Act; Evaluate whether a physician visit to the community is indicated or whether the resident needs to be sent out for an evaluation . 44750 Deficient practice #2. This citation pertains to intake MI00133600. Based on observation, interview, and record review, the facility failed to ensure skin treatments, PICC (Peripherally Inserted Central Catheter) line dressing changes and medications were provided in accordance with professional standards of quality were provided for three residents(R37, R40, and R333 ) reviewed for quality of care from a total sample of ten, resulting in dissatisfaction with care and delay in care and treatment. Findings include: Resident 37 (R37) On 3/6/2023 at 10:30 AM, R37 was observed sitting in their wheelchair. R37 stated that they were waiting for someone to look at their legs. Upon observation, R37 lower legs were red and flaky. R37 stated that they were red and itchy. A review of the medical record revealed that R37 admitted into the facility on [DATE] with the following diagnoses, Dementia and Peripheral Vascular Disease. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 5/15 indicating an impaired cognition. R37 also required one-person extensive assist for transfers. A review of physician orders noted the following order, Order: BLE [Bilateral Lower Extremity]: apply bacitracin ointment to legs and apply tubi grips (elastic support bandage) q [every] day. Directions: Everyday shift for wound. Status: Active. Start Date:2/24/2023. On 3/6 and 3/7,no tubi grips were observed on R37. On 3/7/2023 at 11:00 AM, an interview was conducted with R37. R37 stated that no one put anything on their legs and that they did not know what tubi grips were. On 3/7/2023 at 12:56 PM, an interview was conducted with the Infection Preventionist (IP) who was also serving as the second floor Unit Manager. IP stated was interviewed regarding the care that was supposed to be provided to R37's legs. IP stated that the tubi grips should be applied everyday after the bacitracin is applied. IP was informed that the tubi grips had not been observed on R37 during survey observations. IP stated that they would look further into it. On 3/8/2023 at 1:02 PM, an interview was conducted with the Director of Nursing (DON) regarding following the order for Bacitracin and Tubi Grips. The DON stated that they expect for physician's orders to be followed. The DON stated that sometimes the resident will refuse, but they should follow the process when there is an refusal. Resident 40 (R40) On 3/7/2023 at 10:22 AM, R40 was observed in their bed. R40 stated that their PICC line site was itching a little. Upon observation the dressing was dated 2/27/2023. R40 was asked when does their dressing get changed. R40 stated that it is usually changed every Monday, however the nurse yesterday stated that they would not be able to get to it. A review of the medical record revealed R40 admitted into the facility on [DATE] with the following diagnoses, Urinary Tract Infection and Hypertension. A review of the Minimum Data Set assessment dated [DATE] did not assess cognition. R40 also required one person supervision with bed mobility and transfers. A review of the physician orders did not reveal an order for a PICC line dressing change. On 3/7/2023 at 12:50 PM, an interview was conducted with IP regarding the order not being in and R40's dressing not being changed. IP stated that the dressings are usually changed every Monday or as needed. IP was asked if there are usually orders for the dressing change. IP stated yes there is usually a order for the dressing change and that they would be entering one for R40. Resident 333 (R333) A review of complaint called into the State Agency noted the following, .1. Failing to properly review the medication list and provide [R333] with all prescribed medications. The result was [R333] went into severe withdraw (Effexor - anti-depression medication). A review of the medical record revealed that R333 admitted into the facility on [DATE] with the following diagnoses, Muscle Weakness and Acute Myeloblastic Leukemia, Not having achieved remission. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13/15 indicating intact cognition. R333 also required extensive assistance with bed mobility and transfers. A review of R333's hospital discharge paperwork revealed the following, Continue to take these medications: Venlafaxine 150 MG (milligram) 24. Commonly known as: Effexor XR. Take one capsule (150 mg total) by mouth daily. A review of physician orders noted the following order, Order: Effexor XR Oral Capsule Extended Release 24 Hour 150 MG .(Venlafaxine HCL). Directions: Give 1 capsule by mouth one time a day for depression. Start Date: 12/12/2022. A review of the progress notes revealed the following, 12/12/2022 13:00 [1:00PM]. Note Text: Notified [Nurse Practitioner] about resident missing transfusion appointment today and about missing doses of Effexor from admission until this morning. On 3/8/2023 at 1:02 PM, an interview was conducted with the facility's Director of Nursing (DON). The DON stated that they do not know what happened with R333's admission medications orders. A review of a facility policy titled, Physician Orders did not address quality of care.

This citation pertains to intake # MI 217. Based on observation, interview and record review, the facility failed to maintain bladder function to the fullest potential for two residents (R262 and R268) of three residents reviewed for bladder function, resulting in decreased urinary continence, skin breakdown, a Urinary Tract Infection ([CONDITION(S)]), pain and humiliation. Findings include: R262 On 01/11/2022 at 11:51 AM, during the initial tour, R262 was observed in their room, dressed, and groomed in bed. The resident was alert and oriented to person, place, time, and situation. R262 was asked how their stay was going within the facility. R262 stated, The first night was not so good. I had to use a diaper the first day I was here. I wanted to go to the bathroom, but they (unknown name of facility staff) told me that since therapy wasn't here to assess me, I had to use the bed pan. For some reason, I couldn't go (urinate) in the bed pan. My brain wouldn't let me. So, they put a diaper on and told me to use it, then didn't come back for hours to change me. I had to sit in urine. It is better now; they haven't done that since the first day. A record review of the face sheet revealed that R262 was admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 01/13/2022 at 12:29 PM, the Director of Nursing (DON) was interviewed in regard to staff placing adult diapers (briefs) on residents and being told they have to use the diaper instead of using the bathroom. The DON stated, I just had to talk to a nurse about that, she was a new nurse. The admitting nurse has the ability to assess the situation and decide if they (the new admitted resident) can use the toilet, they have that ability to do that, they don't have to wait for therapy. A record review of the Progress Notes for R262 revealed the following. 1/12/2022 23:47 (11:47 PM) Resident is A&O x 3 (alert and oriented x 3) .One person assist with toileting .Continent of bowel and bladder. Call light is within reach. Safety is maintained. R268 On 01/11/2022 at 11:48 AM, R268 was observed sitting up in their wheelchair dressed and groomed. The Resident had clear speech and was alert and oriented to person, place, time, and situation. R268 was asked about the care received in the facility and stated, Not so good. It takes too long to answer call lights. When I ask or have to use the bathroom, I am told to use the diaper (by staff). I have to pee in my diaper and then sit in and wait for them to come and help me. That is why I have an infection now. I am on an antibiotic. I hate it, it [CONDITION(S)] (when urinating). I have sores on my bottom, too. R268 was asked if the wounds on their bottom were old wounds, or wounds that occurred while in the facility, and explained that the wounds formed in the facility. On 01/12/2022 at 10:20 AM, R268 was asked how their night went and stated, It was a bad night. I walked out in my wheelchair around 4 or 5 PM and I asked if I could go to the bathroom, they (the staff at the nurses desk) said no. They said they had no staff; they were busy, and residents were waiting to eat. I said, 'Well, I am waiting too.' Nobody ever came in to change me until ten o'clock (PM). I had to use my diaper, it was terrible. A record review of the Initial Nursing Evaluation dated 12/01/2021 for R268 revealed the following information in regard to bladder function: Urinary Characteristics .Occasionally incontinent. A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that R268 had a Brief Interview for Mental Status (BIMS) score of 12, indicating an intact cognition. R268 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R268 needed extensive assist with toileting needs and was Always incontinent of urine. A review of the Physician Orders revealed that R268 was currently on [MEDICATION(S)] (an antibiotic) for a [CONDITION(S)]. A record review of the urinalysis results dated 01/07/2022 revealed that R268 had a positive urine culture with the bacteria ENTEROCOCCUS FAECALIS (an infection commonly associated with bacteria entering the urinary tract from exposure to urine and feces directly to the area/ incontinence; or improper personal hygiene). On 01/12/2022 at 04:45 PM, Family Member J was visiting R268 and was asked about R268's urinary continent patterns and explained that R268 was continent of urine and had worn underwear and a pad prior to their admission into the nursing home. Family Member J also explained that R268 had also complained to her as well, that staff were not allowing R268 to utilize the toilet. On 01/13/2022 at 08:44 AM, during a medication observation with Licensed Practical Nurse (LPN) C, R268 stated that they had to use the bathroom and asked, What should I do? LPN C stated, Did you want the bed pan, or were you going to use your diaper? The Resident stated, I would rather use the bed pan. LPN C was asked why R268 is being encouraged to use a diaper if they have the ability to be continent of urine and stated, (R268) doesn't sit on the toilet well so (R268) has to use the brief or bed pan. LPN C was asked if she realized that R268 does not want to use a diaper or brief and stated, I know. At this time, LPN C stated to R268, We will get the bed pan for you. Don't use your brief (to urinate in) because it is not good for your bottom. On 01/13/2022 at 09:47 AM, the Director of Rehabilitation (DOR A) was asked if therapy had recommended that R268 not use the toilet and explained that the Resident had been discharged from case load on 01/07/2022 and was considered dependent (full hands on assist) for toileting hygiene and transfers and had no notation of not being allowed to be toileted. On 01/13/2022 at 10:09 AM, a wound observation was made with LPN C of R268's buttocks. According to LPN C, the wound had developed a few weeks ago, but was improving. Upon removing the dry brief, R268's periarea was bright red and had extended throughout the whole buttocks region, and in between the thighs and perineum. There were two irregular open areas (one on each buttock about the size of a quarter to a half dollar) that was tender to touch, as the Resident stated, It hurts if I sit on it for too long or if it is touched. LPN C was asked why the staff seemed reluctant to transfer R268 (to the toilet) and stated, (R268) can bear weight, (R268) is just fearful and is a two person assist and can't use the toilet. On 01/13/2022 at 10:20 AM, R268 was dressed and groomed in their wheelchair. The Resident was asked if they had underwear that was brought from home so they could wear at the facility and explained they did. R268 had several pairs of clean underwear observed in their wardrobe closet. R268 was asked if they are able to use the toilet and explained that they would use it, but the staff have never tried. R268 stated, If I can't use the bathroom, then I would rather use the bed pan at least. 01/13/2022 at 10:35 AM, the Nursing Home Administrator (NHA) was interviewed regarding R268's concerns for using the toilet, and not having to urinate in the brief. The NHA explained that the Resident had a complaint before regarding being toileting and how the aide was handling them during the process. The NHA stated that they submitted a Facility Reported Incident (FRI) about it (in the past). The NHA stated, I remember that (R268)'s skin (buttock region) was real red then too, it was part of the problem with the FRI. On 01/13/2022 at 12:29 PM, the DON was interviewed regarding R268's concerns with staff making them wear briefs and not changing in a timely manner. The DON stated, I was not aware. It is not our practice to do that (wear briefs and not toilet upon request). I do know (R268) uses the slide board, that could cause friction to the area. A review of the facility policy titled Urinary Incontinence Management Practice Guide dated 03/2012 revealed the following: .Re-evaluate patients with UI (Urinary Incontinence) on a regular basis. Implementation of a bladder diary or bladder retraining program is important during this stage .On Going Management Strategies (Cont.) .Incontinence associated [CONDITION(S)] (IAD) has been defined as 'skin inflammation manifested as redness with or without blistering erosion or the loss of the skin barrier function that occurs as a consequence of chronic or repeated exposure of the skin to urine or fecal matter' .Incontinence itself does not cause pressure ulcers, but combined with other factors such as friction and shear, can weaken the skin's ability to tolerate friction, shear and pressure. IAD is not usually confined to an area over bony prominences but covers a larger area. The affected area will have diffuse irregular margins. Affected skin is no longer an effective barrier and is more easily damaged.

