Every finding on record at Optalis Health and Rehabilitation of Three Rivers

This citation pertains to intake #3051796Based on observation, interview and record review, the facility failed to a safe and orderly discharge was in place for 1 of 1 resident (Resident #100) reviewed for discharge, resulting in Resident #100 being abruptly discharged from the facility without adequate outpatient services, community resources, and/or training on medical needs causing increased anxiety, agitation and emotional distress. Findings include:Resident #100: Review of an admission Record revealed Resident #100 was a female, with pertinent diagnoses which included dysphagia (difficulty swallowing), COPD (chronic obstructive pulmonary disease - lung disease that block airflow and makes breathing difficult), depression, anxiety, emphysema (progressive irreversible lung disease in which the tiny air sacs in the lungs are gradually destroyed), acquired absence of part of stomach, pressure ulcer stage 2 sacral region (between the buttocks), chronic pain, retention of urine (inability to pass urine at all), severe protein malnutrition, and cachexia (unintentional weight loss, muscle wasting, and loss of fat which cannot be reversed by eating more calories or taking nutritional supplements, losing more than 5% of your body weight in six months without trying, significant & progressive atrophy (shrinking) of muscles)Review of Order dated 6/11/26, revealed, .Home Health to follow patient at discharge, skilled nursing for wound care, medication management, PT/OT (physical therapy/occupational therapy), home health aide, DME (durable medical equipment): peg tube supplies, oxygen therapy and wheelchair.Discontinued 06/11/2026. Review of the list of discharged for the last 90 Days received on 6/26/26, revealed, Resident #100 was noted as discharged home/community with services.Received the Notice of Medicare Non-Coverage (NOMNC) for date 6/13/26, signed on 6/11/26. In an interview on 6/30/26 at 09:58 AM, Resident #100 reported she received the notice of her medical coverage ending, she would be charged daily and she would be liable for the bill. Resident #100 reported she did appeal the decision but was denied so she discharged on her last day of coverage. Resident #100 reported when she discharged from the facility she had received four bottles of tube feeding with no education or other supplies for the tube feeding. Resident #100 did not have a pump to dispense the tube feeding so she and her son just did it manually as best as they could. Resident #100 reported she had gone 13 days without oxygen and she had to contact the company to get oxygen in her home. Resident #100 reported she had a pressure ulcer on her bottom which had worsened and had caused her pain since discharge. Resident #100 reported she did not receive any supplies to take care of her pressure ulcer after she was discharged . Resident #100 reported she did not received any supplies except for the four bottles of tube feeding. Resident #100 reported no home health care aides had come in to assist her with cares and she reported had to reach out to home health services after she had been home to see about receiving cares and support for her. Resident #100 reported she received no medical equipment when she went home as well, nothing was in place for her. Tube Feeding: Review of Orders dated 6/2/26 revealed, .Enteral Feed Order every shift Enteral Nutrition Formula Name: osmolite 1.5 (calorically dense tube feeding formula that provides complete balanced nutrition for patients), Rate: 40mL per hour, flush 30ml (water) pre 4 hours Duration: continuous.Type of Tube: G tube (a medical device inserted through the abdomen directly into the stomach. It bypasses the mouth and esophagus to provide a safe, direct route for delivering nutrition, fluids, and medications), Specify Method: via pump. Review of Nutrition/Dietary Note dated 6/12/26 at 12:24 PM, revealed, .Note Text : WEIGHT WARNING: Value: 72.0 (pounds) Vital Date: 2026-06-11 11:47:00.0, -5.0% change [ 5.0% , 3.8 ] Diet: full liquid diet, Tube feed: jevity 1.5 @ml/hr x 24 hours continuous proving 960 cc total( 1440 kcals/day, 60g, 731ml) water flushes 30ml Q (every) 4 hours 180ml.Estimated needs: IBW(52kg) 1300-1560kcals/day and 52-62g, and 1300ml. She appears to be meeting protein needs at this time. RD (Registered Dietician) met with resident she reported she is very hungry and wishes to eat regular foods. RD and resident discussed tolerance. Noted she had just gotten back from therapy and was unhooked from tube feed. RD asked to adjust tube feed to meet more kcals and give rest.Noted wt (weight) appears to be down trending.She reports her appetite is improving. Rd and resident discussed supplements. She enjoys ensure clear (oral nutritional supplement designed for people on clear liquid restricted diets).RD and NP (Nurse Practitioner) discussed liquids diet restrictions and possible wt loss. It appears resident may need a GI (Gastroenterologist) referral, will adjust diet/tf (tube feeding) as needed r/t (related to) possible GI appt. If accurate wt loss is not beneficial or a part of plan. Will inquire about alternate supps. Review of Nursing -Progress Note dated 06/11/2026 at 10:44 AM, revealed, .Takes meds without difficulty via g tube. Appetite good. Continues to need assistance with ADLS (activities of daily living).Sacrum Stage 2 Pressure Ulcer:Review of Emar (Electronic Medication Administration Record) Administration Note dated 6/12/26 at 10:34 AM, revealed, .cleanse coccyx wound (pressure ulcer) with NS (normal saline), Apply medihoney (medical grade sterile honey used for advanced wound and burn care), calcium alginate (highly absorbent wound dressing) and foam dressing change every other day.everyday shift for wound.Review of Braden Evaluation dated 6/12/26 revealed, .Sensory Perception: No impairment. Moisture: Rarely moist. Activity: Bedfast. Resident is Slightly Limited: Makes frequent though slight changes in body or extremity position independently. Nutrition: Very poor. Friction and shear: Potential problem.Score of 15. (The Braden Score for Predicting Pressure Sore Risk score of 15 indicates a mild risk for developing pressure ulcers. This means the resident has a low level but present, susceptibility to skin breakdown and requires preventative interventions such as routine repositioning, skin care, and nutritional monitoring. https://nursingcecentral.com/braden-scale/)Catheter: Review of Nursing - Progress Note dated 05/28/2026 at 6:09 PM, revealed, .Resident arrived via ems from (Local Hospital).Does complain of general discomfort especially to abdomen. Peg tube in place and started osmolite via peg as ordered. Skin assessment completed. Foley catheter 16 french w (with) 10cc balloon in place (is a flexible, sterile tube passed through the urethra into the bladder to drain urine). Review of Order dated 5/29/26, revealed, .Maintain Foley Catheter and provide care every shift. Catheter Size/French: 16FR Balloon CC: 10cc. Diagnosis: every shift for Foley care. Note: There was no documentation of the catheter being removed prior to discharge. Review of Progress Notes revealed no discharge note completed by the social worker and no medical provider discharge note. Review of Care Conference assessment completed on 6/3/26, revealed no other disciplines present for the care conference, medical equipment needed rollator walker (4 wheeled walker with brakes and a seat), wheelchair, oxygen, hospital bed, (tube feeding and foley catheter supplies were not checked), UM wound nurse K completed Nursing Section: signed on 6/4/26, indicated Resident #100 did not have any wounds (had a Stage 2 Pressure Ulcer), Nutritional Interventions - not checked - is resident/family education and/or follow up needed - left blank.Review of MDS Discharge Assessment dated 6/14/26, revealed, Section GG: Toileting Hygiene: Substantial/Maximal assistance.Shower/Bathe Self: Substantial/Maximal assistance.Upper Body Dressing: Supervision or touching assistance.Lower Body Dressing: Substantial/Maximal Assistance.Putting on/taking off footwear: Dependent.Personal Hygiene: Substantial/Maximal Assistance.Section H: Indwelling catheter.resident had a catheter. Section K: Feeding Tube.Section M: Resident has a pressure ulcer.Stage 2.In an interview on 6/26/26 at 1:40 PM, Licensed Practical Nurse (LPN) M reported Resident #100 had left the faciity on a weekend as it was her last covered day and as she did not want to be responsible for a bill. LPN M reported she was unsure why Resident #100 did not qualify for additional time to remain at the facility. LPN M reported Resident #100 was new to tube feeding and she was unsure how she could manage that by herself, she had failed a swallow study so she was on a clear liquid diet only beyond the tube feeding. LPN M reported Resident #100 she was always in pain, she weighed approximately 70 pounds, she was on oxygen and she did have a wound on her bottom. In an interview on 6/30/26 at 10:13 AM, Social Worker (SW) D reported when a resident discharged , the social worker should arrange or make a referral for would obtain home health care services and any durable medical equipment (DME). SW D reported the social worker would have the appropriate departments completed their sections of the discharge summary and nursing would go over the directions with the resident prior to the resident leaving the building. SW D reported the social worker had gone on medical leave the first week of June and she had started to fill in a few days a week; 6/10/26 was her first day in the building. SW D reported the care conference would be set up for 48-72 hours following a resident's admission. During the care conference, goals were discussed on what a resident would accomplish while at the facility and at discharge and a discharge care plan would be developed to address Resident #100's goals were and what was needed to meet those goals. SW D reported the facility was responsible for ordering durable medical equipment (DME) for the resident prior to discharge. SW D reported she was unsure who at the facility was responsible for that. SW D reported that nursing and/or administration was responsible for setting up home health care services for the time being. SW D reported for a resident with tube feeding would require home health care services for monitoring and extra assistance. SW D reported it was not very good for Resident #100 if there were no services in place at discharge. Resident #100 was pretty sick and unfortunately, she did not qualify to stay. In an interview on 6/30/26 at 11:01 AM, Registered Dietician (RD) H reported the nursing department was responsible for the education on the tube feeding pump and bolus amount. The current order would be added to the discharge summary either by the RD or nursing. RD H reported the team had gone back and forth on when Resident #100 was leaving, reported she had just seen her at the end of the week, just before she discharged over the weekend.In an interview on 6/30/26 at 11:47 PM, PT Program Manager F reported typically the social worker arranged for the resident at discharge for the durable medical equipment based on the needed equipment determined by therapy. PT Program Manager F reported it was also discussed that Resident #100's need at home for PT, OT and Speech therapy. PT Program Manager (PM) F reported the building had a managed care meeting every Wednesday and they discussed every patient where they were at, how progressing, and any updates to the insurance. PM F reported Resident #100 was not progressing with physical therapy and she would not want to get out of bed. Resident #100 had 6 stairs at her home to get in, and therapy worked with her on supervised 8 steps. PM F reported she had to be supervised when going up the stairs. In an interview on 6/30/26 at 10:45 AM, Business Office Manager (BOM) I reported the NOMC was discussed and explained to Resident #100. BOM I reported management staff discussed Resident #100 had received the NOMNC and the potential for discharge during the stand down meeting, and BOM I reported Resident #100 had signed the NOMNC. BOM I reported it was discussed that Resident #100's discharge would not be a safe discharge unless there was education and training completed with Resident #100 and a capable care taker on how to manage her tube feeding and other care. BOM I reported Resident #100 completed the appeal and she had heard the appeal was denied. BOM I reported services should have been set up for her prior to her discharge. Review of Discharge Summary started on 6/1/26 revealed, no transportation set up, not documented who was the primary provider and if there were any follow up appointments, pharmacy name and contact information not completed, In home care services only PT and OT were selected, no agencies who were contacted to provide home care services were noted in the summary, indicated no medical equipment was needed at discharge when a wheelchair, tube feeding supplies, oxygen (were listed as needed) Note: no mention of foley catheter care or supplies. Dietary: Regular diet, diet texture - regular, thin liquids.Nutritional Considerations: Tube feeding was not checked.Therapy and Activities sections were not completed.Urinary Function: Continent (Resident #100 had a foley catheter) which was an option to select in this section. Skin Integrity concerns: nothing was noted. (Note: Resident #100 had a stage 2 sacral pressure ulcer).Current treatments: Oxygen.Education provided: Oxygen. Note: Tube Feeding was an option which was not selected.Indicated Medication orders were provided. Review of DC (Discharge) Medications as a scanned document revealed, Resident #100 was provided with the 6 of 10 medications listed on the printed-out order summary dated 6/14/26 at 11:49 AM. Signed by staff member (illegible)/Resident #100). It was reported Resident #100 discharged on 6/13/26. Review of the medical record does not have any documentation by nursing staff to indicate the exact date of discharge. Review of the Minimum Data Set (MDS) Discharge Assessment revealed, Resident #100 was discharged , unplanned, return not anticipated on 6/14/26. In an interview on 6/30/26 at 11:09 AM, Unit Manager (UM) E reported she had contacted 3-4 home health care agencies but a couple of them did not have nurses to care for Resident #100 due to her medical diagnoses, only home health care aides. UM E reported one of the home health care agencies did not accept her insurance. UM E reported a progress note should have been entered when she had contacted the agencies documenting the progress, as well as when Resident #100 discharged from the facility a note should have been entered. UM E reported for a resident who was new to tube feeding, education should be provided to the resident and the care giver on how to manage tube feeding needs and this would be documented in the medical record the education was received. UM E reported Resident #100 needed oxygen at discharge and she had sent information to the oxygen and oxygen equipment supplier, and she had not heard anything back from them. UM E reported the oxygen service provider called her surprisingly, requested additional documentation and UM E reported she did not realize Resident #100 had not been receiving her oxygen as they never contacted me after she had submitted the request to them on 6/13/26. UM E reported at discharge it was not documented Resident #100 received any supplies at discharge for wound care and dressings, tube feeding supplies, and foley catheter supplies. In an interview on 6/30/26 at 10:49 AM, Director of Nursing (DON) B reported checks and balances should have been in place. DON B reported the unit manager was setting up home health care and ensuring that was in place as well as the durable medical equipment (DME). DON B reported education should be provided to the resident as well as any care takers and if the education was offered and refused there should have been a progress note in the record the education was offered and declined. DON B reported a recapitulation of Resident #100's stay should have been completed, the social worker should have entered a progress note, and the discharging nurse should have entered a progress note. DON B reported the nurse on duty when Resident #100 discharged from the facility was an agency nurse. In an interview 6/30/26 at 10:52 AM, Director of Nursing (DON) B reported she had heard Resident #100 had discharged when she returned to work on the following Monday (6/15/26). DON B reported Resident #100's discharge was not smooth, and the facility should have ensured the resident had home care, supplies, and equipment she needed after discharge. DON B reported Resident #100 had appealed the issuance of a NOMNC to attempt to get her more days. DON B reported the MDS nurse and Medical Records staff worked to get the records ready to submit the documentation for the review of her appeal. DON B reported the issuance of the NOMNC and her coverage ending had placed Resident #100 at risk for the discharge. DON B reported Resident #100 did have a g tube for tube feeding and received tube feeding as well as foley catheter for urine retention. DON B reported typically during a care conference each part of the interdisciplinary team would complete their section of the discharge summary, areas such as nursing, social work, therapy, activities, and dietary.

This citation pertains to intake #3051796Based on interview and record review, the facility failed to adhere to the applicable components of the discharge summary for 1 (Resident #100) of 1 resident from the facility resulting in incomplete documentation that ensured the resident, family and outside health care providers were aware of Resident #100's medical needs. Findings include:Resident #100: Review of an admission Record revealed Resident #100 was a female, with pertinent diagnoses which included dysphagia (difficulty swallowing), COPD (chronic obstructive pulmonary disease - lung disease that block airflow and makes breathing difficult), depression, anxiety, emphysema (progressive irreversible lung disease in which the tiny air sacs in the lungs are gradually destroyed), acquired absence of part of stomach, pressure ulcer stage 2 sacral region (between the buttocks), chronic pain, retention of urine (inability to pass urine at all), severe protein malnutrition, and cachexia (unintentional weight loss, muscle wasting, and loss of fat which cannot be reversed by eating more calories or taking nutritional supplements, losing more than 5% of your body weight in six months without trying, significant & progressive atrophy (shrinking) of muscles)Review of Resident #100's Order dated 6/11/26, revealed, .Home Health to follow patient at discharge, skilled nursing for wound care, medication management, PT/OT (physical therapy/occupational therapy), home health aide, DME (durable medical equipment): peg tube supplies, oxygen therapy and wheelchair.Discontinued 06/11/2026. Review of the list of discharged for the last 90 Days received on 6/26/26 revealed, Resident #100 was noted as discharged home/community with services. In an interview on 6/20/26 at 10:31 AM, Social Worker D reported the capitulation (summary of the resident's diagnoses, orders, appointments, transfers), and the discharge note were typically completed by the social worker but in a situation like this there was not a note in eh medical record of who had spoken to community providers, a note about that should be completed in the record. Review of Resident #100's Discharge Summary started on 6/1/26 revealed, no transportation set up, not documented who was the primary provider and if there were any follow up appointments, pharmacy name and contact information not completed, In home care services only PT and OT were selected, no agencies who were contacted to provide home care services were noted in the summary, indicated no medical equipment was needed at discharge when a wheelchair, tube feeding supplies, oxygen (were listed as needed) Note: no mention of foley catheter care or supplies. Dietary: Regular diet, diet texture - regular, thin liquids.Nutritional Considerations: Tube feeding was not checked.Therapy and Activities sections were not completed.Urinary Function: Continent (Resident #100 had a foley catheter) which was an option to select in this section. Skin Integrity concerns: nothing was noted. Resident #100 had a stage 2 sacral pressure ulcer.Current treatments: Oxygen.Education provided: Oxygen. Note: Tube Feeding was an option which was not selected.Indicated Medication orders were provided. Review of DC (Discharge) Medications as a scanned document revealed, Resident #100 was provided with the 6 of 10 medications listed on the printed-out order summary dated 6/14/26 at 11:49 AM. Signed by staff member (illegible)/Resident #100). It was reported Resident #100 discharged on 6/13/26. Review of the medical record does not have any documentation by nursing staff to indicate the exact date of discharge. Review of the Minimum Data Set (MDS) Discharge Assessment revealed, Resident #100 was discharged , unplanned, return not anticipated on 6/14/26. In an interview on 6/30/26 at 11:09 AM, Unit Manager (UM) E reported she had contacted 3-4 home health care agencies but a couple of them did not have nurses to care for Resident #100 due to her medical diagnoses, only home health care aides. UM E reported one of the home health care agencies did not accept her insurance. UM E reported a progress note should have been entered when she had contacted the agencies documenting the progress, as well as when Resident #100 discharged from the facility a note should have been entered. In an interview on 6/30/26 at 10:49 AM, Director of Nursing (DON) B reported checks and balances should have been in place. DON B reported the unit manager was setting up home health care and ensuring that was in place as well as the durable medical equipment (DME). DON B reported education would be provided to the resident as well as any care takers and if the education was offered and refused there should have been a progress note in the record the education was offered and declined. DON B reported a recapitulation of Resident #100's stay should have been completed, the social worker should have entered a progress note, and the discharging nurse should have entered a progress note. DON B reported the nurse on duty when Resident #100 discharged from the facility was an agency nurse.

This citation pertains to intake #3002412Based on observation, interview, and record review, the facility failed to provide the necessary care and services to prevent, treat, and promote healing of pressure ulcers in 1 of 2 residents (Resident #106) reviewed for pressure ulcers, resulting in the lack of repositioning and implementation of care planned interventions, delayed healing of pressure ulcers for the resident, and the potential for infection and the development of new ulcers.Findings include: Resident #106: Review of an admission Record revealed Resident #106 was a female, with pertinent diagnoses which included pressure ulcer of sacral region (triangular bone at the base of the spine between lower back and tailbone), protein calorie malnutrition, sepsis (extreme life threatening response to an infection), diabetes, quadriplegia (partial or total loss of function in all four limbs and the torso), and high blood pressure. Review of Care Plan for Resident #106 dated 11/3/25 revealed the focus, .ADL (Activities of daily living) Self-care d/t (due to) impaired mobility, pain, hx (history) of wound infection, hx of neurogenic shock (spinal cord injury, severe damage to the central nervous system).hx of cervical fracture, functional quadriplegia. with the intervention .Bed mobility assist of 2. 7/16/25: Focus: alteration in skin integrity related to: impaired mobility, pain, stage 4 pressure ulcer to sacrum, right and left ischium. with the intervention .Administer treatment per physician orders.Barrier cream to peri area/buttocks as needed.Elevate heels as able.Encourage and assist as needed to turn and reposition; use assistive devices as needed.ensure green pads are available.Foam Medi boots in place to Bilateral feet, at all times, while in bed and as resident will allow.monitor Placement, functioning of low- air loss mattress and ensure settings are appropriate for the patient.Observe skin condition with ADL care daily; report abnormalities.Obtain Labs as ordered and report results to physician.Use pillows/positioning devices as needed. 10/31/24: Focus: Resident was admitted with stage 4 to left and right ischial, sacrum with risk for delayed wound healing secondary to progressing comorbidities, Debility and generalized weakness with decreased physical mobility and bowel/ bladder incontinence daily. with the intervention .Cushion to wheelchair, check placement prior to transfer.Frequent turning and repositioning.Provide wound care as ordered by physician and wound consult recommendations.Skin Evaluation weekly. Check oral cavity for redness, sores, white patches in the mouth, dried cracked lips or other manifestations reflecting oral conditions. Check skin for open areas, bruises, abrasions, DTI (deep tissue injuries), incisions. Review of Order dated 6/13/26, revealed, .Cleanse sacral area with generic wound cleanser, apply skin prep to periwound, apply medihoney, apply calcium alginate, then apply border foam to open area, change every other day and prn (as needed) every day shift.5/9/26: Paint toe wounds with Betadine and leave open to air daily, and place gauze between toes where needed. every day shift for wound care.6/13/26: Right ischial: Cleanse with generic wound cleanser, apply skin prep to periwound, apply medihoney, calcium alginate, border foam. Change every day and prn. every day shift.5/13/26: Skin Evaluation weekly. every day shift every Wed for monitoring.6/13/26: Wash left ischial with wound cleanser, pat dry, apply skin prep to peri wound, apply medihoney, apply calcium alginate, cover with border foam, change every day and prn every day shift for Pressure injury.6/18/26: Wound Cultures to butt wounds.Review of Treatment Administration Record (TAR) for May 26 revealed, missing sacral area dressing changes for 5/15/26, 5/17/26; Right ischial dressing changes for 5/15/26, 5/17/26; Left ischial dressing changes for 5/15/26, 5/17/26. Review of Treatment Administration Record (TAR) for June 26, revealed missing sacral area dressing changes on 6/1/26, 6/12/26, 6/15/26, & 6/28/26. ; Right ischial dressing changes for 6/15/26, & 6/28/26; Left ischial dressing changes for 6/1/25, 6/15/25, & 6/28/26. 3/20/26: Left Ischial Tuberosity. Issue type: Pressure ulcer / injury. Progress: Deteriorating: wound characteristics deteriorated. Stage 4. Full thickness skin and tissue loss. Length (cm): 3.99 Width (cm):2.67 Depth (cm): 0 Area (cm2): 6.85. Slough (soft, moist, yellowish or white tissue that delays healing, prevents healing tissue from growing): 50%. Eschar (thick, hard layer of dead, necrotic tissue forms over deep wounds): 50%. Exudate amount: Moderate. Seropurulent: mixture of purulent and serous, usually watery, yellow, green, tan or brown. Dressing saturation: Moderate 26-75%.3/24/26: Left Ischial Tuberosity: Pressure Ulcer/Injury: Deteriorating: wound characteristics deteriorated. Stage 4: Length (cm): 4.11 Width (cm):2.41 Depth (cm): 0 Area (cm2): 6.16.Slough: 100% .Exudate: Moderate.Seropurulent: mixture of purulent and serous, usually watery, yellow, green, tan or brown.Sacrum : Pressure Ulcer/Injury emerged. New wound. In house acquired. Length: 1.78.Width: 1.35.Depth: 0.Area: 1.26 CM.Granulation: 100% .Exudate: Light.Type: Serosanguineous: mixture of serous and sanguineous fluid, typically pale, red.Right Ischial: open area noted. 2 CM x 0.8 CM. Wound bed covered with pale green slough. Turn every 2 hours. 3/31/26:Left Ischial: Pressure ulcer, Stage 4, Length (cm): 3.5 Width (cm): 2.27 Depth (cm): 0 Area (cm2): 5.59. Granulation: 20%. Slough: 80%. Eschar: 0%. Exudate amount: Heavy. Seropurulent: mixture of purulent and serous, usually watery, yellow, green, tan or brown. Dressing appearance: Intact. Dressing saturation: Heavy > 75%.Sacrum: Pressure ulcer, Acquired in house, Length (cm): 1.39 Width (cm): 1 Depth (cm): 0 Area (cm2): 1.17. Granulation: 100%. Right gluteus: Pressure ulcer. New wound acquired in house, Length (cm): 1.77 Width (cm): 0.73 Depth (cm): 0 Area (cm2): 0.84; Exudate amount: Light. Seropurulent: mixture of purulent and serous, usually watery, yellow, green, tan or brown.4/4/26: Progress Note: Resident noted with multiple small open areas on the toes of the right foot 2,3, 5th digits and the left foot great toenail area and sole.Paint toes with betadine and leave open to air, place gauze between toes where needed daily.4/7/26:Right Gluteus pressure injury, deteriorating, acquired in house, Length (cm): 4.74 Width (cm): 1.38 Depth (cm): 0.3 Area (cm2): 4.18.Slough: 20%, Eschar: 80% .Exudate: Moderate, serosanguineous, Dressing saturation: 26-75%. 4/8/26: Wound Culture collected and sent to (laboratory). No skin assessment conducted week of 4/13/26. 4/23/26: Left Ischial: Pressure ulcer / injury. Stage 4 Pressure ulcer / injury - full thickness skin and tissue loss. Signs and symptoms of infection: Increased exudate. Length (cm): 5.12 Width (cm): 2.72 Depth (cm): 0 Area (cm2): 8.94. Odor after cleansing: Moderate. Dressing saturation: Heavy > 75%.Sacrum. Pressure ulcer / injury. Progress: Wound acquired in-house. Signs and symptoms of infection: Increased exudate. Length (cm): 2.93 Width (cm): 9.97 Depth (cm): 0 Area (cm2): 13.96. Dressing saturation: Heavy > 75%. Note: Wound worsened since last assessment. Right gluteus. Pressure ulcer / injury. Wound acquired in-house. Signs and symptoms of infection: Increased exudate. Length (cm): 5.18 Width (cm): 3.83 Depth (cm): 0 Area (cm2): 15.69. Note: [NAME] has worsened since last assessment. 4/23/26: Progress Note: .Pressure ulcer of sacral region, stage 3: Culture of wound shows proteus mirabilis-will treat for 14 days, continue with current wound dressing change. Others relevant intervention: Rocephin 1 gram IM (intramuscular) daily for 14 days.Augmentin 875 one tab twice daily for 14 days .04/26/2026: Nursing - Progress Note, revealed, .Resident continues on antibiotics for wounds to coccyx. Dressing changed as ordered. Continues to have large amount of greenish/ yellow colored drainage along with scant amount of blood from each of the wounds. Does have small amount of slough to each of the three wounds. Cleansed and new dressing reapplied.No skin assessment completed the week of 4/27/26.No skin assessment completed the week of 5/4/26.5/13/26: Left Ischial: Pressure ulcer / injury. Stage 4. Length (cm): 5.5 Width (cm): 2.85 Depth (cm): 0.2 Area (cm2): 11.1. Note: Wound worsened since last assessment. Sacrum: Pressure Ulcer / injury. Progress: Stalled: previously improving wound characteristics plateaued. Length (cm): 5.57 Width (cm): 9.46 Depth (cm): 0 Area (cm2): 36.97. Note: Wound worsened since last assessment. Right Gluteus: Pressure ulcer / injury. previously deteriorating wound characteristics plateaued. Length (cm): 4.64 Width (cm): 3.45 Depth (cm): 0.2 Area (cm2): 11.73. Granulation: 30%. Slough: 70%. Exudate amount: Moderate. Exudate type: Purulent: indication of pus, typically thick, yellow, green, tan or brown. Surrounding tissue: Maceration. Dressing saturation: Heavy > 75%. Cleansing.5/15/2026: Braden Scale for Predicting Pressure Ulcer Risk Evaluation: Moisture: Very moist. Activity: Chairfast. Resident is Very Limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. Friction and shear: Problem. Score: 14.0. (Score of 14 indicates a moderate risk for developing pressure ulcers or skin breakdown). No skin assessment completed the week of 5/18/26No skin assessment completed the week of 5/25/26No skin assessment completed the week of 6/8/26No skin assessment completed the week of 6/15/266/18/26: Collected wound cultures of butt wounds and sent to (Local Hospital) awaiting results. 6/20/26: Resident #106 .sent to emergency room due to abnormal wound cultures from butt wounds. Placed on antibiotics, Augmentin by mouth. 6/25/26: Resident #106 .continues on Augmentin for wounds to coccyx. Wounds do still have scant amount of green drainage on dressings.6/29/26: Resident #106 .got up in chair and then stated she didn't feel good. Laid back down. BP (blood pressure) dropped to 79/51 and came back up to 133/91. States feels better after laying down.No documentation of refusals of care/treatment in the progress notes during this time frame.During an observation on 06/25/26 at 2:42 PM, Resident #106 was not in her room and was not in her room until after 4:30 PM when this writer left the facility. During an observation on 06/26/26 at 10:49 AM, Resident #106 was observed seated in the dining room area participating in Bingo. Resident #106 remained up in her chair and in the dining room for lunch. During an observation and an interview on 6/26/26 at 4:40 PM, Resident #106 was observed in the dining room area with another lady sitting at the table. Resident #106 reported she had a lot of sores on her bottom, when I asked if she felt they were taking care of them she indicated she did not want to talk no more.During an observation on 6/30/26 at 1:42 PM, Resident #106 was observed in bed, the bed was high, was laying on her back. Head of the bed was approximately 45 degrees, nothing noted under her legs, and Resident #106 did not have boots on while lying in bed. Resident #106 had pillows located on her right and left sides in the bed but nothing under her four extremities. During an observation on 6/30/26 at 3:44 PM, Resident #106 was observed lying in bed positioned in the same observed earlier. No changes in interventions, no offloading and no boots while she was in bed. In an interview on 6/30/26 at 2:05 PM, Resident #106 reported she was paralyzed and couldn't feel from her abdomen area down, she can feel pressure when someone touches her but not pain. Resident #106 reported she had to rely on staff to tell her if her wounds were getting better or worse. Resident #106 did not have on her boots while she was in bed, they were located on the night stand. Observed her head of bed was approximately 60 degrees. In an interview on 6/30/26 at 9:14 AM, Certified Nursing Assistant (CNA) Z reported she was the only CNA on the hallway today. On D hallway there were 4 sometimes 5 residents who required two person assist with transfers. CNA Z reported it was hard to get things done and take care of the residents when you were the only CNA assigned to a hallway. In an interview on 6/30/26 at 9:22 AM, Scheduler Y reported she had to pull the second for D hall for a one to one, C hall staff had not showed for his shift, had to place someone on C hall. Scheduler Y reported C hall CNA was to assist the D hallway CNA. In an interview on 6/30/26 at 1:54 PM, CNA AA reported Resident #106 liked to get up for Bingo day, yesterday she was not feeling well, and she asked to lie back down, asked if she wanted to get up today and she said no. CNA AA reported she was to have a visitor today and asked again if she wanted to get up and Resident #106 reported she did not. In an interview on 6/25/26 at 3:08 PM, Licensed Practical Nurse (LPN) M reported the facility does not have a wound provider, wound nurse, and the facility nurses were the ones who provided assessment and treatment for all residents with wounds/pressure ulcers. LPN M reported when she transferred hallways Resident #106's wounds began to deteriorate due to not having a consistent nursing staff to view wounds. In an interview on 6/30/26 at 11:23 AM, Unit Manager (UM) E reported UM K was the main wound person, but she had quit. In an interview 6/30/26 at 10:52 AM, Director of Nursing (DON) B reported refusals for a dressing change should be documented in the medical record as well as no missing treatments or holes in the treatment record. DON B reported something should be documented, refused and the nurse would also need to enter a progress note. In an interview on 6/30/26 at 4:08 PM, DON B reported weekly skin assessment scheduled 1first day of the week of the resident's shower day was on, when a resident was on an antibiotic a sepsis screening was completed for monitoring as well as vitals. DON B reported for the last two weeks the facility had been completing treatments and almost have the green stuff gone, smell was down, and the wound appeared cleaner. DON B reported the wound team used to be in the facility weekly to monitor the wounds. DON B reported the facility hadn't had a wound provider for a while and it was the unit manager who was doing the weekly measurement and pictures on all the wounds. The UM who was completing the weekly measurements had left the facility as she was an agency nurse. DON B reported skin issues assessments was where the skin concerns were documented in the medical record. DON B reported since the nurse left the facility was still trying to figure out monitoring and there were some gaps in the things that needed completed. DON B reported she attempted to monitor the treatment administration record (TAR) weekly. DON B reported Resident #106 had a recent wound culture and she was placed on an antibiotic due to infection. DON B reported she informed the NHA (Nursing Home Administrator) she would begin sending out the residents with wounds as there was not a skilled wound nurse in the building if the was not a wound provider secured soon. Positioning interventions redistribute pressure and shearing force to the skin. Elevating the head of the bed to 30 degrees or less decreases the chance of pressure ulcer development from shearing forces (WOCN, 2010). Change the immobilized patient's position according to tissue tolerance, level of activity and mobility, general medical condition, overall treatment objectives, skin condition, and comfort (NPUPA, EUPAP, PPPIA, 2014). A standard turning interval of to 2 hours does not always prevent pressure ulcer development. Consider repositioning the patient at least every 2 hours if allowed by his or her overall condition. When repositioning, use positioning devices to protect bony prominences (WOCN, 2010). The WOCN guidelines (2010) recommend a 30-degree lateral position (Figure 48-15), which should prevent positioning directly over the bony prominence. To prevent shear and friction injuries, use a transfer device to lift rather than drag the patient when changing positions (see Chapter 39). [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 72244-72253). Elsevier Health Sciences. Kindle Edition.Review of Fundamentals of Nursing ([NAME] and [NAME]) 9th edition revealed, .Usually the time that a patient sits uninterrupted in a chair is limited to 1 hour. This interval is shortened in patients who are at very high risk for skin breakdown. Reposition patients frequently because uninterrupted pressure causes skin breakdown. Teach patients to shift their weight in a chair every 15 minutes .Category/Stage 4: Full thickness tissue loss: Full thickness tissue loss with exposed bone, a tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput (back of head) and malleolus (ankle) do not have (adipose/fat) subcutaneous tissue and these ulcers can be shallow. Category/Stage 4 ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable. http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/