This citation pertains to intake numbers MI 479, MI 536 and MI 511. Based on interview and record review the facility failed to implement care planned interventions and maintain a functioning call light system to prevent falls with injuries affecting three residents (R500, R502, and R506) of five residents reviewed for falls, resulting in falls with injuries. Findings include: Resident #500 (R500) On 08/04/2021 at 8:00 AM, R500's confidential complainant was called and interviewed regarding the allegations and stated, [R500] was found on the floor on 07/24/2021 at 6:00 AM, which is questionable because [R500] can hardly move. [R500] was supposed to have a sitter 24/7 due to so many falls in the past five years. On 08/04/2021 at 10:00 AM, R500 was observed laying in bed and a sitter (staff in room monitoring resident) was at the bedside. R500 looked at the sitter when greeted and had no verbal responses to questions. An interview was conducted with Sitter (S I) regarding caring for R500 and stated, My department has been slow, so I've been working with [R500] for about seven months now. S I was asked about the recent fall and stated, It happened a couple of weeks ago. I was not here that day. [R500] looks better now. R500 had a fading bluish yellow bruise on their forehead and around the eyes. S I was asked if R500 became more active when left alone and stated, Not so much any more. Record Review of R500's Electronic Health Record (EHR) revealed R500 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included, Dementia, [CONDITION(S)] (irregular heart beat), and Age Related Physical Debility. The most recent Minimum Data Set (MDS) assessment dated , 07/15/2021 revealed R500 had a severely impaired cognition and needed extensive assistance with Activities of Daily Living (ADLs.) Further record review revealed a progress note written by Nurse M, On 7/23/2021 07:10 General Progress Note Note Text: Resident was observed on the floor by care caregiver, writer assisted resident off of floor the floor, neuro checks initiated, range of motion performed. Physician called, [family] notified, in house manager made aware. Care plan updated. The progress note did not address the presence of a sitter at the bedside. Review of a progress note written by Social Worker D revealed, On 7/23/2021 15:25 General Progress Note Late Entry: Note Text: IDT (interdisciplinary team) follow up s/p (status post) fall: resident had a fall on 7/23/21 at 7:02 am. Resident observed on the floor and it appears that [R500] rolled out of bed. Neuro-checks were initiated as the fall was not witnessed. VS (Vital Signs) and ROM (Range Of Motion) were at resident's baseline level and no injuries were noted. MD (Medical Doctor) & family were notified of fall. IDT (Interdisciplinary Team) is in agreement for an appropriate intervention to be continuing to have bedside companion at bedside for safety. Resident continues to be monitored for any latent fall related pain or bruising; MD to be notified as needed and/or necessary. Review of R500's care plan revealed a fall prevention intervention, - Bedside companion at bedside for safety purposes, due to falls. Date Initiated: 02/17/2020. On 08/04/2021 at 12:40 PM, an interview was conducted with S I regarding R500's past behaviors and stated,Prior to receiving [MEDICATION(S)] (anti-anxiety medication) R500 would scream continuously and it was so bad that I could not feed [R500]. Then when they started the [MEDICATION(S)] [R500] calmed down. The facility does provide relief for me for my breaks. I turn the call light on and they usually come in a few minutes. 90% of the time I come in and relieve the midnight sitter. On the morning of the fall, I think [the midnight sitter] may have left five minutes early. I wasn't here the day [R500] fell , [the midnight sitter] charted until 5:30 (AM) and I usually get here between five to six -to- five after six, I'm very prompt. About one and a half weeks ago I was with [R500] and [R500] was sleeping then suddenly sat up and clearly stated they [R500] had to go to the bathroom. I think that may have been what happened the day [R500] fell . I've never seen [R500] do that before. I leave at 2:00 PM and I don't leave until the afternoon sitter gets here. S I was asked if they ever came in and found that there was not a sitter at the bedside and stated, Well, I'd say that they are there 90% of the time. On 08/04/2021 at 1:27 PM, an interview was conducted with Unit Manager (UM P) regarding R500's behaviors and stated, [R500] is not always sedate. I was on vacation for 10 days when R500 fell . UM P was asked for information regarding the prescience of a sitter at the time of the fall and stated, I checked with the covering manager and it looks like no sitter was with the resident when [R500] fell . On 08/04/2021 at 1:38 PM, S I was interviewed regarding the injuries R500 sustained after the fall and stated, I worked on the 24th of July and [R500's] forehead was very swollen, then their eyes turned red and had a little red bruise on the right knee. On 08/05/2021 at 1:58, an interview was conducted with Nurse T regarding R500's injuries related to the fall and stated, [R500] at first had a big knot on her forehead. Then it looked worse and was going onto her eyelids. I called the Doctor and he said that it was draining down the face. I was concerned. Nurse T was asked if the sitter was at the bedside at the time of the fall and stated, I wasn't here, but I heard the sitter left for some reason or the other. On 08/09/2021 at 9:28 AM, the staffing schedule and staffing assignments for 07/23/2021 were requested. Upon review, no staff had been scheduled or assigned to sit with R500. On 08/09/2021 at 9:28 AM, the Incident and Accident report (I&A) and investigation for the fall sustained by R500 was requested, however the facility did not provide the requested document prior to survey exit. On 08/09/2021 at 11:43 AM, a telephone interview was conducted with Nurse M regarding R500's fall and the presence of a sitter at the time of the fall and stated, No, [R500] did not have the sitter at the bedside at the time of the fall. On 08/09/2021 at 12:45 PM an interview was conducted with the Director of Nursing (DON) regarding the facility's policy and procedure regarding fall prevention and stated, Apparently the sitter left without telling the charge nurse. We did one to one education and educated all of the staff. Resident #506 (R506) On 08/04/2021 at 8:00 AM, review of 506's confidential complainant's allegation revealed, The resident fell and sustained an injury. [R506's] face was cut up. On 05/27/2021 R506's confidential complainant picked up R506's belongings and an anonymous resident told the complainant, Heard [R506] calling for help and heard the call light buzzing. Record review of R506's EHR revealed R506 was admitted into the facility on [DATE] with diagnoses that included, Atherosclerosis (narrowing and hardening) of Coronary Bypass Graft, Encounter for Surgical Aftercare, and Ischemic [CONDITION(S)] (weakened heart muscles). The most recent MDS assessment dated , 05/22/2021 revealed R506 had an intact cognition and needed extensive assistance with ADLs. Review of a progress note written by Nurse L reflected, 05/26/2021 18:43 (6:43 PM) General Progress Note Note Text: Resident observed on the floor face down with wheel chair behind and glasses underneath the face. There was blood on the ground under the face. 911 called and notified of the situation at 1800 (6:00 PM). NP (Nurse Practitioner) notified. Called residents's [spouse], did not answer left a message. Then I called the resident's daughter and I left a message . [Spouse] showed up to resident's window as EMS arrived. I went out and spoke to [spouse] face to face about the situation. On 08/05/2021 at 1:44 PM, an interview was conducted with Nurse L regarding R506's fall and stated, [R506] was in 102 and quite pleasant. [R506] was alert and oriented times three and was very cooperative. I don't recall the circumstances of the fall. On 08/09/2021 at 11:43 AM, a telephone interview was conducted with Nurse M regarding R506's fall. Nurse M revealed, I don't recall [R506] Review of R506's care plan initiated 05/19/2021 revealed, Focus At risk for falls due to history of falls, impaired balance/ poor coordination, potential medication side effects. Goal Minimize risk for injury r/t (related to) falls. Intervention initiated on 05/26/2021 by Nurse L Reinforce need to call for assistance. On 08/09/2021 at 9:28 AM, the Incident and Accident report (I&A) and investigation for the fall sustained by R500 was requested, however the facility did not provide the requested document prior to survey exit. Resident #502 (R502) On 8/4/21 at 2:25 PM, a review of progress notes located in R502's Electronic health record revealed the following, 8:24 am 3/25/21: staff aides observed pt (patient) on the floor. pt was laying on his right side on the floor nearest to the bathroom. pt stated to staff aide they did not know how they got on the floor. vitals obtained and heart rate elevated, and other vitals at baseline. pt was alert and oriented to place, situation, and who they were talking to. nurse stayed with pt along with an aide. pt stated their head and shoulder hurt. another nurse called [Physician] nurse stated [Physician] asked for the pt to be put back in bed. no visible injuries noted. pt had no changes to range of motion. bed was in the lowest position and call light was pulled out from the wall but was not alarming. [Nurse Practitioner] decided to send pt to hospital for evaluation. 911 called and transported pt at 8:45 am. On 8/4/21 at 2:37 PM, a post fall assessment document involving R502 and dated 3/25/21 was reviewed and revealed the following, Call light pulled from wall not functioning. On 8/4/21 at 2:45 PM, R502's Fall care plan was reviewed and indicated the following interventions, Reinforce need to call for assistance. Date Initiated: 3/16/21. Work order for repair to call light. Date Initiated: 3/26/21. On 8/4/21 at 3:12 PM, Nurse A was interviewed regarding R502's fall on 3/25/21 and indicated the following, I vaguely remember [R502's] fall on 3/25/21. [R502's] call light was unplugged from the wall, typically a loud alarm goes off when a call light becomes unplugged. The alarm did not go off for [R502's] call light. On 8/5/21 at 8:35 AM Maintenance Director (MD) B was interviewed regarding R502's fall and their call light not working. MD B indicated that typically when a call light becomes unplugged from the wall a light should go off outside the resident's room to notify staff and then a work order should be put in for it to be repaired. MD B stated, Sometimes the wires don't work. A request was made to review the work order involving R502's call light. MD B indicated that they were unable to locate the work order. On 8/5/21 at 12:21 PM, Second floor Unit Nurse Manager (UNM) E was interviewed regarding R502's fall on 3/25/21. UNM E did not remember R502 and/or the fall and agreed that if it was care planned to encourage resident to ask for assistance than he more than likely was able to use his call light to call for assistance. On 8/9/21 at 9:00 AM, a review of R502's EHR revealed an admitted to the facility on [DATE] with diagnoses that included, Malignant neoplasm of prostate ( [CONDITION(S)]) and Protein calorie malnutrition. R502's most recent Minimum data set assessment (MDS) dated [DATE] revealed that R502 had a severely impaired cognition and required extensive one to two person assistance for all Activities of daily living (ADLs) activities. On 8/9/21 at 12:45 PM the Director of Nursing (DON) was interviewed about R502's fall and indicated that R502's call light should have been working. On 8/9/21 at 1:30 PM, a facility policy titled Falls Practice Guide Issue Date: 12/2011 stated, The purpose of the Falls Practice Guide is to describe the process steps for identification of patient fall risk factors and interventions and systems that may be used to manage falls. Fall management focuses on minimizing fall risk factors and fall related injuries .

This citation pertains to Intake number MI 426. Based on interview and record review the facility failed to ensure a two person assist was provided for safe incontinence care affecting one resident (R503) of two residents reviewed for falls resulting in a fall with injury. Findings include: Record review of R503's Electronic Health Record (EHR) revealed R503 was admitted into the facility 12/02/2013 and readmitted on [DATE] with diagnoses that included, Cerebral Infarct (stroke), [CONDITION(S)] (a disease of the brain), and [CONDITION(S)]. The most recent Minimum Data Set (MDS) assessment dated , 12/14/2020 revealed R503 had a severely impaired cognition and needed extensive assistance of two people for Activities of Daily Living (ADLs) including bed mobility, transfers, and toileting. On 02/01/21 at 1:46 PM, Certified Nurses Aide (CNA D) was asked about the R503's fall and stated, I wasn't actually in the room when [R503] fell . [CNA D] and I were cleaning [R503] up and I went to the closet for a brief and there wasn't any briefs. [R503] was in the middle of the bed, it was a bigger bed. I left to go get some briefs. I don't know what happened but when I was headed back, CNA D was already in the hall and said that [R501] fell out of the bed. I dropped the briefs and went and got the nurse. When we got back in the room [R503] was laying on their back and [R503's] head was bleeding. I don't know if [R503] jerked or something and [CNA D] couldn't hold on to [R503] or what. On 02/01/21 at 2:17 PM, CNA E was asked about R503's fall and stated, I was not helping [CNA D]. [CNA D] asked me to come in because [R503] was a two person assist. [CNA D] said that 'I got it', gave [R503] a bed bath and then I bent down to tie my shoes and then [CNA D] had to get a brief and left the room. When I stood up from tying my shoes [CNA D] was already out the door. By the time I stood up [R503] rolled over and out the bed. It happened faster than you could snap your fingers. CNA D should have waited until I was next to the bed and I thought [CNA D] should have had everything ready when [CNA D] started and asked me to come in. [CNA D] left the bed all the way up. So I looked out in the hall and saw [CNA D] down the hall, I said call the nurse and call 911. The nurse said hold [R503's] head and when I put my hands under [R503's] it was bleeding. Review of R503's progress notes revealed, 1/26/2021 16:35 (4:35 PM) General Progress Note Note Text: Writer was in the nurses station doing documentation when [CNA D] came to the writer and said resident was on the floor. [CNA D] stated that Patient rolled over from bed while CNA was giving resident a bed bath. Writer went to the patient room right away observed patient lying flat on the floor at the left side of bed, noted blood at the back of head, patient eyes are open, answers questions when asked but confused, [R503] don't know the date today and year which is not [R503's] usual mental status, [R503] stares blankly, pupils are equally reacted to light and accommodation. called the other nurse and unit manager for help. Patient kept on the floor without moving [R503] .Called 911 [Nurse G] applied ice pack to the back of the head. noted a lump half size of the golf ball per [Nurse G] unable to see the size of laceration due to head was covered with blood and was afraid to move the patient. Transfer paper works prepared by writer while waiting 911 to arrive. Review of R503's care plan revealed, Bed Mobility- 2 person Date Initiated: 12/09/2020 . On 02/01/21 at 3:23 PM, The Nursing Home Administrator (NHA) was asked about the investigation of R503's fall and stated, We will make a decision tomorrow. Both of them will probably lose their jobs. On 02/01/21 at 3:35 PM, the Director of Nurses (DON) was asked about the facility's policy and procedure regarding fall prevention and stated, Both CNAs should have stayed with the resident. Review of the facility's policy and procedure regarding fall prevention titled, FALLS PRACTICE GUIDE FLOWCHART dated 2016' revealed that the number of people caring for a dependent resident was not addressed.

This Citation Pertains to Intake Number MI 782. Based on interview and record review, the facility failed to ensure timely and appropriate assessment and interventions per professional standards for treatment and monitoring of a small bowel obstruction (blockage) for one (#704) of two Residents reviewed, resulting in unnecessary pain, lack of treatment, delay in transfer, and decline in overall health. Findings include: Review of anonymous intake documentation detailed, (Resident #704) recently passed due to persistent bowel obstruction that should of been avoided . Record review revealed Resident #704 was most recently readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required supervision to limited assistance to complete Activities of Daily Living (ADLs). The medical record further revealed Resident #704 was discharged from the facility to the hospital on 9/17/20. Review of Resident #704's medical record revealed the following progress note documentation: -9/14/20 at 1:26 AM: Respiratory . Presence of Nausea, Vomiting or Diarrhea, include Nausea . resident took all scheduled meds plus a PRN (as needed) [MEDICATION(S)] (anti-nausea medication) . Resident was upset with staff and refused shower yesterday and refused to get out of bed today. Resident has been more confused and argumentative lately . -9/15/20 at 1:59 AM: Respiratory . resident took all scheduled meds plus a PRN [MEDICATION(S)] . Resident refused to get out of bed for the 2nd day in a row. Resident has been more confused and argumentative lately. resident c/o )(complain of) nausea and has been forcing themselves to throw up (phlegm and salvia) . -9/15/20 at 2:13 PM: NP (Nurse Practitioner) Progress Note . Chief Complaint - abdominal pain, weakness . seen per nursing request as (Resident #704) is very weak and cannot self-transfer like usual, hasn't gotten out of bed in 2 days, complains of stomach pain and has tenderness present in the Right upper and lower quadrant . states had a bm (bowel movement) this morning, resident has a poor appetite today . skin has some yellow discoloration present . Pt (Patient) is seen in bed, abd (abdomen) is rounded with mild tenderness to palpation, mostly on the right upper quadrant. Pt pain worsened with deep breaths. Bowel sounds are hypoactive (indicate decreased movement in the bowels) to both right and left lower abd. Pt c/o (complain of) epigastric pain . also c/o bladder tenderness to palpation . acute abd pain . Diagnosis 1: Acute abdominal pain . Diagnosis 1 Plan-- STAT flat plate (abdomen X-Ray), STAT CXR (Chest X-Ray) 2 view and stat (laboratory blood tests), UA C&S (Urinalysis with Culture and Sensitivity) . -9/15/20 at 2:59 PM: Respiratory . Presence of Nausea, Vomiting or Diarrhea, include Nausea . Resident experiencing abdominal pain and weakness, NP aware and stat labs, and chest X-ray and flat plate ordered, UA also ordered . -9/15/20 at 11:19 PM: Radiology . CXR and ABD flat plate ordered today. Report back . ABD flat plate states that resident has a SBO (Small Bowel Obstruction). Doctor called after report read. N/O (New Orders): NPO (Nothing by Mouth), IV (Intravenous) or hypodermoclysis (subcutaneous infusion of fluids) infusion for 0.09 NS (Normal Saline) 80 cc (cubic centimeters) and (sic) hour until 2 bags are completed. ABD flat plate ordered for the afternoon . -9/16/20 at 5:33 AM: General Progress Note . When in to check on resident's IV for infiltration and placement. Resident had pulled IV out at this time. Pump shut off at this time. -9/16/20 at 5:33 AM: General Progress Note . Labs in for resident. Resident's K+ (Potassium- electrolyte that effects muscle function including the heart) is 3.0 (normal is 3.5 to 5.0). New order for 40 meq (milliequivalent) now and 40 meq in the evening. Repeat (blood laboratory testing) on 9/16/20 . -9/16/20 at 5:59 PM: NP (Nurse Practitioner) Progress Note . Chief Complaint - abdominal pain . c/o pain started yesterday, stat flat plate done last night showed: 'There is small bowel loop dilatation (distended loops of the bowel, typically filled with air and fluid that are associated with a bowel obstruction) to 5.2 cm Conclusion: Small bowel obstruction. Clinical or repeat examination follow-up is advised.' Results were reported to MD per nurse with orders for NPO with IVF (Intravenous Fluid) and repeat flat plate in am. Today, pt (patient) is seen resting in bed . received only around 200 cc of IVF as IV was out and had one episode of small emesis this early morning . per nurse K of 3.0 was corrected per MD orders. Abd is soft, nontender today with hypoactive upper BS (Bowel Sounds) and hypoactive lower BS, R (Right) and L (Left). Mild bladder tenderness to palpation . -9/16/20 at 6:03 PM: General Progress Note . continues on IV hydration at this time for small bowel obstruction. repeat X-ray and labs ordered for tomorrow . -9/17/20 at 2:05 AM: Default PN Type for eMAR . flat plate on 9/16/20 to r/o (rule out) SBO . awaiting X-ray -9/17/20 at 10:25 AM: Default PN Type for eMAR . Flat plate dx. (diagnosis) f/u (follow up) of obstruction . doctor made aware of f/u X-ray received orders to start clear liquids, [MEDICATION(S)] and repeat labs tomorrow. orders updated . -9/17/20 at 5:48 PM: General Progress Note . Resident started on clear liquid diet today after been npo due to bowel obstruction around dinner time resident begin to have emesis X 2 spoke with doctor received orders to send resident to hospital . -9/17/20 7:25 PM: General Progress Note . Resident left facility at approx. 725pm . Review of Resident #704's Diagnostic Imaging Reports revealed the following: -9/15/20 at 7:15 PM: X-Ray Abdomen . Results: There is small bowel loop dilatation to 5.2 cm . Conclusion: Small bowel obstruction. Clinical or repeat examination follow-up is advised . -9/16/20 at 9:50 AM: X-Ray Abdomen . Conclusion: There is small bowel distention. This is consistent with a small bowel obstruction or ileus. Consider CT (computerized tomography) follow up . -9/17/20 at 9:20 AM: X-Ray Abdomen . Results: There are abnormal dilated air-filled loops of small bowel in the abdomen, measuring up to 6 cm . Conclusion: Radiographic findings concerning for small bowel obstruction. Consider short interval radiographic follow up to reassess vs further evaluation with CT . Review of Resident #704's bowel movement documentation revealed the Resident's most recent bowel movements prior to transfer occurred on 9/16/20 at 5:24 AM and 9/11/20 at 11:54 AM. The documentation did not specify the amount and/or consistency of the bowel movement. Review of Resident #704's laboratory results revealed no results of repeat testing to confirm potassium level correction. Review of Resident #704's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . on 9/16/20 at 6:31 AM. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #704 received and/or if the IV was restarted after being removed by the Resident on 9/16/20. An interview was completed with the Director of Nursing (DON) on 9/16/20 at 12:29 PM. When queried regarding Resident #704, the DON revealed the Resident had passed away in the hospital related to a bowel obstruction. The DON was unable to recall if the Resident passed away prior to or after they had surgery to repair the obstruction. When queried regarding Resident #704's potassium level indicating [CONDITION(S)] (low blood potassium) level and a repeat laboratory tests not in the Resident's medical record, the DON indicated they would need to review the Resident's documentation. When queried why the Resident was not transferred to the hospital after a bowel obstruction was found on the X-Ray completed on 9/15/20 until 9/17/20 when the Resident was symptomatic, an explanation was not provided. A follow up interview was completed with the DON on 9/30/20 at 1:05 PM. When queried regarding Resident #704, the DON stated, (Resident #704) was supposed to get two doses of 40 meq (potassium) and then (blood) redrawn on the 17th. Lab didn't come in (to complete lab draw) and we were waiting during the day. Ended up sending (Resident #704) out. When asked, the DON verbalized the blood laboratory testing was not completed. When queried regarding progress note documentation indicating the Resident was supposed to receive two doses of potassium 40 meq and the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #704's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked how many doses of potassium Resident #704 received and how many doses they were supposed to receive per health care provider order, the DON revealed the Resident only received one dose and stated, So we didn't give (Resident #704) two (doses). The DON revealed nursing staff did not enter the order in the medical record correctly. An interview was completed with Licensed Practical Nurse (LPN) A on 9/30/20 at 1:10 AM. When queried regarding Resident #704's transfer to the hospital on 9/17/20, LPN A revealed they were assigned to care for the Resident that day. LPN A stated, (Resident #704) had been NPO for a couple days and then started clear liquids that day. (Resident #704) stated with emesis. LPN A revealed they spoke to the Resident's family and then sent them out to the hospital. LPN A was asked if it is typical procedure to keep a Resident at the facility who has a small bowel obstruction and stated, I can't answer that, only the Doctor can. When queried if Resident #704 was having pain related to the obstruction, LPN A stated, (Resident #704) was sleeping all the time and they would normally get up. When queried regarding Resident #704's IV therapy, LPN A replied, The IV had completed that day and that is when we started the clear liquids (orally). LPN A was then asked if they recalled Resident #704's potassium level and stated, I remember the nurse telling me there were gonna give some potassium and it had to be redrawn. LPN A revealed the day Resident #704's level was supposed to be checked was the day that the lab never showed up at all. On 9/30/20 at 1:30 PM, an interview was conducted with Nurse Practitioner (NP) E. When queried regarding Resident #704's care in the facility related to their bowel obstruction and transfer, NP E indicated they would need to review their documentation in the medical record. After reviewing the documentation, NP E stated, Nurse called me to see (Resident #704) for abdomen pain and weakness. I ordered X-Rays, a UA, and labs. NP E continued, I notified the Doctor (Physician B) because they get called for STAT labs and stuff. When asked about the testing results, NP E replied, The results were called to the Doctor. NP E continued, I went and saw (Resident #704) in the morning and learned the Doctor had got the (testing) results and ordered NPO with IV fluids. When queried regarding Resident #704's potassium level, NP E replied, Doctor ordered 40 meq of Potassium times two doses. NP E was asked why the Resident did not receive the two doses as ordered by the Physician and stated, I was not aware of that. NP E then stated, I also ordered to repeat the flat plate (abdomen X-Ray). I remember (Resident #704 had mild tenderness to palpation, and I wanted them (nursing staff) to scan them (bedside bladder scan to determine the amount of urine in the bladder for retention). NP E was then asked how much IV fluid Resident #704 had received as their documentation detailed the Resident had only received 200 cc when one order was for 2000 cc and a separate order was for 2500 cc. NP E stated, I got mixed messages. I think that it was the first liter (of fluid) when the IV infiltrated. NP E was then asked the length of time the Resident had been displaying signs and symptoms of obstruction including nursing documentation dated 9/15/20 at approximately 2:00 AM in which the Resident was making themselves vomit and replied, Not notified. When queried regarding facility procedure and standards of practice for management of a bowel obstruction in a nursing home, NP E stated, If it is an ileus, keep them (Residents) here. If an obstruction, send out. NP E was then asked why Resident #704 was not transferred on 9/15/20 when the first X-ray results revealed the Resident had a small bowel obstruction and reiterated that the Physician made the determination to keep the Resident in the facility and not transfer them to the hospital. An interview was completed with the DON on 9/30/20 at 2:30 PM. When queried which Physician nursing staff contacted for Resident #704, the DON revealed they would look. The Physicians number was requested from the DON at this time. At 2:45 PM on 9/30/20, the DON provided Physician B, Physician C, and Medical Director Physician D's phone numbers. When queried, the DON revealed nursing staff had not documented the Physician they contacted in the medical record. The DON stated, (Physician B) is (Resident #704's) doctor but they work with (Physician C) and staff will call (Physician C) if they can't get ahold of (Physician B). The DON continued, If they can't get ahold of either of them, they call (Medical Director Physician D) and indicated to attempt to call the Providers in the order of Physician B, Physician C, and Medical Director Physician D last. On 9/30/20 at 3:00 PM, Physician B was called, and a voicemail was left with return phone number. A return call was not received by the conclusion of the survey. On 9/30/20 at 3:05 PM, Physician C was called, and a voicemail was left with return phone number. A return call was not received by the conclusion of the survey. On 9/30/20 at 3:10 PM, a phone interview was completed with Medical Director Physician D. When queried regarding Resident #704, Physician D indicated the Resident was not their patient. When queried regarding facility policy/procedure and standards of care for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . At this time, Physician D indicated they recalled this case and stated, They (nursing staff) called me and I asked them why they did not send (Resident #704) out. They should have sent (Resident #704) out immediately. Physician D continued, (Resident #704) needed an NG (nasogastric tube- tube inserted through the nose into the stomach for decompression and suction). I asked the nurse why they waited, and they didn't have an answer. They can't just always blame the Doctor. When queried regarding Resident #704 having three X-Rays all showing a bowel obstruction as well and signs and symptoms, Physician D stated, This is malpractice. This is indefensible. (Resident #704) should have went out (when the first X-Ray showed an obstruction. Physician D continued, There is no excuse. It is a delay in care. An interview was completed with the facility Administrator and DON on 9/30/20 at 3:30 PM. When queried regarding Resident #704 not being transferred for 48 hours after having been diagnosed with a small bowel obstruction including lack of clinical improvement and Medical Director D's statements, the Administrator indicated the facility has had concerns with (Physician B). When queried regarding the delay in transfer to a higher level of care and the Resident's outcome, the DON stated, It breaks my heart. The Administrator indicated they would address the situation and stated, It is awful. Review of facility policy/procedure entitled, Change in Condition (Date: 11/2016) revealed, To provide guidance in the identification of clinical changes that may constitute a change in condition and require intervention .