This citation pertains to intake #3051796Based on interview and record review, the facility failed to provide medically related social services to support the physical and psychosocial health of 1 (Resident #100) of 3 residents reviewed for social services resulting in a lack of advocacy for Resident #100's rights during the discharge planning process. Findings include:Resident #100: Review of an admission Record revealed Resident #100 was a female, with pertinent diagnoses which included dysphagia (difficulty swallowing), COPD (chronic obstructive pulmonary disease - lung disease that block airflow and makes breathing difficult), depression, anxiety, emphysema (progressive irreversible lung disease in which the tiny air sacs in the lungs are gradually destroyed), acquired absence of part of stomach, pressure ulcer stage 2 sacral region (between the buttocks), chronic pain, retention of urine (inability to pass urine at all), severe protein malnutrition, and cachexia (unintentional weight loss, muscle wasting, and loss of fat which cannot be reversed by eating more calories or taking nutritional supplements, losing more than 5% of your body weight in six months without trying, significant & progressive atrophy (shrinking) of muscles)Review of Order for Resident #100 dated 6/11/26, revealed, .Home Health to follow patient at discharge, skilled nursing for wound care, medication management, PT/OT (physical therapy/occupational therapy), home health aide, DME (durable medical equipment): peg tube supplies, oxygen therapy and wheelchair.Discontinued 06/11/2026. Review of the list of discharged for the last 90 Days revealed, Resident #100 was noted as discharged home/community with services.Review of Progress Notes revealed no discharge note completed by the social worker and no medical provider discharge note. Review of Care Conference assessment completed on 6/3/26, revealed no other disciplines present for the care conference, medical equipment needed rollator walker (4 wheeled walker with brakes and a seat), wheelchair, oxygen, hospital bed, (tube feeding and foley catheter supplies were not checked), Unit Manager/Wound nurse K completed Nursing Section: signed on 6/4/26, indicated Resident #100 did not have any wounds (had a Stage 2 Pressure Ulcer), Nutritional Interventions - not checked - is resident/family education and/or follow up needed - left blank. Review of MDS Discharge Assessment for Resident #100 dated 6/14/26, revealed, Section GG: Toileting Hygiene: Substantial/Maximal assistance.Shower/Bathe Self: Substantial/Maximal assistance.Upper Body Dressing: Supervision or touching assistance.Lower Body Dressing: Substantial/Maximal Assistance.Putting on/taking off footwear: Dependent.Personal Hygiene: Substantial/Maximal Assistance. In an interview on 6/30/26 at 10:13 AM, Social Worker (SW) D reported when a resident discharged , the social worker would obtain home health care services and any durable medical equipment (DME) for the resident prior to discharge. SW D reported the social worker would have the appropriate departments completed their sections of the discharge summary and nursing would go over the directions with the resident prior to the resident leaving the building. SW D reported the social worker had gone on medical leave the first week of June and she had started to fill in a few days a week; 6/10/26 was her first day in the building. SW D reported the care conference would be set up for 48-72 hours following a resident's admission. During the care conference, goals were discussed on what a resident would accomplish while at the facility and at discharge and a discharge care plan would be developed to address Resident #100's goals were and what was needed to meet those goals. SW D reported the facility was responsible for ordering durable medical equipment (DME) for the resident prior to discharge. SW D reported she was unsure who at the facility took point on that after the social worker went on medical leave. SW D reported that nursing and/or administration should be setting up home health care services for residents prior to discharge. SW D reported for a resident who had a tube feeding, should be ensuring a home health care service provider was in place for monitoring of the resident and extra assistance when needed. SW D reported it was not very good for Resident #100 if there were no services in place at discharge. Resident #100 was pretty sick and unfortunately she did not qualify to stay. Social Worker D reported the capitulation (summary of a resident's stay at the facility and discharge), and the discharge note were typically completed by the social worker but in a situation like this anybody who had any information, who had spoken to community providers; a note should be completed in the record. Review of Discharge Summary for Resident #100 started on 6/1/26 revealed, no transportation set up, not documented who was the primary provider and if there were any follow up appointments, pharmacy name and contact information not completed, In home care services only PT and OT were selected, no agencies who were contacted to provide home care services were noted in the summary, indicated no medical equipment was needed at discharge when a wheelchair, tube feeding supplies, oxygen (were listed as needed) Note: no mention of foley catheter care or supplies. Dietary: Regular diet, diet texture - regular, thin liquids.Nutritional Considerations: Tube feeding was not checked.Therapy and Activities sections were not completed.Urinary Function: Continent (Resident #100 had a foley catheter) which was an option to select in this section. Skin Integrity concerns: nothing was noted. Resident #100 had a stage 2 sacral pressure ulcer.Current treatments: Oxygen.Education provided: Oxygen. Note: Tube Feeding was an option which was not selected.Indicated Medication orders were provided. Review of a Staff Social Services Worker job description revealed performance standards.17. Works cooperatively with member of the interdisciplinary team to develop, implements and evaluate plan of care.21. Provides information about community resources.23. Evaluates assigned residents for discharge potential. Provide discharge planning services.25. Provides individual assistance for resident at times of adjustment, crisis, or particular need.Review of policy Social Services revised on 3/10/25, revealed, .The social worker, or social service designee, tasks include but are not limited to: o Advocating for residents and helping residents understand their rights in the nursing facility.Assisting the resident in establishing a safe discharge plan with appropriate community referrals when applicable.Arranging for additional resources and referrals, which include but are not limited to: Home health care, Outpatient therapy, Palliative consult, Hospice services.Durable medical equipment.Community referrals, Adult protective services.

This citation pertains to intake #2803349.Based on interview and record review the facility failed to ensure the Director of Nursing (DON) of record worked full time defined as 40 hours a week for 3 weeks (from 3/2/2026 to 3/22/2026) resulting in the potential for unmet care needs for all residents who resided in the building during those weeks. Findings include:During an interview on 3/27/2026 at 1:08 PM, Former Maintenance Director (FMD) II stated DON B's license was used as the DON of record on 3/3/2026 but she didn't start working full time in the facility until 3/23/2026. FMD II stated that the staff reported to Agency Licensed Practical Nurse (LPN) FF during this time which didn't meet regulations since the facility staff needed to report to a Registered Nurse (RN). Upon entrance to the facility on 3/31/2026 at 8:00 AM, Corporate HR (CHR) EE reported that DON B's date of hire was 3/3/2026 but she didn't officially start full time at the facility until 3/23/2026. CHR EE said before 3/23/2026 DON B was very part time about 6 hours a week. During an interview on 3/31/2026 at 9:00 AM, RN CC stated that Agency LPN FF was the acting DON from 3/3/2026 to 3/23/2026 when DON B officially started full time. During an interview on 3/31/2026 at 9:29 AM, LPN FF stated that she couldn't act as the DON in the facility because she wasn't a RN. During an interview on 3/31/2026 at 11:55 AM, Licensed Social Worker (LSW) T stated that LPN FF was contacted after hours for concerns until DON B started in the facility full time on 3/23/2026. LSW T said that DON B came to the facility a few times for a few hours in the evening prior to 3/23/2026.During an interview on 4/1/2026 at 9:50 AM, LPN X stated that there was always a need to contact the DON regarding incidents, scheduling and urgent needs. LPN X stated that that there wasn't a DON in the building for several weeks until DON B started on 3/23/2026. In the meantime, LPN X reported that LPN FF was the contact person for clinical needs and she was only an LPN. During an interview on 4/1/2026 at 10:37 AM, RN BB stated that a DON was contacted when there was a fall, staffing issues and when guidance was needed. RN BB stated that after the previous DON (DON D) left, the only clinical person available was LPN FF so they had to contact her with concerns.During an interview on 4/1/2026 at 3:03 PM, DON B stated that staff should get a hold of the DON for falls with injury, reportable events and when there was a lock down. DON B' stated that she started coming into the facility a few nights a week for 2 weeks after she was hired but she didn't start full time until 3/23/2026. DON B reported that LPN FF and Regional Clinical Director (RCD) OO took calls during 3/3/2026 to 3/23/2026 when she started full time. DON B said that LPN FF was the contact person for falls right now since she was new. During another interview on 4/1/2026 at 3:22 PM, LPN FF stated that DON B came in the evenings for several weeks before she started full time on 3/23/2026. LPN FF stated staff went to her for clinical needs until 3/23/2026 but she (LPN FF) had access to RCD OO if needed. During an interview on 4/2/2026 at 9:08 AM, LPN V stated that LPN FF was telling family members that she was the interim DON until DON B started and there was a paper she posted that said to contact her for clinical needs. Review of the document provided to staff on 3/3/2026 that was hanging on Human Resources door revealed For any clinical on call needs please call (LPN FF) at (phone number deleted). On 4/1/2026 at 4:20 PM, Human Resources (HR) R provided this surveyor with DON B's timesheet. HR R stated that DON B's date of hire was 3/3/2026. DON B's timesheet revealed that during the week of 3/2/2026 to 3/8/2026 she worked a total of 6.5 hours. The week of 3/9/2026 to 3/15/2026 she worked a total of 6.63 hours. The week of 3/16/2026 to 3/22/2026 she did not work at all. During an interview on 4/2/2026 at 9:53 AM, Nursing Home Administrator (NHA) A stated that DON B' came to facility at night and during the day since her date of hire. NHA A reported that LPN FF couldn't be the interim DON because she was an LPN. When discussing the lack of a full time DON in the facility for the 3 weeks prior to DON B's official start date on 3/23/2026, NHA nodded when it was clear DON B did not work 40 hours a week.

This citation pertains to intake #2732469.Based on interview and record review, the facility failed to maintain complete and accurate medical records for bowel and bladder in 1 resident (Resident #1) of 3 residents reviewed for ADLs (Activities of Daily Living) resulting in incomplete information in the medical record and not knowing if a resident received appropriate care.Findings include: Resident #1(R1)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R1's initial admission date to the facility was on 6/26/2025 with pertinent diagnoses including Alzheimer's Disease (neurological disorder characterized by memory loss, cognitive decline and brain shrinkage), depression and severe protein calorie malnutrition (deficiency of protein, carbohydrates and fats leading to severe wasting, weight loss and edema). Brief Interview for Mental Status (BIMS) reflected a score of 2 out of 15 which indicated R1 was severely cognitively impaired. R1started Hospice care on 1/24/2026 and discharged from the facility on 2/18/2026. During an interview on 3/27/2026 at 2:26 PM, R1's Family Member (FM) GG stated that R1 was dependent on care and needed help with his ADLs such as using the bathroom and sometimes she wasn't sure he was being helped when she wasn't there.Review of R1's care plan revealed . Focus: ADL self-care deficit related to Alzheimer's dementia.Date initiated 6/26/2025. Interventions/Tasks: Toileting x 2 person with sit to stand mechanical lift. Date initiated 6/27/2025.Review of Section GG Evaluation Assessment for ADL status for R1 completed on 1/29/2026 revealed . Self-Care. 3. Toileting the ability to maintain perineal (region between the anus and genital organs) hygiene, adjust clothes before and after voiding or having a bowel movement. Dependent.Review of the Documentation Survey Report for Bladder Elimination for R1 revealed the following documentation of whether R1 was continent (able to control the bladder for retention or release) or not and whether he voided (passed urine): December: 42 times of documentation out of 93 opportunities; January: 36 times of documentation out of 93 opportunities; February: 19 times of documentation out of 53 opportunities. Review of the Documentation Survey Report for Bowel Elimination for R1 revealed the following documentation of whether R1 was continent (able to control bowels for retention or release) or not, had no bowel movement, size of his bowel movement and consistency of the bowel movement: December: 43 times of documentation out of 93 opportunities; January: 34 times of documentation out of 93 opportunities; February: 20 times of documentation out of 53 opportunities. During an interview on 4/2/2026 at 1:40 PM, Director of Nursing (DON) B reported she was aware of the holes in documentation.

This citation pertains to intake #2736915.Based on interview and record review, the facility failed to honor resident preferences regarding heating/reheating his favorite foods brought in by family in 1 (Resident #1) of 3 residents reviewed for resident rights resulting in feelings of frustration, not being able to enjoy his favorite foods and potentially causing further weight loss. Findings include: Resident #1(R1)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R1's initial admission date to the facility was on 6/26/2025 with pertinent diagnoses including Alzheimer's Disease (neurological disorder characterized by memory loss, cognitive decline and brain shrinkage), depression and severe protein calorie malnutrition (deficiency of protein, carbohydrates and fats leading to severe wasting, weight loss and edema). Brief Interview for Mental Status (BIMS) reflected a score of 2 out of 15 which indicated R1 was severely cognitively impaired. R1started Hospice care on 1/24/2026 and discharged from the facility on 2/18/2026.During an interview on 3/27/2026 at 2:26 PM, Family Member (FM) GG stated that the previous Nursing Home Administrator (NHA) C told her and her family to only bring shelf stable foods for R1 and told her to not bring food that had to be heated/reheated unless they did it themselves when they were there. FM GG said that NHA C said that she didn't trust the facility staff to heat and serve his meals. FM GG reported that this caused frustration since she couldn't bring R1's favorite foods in unless she was there to serve it to him and she was worried since he had weight loss. During an interview on 4/1/2026 at 11:07 PM, Registered Dietitian (RD) JJ stated R1 had a slow decline for months and had weight loss where she was working with the family to get R1's favorite foods on meal trays and nutritional supplements to prevent further weight loss. RD KK said that NHA C had a heating/reheating food issue and the family struggled with it. RD JJ said that the family was told to only bring food that was shelf stable or food that could be refrigerated and nothing that had to be heated up. During an interview on 4/1/2026 at 1:04 PM, Certified Nursing Assistant (CNA) K stated that staff have been told that they cannot heat/reheat resident foods. CNA K said they can only make popcorn in the breakroom for residents. CNA K stated I don't know why we can't take food to the kitchen and have them warm up it up. During an interview on 4/1/2026 at 1:40 PM, Corporate RD (CRD) KK stated that she wasn't sure what the facility policy said regarding heating/reheating food but outside food wasn't allowed in the kitchen. CRD KK said that family or facility staff can reheat food in the break room.During an interview on 4/2/2026 at 12:10 PM, NHA A and Agency Licensed Practical Nurse (LPN) FF stated that they were unaware of the heating/reheating food issue with R1. NHA A said residents should be able to heat foods up and enjoy it and facility staff should take it to the kitchen and have them take the temperature to make sure it is safe for them to consume. LPN FF said that there was a sign in the breakroom that said staff can only use the microwave to make popcorn for residents and they can't heat food up since there wasn't a thermometer there. When discussing the Outside Food Policy and the contradiction of what staff was told, NHA A said he would have to follow up on the issue. Review of the Outside Food Policy with an approval date of 10/2/2023 revealed . Guidelines: The facility will accommodate resident need to store food from the outside and reheat food safely. Reheating foods from the outside Foods from the outside can never be reheated using the main kitchen. Facilities may offer microwaves for reheating on the unit. Residents must ask a facility employee to reheat their food. Employees should never allow the resident to reheat themselves. Family members may have access to the microwave. Safe reheating methods shall be posted in each microwave area. Facilities shall provide temperature monitoring in each microwave area

Based on observation, interview, and record review, the facility failed to revise a fall care plan for 2 residents (Resident #2, Resident #3) of 3 residents reviewed for fall care plan revision resulting in the potential for inaccurate care interventions that could potentially cause further falls. Findings include: Resident #2 (R2)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R2's pertinent diagnoses included history of falling, muscle weakness, left femur fracture (thighbone fracture) and cervical vertebrae fracture (neck fracture). Brief Interview for Mental Status (BIMS) reflected a score of 13 out of 15 which indicated R2 was cognitively intact.During an interview on 3/31/2026 at 2:12 PM, R2 stated that he had a neck fracture before he came to the facility and then he was set to go home from the facility and he had another fracture when he was out at a restaurant with friends. R2 said he had a few falls at the facility too. Review of the fall report dated 2/9/2026 revealed .Incident Description: Patient was observed on the floor. Resident indicated he was trying to transfer to bed.Pt (patient) noncompliant with asking for assistance to transfer from wheelchair to bed.Was notified of patient fall, patient states he was trying to get himself to bed independently. No apparent injury.Review of the progress note dated 2/11/2026 revealed IDT (Interdisciplinary Team) met to review residents recent fall without injury. Wide bed in place already and resident continues to fall out of bed. Resident continues to be non-compliant with fall interventions despite education. BIMS 13 indicating that resident is cognitively intact and able to retain education. Resident has been witnessed frequently sleeping in bed with his legs dangling off the side of the bed and will potentially benefit from extra support such as an enabler bar. Enabler bar (bed assist bar designed to help individuals with limited mobility get in and out of bed safely) ordered for immediate intervention.Review of R2's Care Plan revealed .Focus: At risk for falls secondary to hx (history) of falling with fracture, unsteadiness, pain, potential side effects from medications, poor safety awareness. Resident will refuse to follow fall risk precautions.recent fall outside of facility.Interventions/Tasks: Enabler bar to bed. Date initiated 2/11/2026.Review of R2's Kardex (resident information that Certified Nursing Assistants have access to) revealed Safety: .enabler bar to bed.Review of R2's orders revealed that there were no orders for the enabler bar.During an observation on 4/1/2026 at 2:48 PM, it was noted that R2's bed did not have enabler bars.Review of R2's progress note dated 3/15/2026 revealed At 1125 CNA (Certified Nursing Assistant) alerted me to the resident (R2) being on the floor. I went in the room and observed resident on the floor face down with his head against the bathroom door. He was alert and told me he hit his head. I asked him how he ended up like that, and he stated, I do not know. Previous to the fall he was alert but drowsy. He kept falling asleep in his wheelchair, and stated he did not sleep well the night before. he has a large hematoma (collection of clotted blood trapped in tissue) on his upper R (right) forehead with another raised contusion (bruise) above it in his scalp. Pt pupils are sluggish and won't constrict fully (concerning as he is on opiates (pain medication) and would expect pinpoint pupils(small constricted pupils)). Pt has upward right gaze and delayed responses. Called (Doctor) Notified Pt son.called report to (hospital name omittied) at 1200. EMS (Emergency Medical Services) arrived and transported Pt via stretcher at 1215.There was no fall report for the fall on 3/15/2026 with new interventions added after the fall. During an interview on 4/1/2026 at 3:39 PM, Agency Licensed Practical Nurse (LPN) FF stated after R2's fall on 2/9/2026, enabler bars were added as an intervention to the fall. LPN FF clarified that enabler bars were in R2's care plan. During an observation on 4/1/2026 at 3:55 PM, LPN FF and this surveyor went to R2's room and she agreed that R2 did not have enabler bars on his bed. LPN FF said she wasn't sure why he didn't have enabler bars but she said, I'm going to put a maintenance request in right now. During an interview on 4/1/2026 at 4:19 PM, LPN FF stated that there wasn't a fall report completed for R2's fall on 3/15/2026 since it was an agency nurse that completed the progress note in the chart and the agency nurse didn't call her about the fall so they could put interventions in place. LPN FF said the agency nurse is not allowed to come back to the building. LPN FF stated that R2 ended up being sent out to the hospital for the fall and when he came back IDT did not discuss the fall or interventions. Resident #3 (R3 )Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R3's initial admission date to the facility was on 11/29/2023 with pertinent diagnoses including depression, anxiety and hemiplegia and hemiparesis following cerebral infarction (weakness and paralysis to one side after a stroke). Brief Interview for Mental Status (BIMS) reflected a score of 9 out of 15 which indicated R3's cognition was moderately impaired. During an interview on 3/31/2026 at 2:01 PM, R3 stated that he had a recent fall where he slid out of bed and he didn't remember what the intervention was. Review of R3's progress note dated 3/9/2026 revealed . Resident was observed sitting on the floor in his room. Resident was sitting with his back against the bed. Resident was assessed for any injuries and ROM (range of motion) was intact. Vital signs were obtained. Resident was assisted off of the floor by staff and assisted into his bed.Review of R3's fall report dated 3/9/2026 did not have any new interventions regarding the fall. Review of R3's Care Plan revealed Focus: (R3) is at risk for falls due to BKA (below knee amputation), hemiplegia, hemiparesis due to hx (history) of CVA (cerebrovascular accident), pain, potential medication side effects, impulsivity, poor vision. There were no new interventions listed from the fall on 3/9/2026. During an interview on 4/1/2026 at 3:48 PM, LPN FF stated on 3/9/2026 R3 fell out of bed reaching for his urinal. LPN FF said that they discussed several interventions in IDT but didn't get an intervention in the care plan and didn't have a progress note regarding the discussion. LPN FF stated that they discuss falls in morning meeting with IDT and they make sure interventions are put in place and care plans were updated. Review of the Fall Management Guidelines Policy with a revised date of 2/3/2026 revealed . Care Planning:.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. Post Fall Evaluation: Complete an incident report in risk management.Attempt to determine the root cause of the event and initiate modifications in the resident's care plan as indicated.IDT review: The interdisciplinary team will review the resident's current care plan and interventions to ensure that the interventions are appropriate and the resident's post fall intervention(s) correlate to the root cause of the fall in an attempt to prevent future falls.Review of the Care Plan-Comprehensive and Revision Policy with a review date of 2/2/2026 revealed . General Guidelines.care plans are revised as information about the residents and the residents' condition change. The interdisciplinary team reviews and updates the care plan.

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety, resulting in the increased potential of food borne illness among all residents that consume food from the kitchen.Findings include: During the initial kitchen tour with Dietary Manager (DM) HH on 12/01/2025 at 8:59 AM, the following items were found:In the walk-in refrigerator: A big bag of spring mix salad mix that was wilted with some brown lettuce pieces and a best by date of 11/20/2025.In the kitchen area: On the counter, a big plastic clear container of thickener that had caked on thickener on the outside of the container with no label and date. In the reach in refrigerator: 3 side salads in small bowls on a tray which were not covered individually and had parchment paper lying on top of it and was dated 11/29/2025. At 8:55 AM on 12/2/25, a follow up tour of the kitchen started. At 9:04 AM on 12/2/25, an interview with Dietary Manager (DM) HH found that most food products are dated for a three-day discard or staff follow their datemarking sheet. At 9:10 AM on 12/2/25, observation of the walk-in cooler found a large plastic bag with a piece of chunk ham dated 11/24 to 11/30. Further observation of the walk-in cooler found a container with six bags of whipped topping with no date to indicate discard. A review of the manufacturers' directions for the whipped topping stated they are good for two weeks under refrigeration. When asked how long the whipped topping had been in the refrigeration unit, DM HH was unsure. At 9:52 AM on 12/2/25, observation of the Nourishment room refrigeration unit found an open juice container with a best by date of 10/2/25. According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY 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 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED 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, based on the temperature and time combinations specified in (A) of this section 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 . According to the 2022 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) . At 9:11 AM on 12/2/25, observation of the walk-in cooler back right storage rack was found with an increased accumulation of debris on portions of the rack and open wires shelves. At 9:37 AM on 12/2/25, observation of the kitchen ice scoop holder found a small amount of stagnant water in the bottom of the holder with an accumulation of crusted brown and white debris. An interview with DM HH found that the ice scoop holder should be cleaned. At 9:53 AM on 12/2/25, observation of the ice machine in the Nourishment room found a heavy accumulation of white crusted debris under and inside the dispense portion of the ice machine. When asked who cleans the ice machine, DM HH stated that Maintenance and Housekeeping share the responsibility. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

Based on interview and record review, the facility failed to ensure the Medical Director was a meaningful participant during QAPI (Quality Assurance and Performance Improvement) meetings, resulting in the potential for lack of coordination of resident care policies and overall medical care that could affect all 82 residents residing in the facility. Findings include: In an interview on 12/03/2025 at 1:31 PM, Nursing Home Administrator (NHA) A reported that the facility had three different Medical Directors (MD) in the past 6 months. The current MD (MD LL) had been in place since the middle of September 2025. NHA A reported that MD LL is only in the facility on Wednesdays and did not attend the QAPI meeting on Tuesday, 9/30/25. NHA A reported that MD LL was not present for the most recent QAPI meeting on Friday 10/31/25 because he was not in the facility, but that he had reviewed the meeting minutes, therefore he signed the attendance sheet. In an interview on 12/03/2025 at 2:42 PM, MD LL reported that he could not remember if he had attended a QAPI meeting at the facility and cannot recall when he became the MD for the facility.

Based on observation, interview, and record review, the facility failed to maintain a safe, clean, homelike environment in 3 of 4 residents (Resident #19, #39, & #69) reviewed for environmental concerns, and maintain cleanliness of storage closets containing resident supplies, resulting in the potential for resident dissatisfaction, injury, and respiratory complications due to dust buildup. Findings include:Resident #19 Review of an admission Record revealed Resident #19 was a male, with pertinent diagnoses which included obstructive lung disease, heart failure, a seizure disorder, gastroparesis (a chronic condition where the stomach empties too slowly due to damaged nerves or muscles), gastrostomy status (an opening in the stomach where a feeding tube is inserted), history of traumatic brain injury, and presence of a tracheostomy (an opening in the neck to the trachea through which a tube is inserted to provide an airway). Review of a Minimum Data Set (MDS) assessment for Resident #19, with a reference date of 9/20/25, revealed he had severe cognitive impairment. Review of a current Care Plan for Resident #19 revealed the focus .The resident has altered respiratory status/difficulty breathing (related to) tracheostomy, COPD (obstructive lung disease) . initiated 5/21/24. In an observation on 12/1/25 at 9:57 AM, Resident #19 was in bed in his room with his eyes closed. Noted a small, black personal fan on the windowsill beside Resident #19's bed with visible dust buildup on the surface of the fan guard. Noted multiple spots of a dried brown substance on the base of Resident #19's tube feeding pole. Observed bits of trash and debris on the floor under Resident #19's bed, and a large amount of drywall dust/debris below the head of Resident #19's bed along the edge of the wall. In an observation on 12/2/25 at 1:51 PM, Resident #19 was in bed in his room. Noted a small, black personal fan on the windowsill beside Resident #19's bed with visible dust buildup on the surface of the fan guard. Noted multiple spots of a dried brown substance on the base of Resident #19's tube feeding pole. Observed bits of trash and debris on the floor under Resident #19's bed, and a large amount of drywall dust/debris below the head of Resident #19's bed along the edge of the wall. In an interview on 12/2/25 at 1:55 PM, Housekeeper Q reported once per week the resident beds are pulled away from the wall, and the floors are cleaned below the beds/along the edges of the wall. Housekeeper Q reported personal fans are cleaned it they are .full of stuff . but not on a regular basis. Resident #39 Review of an admission Record revealed Resident #39 was a male, with pertinent diagnoses which included diabetes with retinopathy (disease of the retina) and macular edema (thickening/swelling on or under the macula of the eye), depression, heart failure, and high blood pressure. Review of a Minimum Data Set (MDS) assessment for Resident #39, with a reference date of 9/12/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated he was cognitively intact. In an observation and interview on 12/1/25 at 2:04 PM, Resident #39 was in bed in his room. Noted a small, black personal fan on Resident #39's tray table with visible dust buildup on the surface of the fan guard. Resident #39 reported he had a visual impairment. Review of the policy/procedure Routine Cleaning and Disinfection, dated 8/2022, revealed .It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible .Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms, and at the time of discharge .Routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces and high touch areas .Horizontal surfaces with infrequent hand contact (window sills and hard surface flooring) in routine resident-care areas should be cleaned .on a regular basis .When soiling and spills occur . Resident #69: Review of an admission Record revealed Resident #69 was a male with pertinent diagnoses which included major depressive disorder, anxiety, drug induced dyskinesia (involuntary movement disorder caused by antipsychotics use), diabetes, malnutrition, and muscle loss. During an observation on 12/01/2025 at 1:10 PM, Resident #69 was lying in his bed the headboard of the bed was broken on the left side. During an observation on 12/02/2025 at 2:05 PM, observed Resident #69's headboard of his bed was unattached to the bed frame and was observed to be hanging down on the left side of his bed. Observed a wide metal rod at the bottom of the headboard which Resident #69 could harm himself on. In an interview on 12/2/25 at 2:39 PM, Maintenance Director (MD) Z reported the broken headboard for Resident #69 had not been entered into the maintenance order system. MD Z reported he was not aware the headboard was not attached to the bed. MD Z reported if there was a work order that needed to be done, the staff were to enter it into the electronic maintenance order system so he would be aware and could address. At the time, MD Z placed Resident #69's headboard back in place. On 12/2/25 at 10:57 AM, a tour of A hall found three storage closets with accumulations of debris and trash on the floor. One of the closets was found with boxes of gloves, packages of briefs, and feminine hygiene products, all stored on the floor. On 12/2/25 at 11:02 AM, a tour of D hall found two closets at the end of the hall, used for storing linens and clean nursing supplies, that were observed with accumulations of dust and dirt on the floor. Further review found one of the closets had three packages of briefs stored on the floor. On 12/2/25 at 11:06 AM, a tour of C hall found two closets at the end of the hall, used for storing linens and clean nursing supplies, that were observed with accumulations of dust, dirt, and used gloves on the floor. On 12/2/25 at 1:00 PM, a tour of the facility was started with Maintenance Z and Housekeeping Manager P. During the tour the following was noted: A review of the B hall closets at the end of the hall found briefs stored on the floor of one of the closets. A review of the closets at the end of C hall found dust and used gloves on the floor. An interview with Housekeeping Manager P found that she will have staff better attend to these areas.