This Citation Pertains to Intake Number MI 590. Based on interview and record review, the facility failed to implement interventions and provide treatments as ordered for one (#702) of three Residents reviewed for pressure ulcers (wounds caused by pressure) resulting in the development of a stage three pressure ulcer, hospitalization , and the likelihood for decline in overall health status. Findings include: An interview was conducted with Confidential Witness A on 11/12/19 at 8:43 AM. When queried regarding Resident #702's stay within the facility, Confidential Witness A stated, They (facility staff) didn't turn (the Resident) and they got a really bad pressure sore. There was a couple times when I went in and there was dried stool stuck on (the Resident). Confidential Witness A then stated, (Resident #702) had to be sent to the hospital. They [MEDICAL CONDITION] from the pressure ulcer being infected. With further inquiry regarding when the pressure ulcer developed, Confidential Witness A stated, It started when they (Resident #702) were at the facility. With additional query concerning statement of the Resident not being turned and how often they were present at the facility with the Resident, Confidential Witness A specified, I was there almost every day. I would sometimes stay for 15 or 16 hours just trying to get them to do what they needed to do. I even spent the night there a couple times. When asked how often facility staff turned or repositioned when they were at the facility, Confidential Witness A replied, They didn't come in unless I put on the call light and then it took a long time. Record review revealed Resident #702 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required extensive assistance to perform Activities of Daily Living (ADLs). The MDS further revealed the Resident did not have any pressure ulcers but was at risk for pressure ulcer development. Additional record review revealed the Resident was transferred to the hospital via ambulance from the facility on 10/25/19 due to infection and a change in condition. Review of Resident #702's Electronic Medical Record (EMR) revealed the following documentation: -10/3/19: Admission Assessment . Skin . Left Heel Wound . -10/4/19: Medical Practitioner Note (Physician/NP) . Admission NOTE . SKIN . Left heel bogginess with bulky dressing no drainage no open area . -10/11/19: MP Wound Progress Note . Initial wound care of buttocks and heel ulcer . open ulcer on Perianal area that is inferior to coccyx with moist [MEDICATION NAME] tissue, mild tenderness on exam, no odor, surrounding skin fragile and intact. Treatment is barrier cream. Diabetic ulcer on left heel . Perianal . Moisture associated [MEDICAL CONDITION] . -10/15/19: MP Wound Progress Note . Wound 1 .Location - coccyx /sacral. Type - Pressure . Severity - Unstageable . Length in cm - 5.5. Width in cm - 1.5. Depth in cm - utd (unable to determine) . roho cushion in chair . upgrade positioning in bed with wedge cushion . dc (discontinue) triad, clean and apply [MEDICATION NAME] and foam and change daily and prn (as needed) . -10/18/19: Skilled Nursing . wound on bottom is worsen. wound consult put in for (Resident) to be seen . -10/22/19: Skin: Wound care rounds completed with the team . Patient has a stage 4 (pressure ulcer) that measures 5.0 cm (centimeters) x 5.0 cm x 1.0 cm in depth. Site has minimal to moderate serous drainage. Wound base has granulation and with maceration on the edges . (pressure ulcer site not specified). -10/25/19: Medical Practitioner Note (Physician/NP) .seen today laying on left side in bed alert O x 3 (Orientated to person, place, and time) with sacral/coccyx dressing change in progress. Pt had been seen at Wound Care Clinic for Thursday 10-24-19 for eval of left foot/heel (regularly managed by Podiatrist) ulcer and sacral/coccyx ulcer which had worsened . Skin . Sacral decub (pressure) ulcer stage 3 . Review of Resident #702's Treatment Administration Record (TAR) revealed the following orders and missed wound treatments: -[MEDICATION NAME] Antimicrobial Gel 0.057 % (Antibacterial ointment) . Apply to affected area topically one time a day (AM) for infection (Start: 10/4/19; Discontinued: 10/25/19). No treatments documented on 10/4/19, 10/6/19, 10/21/19, and 10/25/19. -Santyl Ointment 250 UNIT/GM (grams) ([MEDICATION NAME]). Apply to coccyx topically every day shift for wound care (Start: 10/25/19). No documented treatment. -Santyl Ointment 250 UNIT/GM ([MEDICATION NAME]): Apply to Left heel wound bed topically every day shift for Wound care Cleanse left heel wound with NS (normal saline), pat dry, apply Santyl to wound bed, cover with bulky dressing, change daily (Started: 10/5/19; Discontinued: 10/25/19). No treatments documented on 10/6/19, 10/21/19, and 10/25/19. -Check dressing on coccyx to ensure its in place every shift for And PRN (as needed) (Start: 10/15/19; Discontinued: 10/25/19). No documentation of intervention on 10/16/19 PM, 10/18/19 PM, 10/20/19 PM, 10/21/19 AM, and 10/25/19 AM. -Clean coccyx and sacral area and apply [MEDICATION NAME] and foam dressing every shift . (Start 10/17/19 AM and Discontinued: 10/24/19). No treatments documented on: 10/18/19 PM, 10/20/19 PM, and 10/21/19 AM. -Cleanse with ns pat dry apply triad (wound treatment) and ABD every day and night shift for wound healing and PRN (as needed) (Start Date: 10/12/19; Discontinue: 10/15/19). No treatment documented on 10/15/19. -Cont to elevate foot of bed when HOB (Head of Bed) is increased every shift for PRN (Start: 10/15/10; Discontinue: 10/25/19). No documentation of intervention on 10/16/19 PM, 10/18/19 PM, 10/20/10 PM, 10/21/19 AM, and 10/25/19 AM. -Z-Guard to bilateral buttocks every shift and PRN every shift for preventative skin care (Start: 10/6/19 PM; Discontinued: 10/15/19 PM). No documentation on 10/15/19 AM. -[MEDICATION NAME]-[MEDICATION NAME] Cream (anti-fungal; anti-[MEDICAL CONDITION] cream) 0-0.1 UNIT/GM (gram)-% Apply to affected area topically every 12 hours for redness (Start: 10/3/19; Discontinued: 10/12/19). No treatment documented on 10/4/19 AM, 10/6/19 AM, and 10/6/19 PM. -[MEDICATION NAME]-[MEDICATION NAME] Cream 0-0.1 UNIT/GM-%. Apply to groin topically every day and night shift for redness (Start: 10/12/19; Discontinued: 10/28/19). No treatments documented on 10/16/19 PM, 10/18/19 PM, 10/21/19 AM, and 10/25/19 AM. Review of Resident #702's care plans revealed a care plan entitled, Resident has pressure ulcer to left heel related to: decreased mobility, cancer, Type II diabetes (Initiated: 10/3/19). The care plan included the interventions: -Incontinence management (Created: 10/3/19) -Pressure redistributing support surface (Created: 10/3/19) -Repositioning during ADLs (Initiated: 10/3/19) Resident #702 had a second care plan pertaining to skin integrity entitled, Resident has pressure ulcer to coccyx related to: Decreased mobility, sliding in bed, Cancer, [MEDICAL CONDITION] and Diabetes II (Initiated: 10/17/19). Care plan interventions included: -Administer treatment per physician orders [REDACTED]. -Pressure redistributing support surface (Initiated: 10/17/19) -Wedge cushion for positioning when down in bed (Initiated: 10/17/19) Review of Resident #702's Acute Care Transfer documentation, dated 10/25/19 at 6:38 PM revealed 911 was called regarding the Resident at 6:45 PM. The form further revealed, Code Status . Full Code . Vital Signs . Blood Pressure: 184/62 (elevated) . Pulse: 131 (elevated) . Irregular- new onset . Respiration: 22 (elevated) . Temperature: 100.5 (degrees Fahrenheit) . Date: 10/25/19 18:15 (6:15 PM) . An interview was conducted with the Director of Nursing (DON) on 11/12/19 at 3:40 PM. When queried regarding Resident #702's pressure ulcer, the DON stated, It was facility acquired. When queried regarding the wound on their heel, the DON reviewed the Resident's documentation and indicated the wound on the Residents heel was a diabetic ulcer. When queried regarding interventions implemented to prevent pressure ulcer development due to the assessed risk of pressure ulcer development, the DON indicated they would need to review the Resident's care plans. Resident #702's care plans were reviewed with the DON at this time. After review, the DON indicated the interventions were not individualized for the Resident and stated, Those are check box interventions. When queried regarding Healthcare provider documentation indicating a treatment change on 10/15/19 but the treatment not being changed until 10/17/19, the DON did not provide further explanation. Resident #702's TAR was reviewed with the DON at this time, when asked about missing treatments and interventions, the DON indicated the treatments were not documented as completed but was unable to provide further explanation. On 11/12/19 at 4:30 PM, an interview was completed with the facility Administrator and DON. When queried regarding Resident #703's pressure ulcer development and lack of documented interventions and treatments, the Administrator indicated the Resident had co-morbidities. The DON then stated, It is because the treatments weren't done. No further explanation was provided. Review of facility policy entitled, Skin Practice Guide (Issue Date: 01/2013) revealed, After completion of the initial plan of care . A weekly skin evaluation is completed by the licensed nurse for those patients identified as at risk for skin breakdown that do not have a pressure ulcer. Daily skin evaluations are completed by the licensed nurse for those patients with pressure ulcers. Documentation of skin evaluations is completed on the Treatment Administration Record . If an alteration in skin integrity is identified on admission, a designated member of the wound team evaluates the status of the wound (ideally within 24-hours of admission) and collaborates with the licensed nurse, physician or ARNP (Advanced Practice Nurse Practitioner) to determine the type of alteration present. Treatment orders are obtained, noted and initiated . Daily skin evaluations are completed by the licensed nurse for any patient with a pressure ulcer. Weekly skin evaluations are completed by the licensed nurse for any other patient. Skin evaluations are documented in the clinical record .FYI .Care plans and risk factors need to be individualized to meet patient specific need and risk factors . The wound management team re-evaluates pressure ulcers and complex wounds weekly and other types of wounds as clinically indicated .

This Citation Pertains to Intake Number MI 913. Based on observation, interview, and record review, the facility failed to ensure mobility assistance was provided per assessed need and care planned intervention for one (#701) of three Residents reviewed, resulting in Resident #701 being transferred without a Hoyer lift (mechanical device to transfer dependent individuals), experiencing ongoing, unnecessary pain, and a tibial plateau fracture (break of the upper part of the tibia that involves the knee joint). Findings include: An interview was conducted with the Director of Nursing (DON) on 10/14/19 at 9:00 AM. When queried regarding Resident #701, the DON stated, The CNAs (Nursing Assistants) transferred (Resident #701) without a lift. (The Resident) ended up with a fracture. That is the only thing we can attribute it to. The DON further stated, (Nurse B) and (Nursing Assistant A) were fired. When asked, the DON stated, (Nurse B) had been here a long time. That was their normal hall. They told the CNAs (Resident #701) was a two assist when they asked. The DON further revealed facility staff did not check the Resident's Kardex prior to transferring the Resident. When queried regarding facility policy/procedure, the DON replied, Staff are always supposed to check the Kardex. An interview was completed with the facility Administrator on 10/14/19 at 10:00 AM. When queried regarding Resident #701, the Administrator stated, They (Nursing Assistants) used two assist when they were supposed to use a lift. They asked the nurse and the nurse told them (Resident #701) was a two assist. They did not check the Kardex. When queried regarding facility policy/procedure, the Administrator indicated staff are supposed to check each Resident's Kardex prior to providing care. Record review on 10/14/19 revealed Resident #701 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required limited to extensive assistance to complete Activities of Daily Living (ADLs). Review of Resident #701's care plans revealed a care plan entitled, Requires assistance/ potential to restore function for TRANSFERRING from one position to another (Created, Initiated and Revised: 8/23/19). The care plan included the interventions: -Bed mobility - two person assist (Created and Initiated: 8/23/19) -TRANSFERS: two person dependent assist with mechanical lift medium sling (Created, Initiated and Revised: 8/23/19) Additional review of Resident #701's medical record at this time included a right Tibia/Fibia (lower leg) X-Ray, dated 9/29/19 at 10:45 PM. The results of the X-Ray revealed, Recent fracture lateral tibial plateau . On 10/14/19 at 10:45 AM, Resident #701 was observed laying in bed, positioned on their back. An interview was conducted with Resident #701 at this time. When queried how they get out of bed, Resident #701 stated, I don't get out of bed. I can't walk now. When asked if they used to walk, Resident #701 replied, I used to but it's to hard now. When queried if they had any falls or accidents within the facility, Resident #701 stated, Yeah, they (staff) broke my leg. They picked me up. I was sitting in the chair and they popped me on the bed. It hurts every day. It's the right one (gestured towards right leg). When asked how staff normally transferred them before their leg injury occurred, Resident #701 stated, They always picked me up. When queried regarding use of the Hoyer lift, Resident #701 revealed they have not gotten of bed recently. When asked if they had fallen within the facility, Resident #701 replied, No. Review of Resident #701's Progress Note Documentation in the Electronic Medical Record (EMR) revealed the following: -9/28/19 at 2:22 PM: Skilled Nursing . Pt (Patient) is a 1x person extensive assist with ADLs, transfers, and toileting . -9/29/19: No Progress Note Documentation -9/30/19 at 10:24 AM: Medical Practitioner Note . Pain in right knee . Patient has had complaint of right knee pain; ongoing, however pain has worsened over the weekend. Nursing did note that patient had a area of bruising below right knee yesterday, x-ray was ordered . recent [MEDICAL CONDITION] tibial plateau. Discussed with attending physician will send patient to emergency room for further evaluation by orthopedic doctor . -10/1/19 at 6:30 AM: General Progress Note: Patient returned from visit to ER at 2300 with Dx (Diagnosis) closed fracture to R (Right) tibial plateau . Patient with R (right) leg immobilizer . -10/1/19 at 5:38 PM: Skilled Nursing: I talked with the patient and took vitals. Received a [MEDICATION NAME] (Narcotic pain medication for moderate to severe pain) at 1600 and it was not as effective and Dr. was notified and a one time order for [MEDICATION NAME] was given . Review of Resident #701's Medication Administration Record [REDACTED].Give 1 tablet by mouth every 6 hours as needed for Pain. The following documentation was noted pertaining to administration: -9/28/19: No Administration -9/29/19 at 10:43 AM: Administered for pain level of 2/10 -9/30/19 at 2:18 PM: Administered for pain level of 4/10 Review of facility provided Investigation pertaining to Resident #701 revealed the following: -Resident #701 Statement, Dated: 10/4/19: Date of Incident: 9/28/19 . They picked me up the wrong way and I really got hurt. It was two girls. I was on the chair, sitting. It's how they put me in bed . really hurt . -Nurse B Statement, Dated: 9/30/19: On Saturday, late afternoon around 4:30 PM, the patient complained of pain in both legs. (Resident #701) was in bed when I went to assess them. I did a body audit and they had bruising to both legs like always . I gave them a pain pill. (Resident #701) didn't say anything about how or what happened . Sunday . that afternoon, around 4:00 PM, I heard (Resident #701) yell out so I went in the room and the aide was adjusting the patient in bed. (Resident #701) said their right leg was hurting . It wasn't bruised but you could tell the skin was changing . I called the Doctor and they ordered an X-ray and asked me to leave a note in their book. I let the weekend supervisor know as well. I was not aware (Resident #701) needed to be transferred with a lift. I thought (the Resident) was a two person assist. The statement also included the following handwritten documentation, Correction: I left a note in Physicians book station to review pain medication . On Sunday, I administered an extra strength Tylenol, but it was not effective. The statement was signed by Nurse B. -Nursing Assistant A Statement, Dated: 9/30/19: When I first came in, I got report from the nurse. The patient was on their call light and said they were cold and requested a pain pill. This was around 2:40 PM and (Resident #701) was in their wheelchair. (The Resident) put on their call light again and wanted to get into bed. I got the hall partner to help me transfer (the Resident) to the bed . (Resident #701's) pain was still bothering them and they didn't want me to touch it. So I went back to the nurse and told them (Resident #701) was still in pain. The nurse said they already gave (Resident #701) the Tylenol but would go back in there to see the patient. I used my gait belt with a two person assist. I did not check the Kardex but I got report from the nurse that (Resident #701) was a two person. Later, after dinner, I went back in there to check on them and they asked for something different . (Resident #701) was pointing at their right leg/knee. I informed the nurse . -Nursing Assistant D Statement, Dated: 9/30/19: I helped (Nursing Assistant A) transfer the patient from the wheelchair to the bed. We lifted (the Resident) and they pivoted . I didn't look at the Kardex. (Nursing Assistant A) told me what to do. The patient complained that their legs hurt . -Nursing Assistant [NAME] Statement, Dated: 9/30/19: I took the patient's dinner tray into their room. (Resident #701) said they didn't want their food because their leg was hurting. (Resident #701) said they wanted their leg wrapped. I told the nurse. (The Nurse) said they knew about the pain and would go in there . Signed by Nursing Assistant E. -Employment Termination documentation for Nursing Assistant A and Nurse B -Resident #701 Kardex indicating, Transfers: two person dependent assist with mechanical lift medium sling An interview was conducted with Nursing Assistant A on 10/14/19 at 1:05 PM. When queried if they were assigned to care for Resident #701 on 9/28/19, Nursing Assistant A indicated they were. Nursing Assistant A further stated, I used to take care of (Resident #701) all the time before they (the facility) started switching us (Nursing Assistants) around to different units. With further inquiry regarding when their unit and Resident assignments changed, Nursing Assistant A stated, Probably a month or two ago. When asked if they had transferred Resident #701 prior to 9/28/19, Nursing Assistant A replied, Yes, (Resident #701) was a two person assist, not a mechanical lift. When queried regarding the care they provided to Resident #701 on 9/28/19, Nursing Assistant A stated, When I first get there (assigned unit), I get a report from the nurse about the patients. When asked what information is conveyed in the report, Nursing Assistant A replied, Their assist level, how they transfer either one person, two person or lift, what their diet is, if they have oxygen, or if they are diabetic. When asked who they received report from on 9/28/19, Nursing Assistant A stated, (Nurse B), I usually work nights, but I had picked up afternoon (shift). When asked about Resident #701, Nursing Assistant A stated, (Resident #701) was in a wheelchair sitting up when I got there and they said their leg was bothering them. I went and got help to put Resident #701 in bed. I used two people (to transfer the Resident). (Resident #701) complained of pain and I told (Nurse B). When queried what occurred after the Resident was transferred to bed, Nursing Assistant A stated, (Resident #701) kept on their call light which wasn't normal, so I told the nurse again. I looked at (Resident #701) when I put them in bed, and they didn't want nobody touching their right leg. (Resident #701) just said it hurt. When queried what time their shift started, Nursing Assistant A replied, 2:00 PM. When asked about the Nursing Assistant assigned to care for Resident #701 during the day shift, Nursing Assistant A replied, I never seen an aide before me. When asked if there was a Hoyer lift sling under the Resident in the wheelchair when they transferred the Resident to bed, Nursing Assistant A replied, (Resident #701) didn't have a sling behind them in the wheelchair. When asked if they are supposed to check the Resident's Kardex for the ordered transfer status prior to transferring the Resident per facility policy/procedure, Nursing Assistant A stated, I always ask the nurse because the Kardex isn't always updated. An interview was completed with Nurse B on 10/14/19 at 1:22 PM. When queried if they were assigned to care for Resident #701 on 9/28/19, Nurse B indicated they worked the weekend, 9/28/19 and 9/29/19, and were assigned to care for the Resident on both days. With further inquiry, Nurse B stated, On Saturday nothing happened. Then about 3:30 PM, (Resident #701) began complaining of leg pain because they had been up in their wheelchair. (Resident #701) always complained of pain in their legs or their butt when they got out of their bed. With further inquiry regarding Resident #701's complaints of pain and what they did, Nurse B replied, Later that day, I heard (Resident # 701) scream in pain. (The Resident) already had bruising on their right leg. I texted the Doctor and let them know. They didn't text me back, so I called them and they said to log it (in Doctor book) and I got an order to order an X-Ray. With further inquiry regarding the Resident's condition and what was communicated to the Doctor, Nurse B stated, I told the Doctor that (Resident #701) was in excruciating pain. The Doctor told me they were going to see (the Resident) in the morning and to log it in their book. When queried regarding Resident #701's pain during the rest of their shift, Nurse B stated, I gave (Resident #701) another Tylenol after they screamed. They were still in excruciating pain. When asked about the Resident's unrelieved pain, Nurse B replied, I let the Doctor know and the supervisor know. When queried regarding facility policy/procedure pertaining to unrelieved pain, Nurse B stated, I did call the Doctor back, but they didn't answer. That's when you let the supervisor know. With further inquiry regarding the Resident's injury and pain, Nurse B stated, That weekend was so crazy, I really didn't have time to do anything. When queried regarding documentation in Resident #701's MAR indicated [REDACTED]. I probably gave (Resident #701) one (Tylenol) and forgot to chart it. When queried regarding Resident #701's transfer status and level of assistance needed, Nurse B replied, I thought it was a non-lifting facility. When queried why their signed statement indicated they were not aware Resident #701 needed to be transferred with a lift and the progress note documentation they wrote in the EMR revealed the Resident was a one person assist, Nurse B replied, Well, I thought it was a non-lifting facility so that would mean they were a Hoyer. With further inquiry regarding level of assistant needed by Residents and the use of mechanical lifts, Nurse B did not provide an explanation. Nurse B then stated, I came back the next day and they told me (Resident #701) had a fractured knee. On 10/14/19 at 1:40 PM, an interview was conducted with Nursing Assistant C. When queried if they were assigned to care for Resident #701 on 9/28/19, Nursing Assistant C revealed they worked day shift on 9/28/19 and 9/29/19 and cared for the Resident on both days. When queried if they had assisted Resident #701 into their wheelchair on 9/28/19, Nursing Assistant C replied, Yes. When asked how the Resident was transferred into the wheelchair, Nursing Assistant C stated, Me and another nurses aide transferred (Resident #701). We used a gait belt. When asked if they had transferred Resident #701 prior to 9/28/19, Nursing Assistant C indicated they had. When asked how they had transferred the Resident previously, Nursing Assistant C stated, (Resident #701) was always a two (person) assist. When queried regarding facility policy/procedure pertaining to Hoyer/mechanical lift use for transferring, Nursing Assistant C revealed not all Residents who require assistance utilize a Hoyer/mechanical lift. An interview was completed with the facility Administrator on 10/14/19 at 3:00 PM. When queried regarding facility policy/procedure pertaining to a no lift facility, the Administrator revealed Residents receive assistance as per their assessed need. The Administrator further revealed Hoyer/mechanical lifts are available for Residents who have been assessed to need them and are not used for Resident's who are able to more actively participate in transferring themselves. When queried regarding documentation authored by Nurse B indicating the Resident was a one person assist, the Administrator indicated they were aware of the documentation. An interview was conducted with the DON on 10/14/19 at 3:35 PM. When queried regarding staff statements and lack of documentation in Resident #701's medical record pertaining to assessment of the Resident's leg, pain levels, and pain management including no documentation on the MAR indicated [REDACTED]. Review of facility policy/procedure entitled, Mechanical Lift (Updated 4/2019) revealed, Purpose: To move immobile . patients for whom manual transfer poses potential for staff or patient injury . Procedure: 1. Verify transfer assist needed per Kardex .

Based on observation, interview and record review, the facility failed to ensure physical restraints were not utilized for staff convenience for one (#137) of one Residents reviewed for restraints, resulting in the application and utilization of a restraint for a cognitively impaired Resident without a healthcare provider order, indication and/or care plan, facility staff not getting a resident out of bed and placing a bed in Trendelenburg position (head of the bed tilted downward with the bed flat and the head lower than the feet) to prohibit movement, physical discomfort and psychosocial distress utilizing the reasonable person concept. Findings include: On 6/17/19 at 9:46 AM, yelling was heard in the hallway coming from Resident #137's room. An interview was conducted with Nurse FF. When queried regarding the audible yelling in the hall, Nurse FF replied, It's (Resident #137). They had [MEDICAL CONDITION](stroke) so that is what they do now (yell out). On 6/17/19 at 9:50 AM, Resident #137 was observed in their room in bed. The Resident was positioned on their back and with their bed in Trendelenburg position. Nursing Assistant S was present in the room. The Resident was yelling and crying. When spoken to, the Resident would stop yelling momentarily but did not answer questions appropriately and began yelling out. When queried, Nursing Assistant S indicated they were the assigned sitter for the Resident. When asked why the Resident needed a sitter, Nursing Assistant S indicated the Resident tries to get out of bed. When asked about the Resident yelling out, Nursing Assistant S indicated the Resident frequently yells out, but they are not sure what the Resident needs. On 6/17/19 at 10:50 AM, yelling was heard in the hallway from Resident #137's room. On 6/17/19 at 10:54 AM, Resident #137 was observed in their room in the facility. The Resident was in bed with the head of the bed flat, positioned on their back with foam wedges on both sides of the Resident. The Resident was yelling and screaming. Nursing Assistant S was sitting on a chair in the room, not near the Resident's bed, with a cell phone in their hands. When queried if the Resident gets out of bed, Nursing Assistant S stated, We got (Resident #137) up yesterday but it is really not safe because (the Resident) just tries to get out (of the wheelchair) so we have just been leaving (the Resident) in bed. When asked if the Resident was receiving therapy services, Nursing Assistant S indicated the Resident was not receiving therapy. Record review on 6/17/19 revealed Resident #137 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] did not indicate a Brief Interview for Mental Status (BIMS) score but specified the Resident was moderately cognitively impaired and required extensive assistance to perform Activities of Daily Living (ADL's). The MDS further indicated the Resident did not display any behaviors and no restraints were used. Review of Resident #137's care plans on 6/18/19 revealed the Resident did not have a care plan in place pertaining to restraints. Additional review of Resident #137's medical record documentation revealed the Resident fell three times at the facility on 5/26/19, 6/6/19 and 6/8/19. The Resident had a care plan pertaining to falls which specified, At risk for falls due to weakness and decreased mobility secondary to TBI ([MEDICAL CONDITION]), cerebral infarction (stroke) (Initiated: 5/21/19; Revised: 5/22/19). The care plan included the following interventions: -Air mattress with perimeter (Initiated: 5/26/19; Revised: 6/7/19) -Air mattress settings: On; Middle between hard and soft; Pulsate (Initiated: 6/7/19) -Increased observation (Initiated: 6/10/19) -Refer to the Therapy Plan of Treatment in the medical record for more detail (Initiated: 5/21/19) On 6/18/19 at 10:46 AM, screaming was heard in the facility hallway coming from Resident #137's room. Upon entering Resident #137's room, the Resident was observed in their bed, positioned on their back with two foam wedges on both sides of the Resident. The bed was in Trendelenburg position and the Resident was thrashing their legs in bed while yelling and was observed attempting to throw their legs over the foam wedge on the right edge of the bed while screaming incoherently. Nursing Assistant S was present in the room but was not directly interacting with the Resident. An interview was conducted with Nursing Assistant S at this time. When queried regarding the Resident's bed being in Trendelenburg position, Nursing Assistant S replied, To stop them from climbing out of bed. With further inquiry, Nursing Assistant S stated, It helped the day before yesterday a lot. At 10:54 AM on 6/18/19, Nursing Assistant U entered the Resident's room. Nursing Assistant U raised the bed to a flat position and spoke to the Resident. The Resident stopped yelling when initially spoke to the Nursing Assistant U. Nursing Assistant U was then observed positioning the Resident's bed in Trendelenburg position. The Resident immediately resumed crying out and screaming incoherently and started forcefully thrashing their lower body in bed while attempting to throw their legs over the foam wedge on the edge of the bed. An interview was conducted with Nursing Assistant U at this time. When queried regarding Resident #137's bed being in Trendelenburg position with their head down, Nursing Assistant U stated, (Resident #137) can get right out of bed if the head (of the bed) is not down. Record review on 6/19/19 of Resident #137's medical record revealed the Resident did not have a Health Care Provider order or consent for a restraint and/or to place the Resident's bed in Trendelenburg position. Review of Resident #137's Therapy Discharge Communication documentation, dated 6/11/19, revealed, Locomotion: Walk to bathroom: hand-held assist . An interview was completed with Unit Manager V and Unit Manager W on 6/19/19 at 9:20 AM. When asked why Resident #137's bed would be placed in Trendelenburg position, Unit Manager V replied, For their blood pressure? It shouldn't be. Why? With further inquiry regarding observations of the Residents bed in Trendelenburg position and staff statements of rationale for placing the bed in Trendelenburg position in order to stop the Resident from getting out of bed, Unit Manager W stated, That's a restraint. When asked if they would consider Resident #137's bed being placed in Trendelenburg position a restraint, Unit Manager V replied, Yes. I will take care of that. On 6/19/19 at 10:23 AM, an interview was conducted with Occupational Therapist X. When queried regarding Resident #137's behaviors and level of assistance at time of discharge from therapy services, Occupational Therapist X stated, (Resident #137) was totally calm when they were in therapy and walking with contact guard assist. With further inquiry, Therapist X indicated they were aware that the Resident screams in their room, but they did not do that in therapy. With further inquiry regarding the Resident's ability to get out of bed, Therapist X reviewed the discharge documentation and indicated the Resident was able to get out of bed with the assistance of one person and was able to walk with someone holding their hand. An interview was conducted with the Administrator and Assistant Administrator on 6/19/19 at 12:44 PM. When queried regarding Resident #137's bed being placed in Trendelenburg position including observation and staff statements for rationale, the Administrator stated, it was a poor decision. With further inquiry regarding observation of the Resident yelling, screaming and thrashing in bed and the physical and physiosocial ramifications of having their bed placed in Trendelenburg position to prevent movement or restrain the Resident using the Reasonable Person Concept, the Administrator stated, I have no leg to stand on with that. An interview was completed with the Director of Nursing (DON) on 6/19/19 at 2:00 PM. When queried regarding Resident #137's bed being placed in Trendelenburg position and staff statements regarding reason, the DON indicated they were not aware staff were placing the bed in that position and that was inappropriate. When queried regarding the physical and physiosocial aspects of the bed being placed in Trendelenburg position, the DON indicated they would not want to be placed in that position. Record review on 6/19/19 of facility policy/procedure entitled, Restraint Guidelines (Updated: 11/2016) revealed, Purpose: To describe the steps required for use of a restraint and to guide the selection of the least restrictive device aimed at providing for the patient's highest practicable level of well-being . Guidelines: Patients have the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the patient's medical symptoms. The potential effect of restraints may include: physical- traumatic injuries, decreased muscle mass .psychological- fear, anger, depression, humiliation, emotional isolation .sad or anxious moods, worsening of dementia . Behavioral- withdrawal, anger, combativeness . Restraints are often applied as the result of a patient behavior. The Behavior Practice Guide is utilized to provide guidance on determining the root cause of a patient's behavior and determining a patient focused plan of care that includes the least restrictive interventions to manage the behavior or identify unmet patient needs . The attending physician is responsible for identification of the medical symptom requiring the use of the restraint. A patient history of falls does not constitute a medical symptom .