Based on interview and record review, the facility failed to address and resolve grievances reported in Resident Council Meetings as stated during a confidential Resident Council meeting resulting in unresolved concerns, unmet resident needs and frustration. Findings include:During a confidential Resident Council meeting on 12/02/2025 at 10:34 AM, 6 of 12 residents stated that management didn't follow up on concerns that they brought up in Resident Council meetings and individual concerns that came from the meetings.One resident stated that she didn't hear anything back about her grievances, so she doesn't fill them out anymore.Three residents stated that management did not resolve all of the grievances, only parts of it so they don't get a resolution on everything. One resident stated Nothing becomes of what you write in the concern form. They don't care. It's like talking to the wind.10 of 12 residents stated that food tickets were not read correctly and as a result aren't being followed. The residents said this had been a concern for several months. Review of the Resident Council meeting minutes dated 6/19/2025, 7/17/2025, 8/20/2025, 9/11/2025, 10/17/2025 and 11/13/2025 revealed that there was nothing written under old business, however concerns regarding water pass and reading food tickets correctly were discussed all 6 months. Resident Response forms were only filled out on 8/20/2025, 9/11/2025, 10/17/2025 and 11/13/2025 and the concerns from those months did not address all of the concerns from Resident Council. During an interview on 12/02/2025 at 11:34 AM, Activities Director (AD) R stated that she did not attend resident council meetings. AD R said that the Resident Council President (Resident #14) took the meeting minutes and then she reviews the minutes and concerns with Nursing Home Administrator (NHA) A. AD R stated that NHA A signed the minutes and gave the specific concerns to the department heads to follow up and resolve the grievances. AD R said that she was aware that some of the same issues come up month after month in Resident Council.During an interview on 12/02/2025 at 11:39 AM, Resident #14 stated that she filled out the minutes from the Resident Council monthly meetings and then she goes through the minutes with NHA A. Resident #14 reported that she usually skipped over old business in the meetings because then they would rehash everything from the previous month and nothing was resolved anyways. During an interview on 12/02/2025 at 1:51 PM Dietary Manager (DM) HH stated he was aware of the concerns from Resident Council month after month regarding the food tickets and wasn't sure how to resolve the issue. During an interview on 12/02/2025 at 2:30 PM, NHA A who was also the Grievance Officer stated that Resident #14 brought the monthly minutes to her and they would discuss them and then she (NHA A) gave the concerns to the assigned department head to resolve. NHA A stated she was aware of the ongoing concerns from Resident Council and said it was hard to follow up with some of the concerns. Review of the Concern (Grievance) Process Policy with a revision date of 5/31/2024 revealed .General Guidelines:. Concerns, grievances, recommendations stemming from resident or family group council concerning issues of resident care in the facility will be documented. Actions on such issues will be responded to at or before the next resident or family group meeting. The administrator is the Grievance Officer of the facility. The Grievance Officer is responsible for overseeing the concern (grievance) process which includes receiving and tracking concerns through to their conclusion, maintaining the confidentiality of information associated with grievances, and issuing written grievance decisions to the resident upon their request. The staff member receiving the concern form will review the nature and specifics of the grievance on the concerned form. Take immediate actions needed to prevent further potential violations of the residents rights. Upon receiving, the Grievance Officer will review the concern form and take steps to resolve the concern and document information about the concern, actions taken, and resolution on the concern form. Steps to resolve the concern may involve signing the concern form for investigation and/or follow up to the appropriate department manager or staff member. Any staff involved in the concern investigation or resolution will make prompt efforts to resolve their concern and return the concern form to the Grievance Officer. Prompt efforts include acknowledgement of the concern, actively working toward a resolution of the concern, and keeping the resident appropriately apprised of progress towards resolution. The designated staff member will investigate the concern, follow up with the resident and/or person filing the concern/grievance for any additional information needed, progress with investigation of the concern/grievance and resolution of the concern/grievance. The designated staff member will make every effort to resolve the concern/grievance within 5 to 10 business days and complete the concern form to submit to the Grievance Officer. The designated staff member will review the findings and actions taken with the Grievance Officer. The Grievance Officer will review the concern form to determine if additional actions need to be taken and if the concern has been resolved. The Grievance Officer will notify the complainant to determine if they are satisfied with the resolution, and document the information on the concern form.

Based on interview, and record review, the facility failed to obtain informed consent for psychotropic medications for 2 (Resident #69, #7) out of 5 residents reviewed for psychotropic medications. This deficient practice resulted in the lack of communication/education to the resident/resident representatives for initiation and/or dose changes of psychotropic medications.Findings include:Resident #69: Review of an admission Record revealed Resident #69 was a male with pertinent diagnoses which included major depressive disorder, anxiety, high cholesterol, drug induced dyskinesia (involuntary movement disorder caused by antipsychotics use), diabetes, malnutrition, and paranoid schizophrenia (persistent delusions and hallucinations due to a chronic brain disorder that affects how a person thinks, feels, and behaves, leading to distorted perceptions of reality). Review of Care Plan for Resident #69 revealed the focus, .(Resident #69) is at risk for adverse effects r/t (related to) antipsychotic medications. with the intervention .AIMS (Abnormal Involuntary Movement Scale-assess for dyskinesia) testing.Monitor for signs of tremors.Antipsychotic medications - Monitor for possible side effects.Monitor/document report any side effects/adverse reactions of psychotropic medication.Monitor resident mood state and behavior.Review of Orders dated 1/16/25, revealed, .Invega Sustenna Intramuscular Suspension Prefilled Syringe 234 MG/1.5ML (Paliperidone Palmitate) Inject 234 mg intramuscularly (IM) one time a day starting on the 16th and ending on the 16th every month for schizophrenia. Noted: No consent in the medical record for this medication. Review of Orders dated 2/18/25, revealed, .Invega Sustenna Intramuscular Suspension Prefilled Syringe 234 MG/1.5ML (Paliperidone Palmitate) Inject 234 mg intramuscularly one time a day starting on the 18th and ending on the 18th every month for Schizophrenia. Noted: No consent in the medical record for this medication. Review of Order dated 5/10/25, revealed, .Haldol Decanoate Intramuscular Solution 50 MG/ML (Haloperidol Decanoate) Inject 0.5 ml intramuscularly one time a day every 4 weeks on Sat for Schizophrenia. Noted: No consent in the medical record for this medication. Review of Order dated 6/7/25, revealed, .Haldol Injection Solution (Haloperidol Lactate) Inject 50 mg intramuscularly one time a day every 30 day(s) for behaviors. Noted: No consent in the medical record for this medication. Review of Order dated 5/29/25, revealed, .chlorproMAZINE HCl Oral Tablet 25 MG (Chlorpromazine HCl) Give 1 tablet by mouth three times a day for schizophrenia. Noted: No consent in the medical record for this medication.Review of Nursing -Progress Notes dated 6/4/2025 at 2:07 PM, revealed, .New orders per (Medical Doctor) to start Haldol 50mg injections once a month for behaviors. Dc' d Ingrezza (used to treat involuntary movement disorder). Review of eMAR -Administration Note dated 6/17/2025 at 12:01 PM, revealed, .chlorproMAZINE HCl Oral Tablet (an antipsychotic, brand name Thorazine) 25 MG, Give 1 tablet by mouth three times a day for schizophrenia. Noted: No consent in the medical record for this medication.Review of eMAR - Administration Note dated 7/19/2025, revealed, .Invega Sustenna Intramuscular Suspension Prefilled Syringe 234 MG/1.5ML Inject 234 mg intramuscularly every day shift starting on the 19th and ending on the 19th every month for schizophrenia. Noted: No consent in the medical record for this medication. Review of Orders dated 9/15/25, revealed, .Invega Sustenna Intramuscular Suspension Prefilled Syringe 234 MG/1.5ML (Paliperidone Palmitate) Inject 234 mg intramuscularly every day shift starting on the 28th and ending on the 28th every month for schizophrenia.Started on 9/28/25. Review of Psychotropic Medication Consent dated 12/1/25, revealed, .Invega Sustenna Intramuscular Suspension Prefilled Syringe 234 MG/1.5ML, 234 mg, intramuscularly, every day shift starting on the 28th and ending on the 28th every month. Noted: The consent was not completed in the correct time frame following the order. Review of Behavior Note dated 10/11/2025 at 1:30 PM, .Resident came up to desk very agitated. Mumbling. Jumped up out of chair and started getting loud. Telling this nurse he wants a shot of penicillin, and he wants it now. This nurse explained those orders have to come from the doctor and the medicine has to come from pharmacy. He said you're a liar. I explained that is the procedure. Resident leaned over the counter with hands raised at this nurse and started at this nurse and didn't move for ten minutes. Multiple times staff tried to redirect resident, and he wasn't leaving desk. Kept raising hands at this nurse and stating you're a liar. Explained this nurse would call doctor and let him know. He insisted the shot was in the med cart. Resident eventually got in his w/c (wheelchair) and went to room. On call Np (Nurse Practitioner) ordered one time dose of Ativan (Lorazepam) IM. Pulled from (System for Extra Medications). Administered in left buttock. Noted: No documentation attempt was made to contact Guardian prior to administration. Review of Psychotropic Medication Consent dated 10/18/25, revealed, .LORazepam Injection Solution 2 MG/ML, 2 mg, intramuscularly (IM), one time only.Review of Treatment Administration Record for October 25, revealed, .LORazepam Injection Solution 2 MG/ML (Lorazepam), Inject 2 mg intramuscularly one time only for agitation for 1 Day.Administered on 10/11/25. Noted: No consent in the medical record for this medication. Resident #7: Review of an admission Record revealed Resident #7 was a male with pertinent diagnoses which included contracture of muscle, left ankle and foot, contracture of muscle, right ankle and foot, anxiety disorder, muscle loss, stroke, severe obesity with low oxygen levels due to failure to breath deep enough, and Parkinson's disease.Review of Care Plan for Resident #7 revealed the focus, .At risk for adverse effects r/t (related to) use of antidepression medication, Use of antipsychotic medication.Resident has hx (history) of drug induced subacute dyskinesia (serious condition which causes involuntary movements like lip smacking, grimacing, fidgeting). with the intervention .AIMS testing.Antidepressants - Monitor for possible side effects.Antipsychotic Medications - Monitor for possible side effects.Evaluate effectiveness and side effects of medications for possible decrease/elimination of psychotropic drugs.Monitor for signs of tremor.Monitor resident's mental status functioning on an ongoing basis. Review of AIMS Assessment dated 9/30/25, revealed, .AIMS score of 4 with moderate extremity movements in upper extremities, minimal extremity movements in lower extremities, and patient awareness of abnormal movements without distress.Review of Psychotropic Medication Consent dated 8/11/25, revealed, .Vraylar Oral Capsule 4.5 mg, 1 capsule, by mouth, one time per day.Quetiapine Fumarate 50 mg, 2 tablets, by mouth, Give 2 tablet by mouth one time a day for hallucinations. Noted: This consent did not indicate if the resident representative consented to the change of the medications. Review of Orders dated 10/30/25 revealed, .Quetiapine Fumarate 50 mg one tablet, by mouth, one time per day at bedtime. Noted: No consent completed for the change in this medication. Review of Psychotropic Medication Consent dated 11/7/25, revealed, .Risperdal Oral tablet 0.5 mg, 1 tablet, by mouth, two times a day.Review of Psychotropic Medication Consent dated 11/3/25 revealed, .Risperdal Oral tablet 0.5 mg, 1 tablet, by mouth, two times a day.Risperdal, Oral tablet 0.5 mg, 0.5 tablet, by mouth, two times a day.Seroquel Oral Tablet 50 mg, 1 tablet, by mouth, at bedtime.1. Psychotropic medication education was completed on the indication for use, benefits, risks to include all black box warnings and have had the opportunity to discuss and ask any questions. They:a. Consent voluntarily to all the above listed psychotropic medications treatments without coercion or undue influence and understand that consent can be revoked at any time. (not selected)b. Consent voluntarily to all the above listed psychotropic medications treatments without coercion or undue influence, with the exemption of medication(s) listed below and understand that consent can be revoked at any time. (not selected)c. Do not consent to the above listed psychotropic medications and understands that, as a result of their refusal to consent they absolve the facility and its employees and contractors from any liability or responsibility for anything that might happen to the resident as a result of this refusal. This refusal to consent also may make it necessary to transfer the resident to another healthcare facility as a result of their psychiatric condition. Noted: This change in medications was not consented to and there was no signature for completion. In an interview on 12/02/2025 at 2:47 PM, Social Worker (SW) GG reported she had a difficult time maintaining contact with Resident #69's guardian who wanted to communicate via email only. SW GG reported she would obtain a consent from the guardian/resident representative, or resident prior to administration of psychotropic medications. SW GG reported there was a gap of time there were no consents completed for the changes in medications and dosage changes for medications. SW GG reported the interdisciplinary team (IDT) discuss residents behaviors and medication changes daily during the morning meeting. SW GG reported the IDT reviewed the behavior monitoring and alert chart activity as well as upcoming gradual dose reductions (GDR)s. This writer requested all consents for psychotropic medications for Resident #69 and Resident #7 for the previous 12 months and did not receive consents for all medications ordered. This writer received no additional consents prior to exit from the facility. Review of policy, Psychotropic Medication Use revised on 4/18/25, revealed, .It is the policy of the facility to only prescribe psychotropic medications when it is necessary to treat a specific diagnosed condition, and the medication is deemed as beneficial to the resident. The facility will identify when a resident is prescribed a psychotropic medication and will obtain informed consent from the resident or authorized representative for each psychotropic medication ordered.The resident and/or authorized representative will be educated on the risks versus benefits of psychotropic medication and informed consent obtained (see Informed Consent section below).Informed Consent: For any resident taking a psychotropic medication, the Social Service employee or designee will obtain informed consent from the resident and/or authorized representative using the Psychotropic Medication Consent UDA in the resident's electronic medical record, (psychotropic medication consents prior to the release of the UDA may be on paper in the resident's medical record) .The Social Service employee, or designee, will review the medication prescribed, dosage, side effects, and risks versus benefits of the medication, which are outlined on the psychotropic informed consent evaluation. The Social Service employee, or designee, will discuss any Black Box Warnings associated with the psychotropic prescribed to the resident or authorized presentative so that they are aware of the potential risks .After review, the resident and/or authorized representative will either consent or refuse the psychotropic medication .The consent or refusal of the psychotropic medication may be obtained in person or verbally via a telephone conversation.If the resident and/or authorized representative refuses to consent to the psychotropic medication, the physician/medical practitioner will be notified so that the medication can be discontinued. The resident and/or authorized representative may receive a copy of the informed consent, if requested .

Based on observation, interview, and record review, the facility failed to administer oxygen therapy and provide respiratory care per physician order and professional standards of practice in 1 of 1 resident (Resident #19) reviewed for respiratory care, resulting in the potential for decreased oxygen levels and respiratory complications.Findings include:Resident #19 Review of an admission Record revealed Resident #19 was a male, with pertinent diagnoses which included obstructive lung disease, heart failure, a seizure disorder, history of traumatic brain injury, and presence of a tracheostomy (an opening in the neck to the trachea through which a tube is inserted to provide an airway). Review of a Minimum Data Set (MDS) assessment for Resident #19, with a reference date of 9/20/25, revealed he had severe cognitive impairment, utilized oxygen therapy, and required tracheostomy care. Review of a current Care Plan for Resident #19 revealed the focus .The resident has altered respiratory status/difficulty breathing (related to) tracheostomy, COPD (obstructive lung disease) . initiated 5/21/24. Review of a current Care Plan for Resident #19 revealed the focus .The resident has oxygen therapy r/t (related to) Ineffective gas exchange . with interventions which included .OXYGEN SETTINGS: Oxygen Delivery via Trach (Tracheostomy) Mask Liter flow: 7L (Liters) Duration: continuous At 30% humidification . initiated 5/21/24. Review of an Order Summary Report for Resident #19 revealed the physician order .Change Oxygen Tubing (i.e. Nasal cannulas, oxygen masks), filters and humidification bottle every week and PRN (as needed). every evening shift every (Sunday) for tubing change . with a start date of 8/31/25. Review of an Order Summary Report for Resident #19 revealed the physician order .Oxygen Delivery via Trach Mask Liter flow: 7L Duration: continuous At 30% humidification every shift for breathing . with a start date of 8/29/25. In an observation on 12/1/25 at 9:57 AM, Resident #19 was noted in bed in his room with his eyes closed. Observed Resident #19 had a tracheostomy, with oxygen delivered via a tracheostomy mask. Noted Resident #19's oxygen concentrator was set at 6 liters/minute. Noted the humidifier bottle was empty (no sterile water in the container and no bubbles observed) with no date noted on the bottle. Noted the tubing connected to the oxygen concentrator was dated 11/23/25. Review of the November 2025 Treatment Administration Record (TAR) for Resident #19 revealed the physician order .Change Oxygen Tubing (i.e. Nasal cannulas, oxygen masks), filters and humidification bottle every week and PRN. every evening shift every (Sunday) for tubing change . had missed documentation (no initials) for the scheduled change on 11/30/25. In an observation on 12/2/25 at 1:51 PM, Resident #19 was noted in bed in his room. Observed Resident #19 had a tracheostomy, with oxygen delivered via a tracheostomy mask. Noted Resident #19's oxygen concentrator was set at 6 liters/minute. Observed the humidifier bottle had recently been changed and was dated 12/1/25 with visible sterile water within the bottle (bubbles observed). Noted the tubing connected to the oxygen concentrator was dated 11/23/25. In an observation and interview on 12/2/25 at 2:04 PM, Agency Registered Nurse (RN) KK entered Resident #19's room and checked the settings on his oxygen concentrator. Agency RN KK verified the concentrator was set to 6 liters/minute. Observed Agency RN KK check Resident #19's oxygen saturation, which was at 90% (normal range 95%-100%). In an observation and interview on 12/2/25 at 2:24 PM, Director of Nursing (DON) B entered Resident #19's room and checked the settings on his oxygen concentrator. DON B verified the concentrator was set to 6 liters/minute, reported it should be set to 7 liters/minute based on the physician order, and adjusted the oxygen concentrator to 7 liters/minute. Review of the policy/procedure Oxygen Administration, dated 5/7/24, revealed .Oxygen is a crucial therapy used to maintain adequate tissue oxygenation while minimizing cardiopulmonary work .Oxygen shall be administered using a physician's order unless there is an emergent need .PROCEDURE .Verify physician's order .Turn the equipment on to the desired/ordered liter flow .If utilizing a humidifier reservoir, bubbles should be seen inside the bottle .

Based on observation, interview and record review, the facility failed to ensure indwelling catheter care was completed, monitored urinary output, ensured securement device positioning, and the urinary drainage bag was not resting on the floor for 1 (Resident #70) of 1 resident reviewed for indwelling catheter care, resulting in the potential of a urinary tract infection. Findings include: Review of [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 68514-68515). Elsevier Health Sciences. Kindle Edition, revealed .Securing indwelling catheters reduces risk of urethral trauma, urethral erosion, CAUTI (Catheter-Associated Urinary Tract Infection), or accidental removal .A CAUTI (Catheter associated urinary tract infection), or a UTI (urinary tract infection) associated with a catheter, is common if you have an indwelling catheter inside your urethra.Symptoms are similar to a general UTI and include bloody or cloudy urine, gritty particles or mucus in your urine, urine with a strong odor, pain in your lower back, chills and fever. (https://www.healthline.com/health/sediment-in-urine) Resident #70: Review of an admission Record revealed Resident #70 was a male with pertinent diagnoses which included urinary catheter. Review of Care Plan dated 10/2/5 revealed the focus, .Use of indwelling urinary catheter needed due to obstructive uropathy . with the intervention .Administer medication per physician orders .Catheter Care .Maintain drainage bag below bladder level .Per (name omitted) Urology: Change catheter and catheter bag monthly .Report any changes in amount and color, or odor of urine .Secure catheter with securement device .Change urinary catheter securement device q (every) week every day shift every Sun for Urinary Catheter care .Maintain Foley Catheter and provide care every shift every shift for Foley care .Suprapubic, Foley or condom Catheter Output Amount every 8 hours . Review of Order dated 10/5/25, revealed .Change urinary catheter securement device q (every) week every day shift every Sun for Urinary Catheter care .Maintain Foley Catheter and provide care every shift every shift for Foley care .Suprapubic, Foley or condom Catheter Output every 8 hours . In an interview on 12/03/2025 at 2:04 PM, Assistant Director of Nursing/Infection Preventionist (ADON/IFP) D reported the facility did not have an order to regularly schedule the catheter change, it was done if the resident had a possible UTI and then ordered by the provider at that time the entire system would be changed out. It would also be a scheduled order when an order to change it within a period of time was received by urology. Review of Treatment Administration Record (TAR) for Resident #70 for September 2025, revealed, .Maintain Foley Catheter and provide care every shift. Catheter Size/French: 16 Balloon CC: 10.Diagnosis: BPH (benign prostatic hyperplasia-impaired urinary elimination related to obstruction) .every shift for Foley care.12 Hr. *Missed opportunities on 9/14, 9/19.Suprapubic, Foley or condom Catheter Output Amount, every 6 hours.0000 (12:00 AM), 0600 (6:00 AM) .1200 (12:00 PM) .1800 (6:00 PM) . *Missed opportunities on 9/11 at 1800, 9/14 at 1200, 9/16 at 1800, 9/18 at 1800, 9/20 at 0000, 9/20 at 1800, 9/21 at 1800. Review of Treatment Administration Record (TAR) for Resident #70 for October 2025, revealed, .Suprapubic, Foley or condom Catheter Output Amount, every 8 hours.0600 (6:00 AM).1400 (2:00 PM).2200 (10:00 PM). *Missed opportunities on 10/13 at 2200, 10/23 at 2200, 10/26 at 1400 .Maintain Foley Catheter and provide care every shift, every shift for Foley care.12 Hr. *Missed opportunities 10/23, 10/26 .Change urinary catheter securement device q (every) week every day shift every Sun for Urinary Catheter care.7 AM. *Missed opportunities on 10/19. Review of Treatment Administration Record (TAR) for Resident #70 for November 2025, revealed, .Maintain Foley Catheter and provide care every shift, every shift for Foley care.12 Hr. *Missed opportunities on 11/12, 11/16, 11/30 .Suprapubic, Foley or condom Catheter Output Amount, every 8 hours.0600 (6:00 AM).1400 (2:00 PM).2200 (10:00 PM). *Missed opportunities on 11/9 1400, 11/11 1400 & 2200, 11/12 1400, 11/22 1400, 11/26 1400, 11/20 0600 & 1400. During an observation on 12/01/2025 at 3:05 PM, Resident #70 was lying in his room in bed. Catheter bag was hanging from the side of his bed, the urine was a dark orange color and the urinary bag was 2/3rds full. During an observation on 12/03/2025 9:26 AM, Resident #70 was observed being assisted to the dining room and his catheter bag was hanging under the wheelchair seat, and the bag was touching the floor and was being contaminated by dirt, debris, and bacteria on the floor. In an interview on 12/03/2025 at 10:12 AM Resident #70 reported he had pain due to the securement device did not always stays in place and it pulls on his penis and caused him pain. Resident #70 when the catheter tubing would get clogged up he had pain and that usually happened every 3 months, and he would have a urinary tract infection (UTI). Resident #70's catheter bag was secured under the wheelchair seat, and it was touching the floor and was being contaminated with dirt, debris, and bacteria on the floor. During an observation on 12/03/2025 1:33 PM Resident #70's was seated in his wheelchair eating his lunch and the catheter bag was under the seat of his wheelchair and the catheter bag was touching the floor of his room. In an interview on 12/03/2025 at 1:58 PM, ADON/IFP D reported foley care would need to be done as if it was not done it would increase the risk of infection, urinary tract infections (UTI) and because Resident #70 does have a catheter, the catheter should not be dragging on the floor as it leads to contamination and increased risk of UTIs. ADON/IFP D reported the facility would monitor the output of the catheter to determine whether the kidneys were functioning the kidney, would also observe the urine to determine if there was concern for infection as well as the smell of the urine. Review of policy, Catheter Care dated 8/24/23, revealed, .It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use .Catheter care will be performed every shift and as needed by nursing personnel .Empty drainage bag when it is half to three-fourths full and as needed .

Based on observation, interview and record review the facility failed to ensure residents received care by qualified persons in 1 of 5 residents (Resident #13) reviewed for psychotropic medications, when nursing staff completed Resident #13's Psychotropic Medication Review for GDR (Gradual Dose Reduction) assessment without involvement from the physician or nurse practitioner, resulting in an incomplete GDR assessment for Resident #13.Findings include: According to the facility's policy Psychotropic Medication Use dated 1/10/24 revealed, .Residents who use psychotropic medications will receive gradual dose reductions, unless clinically contraindicated, in efforts to discontinue the medication when appropriate.For any resident who is receiving a psychotropic medication to treat a disorder other that expressions of indications of distress related to dementia (examples include, schizophrenia, bipolar mania, depression with psychotic features, or another medical condition other than dementia, which may cause psychosis), the GDR may be considered clinically contraindicated for reasons that include, but are not limited to: 1. The continued use is in accordance with relevant current standards of practice and the physician has documented the clinical rationale. or the resident's target symptoms returned or worsened after the most recent attempt at a GDR within the facility and the physician has documented the clinical rationale for why any additional attempted dose reduction at the time would be likely to impair the resident's function or exacerbate an underlying medical or psychiatric disorder.Review of an admission Record revealed Resident #13 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: bipolar disorder (depression with extreme highs and lows), anxiety, and PTSD (post-traumatic stress disorder). Review of Resident #13's Care Plan revealed, At risk for adverse effects of psych (psychotropic) medications: Pt (patient) takes antianxiety medication, antipsychotic, and antidepressant medication and mood stabilizer. Date initiated: 5/29/25.In an interview on 12/03/2025 at 2:08 PM, Social Services Coordinator (SSC) GG reported that Resident #13 did not participate in services from behavioral health services, and that SSC GG along with the physician and DON (Director of Nursing) B should be managing the resident's behavioral needs and his psychotropic medications. SSC GG reported that Resident #13 had a Psychotropic Medication Review for GDR on 8/28/25 that was completed by the regional social worker that was in place prior to SSC GG being hired, and then another assessment was documented as completed on 11/29/25 by LPN (Licensed Practical Nurse) G. SSC GG reported that it was odd that the assessment was checked as completed, but there was no indication that the physician or DON was involved in the assessment, and to her knowledge it was not appropriate for a nurse to perform the assessment. SSC GG reported that she was present in the facility and could have completed the assessment the next business day but was not aware.Review of Resident #13's Psychotropic Medication Review for GDR dated 11/29/25 by LPN G revealed, .Medication Class: 1. Antipsychotics: Seroquel 50 mg BID (twice daily), GDR not attempted do to: target symptoms have not been sufficiently relieved by non-pharmacological interventions. The continued use of the current medication regimen is within current standards of practice.Diagnosis or indication for use: bipolar disorder. 2. Antianxiety: Klonopin 0.5 mg TID (three times a day), GDR not attempted, Diagnosis or indication for use: Anxiety and PTSD. 3. Antidepressant: Prozac 40 mg daily, GDR not attempted. Trazadone 50 mg daily, GDR not attempted, Diagnosis or indication for use: Bipolar Disorder and PTSD. 4. Other: Atarax (an antihistamine used to treat anxiety) 25 mg q8hr (every 8 hours) PRN (as needed), GDR not attempted. Depakote (antiseizure medication), GDR not attempted. Diagnosis or indication for use: Anxiety, Depression, Hallucinations, PTSD.An attempt was made to contact LPN G on 12/3/25 at 3:00PM, with no return phone call.In an interview on 12/03/2025 at 3:03 PM, DON B reported that floor nurses were not supposed to complete Psychotropic Medication Review for GDR assessments, and she was not aware that LPN G had documented Resident #13's assessment on 11/29/25. DON B reported that the assessment would need to be completed again with the physician and SSC GG's involvement.

Based on observation, interview and record review, the facility failed to develop a person-centered care plan related to contact precautions for 1 resident (Resident #53) of 18 reviewed for person centered care plans resulting in the potential for unmet care needs of the resident.Findings include:Resident #53 (R53)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R53 admitted to the facility on [DATE] with pertinent diagnoses including depression, anxiety and Clostridium Difficile (C-diff, a bacterium that causes diarrhea and potentially life-threatening inflammation of the colon). Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R53 was cognitively intact (13 to 15 cognitively intact).During an observation on 12/01/2025 at 9:53 AM, there was a contact precautions sign posted outside R53's door. During an interview on 12/01/2025 at 9:56 AM, R53 stated that he had C-diff 4 separate times and had it before he was admitted to the facility. R53 said that this was a recurrent issue and he was seeing a gastroenterologist (doctor who specializes in diagnosing and treating disorders of the digestive system) this month. R53 also stated that staff had to wear gown and gloves when taking care of him due to the C-diff. Review of R53's physician order revealed .Contact Precautions for pending C-diff culture, every shift, active, revised 10/23/2025. Review of R53's chart revealed that there wasn't a care plan focus for contact precautions. During an interview on 12/02/2025 at 12:17 PM, Assistant Director of Nursing who was also the Infection Preventionist (IP) D stated that when a resident was under contact precautions, an order was put in the resident's chart and a care plan was developed specifically for contact precautions. When discussing R53's care plan, IP D said that he should have a care plan for contact precautions. During another interview on 12/02/2025 at 12:36 PM, IP D verified that there wasn't a care plan for R53 related to contact precautions. IP D said that the care plan for contact precautions should have been reactivated last month when R53 started having diarrhea again. Review of the Care Plan-Comprehensive and Revision Policy with a revision date of 8/25/2023 revealed .General Guidelines:.The comprehensive, person-centered care plan: includes measurable objectives and timeframes.reflects currently recognized standards of practice for problem areas and conditions.

Based on observation, interview, and record review, the facility failed to ensure appropriate bariatric bed and assistive devices were available for use to promote independence for 1 resident (Resident #7) of 1 resident reviewed for accommodation of needs, resulting in the development of a stage 3 pressure ulcer. Findings include: Resident #7: Review of an admission Record revealed Resident #7 was a male with pertinent diagnoses which included contracture of muscle, left ankle and foot, contracture of muscle, right ankle and foot, anxiety disorder, muscle loss, stroke, severe obesity with low oxygen levels due to failure to breath deep enough, pressure ulcer stage 3, and Parkinson's disease. Review of Care Plan for Resident #7 initiated on 5/14/24, revealed the focus, .The resident has potential impairment to skin integrity r/t (related to) impaired mobility, obesity, and diabetes . with the intervention .The resident needs pressure relieving/reducing mattress to protect the skin while in bed .Turn/Reposition resident regularly to relieve pressure points .Use a draw sheet or lifting device to move resident . Review of Minimum Data Set (MDS) Section GG dated 11/19/25, revealed, .Lower body - impairment both sides .Mobility: Roll left & right - Dependent .Sit to Lying - Dependent .Lower body dressing - Dependent .Shower - Dependent .Personal Hygiene - Dependent .Sit to Stand - Dependent . In an interview and observation on 12/01/2025 at 11:02 AM, this writer observed Resident #7 lying supine, no wedges, no pillows under his left or right pelvic area. Resident #7 was right on the edge of the bed on his left side and had approximately 6 inches on his right side. Resident #7 reported he was unable to move his right leg, noted foot drop, and he was able to bend his left leg at the knee and move his leg side to side with the leg folded out knee outward. Resident #7 reported he did not feel comfortable lying on his side as he did not have much mobility with his legs and he had no assist bars or abdominal strength to hold himself on his side. Resident #7 reported also doesn't like to lay on his side as he felt like he was going to fall out of the bed, so he preferred to lay on his back. Resident #7's head of bed was approximately 30 degrees and reported he used the trapeze over his bed to help hold himself when staff were providing care or to move himself up in his bed some. In an interview on 12/03/2025 at 8:34 AM, Certified Nursing Assistant (CNA) O reported Resident #7 will scoot down in his bed and then he would have to be repositioned as his knees and legs hurt due to the angle. CNA O reported Resident #7 had indicated to her when she had been providing care to him previously, he was fearful of falling or rolling out of bed especially because he was quite large in his middle section. CNA O reported when care was provided to him there needed to be two staff members due to his size, dependence on staff, lack of mobility and strength. Review of Resident #7's height of 66.04 inches and last weight of 322.6 pounds on 11/2/25, revealed a Body Mass Index (/BMI) of 52.1 approximately.In an interview on 12/02/2025 at 2:35 PM, Maintenance Director (MD) Z reported he was informed by the nursing staff on which size bed to install for a resident. MD Z reported Resident #7 has a 42-inch bed, a standard size bed was 36-inches. MD Z reported Resident #7 would have to be moved to a larger room for a larger bed due to his dependence during care and the use of a hoyer machine for transfers as there would not be enough space in the room for maneuvering the hoyer. In an interview on 12/2/25 at 3:30 PM, Director of Nursing (DON) B reported when considering the size and type of bed a resident would require, the facility would look at the person as a whole to determine the size of the bed. This writer and DON B went to Resident #7's room to speak to him. Resident #7 reported he did not feel comfortable lying on his side as he was fearful of falling out of bed. Resident #7 indicated to DON B he wanted a bigger bed as he was unable to lie on his side due to the size of bed and his size. Review of Bariatric Hospital Bed Size received on 10/3/25, revealed, .Bariatric hospital beds are heavy-duty beds designed for people who need extra support these beds have a higher weight capacity and wider bed width to ensure comfort and safety: 42 to 54 inches wide; 80 to 84 inches long ; and Adjustable height.How to choose the right size bed: Choosing the right hospital bed depends on several factors, all of which contribute to the patient's needs and the caregiver's ease of access .User's size: One of the most important factors in selecting the right bed size is the patient's height and weight.A person with a BMI over 45 will likely be more comfortable in a wider bed to ensure they have enough room to reposition comfortably.Type of Care Needed: Depending on the mobility and needs of the patient, a larger bed may be better for turning, repositioning, and aiding the individual comfortably. Extra width may also be helpful if a caregiver or physical therapist will be treating the individual from the bed. In an interview on 12/3/25 at 10:42 AM, Physical Therapy Aide (PTA) JJ reported she had been working with Resident #7 and he had reported he felt like he was going to fall out of the bed and she had to a certified nursing assistant (CNA) come and assist with repositioning Resident #7 more towards the middle of his bed as he was close to the edge of the bed. PTA JJ reported bed rails/assist bars would be beneficial for Resident #7 as that would allow him to utilize them to off load from his bottom and provide some pressure relief. PTA JJ reported Resident #7 had a trapeze above his bed which he used but expressed concern with the use causing shearing to his bottom as it was used to pull him up in the bed and not able to lift off the bed, especially due to his strength and weight. PTA JJ reported he was able to do more activities when he was first admitted to the facility but has since had decline due to a Parkinson's diagnosis as well his weight was probably a factor as well. PTA JJ reported she felt the use of bed rails/assist bars would also contribute to his abdominal muscles and arm strength as well as mobility while in bed, which she hoped would then allow the resident to feel more comfortable in a wheelchair and not feel like he would slide out of the chair and be able to sit up longer out of the bed which would help improve the pressure ulcer he currently had.