This citation pertains to intake number: 1. Based on observation, interview and record review, the facility failed to implement a clear, appropriate plan to transfer a resident, and failed to follow the care planned transfer status for one (#702) of two residents reviewed for accidents, resulting in a left impacted condyle femur fracture, pain, hospitalization , and emotional distress. Findings include: On 2/27/19 at 11:47 AM, Resident #702 was observed in a hospital gown, awake in bed. Resident #702's left hand was contracted and there was a black immobilizer/brace present on the resident's left leg. A white pain patch was intact across the left knee. Resident #702 stated, I have to wear that (the immobilizer) night and day because I couldn't have surgery. Resident #702 was interviewed about the incident that resulted in being sent to the hospital on [DATE]. The resident stated, I was transferred with one aide because she was frustrated. I need two persons to transfer me or they use the hoyer lift depending on the day. I can sometimes stand and pivot (with right leg). I don't get up anymore because I am in a lot of pain and I am too afraid to try to because of the pain. They are real stingy with the pain medication. Record review of the most recent completed Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #702 was admitted into the facility on [DATE] and readmitted on [DATE] and required extensive assist with transfers, toileting and bed mobility. Resident #702 had a Brief Interview for Mental Status (BIMS) score of 11/15, indicating some cognitive impairment. Resident #702 had [DIAGNOSES REDACTED]. A review of the X-Ray results dated 2/21/19 revealed the following: Left Knee Effusion (a build up of fluid in the knee, usually as a result of trauma) with impaction [MEDICAL CONDITION] femoral condyle. Age cannot be confidentially determined by appearance, though favor an acute injury. Recent trauma or injury help confirm. A review of the Incident/Accident Report dated 2/21/19 revealed the following: Patient had their shower this afternoon, patient c/o (complained of) pain to left leg after the 2 CENA (Certified Educated Nurse Assistant) was trying to transfer from shower chair to bed. Patient stated, 'I heard a cracking sound and it hurts!' no bruise noted. ice applied. A review of the written statements of the Licensed Practical Nurse (LPN) and Certified Nurse Assistant's (CNA's) that transferred Resident #702 on 2/21/19 revealed the following: CENA B-(CENA A) and myself was transferring pt (patient/Resident #702) back to bed from the shower chair, once patient was back in bed they stated that they felt something crack. LPN C-I had a conversation with the aides (CENA A and B). I asked them how did they do the transfer for them (Resident #702) because they are supposed to be a hoyer lift (a mechanical lift used to transfer a resident that cannot stand). They stated they did a two person extensive assist. I re-educated them that it was in the chart (method of transfer). CENA A-I was working with the patient and was assigned to give a shower to the patient .I asked (CENA B) to help me with transfer, we put patient on a shower chair two person assist (CENA B) was in room talking to bed one about a shower and I did not think about the (hoyer) lift because (Resident #702) can help with transfers. Once after showering patient, I asked the same aide to help transfer back to bed. Again two person assist we layed them down .the patient stated 'My leg hurt and I want a pain pill' the patient pointed to their left leg. CENA B- .(CENA A) came in went to bed two and then said can you help me with putting (Resident #702) to the shower chair I went over and we lifted them from bed to chair and (CENA A) took the patient to the shower area .I continued to work on my assignment for the night, the light went on and the patient asked for pain pill .The light came back on about 15 minutes later and patient was still asking for pain meds. On 2/27/19 at 12:00 PM, an interview was completed with the Administrator in regards to the status of CENA A and CENA B. The Administrator stated, We have been educating them. During that time, a review of the education provided to the staff revealed the following: Topic .Kardex (a specific care guide based of the care plan for a resident/Transfers. Purpose: Educate on proper use of Kardex, importance of referring to using Kardex to avoid harm and injury. Program Objectives-Follow established safety policies. Observing needs of patients. Using correct safety equipment and supplies. Understand disregarding orders/Kardex may result in harm or injury. When transferring a resident the Caregiver must first check the Kardex for the correct transfers. On 2/27/19 at 12:15 PM, an interview was completed with the Director of Nursing (DON) in regards to Resident #702's transfer status and cause of the left femur fracture. The DON stated, (Resident #702) is a lift of two person depending on how they are doing. The aides used two persons. Therapy screened (Resident #702) on 2/1/19 and said two person assist was appropriate. Both the aides are suspended right now. We educated them. We are going to discipline one of them for not following the Kardex, which said hoyer lift. They have to follow what the Kardex says. During the time of the interview, the Kardex was reviewed and revealed that Resident #702 was to be transferred via a hoyer lift. A record review of the Activity of Daily Living (ADL) care plan for Resident #702 revealed the following: Mechanical (hoyer) lift for transfers Initiated 5/18/18. Kardex-Hoyer lift Initiated 5/18/18. A record review of the progress notes revealed the following: 2/21/19 4:59 PM Skilled Nursing Note Text: Patient had their shower this afternoon, patient c/o pain to left leg after the two CENA was trying to transfer patient from shower chair to bed. Patient stated, I heard a cracking sound and it hurts! no bruise noted. ice applied .NP (Nurse Practitioner) notified and ordered X-ray . 2/25/19 10:06 PM Admit/Readmit Note Text: Patient admitted from (hospital) via stretcher. Daughter waiting in room prior to arrival. S/p (status [REDACTED]. No surgical intervention .Immobilizer in place. 2/27/19 7:08 AM Skilled Nursing Note Text: Patient S/p closed distal femur fx r/t trauma. No surgical intervention .Pain managed with prn (as needed) [MEDICATION NAME] and scheduled medications. Pillows used for positioning. Immobilizer in place .Anxiety is better this morning compared to yesterday . On 2/27/19 at 12:33 PM, an interview was completed with CENA B via telephone. CENA B stated, I was not in charge of (Resident #702) that day. CENA A asked me to come in and help her transfer, so we did a 2 person assist . On 2/27/19 at 12:42 PM, LPN C was interviewed in regards to the transfer status of Resident #702 on 2/21/19. LPN C stated, I believe that they were a two person assist at one point but then therapy changed it to a hoyer lift. When asked why the CENA's did not use a hoyer lift on that day, LPN C stated, The way it was written in the Kardex was confusing, it said two person assist, but then below it had hoyer lift in parenthesis. A voicemail message was left for CENA A however, there was no return phone call by the end of the survey. On 2/27/19 at 1:05 PM, Physical Therapy (PT) Staff member D was interviewed in regards to the transfer status of Resident #702. According to PT D, she had worked with Resident #702 on several occasions prior to 2/21/19. PT D stated, (Resident #702) was a hoyer lift and a two person assist depending on their functional needs. They are very particular and would often refuse the hoyer lift. They did not like it. (Resident #702) was completely flaccid on the left side and could not bear weight from a stroke. During the interview, a Therapy Discharge Communication form was reviewed. The form was dated 2/1/19. The form revealed the following: Transfer from bed to chair 'Two + persons physical assist*' *consider using a mechanical lift A record review of the most recent PT notes prior to 2/21/19 for Resident #702 revealed the following: Start of Care 12/12/18-Reason for Referral/Current Illness: Pt has declined in their ability to do transfers . Transfers-Total Dependence with attempts to initiate . PT Progress Note-[MEDICAL CONDITION] and [MEDICAL CONDITION] (paralysis and weakness) .affecting left side. Transfers-Baseline/Previous (12/12/18) Total Dependence (TD) . Current (1/10/19) Total Dependence . 1/28/19-Pt needs TD+assist for bed mobility and transfers. A review of the facility policy titled, Transfer-Bed-Chair/Wheelchair dated 1/2011 did not reveal specific information in regards to the procedure of the transfer status of residents.

This citation pertains to intake number . Based on interview and record review, the facility failed to ensure that staff check the temperature of the water with a thermometer for 1 (#501) of three sampled residents, resulting in the resident obtaining a first degree burn. Findings include: On 11/21/18 at 9:35 AM, a review of an incident report dated 10/20/18 at 7:30 PM, indicated the following: Description of Incident: Nurse called to patient's room by patient complaining of pain to right axilla area. Patient stated while drinking their hot chocolate it spilled and was causing pain. Describe cause of incident if known: Patient was drinking hot chocolate in bed and it spilled on their right upper arm and axilla area. Describe corrective action taken following incident, if applicable: Area assessed. Cool compress applied initially .[MEDICATION NAME] cream applied per physician order [REDACTED]. On 11/21/18 at 9:43 AM, a review of a written statement made by Certified Nursing Assistant (CNA) F regarding the incident which occurred on 10/20/18 involving R#501 stated the following, Patient asked me to get hot water for cocoa in their room. I went and got a white small disposable cup and water, and heated the water up in the microwave, I did not measure the temperature of the water with a thermometer but I did test the water on my finger. I took the cup to the patient room and mixed up their cocoa and gave them the cup with the lid on it and the two small straws, and set it on the bedside table, and I left the room. On 11/21/18 at 9:50 AM, a review of a document titled, Employee Warning Notice dated 10/25/18 involving CNA F indicated the following, On 10/20/18 employee heated up water for cocoa in a microwave for a patient and did not temp water to ensure safety, which resulted in patient spilling cocoa on themselves causing a burn. Describe the counseling received by employee: Reviewed policy for proper temperature for food and drinks served to patients. If food or drinks need to be heated employee to take item to kitchen for testing for proper temperature. On 11/21/18 at 9:55 AM, a review of a document titled CNA Meeting dated 4/22/18, which was attended by CNA F indicated the following, Reheating Food Items - Only family and visitors are allowed to reheat food items using the microwaves in the nutritional rooms. On 11/21/18 at 10:00 AM, a review of a Nurse Practitioner progress note involving R#501 and dated 10/22/18 stated the following, Chief Complaint-Right axilla burn. Pt is seen and examined at bedside per nursing request for the above. Pt reports they spilled hot chocolate on their left axilla 2 days ago. Examined skin to note mild redness .Pt reports pain is improving. Diagnosis 1-Left axilla first degree burn. On 11/21/18 at 10:05 AM, a review of R#501's medical record indicated an admission to the facility on [DATE] and a readmission on 5/5/17 with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment for R#501 dated 8/13/18, indicated an intact cognition and extensive assistance with activities of daily living. On 11/21/18 at 10:10 AM, the Director of Nursing (DON) was queried on the incident involving R#501 on 10/20/18 and heating food or drink items up in the microwave on the unit. The DON stated, It is the policy that CNAs are not to heat anything up for residents, they are to take it to the kitchen to be heated up and temperature checked. On 11/21/18 at 10:15 AM, R#501 was queried on the incident which occurred on 10/20/18, they indicated, I reached for the hot chocolate off my table and spilled it on my armpit. It hurt. On 11/21/18 at 10:45 AM, Nurse A was queried on the policy for heating up beverages for residents on the unit. Nurse A stated, We do not re-heat hot liquids. On 11/21/18 at 10:48 AM, Nurse B was queried on the policy for heating up beverages for residents on the unit. Nurse B stated, We do not use the microwave to re-heat things. We use the hot water from the coffee cart on the unit. Anything that needs to be re-heated needs to go to the kitchen. On 11/21/18 at 11:00 AM, CNA C was queried on the policy for heating up beverages for residents on the unit. CNA C stated, We are not supposed to heat things up in the microwave. On 11/21/18 at 11:05 AM, CNA D was queried on the policy for heating up beverages for residents on the unit. CNA D stated, We don't heat liquids up in the microwave, we take it to the kitchen if it needs to be heated up. On 11/21/18 at 11:10 AM, CNA E was queried on the policy for heating beverages for residents on the unit. CNA E stated, We are not allowed to heat anything up. I would have the kitchen bring hot water up to the floor so they could temp it. On 11/21/18 at 11:15 AM, CNA F was queried on the incident which occurred on 10/20/18 involving R#501. CNA F stated, The resident asked me for hot water. I heated up water in the microwave for them. CNA F was further queried on if CNAs were supposed to be using the microwave to heat up beverages for the residents. CNA F stated, I'm not sure. On 11/21/18 at 3:25 PM, the facility investigation regarding the incident which occurred on 10/20/18 involving R#501 was reviewed with the Administrator. The Administrator acknowledged that CNA F should not have been using the microwave to heat up R#501's beverage. On 11/21/18 at 3:35 PM, a facility policy titled Serving Hot Beverages .Revised 3/2010 indicated the following, The facility will follow established methods for the safe distribution of hot beverages to patients .Consider the temperature range of 150-155 Fahrenheit (F) as an approximate guide for hot beverages .

Based on observation, interview and record review, the facility failed to provide assessment, treatment, and individualized care interventions for one (#40) of one Residents reviewed for dementia care, from a total sample of 28, resulting in lack of assessment and identification of Resident needs, provision of individualized care, staff not respecting Resident wishes, Resident expressions of frustration and anger, and psychosocial distress. Findings include: On 4/17/18 at 12:41 PM, Resident #40 was observed in the community dining room of the facility sitting in a wheelchair eating lunch. The leg rests on the wheelchair were positioned to the side and the Resident's feet were noted to be on the floor. At 1:29 PM on 4/17/18, Resident #40 was observed ambulating, without staff assistance or an assistive device, in the hall of the facility outside of their room. The Resident took small steps but was not unsteady with ambulation. Facility staff, including Unit Manager Nurse C and Nurse X, were noted to be present in the hall at this time. The Resident was observed walking up and down the hall twice and then returning to their room. An interview was completed with the Resident at this time. The Resident was pleasantly confused and answered direct questions appropriately. When asked about pictures within their room, the Resident indicated they were a Veteran. The Resident further specified they used to go for walks with their spouse. When queried regarding their lunch, Resident #40 indicated they wanted to talk in the hall. While standing in the hall with Resident #40, Unit Manager Nurse C approached the Resident and stated, Where is your wheelchair? You need to use your wheelchair. Nurse C proceeded to enter the Resident's room and brought the wheelchair to where the Resident was standing. Nurse C instructed the Resident to sit down in the wheelchair. Resident #40 told Nurse C they were talking and did not want to sit down. Nurse C then told the Resident they needed to sit because they were not steady enough to walk by themselves. The Resident was heard stating, I know what I need. At this time, the Resident walked to the closet in their room and began looking through closet. Nurse C brought the wheelchair into the room and instructed the Resident to sit again. Resident #40 was observed becoming visually agitated. The Resident did not respond to Nurse C and continued to search in their closet. Resident #40 stated, I can't find it. My cane. Nurse C told the Resident to sit in the wheelchair again and the Resident turned toward Nurse C and yelled, Who took it. At this time, Nursing Assistant AA entered the room and Nurse C exited the room. Nursing Assistant AA repeatedly told Resident #40, You have to sit. After being told to sit in the wheelchair multiple times, Resident #40 yelled at Nursing Assistant AA indicating they wanted their cane and did not want to sit. Nursing Assistant AA was observed telling the Resident their cane was probably in Therapy and they would take them to find it if they sat in the wheelchair. After stating again that they wanted their cane, the Resident hesitantly sat down in the wheelchair. An interview was conducted with Unit Manager Nurse C on 4/17/18 at 1:50 PM and when queried regarding Resident #40 ambulating in hall unassisted without difficulty prior to being instructed to sit in their wheelchair, Nurse C indicated the Resident is not supposed to be up because they are a fall risk. No further explanation was provided. Resident #40 was observed in the hall of the facility, sitting in their wheelchair without a cane, at 1:55 PM on 4/17/18. When queried if they found their cane, the Resident shook their head indicating no. The Resident appeared visibly distressed with tears noted in their eyes. Record review on 4/17/18 at 4:15 PM revealed Resident #40 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired, displayed no behavioral symptoms, and required supervision to extensive assistance to perform Activities of Daily Living (ADL's). Review of Resident #40's care plan occurred on 4/17/18 at 4:25 PM. Review revealed the following care plans and interventions: -At risk for falls due to weakness of the (R) side of the body (Initiated: 2/17/18; Revised: 2/18/18). The care plan included the interventions, Provide assist to transfer and ambulate as needed (Initiated: 2/27/18) and Psych to reevaluate medications (Initiated: 2/28/18). -Difficulty communicating as evidenced by severe cognitive impairment related to dementia, [MEDICAL CONDITION] with behavioral disturbances (Initiated: 2/27/18). The care plan included the interventions, Mirror patient's facial expressions/body language to communicate your understanding of emotion being expressed (Initiated: 2/27/18) and When talking to patient, use gestures and simple sentences while maintaining eye contact (Initiated: 2/27/18). -ADL Self care deficit as evidenced by (R) side weakness related to left occipital ischemic infarct, UTI, dementia, [MEDICAL CONDITION] with behavioral disturbances (Initiated: 2/17/18; Revised: 2/27/18). The care plan included the intervention, Assist with daily hygiene, grooming, dressing, oral care and eating as needed (Initiated: 2/17/18). Record review of Psychiatric Provider documentation for Resident #40 on 4/18/18 at 4:20 PM revealed the Resident was evaluated and seen by a mental health care provider on 2/23/18 and 2/26/18. Documentation revealed the following Psychiatric Provider notes: -2/23/18: Assessment and Plan: Presents with agitated [MEDICAL CONDITION]. Resident being treated for [REDACTED]. -2/26/18: Complaint: Cognitive assessment to assist with treatment planning . Will follow up as needed . Assessment and Plan: Patient demonstrating significant impairment in orientation, memory and comprehension, Patient does not appear able to make informed medical or financial decisions independently at this time. Support as needed/requested to facilitate adjustment and to monitor cognition . Review of Resident #40's healthcare provider orders and Medication Administration Record [REDACTED]. Review further revealed the Resident was started on [MEDICATION NAME] (antipsychotic medication) 50 milligrams (mg) twice a day on 2/23/18 and was still taking the medication. An interview was completed with Nurse DD on 4/18/18 at 4:30 PM. When queried regarding Resident #40, Nurse DD stated, (Resident #40) has had behaviors ever since they were admitted . When queried regarding the Resident's activity level, Nurse DD indicated the Resident was a fall risk and they did not walk. With further inquiry, Nurse DD stated, (Resident #40) stays in their wheelchair. When asked about observations of the Resident walking in the hall, Nurse DD did not provide further explanation. On 4/18/18 at 4:40 PM, an interview was conducted with Social Worker CC. When queried regarding further psychiatric follow up and documentation for Resident #40, Social Worker CC reviewed the Resident's medical record and stated, I'm not sure why they haven't seen (Resident #40). When queried regarding social services evaluation of the Resident including assessment of adjustment to the facility and monitoring of Resident status following initiation of new antipsychotic medications, Social Worker CC indicated they had not reevaluated the Resident. Review of Resident #40's Incident and Accident Reports occurred on 4/19/18 at 8:00 AM. Review revealed the Resident fell twice within the facility on 2/26/18 and 2/28/18. The Incident and Accident Report details included the following: -2/26/18 at 7:30 PM: Description of the Incident: At approx 1930 patient stood from wheelchair and took steps. Patients wheelchair was at nurses station. Nurses at the station attempted to reach patient before patient fell , but patient stumbled and fell over and hit head on the wall. Nurses witness the fall and patient appeared to hit right side of head very hard. Patient did not have redness, abrasion, or lump to head. Patient c/o (complain of) blurriness and pupil not reactive to right eye . Patient assessed for injury. Remained on floor until EMT (Emergency Medical Technician) arrived to transport to hospital . Describe cause of incident, if known: Patient has been attempted to stand and walk on own multiple times during day. This time patient attempted and stumbled over attempted to get away from nurses that was attempted to reach patient . Describe corrective action taken . Patient transported to hospital via EMT. -2/28/18 at 3:45 PM: Description of the Incident: Resident while up and in his wheelchair at the nurses station slowly slid out of chair, fall was witnessed by Nurse on duty and dietician. Resident did not hit head. Resident lethargic and assisted backed to wheelchair and placed in bed per request . Describe cause of incident, if known: Resident lethargic, Resident recently placed on [MEDICATION NAME] (antipsychotic medication) and is making drowsy and disorientated . Describe corrective action taken . Medication review . An interview was conducted with the Director of Nursing (DON) on 4/19/18 at 9:46 AM. When queried regarding Resident #40's level of activity and assistance required, the DON reviewed the Resident's medical record and stated, The Kardex states usually two person with level of assist. With further inquiry regarding why the Resident was instructed to sit if they wanted to walk and had been walking unassisted in the hall with staff present, the DON stated, I would have walked with him. The DON then stated, (Resident #40) has had two falls since they have been here. With additional inquiry related to the Resident's falls including identified causes of falls and interventions implemented to prevent falls, the DON was unable to provide an explanation. When asked about facility policy/procedure pertaining to care of Resident's with dementia in the facility including the Resident's reaction to staff and not wanting to sit down, the DON stated, If the Resident can walk, there is no reason we are not walking them. I agree with you. I will talk to the Unit Manager and add it (walking) to the Resident's tasks. When asked about facility policies/procedures pertaining to care of Resident's with dementia, the DON indicated they would look for a policy. A policy/procedure pertaining to care of Resident's with Dementia was requested but not received by the conclusion of the survey.