Based on observation, interview and record review the facility failed to ensure residents medication was not left at bedside in 1 of 4 residents (Resident #69) reviewed for medication administration, when licensed nursing staff failed to ensure that Resident #69's medications were administered as ordered and per facility policy. Findings include:Resident #69: Review of an admission Record revealed Resident #69 was a male with pertinent diagnoses which included major depressive disorder, anxiety, high cholesterol, drug induced dyskinesia (involuntary movement disorder caused by antipsychotics use), diabetes, malnutrition, and paranoid schizophrenia (persistent delusions and hallucinations due to a chronic brain disorder that affects how a person thinks, feels, and behaves, leading to distorted perceptions of reality). During an observation on 12/02/2025 at 2:08 PM, This writer observed a medication cup on the resident's tray table with an unidentified pill in the cup which was a reddish-brown color and had a stamp on the pill. Noted: The medication cup and pill were not on the tray table on 12/1/25 when this writer observed Resident #69. Review of Resident #69's medical record revealed no order or completed assessment for the resident to self-administer medications. In an interview on 12/02/2025 at 2:10 PM, Licensed Practical Nurse (LPN) F reported the tablet was a stool softener and he was prescribed two of those pills for administration on an as needed basis. LPN F reviewed the medical record, and she wondered if he had asked for the medication last night, reported he must not have taken the second one and left it in his room on the tray table. LPN F reported the medication should absolutely not be left in the room as well as the nurse was to watch the resident take the medication. LPN F disposed of the medication in the trash on the medication cart. Review of Order dated 10/5/24, revealed, .Senna Oral Tablet 8.6 MG (Sennosides) Give 2 tablet by mouth every 24 hours as needed (PRN) for Constipation PRN at bedtime. In an interview on 12/03/2025 at 8:50 AM, LPN F reported if a resident was to administer medications there would be a safety box with key in the room. LPN F reported in order for a resident to be able to self-administer medications the resident had to be able to recite the side effects of the medication. LPN F reported Resident #69 has asked for the Haldol and Thorazine as he had taken those medications prior with good results, so the nurse practitioner prescribed those medications. LPN F reported the nurse who had given Resident #69 the medication found in the trash should have watched the resident take the medication because being thrown in the trash opened up the ability of other residents to have access to the medication. In an interview on 12/03/2025 at 2:41 PM, Director of Nursing (DON) B reported if a medication was offered to a resident and it was refused, the nurse was to waste the medication and note the resident refused the medication on the medication administration record. DON B reported if it was a controlled substance, then two nurses would need to sign off for the wasting.Review of policy, Medication Administration issued on 8/7/23, revealed, .Procedure: Administer Medication: Remain with resident until administration of medication is complete.Report and document an adverse effects or refusals. Review of policy, Medication Administration Guidelines - Destruction of Medications effective 3/1/2028, revealed, .Tablets, capsules, and liquids are washed down the toilet or hopper sink or disposed of in another manner by authorized licensed personnel as per facility policy.Controlled substances are retained in a secondary locked area with restricted access until destroyed according to Destruction of Controlled Substances.

Based on observation, interview, and record review, the facility failed to promote dignity in 2 of 4 residents (Resident #48, #69) reviewed for dignity/respect, resulting in long wait times for assistance, feelings of frustration, and dissatisfaction with care. Findings include:Resident #48 Review of an admission Record revealed Resident #48 was a female, with pertinent diagnoses which included peripheral vascular disease, high blood pressure, atrial fibrillation (an irregular heart rhythm that results in poor blood flow), heart failure, irritable bowel syndrome (a chronic disorder causing symptoms such as abdominal cramping, gas, and changes in bowel habits), and neuromuscular dysfunction of the bladder (occurs when nerve damage interferes with the bladder's ability to store and release urine properly). Review of a Minimum Data Set (MDS) assessment for Resident #48, with a reference date of 11/17/25, revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total score of 15, which indicated moderate cognitive impairment. In an interview on 12/1/25 at 10:22 AM, Resident #48 reported she often experienced long wait times for assistance when needing to use the restroom, especially around mealtimes. In an observation on 12/2/25 at 9:36 AM, Resident #48 was noted in her bed in her room. Observed Resident #48 call out to a Certified Nursing Assistant (CNA) in the hallway that she needed to use the restroom urgently, stating she had been waiting for assistance for 45 minutes. Noted Resident #48's call light was not activated at this time. The CNA acknowledged Resident #48's request, stating she would be back to assist her when she was done providing care to another resident. In an observation on 12/2/25 at 9:45 AM, Resident #48 again called out from her room for toileting assistance. Noted Resident #48's call light was not activated at this time. Observed Admissions Coordinator FF respond to Resident #48 and notify the resident that she would find someone to help. Noted Resident #48 appeared frustrated and upset. In an observation on 12/2/25 at 9:50 AM, observed two CNAs enter Resident #48's room to provide toileting assistance. In an interview on 12/2/25 at 11:43 AM, Resident #48 reported she turned her call light on after breakfast (between 9:00 AM and 9:15 AM) and Agency Registered Nurse (RN) KK turned the call light off and told her the CNA was aware of her request and would be coming to assist her shortly. Resident #48 state by the time staff came to assist her (at 9:50 AM) she was .very uncomfortable . and reported having to wait a long time for assistance is frustrating. In an interview on 12/2/25 at 4:36 PM, Agency RN KK reported after breakfast, she was passing medications on the hall when Resident #48 turned her call light on. Agency RN KK reported she responded to the call light and Resident #48 reported she needed to use the bedpan. Agency RN KK reported she relayed the message to the CNA and then deactivated Resident #48's call light. Agency RN KK reported Resident #48 expressed a concern that staff would forget about her request for assistance without the call light activated. In an interview on 12/3/25 at 1:06 PM, Administrator A reported activated call lights should not be turned off (deactivated) until the resident's need is met. Review of the policy/procedure Call Light Accessibility and Timely Response, dated 8/16/23, revealed .Staff members who see or hear an activated call light are responsible for responding, regardless of assignment. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified .Turn off call light when resident's request is met . Review of the policy/procedure Dignity, dated 9/21/23, revealed .It is the policy of this facility that each resident will be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth, and self-esteem .Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents, for example .promptly responding to a resident's request for assistance . Resident #69: Review of an admission Record revealed Resident #69 was a male with pertinent diagnoses which included major depressive disorder, anxiety, drug induced dyskinesia (involuntary movement disorder caused by antipsychotics use), diabetes, malnutrition, and muscle loss. During an observation on 12/01/2025 at 1:10 PM, Resident #69 was lying in his bed the headboard of the bed was broken off. A urinal, which appeared 3/4 full, was hung on the side of the trash basin by his bed which was soiled around the rim and seams. Resident #69's hair was matted, knotted and uncombed. No hair care products appropriate for a person of African American decent were visible in the resident's assigned area. During an observation on 12/02/2025 at 2:05 PM, observed Resident #69's urinal hanging on the side of his trash bin next to his nightstand and it was soiled with dried dark urine around the rim and in the grooves and seams. In an interview on 12/02/2025 at 2:08 PM, Certified Nursing Assistant (CNA) W reported the urinal would get replaced when it was getting bad with dried urine, dirtiness. CNA W reported the urinal was cleaned using water in the resident's sink and then dumped into the toilet. CNA W reported she did not think the facility had a pick (a styling tool with long, slender teeth designed to for curly hair) for African American type hair or any special hair care products. In an interview on 12/3/25 at 12:07 PM, Central Supply reported the facility did order hair picks, but they did not currently have any in the building.

This citation pertains to intake #2641096.Based on observation, interview, and record review, the facility failed to ensure adequate supervision to prevent resident to resident abuse for 1 resident (Resident #1) of 3 residents reviewed for abuse, resulting in Resident #2 who had a history of delusions, hallucinations and aggression, pushed Resident #1. Resident #1 fell and sustained a closed left femoral neck (hip bone) fracture and subsequent surgical intervention. Findings include: Review of the Facility Report Incident (FRI) initial report to the State Agency on 10/11/2025 revealed {Licensed Practical Nurse (LPN) M} notified the Administrator that at approximately 11:30 AM resident (Resident #1) was observed on the floor near the doorway of resident (Resident #2's) room. Upon assessment, (Resident #1) reported pain in her left hip, accompanied by impaired range of motion. resident was transported to the emergency room for further evaluation. Statements: (LPN M): LPN M reported that during her interview with (Resident #2), he verbalized that he pushed the female resident (Resident #1) because she was entering his room and he did not want her in there. (LPN M) also stated that (Resident #1) told her, That man pushed me.Resident #1 (R1)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R1's initial admission date to the facility was on 10/16/2024 with pertinent diagnoses including dementia (decline in mental abilities such as memory, thinking and reasoning that is severe enough to interfere with daily life) and depression. Brief Interview for Mental Status (BIMS) reflected a score of 4 out of 15 which indicated R1 was severely cognitively impaired (00 to 07 is severe cognitive impairment). R1 was transferred to the hospital on [DATE] and returned to the facility on [DATE] with a closed left femoral neck fracture that required surgical intervention.Review of R1's hospital records dated 10/11/2025 revealed .Summary: (R1) is a 78 y.o. female with PMHx (past medical history) of dementia who presented to the ED (emergency department) from SNF (Skilled Nursing Facility) after an unwitnessed ground level fall in the hallway. She was reportedly pushed by another resident after she walked into the wrong room. Unknown how long she was down. Patient is on Hospice but she and daughter, her DPOA (durable power of attorney), agrees to revoke Hospice for surgery with plan to go back on Hospice after. Patient denies any pain currently. ED Course: X-ray of the left hip showed a left femoral neck fx (fracture) with possibility of a superior pubic rami fx (fracture) . Orthopedic surgery was consulted.asked to admit.Review of R1's Discharge GG Evaluation dated 10/11/2025 revealed that R1 was independent with transfers prior to discharge to the hospital.During a phone interview on 10/20/2025 at 12:09 AM, Family Member (FM) E stated that R1 wandered around the facility independently since admission and could do ADLs (Activities of Daily Living) independently with some encouragement by staff prior to the incident.During a phone interview on 10/20/2025 at 11:53 AM, LPN M stated that she did not witness the incident on 10/11/2025. She said she was at the nurses' station and R1 was at the nurses' station and shortly after that CNA N came to her and said R1 was on the floor outside of R2's door, LPN M stated that R1 said that man pushed me (referring to R2). LPN M reported that since R1 came back from hospital, that she (R1) needs assistance with ADLs and walking where she was independent prior to the incident only needing guidance for the order of doing certain tasks such as pulling up her pants after using the bathroom. During an interview and observation on 10/20/2025 at 8:42 AM, R1 was lying in bed and said she needed to use the bathroom. She appeared confused and wasn't sure if she needed staff to help her use the bathroom. R1 did not remember the incident, how she got the fracture, or that a resident pushed her.Review of R1's admission Evaluation dated 10/16/2024 revealed .VII. Elopement.2. Mental Status: disoriented, wanders aimlessly. 3. Mobility: is independent with locomotion with or without an assisted device including a wheelchair.6. Wandering/exit seeking: behaviors redirectable .Review of R1's Behavior log from 7/1/2025 to 10/21/2025 revealed there were 12 days of documented behaviors related to wandering out of 112 days reviewed and with the question Has the resident exhibited this behavior before? yes was documented. Review of R1's care plan for behavior revealed At risk for changes in behavior and mood related to depression, anxiety, dementia, history of CVA (cardiovascular accident), cognitive communication deficit. Date initiated: 10/6/2025. interventions/tasks.encourage resident to attend activities of choice, date initiated 10/20/2025, evaluate for physical needs: hunger, thirst, positioning, toileting, pain, cold/warm, etc , date initiated 10/20/2025. May attempt distraction interventions: music, activities, relaxation techniques, positioning, etc., date initiated 10/6/2025, non-pharmacological interventions: invite to activities and talk with resident about cooking, jewelry making, animals (dogs/cats), watching tv (all kinds), music (country), date initiated 10/20/2025.targeted behaviors: sadness, anxiousness, may wander down the hallways, may wander near/in resident rooms, date initiated 10/20/2025 .Review of R1's care plan for dementia revealed The resident has impaired cognitive function or impaired thought processes r/t (related to) dementia. Date initiated 8/11/2025. interventions/ tasks.cue, reorient and supervise as needed. provide a program of activities that accommodates the resident's abilities. Resident #2 (R2)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R2's initial admission date to the facility was on 10/5/2024 with pertinent diagnoses including paranoid schizophrenia (persistent delusions and hallucinations, primarily involving themes of persecution, mistrust, and suspicion), depression and anxiety. Brief Interview for Mental Status (BIMS) reflected a score of 14 out of 15 which indicated R2 was cognitively intact (13 to 15 cognitively intact).During an observation and interview on 10/20/2025 at 11:00 AM, R2 was lying in bed and had 3 repetitive movements of getting out of bed, swinging his feet over his wheelchair, walking to the foot of the bed and crawling over to lay down again. During these movements, R2 stated that woman (R1) came into his room a few times and he asked her to leave, and she wouldn't leave. R2 said that he thought she was going to choke him so he pushed her but didn't mean to hurt her.Review of R2's physician orders revealed Invega Sustenna Intramuscular Suspension Prefilled Syringe 234 MG (milligrams)/1.5ML (milliliters) (Paliperidone Palmitate). Inject 234 mg intramuscularly every day shift starting on the 28th and ending on the 28th every month for schizophrenia.Review of R2's Interdisciplinary (IDT) note dated 10/13/2025 revealed IDT met to review recent incident with resident where he (R2) reportedly pushed another resident (R1) who was entering his personal room, causing that resident to fall. Resident verbalized today that when the woman entered his room that he was scared she was going to choke him, which lead him to push her. Resident (R1) does have paranoid schizophrenia that at times manifests delusions and paranoia. Resident was seen and evaluated at ER (Emergency room) after incident related to change in behaviors, had CT (Computed tomography scan) without contrast performed, and was returned to facility. No increase in behaviors noted this shift. Resident has since had a velcro stop sign placed to his doorway to deter wandering residents from entering his personal space and he states he believes it will help. Mood/behavior charting in place and (name deleted) psych (psychiatric) services requested to visit with resident upon next visit to facility. Care plans reviewed and updated appropriately.Review of R2's behavioral progress note dated 10/11/2025 and documented by LPN M after the incident with R1 and after R1 was sent to the hospital revealed Resident came up to desk very agitated. Mumbling. Jumped up out of chair and started getting loud. Telling this nurse he wants a shot of penicillin and he wants it now. This nurse explained those orders have to come from the doctor and the medicine has to come from pharmacy. He said you're a liar. I explained that is the procedure. Resident leaned over the counter with hands raised at this nurse and started (stared) at this nurse and didn't move for ten minutes. Multiple times staff tried to redirect resident and he wasn't leaving desk. Kept raising hands at this nurse and stating your (sic) a liar. Explained this nurse would call doctor and let him know. He insisted the shot was in the med cart. Resident eventually got in his w/c (wheelchair) and went to his room. On call NP (nurse practitioner) ordered one time dose of ativan IM (prescription sedative medication used to treat anxiety, insomnia, seizures, and other conditions). Pulled from pixus (pyxis-automated medication dispensing system used in healthcare settings). Administered in left buttock.Review of R2's behavioral progress note dated 9/14/2025 revealed Resident very upset this AM. Asked nurse to call police and report staff for taking his breakfast tray. When CNA (Certified Nursing Assistant) went into grab tray resident started yelling and got out of bed quickly and ran towards aide. Also requesting penicillin shot. NP notified of behaviors.Review of R2's outside psychology services progress note dated 10/13/2025 revealed When asked about the weekend incident, patient (R2) stated a lady (R1) came into his room and continued to do so even after he asked her to go away multiple times. He states that 2 or 3 other people were coming in and looking in his door with a frown on their face, which he believes were real people. Patient reports, This lady never came to me before, I pushed her on the back with 1 hand then she fell down. I was not really that mad. I felt threatened; her hand is always balled up in a fist. He states that he feels bad about pushing her and denies any suicidal or homicidal ideations, stating he is not really having bad thoughts. He states he sometimes hears voices, which he perceives as real people telling him different things in his head. When asked about his appetite, he states the cook is spitting and urinating in his food, so he mainly eats snacks. He also believes that the hospital drained his bank account. Shortly after the incident, the resident came to the nurses' station very agitated and anxious. He was yelling, jumped out of his wheelchair, and demanded a shot of penicillin. Nursing obtained a one-time dose of Ativan IM (intramuscular) from the on-call physician to manage his agitation. Nursing reported continued delusions, though he did take his Invega injection that month. He had been refusing showers and all oral medications, with a behavioral incident on 9/14/2025 where he became upset with nursing staff for removing his breakfast tray, requesting police be called. Symptom(s): Other: Refusal of oral medications, comments to staff including paranoia that they are poisoning his food, believing his medication is heroin.Review of R2's outside psychology services progress noted dated 10/2/2025 revealed .Psych (Psychiatric) History: Social Psychiatric: Ongoing Refusal of oral medications and intermittent refusal of monthly injections; prefers (LPN M) for injections. History rejecting care, refusing showers, and prior refusals of COVID testing and skin observations. Behavioral incident 9/14/2025 demanded police be called after breakfast tray was removed. Nursing reports ongoing delusions; sleeps most of the time.Review of R2's outside psychology services progress noted dated 9/4/2025 revealed .Review of Systems: Psychiatric: believes he has herpes, consistently asks for penicillin shot despite negative STD (sexually transmitted disease) testing, sexually inappropriate behavior with nursing, accuses staff of poisoning his food, limited diet consisting mostly of ice cream and sometimes cereal, multiple refusals of medications, refusing COVID testing per facility protocol, refusing skin observations, rejection of care, prefers specific nurse (LPN M) to administer injections.Review of R2's outside psychology services progress noted dated 7/24/2025 revealed Nursing states that the patient still thinks that he has a venereal disease, he first thought that he had gonorrhea, now it is herpes, and he consistently asked for a penicillin shot. I reviewed his progress notes, and behavior task logs he was noted to have sexually inappropriate behavior with nursing on 7/18/2025. On 7/2/2025 he was fixated on receiving a dose of penicillin despite negative STD testing and continues to insist on having a penicillin shot. Nursing reports that the patient will eat mostly ice cream and sometimes cereal. They report most of the times (sic) patient accuses them of poisoning his food. Previously, patient was seen on 6/26/2025 where he was agitated and stated that lab results showing negative venereal disease panel were a lie. He believed the facility was poisoning his food and refused to take medications.Review of R2's outside psychology services progress noted dated 6/26/2025 revealed .History of Present Illness. Patient states that the facility is poisoning his food, he refuses to take medications, he thinks nurses are giving him medications that are not what he is supposed to be taking. Review of R2's outside psychology services progress noted dated 5/29/2025 revealed .History of Present Illness. Patient states people are messing with my meds. Nursery (nursing) reports that patient has been having hallucinations and delusions, including thinking that people are poisoning his food. Patient also made statements that he believes his medication is heroin, which is why he will not take them.Review of R2's Emergency Department visit dated 10/11/2025 revealed discharge instructions on how to manage his anger.Review of R2's care plan revealed At risk for changes in behavior and mood r/t (related to) dx (diagnosis) of paranoid schizophrenia, major depressive disorder and generalized anxiety disorder. Resident has a tendency to refuse staff assistance with showers and medications. Resident often won't take his Invega injection unless he believes it is a penicillin shot. Resident has delusions that staff is poisoning his food and he believes that he has venereal diseases (he accuses staff of lying when they try to prove to him that he does not). Resident has a fixation on receiving penicillin injection. Resident is very particular about staff not touching his breakfast tray without permission. Resident has a history of being sexually inappropriate towards staff. Date initiated 10/7/2024.Non-pharmacological interventions: play R & B music, read newspaper, watch a variety of TV shows, watch basketball, go to bingo when scheduled, offer snacks of his choice (ice cream, fritos, chocolate, coca-cola) .During a phone interview on 10/20/2025 at 11:53 AM, LPN M stated that she did not witness the incident on 10/11/2025. She said she was at the nurses' station and R1 was at the nurses' station and shortly after that CNA N came to her and said R1 was on the floor outside of R2's door, LPN M stated that R1 said that man pushed me (referring to R2). When she talked to R2, he said he pushed her because she was in his room and wouldn't leave. LPN M stated that R2 gets agitated with staff at times, he thought his food was poisoned and wanted to call the police. She said R2 was paranoid and chased a CNA out of his room and down the hall when she was in there getting his meal tray. On 10/11/2025 after the incident occurred, LPN M said R2 was mad and wanted a penicillin shot and raised his hand at her and stared at her for a long time but didn't hit her. She stated, I was so scared he was going to hit me. During an interview on 10/21/2025 at 9:03 AM, CNA N stated on 10/11/2025, she was coming around the nurses' station and saw R1 on the floor outside R2's room. CNA N said that R2 reported he (R2) pushed R1. CNA N said that R1 would wander down the hall independently and go into resident rooms due to her confusion and R2 gets feisty and yells at times. CNA N said R2 chased her down the hallway when she took his meal tray out of his room because he thought he was being poisoned. CNA N said she doesn't feel safe being around R2 at times and will take another staff member into his room with her.During an interview on 10/20/2025 at 3:43 PM, CNA U stated on 10/11/2025, she was in the room next to R2 when she heard a woman shout, my leg and she went out of the room and found R1 on the floor and she got the nurse. CNA U said that R1 liked to wander the hall and would linger in resident doorways. CNA U stated that R2 has yelled and had threatening behavior before. Review of R2's Behavior Log from 7/1/2025 to 10/21/2025 revealed there were 6 days of documented behaviors related to movements (repetitive movements in room), rejection of care and threatening behavior out of 112 days reviewed. The question Has the resident exhibited this behavior before? yes was documented each time.During an interview on 10/20/2025 at 3:17 PM, Social Services Coordinator (SSC) V stated she wasn't working on 10/11/2025 on the day of the incident but she followed up with both residents when she came back to work. SSC V said they don't have behavior meetings but they discuss residents' medication changes and behaviors in IDT and clinical meetings, and with continued issues they discuss new interventions. SSC V said R1 was confused and wandered the halls and R2 had delusions and wasn't aware of his physical aggression towards others. During an interview on 10/21/2025 at 9:44 AM, CNA O stated that R2 was unpredictable and would yell at staff and gets in their face. CNA O said she doesn't feel safe when she goes into R2's room and will usually take another staff member in with her. CNA O' said management isn't quick to help when it comes to residents with behaviors. During second interview on 10/22/2025 at 9:03 AM, SSC V stated that R1 liked to walk down the halls, and they didn't have a concern with it until the incident on 10/11/2025. SSC V' said staff educated R1about not going into other resident rooms and would redirect her and have her go to activities. When further queried, SSC V said that R1 doesn't attend activities which can keep her busy since she likes alone time and looking out of her window. When asked if R1 can understand education when she had a dementia diagnosis, SSC V stated that R1 understands education and then forgets so she needs reminders to not go into resident rooms. SSC V stated that she meets with the resident and resident's POA (Power of Attorney) when there are behavior issues, but she wasn't able to get a hold of FM E to discuss R1. During an interview on 10/21/2025 at 8:45 AM, Activities Manager (AM) K stated that R1 doesn't attend any activities, but her staff will provide 1:1 activities with her daily and R2 only attends activities he chooses that involves food. During an interview on 10/22/2025 at 10:35 AM, Minimum Data Set Registered Nurse (MDS) L stated that R1 was currently weight bearing as tolerated and needed assistance now versus before the fracture on 10/11/2025. MDS L said R1 was a 1 assist now with walking and ADLs and as a result a significant change assessment was being completed. During an interview on 10/22/2025 at 10:39 AM, Director of Nursing (DON) B stated that R1 wandering down the halls and into resident rooms wasn't an issue prior to the incident on 10/11/2025 and if that was the case, they would have put interventions into place prior to the incident. DON B said IDT discussed abnormal behaviors and they did not feel a 1:1 with staff supervision was needed for either R1 or R2. DON B stated she wasn't aware that staff were concerned about their safety while being around R2 in the facility common areas or when going into his room and said other residents would let her know if R2 was bothering them or if they didn't like R1 coming into their room.

This citation pertains to intake #2616813Based on observation, interview and record review, the facility failed to prevent an unnecessary discharge by providing individualized care for 1 of 1 resident (Resident #101) reviewed for discharge, resulting in Resident #101 being abruptly discharged from the setting in which he was familiar, to an unfamiliar locked memory care unit and subsequently experiencing increased anxiety, agitation and emotional distress requiring pharmacological treatment.Findings include:Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: dementia (general term used for loss of memory, language, thinking skills that interfere with daily life) with behavioral disturbance.Review of a Minimum Data Set (MDS) assessment for Resident #101 with a reference date of 9/11/25, revealed a Brief Interview for Mental Status (BIMS) assessment score of 3/15, which indicated the resident was severely cognitively impaired. Section E of the MDS revealed Resident #101 did not display the presence of wandering during the 7-day assessment period.Review of a Care Plan for Resident #101 with a reference date of 7/23/25 revealed the following focus/goal/interventions: Focus: Altered behavior in which resident acts (are) sic characterized by ineffective coping skills.Goal: Decrease episodes of anxiety.Interventions.if (Resident #101) becomes agitated in congested areas assist him into a less congested area. Involve resident in 1:1 recreational activity, keep schedules routine and predictable.Review of a Behavior Monitoring and Interventions Report for Resident #101 with a reference date of 8/1-9/9/25, revealed the resident had no behaviors for on 34/40 days. Resident #101 had 2 occurrences of swearing, expressing frustration, agitation/restlessness, 1 episode of wandering/exit seeking, 1 episode of pushing and 1 episode of hitting staff.In an interview on 10/7/25 at 12:58pm, Unit Manager/Registered Nurse (UM/RN) II reported Resident #101 was redirectable and had no unsafe situations regarding his behaviors. UM/RN II reported the facility was concerned about other residents who were ganging up on (Resident #101) because of his memory issues and because he spent much of his time maneuvering his wheelchair through the common areas of the facility. UM/RN II reported the decision to send admission referrals for Resident #101 to seek a transfer to another facility, was made by the Interdisciplinary Team (IDT). When further queried, UM/RN II reported Nursing Home Administrator (NHA) A and Director of Nursing (DON) B decided to send admission referrals out for Resident #101. When asked about interventions the facility put in place regarding other residents ganging up on Resident #101, UM/RN II reported the only intervention was to encourage staff to supervise him as available.In an interview on 10/7/25 at 1:53pm, Certified Nursing Assistant (CNA) U reported she cared for Resident #101 and felt he did not have any behavioral issues that could not be managed at the facility. CNA U reported staff were told the keep a better eye on Resident #101 related to how other residents treated him.In an interview on 10/7/25 at 2:21pm, Assistant Director of Nursing (ADON) F reported Resident #101 wandered at times but was easily redirected, and that he seemed content at the facility. ADON F reported another resident was frustrated with Resident #101because he wandered through the common areas. ADON F reported the facility initiated transferring Resident #101 to another facility, but she was unsure why.In an interview on 10/7/25 at 8:53am, DPOA GG reported she received a telephone call on 9/11/25 from Admissions Coordinator (AC) Z at approximately 1:00pm, who told her Resident #101 had to transfer to another skilled nursing facility on this date. DPOA GG reported she was told she had to come to the facility immediately to transport the resident and was never given the option of appealing the discharge and was not told this discharge was voluntary. DPOA GG reported she was aware the facility had decided to send admission referrals to other nearby facilities due to Resident #101's need for dementia care, but she wanted to keep the resident where he was because he seemed content, recognized some staff members, and had developed a daily routine that included maneuvering his wheelchair around the facility. DPOA GG reported Resident #101 liked to walk the sun in the halls. DPOA GG reported during her visits when Resident #101 would get antsy she would walk next to him, while he was in is wheelchair and they would walk down each hall, touch the door at the end, return to the beginning of the hall, and then walk down the next hall, until they returned to his room; due to the shape of the hallways (4 halls branching from the circle in the middle) she referred to the activity as walking the sun. DPOA GG reported Resident #101 wandered as a stress relief. DPOA GG reported she insisted on meeting with Nursing Home Administrator (NHA) A when she arrived at the facility to transport the resident to another facility on 9/11/25. During the meeting she was told the facility felt Resident #101 needed to move immediately because he was wandering around the facility more and was being threatened by a female resident. DPOA GG reported she had not been informed until this date that Resident #101 was being threatened by another resident. DPOA GG reported when she was told another resident had threatened Resident #101, she asked what the facility had been done to address the concern and was given no response.In an interview on 10/7/25 at 3:17pm, Director of Nursing (DON) B reported Resident #101 had increased wandering and agitation that lead to the facility discharging him to a locked memory care unit. DON B reported Resident #101 had 0 elopements from the facility. DON B confirmed the facility had 23 other residents with a diagnosis of dementia that she felt the facility was able to successfully care for. DON B reported Resident #101 became agitated around large crowds and needed care in a dementia unit. When further queried about how care in a dementia unit might better meet Resident #101's needs, DON B stated I don't know I've never worked in a dementia care unit. When asked about new interventions the facility had put in place to address Resident #101's wandering, agitation and potential need for discharge, DON B reported Resident #101 had started a new medication 3 days prior to his discharge, but it would take time to be effective.Review of IDT late entry note for Resident #101 dated 9/5/25 at 12:35 PM, revealed .wandering throughout the facility per usual today and is easily redirectableReview of IDT note for Resident #101 dated 9/8/25 at 9:42 AM, revealed .met with resident this morning who is wandering down hallway per baseline. Resident remains confused per baseline and easily redirectable. Review of a Psychiatry Follow Up for Resident #101 with a reference date of 9/4/25 revealed Assessment and Plan: Vascular Dementia.and behavioral disturbances. Status: Inadequately Controlled.he displays impaired judgment, lacks insight into his limitations.will start rivastigmine patch 4.6mg(milligrams) per 24 hours for 4 weeks, then increase to 9.5 mg per 24-hour patch if tolerating. Adjustment Disorder with mixed disturbance of emotions and conduct, Status Inadequately Controlled: patient demonstrates behavioral disturbances.by becoming verbally agitated with staff, being difficult to redirect and rejection of care.Wandering: Status: Well Controlled.this wandering is associated with his cognitive impairment.Review of Drug Facts: Rivastigmine, https://www.alzinfo.org/articles/drug-facts-exelon-rivastigmine/, 8/3/10, revealed Onset of Effect: Benefits, if they occur, may appear within several weeks of starting the drug.In an interview on 10/7/25 at 3:41pm, Nursing Home Administrator (NHA) A reported Resident #101 was discharged because he was having increased behaviors a little bit including wandering. NHA A reported Resident #101 would propel his wheelchair up to exit doors and push the release bar but did not have enough strength to open the door, and wasn't trying to get out. When asked about additional interventions were put in place to address Resident #101's behaviors related to his dementia, NHA A stated I don't know. NHA A reported she became increasingly concerned for Resident #101's safety when another resident became frustrated with him, made a verbal threat toward him, began announcing his whereabouts regularly and asked, why do we have to people that are messed up in the head, referring to Resident #101 who wandered within the common areas of the facility. When queried about interventions put in place to maintain Resident #101's safety, NHA A reported she attempted once to educate the other resident about dementia, but the resident was upset and did not receive the information. NHA A reported the resident who was acting out toward Resident #101 was able to discharge any time she wants to but it's not her goal. NHA A then reported the facility did not have a social worker at that time, so no resources were not pursued to support the other resident discharging to the community. NHA A reported staff were told to increase their supervision of Resident #101 but she did not know if this was documented. NHA A was asked to provide documentation of all interventions that were put into place.Additional information regarding any interventions the facility put in place to address Resident #101's and Resident #100's behaviors was requested. No additional information was received by the conclusion of the survey. NHA A agreed to provide any additional information if available by the conclusion of the survey. Review of a Discharge Summary for Resident #101 with a reference date of 9/11/25 at 8:00am, revealed Dementia.with behavioral disturbance: Patient appears stable, he is non-verbally communicating at this time, but is cooperative. Medications: Continue- Rivastigmine transdermal patch.Notes. (Resident #101) .is being discharged today from this facility and transferring to (name of facility omitted). He has behavioral and mental health changes and appears stable on his current medication regime.In an interview on 10/8/25 at 10:12am, admission Coordinator (AC) HH, who worked at the facility Resident #101 transferred to, reported the referral for Resident #101 was done via telephone by Nursing Home Administrator (NHA) A and Resident #101's transfer happened quickly. AC HH reported she was told Resident #101 was wandering more and was being targeted by a female resident who had verbally harassed him.In an interview on 10/8/25 at 10:15am, DPOA GG reported she drove Resident #101 to the new facility on 9/11/25 and completed the admission paperwork for him. DPOA GG reported Resident #101 experienced significant anxiety that day that worsened in the following days. DPOA GG reported during the admission process, Resident #101 stated repeatedly Let's go, let's go, I don't want to be here. DPOA GG reported she returned the following day to check on Resident #101. DPOA GG described Resident #101 as off the wall upset on the second day of his admission to the locked unit and reported the resident cried throughout the visit. DPOA GG reported Resident #101 remained upset and agitated for approximately 2 weeks after the move and had since been put on several medications to reduce his anxiety and agitation. DPOA GG stated I've gotten more calls about him having behaviors, being combative, swearing at staff in the last 2 weeks than I did the entire time he was at the first facility. He was mentally in a good place before the move. It's like he's starting all over again with adjusting to being at a nursing home after this move. DPOA GG reported Resident #101 remains preoccupied with his surroundings and regularly says You know the damn door is locked when she escorts Resident #101 around the locked unit.During an observation on 10/8/25 at 10:30 am, Resident #101 sat supported in his bed, was aware when he was spoken to; made eye contact and verbalized short statements in response to a friendly greeting.In an interview on 10/8/25 at 10:12am Unit Manager (UM) LL for the locked memory care unit where Resident #101 now resides, reported Resident #101 became extremely agitated and anxious after his admission to the new facility. UM LL reported Resident #101 became physically aggressive toward staff in the new environment and ultimately was placed on 3 psychotropic medications to address his intensified behaviors.In an interview on 10/8/25 at 10:00am NHA KK reported DPOA GG told him when she and Resident #101 arrived at the new facility that she was not aware of the transfer until the day on which it occurred, and that she was told Resident #101 had to leave.Review of a Transfers and Discharge policy with a reference date of 4/18/25 revealed .GENERAL GUIDELINES: .Once admitted , the resident has the right to remain at the facility unless their transfer or discharge meets one of the following specified exemptions: The discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility.DISCHARGE WHEN NEEDS CANNOT BE MET OR SAFETY OR HEALTH OF INDIVIDUALS IS ENDANGERED: The facility's transfer/discharge notice will be provided to the .resident's representative.The notice will include.:specific reason and basis for discharge .information on how to obtain an appeal.Generally, the notice must be provided at least 30 days prior to a transfer or discharge.For circumstances where the discharge.is necessary for the resident's welfare and the facility cannot meet the resident's needs.the resident's physician must document information about the basis for the discharge and will include: The specific reason resident needs the facility could not meet, the facility efforts to meet those needs and the specific services the receiving facility will provide to meet the needs of the resident which cannot be met at the current facility.Using the reasonable person concept, although Resident #101 could not verbalize the psychosocial harm he endured when the facility failed to add interventions to maintain his safety, and abruptly discharged him to an unfamiliar, locked memory care unit, he clearly experienced increased fear, panic, resistance to care and emotional distress for an ongoing period of time and ultimately required pharmacological intervention for symptom management.

This citation pertains to intake MI00150239. Based on interview and record review, the facility failed to prevent the use of physical restraint/confinement for 1 (Resident #100) of 3 residents reviewed for abuse, resulting in Resident #100 being confined by a locked wheelchair placed against the nurse's station and restrained into a seated position. Findings include: Review of an Admission Record revealed Resident #100 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: unspecified psychosis (a mental disorder characterized by a disconnection from reality), vascular dementia (progressive disease resulting in loss of cognitive abilities), and generalized anxiety disorder. Review of a Minimum Data Set (MDS) assessment for Resident #100 with a reference date of 11/29/24, revealed a Brief Interview for Mental Status (BIMS) score of 5/15 which indicated Resident #100 was severely cognitively impaired. Section GG of the MDS revealed Resident #100 could walk 50' independently, and did not regularly use a wheelchair. Review of a Care Plan for Resident #100 with a reference date of 9/30/24, revealed a focus/goal/interventions of: At risk for falls due to lack of safety awareness .unsteadiness. Goal: Minimize risk of falls. Interventions: Bed at transfer height .nonskid tape to bedside floor .staff to offer and assist to toilet during nighttime hours . In an interview on 1/18/25 at 1:38pm, Licensed Practical Nurse (LPN) S reported at approximately 2:30am on 2/12/25 she walked by Resident #100 who was seated in a wheelchair, facing the cut out window of the nurse's station. LPN S reported the brakes on the wheelchair were locked, the armrests were against the half wall of the nurse's station and the resident was saying she wanted to get up. LPN S reported she heard the resident saying can you help me get up, can you help me, I can't get up!. LPN S reported she initially told the resident that getting up would not be a good idea because the resident's legs had not been working as well lately. Resident #100 then replied No, I can't get this belt off of me. LPN S looked at Resident #100 who then lifted her shirt and revealed a black gait belt across her ribs, fastened around the back of the wheelchair. LPN S reported Resident #100 appeared emotionally upset about the situation. LPN S reported she immediately went to LPN Z and asked if Resident #100 was supposed to be restrained. LPN Z confirmed the resident was not supposed to be restrained. LPN S stated she felt shocked seeing Resident #100 in that situation and left the floor to call Director of Nursing (DON) B. LPN S reported DON B instructed her to return to the floor immediately and release Resident #100, then complete a skin and pain assessment for the resident. LPN S reported when she returned, Resident #100 was in bed with no restraint. LPN S reported Resident #100 had no injuries and no complaints of pain following the incident. In an interview on 2/18/25 at 2:20pm, Certified Nursing Assistant (CNA) E reported she cared for Resident #100 on the overnight shift of 2/11/25. CNA E reported she assisted LPN Z with getting the resident into a wheelchair after she was found standing by her room door at approximately midnight on 2/12/25. CNA E reported she recalled seeing Resident #100 seated at the cutout window area with her wheelchair against the half wall of the nurse's station. CNA E reported it was difficult to provide the amount of supervision Resident #100 needed while also caring for other residents. CNA E reported at that time, Resident #103 was transferring from sitting to standing about every 5 seconds. CNA E denied placing or seeing a gait belt around Resident #100 and her wheelchair. In an interview on 1/19/25 at 8:06am, LPN Z reported he transferred Resident #100 to a wheelchair after she was found standing by her room door at approximately midnight on 2/12/25. LPN Z reported he positioned Resident #100 at the cutout window of the nurse's station, with her wheelchair against the half wall of the nurse's station. LPN Z reported Resident #100 could not unlock the wheelchair breaks on her own. LPN Z reported he confined Resident #100 to that area by using her wheelchair in this manner in effort to reduce her likelihood of falling. LPN Z reported Resident #100 did not have a gait belt restraining her to her chair at that time and that she stood and sat back down repeatedly. LPN Z reported Resident #100 was upset that night and thought she needed to find her family. LPN Z reported he had difficulty supervising Resident #100 because of the number of residents in his assignment that night. LPN Z reported at approximately 2am, 2 CNA's left the floor for their break, leaving even fewer staff to supervise the residents, including Resident #100 who remained at the nurse's station. In an interview on 1/19/25 at 10:12am, CNA H reported she worked overnight on 2/11-2/12/25. CNA H reported Resident #100 was restless that night and had recently had several falls. CNA H reported it was difficult to help her remain safe and that sometimes we gotta hold down residents to keep them safe. CNA H explained that we had her (Resident #100) pushed all the way up against the desk and locked the brakes so she could not attempt to walk. CNA H reported Resident #100 appeared anxious, verbalized a desire to move away from the nurse's station, that the resident was looking for her loved ones and stated, I have to find them, referring to her family. CNA H denied any knowledge of Resident #100 having a gait belt wrapped around her and the wheelchair. Review of an Investigation Summary with a reference date of 2/11/25, revealed at 3:15am: (Resident #100) when shown a picture of LPN Z, she confirmed emphatically that he was the one who placed the gait belt around her. In an interview on 2/19/24 at 12:41pm, Resident #100 did not appear to recall the event that took place on 2/12/25. In an interview on 2/20/25 at 10:53am, DON B reported she came to the facility at approximately 3am on 2/12/25 to initiate an investigation after Resident #100 was found physically restrained. DON B reported at that time, Resident #100 reported a man tied her to a wheelchair and voiced that she didn't like it. In an interview on 2/20/25 at 2:01pm, Guardian Y reported the facility had informed her Resident #100 had been found physically restrained in the early morning hours of 2/12/25. Guardian Y reported she would expect that any reasonable person would be significantly emotionally distressed by the act of being physically restrained. Using the reasonable person concept, though Resident #100 and Resident had decreased ability to verbally express their own thoughts due to medical diagnoses, any reasonable person would likely feel frustration, a decreased sense of autonomy and decreased sense of psychological wellbeing because of being physically restrained.

This citation pertains to intake MI 301. Based on interview and record review, the facility failed to prevent the development and worsening of pressure ulcers and implement treatments and monitoring for pressure ulcer prevention and healing for 1 of 2 residents (Resident #104) reviewed for wounds/pressure ulcers, resulting in the development of an Unstageable Pressure Ulcer on sacrum (tailbone), hospitalization due to wound infection, surgical intervention and [CONDITION(S)] (bone infection). Findings include: Resident #104 Review of an Admission Record revealed Resident #104 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Minimum Data Set (MDS) assessment for Resident #104, with a reference date of 1/30/22 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #104 was cognitively intact. Review of the Functional Status revealed that Resident #104 required extensive assistance of 2 people for bed mobility, transfer and personal hygiene. Review of Skin Conditions revealed that Resident #104 was at risk for pressure ulcers, had 0 unhealed pressure injuries, and had no MASD (Moisture Associated Skin Damage). During an interview on 4/1/22 at 1:34 P.M., Family Member (FM) Q reported that Resident #104's care at the facility did not go well from the start and stated, .his wound got so painful that he couldn't do therapy .sometimes he couldn't go to [CONDITION(S)] .I repeatedly asked for the doctor to look at him .they finally referred him to the wound clinic, but that took a couple weeks to get in .it was too bad by that point .the wound doctor transferred him to the hospital for surgery immediately . Review of Hospital Records for Resident #104's emergency department visit dated 3/8/22 at 10:06 A.M. revealed, Chief Complaint: .presents with concern for infected sacral wound .Over the last several weeks, this wound has significantly worsened. It is quite painful. He rates 10 out of 10 severe sharp stabbing pain, constant, worse when he sits on his buttock area. He is [CONDITION(S)] dependent on Tuesday/Thursday/Saturday hemodialysis, but he has been unable to go to [CONDITION(S)] due to his severe sacral pain, as he cannot sit in the chair. He was evaluated in wound clinic today. In wound clinic, concern was raised for infectious component of sacral wound, and he was directed here for further evaluation .Physical Exam: .Large sacral decubitus (bed sore) wound extending at least into the subcutaneous tissue with surrounding [CONDITION(S)] (red) and purulent discharge from the wound .the patient appears chronically ill but in no acute distress .Labs show significant leukocytosis (indicates infection) at 26.0 .CT abdomen/pelvis without contrast obtained. This confirms decubitus ulcer but no definitive evidence of drainable fluid collection or [CONDITION(S)] .Clinically, I suspect that [CONDITION(S)] is multifactorial due to infected decubitus wound, possible [CONDITION(S)], and urinary tract infection. Culture sent. Patient given broad coverage with [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] (antibiotics) .Patient will require admission for further care .Final Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] .Pressure injury of skin of sacral region, unspecified injury stage . Review of Resident #104's Sacral Wound Debridement (removal of dead, infected tissue) dated 3/8/22 at 15:02 (3:02 P.M.) revealed, Wound Class: 4- Dirty or Infected, confirmed with surgeon Findings: 1. Unstageable sacral decubitus ulcer with overlying necrotic eschar (dead tissue) and underlying purulent drainage involving skin, subcutaneous tissue, sacral fascia, and gluteal muscle 2. Necrosis extending down to the level of the sacrum -debrided with electrocautery; final wound measurements were 13 x 7 x 1 cm .Wound Class: IV .Indication for Procedure: .Patient was found to have a large decubitus ulcer overlying the entire sacrum, which also contained an overlying necrotic eschar with foul-smelling drainage . Review of Resident #104's Hospitalist Discharge Summary revealed, .Hospital Day: 17 admitted : 3/8/2022 discharge date : 3/25/2022 Primary Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] .Summary of hospitalization : Patient was found to have subacute [CONDITION(S)] of the sacrum with a large sacral decubitus ulcer. Infectious disease and general surgery teams were consulted. He was started on empiric broad-spectrum IV antibiotics. Sacral wound was found to be necrotic and required surgical debridement on 3/08/22 by the general surgery team. Wound vac was then placed. Blood cultures from admission grew [CONDITION(S)] & Bacteroides species Surgical cultures were positive for Enterococcus faecalis and MSSA as well as yeast on the gram stain, likely a [MEDICATION(S)] species. Antifungal coverage with [MEDICATION(S)] was added. Bone biopsy was obtained on 3/16 with confirmation of suspected [CONDITION(S)]. 6 weeks of IV antibiotics were recommended . During an interview on 4/5/22 at 10:39 A.M., Licensed Practical Nurse (LPN) E reported that Resident #104's wounds only got worse while he was at the facility. LPN E reported that wound treatments were frequently missed and stated, .some days I could not believe what I would see when I got here . LPN E reported that Resident #104 did not refuse wound care or repositioning and stated, .he waited a long time to get into the wound clinic .then he never came back after that appointment . During an interview on 4/5/22 at 11:43 P.M., DON reported that the facility had recently identified that some wound treatments and weekly skin observations were not getting done and have started staff re-education. During an interview on 4/5/22 at 3:00 P.M., DON reported that Resident #104 did not admit with any wounds and stated, .clearly there was fragile, macerated skin .a pressure area on his bottom . DON reported that she would have expect the nurses to report wound worsening, or lack of progression, and the doctor to a change treatment or an antibiotic and stated, .there were not any changes throughout the course of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 4/6/22 at 9:41 A.M., Medical Doctor (MD) M reported that he did not see Resident #104's wound unless the nurses contacted him about a concern and stated, .I don't know if it wasn't getting better .I am not here to see the progression .it developed very fast .he was referred to the wound clinic .I did not prescribe an antibiotic .he needed debridement . Review of Resident #104's Admissions assessment dated [DATE] revealed, .Current skin integrity issues: Sacrum (tailbone), denuding (loss of top layer) of the skin . Review of Resident #104's Braden Scale for Predicting Pressure Ulcer Sore dated 1/26/22 revealed a score of 13, which indicated a moderate risk. Review of Resident #104's Skin & Wound Evaluation dated 1/27/22 revealed, .Type: MASD, (no location recorded), present on admission, 10.9 cm x 5.9 cm .no slough .no eschar .no exudate (fluid drainage) .normal surrounding tissue .no pain, healable, no dressing applied . The attached imaged indicated that the location was sacrum and there were no open areas. Review of Resident #104's Treatment Administration Record (TAR) for January/February 2022 revealed, Venelex Ointment (liquid wound barrier, skin protectant) Apply to coccyx topically two times a day for Wound treatment, Start date of 1/27/22, and End date of 2/2/22. This record indicated that Resident #104 did not receive 5 of 14 opportunities for the treatment. Review of Resident #104's Progress Note dated 2/1/22 at 15:21 (3:21 P.M.) revealed, .c/o (complains of) pain to buttocks, treatment continues and improvement seen Review of Resident #104's Skin & Wound Evaluation dated 2/2/22 revealed, .Type: MASD, (no location recorded), 8.1 cm x 6.3 cm .30% of wound filled with slough, eschar (not recorded) .bleeding, pink or red, light exudate .surrounding skin: discoloration-black/blue, [CONDITION(S)] (red), macerated, pain level 3/10, healable .no dressing applied .progress: stalled . The attached image showed open areas on the buttocks, and macerated skin in the sacral area embedded with black feces. Review of Resident #104's Physician Note dated 2/2/22 revealed, .The patient has skin issues to the buttock area .Assessment: Skin issues secondary to skin lacerations .Plan: [MEDICATION(S)] (breathable barrier to promote skin health) cream to excoriated, open area on bottom and coccyx every shift and prn (as needed) . Review of Resident #104's TAR for February 2022 revealed, [MEDICATION(S)] cream to excoriated open area on bottom/coccyx every shift and prn every shift. Start date 2/2/22, End date 2/10/22. This record indicated that Resident #104 did not receive 5 of 16 opportunities for the treatment. Review of Resident #104's Skin & Wound Evaluation dated 2/9/22 revealed, .Type: MASD, (no location recorded) .2.9 cm x 1.3 cm .surrounding skin: macerated, pain level 5/10, healable .no dressing applied .progress: improved . The attached image showed an open sacral wound with embedded feces on the surrounding macerated skin, and an obvious decline in progress. Review of Resident #104's Progress Note dated 2/10/22 at 15:01 (3:01 P.M.) revealed, Resident returning from [CONDITION(S)] 2hr early per resident request. [CONDITION(S)] center aide (name omitted) called this nurse to report that resident is c/o severe pain on his bottom . Review of Resident #104's Progress Note dated 2/10/22 at 16:17 (4:17 P.M.) revealed, Resident's area to coccyx appears to be worsening. N/O (new order) for Calcium Alginate (a flat pad-like dressing used to promote wound healing) soaked in NS (normal saline) applied to wound bed and covered with foam drsg (dressing) daily and prn ordered. Air mattress ordered. Review of Resident #104's TAR for February 2022 revealed, Clean coccyx wound with NS, Apply Calcium Alginate moistened with NS to wound bed, cover with foam drsg daily and PRN every night shift for wound care. Start date 2/11/22, End date 2/24/22. This record indicated that Resident #104 did not receive 2 of 13 opportunities for the treatment. Review of Resident #104's Physician Note dated 2/11/22 revealed, .I am asked by nursing staff to evaluate patient's uncontrolled pain .patient finished [CONDITION(S)] early due to lower back pain .Will start patient on [MEDICATION(S)] (pain medication) . Review of Resident #104's Skin & Wound Evaluation dated 2/16/22 revealed, .Type: MASD, (no location recorded) .2.6 cm x 1.5 cm .Wound bed: slough (not recorded), eschar: 80% of wound filled .Exudate: light serosanguineous, Surrounding tissue: Denuded, Discoloration-black/blue, [CONDITION(S)] .Pain level 3/10, Healable, Progress: Stalled . Attached image showed an open wound on the sacrum, covered with slough, embedded black feces on the large area of macerated skin surrounding the wound, and an obvious decline in progress. Review of Resident #104's Skin & Wound Evaluation dated 2/23/22 revealed, .Type: Pressure, Stage: Unstageable, due to slough or eschar, location: sacrum, length 2.3 cm x width 4.4 cm x 0.5 cm depth cm .Wound bed: slough 50% of wound filled, eschar: 50% of wound filled .Exudate: light serous, Surrounding tissue: .[CONDITION(S)], fragile, Pain level 5/10, Healable, Progress: Stalled . Attached image showed a wound on the sacrum, covered with slough and black eschar, and with obvious decline in progress. Review of Resident #104's Physician Note dated 2/24/22 revealed, .The patient's family is concerned regarding wound on back, wound cleaning .Assessment: .Cleanse the coccyx wound with normal saline, pat dry and [MEDICATION(S)] to surrounding tissue, apply Calcium Alginate. This order was not a change in treatment, but a restart of [MEDICATION(S)] to surrounding tissue which had been discontinued on 2/10/22. Review of Resident #104's TAR for February 2022 revealed, Clean coccyx wound with NS, pat dry, spray [MEDICATION(S)] to surrounding tissue, Apply Calcium Alginate moistened with NS to wound bed, cover with foam drsg daily and PRN every night shift for wound care. Start date 2/24/22. End date 3/8/22. The record indicated that Resident #104 did not receive 2 of 12 opportunities for the treatment. Review of Resident #104's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Appointment Coordination Document dated 2/28/22 provided by DON indicated that Resident #104 had transportation arranged for 3/8/22 at 8:00 A.M. to the wound clinic. Review of Resident #104's Skin & Wound Evaluation dated 3/2/22 revealed, .Type: Pressure, Stage: Unstageable-due to slough or eschar, Location: sacrum, length 4.9 cm x width 6.8 cm .Wound bed: Slough not recorded, Eschar: 80% of wound filled .Other: pink or red, Exudate: light sanguineous/bloody, Odor: faint, Surrounding tissue: Denuded, Discoloration-black/blue, [CONDITION(S)], Excoriated, fragile, Pain level 3/10, Healable, Progress: Stalled . Attached image showed a wound on the sacrum, covered with slough and black eschar, and obvious decline in progress. Review of Resident #104's Progress Note dated 3/3/22 at 14:50 (2:50 P.M.) revealed, [CONDITION(S)] called and resident returning early. he is unable to tolerate [CONDITION(S)] treatment today because of pain when sitting in chair. medicated before he left for treatment . Review of Resident #104's Physician Note dated 3/3/22 revealed, Reason for evaluation: Unstageable pressure ulcer to lower back .Assessment: This patient has a Kennedy unstageable wound (a wound that develops rapidly during the final stages of a person's life) . Review of Resident #104's Progress Note dated 3/6/22 at 01:19 (1:19 A.M.) revealed, Treatment to wound on coccyx completed. Wound bed appearing larger, and is odorous MD notified. No new orders, at this time. Review of Resident #104's Progress Note dated 3/8/22 at 7:00 A.M. revealed, .getting ready for wound clinic appt. resident crying out in pain while adl (activities of daily living) care being given. medicated with prn [MEDICATION(S)] at this time. talked with resident about pain and asked him if he was sure he wanted to go to appt. he stated yes, I ' m going, I want to get well and this is the only way. Resident left for wound clinic appt at 0730. Review of Resident #104's Care Plan revealed, At risk for alteration in skin integrity .Date Initiated: 01/27/2022. Interventions: air mattress Date Initiated: 02/15/2022, Barrier cream to peri area/buttocks as needed. Date Initiated: 01/27/2022. Daily body audit. Date Initiated: 02/03/2022. Diet and supplements per physician order. Date Initiated: 01/27/2022. Elevate heels as able. Date Initiated: 01/27/2022. Encourage fluids. Date Initiated: 01/27/2022. Encourage to reposition as needed; use assistive devices as needed. Date Initiated: 01/27/2022. Geo matt (pressure reducing pad) on back of w/c (wheelchair) to use while at [CONDITION(S)]. Date Initiated: 02/02/2022. Observe skin condition with ADL (activities of daily living) care daily; report abnormalities Date Initiated: 01/27/2022. Toileting program as indicated. Date Initiated: 01/27/2022. Use pillows/positioning devices as needed. Date Initiated: 01/27/2022. Review of Resident #104's Care Plan revealed, admitted with open excoriation to bilateral buttocks related to: impaired mobility, GBS, decreased sensory perception, incontinence, sitting at [CONDITION(S)], 2/11 wound unstageable Date Initiated: 01/27/2022. Interventions: Administer analgesia per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Date Initiated: 02/15/2022. Administer treatment per physician orders. Date Initiated: 01/27/2022. Diet and supplements per physician orders. Date Initiated: 02/15/2022. Encourage and assist as needed to turn and reposition; use assistive devices as needed Date Initiated: 02/15/2022. Follow up care with physician as ordered. Date Initiated: 01/27/2022. Has Geo matt on back of chair for [CONDITION(S)] chair. Date Initiated: 02/15/2022. Obtain Labs as ordered and report results to physician. Date Initiated: 02/15/2022. Pressure reducing surface on bed APM/wheelchair/cushion Report evidence of infection such as purulent drainage, swelling, localized heat, increased pain, etc. Notify physician prn. Date Initiated: 02/15/2022. Review of the NCBI (National Center for Biotechnology Information) article, [CONDITION(S)] revealed, Bone infection is called [CONDITION(S)]. It is an acute or chronic [CONDITION(S)] process involving the bone and its structures secondary to infection with pyogenic organisms, including bacteria, fungi, and mycobacteria . The bone becomes susceptible to disease with the introduction of a large inoculum of bacteria, from trauma, ischemia, or the presence of foreign bodies because bone sites to which microorganisms can bind are exposed . Contiguous [CONDITION(S)] frequently develops in debilitated patients who are wheelchair or bedbound and are predisposed to pressure-related skin ulcerations, especially in the sacrum, buttock, hips, and heel. Momodu II, Savaliya V. [CONDITION(S)]. [Updated 2022 [DATE]]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK 0/ Review of the Fundamentals of Nurse (Potter and Perry) revealed, When you identify the presence of a skin wound or pressure injury, closer assessment is required. Assess the type of tissue in the wound base so that you can plan appropriate interventions. The assessment includes the amount (percentage) and appearance (color) of viable and nonviable tissue . Soft yellow or white tissue is characteristic of slough (stringy substance attached to wound bed), and it must eventually be removed by a qualified clinician or by an appropriate wound dressing before the wound is able to heal. Black, brown, tan or necrotic tissue is eschar, which also needs to be removed before healing can occur . Assessment of wound exudate should describe the amount, color, consistency, and odor of wound drainage. Excessive exudate indicates the presence of infection. Wound pain, including the location, distribution, type, quality and intensity, and any aggravating or relieving factors, also should be assessed ([NAME], 2016). Examine the skin around the wound (periwound) for redness, warmth, and signs of maceration, and palpate the area for signs of pain or induration. The presence of any of these factors on the periwound skin indicates wound deterioration. Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia A.; Hall, Amy. Fundamentals of Nursing - E-Book (p. 1247). Elsevier Health Sciences. Kindle Edition.

Based on observation, interview, and record review, the facility failed to provide care to prevent the formation of avoidable pressure ulcers for one of six residents reviewed for pressure ulcers (Resident #18), resulting in Resident #18 not maintaining his highest practicable physical well-being and placing him at increased risk for infection and physical decline. Findings include: Review of Resident #18's (R18) Minimum Data Set, dated dated [DATE], revealed R38 was a [AGE] year-old male, admitted to the facility on [DATE], who was cognitively intact, needed extensive assistance with bed mobility, was totally dependent on staff for transfers and had [DIAGNOSES REDACTED]. During an interview/observation on 06/10/19 at 12:02 PM, R18 reported, I got sores on my feet from the boots. I got them while I've been here. There was a pair of ridged black orthotic-type boots lying on the floor near R18's bed. Review of R18's Activities of Daily Living Care Plan (ADL), dated 4/9/2019, revealed, ADL Self care deficit as evidenced by generalized weakness, immobility d/t (due to) metastatic non small cell [MEDICAL CONDITIONS], Bilateral LE [MEDICAL CONDITION] (left extremity [MEDICAL CONDITION]/blood clot), PE (pulmonary/lung embolism/blood clot) . (added 4/19/2019) BLE (bilateral lower extremity) splints on while in bed as tolerated, q (every) shift skin checks (on hold as of 5/09/19). During an observation/interview on 6/11/19 at 10:58 AM, Licensed Practical Nurse (LPN) S measured three wounds on R18's lower extremities. LPN S said treatments were being done a few times a day and reported the wounds were acquired here . The boots kind of tore up his ankles. R18 commented, Yes, I was wearing them all day. Although there was a pillow under R18's calves, the pillow was compressed and R18's heels were resting directly on the mattress. LPN S reported, and this Surveyor observed, a black eschar (black, dead skin) (2.3 cm x 2.0 cm) on R18's left heel, a flesh colored scab (1.5 cm x 0.8 cm) on R18's right heel and a red, depressed, closed area (1.3 cm x 0.3 cm) on R18's right outer ankle. LPN S reported she had seen red areas on R18's skin when the boot were taken off prior to R18 developing the pressure sores, but did not report or document her findings. In an interview, on 06/11/19 at 11:18 AM Nurse Aide (CNA) V reported, (R18) had (the boots) on when he was in bed and we took them off when he got up. He hasn't been feeling really good, so he hasn't been getting up, but he had been getting up daily then, refused to get out of bed. I was gone for four days, when I came back, he had the sores. Usually, (R18) had the boots on most of the shift unless he was up for lunch or appointments; they were on at least four hours at a time. (R18's) feet do swell up and sometimes get a little red. It happened really fast. He can't feel his feet. (The wounds) look the same as when I first saw them. We've been propping his legs up and his heels floating. Not wearing the boots anymore. I would say it was unavoidable because of the boots; they were to be on when he was in bed. (R18) was in bed a lot, rarely would he want to get up. (R18) [MEDICAL CONDITION] spreading from lungs to his spine. I don't think (the wounds) are going to heal well. Review of a Nursing Skin Note, dated 5/9/2019 at 6:30 PM, revealed, Body audit completed and noted deep tissue injury to bilat (both) backs of heels from foot drop splints that are worn in bed. Back of left heel measures 2 (cm) x 2 cm closed deep purple non blanching area. No drainage. Surrounding tissue is normal in appearance. Back of right heel measures 1.8 (cm) x 1 cm closed deep purple non blanching area. No drainage. Surrounding tissue is normal in appearance. No pain to either area r/t his [MEDICAL CONDITION]. Abrasion note to right outer ankle measuring 3 (cm) x 2 (cm) at the widest area. Scabbed over and surrounding tissue is slightly red and blanching. No drainage noted. New order received for cavalon spray to bilat backs of heels and to leave open to air and to hold splints until further notice. (R18) states he does not want anyone notified and that he will himself. MD (Medical Director U) aware and in the building. Splints removed, treatment applied, and feet bridged with pillows to relieve pressure. Review of physician progress notes [REDACTED]. However, there was no documentation regarding the afore mentioned pressure ulcers in this Note or any other physician progress notes [REDACTED]. to retrieve those. (DON B was asked to provide a copy of the missing physician progress notes [REDACTED]. The missing physician progress notes [REDACTED].) Review of R18's Pressure Ulcer records revealed no improvement between 5/09/19 - 6/11/19 for R18's Right Heel or Left Heel. There was no Pressure Ulcer Record for R18's Right Outer Ankle wound. R18's Right Outer Ankle wound was documented on a Skin Alteration Record - Do Not Use for Pressure Ulcers; on 5/09/19 it measured 3 cm x 2 cm and this wound was resolved on 6/05/19. In an interview, on 06/12/19 at 09:38 AM, Unit Manager/Registered Nurse (RN) D reported, (R8's) splints were recommended by therapy to be on while in bed as tolerated and removed twice a day for skin checks. I'm not sure it's on the care plan or not. He had them ordered 4/19/19 and developed pressure ulcers on 5/0/19. (R18) was still getting chemo and [MEDICAL CONDITION] at that time. He was to have them on while in bed. (The pressure ulcers) were avoidable. The splints could have been more personalized to his specific need. Off-cycle more frequently. LPN S did not report the red areas to me. Nurse Practitioner (NP) X was here yesterday to assess the right ankle it was a scabbed abrasion. Healing has been going on. In a telephone interview, on 6/12/19 at approximately 3:00 PM, MD U reported, The injury on (R18's) right outer ankle is a pressure injury.