This citation pertains to intake MI 930 Based on interview and record review, the facility failed to provide two person assistance while rendering care per the nursing assessment and Certified Nursing Assistant (CNA) Care Guide for two ( #'s 17 and 26) of 10 residents reviewed for falls from a total sample of 27, resulting in a nasal bone fracture and bilateral meniscal tear of the right knee for Resident #17 and the potential for injury for Resident #26. Findings include: On 04/18/18 at approximately 9:30 a.m., the clinical record for Resident #17 was reviewed and revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The resident required assistance with personal care. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated cognitive impairment and required extensive assistance of two persons for all activities of daily living (ADL). On 04/19/18 at 09:38 AM, Resident #17 was observed dressed and sitting in the wheelchair watching television, with the right arm on a supportive table attached to the wheelchair. On 04/19/18 at 08:54 AM, review of the clinical record revealed: Incident report: Date of incident 2/27/18 5:30 PM. Description: called writer and stated that patient fell in bed. observed patient in the floor in prone position with face down, noted blood in the floor. cut noted on patient nose and forehead . Describe cause of incident, if known: (Certified Nursing Assistant) CENA was trying to change patient by herself and patient rolled over and fell . Corrective Action: Educate CNA that she needs to ask assistance when needed to change patient for patients safety. Reported by: Charge Nurse V. Progress notes: 02:38:48, 2/25/18. Fall note: Patient received in bed awake and alert. [MEDICAL CONDITION] present. Uses communication board and nods head yes or no to simple questions. Tube feeding tolerated with no n/v/d (nausea, vomiting, diarrhea). Vitals stable. Incontinent of bowel and bladder. Extensive 2 person assist with transfers, dressing, bed mobility and toileting. Call light in reach. Safety maintained . Progress note: 20:03:18, 2/25/18. CENA called writer to patient room; when writer arrived to patient room, writer observed patient on floor, sitting on buttock, in-front of wheelchair . Neurochecks started-neurological status remains same-no changes. Patient then assisted off floor with use of mechanical lift. No c/o (complaint of) pain during transfer. no new skin alterations noted . Progress note: 19:32:19, 2/27/18, CENA (CNA A) called writer and stated that patient fell in bed. observed patient in the floor in prone position with face down, noted blood in the floor. cut noted on patient nose and forehead . patient remain alert and responsive unable to understand patient when asked what happened r/t (related to) slurred speech. cleanse forehead and nose with NS (normal saline) and applied dry dressing and ice pack applied. CENA stated she was trying to change patient by herself and he rolled out of bed and fell . Educate CENA that she should ask help and assistance when changing patient for patient's safety since patient is extensive assist related to right sided weakness . Notified Dr and order to transfer to hospital . called 911 and transfer patient to local hospital . Progress note/Admission note: 3/1/2018, patient returned from hospital this shift. (Diagnose) DX: possible right knee fx (fracture) and possible broken nose. Patient is a 2x person extensive assist with transfers and ADLs . swelling to right foot and right hand . Progress note/NP/Physician Comprehensive, 3/2/2018, 14:33:09 . On 2/27/18, patient s/p (status [REDACTED]. -Suspected right anterior cruciate ligament rupture and complex bilateral meniscal tear of the right knee s/p fall from bed 2/27/18 -Nasal bone fracture s/p fall from bed 2/27/18 . Care plan: At risk for falls due to impaired balance/poor coordination, potential medication side effects, unsteady gait Date Initiated: 01/19/2018, Created on: 01/19/2018, Revision on: 01/22/2018. No other interventions added after 2/25/18 or 2/27/18 falls. Kardex ADL Assist - Usually 2 person with extensive level of assist with gait belt level. Resident is a two person when doing peri care *SPECIAL NEED: roll patient towards cena when changing. Undated. On 04/19/18 at 09:41 AM, Nurse Manager, RN C was interviewed about the fall that occurred on 2/27/18, NM C said, The fall happened around 5:30 - 6:00 p.m. NM C was not able to offer any other information. On 04/19/18 at 10:23 AM during an interview via phone, CNA A was interviewed about the fall on 2/27/18, CNA A said, I was providing care. This was not the first time I provided care to him, I had did it before by myself. This was the first time he fell while I was giving care. CNA A was asked how many staff persons was needed to provide care to Resident #17, CNA A said, 2 people is what is on the Kardex. CNA A was asked if she was aware of the required 2 staff persons prior, CNA A said, Yes. CNA A was asked for an explanation on to why care was given by one person and not the required two, CNA A replied, He needed his brief changed. On 04/19/18 at 2:36 p.m., documents reviewed: 1. One-On-One In-service Record, CNA A, date 2/27/18, In-service Topic: Transfer status. Description of Procedure: Using task to be informed about patient transfer status 2 person assist and never to roll patient away from self. 2. One-On-One In-service Record, CNA A, date 3/5/18, In-service Topic: Transfer status/Kardex. Description of Procedure: To follow the transfer status that is written in the task. To make sure that you read the task for each of your assign patient at the beginning of your shift. (Kardex). On 04/19/18 at 10:30 AM, a telephone call and voice mail was left to the Charge Nurse V. There was no call back during the survey process. On 04/19/18 at 10:12 AM during an interview, the Director of Nursing was asked about the fall that occurred on 2/27/18, the DON referred to Resident #17's medical chart. The DON said, That CNA A was providing peri care. The DON was asked how many people were required to provide adl care, the DON said, Two persons for ADL care. Resident #26 On 4/18/18 at 8:45 a.m., the clinical record for Resident #26 was reviewed and revealed that the resident was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 2/12/18, indicated an intact cognition and required extensive assistance of two persons for all transfers. On 4/18/18 at 9:06 a.m., Resident #26 was observed in bed and reported that she had a fall with injury approximately one month ago. On 4/18/18 at 10:15 a.m., a review of an incident report, dated 2/28/18 at 11:25 a.m., indicated the following: CENA called the writer and stated that she lowered the patient to the floor while she was trying to transfer her from bed to w/c to give patient a shower. Patient stated I'm okay, I'm not hurt, she just lowered me to the floor. Describe cause of incident, if known: Patient required 2 person assist for transfer, CENA is not supposed to transfer patient by herself. Describe corrective action taken following incident, if applicable: Educate the CENA not to transfer patient by herself, she should ask for assistance because patient required 2 person assist with hoyer or gait belt for transfer. On 4/19/18 at 2:45 p.m., CNA L was queried on incident which occurred involving Resident #26 on 2/28/18 at 11:25 a.m. CNA L stated, I was transferring the resident from the bed to the wheel chair and she fell . CNA L was queried on how many persons are supposed to assist Resident #26 when transferring. CNA L stated, I think two. CNA L was queried on if she had someone assisting her with transferring Resident #26 when this fall occurred. CNA L stated, No. On 4/19/18 at 3:37 p.m., the Director of Nursing (DON) was queried on the transfer status of Resident #26. The DON indicated that Resident #26 was a two person assist for all transfers. Deficient Practice Statement #2 This citation pertains to MI intake # Based on interview and record review, the facility failed to investigate a root cause of falls and implement appropriate and planned interventions to help prevent falls for 1 (#50) out of 10 residents sampled for falls, from a total sample of 27, resulting in continued, reoccurring falls and the potential for a major injury. Findings include: On 4/17/18 at 11:42 AM, Resident #50 was observed in the room laying in bed. Resident #50 was confused. Certified Nursing Assistant (CNA) D was sitting in a chair next to Resident #50. CNA D was queried as to why she was sitting with Resident #50. CNA D stated, He (Resident #50) tries to get up and falls all the time, so I am sitting with him today. On 4/17/18 at 12:00 PM, a record review of the face sheet revealed that Resident #50 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/19/18 at 10:09 AM, a review of the Incident Reports for Resident #50 revealed the following documentation: 3/18/18 3:35 AM-fell out of bed, trying to answer phone. Phone in reach. Corrective Action-Call light, phone, on bedside table in reach; grippy socks. 3/30/18 9:00 AM-Laying next to bed. Corrective Action-toileted. 4/11/18 2:30 AM-Sitting next to bed. Corrective Action-put at nurses station. 4/11/18 7:30 AM-fell out of wheelchair. Corrective Action-none listed. 4/11/18 11:35 AM-fell out of wheelchair. Corrective Action-foot rest, psych consult. On 4/19/18 at 10:25 AM, a review of the Fall care plan for Resident #50 and revealed the following: Focus At risk for falls due to history of falls, impaired balance/poor coordination, potential medication side effects, poor cognition, [MEDICAL CONDITIONS] Created 4/10/18 Goal Minimize risk for falls 4/10/18 Interventions Bed in low position 4/11/18 Encourage to transfer and change positions slowly 4/10/18 Have commonly used articles within easy reach 4/10/18 Low bed 4/11/18 Refer to Therapy Plan of Treatment in the medical record for more detail 4/10/18 Reinforce need to call for assistance 4/10/18 Sitter due to impulsive behaviors and HX (history) [MEDICAL CONDITION]([MEDICAL CONDITION] or stroke) 4/11/18 Therapy evaluation and treatment per orders, 4/11/18 On 4/19/18 2:21 PM, an interview was completed with the Social Worker (SW) Y in regards to the psychiatric evaluation requested as part of the 4/11/18 fall(s) intervention for Resident #50. SW Y began to look through the medical record and was unable to locate any notes that psychiatry had seen the resident. SW Y stated, It looks like the order was written on 4/11/18, I don't see any notes or that he was on the list that he was seen. I will add him on for next time. On 4/19/18 at 2:45 PM, a record review of the Progress Notes for Resident #50 dated 4/11/18 revealed the following: Chief Complaint-status [REDACTED].>Patient is seen today status [REDACTED]. Assessment/Plans We will review all medications. Obtain orthostatic vital signs. Labs drawn this morning and are pending. Recommend one-to-one sitter for patient safety due to impulsive behavior, frequent falls. Will also consult psych due to [MEDICAL CONDITION]/altered mental status . On 4/19/18 at 2:50 PM, an interview was attempted with the Director of Nursing (DON) to discuss the falls. A list of the falls, and the questionable interventions (3/30/18-toileted, 4/11/18 2:30 AM-placed at nurses station), including the fall with no interventions listed (4/11/18 7:30 AM) was given and reviewed with the DON. The DON did not offer an explanation but did state that she would look into it. No further explanation was provided by the end of the survey. On 4/19/18 at 4:23 PM, a record review was completed of the facility policy titled, Falls Practice Guide Issued 12/2011 and revealed the following: Purpose-The purpose of the Falls Practice Guide is to describe the process steps for identification of patient fall risk factors and interventions and systems that may be used to manage falls. Fall management focuses on minimizing fall risk factors and fall related injuries while continuing to promote the patient's quality of life. Change in Condition or Fall Occurrence-An evaluation of the patient is completed timely following a fall .Upon completion of the evaluation, the physician is notified and orders are documented, noted and implemented, as indicated .

This citation pertains to intake MI 163 Based on interview and record review, the facility failed to administer anti-[MEDICAL CONDITION] medications to one (#722) of 23 sampled residents who receive anti - [MEDICAL CONDITION] medications, resulting in [MEDICAL CONDITION] activity and a discharge to the hospital. Findings include: On 5/15/16, at 10:00 AM, the family member of resident # 722 was interviewed and stated that resident # 722 was discharged from the hospital on [DATE] and admitted into the facility on [DATE] at 6:30 p.m. According to the family member, she had spoken to the resident on 4/30/16 and was told by resident #722 that she didn't think she was getting any medications. The family member stated that resident #722 was discharged from the facility and was admitted back to a local hospital for uncontrolled [MEDICAL CONDITION] and is currently on a ventilator (a machine that mechanically operates the lungs to allow the patient to breath) in the Intensive Care Unit because she did not get her [MEDICAL CONDITION] medications. On 5/16/16, at 2:00 p.m., review of the hospital discharge instructions, dated 4/29/16 stated, Discharge Summary: continue to receive the [MEDICATION NAME], Depakon and [MEDICATION NAME]. On 5/16/16, at 2:50 p.m., record review revealed that resident #722 was admitted into the facility on [DATE] at 6:30 p.m., following a hospital stay with [DIAGNOSES REDACTED]. The hospital history and physical revealed that resident #722 also had [MEDICAL CONDITIONS] (a malignant [DIAGNOSES REDACTED]) and had undergone a craniotomy (a surgical opening in the skull) on 3/7/16 and was placed on [MEDICATION NAME] (a steroid used to control swelling). The history and physical also notes that neurology was consulted and recommended that the patient (resident #722) continue [MEDICATION NAME] and be started on Depakon (a medication used to control [MEDICAL CONDITION]) and continue on [MEDICATION NAME] and [MEDICATION NAME] (both medications are used to control [MEDICAL CONDITION] activity). The Director of Nursing (DON) was interviewed on 5/16/16 at 3:00 p.m., and asked if the facility received a copy of the resident's hospital discharged summary. The DON stated, we only got what is in the record. Review of the hospital Medication Administration Record [REDACTED]. On 5/16/16, at 2:00 p.m., record review revealed a progress noted by physician Dr. I dated 4/30/16 which stated, 4/30/16 history and physical dict (dictated) Hx (history) [MEDICAL CONDITIONS]. [MEDICATION NAME] 200 milligrams (mg) 2 PO (by mouth) BID (twice per day). Review of the controlled substance sheet revealed that the medication had not been shipped from the pharmacy until 5/1/2016 at 5:50 a.m. The April MAR, revealed that the resident had [MEDICATION NAME] scheduled to be given at 9:00 a.m. and 5:00 p.m. for 4/30/16. There were initials as if medications were given at that time, however, [MEDICATION NAME] was not available according to the drop ship delivery confirmation sheet. There was no documented evidence on the May MAR indicated [REDACTED] The Director of Nursing (DON) was interviewed on 5/17/16 at 8:00 a.m., and asked why the [MEDICATION NAME] was signed out as given and initialed by the nurse. The DON stated, that was a mistake, the medication was not given. The DON was asked if whether the [MEDICATION NAME] was available in the pharmacy back up system located within the facility. The DON replied, No, it is not. On 5/16/16, at 3:00 p.m., review of a hospital document titled, Your Medication List had the following medications listed: [MEDICATION NAME], Iron, Lacosamide ([MEDICATION NAME]), Latanoprost, [MEDICATION NAME] and Senna. [MEDICATION NAME], Depakon and [MEDICATION NAME] were not present on this list. On 5/16/16 at 3:00 p.m., the admitting nurse J was interviewed regarding the medications ordered for resident #722. Nurse J stated, I had four admissions that night. I came in at 7 p.m. and she was already in the room. Around 10:00 PM I realized that her pills were not in the system so I went ahead and put them in the system so they could be ordered. The [MEDICATION NAME] needed a script (because it is a narcotic, or controlled substance), so I called the doctor (Dr. I) but he did not answer the phone so I texted him, but he never got back to me. Nurse J was queried about what information she used to order the medications, she described the list received from the hospital as the list used to order the medications. When asked if she had read the patient hospital notes to learn about the course of stay and how the resident was treated for [REDACTED]. On 5/17/16, at 8:00 a.m., the Administrator, DON and Attending Physician Dr. I. were interviewed and the Administrator provided a file folder with the facility's internal investigation. It revealed the following information: the Internal Customer Service Tech from a local pharmacy had emailed an investigation outlining the delay with the [MEDICATION NAME]. According to the pharmacy, there was a telephone order on 4/30/16 at 18:19 (6:19 p.m.) for [MEDICATION NAME]. On 5/1/16, a nurse called and requested a drop shipment (a method the pharmacy may use to quickly deliver medications to a facility). The pharmacy was unable to get the medication from a local pharmacy and had to use a Toledo pharmacy to send the medication. On 5/1/16, at 12:09 p.m. a request was faxed to the facility to clarify the dose of the [MEDICATION NAME]. There was no response from the facility. The pharmacy also attempted to call the facility, but received no response. On 5/1/16, at 6:10 a.m., Dr. I was notified that resident # 722 was convulsing. Dr. I ordered for the resident to be sent to the hospital. Dr. I was asked if he was notified that resident # 722 had not received any [MEDICAL CONDITION] medications since admitted into the facility. He replied, No. When asked if he would have wanted to have known that information, he stated, Yes. Dr. I was also asked if he received a call notifying him of resident #722 admission. He replied, I honestly don't remember. Attempts to retrieve the hospital emergency room report for resident # 722 was unsuccessful. ( )