Based on observation, interview, and record review, the facility failed to prevent loss of function for 1 of 10 residents reviewed for falls (Resident #4), from a total of 16 sampled residents, resulting in Resident #4 sustaining an avoidable functional loss of strength in her legs, inability to walk, and resultant pain. Findings include: According to the MDS/Minimum Data Set, dated dated [DATE], the EMR/Electronic Medical Record, the paper medical record, and Incident Reports, Resident #4 was a [AGE] year- old woman, readmitted on [DATE] and again readmitted on [DATE], who was cognitively intact, taking an antibiotic and an antidepressant. She was a Full Code. Resident #4's [DIAGNOSES REDACTED]. In an interview, on 9/14/16 at 10:35 AM, Resident #4 was alert, conversant, and oriented to person, place, and time. Resident #4 propelled herself backward from the Dining Room to her own Room, almost running into two (unnamed) residents and once almost into the wall. During the interview, Resident #4 had a wet sounding cough. Resident #4 said, The good old days of walking are over. They (nursing staff) are supposed to walk me, but they haven't walked me since I was discharged from Therapy; I was walking with them (Therapists). I have a walker in my room, but they don't use it. I propel myself backwards because it doesn't hurt as much as using my legs to move forward. Resident #4 said while she was in bed she had no leg pain, but when she was up in her wheelchair her pain was constant, and when propelling forward her pain level was 8 out of 10. According to the DON/Director of Nursing, in an interview, on 9/13/16 at 2:45 PM, Resident #4 was currently being transferred with the Sit to Stand if at all wobbly - she (Resident #4) judges. In an interview, on 9/14/16 at 10:10 AM, Nurse Aide K reported she had worked at the facility for 4 years and was present when Resident #4 fell on [DATE]; she reported she wrote a witness statement at the time of the fall. When asked about the instructions on the Kardex Transfer with supervision with walker for all transfers except early in morning & when feeling weak. May use sit to stand with purple size sling if resident not feeling well, Nurse Aide K said she wasn't sure what, early in the morning meant, but to her it meant, when she first wakes up. Nurse Aide K reported Resident walked with a walker before she fell and sustained an ankle fracture (12/30/15) and was doing pretty well with walking before her last admission to the hospital (5/06/16). When asked how she was currently being transferred, Nurse Aide R said, Hoyer (body lift). If we feel she needs it. she doesn't stand well with 2 of us; because her legs were so weak; for the past 2-3 weeks she was unable to bear weight while being transferred safely with 2 assist or while using the Sit to Stand mechanical lift. With the Sit to Stand, she is not bearing weight .the (Licensed) Nurses are aware. We have to have 2 people with all lifts. We haven't transferred her with a walker since 6/29/16. In an interview, on 9/15/16 at 9:25 AM, Nurse Aide P reported she was assigned to Resident #4 on a regular basis a few days a week. When asked if she found Resident #4 to be non-compliant, Nurse Aide P said, She's not non-compliant with anything. Nurse Aide P reported Resident walked with a walker before she fell and sustained an ankle fracture (12/30/15) and was doing pretty well before her last admission to the hospital (5/06/16), but had not been walked since. Nurse Aide P reported staff had used a Hoyer since May 2016 to transfer Resident #4, but that morning, because she refused the Hoyer, they transferred her with a Sit to Stand, 2 people, and a gait belt . When asked if she was able to bear weight on her legs, Nurse Aide P said, Not so much on her left leg.Nurse Aide P said she felt uncomfortable with a 2 person assist or a Sit to Stand with Resident #4 and thought Resident #4 should be being transferred with a mechanical Hoyer lift because her legs were so weak. Nurse Aide P said, We never transfer her with a walker, for the past 2-3 weeks she was unable to bear weight while being transferred safely with 2 assist or while using the Sit to Stand mechanical lift. Nurse Aide P said Resident #4 had been propelling herself backwards in her wheelchair for about 2 weeks, She told me it was easier. Nurses have seen her. No, I didn't report it. In an interview, on 9/15/16 at 11:05 AM, Nurse Aide R reported she wrote a witness statement regarding Resident #4's fall on 12/30/15, but did not know why it was not with the Incident data. Nurse Aide R reported, she had worked at the facility for [AGE] years, and said, I did not have my gait belt around her at the time. Nasty, naught, me .I was by myself .I did a 1 person transfer without a walker from the wheelchair to the toilet .she was supposed to be a 2 person. In an interview, on 9/14/16 at 10:45 AM, PT/Physical Therapist L reported he was the Therapist that had began working with Resident #4, on 6/07/15 for strengthening, and discharged her from therapy on 6/24/16. PT L reported at the time of discharge from therapy Resident #4 was a stand by assist with bed mobility and transfers, and was ambulating with a walker with 1 staff assist 30 feet every day. Physical Therapist L said it was expected the Nurse Aides would ambulate her daily going forward. PT L said, I would expect they would let me know if they were not doing that; I haven't heard anything. PT L reported he had seen Resident #4 propelling herself backwards in the facility recently, stopped her and told her it was not safe, but did not document in her medical record or speak with DON B about it. PT L said if Resident #4 was unable to bear weight and was not walking, she should have been reassessed by Therapy and probably been readmitted for additional therapy. ( )

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices to prevent falls and accidents for 1 of 10 residents reviewed for falls (Resident #4), from a total of 16 sampled residents, resulting in potential accidents (from propelling herself backwards), a fall with resultant fracture, and continued falls. Findings include: According to the MDS/Minimum Data Set, dated dated [DATE], her EMR/Electronic Medical Record [DIAGNOSES REDACTED].#4 was a [AGE] year old, admitted on [DATE] woman who had [DIAGNOSES REDACTED]. On 9/14/16 at 11:35 AM, RN/Registered Nurse J reported Resident #4's current weight was 250 pounds, and review of Resident #4's Medication Administration Record for September, 2016, revealed she was not taking an antidepressant, statin/cholesterol lowering medication, or an antibiotic in September; Resident #4 was taking a medication for to lower her cholesterol prior to her admission. Review of the past 12 months of Resident #4's Incident Reports revealed she sustained falls on 9/12/15 at 7:00 PM, 11/21/15 at 2:39 PM, and 11/24/15 at 1:40 PM (all 3 occurred during self transfers without injury), 12:30 at 1:30 PM (during an assisted transfer without the use of a gait belt with resultant ankle fracture), and falls with no apparent injuries on 5/13/16 at 10:16 AM, and 6/26/16 at 7:00 AM. Review of the Incident Report data, dated 12/30/15 at 1:30 PM, Fall without injury (or minori (sic) .(Resident #4) left knee buckled .slide down the wall to the floor . It was not documented in the Incident report that Nurse Aide R was not using a gait belt at the time of the fall, there was no witness statement from Nurse Aide R in the investigation file. The document entitled Facility Past Non-Compliance Checklist revealed Left Malleolus ankle Fracture but did not mention a gait belt was not in use during the fall; however, according to the One-On-One Inservice Record, Nurse Aide R was given a verbal review to follow policy and use gait belt at all times. The Kardex in the Incident file was dated 12/03/16 and revealed, .hoyer lift to transfer patient .Offer and encourage resident to toilet in am and pm .with assistance of hoyer (sic). Review of the Incident Report data, dated 5/13/16 at 10:16, revealed, the Sit to Stand was being used and (Resident #4) just let go .probably from buckling feet . Review of the Incident Report data, dated 6/26/16 at 7:00 AM, revealed, Pt (Resident #4) transferring into w/c (wheelchair) with cena (a Nurse Aide) pt's (Resident #4's) legs gave out pt lowered to floor with cena and supervisor .legs get weak - never know when this will happen . Nurse Aide K was not identified in the Incident Report data and there was no witness statement from Nurse Aide K. According to Nursing Progress Notes, dated 6/27/16 at 6:17 PM, Resident was lowered to the floor yesterday. Complains of pain that is more than typical to left ankle . According to Nursing Progress Notes, dated 6/28/16 at 7:53 PM, she was weak when being transferred in the sit to stand for transfer from the bathroom to her bed. According to Nursing Progress Notes, dated 7/20/16 at 2:21 PM, .movement adlib (as desired) w/c (wheelchair), ext 2 (extensive assist with 2 persons) transfers . Review of Resident #4's Kardex/Nurse Aide Care Guide, dated 9/14/16, revealed the Kardex instructed Nurse Aides to Transfer with supervision with walker for all transfers except early in morning & when feeling weak. May use sit to stand with purple size sling if resident not feeling well. According to the DON/Director of Nursing, in an interview, on 9/13/16 at 2:45 PM, Resident #4 was currently being transferred with the Sit to Stand if at all wobbly - she (Resident #4) judges. In an interview, on 9/14/16 at 10:10 AM, Nurse Aide K reported she had worked at the facility for 4 years and was present when Resident #4 fell on [DATE]; she reported she wrote a witness statement at the time of the fall. When asked about the instructions on the Kardex Transfer with supervision with walker for all transfers except early in morning & when feeling weak. May use sit to stand with purple size sling if resident not feeling well, Nurse Aide K said she wasn't sure what, early in the morning meant, bu to her it meant, when she first wakes up. Nurse Aide K reported Resident walked with a walker before she fell and sustained an ankle fracture (12/30/15) and was doing pretty well with walking before her last admission to the hospital (5/06/16). When asked how she was currently being transferred, Nurse Aide R said, Hoyer (body lift). If we feel she needs it. she doesn't stand well with 2 of us;because her legs were so weak; for the past 2-3 weeks she was unable to bear weight while being transferred safely with 2 assist or while using the Sit to Stand mechanical lift With the Sit to Stand, she is not bearing weight .the (Licensed) Nurses are aware. We have to have 2 people with all lifts. We haven't transferred her with a walker since 6/29/16. In an interview, on 9/15/16 at 9:25 AM, Nurse Aide P reported she was assigned to Resident #4 on a regular basis a few days a week. Nurse Aide P reported staff had used a Hoyer since May 2016 to transfer Resident #4, but that morning, because she refused the Hoyer, they transferred her with a Sit to Stand, 2 people, and a gait belt .we never transfer her with a walker. When asked if she was able to bear weight on her legs, Nurse Aide P said, Not so much on her left leg. Nurse Aide P said Resident #4 had been propelling herself backwards in her wheelchair for about 2 weeks, She told me it was easier. Nurses have seen her. No, I didn't report it. When asked if Resident #4 was non-compliant, Nurse Aide P replied, She's not non-compliant with anything. In an interview, on 9/15/16 at 11:05 AM, Nurse Aide R reported she wrote a witness statement regarding Resident #4's fall on 12/30/15, but did not know why it was not in the Incident information. Nurse Aide R reported, she had worked at the facility for [AGE] years, and said, I did not have my gait belt around her at the time. Nasty, naught, me .I was by myself .I did a 1 person transfer without a walker from the wheelchair to the toilet .she was supposed to be a 2 person. In an interview, on 9/14/16 at 10:45 AM, PT/Physical Therapist L reported he was the Therapist that had began working with Resident #4, on 6/07/15 for strengthening, and discharged her from therapy on 6/24/16. PT L reported at the time of discharge from therapy Resident #4 was a stand by assist with bed mobility and transfers, and was ambulating with a walker with 1 staff assist 30 feet every day. Physical Therapist L said it was expected the Nurse Aides would ambulate her daily going forward. PT L said, I would expect they would let me know if they were not doing that; I haven't heard anything. PT L reported he had seen Resident #4 propelling herself backwards in the facility recently, stopped her and told her it was not safe, but did not document in her medical record or speak with DON B about it. PT L said if Resident #4 was unable to bear weight and was not walking, she should have been reassessed by Therapy and probably been readmitted for additional therapy. Resident #4's Care Plans showed no mention of the risks or interventions regarding walking Resident #4 or interventions to prevent injury to self and other due to propelling backwards. ( )

This citation pertains to MI 002 Based on interview and record review, the facility failed to provide adequate supervision and a safe environment to prevent a fall with injury and subsequent death in 1 of 6 sampled residents (Resident #101) reviewed for falls, from a total sample of 6 resident, resulting in an Immediate Jeopary when, on [DATE] at 6:00 a.m., Resident #101, who was identified as a fall risk and required extensive 1 person assist with transfers and ambulation, who had a known history of non-compliance with safety interventions, was left unattended at the nurses station, fell from his wheelchair, sustained a hip fracture and subsequently died on [DATE] due to the traumatic injury. This deficient practice placed 4 residents identified as at risk for falls and a history of behaviors, at risk for serious harm, injury, and/or death. Findings include: According to Geriatric Nursing Protocols for Best Practice, Second Edition. (2003) Springer Series on Geriatric Nursing, "The majority of all falls that occur in the acute care setting involve individuals over the age of 65...The increased risk of falling in older adults may be due to a number of age-related changes, such as altered visual acuity, decreased reaction time, decreased balance and muscle strength...Nurses in the acute care setting have the most contact with patients and are in key positions to evaluate these individuals and implement interventions to decrease falls...A prior history of falls is frequently cited in the literature as a risk factor contributing to falls. Once an older adult has fallen, there is a significant increased risk that he or she will fall again under similar circumstances...a major concern with a fall is the subsequent fear of falling that can occur. The intention of a fall prevention program in acute care is not only to prevent falls, but also to provide patients with nursing care that focuses on improving and maintaining the functional ability of older patients". Review of the Face Sheet and the Minimum Data Set ((MDS) dated [DATE] revealed Resident #101 was a [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #101 required extensive 1 person assist with transfers, ambulation, and Activities of Daily Living (ADL's). The MDS indicated Resident #101's Brief Interview for Mental Status score was 4 which indicated he was severely cognitively impaired. Resident #101 was only able to stabilize with staff assistance moving from a seated to standing position, walking with assistive devices, turning around, moving on and off the toilet and from surface to surface. Review of the "Fall" Care Plan dated [DATE] revealed Resident #101 was identified as a fall risk due to unsteady gait, history of falls, noncompliance with the use of assistive devices related to (r/t) dementia with poor safety awareness with interventions that included: bed at transfer height, commonly used articles within easy reach, provide assist with transfer & ambulation as needed, and reinforce need to call for assistance. Review of the "ADL" (Activities of Daily Living) Care Plan dated [DATE] revealed Resident #101 required assistance with ADL's. Interventions included: transfer with 1 person for all functional transfers and walking with four wheeled walker (FWW). Review of the 24 hour report log dated [DATE] "Resident #101 awake from 10 PM- 2 AM attempted multiple times to get out of exit doors. Non-compliant with redirection. Crying and wanting to go home". Review of the Progress Notes dated [DATE] at 10:11 p.m. revealed Resident #101 was constantly up out of the wheelchair ambulating by himself. Review of the 24 hour report log dated [DATE] "resident urinated on the floor at 4:45 am. refusing care and calling staff names very rude. combative acting ready to punch nurse refusing PRN Xanax after attempting medication spit it out". Review of the Progress Notes dated [DATE] at 6:30 a.m. revealed Resident #101 was getting out of his room, walking in hallway very unsteady, non-compliant with safety device, not staying seated in his wheelchair. The note indicated Resident #101 was "monitored closely by staff as he continuously being non-compliant, keeps getting up tries to walk. Unsteady gait." Review of the Progress Note dated [DATE] at 9:28 p.m. revealed Resident #101 was found on the floor on his buttocks in room C-104 (not his room) at 2:30 p.m. The note indicated the Certified Nurse Aide (CNA) watched the resident go try to sit on the bed and missed and went down slowly to floor. The note indicated the CNA was unable to get to Resident #101 in time. During an interview on [DATE] at 4:23 PM, Registered Nurse (RN) #7 reported Resident #101 went into room C-104 on [DATE] and the CNA couldn't reach him in time and he fell . RN #7 stated, "He was more unsteady on his feet and that night and very confused. He shook his fist at me. I kept reporting to the DCD (director of care delivery/manager) and DON (director of nurses) on the 24 hour report log and they asked 'what more do you want'? My DCD was aware we had to keep redirecting him. He was also moved from the C-hall to D-hall and we had to keep him in the hall to see him." During an interview on [DATE] at 5:36 PM, Director of Care Delivery (DCD) #4 reported that Resident #101 had no awareness of his own safety, that he self-propelled in a wheelchair around the facility. When asked what specific interventions were put in place to ensure the resident's safety DCD #4 replied staff needed permission for 1:1 due to staffing, the resident was moved from C-hall to D-hall because staff were unable to handle the resident due to his behaviors". Review of the medical record revealed no new updates to Resident #101's care plans to prevent falls as indicated by the facility falls investigation. The section "plan revised" was checked "no" with comments that included, "MD (physician) and IDT (interdisciplinary team) feel a reduction in medication would benefit this resident. This intervention with hopes increase residents safety awareness and strengthen his gait". Review of the facility 24 hour report logs dated [DATE] Resident #101 "awake from 10 PM - 1 AM, crying wants to get out of the facility. Redirection ineffective. Non-compliant with wheelchair". Review of the Progress Notes dated [DATE] at 3 PM "forgetful where he is and why he is here. Redirected multiple times throughout shift". Review of the Incident report dated [DATE] at 11:30 p.m. revealed Resident #101 was agitated, attempted to stand from wheelchair and lost his balance and fell . Resident #101 fell on to his bottom. The note indicated Resident #101 received Benadryl x 1 dose at 12:30 AM. "Resident was encouraged to maintain seated, encouraged resident to lock wheels before standing and ask for assistance". Review of the 24 hour report log dated [DATE] "resident fell at 11:30 PM witnessed no injuries. very combative & agitated prior to and after fall. received PRN Xanax at 6 PM, and scheduled at 8 PM. Next PRN could not be given until 2 AM, given Benadryl 50 mg". Review of the Progress notes dated [DATE] at 1:08 AM "resident very agitated and combative from 11 PM-1 AM. at 11:30 PM ([DATE]) observed the resident attempting to stand from his wheelchair, lose his balance and fall on his bottom. Resident assisted back to his wheelchair and encouraged to remain seated. Denies pain or discomfort but continues to be very agitated. Doctor contacted and ordered Benadryl 50 mg now X 1 dose". Review of the Progress note dated [DATE] at 1:10 AM revealed, "not wearing hipsters at the time and refused to put them on at this point. One on one observation will continue". Review of the Progress note dated [DATE] at 3 AM revealed, " resident was becoming restless so he was taken to vending machine. Brought back behind nurses circle". Review of the Progress Notes dated [DATE] at 3:31 a.m. revealed Resident #101 was awake and up in his wheelchair at the nurses station. The note indicated Resident #101 "had trouble keeping his eyes open and was assisted to bed numerous times, but assisted back to his wheelchair after attempting to get out of bed multiple times and was at an increased risk for falls due to Xanax and Benadryl administration and fatigue. The note indicated Resident #101 was "one on one at this time due to fatigue and desire to get up and walk. " Review of the Incident report dated [DATE] at 6:00 a.m. revealed Resident #101 was attempting to stand from wheelchair and fell . The note indicated Resident #101 was agitated and exhibiting exit seeking behaviors. Resident was found on the floor in front of the wheelchair lying on his left side. Review of the Progress Notes dated [DATE] at 6:00 a.m. revealed, "CNA calling for help over by lobby doors. Resident (Resident #101) was lying on the floor. When approached resident was lying on left side with his head being supported by CNA. Wheelchair was off to right side just behind resident. Resident was stabilized. Vitals, neuro's, and range of motion started. Pupils equal and reactive to light. Alert and oriented to self. Complains of LLE (left lower extremity) pain with range of motion but no abduction noted. Patient was transferred by staff back to wheelchair. When asked what happened, he said "I was trying to get to my car". Prior to fall, resident was propelling self by nurses station and was noted to be at side door trying to push on it. " In an interview on [DATE] at 4:50 p.m., RN #8 stated, "He wouldn't stay in bed, so he had two doses of Xanax at 6 and 8 PM so I called the doctor and he gave me the Benadryl order. He was unsteady on his feet. We walked him to the end of the hall, from 3 am-6 am someone was with him. We were doing 1:1 between me and the CNA. At 6 AM, it was shift change and another nurse came in and wanted me to check on another resident I hadn't gotten to that night because I was so busy with him. I thought I could handle him (Resident #101). I left the nurses station, but didn't tell anyone to monitor him (Resident #101) while I was gone since he had to be redirected to sit back down so many times. I should have. I didn't call anyone. I was trying to deal with the rest of the residents and yes when we were with other residents he was left alone". During an interview on [DATE] at 9:40 AM, RN #2 reported that she arrived at the facility for work at 5:50 AM and saw Resident #101 sitting by the nurses station talking with a resident. RN #2 stated, "I heard him shaking the exit doors and the next thing I saw him lying on the floor in front of the doors on the mat on his left side with the wheelchair behind him. I did not see him fall, he told me his bottom was hurting and he was trying to get up, but wouldn't let him until I checked him over, he could move all extremities, and with 2 other people got him into his wheelchair. He then complained about his left leg hurting and was propelling himself around, he was known for doing things alone, going to the doors yelling out, self propelling around the building, always wanted to go to the door wanting his car". During an interview on [DATE] at 4:10 PM, Licensed Practical Nurse (LPN) #6 reported Resident #101 was known to be confused and trying to get out of his wheelchair. LPN #6 stated, "He had an unsteady gait and was wobbly on his feet. He would lose interest in anything quickly. A couple of times he set off the alarms trying to leave. Medications were being adjusted for anxiety, the Xanax was changed from routing to PRN (as needed) that didn't seem to work. We tried to do the best we could. You can't force them to do anything. That morning he fell , I came in at 6 AM and he was sitting in the wheelchair at the nurses station. He was complaining of left leg pain, he couldn't raise his leg without holding it. I called the doctor to get an x-ray ordered, put him back to bed with the Hoyer lift (mechanical lift). I know that I would have to take him with me while I was passing med's and leave him unattended while I was in the rooms just to prevent him from falling, I would instruct staff to do that taking turns watching him. I didn't know that morning he needed watching". Review of the Progress Notes dated [DATE] at 10:10 a.m. revealed Resident #101's x-ray showed left neck femoral (hip) fracture. Resident #101 was transferred to the hospital for evaluation and treatment Review of the Hospital Record dated [DATE] revealed Resident #101 was brought to the Emergency Department and found to have a left femoral neck fracture. The discharge summary dated [DATE] revealed Resident #101 died due to the fracture. Review of the Death Certificate dated [DATE] revealed Resident #101's cause of death was "hip fracture". On [DATE] at 5:10 PM, the Administrator and Director of Nurses were notified of the Immediate Jeopardy that began on [DATE] and was identified on [DATE], due to the facility's failure to provide adequate supervision and a safe environment to prevent a fall with injury and subsequent death of Resident #101. On [DATE], the surveyor confirmed that the facility implemented the following to remove the Immediate Jeopardy: 1. On [DATE], the interdisciplinary team reviewed ,[DATE] residents clinical records and fall incident reports that currently reside in the facility for residents who have behavior symptoms that place them at high risk for falls. IDT identified ,[DATE] residents who display behaviors that place them at high risk for falls. 2. On [DATE], the IDT team reviewed and revised like residents' care plans for falls and kardex for non-pharmacological interventions including increased supervision during times of increased agitation. 3. On [DATE], IDT team did visual rounds to like residents to ensure fall interventions were in place and appropriate. 4. Beginning [DATE], newly admitted residents will be evaluated for being at high risk for falls in admission assessments including evaluation of cognitive status and factors placing them at high risk for falls. 5. Beginning [DATE], IDT will review new admissions for behaviors that place them at high risk for falls and care plans and kardex's will be reviewed and revised as indicated. 6. Beginning on [DATE], the Director of Nursing began education to nursing staff on the process of ongoing management for implementing 1:1 supervision when needed. 7. Since [DATE], ,[DATE] licensed nurses had been educated and ,[DATE] CNA's had been educated, with new nursing staff hires to receive education prior to scheduled shifts during orientation. 8. Beginning [DATE], non-nursing department facility staff will be educated on non-pharmacological interventions to prevent falls including implementing 1:1 supervision. 9. Beginning [DATE], the DCD will audit nursing notes through computerized reports for progress notes documented in the resident electronic record Monday-Friday for behaviors that place the resident at high risk for falls ensuring documentation and interventions are in place to prevent falls. 10. On [DATE] and [DATE], the IDT and Quality Assessment Committee reviewed the fall practice guideline that included care plan revisions and non-pharmacological interventions, mood and behaviors guideline including care plan revisions, wandering practice guidelines including 1:1 supervision. The BEERS list (criteria used in improving the safety of prescribing medication in older adults) was reviewed with licensed nurses related to the use of Benadryl in the elderly. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance with a scope of pattern and severity of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy due to all education had not yet been completed and sustained compliance had not been verified by the State agency. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PREPARE INTERVENTIONS TO ENSURE PAIN CONTROL AND DIABETIC/NUTRITIONAL SUPPORT WHILE OUT OF THE FACILITY FOR MEDICAL APPOINTMENTS FOR 1 OF 6 RESIDENTS (#5) REVIEWED FOR PAIN OR DIABETIC MANAGEMENT, FROM A TOTAL SAMPLE OF 16 RESIDENTS REVIEWED, RESULTING IN THE RESIDENT REPORTING AVOIDABLE, SIGNIFICANT EXPERIENCE OF PAIN WHILE OUT OF THE FACILITY FOR A MEDICAL APPOINTMENT AND POTENTIALLY BEING PLACED AT INCREASED RISK FOR A HYPO/HYPERGLYCEMIC (ABNORMALLY HIGH OR LOW BLOOD SUGAR) EPISODES. FINDINGS INCLUDE: A REVIEW OF RESIDENT #5'S MEDICAL RECORD REFLECTED THE FOLLOWING: THE FACILITY'S FACE SHEET DATED 2/19/13, REFLECTED RESIDENT #5 WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. RESIDENT #5'S QUARTERLY MINIMUM DATA SET (MDS) assessment dated [DATE] REFLECTED A BRIEF INTERVIEW FOR MENTAL STATUS (BIMS) SCORE OF 15 OUT OF A POSSIBLE TOTAL OF 15, MEANING THAT RESIDENT #5 WAS COGNITIVELY INTACT. UNDER THE PAIN ASSESSMENT SECTION OF THE MDS, RESIDENT #5 REPORTED THAT SHE OCCASIONALLY HAD PAIN THAT LIMITED HER ABILITY TO COMPLETE DAY-TO-DAY ACTIVITIES. SHE RATED HER HIGHEST PAIN LEVEL (ON A ZERO TO TEN SCALE, FOR THE PAST 5 DAYS) AS A "6" (WITH ZERO BEING NO PAIN AND 10 BEING THE WORST POSSIBLE PAIN). A REVIEW OF THE FACILITY'S APRIL 2013, PHYSICIAN ORDERS/MARS (MEDICATION ADMINISTRATION RECORDS FOR RESIDENT # 5 REFLECTED ORDERS THAT INCLUDED THE FOLLOWING: [MEDICATION NAME] (MEDICATION USED TO TREAT NERVE PAIN) 300 MILLIGRAMS (MG) BY MOUTH TWICE DAILY AT 8:00 AM AND 8:00 PM AND [MEDICATION NAME] 100 MG BY MOUTH ONCE DAILY AT NOON. [MEDICATION NAME] (NARCOTIC PAIN MEDICATION) 10-325 MILLIGRAM TABLETS, ONE BY MOUTH EVERY FOUR HOURS DURING THE DAY WHILE AWAKE, AT 8:00 AM, NOON, 4:00 PM AND 8:00 PM. HUMALOG (RAPID ACTING INSULIN) 100 UNITS, INJECT SUBCUTANEOUSLY PER SLIDING SCALE; ACCUCHECKS (BLOOD SUGAR ASSESSMENTS) BEFORE MEALS AND AT BEDTIME AT 7:30 AM, 11:30 AM, 4:30 PM AND 8:00 PM. THE APRIL 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. ON 4/16/13 AT APPROXIMATELY 10:30 AM, DURING INITIAL TOUR OF FACILITY, THE DIRECTOR OF CARE DELIVERY, REGISTERED NURSE (RN) STAFF "A" REPORTED THAT RESIDENT # 5 WAS OUT OF THE FACILITY AT A SCHEDULED APPOINTMENT AND WAS NOT EXPECTED BACK UNTIL LATER IN THE DAY. ON 4/16/13 AT APPROXIMATELY 3:30 PM, DURING REVIEW OF RESIDENT # 5'S COMPUTER AND HARD-COPY RECORDS, THIS SURVEYOR WAS UNABLE TO FIND ANY DOCUMENTATION RELATED TO RESIDENT #5 BEING OUT OF THE FACILITY. DURING AN INTERVIEW IMMEDIATELY FOLLOWING, REGISTERED NURSE (RN) STAFF "D" WAS ASKED WHERE THE DOCUMENTATION WOULD BE. RN STAFF "D" REPORTED THE DOCUMENTATION WOULD BE LOGGED IN THE THE LEAVE-OF-ABSENCE (LOA) BOOK. STAFF "D" WAS OBSERVED TO LOCATE THE LEAVE-OF-ABSENCE BOOK AND OPEN IT TO RESIDENT # 5'S PAGE, BUT THE LAST ENTRY FOR RESIDENT #5 WAS MADE ON 3/30/13. DURING AN INTERVIEW ON 4/16/13 AT APPROXIMATELY 4:00 PM, RN STAFF "A" WAS ASKED IF THERE WAS ANY DOCUMENTATION OF RESIDENT # 5 BEING ON AN APPROVED LEAVE-OF-ABSENCE FROM THE BUILDING. RN STAFF "A" WAS OBSERVED TO POINT TO A DESK FLIP-PAGE CALENDAR THAT REFLECTED RESIDENT # 5 WAS PICKED UP AT 9:00 AM FOR A SCHEDULED UNIVERSITY HOSPITAL CLINIC APPOINTMENT. DURING CONTINUED INTERVIEW, STAFF "A" SAID THAT RESIDENT # 5 WAS EXPECTED TO RETURN AT 9:00 PM. THAT SAME NIGHT. RN STAFF "A" WAS THEN ASKED IF FOOD OR MEDICATIONS WERE SENT WITH RESIDENT #5. RN STAFF "A" WAS ALSO ASKED TO EXPLAIN HOW THE FACILITY HAD PREPARED THE RESIDENT TO ENSURE PAIN CONTROL COVERAGE AND BLOOD SUGAR CONTROL, SINCE RESIDENT # 5 WAS OUT OF THE BUILDING FOR EXTENDED PERIODS WHEN SHE WENT TO HER MEDICAL APPOINTMENTS. RN STAFF "A" STATED, "THAT IS A GOOD QUESTION." STAFF "A" WAS THEN ASKED TO PROVIDE THE FACILITY'S LEAVE-OF-ABSENCE POLICY AND TO CLARIFY HOW MANY TIMES RESIDENT #5 HAD GONE OUT OF THE FACILITY FOR SCHEDULED EXTENDED PERIODS. FACILITY'S PROGRESS NOTES FOR RESIDENT #5 DATED 1/9/13 AT 9:13 AM REFLECTED A LEAVE-OF-ABSENCE TO A UNIVERSITY HOSPITAL CLINIC APPOINTMENT, AND PROGRESS NOTES DATED 1/29/13 AT 1:32 PM ALSO REFLECTED A LEAVE-OF-ABSENCE RELATED TO A UNIVERSITY HOSPITAL CLINIC APPOINTMENT. RESIDENT #5 WAS INTERVIEWED ON 4/17/13 AT 8:00 AM. DURING THE INTERVIEW, RESIDENT # 5 WAS ASKED WHAT TYPE OF FOOD SHE TOOK WITH HER THE PREVIOUS DAY, WHEN SHE HAD BEEN OUT OF THE FACILITY. RESIDENT #5 STATED, "THANKFULLY MY ROOMMATE HAD A BANANA AND WAS WILLING TO GIVE IT TO ME, BECAUSE I KNOW I NEED SOMETHING. I DIDN'T GET BACK UNTIL AFTER 7, AND I HAD NO WAY TO CHECK MY BLOOD SUGAR, AND I WAS IN PAIN BECAUSE I DIDN'T HAVE MY MEDICINE." WHEN ASKED MORE ABOUT HER PAIN YESTERDAY DURING HER LEAVE, RESIDENT # 5 REPORTED THAT IT STAYED A "7 OR 8" ALL DAY (REFERRING TO THE SCALE WHERE ZERO MEANT NO PAIN AND 10 MEANT THE WORST POSSIBLE PAIN). WHEN ASKED TO RATE HER PAIN AT PRESENT, RESIDENT REPORTED HER PAIN LEVEL AS "4". RESIDENT #5 WAS THEN ASKED IF THE FACILITY HAD SENT ANY FOOD WITH HER TO EAT WHILE SHE WAS AWAY, AND RESIDENT # 5 STATED, "NO". RESIDENT #5 WAS THEN ASKED IF SHE TOOK ANY MEDICATIONS WITH HER, AND RESIDENT # 5 STATED, "NO THEY NEVER SEND ANY MEDICATION, AND I DON'T KNOW WHY, I HAVE NERVE PAIN AND, IF I TAKE MY MEDICATION, IT STAYS ABOUT A 4". RESIDENT #5 WAS THEN ASKED ABOUT THE PROCESS FOR SIGNING OUT ON THE LEAVE-OF-ABSENCE BOOK, AND RESIDENT #5 STATED, "MY SISTER USUALLY ALWAYS DOES, BUT SHE COULDN'T FIND ANYONE AT THE NURSES STATION (YESTERDAY)." RESIDENT #5 WAS OBSERVED ON 4/17/13 AT 12:25 PM, SITTING AT A TABLE IN THE DINING ROOM, IN HER WHEEL CHAIR, WAITING FOR LUNCH AND WAS OBSERVED AGAIN, ON 4/19/13 AT 8:30 AM, SITTING IN HER WHEEL CHAIR IN HER ROOM, WAITING FOR HER BREAKFAST. A REVIEW OF RESIDENT # 5'S Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. NOON AND 4:00 PM DOSES OF SLIDING SCALE INSULIN (TO BE ADMINISTERED BASED ON ASSESSMENTS OBTAINED FROM GLUCOSE METERS) WERE ALSO ORDERED. RESIDENT #5'S CARE PLAN TITLED "GENERALIZED PAIN RELATED TO [MEDICAL CONDITION], PATIENT HAS HISTORY OF CHRONIC SINUS HEADACHES" (INITIATED ON 11/8/12, AND LAST UPDATED 3/25/13) IDENTIFIED THE FOLLOWING CARE GOAL: "WILL EXPRESS THAT PAIN MANAGEMENT IS WITHIN ACCEPTABLE LIMITS, INTERVENTIONS INCLUDE ADMINISTER PAIN MEDICATION PER PHYSICIANS ORDERS." BUT, THERE WERE NO INTERVENTIONS TO EXPLAIN HOW PAIN WOULD BE MANAGED WHEN THE RESIDENT WAS OUT OF THE BUILDING FOR MEDICAL APPOINTMENTS. RESIDENT #5'S CARE PLAN TITLED "ENDOCRINE SYSTEM RELATED TO DIABETES, [MEDICAL CONDITION]" (INITIATED ON 11/8/12) LISTED THE FOLLOWING CARE GOAL: "MINIMIZE/ BE FREE OF COMPLICATIONS RELATED TO DISEASE PROCESS. INTERVENTIONS INCLUDE ADMINISTER MEDICATION PER PHYSICIANS ORDERS, OBTAIN GLUCOMETER READING AND REPORT ABNORMALITIES AS ORDERED, REPORTS SYMPTOMS OF [MEDICAL CONDITION] (ABNORMALLY ELEVATED BLOOD SUGARS) AND REPORT SYMPTOMS OF [DIAGNOSES REDACTED] (ABNORMALLY LOW BLOOD SUGARS)." BUT, THERE WERE NO INTERVENTIONS TO EXPLAIN HOW THE RESIDENT'S DIABETES WOULD BE MANAGED WHEN THE RESIDENT WAS OUT OF THE BUILDING FOR EXTENDED PERIODS. REVIEW OF THE FACILITY'S POLICY DATED MARCH OF 2010, PROVIDED BY RN STAFF "A" AND TITLED "LEAVE OF ABSENCE: PATIENT" REFLECTED THE FOLLOWING: (UNDER THE SECOND BULLET POINT LISTED UNDER PROCEDURE) PATIENT OR AUTHORIZED REPRESENTATIVE READS AND SIGNS ACKNOWLEDGEMENT STATEMENT ON LEAVE OF ABSENCE FORM IN THE PRESENCE OF A WITTINESS THAT ALSO SIGNS THE FORM; (UNDER THE SIXTH BULLET POINT LISTED UNDER PROCEDURE) LICENSED NURSING STAFF FOLLOW CENTER PROCEDURES FOR LEAVE OF ABSENCE MEDICATIONS IF PATIENT HAS PHYSICIAN ORDERS [REDACTED]. ( )

This citation pertains to Intake Number MI 429. Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent elopement in 1 of 5 sampled residents (Resident #101) with a known elopement risk, from a total sample of 5 residents, resulting in an Immediate Jeopardy when Resident #101, who was a known elopement risk and had a Wanderguard (Secure Care bracelets), cut off the Wanderguard bracelet and exited the facility on [DATE] at approximately 10:50 a.m., unbeknownst to facility staff, and was found at 10:59 a.m. walking down the sidewalk approximately 200 yards from the facility, which placed 15 additional residents, identified as an elopement risk, at risk for serious harm, injury, and/or death. Findings include: Per the "Minimum Data Set", dated [DATE], Resident #101 was admitted to the facility on [DATE], scored ,[DATE] on "Cognitive Patterns" (indicating he had some memory problems), had not exhibited "Wandering" behavior, walked with supervision and with a "cane/crutch", was 64 inches tall and weighed 142 pounds, with [DIAGNOSES REDACTED]. Per the "Behavior Symptoms" assessment completed on [DATE], "Resident is a risk for exit seeking wandering. Secure Care administered. Wants to leave to go to his church/home. IDT (Interdisciplinary Team) to continue to monitor for change in moods/behaviors". Per Resident #101's plan of care, dated [DATE], revealed "Focus - elopement risk related to: dementia, cognitive impairment. Secure care (Wanderguard) to right ankle. Goal - Will not leave center (facility) unattended". Per the "Summary of Facility Investigation", dated [DATE], reflected that "(Resident #101) was noted to be outside of the facility on the sidewalk at 10:59 am on [DATE] per facility staff. (Resident #101) was immediately accompanied into the facility willingly with no injury noted and was appropriately dressed for weather conditions with a winter coat and hat. Upon return to the facility, assessment showed that the secure care device (Wanderguard) to (Resident #101's) right ankle that was verified in place and properly functioning earlier in the AM was now not present. (Resident #101) unable to state where the Secure Care device was...it was noted (Resident #101) was last seen visiting another resident in the facility approximately eight minutes prior to the discovery of this incident." The facility "Investigation Report Conclusion" documented that, "...The (approximate) time the resident (Resident #101) was unaccompanied outside of the facility was (approximately ,[DATE] minutes..." The "Investigation Report" included witness statements and an attachment entitled, "Elopement Timeline" that revealed that Resident #101 was, "observed at nursing station or in hallway by 7 nursing staff, 1 activity staff, 2 housekeeping staff and 1 therapy staff" between 9:,[DATE]:45 AM on [DATE]. On [DATE] at 10:55 AM, the outside windchill temperature in the city where the facility was located was 28.7 degrees Fahrenheit. (http://www.wunderground.com/history/airport/KHAI/[DATE]/DailyHistory.html?req_city=Three+Rivers&req_state=MI&req_statename=Michigan) On [DATE] at 9:00 AM, accompanied by Maintenance Director #4, this Surveyor observed the functioning of the 6 egress doors in the facility. The 4 egress doors at the end of the 4 resident units, not alarmed with a Secure Care system, were observed to be functioning properly with a 15 second release alarm. The door leading into the service hall had a Secure Guard (Wanderguard) alarm system in place that functioned properly; it alarmed when a Secure Care device, held by the Maintenance Director #4, came within 3 feet of the door. The egress door at the end of the service hall could opened without an alarm sounding when the Maintenance Director #4 entered a code on a keypad; this door also had 15 second release alarm that opened the door and sounded an alarm if the bar was pushed for 15 seconds or more (demonstrated by Maintenance Director #4). The front lobby egress was a double exit door, the inner most door had a Secure Guard alarm system in place that loudly alarmed when a Secure Guard device, held by the Maintenance Director #4, came within 3 feet of the door, and the outer door locked when the Secure Guard device activated. This outer front lobby door had a 15 second release mechanism which allowed the door to open and alarm after the Maintenance Director #4 pushed on the bar for 15 seconds. On [DATE] at 9:28 AM, Resident #101 was observed wearing a sweat shirt, jeans, shoes, and socks, sitting on his bed. A cane was leaning against the wall. When asked about being outside on [DATE], Resident #101 explained that he was trying to go to his doctor's office to get his coat that he thought he left there. Resident #101 stated, "He (his physician) had 3 rooms. I didn't know what room I left it (coat) in. My wife passed last labor day. If they sent it to my home, I wouldn't get it. I wanted to go there to tell them not to send it. That's when they caught me. Its not too far away. Its a good walk though. I thought if I could get right back, they wouldn't miss me...I didn't want to run away. I just wanted my coat". When asked about the Secure Guard device missing from his right ankle on [DATE], Resident #101 stated, "I don't know who cut it off. It was hurting and I was rubbing and rubbing. I might have pushed it off. I could have hidden if I went over to the next street...My wife had cancer...I can walk on my hands for 2 hours. I had to learn to balance on one hand. They pay good money for that in (name of city)". In an interview on [DATE] at 9:25 AM, Receptionist #13 stated that she, "wasn't here the day (Resident #101) eloped". In an interview on [DATE] at 12:06 PM, Business Office Manager #11 told this Surveyor she was the staff person who was acting as the receptionist on [DATE]. Business Office Manager #11 stated, "Yes, I was at the desk when (Resident #101) went through that way". Business Office Manager #11 further stated, "I was either in the office or in the lobby area speaking to family members. I didn't see him (Resident #101)...We have our Wander List, so we know who to watch for". In a telephone interview on [DATE] at 1:49 PM, Nurse Aide #1 told this Surveyor, "I went home on my lunch break to walk my dog. I left the facility at 10:27 AM and came back just before 11:00 AM. I went (drove) the same way, didn't see (Resident #101) the first time (when she left at 10:27 AM)". Nurse Aide #1 said she stopped at a yield sign by "the church" when she saw Resident #101, called the facility, and placed Resident #101 into her car to return him to the front entrance of the facility. Nurse Aide #1 stated, "(Resident #101) was moving along pretty good. I put him in my car and drove him back...he was cooperative but he wanted me to keep going to the hospital to get his jacket. He carried on a conversation and was pleasant. He had a hat and coat on. He wanders around inside the facility. I don't know if he's attempted it (elopement) before". On [DATE] at 2:16 PM, Maintenance Director #4 stated he measured the distance Resident #101 traveled on [DATE] from the front entrance of the facility, east down a sidewalk away from the facility, then south down a sidewalk on a residential street, towards the local hospital. The distance measured approximately 200 yards. In an interview on [DATE] at 9:45 AM, Nurse Aide #3 reported that she was working on [DATE], at the time Resident #101 was found outside alone. Nurse Aide #3 stated, "There was no alert that (Resident #101) was missing". In an interview on [DATE] at 10:05 AM, Registered Nurse (RN) #6 stated she was the Treatment Nurse on [DATE] and was doing "treatments" between 6:00 AM and 7:00 AM when she checked all door alarms and found them to be working properly, and checked Resident #101's Secure Care device on his right ankle and found it to be functioning properly. RN #6 stated, "I saw (Resident #101) standing at the yield sign and (Nurse Aide #1) had her car parked next to him. (Nurse Aide #1) called the facility by phone. (Resident #101) was wearing a hat, long trench coat, suit jacket, pants, shoes and socks. He looked like he was going to church...There was snow on the ground...He held my hand. I asked if I could assist him back to his room...his hands were warm. I didn't ask him how long he'd been outside. There were no scrapes on his hands or his face...(Licensed Practical Nurse (LPN) #9) assessed him (on second shift) and found the (Secure Care) bracelet the same day. When I went to do his body assessment, the psychiatrist was in there with him. The second time I went back in, family and friends were there and he (Resident #101) refused (the assessment)...asked if I could look through his dresser and found a pair of scissors in the top dresser drawer; little yellow sewing scissors". In a telephone interview on [DATE] at 11:15 AM, LPN #9 stated, "I found the actual alarm (Secure Care bracelet) laced with elastic (tied onto Resident #101's bed frame). The bracelet was cut, but there were holes punched and laced so he could put it back on". LPN #9 stated he tried to do an assessment on Resident #101 at the beginning of second shift but, "The people (visitors) just wouldn't leave". Per Resident #101's "Nurse's Notes", written by LPN #9, Resident #101's vital signs and body assessment were within normal limits on [DATE] at 9:20 PM. In an interview on [DATE] at 11:52 AM, Nurse Aide #10 stated she was assigned to Resident #101 on [DATE] at the time of the elopement. Nurse Aide #10 stated she last saw Resident #101 "around 9:00 AM or after" and said, "(Resident #101) was walking around the nurses' station. I asked him if I could help him with anything. He looked lost. He had his hat and coat on. He said he was looking for his friend on B Hall...The next time I saw him was after I was told he was outside of the building. About one hour had elapsed between the two times." On [DATE] between 1:01 PM and 1:44 PM, this Surveyor observed the Director of Nursing (DON) #7 check placement, expiration date, and functioning (with a test device that blinked green if working) of Secure Care bracelets on all 9 facility residents' assessed at risk for elopement. All nine residents had Secure Care bracelets in place on their bodies that had not expired, and were functioning properly. In an interview on [DATE] at 2:43 PM, Administrator #2 stated the front door was on an automatic timer that opened the door at 8:00 AM and locked the front door at 5:00 PM. The Administrator #2 said the job descriptions of the office staff and receptionist did not include watching for residents at risk for elopement because, "of bracelets" (the Secure Care guard system on the front door). On [DATE] at 4:00 PM, the administrator was notified of the Immediate Jeopardy that began on [DATE] at 10:45 PM, and was identified on [DATE] at 3:30 PM when Resident #101, who was a known elopement risk and had a Wanderguard bracelet, cut off the Wanderguard bracelet and exited the facility on [DATE] at approximately 10:50 a.m., unbeknownst to facility staff, and was found at 10:59 a.m. walking down the sidewalk approximately 200 yards from the facility, On [DATE] at 5:00 PM, this Surveyor confirmed that the facility implemented the following to remove the immediate jeopardy: 1. On [DATE] at 10:59 AM, Resident #101 was observed outside and was returned to the facility. One to one supervision for Resident #101 was implemented upon his return to the facility on [DATE] at 10:59 AM and continued until [DATE] at 2:00 PM. At 9:20 PM, a complete physical assessment was conducted; no physical injuries were found. 2. Upon return to the facility, Resident #101's Secure Care bracelet was found to be missing on his body. A new Secure Care bracelet was applied to Resident #101's right ankle and was checked for expiration, tested , and found to be functioning properly. 3. On [DATE] at 11:30 AM, Resident #101's plan of care was reviewed and updated. 4. On [DATE] at 11:10 AM, the facility psychologist met with Resident #101 and made recommendations for medication changes. 5. On [DATE] at 11:30, all other (15 residents) wearing Secure Care devices were validated for placement and function. 6. Between [DATE]-[DATE], all 16 residents identified at risk for elopement had their Plans of Care reviewed and updated. 7. On [DATE], Center Watch Binders (data, including pictures on residents at risk for elopement) were updated and a new Center Watch Binder was created for the receptionist in the front lobby. 8. On [DATE], all facility residents, not currently identified as a risk for elopement, were reassessed for elopement risk potential. Plans of care will be reviewed/revised as needed. 9. On [DATE] at 4:00 PM, a front door monitor (assigned staff) was put in place to monitor for residents exiting the building. 10. On [DATE] at 5:00 PM, education of management staff and receptionist on new interventions related to door monitoring was completed . 11. On [DATE], education of staff was initiated on indicators of elopement and possible interventions, review of the Wandering Practice Guide to include Missing Patine Actions. As of [DATE], 120 employees had been in-serviced and the 5 remaining employees, not in-serviced, will not be allowed to work until education is provided. 12. Beginning [DATE], the front door was locked with key pad exit and remote release via closed circuit television for entrance during business hours. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of pattern and severity of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy due all employees not being educated and sustained compliance had not been verified by the State agency. ( ).

Based on observation, interview, and record review the Facility failed to provide the necessary care and services (adequate and appropriate emergency assessment and treatment) to maintain the highest practicable physical well-being resulting in Immediate Jeopardy for 1 of 11 residents (Resident #101) who had fallen out of a sample of 16 resulting in the potential for life threatening complications (such as skull fracture, neck fracture, excessive blood loss, and infection) and the high risk for serious harm, injury, or death for all residents at the facility who may fall and sustain a possible head or neck injury. Findings include: Interviews on 1/6/11 with Licensed Practical Nurse (LPN) #10 (at 9:58 a.m.), Nurse Aide #11(at 12:47 p.m.) and Nurse Aide #12 (at 2:04 p.m.) and review of the Nurses' Notes and Neurological Evaluation Flow Sheet identified by LPN #10 as written by herself on 12/13/10 revealed Resident #101 was: a. Placed at risk of severe harm when she was moved from the floor with a visible head wound: 1. "General Trauma Interventions: Keep the victim lying down or in the position in which he or she is found..." (Phipps, W. J., Monahan, F. D., Sands, J. K., Marek, J. F., & Neighbors, M. (2003) Medical-Surgical Nursing Health and Illness Perspectives (7th ed.). St. Louis: Mosby). 2. "Spinal injuries include fractures, contusions, and compressions of the vertebral column, usually the result of trauma to the head or neck. The real danger lies in possible spinal cord damage...The primary treatment after spinal injury is immediate immobilization to stabilize the spine and prevent cord damage." Stabilization of the head and neck is done prior to moving the victim to prevent secondary injuries such as paralysis from destabilization of a cervical vertebrae fracture..." (Diseases: Causes and [DIAGNOSES REDACTED].). Pennsylvania: Springhouse). b. Received inappropriate and inadequate wound treatment and inadequate wound treatment which placed her at risk of infection (wound cleansed with tap water and washcloths and Kleenex held to the wound). c. Received inadequate wound treatment which resulted in blood loss (Steri Strips applied and reapplied as she bled throughout the night and was not sent to the hospital until the next day for sutures to close the head wound). d. Was not adequately and appropriately assessed and monitored at the scene of, and in the hours after, the incident (incomplete and/or no neurological assessments done). Per the Incident Report dated 12/13/10 Resident #101 "fell from bed. Open wound noted to right forehead. Bruising noted to right elbow and right knee. Assisted patient back to bed. Provided first aide care to open wound noted to right forehead. Cleansed area and applied Steri Strips to stop bleeding..." In an interview on 1/6/11 at 9:58 a.m. LPN #10 gave the following information: 1. At approximately 7:00 p.m. on 12/13/10 she was called to Resident #101's room by Nurse Aide #11 via the walkie-talkie. Upon arrival she saw Resident #101 lying on the floor between the bed and the wall on her right side facing the bed. 2. She saw "blood on the floor. It was from her head..." LPN #10 said, "My biggest concern was to get the bleeding" under control. LPN #10 said she took a "visual assessment to anything else that might be wrong, grabbed Kleenex off the table" and applied the Kleenex to the open wound. 3. LPN #10 and Nurse Aides #11 and #12 "helped" Resident #101 to "sit up on the floor." 4. She then asked Resident #101 "if she hurt anywhere else" and "checked her knee." LPN #10 said she found a dime sized reddened bruise on the knee cap and a bruised right elbow. LPN #10 said she "pushed the pant leg" of Resident #101's pajamas up in order to examine her legs and was able to see the elbow due to the pajama top having short sleeve. LPN #10 then changed her statement to say the sleeves were "actually more long sleeved" and she "pulled them up to half way up the upper arm." Nurse Aide #10 admitted she did not visualize Resident #101's hips. 5. Upon completion of the "visual check" after Resident #101 had been moved to a sitting position LPN #10 (without benefit a thorough examination or x-rays or CT scans) made the determination that there were no other injuries (such as fractured skull, bleeding in the brain, fractured neck, or [MEDICAL CONDITION]). LPN #10 said Resident #101, "was not embracing the area. She was not saying she hurt. She was not saying anything." 6. Initially LPN #10 said she and Nurse Aides #11 and #12 then lifted Resident #101 off the floor by "holding underneath her body" which she said meant the "trunk." LPN #10 said none of the 3 supported Resident #101's head or neck. 7. Upon further questioning LPN #10 changed her statement saying she also did "neuro checks" before lifting Resident #101 off the floor. LPN #10 said the "neuro checks" consisted of determining "alertness," by watching Resident #101 move her arms and legs, and by "looking at her eyes by putting my hand over her eyes" in the room light. LPN #10 said she was able to see that Resident #101's pupils were "equal and reactive" by utilizing this technique rather than following standards of practice for neurological assessment of the pupils (shining a light directly into each eye). 8. LPN #10 said after Resident #101 was on the bed she "cleaned her up" with "washcloths." LPN #10 said there was blood on the side of Resident #101's face and "around her ear." LPN #10 said she then applied "Steri Strips" (tape used to help maintain the edge of the wound in place). 9. LPN #10 said she gave the thermometer and pulse oximetry machine (used to check the oxygen level of the blood) to Nurse Aides #11 and #12 and instructed them to get Resident #101's vital signs. LPN #10 admitted she did not obtain vital signs before moving Resident #101. 10. LPN #101 said she then called the physician and reported the fall but did not report the vital signs. 11. "20 minutes later" LPN #10 entered Resident #101's room and found her "sleeping." Resident #101 "opened her eyes but didn't talk" when LPN #10 called her name. The Steri Strips were not intact; LPN #10 said Resident #101 "was starting to pick at" them. LPN #10 said she reapplied Steri Strips to the wound. 12. "10 minutes later" Nurse Aide #11 called her to the room and LPN #10 used a washcloth wet with tap water to clean the bleeding wound and reapplied Steri Strips after removing the old ones. 13. "20 minutes later" LPN #10 said she "peeked at" Resident #101 who was "sleeping" and alone in her room. LPN #10 stated she did nothing else at this time. 14. "20 minutes later" Nurse Aide #11 called her to the room because Resident #101 "started picking" and had "opened up the wound. I grabbed a big Band-Aid, took off the old Steri Strips, put on new and covered them with the Band-aid." LPN #10 admitted she did not cleanse the wound during this dressing change. 15. LPN #10 said she did not see Resident #101 again on her shift. Nurse Aide #11 said in an interview on 1/6/11 at 12:47 p.m. that on 12/13/10 he "heard a call for help" from Resident #101's roommate who said Resident #101 had fallen. Upon entering the room Nurse Aide #11 said he saw Resident #101 on the floor between the bed and the wall. "Her feet were tangled in her blankets." Resident #101 was lying parallel with the bed on her right side and slightly on her stomach facing the bed. Resident #101 was wearing a gown and incontinence briefs. "Her legs were bare. There was blood on the floor by her head. She picked at it with her hand. She wiped blood on her gown, on the sheets on the bottom (the fitted sheet still covering the mattress) and on her left hand. Her right hand was tucked under her trunk. Blood was running on her face. She said, 'Help get me off the floor-it's cold.' I called the nurse to check her. We don't move 'em (fallen residents) until the nurse checks. I removed the blankets from her feet and scooted the bed away to give (LPN #10) room." Nurse Aide #11 said LPN #10 conducted an assessment which consisted of asking her if she had any pain and cleansed the wound with "wet washcloths" and an "alcohol prep pad" and "saline solution in a squirt bottle." Nurse Aide #11 said "5 of us helped her to stand up and pivoted. First we sat her up. Two of us got a hold of her to stand her up. I had one arm (LPN #10) had the other arm" and other staff members were behind and in front of her. Nurse Aide #11 said, "Wait a minute. Maybe I'm wrong. I think we picked her up. We got her into a sitting position. She didn't have any pain or anything. One (staff person) under each arm with the other hand on her back in the lower spine area, one (staff person) under each knee and one under the butt. Then we continued cleaning her up. LPN #10 bandaged the wound on her head once we got her cleaned." Nurse Aide #11 said he checked on Resident #101 "every 15 minutes" and Resident #101 "kept picking at" the wound on her forehead. Nurse Aide #11 stated he obtained vital signs as instructed by LPN #10 but he did not know the time. He said he "wrote the first one on a paper towel and gave it to (LPN #10) in the room." Nurse Aide #11 identified the vital signs in the 3rd column timed 2100 (9:00 p.m.) on the Neurological Evaluation Flow Sheet as the set of vital signs he obtained. Nurse Aide #11 said the vital signs recorded in columns 1 and 2 were obtained by Nurse Aide #12 and he had "no idea" what time the vital signs were taken. Nurse Aide #12 said in an interview on 1/6/11 at 2:04 p.m. that he dressed Resident #101 in a gown, incontinence brief and socks and put her to bed at 6:30 p.m. on 12/13/10. Nurse Aide #12 said at approximately 7:00 p.m. upon returning from his break he saw LPN #10 and #14 and Nurse Aides #11 and #36 at Resident #101's bedside. Nurse Aide #12 said Resident #101 was on the bed and a "pool of blood was on the floor by the nightstand. Her face was starting to bruise. She was bleeding pretty good from that area." Upon further questioning Nurse Aide #12 said, "Yeah, I did help put her in bed. A 2-man lift. One had her legs and one had her upper body. I had the upper body. (LPN #14) or (LPN #10) had the legs." Upon being told what LPN #10 and Nurse Aide #11 said about lifting Resident #101 back into bed Nurse Aide #12 it was "probably like (LPN #10) said." Nurse Aide #12 said, "We tipped her onto her back to see her injuries. There was blood over her eyes, forehead and hair. We tipped from her side to her back. They had me run down and get equipment for vital signs after she was in bed. I took the temperature, wrote it on a slip of paper and gave it to the nurse." Nurse Aide #12 said "20 minutes later" the blood spill was cleaned and he repositioned Resident #101 in the bed. Nurse Aide #12 said there were Steri Strips above the right eye but the blood was "still seeping through. She was picking at it. I went and told (LPN #10) she was digging into it. Her first option was a Band-Aid. It was still seeping through. Then 2 x 4 (gauze dressing). That stopped it for awhile but she was still picking at it. I changed her bed at 7:00 p.m. and then I changed at least 2 more times. (Resident #101) had blood on her hands, the bedding and her nightgown. She was bruising up real bad. She did a number on her nose. I asked (LPN #10) if she broke her nose but she said she just bruised it. When they actually shipped her out the following morning she came back with sutures." LPN #14 said in an interview on 1/11/11 at 3:45 p.m. that on 12/13/10 he obtained "Steri Strips and triple antibiotics, bacterial bottle and sterile [DEVICE] pad" at LPN #10's request. LPN #14 said he saw Resident #101 on the floor in a "fetal position" and he "lifted the bed up so we could get it off of her." LPN #14 clarified that Resident #101 was under the bed but the bed was not resting on her body. LPN #14 said he saw "tiny amounts of blood" and admitted he did not observe LPN #10's assessments or wound care however he was aware there was a "gash, a slit on (Resident #101's) forehead" and knew that LPN #10 applied the Steri Strips to "cosmetically put it back together." LPN#14 said he did not instruct LPN #10 to call 9-1-1 or to stabilize Resident #101 on the floor until appropriate emergency personnel arrived and emergency care was given. LPN #14 stated he was unaware that a neurological assessment included steps such as assessing hand grips and foot pushes. LPN #14 said he had training at the facility but did not recall having training about neurological assessments in nurses' training (which he completed 6 years before). LPN #14 said, "We have check lists" of the "things we should do" in a neurological assessment and he was unfamiliar with the steps mentioned by this Surveyor. Changes in vital signs alone rarely indicate neurologic compromise and any changes should be related to a complete neurologic assessment. Because vital signs are controlled at the medullary level, changes related to neurologic compromise are ominous. (Diseases: Causes and [DIAGNOSES REDACTED].). Pennsylvania: Springhouse). Per Resident #101's Neurological Evaluation Flow Sheet the initial vital signs were listed in the column dated "12/13." The time of the entry was scribbled over to read "2000" (8:00 p.m.) When questioned in the interview on 1/6/11 at 9:58 a.m. about the vital signs in the first column LPN #10 stated they were the ones obtained by the nurse aides and handed to her on a paper towel. LPN #10 admitted she did not know what time the vital signs were obtained yet she documented them as being obtained at "2000". LPN #10 said she scribbled out and wrote over the times in the first 5 columns on the Neurological Evaluation Flow Sheet to "match" the 30 minute interval she believed she was expected to follow for Neurological checks. The rows in the section entitled "Level of Consciousness," "Orientation," "Pupils," "Motor Movement Evaluation," and "Communication/Language" in the columns timed "2000," "2030," "2100," "2130,"and "2200" all contained assessment data in every box. When reminded that in this interview she said she "peeked in" at Resident #101 and did nothing else LPN #10 admitted she falsified the Neurological Evaluation Flow Sheet not only by changing the times but by entering information (such as pupil size/reaction and limb movement) that she had not obtained. Per the hospital emergency room physician's note dated 12/14/10, the injury to Resident #101's head was described as a "laceration" and as a "puncture" located on the right forehead; it was noted to be "irregular" with a 2.0 cm length X 10.0 mm width X 6.0 mm depth; and it was closed with 5 sutures. Per the Computerized Tomography (CT) of the sinuses and of the head dated 12/14/10 Resident #101's "nasal bone deviate toward the left. If there is pain/swelling this region a non-displaced nasal bone fracture is possible." Per a "late entry" in Resident #101's Nurses' Notes dated 12/15/10, "Bruises remain to bilateral eyes..." Per Resident #101's Nurses' Notes dated 12/16/10 at 5:00 a.m. she was "medicated" for pain and "facial [MEDICAL CONDITION] and bruising ongoing." Per Resident #101's Nurses' Notes dated 12/16/10 at 1300 (1:00 p.m.) "Bruising remains to bilateral eyes..." Per Resident #101's Nurses' Notes dated 12/16/10 at 1600 (4:00 p.m.) "Bruising noted to right and left eye..." Per Resident #101's Nurses' Notes dated 12/17/10 at 0100 (1:00 a.m.) "Bruises remain to bilateral eyes..." Per the Minimum (MDS) data set [DATE] Resident #101 had identified memory loss and impaired ability to make decisions. Per the Minimum (MDS) data set [DATE] Resident #101's Cognitive Pattern score was 12 indicating a moderately impaired cognitive status; her Recall scores indicated there was some impairment. Per the Minimum Data Sets dated 8/17/10 and 11/19/10 Resident #101 required extensive assistance with bed mobility and transfers and she was unable to walk. Per the Minimum (MDS) data set [DATE] Resident #101's [DIAGNOSES REDACTED]. Per the January 2011 Routine Physician order [REDACTED]. In an observation on 1/6/11 at 9:30 a.m. Resident #101 was seated atop a mechanical lift sling in a wheelchair in her room. Resident #101 stated she did not remember falling from her bed. There was no wound visible on her forehead. The Administrator was notified on 1/6/11 at 4:55 p.m. of the Immediate Jeopardy that began on 12/13/10 as a result of failure to provide adequate assessment and emergency treatment after a fall with obvious head injury, including not calling 9-1-1, moving Resident #101 without adequate support, and failure to take appropriate emergency interventions including, but not limited to, initial treatment of [REDACTED]. This deficient practice placed all residents who had fallen at high risk for possible physical harm, injury, and death. On 1/13/11, the Surveyor confirmed that the facility staff completed the following to remove Immediate Jeopardy: 1. On 12/14/10 a fall risk assessment for Resident #101 was completed and bed bolsters and floor mats were provided. 2. On 12/15/10 licensed nurses received in-service training on assessment of a patient when a fall occurs. 3. On 12/15/10 the Quality Assessment and Assurance Committee met and developed an action plan to identify like residents and complete additional fall risk assessments. 4. On 1/6/11 one-to-one education was provided with LPN #10. 5. As of 1/7/11, 27 of 28 licensed nurses completed in-service training on completing Neurological Evaluation per the facility's guideline; not moving a patient with an obvious or suspected head, neck or back injury before completion of the Neurological Evaluation, securing head/neck during assessment, calling 9-1-1 when negative findings are present, and initial treatment of [REDACTED]. 6. As of 1/7/11 the in-service training (above) was added to the licensed nurse general orientation for newly hired employees. 7. On 1/6/11 the Neurological Evaluation guideline was placed in the front of all Medication Administration manuals. 8. On 1/6/11 additional flashlights and pen lights were placed in all medications carts and licensed nurses were in-serviced as to where the equipment was located. 9. On 1/6/11 like residents were identified for fall risk and care plans were updated. 10. A statement that residents admitted to the center will be evaluated for fall risk and care plans will be developed for fall prevention was included in the POC. 11. A plan to monitor falls at the management meetings held 5 days a week was started on 1/6/11. 12. On 1/6/11 the QA committee met and added the Emergency Response Education to new nurse orientation. Although the Immediate Jeopardy was removed on 1/7/11, the facility remained out of compliance at a scope and severity of pattern with no actual harm but the potential for more than minimal harm that is not immediate jeopardy due to policies and procedures for neurological assessments were not revised, not all staff in-service training was completed, and sustained compliance had not been verified by the State Agency. ( )

Based on observations, interviews and records review the Facility failed to ensure that the following Standards of Practice were implemented for 16 of 16 residents in the sample (#101, #102, #103, #104, #105, #106, #107, #108, #109, #110, #111, #112, #113, #114, #115 & #116): 1. Assessment to prevent falls resulting in a fall with actual harm (closed head injury and sutures) for Resident #101 and the potential for falls with injuries for Residents #102, #104, #105, #106, #107, #108 and #109; 2. Documentation of incident reports and nurses' notes-after a fall (#104, #108, #110 , #112, #113, #115 & #116) resulting in repeated falls with potential for actual harm-injuries; 3. Assessment for delayed consequences from a known or suspected injury to the head (#101, #104, #113, #115) which placed them at risk of unrecognized and untreated delayed consequences such as bleeding inside the brain resulting in paralysis or death; 4. Obtain physician's orders [REDACTED].#104 & #113) resulting in the potential for actual harm due to excessive length of time of bleeding and the potential for infection and/or non-healing of the wound 5. Standards of Practice for Documentation of Change in Condition (#101, #109) resulting in the potential for lack of adequate assessment and timely response to changes in condition; 6. Standards of Practice for Documentation of Medication Administration (#109) resulting in the potential for medication error and lack of treatment for [REDACTED]. 7. Nurses' Notes Out-of-Sequence (#114) resulting in the potential for miscommunication and errors in assessment and care; 8. physician's orders [REDACTED]. 9. physician's orders [REDACTED].#103, #104, #105, #106, #107, #108, #109, #110, #111, #112, #113, #114 & #115 resulting in the potential for inadequate monitoring of medications. Findings include: 1. Standard of Practice-Assessment to Prevent Falls Per the Clincal Process Guidelines for Evaluation of Falls/Fall Risk (MDCH, 2001) fall risk assessments must be conducted on admission, after a fall and if there was a significant change; major risk factors for falls must be considered. Per an undated list labeled "Residents beds moved away from the wall prior to [DATE]" 30 residents' beds were repositioned in their rooms. In an interview on [DATE] the Administrator stated there was no documented assessment of fall risk related to moving the beds from the wall in the clinical records of these 30 residents. In addition to Resident #101, seven additional residents (Residents #102, #104, #105, #106, #107, #108 and #109), whose names were on the list of 30 residents whose beds were moved away from the wall prior to Resident #101's fall on [DATE], were added to the sample. Review of the clinical records for Residents #102, #104, #105, #106, #107, #108 and #109 revealed there was no documented assessment for fall risk related to moving their beds from against the wall dated before the beds were moved. Observations on [DATE] of Residents #102 (at 9:45 a.m.), #104 (at 9:45 a.m.), #105 (at 9:15 a.m.), #106 (at 9:20 a.m.), #107 (at 9:25 a.m.), #108 (at 9:25 a.m.) and #109 (at 9:55 a.m.) revealed their beds were positioned away from the wall. Resident #104 said in an interview on [DATE] at 9:45 a.m. that his wife (#102)'s bed was moved away from the wall "just about a week ago" and he did not know why the decision was made to do so. Resident #101 Review of the clinical record for Resident #101 revealed no documented evidence of a comprehensive assessment for safety issues related to repositioning her bed away from the wall. Per the incident report dated [DATE] Resident #101 "fell from bed" and sustained an "open wound" to her forehead and bruises to her right elbow and right knee. Per the Incident Report State Addendum "an assessment had not been completed prior to the move" of her bed from against the wall and no new safety interventions were instituted. In an interview on [DATE] at 2:04 p.m. Nurse Aide #12 stated Resident #101 slept "against the wall since she's been here. She's always hugging (the wall) on the left side (of her bed)." Nurse Aide #12 said after Resident #101's bed was moved away from the wall "no precautions" to prevent falling out of bed were put into place for Resident #101. Nurse Aide #12 said, "Nothing was put on the bed" referring to bed bolsters and no mats were placed on the floor along the sides of the bed until after Resident #101 fell and was injured. 2. Standard of Practice following a fall: After repeated requests made by this Surveyor to the Facility administrative team members for Policies and Procedures regarding what the staff were expected to do when a resident had fallen, a printed copy from an undated power point presentation was provided which read: "In the event of a fall: After providing the appropriate level of care to the patient: 1. Complete an incident/accident report form... 2. Document the event in your progress notes. The progress note is the record of events in the clinical record. The progress note includes date, time and facts of the event. Include assessment findings, notifications to physician and responsible party and new orders initiated..." Steps #3 and #4 were 4 pages of instructions regarding the assessment of the resident after the event including root cause analysis, historical perspective of the resident, and much more. "5. Obtain necessary physician orders...immediate first aid care... 6. Update the patient care plan. Every order written requires reevaluation of the patient's plan of care...The care plan needs to reflect that it was reviewed in a timely manner after any fall..." Resident #104 Per the Incident Report dated [DATE] Resident #104 "fell and hit his head and right knee" at 9:30 p.m. in the bathroom. Per the "Center Action" section of the Incident Report "applied ice on the R head knee (sic), cleaned w/ antimicrobial deodorizing cleanser, steri-stripps (sic) and dressing gauze given (sic)." There was no other documentation on the Incident Report: the names of the staff involved in the incident were not given; the size and a thorough description of the location and types of wounds was not given; and the condition of the location of the incident was not described (such as whether the call light was activated or if the floor was wet or if the resident was not wearing appropriate footwear). There was no documentation regarding whether the fall alarm was sounding and in working order; the Falls Risk care plan initiated on [DATE] included the intervention initiated on [DATE] for a sensor alarm to the bed and the wheelchair. Per the Nurses' Notes dated [DATE] at "21:30" (9:30 p.m.) Resident #104 "fell . Found in the bathroom by aide. Applied ice, steri-stripps (sic) and gauze dressing given (sic). Denies pain." Other than the vital signs there was nothing else written about the incident in that Nurses' Note. Per the Nurses' Notes dated [DATE] Resident #104 had "steri-strips intact to right eyebrow area. No drainage. Bruising and swelling to right peri-orbital area." The note did not describe the size of the laceration held together with the Steri Strips. Per the Skin Alteration Record dated [DATE] the "type of alteration" was a hematoma (bruising) with laceration" and a circle was drawn around the right eye, right side of the nose, right cheek, right upper lip and onto the right forehead on the human body sketch. Measurements were documented as 3.0 cm x 0.2 cm. It was unknown if the measurements were intended to describe the entire area circled on the sketch or the entire "hematoma-bruising with laceration" or just the laceration. A circle was drawn encompassing and extending beyond the right knee and the numbers "2.2 x 0.9" were written at the beginning of a line that ended in the circle. It was unknown whether the size of the wound was measured in centimeters or in inches. "Description of alteration" was "edges approximated". It was unknown if the author was describing the laceration or the injuries to the face or knee. The "Skin Surrounding Alteration" section contained check marks in the boxes for "[MEDICAL CONDITION]-swelling" and "discoloration-blue, purple, yellow" with three words written beside it which appeared to be "raised blue bruise" or "raised BUE (abbreviation for "bilateral upper extremities") Bruise." Review of the Clinical Record revealed a Care Plan dated [DATE] entitled "Skin Tear Right Knee." The interventions included changing Steri Strips on the right knee skin tear. Another Care Plan entitled "Bruising with laceration to right periorbital are" was also dated [DATE] and interventions were the same as the ones for the right knee. The Administrator and Nurse Consultant were asked repeatedly on all days of the investigation for any other information they had regarding an investigation of this fall and the falls sustained by other residents in the sample. The Administrator and Nurse Consultant repeatedly stated the falls were discussed in team meetings held twice a day and that information was gathered by the staff but a falls investigation file was not maintained for all falls. The meeting documentation consisted of entries written on poster sized paper which the Administrator said was hung on the wall and used during the team meetings. A "Falls (off cycle)" report was produced which stated the fall occurred on [DATE] at 21:30. The following boxes had a check mark in them: "Need to rock body or push off on arms of chair when standing up from chair," "Impaired balance during transitions," "Antidepressants," "Cardiovascular medications," "Cardiac [MEDICAL CONDITION]," "Muscle weakness," "Impulsivity or poor safety awareness: and "Other dementia." The second page contained the following: "Pt has a hx (history) of falls at this facility r/t (related to) noncompliance with call-light use secondary to dementia. Pt. able to walk with walker with standby assist, however, has difficulty making the transitions. After completing fall round with therapy it was decided that putting the pt (sic) on a walk to dine schedule would be most appropriate. Pt. may then have the autonomy to walk independently, but will also have the supervision. All other interventions remain in place. Goal continues; reduce the risk for injury." There was no documented explanation found as to how the "walk-to-dine" program would reduce further episodes of Resident #104 going to the bathroom without assistance. The Author of the "Falls (off-cycle)" report-RN #22-was interviewed at 10:55 a.m. on [DATE]. RN #22 said he did not seek out or interview any of the staff who were present during and following the fall incidents. RN #22 said, "I fill out my portions. I complete the second page." RN #22 said he reviews the Incident Reports and makes his decisions for the care plan based on what is written on the Incident Reports. Resident #104 was observed seated in his chair in his room on [DATE] at 9:45 a.m. A personal fall alarm was visible in the wheelchair which was facing Resident #104 as he sat in another chair next to his bed. A fall alarm was not visible on Resident #104 (but may have been under him). Resident #104 stated prior to admission to this facility he had fallen at home and sustained a head injury. Resident #104 stated he lay on the floor for 60 hours until his daughter found him. Review of the Physician's Progress Note dated [DATE] revealed Resident #104 had a fall resulting in a [MEDICAL CONDITION]-1 vertebrae and rhabdomyolysis (a condition caused by lack of movement of the body for an extended period of time-such as lying on the floor for 60 hours-resulting in death of skeletal muscle and the body's attempt to cleanse itself of the dead tissue). Per the Minimum (MDS) data set [DATE] Resident #104 had few memory deficits; he required extensive assistance with bed mobility and transfers; he required limited assistance with walking in his room or in the corridor; and he required extensive assistance with toileting. Resident #108 Per the Incident Report dated [DATE] at 4:00 p.m. Resident #108 stated the nurse aide hit her in the left eye with the mechanical lift. The nurse aide was not identified on the incident report or in the Nurses' Notes. No further investigation data was provided thus it was unknown if the Facility determined nurse aide error/competency. The only Nurses' Note after the day of the incident was dated [DATE] and did not mention the condition of her left eye. Resident #108 was observed in her room on [DATE] at 9:25 a.m. and in bed on [DATE] at 9:57 a.m. with no visible injury to her eye. Resident #110 Review of the Nurses' Notes in the closed record for Resident #110 revealed entries on [DATE] which stated he had fallen and told the staff he hit his head and on [DATE] which stated he "stood up and fell to the floor." Repeated requests made to the administrative team resulted in no Incident Report provided for these 2 incidents. The Nurses' Notes for these 2 incidents did not mention that the physician was notified of the falls and did not provide information such as the staff members present, cause of the fall and interventions to prevent recurrence of falls. Per the Incident Report dated [DATE] Resident #110 was witnessed falling onto the floor mat from a standing position. The section for date/time and name of physician notified was blank. The Nurses' Notes dated [DATE] said, "Parties notified" but did not provide the names of these "parties" or what time they were notified. On [DATE] at 1:50 p.m. Resident #110 was observed in his bed deceased with family members present. Resident #112 Per the Incident Report dated [DATE] at 3:30 p.m. Resident #112 was "found on the floor next to the floor (sic)" and an "Ice pack compressed (sic) given." There was no description of the wound or injury that required an ice pack and the names of staff members on the scene were not documented. There was no Nurses' Note dated [DATE]. Review of the Incident Reports dated [DATE] and [DATE] and interview with RN #33 revealed the cause of Resident #112's fall on [DATE] was not documented or reported and Resident #112 fell due to the same cause on [DATE]. In an interview on [DATE] at 10:10 a.m. RN #33 said on [DATE] she was "two rooms away" when "we heard a noise." RN #33 could not remember the name of the Nurse Aide who was with her at that time. RN #33 said she found Resident #112 "on her side" on the floor. RN #33 said Resident #112 "said she hurt her right hip. I put ice pack" on the hip. RN #33 said she determined that the right hip was not broken because Resident #112 "was able to lift her leg." RN #33 said Resident #112 told her she "'lost her balance.' The wheelchair brakes were not locked." RN #33 said she could see the brakes were off and the wheelchair had rolled away in such a position that she knew the reason Resident #112 fell was because the wheelchair rolled away as she tried to either get into or out of it. RN #33 said she did not hear a fall alarm sound during this incident. RN #33 stated she "missed the Nurses' Notes that day." RN #33 did not communicate the cause of the fall to the staff via the Incident Report or through Nurses' Notes and she did not update the care plan. Per the Incident Report dated [DATE] at 3:30 p.m. RN #33 "witnessed the fall incident. I was acrossed (sic) the room passing meds and i (sic) heard noise (sic) and saw the pt. on the floor next to her bed." "Apply ice compressed at the left lower chin and routine Tylenol given." In the interview on [DATE] RN #33 said on [DATE] she "heard a noise and went there right away. I asked her what happened. The wheelchair was close to the bed. The locks were not locked." When questioned to explain how she "witnessed" the incident (per her statement on the Incident Report) but now said she "heard a noise" and then went to the scene, RN #33 said she "actually did" see the incident. RN #33 said Resident #112 was sitting on the mat "facing the bed" and she saw the wheelchair "move slightly. I heard the oxygen (concentrator) move. She pushed the oxygen (concentrator during the fall). I saw the wheelchair move away and (Resident #112) go down on her butt." RN #33 said she did not see Resident #112 hit her chin however Resident #112 said she did so. RN #33 said she applied the ice compress to prevent swelling and administered "routine Tylenol." RN #33 did not recall the name of the Nurse Aide who was on the scene with her. Per the Nurses' Notes dated [DATE] Resident #112 "fell at 15:20 (3:20 p.m.). c/o (complained of) pain at left chin. No bruise noted. B/P ,[DATE]..." In the interview on [DATE] at 10:10 a.m. RN #33 said the blood pressure reading of ,[DATE] was obtained immediately after the fall occurred and she did not investigate whether Resident #112 fell because she became dizzy due to the low blood pressure. RN #33 said Resident #112 fell because the wheelchair rolled away. Nurse Aide #28 said in an interview on [DATE] at 2:43 p.m. that on [DATE] she heard Resident #112's fall alarm sounding and upon entering the room noted the call light was activated and Resident #112 was sitting on the mat next to her bed. "She slipped down. The nurse checked her for injury. Nurse Aide #28 said on [DATE], "The nurse heard the incident. Her alarm was sounding and her call light was on." Nurse Aide #28 said she was giving care to another resident when the fall occurred but she went to the scene and saw Resident #112 in a sitting position on the mat next to her bed. Nurse Aide #28 said Resident #112 "said she hit her chin." Nurse Aide #28 said she put a gait belt on Resident #112, "stood her up and put her onto the bed." Nurse Aide #28 said she and the nurse "lifted" Resident #112 off the floor. Per the Minimum (MDS) data set [DATE] Resident #112 was a [AGE] year-old female diagnosed with [REDACTED]. On [DATE] at 1:52 p.m. Resident #112 was observed on her bed. Resident #112 said, "I fall a lot. I had a black eye. I slipped off the bed." Resident #113 Per the Incident Report dated [DATE] at 3:00 p.m. Resident #113 "fell forward out of wheelchair. She hit her head on floor...Bruise and cut above right eye. Steri Strips applied after clearing (sic). Nuro (sic) checks began and WNL (within normal limits). Bruising to left knee noted." The staff members present on the scene were not named. The size of the cut which required Steri Strips to hold the wound together was not documented. "Steri Strips" are individual pieces of tape used to "maintain the edge of the wound in place...instead of stitches" (steristrips.com). Per the Nurses' Notes dated [DATE] Resident #113 "fell out of the wheelchair on B Hall hitting head on floor. Head bleeding cleaned. Steri strip (sic) applied. Bruising and cut above right eye and bruising to left knee. Pt. c/o (complained of) HA (headache). Routine Vic ([MEDICATION NAME]-narcotic pain medication) was effective..." Per the Nurses' Notes dated [DATE] at 0250 (2:50 a.m.) Resident #113 had "bruising noted to right eye and left knee." Per the Nurses' Notes dated [DATE] at 9:40 a.m. Resident #113 had "bruising right eye with swelling. Skin left knee bruising...denies severe pain. Is sore. [MEDICATION NAME] effective for pain..." Per the Nurses' Notes dated [DATE] at 3:00 a.m., 1:00 p.m., and 8:00 p.m. bruising and swelling to the right eye was present. The 2 Nurses' Notes dated [DATE] did not mention the eye or the knee. The first recorded measurements of the cut above Resident #113's right eye found in her clinical record were dated 3 days after the incident. On [DATE] the Skin Alteration Record described the wound as "0.4 cm x 0.1 cm laceration" with "scant (illegible)" serosanguinous drainage, "[MEDICAL CONDITION]-swelling," "Discoloration" (the color was not circled), and "Lg (large) illegible R (right) illegible Periorbital." The knee was not mentioned. In an interview on [DATE] at 3:24 p.m. RN #31 identified the [DATE] Nurses' Note as authored by herself. RN #31 stated she did not measure the injuries. RN #31 said she did not cleanse the wound but rather "dabbed around it" with washcloths. Per the Minimum (MDS) data set [DATE] Resident #113 was diagnosed with [REDACTED]. On [DATE] at 1:40 p.m. Resident #113 was observed on her bed. Resident #113 stated she did not remember falling however she said "yeah" she had cut her head and lifted her bangs. No wound was visible to the forehead. Resident #115 Per the Incident Report dated [DATE] a bruise was discovered on Resident #115's forehead. The incident report did not describe the size of the bruise nor did it list the name of the staff member involved in the incident. The incident report did not describe the circumstances that resulted in the bruise. Resident #116 Review of the Incident Reports dated [DATE], [DATE] at 8:00 a.m., [DATE] at "12:15 p.m.," [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] & [DATE] revealed the names of the staff present during the incidents were not listed and thorough descriptions of the incidents were not documented. Review of the Nurses' Notes revealed the following falls occurred but no incident reports were provided: [DATE] at "23:15" (11:15 p.m.) and [DATE] at "00:15" (15 minutes after midnight). There were no Nurses' Notes found regarding the fall on [DATE]. 3. Standards of Practice-assessment for delayed consequences of head injury Per the Falls/Fall Risk Process Guidelines (MDCH, 2001) residents who have fallen are at risk for delayed consequences which may occur "within several days after the fall; occasionally they can occur several weeks later." "Acute subdural hematomas develop within 48 hours of injury and have an organized clot. Subacute subdural hematomas develop within 3 days to 2 weeks after a head injury. The chronic subdural hematoma can produce symptoms from about 3 weeks to several months after the injury. The damaged area is filled with fluid rather than an organized clot." (Phipps, W. J., Monahan, F. D., Sands, J. K., Marek, J. F., & Neighbors, M. (2003) Medical-Surgical Nursing Health and Illness Perspectives (7th ed.). St. Louis: Mosby.) Resident #101 Per the hospital emergency room physician's notes dated [DATE], on [DATE] Resident #101 sustained a "closed head injury" with a laceration to her forehead which required 5 sutures for closure. Review of the Neurological Evaluation Flow Sheet reviewed monitoring Resident #101's Neurologic status did not extend beyond [DATE]. Resident #104 Per the Incident Report dated [DATE] Resident #104 "fell and hit his head and right knee" and ice and Steri Strips were applied. Review of the Neurological Evaluation Flow Sheet the neurological assessments ended on [DATE] (3 days later) although he had sustained an injury to his head as evidenced by the Nurses' Notes dated [DATE] which stated Resident #104 had "steri-strips intact to right eyebrow area. No drainage. Bruising and swelling to right peri-orbital area." Resident #113 Per the Incident Report dated [DATE] Resident #113 "fell forward out of wheelchair. She hit her head on floor...Bruise and cut above right eye. Steri Strips applied after clearing (sic)." Review of the Neurological Evaluation Flow Sheet revealed Resident #113's neurological evaluations were conducted from [DATE] through the last entry on [DATE] at 23:00 (11:00 p.m.). There were no Nurses' Notes between [DATE] and [DATE]. Resident #115 Per the Incident Report dated [DATE] a bruise was discovered on Resident #115's forehead. In a telephone interview on [DATE] at 11:20 a.m. Nurse Aide #34 admitted the bar of the mechanical lift hit into Resident #115's head during the transfer. Per the Skin Alteration Record entry dated [DATE] Resident #115 had a 2.5 cm x 2.0cm bruise on her left eye and forehead. Per the Hospice Clinical Note-Psychosocial dated [DATE] Resident #115 had a "small quarter-sized bruise on her forehead. Per staff happened on 3rd shift ,[DATE]-,[DATE] with Hoyer lift." Review of the Hospice Notes revealed the bruise to Resident #115's forehead remained visible on [DATE]. Review of the Neurological Evaluation Flow Sheet revealed Resident #115's neurological evaluations were conducted from [DATE] through the last entry [DATE] at 24:00 (midnight). 4. Standards of Practice-Physician Orders "A Physician is responsible for directing medical treatment..." (Phipps, W. J., Monahan, F. D., Sands, J. K., Marek, J. F., & Neighbors, M. (2003) Medical-Surgical Nursing Health and Illness Perspectives (7th ed.). St. Louis: Mosby.) Resident #101 Per the incident report and Nurses' Notes dated [DATE] and interviews with LPN #10 ([DATE] at 9:58 a.m.), Nurse Aide #11 ([DATE] at 12:47 p.m.) & Nurse Aide #12 [DATE] at 2:04 p.m.) Resident #101 sustained a laceration to her forehead when she fell on [DATE]. LPN #10 applied Steri Strips to the wound without a physician's orders [REDACTED]. Per the hospital emergency room physician's notes dated [DATE] Resident #101's laceration was closed with 5 sutures. Resident #104 Per the Incident Report dated [DATE] Resident #104 "fell and hit his head and right knee" at 9:30 p.m. in the bathroom. Per the "Center Action" section of the Incident Report "applied ice on the R head knee (sic), cleaned w/ antimicrobial deodorizing cleanser, steri-stripps (sic) and dressing gauze given (sic)." Per the Incident Report the Physician was notified on [DATE] at 10:30 p.m. The telephone orders for the treatments of the injuries Resident #104 sustained to his head and knee on [DATE] were dated the following day-[DATE] at 9:30 a.m. and "13:00" (1:00 p.m.) respectively. There was no documented explanation found in the Nurses' Notes to explain why treatment was given without physician's orders [REDACTED]. In a telephone interview on [DATE] at 3:47 p.m. RN #33 said she provided treatment on [DATE] under "protocols" which consisted of instructions for wound cleansing, application of Steri Strips and application of Triple Anti-biotic ointment "unless the resident is allergic to it." RN #33 said the "protocols" were kept in a "white folder" at the desk. This Surveyor asked RN #33 to get said protocols and read them to her. After waiting on-hold for 20 minutes RN #33 returned to the line and stated the protocols would be sent to this Surveyor to review. Within minutes via e-mail the Facility sent a copy of the same telephone order dated [DATE] mentioned above. No "protocols" for wound treatment which allowed the nursing staff to provide treatments without a physician's orders [REDACTED]. In the interview on [DATE] at 3:47 p.m. RN #33 said the Facility's Wound Care nurse was the person who called physician for wound treatment orders. The Wound Care nurse was not available for interview. Resident #113 Per the Incident Report dated [DATE] at 3:00 p.m. Resident #113 fell forward from her wheelchair, hit her head on floor and sustained an injury above her right eye. RN #31 said she did not telephone the physician however she said a hospice nurse who was in the facility made the call. RN #31 said she did not obtain orders for wound care on [DATE]. RN #31 said she applied Steri Strips to Resident #113's injury on [DATE]. RN #31 said, "It was like a cut. It didn't need Steri Strips to hold it together" but she applied them anyway. RN #31 admitted that the facility stocked normal saline for use in cleansing wounds. Review of the physician's orders [REDACTED]. Change Steri-strips R brow PRN (as needed)" were not obtained until [DATE] which was 3 days after the fall and injury of [DATE]. 5. Standards of Practice-Documentation of Change in Condition "The record is a means by which health care team members communicate (resident) needs, and progress, individual therapies...The record should be the most current and accurate source of information about a (resident)'s health care status." (Potter, P. A. & Perry, A. G. (2005) Fundamentals of Nursing (6th ed.). St. Louis: Mosby). Resident #101 Per the incident report dated [DATE] Resident #101 "fell from bed" and sustained an "open wound" to her forehead and bruises to her right elbow and right knee. Per the Nurses' Notes dated [DATE] at "19:30" (7:30 p.m.) there was a "moderate amount of blood noted from (Resident #101's) right forehead. Bruising noted to right elbow, right knee, nose, (sic) right side of forehead." The size and dimensions of the bleeding area and of the bruises was not documented. Per the Nurses' Notes dated [DATE] at 1:00 a.m. the size of Resident #101's forehead wound was again not described however the wound was cleansed and a "DSD (dry sterile dressing) applied with pressure. Bruising and swelling to both eyes. Bruise to right elbow and right knee" with no further description as to the size of the bruises. The Physician was telephoned and Resident #101 was sent to the hospital via ambulance at 7:40 a.m. Per the Nurses' Notes dated [DATE] at 13:15 (1:15 p.m.) Resident #101 returned from the hospital at 12:30 p.m. with sutures in her forehead. The number of sutures was not documented. Resident #101 had "bruising cont. (sic) to right shoulder, right elbow, right knee...Bruising and swelling to both eyes and bridge of nose." Again there was no documentation of measurements of the injured areas and no description of the bruises (color and intensity) documented. The first documented measurements of Resident #101's wounds that were found in the clinical record were documented on the "Skin Alteration Record" dated [DATE]. The penmanship was illegible in places and measurements were inconsistently described. A line that pointed to the left hairline-part on the human body sketch stated "laceration 1.5 cm with (the next word was scribbled but possibly was) "bruises." An oval shape was drawn around the eyes and nose with a scribbled word (possibly "bruises") at the end of a line pointing to it. An oblong shape was drawn on the right upper/outer femur (leg) with illegible words written next to it. A circle on the right knee was labeled "1x1" with no identification as to whether the measurements were in inches or in centimeters. A larger circle was drawn on the front of the left shin below the knee but not quite at the half-way mark between knee and foot. No measurements were given. The word "Bruised" and another illegible word were written at the end of a line that extended from the words to the circle on the left shin. A circle on the back side of the right elbow with "5x5" printed next to it again did not identify whether the measurements were in inches or in centimeters and there were no words indicating what the circle was meant to identify such as a bruise or some other type of injury. Per the hospital emergency room physician's note dated [DATE], the injury to Resident #101's head was described as a "laceration" and as a "puncture" located on the right forehead; it was noted to be "irregular" with a 2.0 cm length X 10.0 mm width X 6.0 mm depth. The discharge orders included instructions to remove the sutures in ",[DATE] days" however the orders did not state how many sutures were in place. The number of sutures was not documented in the Nurses' Notes dated [DATE] at 13:15 upon Resident #101's return to the facility or in the subsequent Nurses' Notes (dated [DATE] at 21:35, [DATE] at 0100, [DATE] at 2000, [DATE] at 0500, late entry [DATE] at 1300, [DATE] at 1300, [DATE] at 1600, [DATE] at 0100, ,[DATE]/

Based on observation, interview and record review the Facility failed to: 1) ensure services (wheelchair transport) were provided by qualified persons for 2 of 16 sampled residents (#113 & #116) resulting in actual harm-falls with injuries (lacerations and emergency room care/computerized tomography testing) and, 2) for emergency treatment at the scene and neurological assessment for 1 of 16 sampled residents (#101) who fell and sustained an injury to her head resulting in the potential for serious harm (paralysis). Findings include: Resident #113 Per the Incident Report dated 11/19/10 Resident #113 "fell forward out of wheelchair. She hit her head on floor" and she sustained a "bruise and cut above the right eye...bruising to left knee." In an interview on 1/11/11 at 2:00 p.m. Central Supply Clerk/Medical Records Clerk #15 stated she was pushing Resident #113 forward in her wheelchair without use of footrests when Resident #113 fell forward and out of the chair. Clerk #15 said she "didn't know it was so important" to use wheelchair footrests during transport. Review of the Central Supply Clerk and Medical Records Clerk Job Descriptions revision date 2/08 revealed the responsibilities did not include transporting residents in wheelchairs. Review of Clerk #15's employee file with the assistance of Human Resources #32 revealed Clerk #15's nurse aide certification lapsed in 2004 and Clerk #15 was employed as the Central Supply Clerk/Medical Records Clerk since 2003. Human Resources #32 stated Clerk #15 had not worked as a nurse aide at least since 2003 and did not attend any nurse aide in-service trainings. Per the Minimum (MDS) data set [DATE] Resident #113 was diagnosed with [REDACTED]. Resident #113 was observed on 1/6/11 at 1:40 p.m. on her bed. She denied falling out of her wheelchair but replied "yeah" when asked if she had cut her head. Resident #113 said she did not know how the cut happened. Observation revealed no visible wound to her forehead when Resident #113 lifted her bangs. Resident #116 Per the Incident Report dated 11/26/10 Resident #116 was found lying on the floor in front of his wheelchair, "facing flat down on his stomach with arm underneath head. Patient states he hit his head." Per the Incident Report State Addendum (second page of the incident report) Resident #116 was "left unattended in room by another staff person which was never communicated to the nursing staff. Pt. has hx (history) of self transfers without assistance. Previous intervention to direct patient to areas of supervision." Per the Nurses' Notes dated 11/26/10 Resident #116 was sent to the hospital for evaluation and returned on 11/26/10 at 1840 (6:40 p.m.) having had a CT scan which was negative and with instructions to hold the anticoagulant [MEDICATION NAME] for 3 days and recheck his anticoagulation status before resuming it. In a telephone interview on 1/18/11 at 2:27 p.m. Laundry Aide #35 stated on 11/26/10 she witnessed Resident #116 attempting to stand up from his wheelchair in the corridor. Laundry Aide #35 stated Resident #116, "asked to go back to his room so I took him to his room. I thought the nurse saw me. About an hour later they came and told me he fell ." Laundry Aide #35 stated she did not know that Resident #116 was not supposed to be left alone while up in his wheelchair until after he fell . Laundry Aide #35 said after he fell a nurse aide (she could not recall the name) said "he wasn't supposed to be in his room alone" while up in his chair. Laundry Aide #35 stated she did not review the residents' care plans or the nurse aide instructions found on the "Resident Information Sheets" which were available at the Nurses' Station. Review of the job description "Laundry Aide" signed by Laundry Aide #35 on 4/8/08 revealed the duties and responsibilities of a laundry aide did not include transporting residents in wheelchairs or reading and being knowledgeable about care plan interventions. Laundry Aide #35 admitted she had no training to transport residents in wheelchairs. Per the Discharge Summary Resident #116 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. ( ) Resident #101 Per the Incident Report dated 12/13/10 Resident #101 fell to the floor from her bed and sustained an open wound to right forehead and bruises to her right elbow and right knee. In the following interviews LPN #10 and LPN #14 demonstrated a lack of knowledge of emergency treatment and neurological assessments: In an interview on 1/6/11 at 9:58 a.m. LPN #10 said at approximately 7:00 p.m. on 12/13/10 she saw Resident #101 lying on the floor with visible "blood on the floor. It was from her head..." LPN #10 said, "It was my first major fall that I've ever seen." LPN #10 said when she was hired by the Facility 14 months earlier (October 2009) when she was a new graduate nurse at that time. LPN #10 admitted she moved Resident #101 from the floor without stabilizing her head or neck and that she closed the head wound with Steri Strips which did not control the bleeding. LPN#10 admitted she did not perform neurological checks in accordance with Standards of Practice and that she falsified the clinical record when she documented neurological checks that she did not do. LPN #10 stated she attended the Facility's orientation program when she was hired. Review of LPN #10's employee file revealed she attended the Facility's orientation program on 9/30/10. Review of the orientation materials provided by the Facility revealed no documented evidence that LPN #10 was instructed by the Facility not to move a resident who had sustained a head injury, or to obtain vital signs before moving any injured resident off the floor or how to conduct a neurological assessment. LPN #14 said in an interview on 1/11/11 at 3:45 p.m. that on 12/13/10 he obtained "Steri Strips and triple antibiotics, bacterial bottle and sterile [DEVICE] pad, "at LPN #10's request. LPN #14 admitted he did not observe LPN #10's assessments or wound care however he was aware there was a "gash, a slit on (Resident #101's) forehead" and knew that LPN #10 applied the Steri Strips to "cosmetically put it back together." LPN#14 said he did not instruct LPN #10 to call 9-1-1 or to stabilize Resident #101 on the floor until appropriate emergency personnel arrived and emergency care was given. LPN #14 stated he was unaware that a neurological assessment included steps such as assessing hand grips and foot pushes. LPN #14 said he had training at the facility but did not recall having training about neurological assessments in nurses' training (which he stated he completed 6 years before this interview). LPN #14 said, "We have check lists" of the "things we should do" in a neurological assessment and he was unfamiliar with the steps mentioned by this Surveyor. Review of the "check list" revealed it did not contain cues for all steps in a neurologic assessment. ( )